Profilaksis antibiotik untuk mengurangkan jangkitan saluran pernafasan dan kematian di kalangan orang dewasa yang menerima rawatan intensif
Abstract
Background
Pneumonia is an important cause of mortality in intensive care units (ICUs). The incidence of pneumonia in ICU patients ranges between 7% and 40%, and the crude mortality from ventilator‐associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to pneumonia, it has been shown to contribute to mortality in ICUs independently of other factors that are also strongly associated with such deaths.
Objectives
To assess the effects of prophylactic antibiotic regimens, such as selective decontamination of the digestive tract (SDD) for the prevention of respiratory tract infections (RTIs) and overall mortality in adults receiving intensive care.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register; MEDLINE (January 1966 to March 2009); and EMBASE (January 1990 to March 2009).
Selection criteria
Randomised controlled trials (RCTs) of antibiotic prophylaxis for RTIs and deaths among adult ICU patients.
Data collection and analysis
At least two review authors independently extracted data and assessed trial quality.
Main results
We included 36 trials involving 6914 people. There was variation in the antibiotics used, patient characteristics and risk of RTIs and mortality in the control groups. In trials comparing a combination of topical and systemic antibiotics, there was a significant reduction in both RTIs (number of studies = 16, odds ratio (OR) 0.28, 95% confidence interval (CI) 0.20 to 0.38) and total mortality (number of studies = 17, OR 0.75, 95% CI 0.65 to 0.87) in the treated group. In trials comparing topical antimicrobials alone (or comparing topical plus systemic versus systemic alone) there was a significant reduction in RTIs (number of studies = 17, OR 0.44, 95% CI 0.31 to 0.63) but not in total mortality (number of studies = 19, OR 0.97, 95% CI 0.82 to 1.16) in the treated group.
Authors' conclusions
A combination of topical and systemic prophylactic antibiotics reduces RTIs and overall mortality in adult patients receiving intensive care. Treatment based on the use of topical prophylaxis alone reduces respiratory infections but not mortality. The risk of resistance occurring as a negative consequence of antibiotic use was appropriately explored only in one trial which did not show any such effect.
PICO
Plain language summary
Antibiotik untuk mengurangkan kematian dan jangkitan saluran pernafasan di kalangan orang yang menerima rawatan intensif di hospital
Jangkitan yang diperolehi di unit rawatan intensif (ICUs) adalah komplikasi penting dalam rawatan pesakit dengan penyakit yang sangat teruk yang memerlukan ventilasi (sokongan pernafasan mekanikal). Sesetengah orang akan mati kerana jangkitan ini. Banyak usaha telah dilakukan untuk menilai kaedah‐kaedah untuk menangani masalah ini; salah satunya melibatkan penggunaan antibiotik yang diberikan sebagai pencegahan, biasanya dipanggil sebagai dekontaminasi selektif saluran pencernaan (SDD). Ulasan ini merangkumi 36 kajian yang melibatkan 6914 pesakit yang dirawat di ICU untuk menyiasat sama ada pemberian antibiotik akan menghalang perkembangan jangkitan. Antibiotik diberikan melalui dua cara yang berbeza. Dalam beberapa kajian, antibiotik digunakan secara langsung ke orofarynx melalui tiub nasogastrik (topikal) dan intravena (sistemik). Dalam kajian lain, antibiotik hanya digunakan secara topikal. Keputusan kajian kami menunjukkan bahawa terdapat pengurangan jangkitan dan kematian apabila pesakit menerima kombinasi antibiotik topikal dan sistemik. Apabila pesakit menerima rawatan topikal sahaja, kadar jangkitan berkurang tetapi jumlah kematian tidak berubah. Walaupun rawatan ini dinampak berkesan, tetapi ia tidak dilaksanakn secara meluas kerana terdapat kebimbangan mengenai kemungkinan perkembangan rintangan antibiotik (iaitu, antibiotik tidak berkesan terhadap bakteria).
