Liberati A, D'Amico R, Torri V, Brazzi L
Italian Cochrane Centre, University of Modena and Reggio Emilia and Mario Negri Institute, Via del Pozzo 71, Modena, Italy.
Cochrane Database Syst Rev. 2004(1):CD000022. doi: 10.1002/14651858.CD000022.pub2.
Pneumonia is an important cause of mortality in intensive care units. The incidence of pneumonia in such patients ranges between 7% and 40%, and the crude mortality from ventilator associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to pneumonia, it has been shown to contribute to mortality in intensive care units independently of other factors that are also strongly associated with such deaths.
The objective of this review was to assess the effects of antibiotics for preventing respiratory tract infections and overall mortality in adults receiving intensive care.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 3, 2003), which contains the Acute Respiratory Infections (ARI) Group specialised trials register; MEDLINE (January 1966 to September 2003); EMBASE (January 1990 to September 2003); proceedings of scientific meetings and reference lists of articles from January 1984 to December 2002. We also contacted investigators in the field.
Randomised trials of antibiotic prophylaxis for respiratory tract infections and deaths among adult intensive care unit patients.
At least two reviewers independently extracted data and assessed trial quality.
Overall 36 trials involving 6922 people were included. There was variation in the antibiotics used, patient characteristics and risk of respiratory tract infections and mortality in the control groups. In 17 trials (involving 4295 patients) that tested a combination of topical and systemic antibiotic, the average rates of respiratory tract infections and deaths in the control group were 36% and 29% respectively. There was a significant reduction of both respiratory tract infections (odds ratio 0.35, 95% confidence interval 0.29 to 0.41) and total mortality (odds ratio 0.78, 95% confidence interval 0.68 to 0.89) in the treated group. On average 5 patients needed to be treated to prevent one infection and 21 patients to prevent one death. In 17 trials (involving 2664 patients) that tested topical antimicrobials alone (or comparing topical plus systemic versus systemic alone) the rates of respiratory tract infections and deaths in the control groups were 30% and 26% respectively. There was a significant reduction of respiratory tract infections (odds ratio 0.52, 95% confidence interval 0.43 to 0.63) but not in total mortality (odds ratio 0.97, 95% confidence interval 0.81 to 1.16) in the treated group.
REVIEWER'S CONCLUSIONS: A combination of topical and systemic prophylactic antibiotics reduces respiratory tract infections and overall mortality in adult patients receiving intensive care. A treatment based on the use of topical prophylaxis alone reduces respiratory infections but not mortality. The risk of occurrence of resistance as a negative consequence of antibiotic use was appropriately explored only in the most recent trial by de Jonge which did not show any such effect.
肺炎是重症监护病房患者死亡的重要原因。此类患者的肺炎发病率在7%至40%之间，呼吸机相关性肺炎的粗死亡率可能超过50%。虽然并非所有此类肺炎患者的死亡都直接归因于肺炎，但研究表明，它在重症监护病房的死亡率中起作用，独立于其他也与此类死亡密切相关的因素。
本综述的目的是评估抗生素对接受重症监护的成年人预防呼吸道感染和总体死亡率的影响。
我们检索了Cochrane对照试验中心注册库（CENTRAL）（2003年第3期），其中包含急性呼吸道感染（ARI）组的专门试验注册库；MEDLINE（1966年1月至2003年9月）；EMBASE（1990年1月至2003年9月）；1984年1月至2002年12月科学会议论文集和文章参考文献列表。我们还联系了该领域的研究人员。
针对成年重症监护病房患者呼吸道感染和死亡进行抗生素预防的随机试验。
至少两名综述作者独立提取数据并评估试验质量。
共纳入36项试验，涉及6922人。所使用的抗生素、患者特征以及对照组呼吸道感染和死亡风险存在差异。在17项试验（涉及4295名患者）中测试了局部和全身联合使用抗生素，对照组呼吸道感染和死亡的平均发生率分别为36%和29%。治疗组呼吸道感染（比值比0.35，95%置信区间0.29至0.41）和总死亡率（比值比0.78，95%置信区间0.68至0.89）均显著降低。平均每治疗5名患者可预防1例感染，每治疗21名患者可预防1例死亡。在17项试验（涉及2664名患者）中仅测试了局部抗菌药物（或比较局部加全身与仅全身使用），对照组呼吸道感染和死亡的发生率分别为30%和26%。治疗组呼吸道感染显著降低（比值比0.52，95%置信区间0.43至0.63），但总死亡率未降低（比值比0.97，95%置信区间0.81至l.16）。
局部和全身预防性联合使用抗生素可降低接受重症监护的成年患者的呼吸道感染和总体死亡率。仅基于局部预防的治疗可降低呼吸道感染，但不能降低死亡率。作为抗生素使用负面后果的耐药发生风险仅在de Jonge的最新试验中得到适当探讨，该试验未显示任何此类影响。
