Impact of selective digestive decontamination on respiratory tract Candida among patients with suspected ventilator-associated pneumonia. A meta-analysis

Abstract

The purpose here is to establish the incidence of respiratory tract colonization with Candida (RT Candida) among ICU patients receiving mechanical ventilation within studies in the literature. Also of interest is its relationship with candidemia and the relative importance of topical antibiotic (TA) use as within studies of selective digestive decontamination (SDD) versus other candidate risk factors towards it. The incidence of RT Candida was extracted from component (control and intervention) groups decanted from studies of various TA and non-TA ICU infection prevention methods with summary estimates derived using random effects. A benchmark RT Candida incidence to provide overarching calibration was derived using (observational) groups from studies without any prevention method under study. A multi-level regression model of group level data was undertaken using generalized estimating equation (GEE) methods. RT Candida data were sourced from 113 studies. The benchmark RT Candida incidence is 1.3; 0.9-1.8 % (mean and 95 % confidence intervals). Membership of a concurrent control group of a study of SDD (p = 0.02), the group-wide presence of candidemia risk factors (p < 0.001), and proportion of trauma admissions (p = 0.004), but neither the year of study publication, nor membership of any other component group, nor the mode of respiratory sampling are predictive of the RT Candida incidence. RT Candida and candidemia incidences are correlated. RT Candida incidence can serve as a basis for benchmarking. Several relationships have been identified. The increased incidence among concurrent control groups of SDD studies cannot be appreciated in any single study examined in isolation.

Unusually High Incidences of Staphylococcus aureus Infection within Studies of Ventilator Associated Pneumonia Prevention Using Topical Antibiotics: Benchmarking the Evidence Base

“…The disparity in the incidence of S. aureus VAP among studies of topical antibiotics versus the respective benchmarks recapitulates similar observations for various endpoints among studies of SDD versus externally derived benchmarks from populations of patients receiving prolonged mechanical ventilation. For example, with respect to Candida as a respiratory tract isolate [ 221 ], candidemia [ 222 ], and overall bacteremia [ 220 ] in each case, the incidence of these end points are higher among control groups of studies of SDD versus the respective literature derived benchmarks.…”

“…Firstly, there is a concern that decontamination regimens might alter the ICU microbiome and the infection risk for those patients concurrent in the ICU not receiving the intervention [ 219 , 220 , 221 , 222 ]. Where any contextual risk leads to decreases or increases in infections rates it is termed “herd protection” and “herd peril”, respectively [ 223 ].…”

Incidences of Pseudomonas aeruginosa-Associated Ventilator-Associated Pneumonia within Studies of Respiratory Tract Applications of Polymyxin: Testing the Stoutenbeek Concurrency Postulates

“…The disparity in the incidence of PsVAP among studies of topical polymyxin versus the respective benchmarks recapitulates similar observations for various endpoints among studies of SOD/SDD versus externally derived benchmarks from populations of MV patients. For example, with respect to Staphylococcus aureus as a VAP isolate (27), Staphylococcus aureus bacteremia (36), Candida as a respiratory tract isolate (37), and candidemia incidence (35), in each case, the endpoint is higher among control groups of SOD/SDD studies than the respective benchmarks.…”

“…The analytic approach is as undertaken previously (27,28,36,37,45,46). Two methods of metaregression were used.…”

Yeast Infections after Esophagectomy: A Retrospective Analysis

“…Lastly, SDD therapy is mainly applied in the Netherlands, because it is supported by several prospective, multi-center randomized controlled trials 10,12 . However, there has been no prospective investigation on whether antifungal prophylaxis, especially pre-operatively, should be used in esophagectomy patients.…”