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

Richard Price, Graeme MacLennan, John Glen, SuDDICU Collaboration, Richard Price, Graeme MacLennan, John Glen, SuDDICU Collaboration

Abstract

Objectives: To determine the effect on mortality of selective digestive decontamination, selective oropharyngeal decontamination, and topical oropharyngeal chlorhexidine in adult patients in general intensive care units and to compare these interventions with each other in a network meta-analysis.

Design: Systematic review, conventional meta-analysis, and network meta-analysis. Medline, Embase, and CENTRAL were searched to December 2012. Previous meta-analyses, conference abstracts, and key journals were also searched. We used pairwise meta-analyses to estimate direct evidence from intervention-control trials and a network meta-analysis within a Bayesian framework to combine direct and indirect evidence.

Inclusion criteria: Prospective randomised controlled trials that recruited adult patients in general intensive care units and studied selective digestive decontamination, selective oropharyngeal decontamination, or oropharyngeal chlorhexidine compared with standard care or placebo.

Results: Selective digestive decontamination had a favourable effect on mortality, with a direct evidence odds ratio of 0.73 (95% confidence interval 0.64 to 0.84). The direct evidence odds ratio for selective oropharyngeal decontamination was 0.85 (0.74 to 0.97). Chlorhexidine was associated with increased mortality (odds ratio 1.25, 1.05 to 1.50). When each intervention was compared with the other, both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine. The difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain.

Conclusion: Selective digestive decontamination has a favourable effect on mortality in adult patients in general intensive care units. In these patients, the effect of selective oropharyngeal decontamination is less certain. Both selective digestive decontamination and selective oropharyngeal decontamination are superior to chlorhexidine, and there is a possibility that chlorhexidine is associated with increased mortality.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4793672/bin/prir014059.f1_default.jpg
Fig 1 Inclusion of studies in analysis of effect of selective digestive decontamination (SDD), selective oropharyngeal decontamination (SOD), and topical oropharyngeal chlorhexidine for prevention of death in adults in intensive care
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4793672/bin/prir014059.f2_default.jpg
Fig 2 Forest plot of intervention-control pairwise meta-analysis of selective digestive decontamination v control in adult patients in intensive care
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4793672/bin/prir014059.f3_default.jpg
Fig 3 Forest plot of intervention-control pairwise meta-analysis of selective oropharyngeal decontamination v control in adult patients in intensive care
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4793672/bin/prir014059.f4_default.jpg
Fig 4 Forest plot of intervention-control pairwise meta-analysis of chlorhexidine v control in adult patients in intensive care

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