Background
Methods
Eligibility criteria
Search strategy
Study selection
Data extraction
Grading the quality of evidence
Statistical analysis
Trial sequential analysis
Results
Trial selection
Trials characteristics
Study | Population (n) | Settings | Definition of VAP | Inclusion criteria | Exclusion criteria | Method of SSS | Antibiotic use | Evaluation unit of antibiotic consumption |
---|---|---|---|---|---|---|---|---|
Mahul, 1992 [30] | 145 | Medical-surgical ICU | Positive bronchoalveolar lavage culture required | Expected duration of MV >3 days | Gastrointestinal bleeding, tracheostomy, risk of reintubation, intubated before ICU | Intermittent | Antibiotic use at randomization not reported | NA |
Valles, 1995 [31] | 153 | Medical-surgical ICU | Clinical features confirmed with bronchoscopically obtained cultures | Expected duration of MV >3 days | Intubated before arriving at the emergency department or ICU; tracheostomy | Continuous | Patients receiving antibiotics at time of randomization: 64 % and 58 %, intervention and control group respectively | NA |
Kollef, 1999 [32] | 343 | Cardiothoracic ICU | Clinical features, positive tracheal, blood, or pleural cultures; radiographic abscess, or positive histology | Need for MV after cardiac surgery | Intubated before ICU; transfer from outside hospital | Continuous | Antibiotics were given to 99 % and 98 % of intervention and control patients, respectively | NA |
Bo, 2000 [33] | 68 | Surgical ICU | Clinical features or positive blood/pleural cultures | Expected duration of MV >72 h | Intubated outside hospital; high-risk surgery or trauma; pre-existing infection | Continuous | Antibiotics were used in 29 % of intervention group and 36 % of control group | NA |
Smulders, 2002 [34] | 150 | Medical-surgical ICU | Clinical features or positive blood/pleural cultures | Expected duration of MV >72 h | Patients expected to require >72 h MV | Intermittent | 48 % of intervention group and 51 % of control group were receiving antibiotics | NA |
Girou, 2004 [35] | 18 | NA | Clinical features and significant quantitative culture of aspiration | Expected duration of MV >5 days | NA | Continuous | Prior antibiotic therapy: 1 patient in suctioning group and 4 patients in control group | NA |
Liu SH, 2006 [37] | 98 | Respiratory ICU | MV >48 h, the chest X-ray showed pulmonary new or progressive infiltration lesions, and excluding atelectasis, pulmonary edema, and pleural effusion | Age older than 60 years, expected MV >48 h | NA | Intermittent | NA | NA |
Liu QH, 2006 [36] | 86 | NA | Received MV for >48 h, clinical features and culture of endotracheal aspirate; reduction of oxygen | Age older than 60 years, expected MV >48 h | 1) expected death within 48 h; 2) expected weaning within 48 h; 3) existing lung infection when MV beginning | Continuous | NA | NA |
Lorente, 2007 [38] | 280 | NA | Clinical features and significant quantitative culture via ETT aspiration | Expected MV >24 h | Age less than 18 years, pregnancy, infection with human immunodeficiency virus, blood leukocyte count less than 1000 cells/mm3, solid or hematological tumor, and/or immunosuppressive therapy | Continuous | 83.6 % of ETT-PUC-SSD group and 85 % of ETT-C group were receiving antibiotics after cardiothoracic surgery | NA |
Bouza, 2008 [39] | 704 | Cardiothoracic ICU | Received MV for >48 h, clinical features and culture of endotracheal aspirate; reduction of oxygen | Major heart surgery | NA | Continuous | Both group respectively received antibiotics before surgery and every 8 h thereafter for a total of three doses in the ICU | Daily defined doses |
Yang, 2008 [40] | 91 | Medical-surgical ICU | Clinical features and culture of endotracheal aspirate | MV >48 h | Intubated before ICU | Continuous | NA | NA |
Zheng, 2008 [41] | 61 | Medical-surgical ICU | NA | MV >48 h | NA | Continuous | NA | NA |
Lacherade, 2010 [42] | 333 | Multicenter, medical-surgical ICU | Quantitative culture of protected telescoping catheter sample or bronchoalveolar lavage fluid following clinical suspicion | Expected MV >48 h | Intubated before ICU; tracheostomy; psychotropic drug overdose; acute drunkenness; cardiac arrest | Intermittent | Antibiotics therapy was used in 94 % and 92 % of intervention and control groups respectively | NA |
Seyfi, 2013 [43] | 80 | ICU of Hazrat Rasool Akram Hospital of Tehran, Iran. | NA | NA | NA | Intermittent | NA | NA |
Safdari, 2014 [23] | 76 | In four ICUs of Educational Hospital in Isfahan, Iran | NA | Intubated with a conventional endotracheal tube and connected to ventilators for more than 48 h | Patients who were admitted to the ICUs with tracheostomy or likely to die in the next 48 h or admitted to these units for treatment of pneumonia or with lung complications like fibrosis or cancer | Intermittent performed every 3 h | NA | NA |
Koker, 2014 [24] | 51 | In a 14-bed ICU | NA | Requiring prolonged MV for more than 48 h | NA | Continuous | NA | NA |
Tao, 2014 [22] | 149 | NA | Received MV for >48 h, clinical features and culture of endotracheal aspirate; reduction of oxygen | Expected MV >48 h with APACHE score 20–30 | Existing lung infection when MV beginning | Continuous or intermittent every 4 h | NA | NA |
Damas, 2015 [17] | 352 | All ICUs of a tertiary hospital | Clinical features and culture of endotracheal aspirate | Age over 18 years, intubation with a Teleflex Isis™ endotracheal tube (TIET) allowing subglottic secretion suctioning | Patient participating in another study or having already participated in this study | NA | NA | The numberof antibiotic days |
Gopal, 2015 [21] | 240 | Cardiothoracic surgery | Europe Infection Control through Surveillance definition | Age over 70 years and/or left ventricular ejection fraction <50 % and cardiac surgery | NA | Intermittent every 6 h | NA | NA |
Deem, 2016 [20] | 66 | All ICUs at Harborview Medical Center | Criteria of Center for Disease Control | Age over 18 years with intubation and needed critical care | 1) Out-of-hospital cardiac arrest; 2) non-study designated intubation devices; 3) airway management other than orotracheal intubation; 4) Federally protected populations, pregnant women, and prisoners | Continuous | NA | NA |
Risk of bias assessment
Primary outcome: incidence of VAP
Categaries | Outcomes | Number of studies | Risk ratio or mean difference (95 % CI) |
P
|
P for heterogeneity | I2 (%) | Quality |
---|---|---|---|---|---|---|---|
Primary outcome Sensitivity analysis | VAP high-quality trials | 0.54 (0.40, 0.74) | <0.00001 | 0.39 | 0 | Moderatec
| |
VAP total trials | 0.55 (0.48, 0.63) | <0.00001 | 0.85 | 0 | Higha
| ||
VAP invasive diagnosis | 0.55 (0.47, 0.65) | <0.00001 | 0.60 | 0 | Higha
| ||
VAP excluding trials with multiple manipulations | 0.55 (0.48, 0.65) | <0.00001 | 0.97 | 0 | Higha
| ||
VAP randomization | 0.56 (0.47, 0.66) | <0.00001 | 0.37 | 7 | Higha
| ||
VAP allocation concealment | 0.56 (0.42, 0.74) | <0.00001 | 0.53 | 0 | Moderatec
| ||
VAP assessment blinded | 0.53(0.42, 0.66) | <0.00001 | 0.34 | 11 | Moderatec
| ||
VAP participants more than 100 | 0.54(0.45, 0.65) | <0.00001 | 0.55 | 0 | Higha
| ||
VAP intermittent SSS | 0.52 (0.43, 0.64) | <0.00001 | 0.25 | 22 | Higha
| ||
VAP continuous SSS | 0.61(0.5, 0.73) | <0.00001 | 0.91 | 0 | Higha
| ||
Secondary outcomes | Early-onset VAP | 0.34 (0.25, 0.47) | <0.00001 | 0.84 | 0 | Moderatec
| |
Late-onset VAP | 0.80 (0.62, 1.02) | 0.07 | 0.17 | 35 | Moderatec
| ||
Gram-negative bacteria | 0.58(0.43, 0.77) | 0.0002 | 0.69 | 0 | Moderatec
| ||
Gram-positive bacteria | 0.32 (0.17, 0.61) | 0.006 | 0.61 | 0 | Lowb
| ||
ICU mortality | 0.98(0.85, 1.13) | 0.77 | 0.88 | 0 | High | ||
Hospital mortality | 0.92 (0.80, 1.05) | 0.20 | 0.82 | 0 | High | ||
Time-to-onset of VAPg
| 3.92 (2.56, 5.27) | <0.00001 | <0.00001 | 92 | Moderated
| ||
Duration of MVg
| −1.17 (–2.28, –0.06) | 0.006 | 0.06 | 54 | Moderated
| ||
ICU length of stayg
| −1.64 (–3.95, 0.66) | 0.16 | 0.001 | 81 | Moderated
| ||
Hospital length of stay | −1.44 (–3.93, 1.04) | 0.25 | 0.99 | 0 | High | ||
Reintubation | 0.77 (0.45, 1.32) | 0.34 | 0.19 | 38 | Lowb
| ||
Tracheotomyg
| 1.14 (0.75, 1.72) | 0.55 | 0.79 | 54 | Lowb
|