Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia.
Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia.
JAMA. 2022 Nov 15;328(19):1922-1934. doi: 10.1001/jama.2022.19709.
The effectiveness of selective decontamination of the digestive tract (SDD) in critically ill adults receiving mechanical ventilation is uncertain.
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.
The primary search was conducted using MEDLINE, EMBASE, and CENTRAL databases until September 2022.
Randomized clinical trials including adults receiving mechanical ventilation in the ICU comparing SDD vs standard care or placebo.
Data extraction and risk of bias assessments were performed in duplicate. The primary analysis was conducted using a bayesian framework.
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.
There were 32 randomized clinical trials including 24 389 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 24 034 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.
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.
在接受机械通气的重症成人中，选择性消化道去污染（SDD）的有效性尚不确定。
确定与标准护理相比，SDD 是否与接受重症监护病房（ICU）机械通气的成人死亡风险降低相关。
主要搜索使用了 MEDLINE、EMBASE 和 CENTRAL 数据库，截至 2022 年 9 月。
随机临床试验，包括在 ICU 接受机械通气的成年人，将 SDD 与标准护理或安慰剂进行比较。
数据提取和偏倚评估均由两人进行。主要分析采用贝叶斯框架进行。
主要结局是医院死亡率。亚组包括与 SDD 静脉药物治疗相比的 SDD 无静脉药物治疗。有 8 个次要结局，包括呼吸机相关性肺炎、ICU 获得性菌血症和抗菌药物耐药菌阳性培养的发生率。
有 32 项随机临床试验纳入了 24389 名参与者。纳入研究参与者的中位年龄为 54 岁（IQR，44-60），中位女性参与者比例为 33%（IQR，25%-38%）。来自 30 项试验的 24034 名参与者的数据为主要结局做出了贡献。与标准护理相比，SDD 的死亡率估计比值比（RR）为 0.91（95%可信区间[CrI]，0.82-0.99；I2=33.9%；中等确定性），SDD 降低医院死亡率的后验概率为 99.3%。在有静脉药物治疗的试验中（RR，0.84 [95% CrI，0.74-0.94]），SDD 与有益的关联是明显的，但在没有静脉药物治疗的试验中（RR，1.01 [95% CrI，0.91-1.11]）（亚组间交互作用的 P 值为<.02）。SDD 与呼吸机相关性肺炎（RR，0.44 [95% CrI，0.36-0.54]）和 ICU 获得性菌血症（RR，0.68 [95% CrI，0.57-0.81]）风险降低相关。关于抗菌药物耐药菌阳性培养的发生率的数据不适于合并，且确定性极低。
在接受机械通气治疗的 ICU 成人中，与标准护理或安慰剂相比，使用 SDD 与较低的医院死亡率相关。关于 SDD 对抗菌药物耐药性影响的证据确定性极低。
