Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: Systematic review and network meta-analysis

BMJ (Online)

Volumn 348, Issue , 2014, Pages

  Price, Richard ^a   MacLennan, Graeme ^b   Glen, John ^c  

^a ROYAL ALEXANDRA HOSPITAL   (United Kingdom)

^b UNIVERSITY OF ABERDEEN   (United Kingdom)

^c GLAN CLWYD HOSPITAL   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ADMINISTRATION, ORAL; ADULT; ANTI-BACTERIAL AGENTS; CHLORHEXIDINE; DECONTAMINATION; DISINFECTANTS; GASTROINTESTINAL TRACT; HOSPITAL MORTALITY; HUMANS; INTENSIVE CARE; OROPHARYNX;

EID: 84898002266     PISSN: None     EISSN: 17561833     Source Type: Journal    
DOI: 10.1136/bmj.g2197     Document Type: Article

References (66)

1. Johanson WG, Pierce AK, Sanford JP, Thomas GD. Nosocomial respiratory infections with Gram-negative bacilli: the significance of colonization of the respiratory tract. Ann Int Med 1972;77:701-6.
2. Garrouste-Orgeas M, Chevret S, Arlet G, Marie O, Rouveau M, Popoff N, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients a prospective study based on genomic DNA analysis. Am J Respir Crit Care Med 1997;156:1647-55. (Pubitemid 27505538)
3. De Smet A-M, Bonten MJ, Kluytmans JA. For whom should we use selective decontamination of the digestive tract? Curr Opin Infect Dis 2012;25:211-7.
4. Bonten MJ Brun-Buisson C, Weinstein RA. Selective decontamination of the digestive tract: to stimulate or stifle. Intensive Care Med 2003;29:672-6. (Pubitemid 36609556)
5. Van Saene HK, Petros AJ, Ramsay G, Baxby D. All great truths are iconoclastic: selective decontamination of the digestive tract moves from heresy to level 1 truth. Intensive Care Med 2003;29:677-90. (Pubitemid 36609557)
6. Kollef MH. Selective digestive decontamination should not be routinely employed. Chest 2003;123:464-8S. (Pubitemid 36549815)
7. Bastin AJ, Ryanna KB. Use of selective decontamination of the digestive tract in United Kingdom intensive care units. Anaesthesia 2009;64:46-9.
8. National Institute for Health and Clinical Excellence. Technical patient safety solutions for ventilator-associated pneumonia in adults. www.nice.org.uk/nicemedia/pdf/PSG002Guidance.pdf
9. Rello J, Lode H, Cornaglia G, Masterton R. A European care bundle for the prevention of ventilator associated pneumonia. Intensive Care Med 2010;36:773-80.
10. How-to Guide: prevent ventilator-associated pneumonia. Institute for Healthcare Improvement, 2012. www.ihi.org.
11. Walden AP, Bonten MJ, Wise MP. Should selective digestive decontamination be used in critically ill patients? BMJ 2012;345:e6697.
12. Liberati A, D'Amico R, Pifferi S, Torri V, Brazzi L, Parmelli E. Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev 2009;4:CD000022.
13. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007;334:889-93. (Pubitemid 46724331)
14. Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis 2011;11:845-54.
15. Pileggi C, Bianco A, Flotta D, Nobile CGA, Pavia M. Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units. Crit Care 2011;15:R115.
16. Carvajal C, Pobo A, Diaz E, Lisboa T, Llaurado M, Rello J. Higiene oral con clorhexidina para la prevencion de neumonia en pacientes intubatos: revision sistematica de ensayos clinicos aleatorizados. Med Clin (Barc) 2010;135:491-7.
17. Pugh RJ, Rathbone P. Oral chlorhexidine to prevent nosocomial pneumonia in critically ill patients: a systematic review and meta-analysis. Crit Care 2010;14(suppl 1):85.
18. De Jonge E, Schultz MJ, Spanjaard L, Bossuyt PM, Vroom MB, Dankert J, et al. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 2003;362:1011-6. (Pubitemid 37186877)
19. De Smet AM, Klutymans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009;360:20-31.
20. Chlebicki MP, Safdar N. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 2007;35:595-602. (Pubitemid 46148554)
21. Kola A, Gastmeier P. Efficacy of oral chlorhexidine in preventing lower respiratory tract infections. Meta-analysis of randomized controlled trials. J Hosp Inf 2007;66:207-16. (Pubitemid 46979844)
22. Pineda LA, Saliba RG, El Solh AA. Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Crit Care 2006;10:R35.
23. Schultz MJ, Haas LE. Antibiotics or probiotics as preventive measures against ventilator-associated pneumonia: a literature review. Crit Care 2011;15:R18.
24. Silvestri L, van Saene HKF, Zandstra DF, Marshall JC, Gregori D, Gullo A. Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: systematic review of randomized controlled trials. Crit Care Med 2010;38:1370-6.
25. Silvestri L, van Saene H K F, Weir I, Gullo A. Survival benefit of the full selective digestive decontamination regimen. J Crit Care 2009;24:474.e7-14.
26. Silvestri L, van Saene H K F, Casarin A, Berlot G, Gullo A. Impact of selective decontamination of the digestive tract on carriage and infection due to Gram-negative and Gram-positive bacteria: a systematic review of randomised controlled trials. Anaesth Intensive Care 2008;36:324-38.
27. Silvestri L, van Saene HK, Milanese M, Gregori D, Gullo A. Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients. Systematic review of randomised controlled trials. J Hosp Infect 2007;65:187-203.
28. Van Till JWO, van Ruler O, Lamme B, Weber RJ, Reitsma JB, Boermeester MA. Single-drug therapy or selective decontamination of the digestive tract as antifungal prophylaxis in critically ill patients: a systematic review. Crit Care 2007;11:R126.
29. Dias S, Welton NJ, Sutton AJ, Ades AE. A generalised linear modelling framework for pairwise and network meta-analysis of randomised controlled trials. NICE DSU Technical Support Document 2. 2012. www.nicedsu.org.uk
30. Lunn DJ, Thomas A, Best N, Spiegelhalter D. WinBUGS - a Bayesian modelling framework: concepts, structure, and extensibility. Statistics Computing 2000;10:325-37.
31. Aerdts SJ, van Dalen R, Clasener HA, Festen J, van Lier HJ, Vollard EJ. Antibiotic prophylaxis of respiratory tract infection in mechanically ventilated patients: a prospective, blinded, randomised trial of a novel regimen. Chest 1991;100:783-91.
32. Blair P, Rowlands BJ, Lowry K, Webb H, Armstrong P, Smilie J. Selective decontamination of the digestive tract: a stratified, randomised, prospective study in a mixed intensive care unit. Surgery 1991;110:303-10.
33. Boland JP, Sadler DL, Stewart WA, Wood DJ, Zerick W, Snodgrass KR. Reduction of nosocomial respiratory tract infection in the multiple trauma patient requiring mechanical ventilation by selective parenteral and enteral antisepsis regimen (SPEAR) in the intensive care unit. XVII Congress of Chemotherapy, 1991.
34. Cockerill FR, Muller SR, Anhalt JP, Marsh HM, Farnell MB, Mucha P, et al. Prevention of infection in critically ill patients by selective decontamination of the digestive tract. Ann Intern Med 1992;117:545-53.
35. Jacobs S, Foweraker JE, Roberts SE. Effectiveness of selective decontamination of the digestive tract in an ICU with a policy encouraging a low gastric pH. Clin Intensive Care 1992;3:52-8.
36. Krueger WA, Lenhart F-P, Neeser G, Ruckdeschel G, Schreckhase H, Eissnet H-J, et al. Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions and mortality in critically ill surgical patients: a prospective, stratified, randomised, double blind placebo controlled clinical trial. Am J Respir Crit Care Med 2002;166:1029-37. (Pubitemid 35178699)
37. Palomar M, Alvarez-Lerma F, Jorda R, Bermejo B. Prevention of nosocomial infection in mechanically ventilated patients: selective digestive decontamination versus sucralfate. Clin Intensive Care 1997;8:228-35. (Pubitemid 27480641)
38. Rocha LA, Martin MJ, Pita S, Paz J, Seco C, Margusino L, et al. Prevention of nosocomial infection in critically ill patients by selective decontamination of the digestive tract: a randomised, double-blind, placebo controlled study. Intensive Care Med 1992;18:398-404. (Pubitemid 23009485)
39. Sanchez Garcia M, Cambronero Galache JA, Lopez Diaz J, Cerda Cerda E, Rubio Blasco J, Gomez Aguinaga MA, et al. Effectiveness and cost of selective decontamination of the digestive tract in critically ill intubated patients: a randomised, double-blind, placebo controlled multicentre trial. Am J Respir Crit Care Med 1998;158:908-16. (Pubitemid 28449460)
40. Stoutenbeek CP, van Saene HK, Little RA, Whitehead A. The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multi-center randomised controlled trial. Intensive Care Med 2007;33:261-70. (Pubitemid 46221231)
41. Ulrich C, Harinck-de Weerd JE, Bakker NC, Jacz K, Doornbos L, de Ridder VA. Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU acquired infections: a prospective randomised study. Intensive Care Med 1989;15:424-31. (Pubitemid 20001209)
42. Verwaest C, Verhaegen J, Ferdinande P, Schetz M, van den Berghe G, Verbist L, et al. Randomised, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit. Crit Care Med 1997;25:63-71.
43. Winter R, Humphreys H, Pick A, MacGowan AP, Willatts SM, Speller DC. A controlled trial of selective decontamination of the digestive tract in intensive care and its effect on nosocomial infection. J Antimicrob Chemother 1992;30:73-87.
44. Bergmans DC, Bonten MJ, Gaillard CA, Paling JC, van der Geest S, van Tiel FH, et al. Prevention of ventilator-associated pneumonia by oral decontamination: a prospective, randomised, double-blind, placebo-controlled study. Am J Respir Crit Care Med 2001;164:382-8. (Pubitemid 32778203)
45. Pugin J, Auckenthaler R, Lew DP, Suter PM. Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia. JAMA 1991;265:2704-10.
46. Rios F, Maskin B, Saenz Valiente A, Galante A, Cazes Camarero P, Aguilar L, et al. Prevention of ventilator associated pneumonia (VAP) by oral decontamination (OD). Prospective, randomised, double-blind, placebo-controlled study. Proceedings of the American Thoracic Society 2005:A820.
47. Bellissimo-Rodrigues F, Bellissimo-Rodrigues WT, Viana JM, Teixeria GC, Nicolini E, Auxiliadora-Martins M, et al. Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infect Control Hosp Epidemiol 2009;30:952-8.
48. Berry AM, Davidson PM, Masters J, Rolls K, Ollerton R. Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: a randomised control trial. Int J Nursing Stud 2011;48:681-8.
49. Cabov T, Marcan D, Husedznovic I, Skrlin-Subic J, Bosnjak D, Sestan-Crnek S, et al. The impact of oral health and 0.2% chlorhexidine oral gel on the prevalence of nosocomial infections in surgical intensive care patients: a randomized placebo controlled study. Wien Klin Wochenschr 2010;122:397-404.
50. Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M, Chopin C. Effects of dental plaque antiseptic decontamination of bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med 2000;26:1239-47.
51. Fourrier F, Dubois D, Pronnier P, Herbecq P, Leroy O, Desmettre T, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med 2005;33:1728-35. (Pubitemid 41153697)
52. Koeman M, van der Ven AJ, Hak E, Joore HC, Kaasjager K, de Smet AM, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006;173:1348-55. (Pubitemid 43900709)
53. MacNaughton PD, Bailey J, Donlin N, Branfield P, Williams A, Rowswell H. A randomised controlled trial assessing the efficacy of oral chlorhexidine in ventilated patients. Intensive Care Med 2004;30:S12.
54. Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing and preventing ventilator associated pneumonia in critically ill adults. Am J Crit Care 2009;18:428-38.
55. Panchabhai TS, Dangayach NS, Krishnan A, Kothari VM, Karnad DR. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients. Chest 2009;135:1150-6.
56. Scannapieco FA, Yu J, Raghavendran K, Vacanti A, Owens SI, Wood K, Mylotte JM. A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Crit Care 2009;13:R117.
57. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomised controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hospital Epidemiol 2008;29:131-6. (Pubitemid 351269208)
58. Van Saene HK, Stoutenbeek CP, Stoller JK. Selective decontamination of the digestive tract in the intensive care unit: current status and future prospects. Crit Care Med 1992;20:691-703.
59. Verbrugh HA. Selective decontamination of digestive tract in intensive care. Lancet 2003;362:2117-8.
60. De Jonge E, Schultz M, Spanjaard L, Bossuyt P, Kesecioglu J. Selective decontamination of digestive tract in intensive care. Lancet 2003;362:2119-20.
61. Bonten MJ, Gaillard CA, Johanson WG, van Tiel FH, Smeets HG, van der Geest S, et al. Colonisation in patients receiving and not receiving topical antimicrobial prophylaxis. Am J Respir Crit Care Med 1994;150:1332-40. (Pubitemid 24356649)
62. Humphreys H, Winter R, Pick A. The effect of selective decontamination of the digestive tract on gastrointestinal enterococcal colonisation in ITU patients. Intensive Care Med 1992;18:459-63. (Pubitemid 23027444)
63. Tad-Y D, Soueidan A, Tehrani H, Visconti E, Bakoss I, El-Kass G, et al. Efficacy of chlorhexidine oral decontamination in the prevention of ventilator-associated pneumonia. Chest 2007;132:498a.
64. Bekaert M, Timsit J-F, Vansteelandt S, Depuydt P, Vesin A, Garrouste-Orgeas M, et al. Attributable mortality of ventilator-associated pneumonia. A reappraisal using causal analysis. Am J Respir Crit Care Med 2011;184:1133-9.
65. Oostdijk EA, Wittekamp BH, Brun-Buisson C, Bonten MJ. Selective decontamination in European intensive care patients. Intensive Care Med 2012;38:533-8.
66. Cuthbertson BH, Francis J, Campbell MK, MacIntyre L, Seppelt I, Grinshaw J. A study of the perceived risks, benefits and barriers to the use of SDD in adult critical care units (the SuDDICU study). Trials 2010;11:117.