Meta Analysis Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis.
This review may be edited
Summary
Posted By:	Gordon S Doig
E-Mail:	Gordon.Doig@EvidenceBased.net
Posted Date:	5 July 2007
Title:	Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis.
Authors:	Chan EY, Ruest A, Meade MO, Cook DJ.
Reference:	BMJ. 2007 Apr 28;334(7599):889. Epub 2007 Mar 26.
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Abstract:	Objective To evaluate the effect of oral decontamination on the incidence of ventilator associated pneumonia and mortality in mechanically ventilated adults. Design Systematic review and meta-analysis. Data sources Medline, Embase, CINAHL, the Cochrane Library, trials registers, reference lists, conference proceedings, and investigators in the specialty. Review methods Two independent reviewers screened studies for inclusion, assessed trial quality, and extracted data. Eligible trials were randomised controlled trials enrolling mechanically ventilated adults that compared the effects of daily oral application of antibiotics or antiseptics with no prophylaxis. Results 11 trials totalling 3242 patients met the inclusion criteria. Among four trials with 1098 patients, oral application of antibiotics did not significantly reduce the incidence of ventilator associated pneumonia (relative risk 0.69, 95% confidence interval 0.41 to 1.18). In seven trials with 2144 patients, however, oral application of antiseptics significantly reduced the incidence of ventilator associated pneumonia (0.56, 0.39 to 0.81). When the results of the 11 trials were pooled, rates of ventilator associated pneumonia were lower among patients receiving either method of oral decontamination (0.61, 0.45 to 0.82). Mortality was not influenced by prophylaxis with either antibiotics (0.94, 0.73 to 1.21) or antiseptics (0.96, 0.69 to 1.33) nor was duration of mechanical ventilation or stay in the intensive care unit. Conclusions Oral decontamination of mechanically ventilated adults using antiseptics is associated with a lower risk of ventilator associated pneumonia. Neither antiseptic nor antibiotic oral decontamination reduced mortality or duration of mechanical ventilation or stay in the intensive care unit.
Are the Results Valid?
1. Did the overview address a focused clinical question?
	Yes. The final paragraph of the introduction states the explicit objectives of the review in the form of a focused clinical question: "to estimate the effect of oral decontamination using topical antibiotics or antiseptics on ventilator associated pneumonia and mortality in mechanically ventilated adults."
2. Were the criteria used to select articles for inclusion appropriate?
	Yes. The authors selected published or unpublished trials. Trials of SDD were excluded.
3. Is it unlikely that important, relevant studies were missed?
	No. An extensive electronic search of various databases (Medline, CENTRAL, CINAHL) was conducted. The authors also searched trial registers, web postings of conference proceedings, hand searched reference lists of reviews and contacted experts.
4. Was the validity of the included studies appraised?
	Yes. The authors evaluated randomisation, allocation concealment, blinding techniques, clarity of inclusion and exclusion criteria and outcome definitions, similarity of baseline characteristics, and completeness of follow-up.
5. Were assessments of studies reproducible?
	Yes. Two reviewers independently screened papers for eligibility in the review and two reviewers independently appraised the quality of included trials. The authors report excellent agreement for the selection of trials for inclusion(kappa=0.84).
6. Were the results similar from study to study?
	The I2 measure of heterogeneity for VAP ranged between 48% to 59% for the primary analyses. The I2 measure of heterogeneity for mortality ranged between 34% to 42% for the primary analyses. Heterogeneity could be viewed as being moderate to high.
What are the Results?
1. What are the overall results of the overview?
	VAP oral application of antibiotics did not significantly reduce VAP (relative risk 0.69, 95% confidence interval 0.41 to 1.18). Mortality oral application of antiseptics significantly reduceded VAP (RR 0.56, 95% CI 0.39 to 0.81). neither antibiotics (RR 0.94, 95% CI 0.73 to 1.21) nor antiseptics (RR 0.96, 95% CI 0.69 to 1.33) reduced mortality. Other outcomes duration of mechanical ventilation or ICU LoS were not reduced.
2. How precise were the results?
	See confidence intervals, above.
Will the Results Help Me In Caring For My Patients?
1. Can the results be applied to my patient care
	Yes. Oral antiseptics are relatively inexpensive and may result in a reduction in VAP in mechanically ventilated ICU patients.
2. Were all clinically important outcomes considered?
	The authors do assess mortality, duration of ICU stay and duration of mechanical ventilation. The studies were unable to assess long term resistance patterns.
3. Are the benefits worth the harms and costs?
	Depends on the relative importance of VAP and potential resistance to each unit.
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