Peter Dodek, MD, MHSc; Sean Keenan, MD, MSc(Epid); Deborah Cook, MD, MSc(Epid); Daren Heyland, MD, MSc(Epid); Michael Jacka, MD, MSc; Lori Hand, RRT; John Muscedere, MD; Debra Foster, RN; Nav Mehta, MD; Richard Hall, MD; Christian Brun-Buisson, MD; Canadian Critical Care Trials Group and the Canadian Critical Care Society
Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, et al. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med. 2004;141:305-313. doi: 10.7326/0003-4819-141-4-200408170-00011
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Published: Ann Intern Med. 2004;141(4):305-313.
Ventilator-associated pneumonia (VAP) is an important patient safety issue in critically ill patients.
To develop an evidence-based guideline for the prevention of VAP.
MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews.
The authors systematically searched for relevant randomized, controlled trials and systematic reviews that involved mechanically ventilated adults and were published before 1 April 2003.
Physical, positional, and pharmacologic interventions that may influence the development of VAP were considered. Independently and in duplicate, the authors scored the validity of trials; the effect size and confidence intervals; the homogeneity of results; and safety, feasibility, and economic issues.
Recommended: The orotracheal route of intubation, changes of ventilator circuits only for each new patient and if the circuits are soiled, use of closed endotracheal suction systems that are changed for each new patient and as clinically indicated, heat and moisture exchangers in the absence of contraindications, weekly changes of heat and moisture exchangers, and semi-recumbent positioning in the absence of contraindications. Consider subglottic secretion drainage and kinetic beds. Not recommended: Sucralfate to prevent VAP in patients at high risk for gastrointestinal bleeding and topical antibiotics to prevent VAP. Because of insufficient or conflicting evidence, no recommendations were made about systematically searching for maxillary sinusitis, chest physiotherapy, the timing of tracheostomy, prone positioning, prophylactic intravenous antibiotics, or intravenous plus topical antibiotics.
No formal economic analysis was performed, and patient perspectives were not considered.
If effectively implemented, this guideline may decrease the morbidity, mortality, and costs of VAP in mechanically ventilated patients.
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James R. Johnson
VA Medical Center, Minneapolis, MN
September 26, 2004
Gut decontamination to prevent VAP
To the editor,
In their guidelines for prevention of ventilator-associated pneumonia, Dodek et al. make no recommendation regarding selective digestive tract decontamination (SDD), despite the solid evidence of its efficacy, because of persisting uncertainty regarding costs and the possible risk of selecting for resistant organisms (1). Their assessment was based on a review of studies published through April 2003. However, in September 2003, de Jonge et al. reported a large trial of SDD that showed significant reductions not only in infections (including ventilator- associated pneumonia) but also in mortality and, most strikingly, the prevalence of antimicrobial-resistant bacteria (2). It would be interesting to know the guidelines panel's opinion regarding whether this added evidence is sufficient to support a recommendation for SDD as a desirable intervention, even if only for selected patients, as others have argued (3), or if further study, especially in a setting with a higher background prevalence of methicillin-resistant staphylococci and/or vancomycin-resistant enterococci, is still needed.
1. Dodek P, Keenan S, Cook D, et al.; Canadian Critical Care Trials Group; Canadian Critical Care Society. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004 ;141:305-13.
2. de Jonge E, Schultz MJ, Spanjaard L, 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.
3. Aarts MA, Marshall JC. In defense of evidence: the continuing saga of selective decontamination of the digestive tract. Am J Respir Crit Care Med. 2002;166:1014-5.
Hendrik K van Saene
University of Liverpool
December 6, 2004
THE EMPEROR'S NEW CLOTHES
TO THE EDITOR: Dodek and colleagues' evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia1 illustrates that the original Canadian promoters of examination of evidence from clinical research do not escape the fate of becoming experts after little more than a decade of evidence-based medicine [EBM]2. Selective decontamination of the digestive tract [SDD] "“ albeit the only ICU intervention with a grade A recommendation from the Agency for Health Research and Quality of the US Department for Health and Human Services3 "“ was not granted a recommendation by a panel of experts selected by the Canadian Critical Care Trials group and the Canadian Critical Care Society due to their low scoring for safety and costs of SDD.
Remarkably, the panel of 11 experts, decided to review only systematic reviews of randomised controlled trials [RCTs] of SDD, whereas they reviewed RCTs for the other interventions. However, of the meta- analyses three4-6 incorporate non-RCTs, three conducted by the Cochrane7-9 were updates of the same meta-analysis of only RCTs, and one was a translation of the first update of Cochrane systematic review from English into Swedish10. Therefore, the panel only assessed four instead of 10 meta -analyses. We would like to clarify our disagreement with the panel's conclusion using the latest Cochrane Library meta-analysis, as its authors applied a well recognised methodology9.
Firstly, a poor score of 1 for the safety of SDD implies that the existent data supports a potential link between antimicrobial resistance and SDD. An analysis of resistance requires the distinction of the number of patients with infections due to resistant aerobic Gram-negative bacilli [AGNB] from patients with infections due to methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]. Additionally, low level evidence studies including before-after studies are distinguished from RCTs and long-term resistance studies providing high level of evidence. Again, the meta-analyses evaluated by the panel do not provide data for a link between SDD and antimicrobial resistance. The Cochrane Library meta-analysis "“ the only one that includes the first ever RCT on antimicrobial resistance11 "“ reports that SDD does not lead to resistance amongst AGNB but, even better, the addition of enteral polymyxin/tobramycin to the parenteral antimicrobials reduces resistance compared with the parenteral antibiotics only. This is in line with a previous RCT demonstrating that enteral antimicrobials control extended spectrum beta-lactamase producing Klebsiella12. SDD implemented in two American ICUs with endemic VRE did not lead to an increased number of VRE infections13,14. SDD is not designed to control MRSA. There are seven RCTs conducted in ICUs where MRSA was endemic at the time of the trial, so they report a trend towards higher MRSA infection rates in patients receiving SDD15-21. The addition of enteral vancomycin to SDD is required to control MRSA in ICUs with endemic MRSA22,23. VRE did not emerge in any of the RCTs using enteral vancomycin22-29. Antimicrobial resistance, being a long term issue, has been evaluated in eight SDD studies monitoring antimicrobial resistance between two and seven years, and bacterial resistance associated with SDD has not been a clinical problem30-37.
Secondly, SDD was also given the lower score of 1 for the outcome measure of costs, implying a higher cost to implement SDD on ICU. This is despite the statement "˜Cost-effectiveness of SDD is of unknown magnitude' in the text1. This panel's opinion contrasts the conclusion of the recent report of the Agency for Health Research and Quality of the US Department for Health and Human Services that SDD is cheap and easy to implement3. Fair enough, the cost-effectiveness of SDD is not yet properly assessed, but, costs can hardly be a major concern for a manoeuvre of $6 a day that reduces pneumonia by 65% and mortality by 22% without antimicrobial resistance emerging in unselected ICU patients. This is even more surprising when physiotherapy with its attendant staff costs is considered a low cost strategy.
The conclusion of the Canadian panel that no recommendation could be made about SDD for the prevention of pneumonia during ventilation is not based on evidence from RCTs but on the opinion of the panel, i.e., the lowest level of evidence. Finally, can we remind the panel members and their followers that on average for every five patients who do not receive SDD one extra patient develops a pneumonia and that there is one extra death every 21 patients in units who do not administer SDD. EBM-guidelines should be developed by a critical analysis of the available scientific data with clearly described methodology. The Canadian guidelines do not meet these requirements. Despite the claims of a rigorous evidence base, the members of the panel are not dressed in the robes of EBM but as in the fairy tale "˜The Emperor's New Clothes, they are bare38.
Miguel Angel de la Cal Dept Critical Care Medicine, Getafe Hospital, Madrid, Spain
Luciano Silvestri Dept Anaesthesia and Critical Care, Gorizia Hospital, Italy
Paul Baines Paediatric Intensive Care Unit, Royal Liverpool Children's Hospital, UK
Hendrik van Saene Dept Medical Microbiology, University of Liverpool, UK
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