Selective digestive decontamination-Con

Hurley, James C.

doi:10.1007/s00134-023-07146-0

Cited by 8 publications

(3 citation statements)

References 6 publications

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“…The high S. aureus VAP and S. aureus BSI incidences within the concurrent control groups of antibiotic-BDI studies noted here as a spill-over effect, which is as previously noted for several end points [8,[17][18][19]23,43,45,46], would conflate the apparent prevention effect.…”

Section: Discussionsupporting

confidence: 81%

“…Reducing both patient and ICU colonization, through decontamination interventions, would seem logical to prevent S. aureus infections, whether occurring as pneumonia or blood stream infections (BSIs), and multiple potential candidate agents have been tested in various singleton and combination regimens [5,6]. However, the results of numerous studies of decontamination interventions conducted in ICU populations are unclear at four levels [7,8].…”

Section: Introductionmentioning

confidence: 99%

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Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay

Hurley

2024

Antibiotics

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Could rebound explain the paradoxical lack of prevention effect against Staphylococcus aureus blood stream infections (BSIs) with antibiotic-based decontamination intervention (BDI) methods among studies of ICU patients within the literature? Two meta-regression models were applied, each versus the group mean length of stay (LOS). Firstly, the prevention effects against S. aureus BSI [and S. aureus VAP] among 136 studies of antibiotic-BDI versus other interventions were analyzed. Secondly, the S. aureus BSI [and S. aureus VAP] incidence in 268 control and intervention cohorts from studies of antibiotic-BDI versus that among 165 observational cohorts as a benchmark was modelled. In model one, the meta-regression line versus group mean LOS crossed the null, with the antibiotic-BDI prevention effect against S. aureus BSI at mean LOS day 7 (OR 0.45; 0.30 to 0.68) inverted at mean LOS day 20 (OR 1.7; 1.1 to 2.6). In model two, the meta-regression line versus group mean LOS crossed the benchmark line, and the predicted S. aureus BSI incidence for antibiotic-BDI groups was 0.47; 0.09–0.84 percentage points below versus 3.0; 0.12–5.9 above the benchmark in studies with 7 versus 20 days mean LOS, respectively. Rebound within the intervention groups attenuated and inverted the prevention effect of antibiotic-BDI against S. aureus VAP and BSI, respectively. This explains the paradoxical findings.

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Section: Discussionsupporting

confidence: 81%

Section: Introductionmentioning

confidence: 99%

Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay

Hurley

2024

Antibiotics

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“…The summary difference in bacteraemia incidence between studies with an RCCT versus a CRT design are similarly discrepant. 46 Moreover, an analysis of the secular trend in underlying risk of ICU patients in 210 studies published over three decades, of which only 90 appear in the analysis here, fails to account for the high ICU mortality among the control groups of TAP-RCCTs. 47 The rationale and design for a postulated CRT (The SHEET trial) to demonstrate the population safety of TAP has been published.…”

Section: Open Accessmentioning

confidence: 89%

Indirect (herd) effects of topical antibiotic prophylaxis and oral care versus non-antimicrobial methods increase mortality among ICU patients: realigning Cochrane review data to emulate a three-tier cluster randomised trial

Hurley

2023

BMJ Open

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ObjectiveThis study aimed to estimate the direct effects to recipients and indirect (herd) effects to non-recipients of each of topical antibiotic prophylaxis (TAP) and oral care methods on patient mortality within randomised concurrent controlled trials (RCCT) using Cochrane review data.DesignControl and intervention groups from 209 RCCTs of TAP (tier 3), oral care (tier 2) each versus non-antimicrobial (tier 1) ventilator-associated pneumonia (VAP) prevention interventions arranged to emulate a three-tiered cluster randomised trial (CRT). Eligible RCCTs were those including ICU patients with >50% of patients receiving >24 hours of mechanical ventilation (MV) with mortality data available as abstracted in 13 Cochrane reviews.ExposuresDirect and indirect exposures to either TAP or oral care within RCCTs versus non-antimicrobial VAP prevention interventions.Main outcomes and measuresThe ICU mortality within control and intervention groups, respectively, within RCCTs of either TAP or oral care versus that within non-antimicrobial VAP prevention RCCTs serving as benchmark.ResultsThe ICU mortality was 23.9%, 23.0% and 20.3% for intervention groups and 28.7%, 25.5% and 19.5% for control groups of RCCTs of TAP (tier 1), oral care (tier 2) and non-antimicrobial (tier 3) methods of VAP prevention, respectively. In a random effects meta-regression including late mortality data and adjusting for group mean age, year of study publication and MV proportion, the direct effect of TAP and oral care versus non-antimicrobial methods were 1.04 (95% CI 0.78 to 1.30) and 1.1 (95% CI 0.77 to 1.43) whereas the indirect effects were 1.39 (95% CI 1.03 to 1.74) and 1.26 (95% CI 0.89 to 1.62), respectively.ConclusionsIndirect (herd) effects from TAP and oral care methods on mortality are stronger than the direct effects as made apparent by the three-tiered CRT. These indirect effects, being harmful to concurrent control groups by increasing mortality, perversely inflate the appearance of benefit within RCCTs.

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Selective digestive decontamination: We must make an international decision on this 40-year old controversy

Carlet

2023

Intensive Care Med

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Selective digestive decontamination-Con

Cited by 8 publications

References 6 publications

Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay

Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay

Indirect (herd) effects of topical antibiotic prophylaxis and oral care versus non-antimicrobial methods increase mortality among ICU patients: realigning Cochrane review data to emulate a three-tier cluster randomised trial

Selective digestive decontamination: We must make an international decision on this 40-year old controversy

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