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Oral decontamination and ventilator-associated pneumonia

Citation/s: Chan EY, Ruest A, O’Meade M, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: review and meta-analysis. BMJ 2007; 334:889-893

Lead author’s name and fax: Dr. E. Y. Chan, Department of nursing services, Tan Tock Sern Hospital, Singapore. ee_yuee_chan@ttsh.com.sg

Three-part Clinical Question:

Patients: Mechanically ventilated adults in intensive care units. 

Interventions: Oral anti-septic mouthwash, oral antibiotics. 

Outcomes: Primary - Incidence of ventilator associated pneumonia, mortality. Secondary - Mean duration of ventilation, length of stay in ICU

Search Terms: mechanically ventilated, ventilator associated pneumonia, oral decontamination, mortality, meta-analysis

The Review:
Data Sources: Cochrane Library, Medline, Embase, CINAHL, trials registers (www.clinicaltrials.gov/ and www.controlled-trials.com/), reference lists from all retrieved articles, conference proceedings, authors and experts in the specialty.
 

Study Selection: Included published or unpublished parallel design RCTs in adults (11 trials, 3242 patients) evaluating the effect of oral decontamination (any type or combination of antibiotic or antiseptic agent) on incidence of pneumonia and mortality in mechanically ventilated adults in ICU.  Excluded: Children, animal studies, trials looking at selective decontamination of the digestive tract, observational studies, editorials and commentaries. Also excluded trials that used the clinical pulmonary infection score alone to define ventilator-associated pneumonia (VAP).
 

Data Extraction: Two independent reviewers. Assessment of randomisation, allocation concealment, blinding, diagnostic criteria, clarity of inclusion and exclusion criteria, outcome definitions, baseline characteristics and completeness of follow-up. Intra-observer agreement measured with Cohen’s alpha statistic.

Patients - 11 studies enrolling total of 3242 mechanically ventilated adults in ICU. Treatment -Oral antibiotic prophylaxis (4 trials, 1098 patients) versus no prophylaxis. Oral antiseptic versus no prophylaxis (7 trials 2144 patients).

Outcomes - Primary: incidence of VAP, mortality.  Secondary: mean ventilated days, length of ICU stay. Pneumonia was defined differently across included studies

The studies were multiple independent reviews of individual reports. They were tested for heterogeneity.

The Evidence:

EBM questions:

1.      Do the methods allow accurate testing of the hypothesis? Yes, with some limitations: Heterogeneity between trials: different patient populations, duration of therapy, anti-septic / antibiotic regimens, diagnostic criteria for VAP and duration of follow up. No consideration of other confounding methods of reducing VAP (e.g. semi-recumbent positioning, humidification of ventilator circuit, gastric prophylaxis, subglottic tracheal tubes etc.)

2.      Do the statistical tests correctly test the results to allow differentiation of statistically significant results? Yes.

3.      Are conclusions valid in light of the results? Yes

4.      Did results get omitted and why? One control arm in one study which included the use of chlorhexidine and antibiotics was excluded.

5.      Did they suggest areas of further research? Yes. Further studies examining: the risks of developing anti-septic and antibiotic resistant organisms, direct comparison of antiseptic versus antibiotic oral decontamination, clarification of the most effective concentration / regimen of antiseptic agent. Adequately powered studies looking at mortality, duration of mechanical ventilation and ICU stay.

6.      Did they make any recommendations based on the results and were they appropriate? Yes. More evidence required before firm recommendations can be made on the use of oral decontamination.

7.      Is the study relevant to my clinical practice? Yes

8.      What level of evidence does this study represent? 1^{+ +} (meta-analysis with a very low risk of bias)

9.      What grade of recommendation can I make on this result alone? A

10.  What grade of recommendation can I make when this study is considered along with other available evidence? A

11.  Should I change my practice because of these results? Oral decontamination with anti-septic should be considered as part of a package of VAP prevention. Further evidence regarding patient outcomes, potential risks and cost-effectiveness is required before firm recommendations can be made.  The use of oral antibiotics would seem less attractive in view of the lack of evidence to suggest a superior effect when compared to oral antiseptic and the potential for development of resistant micro-organisms.

12.  Should I audit my current practice because of these results? Yes. It would be useful to audit the incidence of VAP and current preventative measures employed in individual ICUs across the UK.

Appraised by: Rachel Kearns (SHO), Department of Anaesthetics, Glasgow Royal Infirmary, G4 0SF.; 29 May 2007
Email: rkearns79@hotmail.com
Kill or Update By: May 2012

Reviewed & edited by CC & BLT

Citation: EBM Critical Appraisals. Scottish Intensive Care Society EBM Group. 2007 & JICS 2007 Vol8(2). Kearns R. Chan EY, Ruest A, O’Meade M, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: review and meta-analysis. BMJ 2007; 334:889-893

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