Selective digestive decontamination, a seemingly effective regimen with individual benefit or a flawed concept with population harm?

Table 1 Summary of findings from Cochrane reviews of VAP prevention interventions ^a

Intervention	Ref	VAP incidence (per 1000 patients)				Mortality incidence (per 1000 patients)
Intervention	Ref	Control	Intervention	RR; (95% CI)	n/N	Control	Intervention	RR; (95% CI)	n/N
Semi-recumbent ^b	[20]	316	139	0·44; 0·11–1·77	3/419	276	240	0·87; 0·59–1·27	2/307
HME ^c	[21]	167	155	0·93; 0·73–1·19	13/2251	247	257	1·03; 0·89–1·2	12/1951
Probiotic ^d	[22]	309	238	0·7; 0·52–0·95	8/1018	214	186	0·84; 0·58–1·22	5/703
Chlorhexidine ^e	[23]	243	180	0·75; 0·62–0·91	18/2451	222	242	1·09; 0·96–1·23	14/2014
Tooth brushing ^f	[23]	253	206	0·69; 0·44–1·09	5/889	269	237	0·87; 0·7–1·09	5/889
TAP + PPAP ^g	[1]	417	179	0·43; 0·35–0·53	17/2951	303	255	0·84; 0·73–0·96	18/5290
TAP (alone) ^h	[1]	324	162	0·50; 0·36–0·69	13/1848	305	296	0·97; 0·87–1·07	15/3274
TAP + PPAP (versus PPAP) ^{i, j}	[1]	303	278	0·82; 0·58–1·16	6/247	237	221	0·92; 0·72–1·18	7/1039

^an/N is number of participants/number of studies
^bSemi-recumbent position; pneumonia is microbiologically confirmed VAP at > 48 h and mortality is ICU mortality at > 48 h
^cHME (heat and moisture exchanger); pneumonia measured at a median 4 days (from Analysis 1.3 on page 65 of ref [21]) and mortality measured at a median 8 days
^dProbiotic; pneumonia is VAP measured at a median 37 days and mortality measured at a median 35 days
^eChlorhexidine (mouth rinse or gel); pneumonia is VAP measured at a median 1 month and mortality measured at a median 1 month
^fToothbrushing; pneumonia is VAP measured at a mean 1 month and mortality measured at a mean 1 month
^gTAP + PPAP studies; pneumonia is respiratory tract infection at unspecified follow up and mortality is at unspecified follow up. These studies resemble those having designs as in Fig. 1b
^hTAP alone; pneumonia is respiratory tract infection at unspecified follow up (note this does not include 6 studies for which the control group received PPAP) and mortality is at unspecified follow up. These studies resemble those having designs as in Fig. 1a
ⁱTAP + PPAP versus PPAP (duplex studies); pneumonia is respiratory tract infection at unspecified follow up and mortality is at unspecified follow up. These studies resemble those having designs as in Fig. 1c
^jNote that only one study [10] having a NCC design (as in Fig. 1d) is included within the systematic review of TAP[1]

ISSN: 1364-8535