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      Selective oropharyngeal decontamination versus selective digestive decontamination in critically ill patients: a meta-analysis of randomized controlled trials

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          Abstract

          Background

          Selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) are associated with reduced mortality and infection rates among patients in intensive care units (ICUs); however, whether SOD has a superior effect than SDD remains uncertain. Hence, we conducted a meta-analysis of randomized controlled trials (RCTs) to compare SOD with SDD in terms of clinical outcomes and antimicrobial resistance rates in patients who were critically ill.

          Methods

          RCTs published in PubMed, Embase, and Web of Science were systematically reviewed to compare the effects of SOD and SDD in patients who were critically ill. Outcomes included day-28 mortality, length of ICU stay, length of hospital stay, duration of mechanical ventilation, ICU-acquired bacteremia, and prevalence of antibiotic-resistant Gram-negative bacteria. Results were expressed as risk ratio (RR) with 95% confidence intervals (CIs), and weighted mean differences (WMDs) with 95% CIs. Pooled estimates were performed using a fixed-effects model or random-effects model, depending on the heterogeneity among studies.

          Results

          A total of four RCTs involving 23,822 patients met the inclusion criteria and were included in this meta-analysis. Among patients whose admitting specialty was surgery, cardiothoracic surgery (57.3%) and neurosurgery (29.7%) were the two main types of surgery being performed. Pooled results showed that SOD had similar effects as SDD in day-28 mortality (RR =1.03; 95% CI: 0.98, 1.08; P=0.253), length of ICU stay (WMD =0.00 days; 95% CI: −0.2, 0.2; P=1.00), length of hospital stay (WMD =0.00 days; 95% CI: −0.65, 0.65; P=1.00), and duration of mechanical ventilation (WMD =1.01 days; 95% CI: −0.01, 2.02; P=0.053). On the other hand, compared with SOD, SDD had a lower day-28 mortality in surgical patients (RR =1.11; 95% CI: 1.00, 1.22; P=0.050), lower incidence of ICU-acquired bacteremia (RR =1.38; 95% CI: 1.24, 1.54; P=0.000), and lower rectal carriage of aminoglycosides (RR =2.08; 95% CI: 1.68, 2.58; P=0.000), ciprofloxacin-resistant Gram-negative bacteria (RR =1.84; 95% CI: 1.48, 2.29; P=0.000), and respiratory carriage of third-generation cephalosporin-resistant Gram-negative bacteria (RR =2.50; 95% CI: 1.78, 3.5; P=0.000).

          Conclusion

          SOD has similar effects as SDD in clinical outcomes, but has higher incidence of ICU-acquired bacteremia, and higher carriage of antibiotic-resistant Gram-negative bacteria. However, due to the high cost of SDD and the increased risk of development of antibiotic resistance with the widespread use of cephalosporins in SDD, we would recommend SOD as prophylactic antibiotic regimens in patients in the ICU. More well-designed, large-scale RCTs are needed to confirm our findings.

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          Most cited references 19

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          Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship.

          Organisms resistant to antimicrobials continue to emerge and spread. This study was performed to measure the medical and societal cost attributable to antimicrobial-resistant infection (ARI). A sample of high-risk hospitalized adult patients was selected. Measurements included ARI, total cost, duration of stay, comorbidities, acute pathophysiology, Acute Physiology and Chronic Health Evaluation III score, intensive care unit stay, surgery, health care-acquired infection, and mortality. Hospital services used and outcomes were abstracted from electronic and written medical records. Medical costs were measured from the hospital perspective. A sensitivity analysis including 3 study designs was conducted. Regression was used to adjust for potential confounding in the random sample and in the sample expanded with additional patients with ARI. Propensity scores were used to select matched control subjects for each patient with ARI for a comparison of mean cost for patients with and without ARI. In a sample of 1391 patients, 188 (13.5%) had ARI. The medical costs attributable to ARI ranged from $18,588 to $29,069 per patient in the sensitivity analysis. Excess duration of hospital stay was 6.4-12.7 days, and attributable mortality was 6.5%. The societal costs were $10.7-$15.0 million. Using the lowest estimates from the sensitivity analysis resulted in a total cost of $13.35 million in 2008 dollars in this patient cohort. The attributable medical and societal costs of ARI are considerable. Data from this analysis could form the basis for a more comprehensive evaluation of the cost of resistance and the potential economic benefits of prevention programs.
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            Nosocomial infections in adult intensive-care units.

            Nosocomial infections affect about 30% of patients in intensive-care units and are associated with substantial morbidity and mortality. Several risk factors have been identified, including the use of catheters and other invasive equipment, and certain groups of patients-eg, those with trauma or burns-are recognised as being more susceptible to nosocomial infection than others. Awareness of these factors and adherence to simple preventive measures, such as adequate hand hygiene, can limit the burden of disease. Management of nosocomial infection relies on adequate and appropriate antibiotic therapy, which should be selected after discussion with infectious-disease specialists and adapted as microbiological data become available.
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              Colonization resistance of the digestive tract in conventional and antibiotic-treated mice.

              The effect of oral administration of antibiotics on the intestinal flora of conventional mice and their resistance to colonization by orally introduced Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa was studied. Colonization resistance (CR) was expressed as the log of the oral bacterial dose followed by a persistent take in 50% of the contaminated animals. The intestinal flora was virtually eliminated by the antibiotics and this elimination was accompanied by a precipitous fall of CR. CR gradually returned to normal values during the period of repopulation of the intestinal tract by the organisms surviving the treatment. Antibiotic treatment resulted in the disappearance of Enterobacteriaceae, enterococci, staphylococci and yeasts and, under appropriate housing conditions, the animals remained free of these organisms indefinitely. Germ-free mice contaminated with the intestinal flora of an antibiotic-treated animal and their offspring housed in a germ-free isolator showed high values of CR. Their intestinal flora consisted of anaerobic bacteria only. Apparently, these anaerobes are responsible for CR in these and in conventional mice.
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                Author and article information

                Journal
                Drug Des Devel Ther
                Drug Des Devel Ther
                Drug Design, Development and Therapy
                Drug Design, Development and Therapy
                Dove Medical Press
                1177-8881
                2015
                14 July 2015
                : 9
                : 3617-3624
                Affiliations
                [1 ]Department of Neurosurgery, The First Hospital of Hebei Medical University, Shijiazhuang People’s Republic of China
                [2 ]Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang People’s Republic of China
                [3 ]Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang People’s Republic of China
                [4 ]Hebei Provincial Procurement Centers for Medical Drugs and Devices, The Second Hospital of Hebei Medical University, Shijiazhuang People’s Republic of China
                [5 ]Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang People’s Republic of China
                Author notes
                Correspondence: Di Zhao, Department of Neurosurgery, The First Hospital of Hebei Medical University, 89 Donggang road, Shijiazhuang, People’s Republic of China, Tel +86 133 6383 3833, Email 179381749@ 123456qq.com
                [*]

                These authors contributed equally to this work

                Article
                dddt-9-3617
                10.2147/DDDT.S84587
                4507487
                © 2015 Zhao et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

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