澳大利亚乔治全球健康研究所Anthony Delaney团队研究了在接受机械通气的重症监护病房患者中，消化道选择性去污染与住院死亡率之间的相关性。相关论文于2022年10月26日发表在《美国医学会杂志》上。
选择性消化道去污染（SDD）在接受机械通气的危重成年人中的有效性尚不确定。为了确定在重症监护病房（ICU）接受机械通气的成人中，SDD与标准护理相比，是否与降低死亡风险相关。研究组在MEDLINE、EMBASE和CENTRAL等数据库中检索直到2022年9月的相关文献，筛选出比较ICU机械通气成人患者分别接受SDD与标准护理或安慰剂的随机临床试验。
数据提取和偏倚风险评估一式两份。使用贝叶斯框架进行初步分析。主要结局是住院死亡率。亚组包括使用静脉药物的SDD与不使用静脉药物的SDD。共有8个次要结局，包括呼吸机相关性肺炎的发生率、ICU获得性菌血症和耐药微生物培养阳性的发生率。
共有32项随机临床试验，包括24389名参与者。纳入研究的参与者平均年龄为54岁，女性试验参与者的平均比例为33%。来自包括24034名参与者在内的30项试验的数据有助于初步结果分析。与标准护理相比，SDD死亡率的合并估计风险比（RR）为0.91（I2=33.9%；中度确定性），SDD降低医院死亡率的后验概率为99.3%。
SDD的有益关联在使用静脉药物的试验中是明显的（RR为0.84），但在没有静脉药物的实验中不明显（RR为1.01）（亚组间相互作用的P值=0.02）。SDD与呼吸机相关性肺炎（RR为0.44）和ICU获得性菌血症（RR为0.68）的风险降低相关。关于耐药微生物阳性培养物发生率的现有数据不适合合并，且确定性很低。
研究结果表明，在ICU接受机械通气治疗的成人中，与标准护理或安慰剂相比，SDD的使用与较低的住院死亡率相关。关于SDD对抗生素耐药性影响的证据非常不确定。
附：英文原文
Title: Association Between Selective Decontamination of the Digestive Tract and In-Hospital Mortality in Intensive Care Unit Patients Receiving Mechanical Ventilation: A Systematic Review and Meta-analysis
Author: Naomi E. Hammond, John Myburgh, Ian Seppelt, Tessa Garside, Ruan Vlok, Sajeev Mahendran, Derick Adigbli, Simon Finfer, Ya Gao, Fiona Goodman, Gordon Guyatt, Joseph Alvin Santos, Balasubramanian Venkatesh, Liam Yao, Gian Luca Di Tanna, Anthony Delaney
Issue&Volume: 2022-10-26
Abstract:
Importance The effectiveness of selective decontamination of the digestive tract (SDD) in critically ill adults receiving mechanical ventilation is uncertain.
Objective To determine whether SDD is associated with reduced risk of death in adults receiving mechanical ventilation in intensive care units (ICUs) compared with standard care.
Data Sources The primary search was conducted using MEDLINE, EMBASE, and CENTRAL databases until September 2022.
Study Selection Randomized clinical trials including adults receiving mechanical ventilation in the ICU comparing SDD vs standard care or placebo.
Data Extraction and Synthesis Data extraction and risk of bias assessments were performed in duplicate. The primary analysis was conducted using a bayesian framework.
Main Outcomes and Measures The primary outcome was hospital mortality. Subgroups included SDD with an intravenous agent compared with SDD without an intravenous agent. There were 8 secondary outcomes including the incidence of ventilator-associated pneumonia, ICU-acquired bacteremia, and the incidence of positive cultures of antimicrobial-resistant organisms.
Results There were 32 randomized clinical trials including 24389 participants in the analysis. The median age of participants in the included studies was 54 years (IQR, 44-60), and the median proportion of female trial participants was 33% (IQR, 25%-38%). Data from 30 trials including 24034 participants contributed to the primary outcome. The pooled estimated risk ratio (RR) for mortality for SDD compared with standard care was 0.91 (95% credible interval [CrI], 0.82-0.99; I2=33.9%; moderate certainty) with a 99.3% posterior probability that SDD reduced hospital mortality. The beneficial association of SDD was evident in trials with an intravenous agent (RR, 0.84 [95% CrI, 0.74-0.94]), but not in trials without an intravenous agent (RR, 1.01 [95% CrI, 0.91-1.11]) (P value for the interaction between subgroups=.02). SDD was associated with reduced risk of ventilator-associated pneumonia (RR, 0.44 [95% CrI, 0.36-0.54]) and ICU-acquired bacteremia (RR, 0.68 [95% CrI, 0.57-0.81]). Available data regarding the incidence of positive cultures of antimicrobial-resistant organisms were not amenable to pooling and were of very low certainty.
Conclusions and Relevance Among adults in the ICU treated with mechanical ventilation, the use of SDD compared with standard care or placebo was associated with lower hospital mortality. Evidence regarding the effect of SDD on antimicrobial resistance was of very low certainty.
DOI: 10.1001/jama.2022.19709
Source: https://jamanetwork.com/journals/jama/fullarticle/2798010
JAMA-Journal of The American Medical Association：《美国医学会杂志》，创刊于1883年。隶属于美国医学协会，最新IF：157.335
官方网址：https://jamanetwork.com/
投稿链接：http://manuscripts.jama.com/cgi-bin/main.plex
本期文章：《美国医学会杂志》：Online/在线发表
