Cui Zhenwen, Wang Baofeng, Zhong Zhihong, Sun Yuhao, Sun Qingfang, Yang Guoyuan, Bian Liuguan
Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Neuroscience and Neuroengineering Research Center, Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.
Am J Infect Control. 2015 Jul 1;43(7):e23-32. doi: 10.1016/j.ajic.2015.03.015. Epub 2015 Apr 29.
External ventricular drainage (EVD) is one of the most common and effective procedures in neurosurgery practice. However, catheter-related infection (CRI), which is associated with significant mortality and morbidity, plagues this procedure. We evaluated the efficacy of antibiotic-impregnated EVD (AI-EVD) and silver-impregnated EVD (SI-EVD) catheters compared with plain EVD catheters for the prevention of CRI.
The authors performed an independent search of Medline, Embase, and the Cochrane Library to identify eligible studies published between January 2002 and August 2014. We searched all relevant literature using an exhaustive search strategy. Randomized controlled trials or observational studies that compared AI-EVD catheters with plain EVD catheters for the prevention of CRI were included. The quality of each included study was assessed using a risk of bias assessment tool and the Newcastle-Ottawa Scale. RevMan5.3 software (The Cochrane Collaboration, Oxford, UK) was used to perform this meta-analysis, and publication bias was investigated using funnel plot constructions and Egger test.
A total of 4 randomized and 10 observational studies involving 4,399 patients were included in this meta-analysis. Pooled results comparing AI-EVD catheters with plain EVD catheters in the management of patients with acute high intracranial pressure demonstrated the superiority of antimicrobial EVDs for the prevention of CRI with a risk induction of 62% (95% confidence interval [CI], 0.25-0.58; P < .00001). Subgroup analyses of pooled data from separate analyses of AI-EVDs and SI-EVDs showed the efficacy of both measures for CRI prevention, with a risk ratio (RR) of 0.31 (95% CI, 0.18-0.55; P < .0001) and an RR of 0.59 (95% CI, 0.40-0.88; P = .010), respectively. The protective effects of these AI-EVD catheters remained significant in the subgroup of randomized controlled trials with an RR of 0.48 (95% CI, 0.25-0.90; P = .02). A similar result was also seen after a pooled analysis of observational studies with an RR of 0.35 (95% CI, 0.21-0.60; P = .0001). The heterogeneity among studies was moderate (I(2) = 49%) and was primarily attributed to the inclusion of 1 large, positive cohort study. Publication bias was unlikely in the current meta-analysis.
Our restults indicate that both AI-EVDs and SI-EVDs are more effective than plain EVDs for the prevention of CRI. There is no conclusive evidence on the preference of AI-EVDs vs SI-EVDs because of insufficient data. Further well-designed, multicenter randomized controlled trials are required to confirm the findings of this meta-analysis.
脑室外引流（EVD）是神经外科实践中最常见且有效的操作之一。然而，与显著的死亡率和发病率相关的导管相关感染（CRI）困扰着这一操作。我们评估了抗生素浸渍EVD（AI-EVD）导管和银浸渍EVD（SI-EVD）导管与普通EVD导管相比预防CRI的效果。
作者独立检索了Medline、Embase和Cochrane图书馆，以识别2002年1月至2014年8月期间发表的符合条件的研究。我们使用详尽的检索策略搜索了所有相关文献。纳入了比较AI-EVD导管与普通EVD导管预防CRI的随机对照试验或观察性研究。使用偏倚风险评估工具和纽卡斯尔-渥太华量表评估每个纳入研究的质量。使用RevMan5.3软件（英国牛津Cochrane协作网）进行这项荟萃分析，并使用漏斗图构建和Egger检验调查发表偏倚。
这项荟萃分析共纳入了4项随机研究和10项观察性研究，涉及4399例患者。在急性高颅内压患者管理中比较AI-EVD导管与普通EVD导管的汇总结果显示，抗菌EVD在预防CRI方面具有优势，风险降低62%（95%置信区间[CI]，0.25 - 0.58；P <.00001）。对AI-EVD和SI-EVD单独分析的汇总数据进行亚组分析显示，两种措施预防CRI均有效，风险比（RR）分别为0.31（95%CI，0.18 - 0.55；P <.0001）和0.59（95%CI，0.40 - 0.88；P =.010）。在随机对照试验亚组中，这些AI-EVD导管的保护作用仍然显著，RR为0.48（95%CI，0.25 - 0.90；P =.02）。观察性研究汇总分析后也得到了类似结果，RR为0.35（95%CI，0.21 - 0.60；P =.0001）。研究间的异质性为中度（I² = 49%），主要归因于纳入了1项大型阳性队列研究。在当前的荟萃分析中不太可能存在发表偏倚。
我们的结果表明，AI-EVD和SI-EVD在预防CRI方面均比普通EVD更有效。由于数据不足，关于AI-EVD与SI-EVD的偏好尚无确凿证据。需要进一步设计良好的多中心随机对照试验来证实这项荟萃分析的结果。
