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Critical Care Medicine Feb 2013Oral care may decrease ventilator-associated pneumonia in the ICU. The objective of this review was to summarize and critically appraise randomized trials in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Oral care may decrease ventilator-associated pneumonia in the ICU. The objective of this review was to summarize and critically appraise randomized trials in mechanically ventilated patients in the ICU testing the effect of oral care strategies involving toothbrushing on ventilator-associated pneumonia.
SEARCH METHODS
We searched EMBASE, MEDLINE, and the Cochrane Controlled Trials Register and Database of Systematic Reviews from 1980 until March 2012, independently and in duplicate, as well as personal files and reference lists. In duplicate, articles were selected if they were randomized trials, enrolled adult critically ill patients, compared any kind of oral care involving toothbrushing with any other kind of oral care or control with or without toothbrushing, and examined ventilator-associated pneumonia. In duplicate, we abstracted trial characteristics and quality using the Cochrane risk of bias tool. The results were combined using a random effects model.
RESULTS
We included six trials enrolling 1,408 patients, five of which compared toothbrushing to usual oral care and one of which compared electric with manual toothbrushing. In four trials, there was a trend toward lower ventilator-associated pneumonia rates (risk ratio, 0.77; 95% confidence interval, 0.50-1.21; p = 0.26). This trend was also observed in one trial reporting fewer cases of ventilator-associated pneumonia per 1,000 ventilator days (20.68 vs. 25.89; p = 0.53) in patients receiving toothbrushing vs. no toothbrushing. The only trial with low risk of bias suggested that toothbrushing significantly reduced ventilator-associated pneumonia (risk ratio, 0.26; 95% confidence interval, 0.10-0.67; p = 0.006). Use of chlorhexidine antisepsis seems to attenuate the effect of toothbrushing on ventilator-associated pneumonia (p for the interaction = 0.02). One trial comparing electric vs. manual toothbrushing showed no difference in ventilator-associated pneumonia rates (risk ratio, 0.96; 95% confidence interval, 0.47-1.96; p = 0.91). Toothbrushing did not impact on length of ICU stay, or ICU or hospital mortality.
CONCLUSIONS
In intubated, mechanically ventilated critically ill patients, toothbrushing did not significantly reduce the risk of ventilator-associated pneumonia overall. Toothbrushing has no effect on mortality or length of stay. Electric and manual toothbrushing seem to have similar effects. More research is needed on this aspect of oral care to evaluate its potential to decrease ventilator-associated pneumonia.
Topics: Chlorhexidine; Critical Illness; Hospital Mortality; Humans; Intensive Care Units; Length of Stay; Mouthwashes; Pneumonia, Ventilator-Associated; Randomized Controlled Trials as Topic; Respiration, Artificial; Toothbrushing
PubMed: 23263588
DOI: 10.1097/CCM.0b013e3182742d45 -
PloS One 2012Skin antisepsis is a simple and effective measure to prevent infections. The efficacy of chlorhexidine is actively discussed in the literature on skin antisepsis.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Skin antisepsis is a simple and effective measure to prevent infections. The efficacy of chlorhexidine is actively discussed in the literature on skin antisepsis. However, study outcomes due to chlorhexidine-alcohol combinations are often attributed to chlorhexidine alone. Thus, we sought to review the efficacy of chlorhexidine for skin antisepsis and the extent of a possible misinterpretation of evidence.
METHODS
We performed a systematic literature review of clinical trials and systematic reviews investigating chlorhexidine compounds for blood culture collection, vascular catheter insertion and surgical skin preparation. We searched PubMed, CINAHL, the Cochrane Library, the Agency for Healthcare Research and Quality website, several clinical trials registries and a manufacturer website. We extracted data on study design, antiseptic composition, and the following outcomes: blood culture contamination, catheter colonisation, catheter-related bloodstream infection and surgical site infection. We conducted meta-analyses of the clinical efficacy of chlorhexidine compounds and reviewed the appropriateness of the authors' attribution.
RESULTS
In all three application areas and for all outcomes, we found good evidence favouring chlorhexidine-alcohol over aqueous competitors, but not over competitors combined with alcohols. For blood cultures and surgery, we found no evidence supporting chlorhexidine alone. For catheters, we found evidence in support of chlorhexidine alone for preventing catheter colonisation, but not for preventing bloodstream infection. A range of 29 to 43% of articles attributed outcomes solely to chlorhexidine when the combination with alcohol was in fact used. Articles with ambiguous attribution were common (8-35%). Unsubstantiated recommendations for chlorhexidine alone instead of chlorhexidine-alcohol were identified in several practice recommendations and evidence-based guidelines.
CONCLUSIONS
Perceived efficacy of chlorhexidine is often in fact based on evidence for the efficacy of the chlorhexidine-alcohol combination. The role of alcohol has frequently been overlooked in evidence assessments. This has broader implications for knowledge translation as well as potential implications for patient safety.
Topics: Alcohols; Anti-Infective Agents, Local; Antisepsis; Blood Specimen Collection; Catheter-Related Infections; Chlorhexidine; Humans; Skin; Surgical Wound Infection; Treatment Outcome; Vascular Access Devices
PubMed: 22984485
DOI: 10.1371/journal.pone.0044277 -
Infection Control and Hospital... Jun 2012To evaluate the clinical effectiveness of preoperative skin antiseptic preparations and application techniques for the prevention of surgical site infections (SSIs). (Review)
Review
OBJECTIVE
To evaluate the clinical effectiveness of preoperative skin antiseptic preparations and application techniques for the prevention of surgical site infections (SSIs).
DESIGN
Systematic review of the literature using Medline, EMBASE, and other databases, for the period January 2001 to June 2011.
METHODS
Comparative studies (including randomized and nonrandomized trials) of preoperative skin antisepsis preparations and application techniques were included. Two researchers reviewed each study and extracted data using standardized tables developed before the study. Studies were reviewed for their methodological quality and clinical findings.
RESULTS
Twenty studies (n = 9,520 patients) were included in the review. The results indicated that presurgical antiseptic showering is effective for reducing skin flora and may reduce SSI rates. Given the heterogeneity of the studies and the results, conclusions about which antiseptic is more effective at reducing SSIs cannot be drawn.
CONCLUSIONS
The evidence suggests that preoperative antiseptic showers reduce bacterial colonization and may be effective at preventing SSIs. The antiseptic application method is inconsequential, and data are lacking to suggest which antiseptic solution is the most effective. Disinfectant products are often mixed with alcohol or water, which makes it difficult to form overall conclusions regarding an active ingredient. Large, well-conducted randomized controlled trials with consistent protocols comparing agents in the same bases are needed to provide unequivocal evidence on the effectiveness of one antiseptic preparation over another for the prevention of SSIs.
Topics: Administration, Cutaneous; Anti-Infective Agents, Local; Baths; Humans; Preoperative Care; Skin; Surgical Wound Infection
PubMed: 22561717
DOI: 10.1086/665723 -
Infection Control and Hospital... Dec 2010To compare use of chlorhexidine with use of iodine for preoperative skin antisepsis with respect to effectiveness in preventing surgical site infections (SSIs) and cost. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To compare use of chlorhexidine with use of iodine for preoperative skin antisepsis with respect to effectiveness in preventing surgical site infections (SSIs) and cost.
METHODS
We searched the Agency for Healthcare Research and Quality website, the Cochrane Library, Medline, and EMBASE up to January 2010 for eligible studies. Included studies were systematic reviews, meta-analyses, or randomized controlled trials (RCTs) comparing preoperative skin antisepsis with chlorhexidine and with iodine and assessing for the outcomes of SSI or positive skin culture result after application. One reviewer extracted data and assessed individual study quality, quality of evidence for each outcome, and publication bias. Meta-analyses were performed using a fixed-effects model. Using results from the meta-analysis and cost data from the Hospital of the University of Pennsylvania, we developed a decision analytic cost-benefit model to compare the economic value, from the hospital perspective, of antisepsis with iodine versus antisepsis with 2 preparations of chlorhexidine (ie, 4% chlorhexidine bottle and single-use applicators of a 2% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA] solution), and also performed sensitivity analyses.
RESULTS
Nine RCTs with a total of 3,614 patients were included in the meta-analysis. Meta-analysis revealed that chlorhexidine antisepsis was associated with significantly fewer SSIs (adjusted risk ratio, 0.64 [95% confidence interval, [0.51-0.80]) and positive skin culture results (adjusted risk ratio, 0.44 [95% confidence interval, 0.35-0.56]) than was iodine antisepsis. In the cost-benefit model baseline scenario, switching from iodine to chlorhexidine resulted in a net cost savings of $16-$26 per surgical case and $349,904-$568,594 per year for the Hospital of the University of Pennsylvania. Sensitivity analyses showed that net cost savings persisted under most circumstances.
CONCLUSIONS
Preoperative skin antisepsis with chlorhexidine is more effective than preoperative skin antisepsis with iodine for preventing SSI and results in cost savings.
Topics: 2-Propanol; Anti-Infective Agents, Local; Chlorhexidine; Cost-Benefit Analysis; Humans; Iodine; Odds Ratio; Pennsylvania; Pharmaceutical Solutions; Preoperative Care; Randomized Controlled Trials as Topic; Surgical Wound Infection
PubMed: 20969449
DOI: 10.1086/657134 -
The British Journal of Surgery Nov 2010Surgical-site infection increases morbidity, mortality and financial burden. The preferred topical antiseptic agent (chlorhexidine or povidone-iodine) for preoperative... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Surgical-site infection increases morbidity, mortality and financial burden. The preferred topical antiseptic agent (chlorhexidine or povidone-iodine) for preoperative skin cleansing is unclear.
METHODS
A meta-analysis of clinical trials was conducted to determine whether preoperative antisepsis with chlorhexidine or povidone-iodine reduced surgical-site infection in clean-contaminated surgery.
RESULTS
The systematic review identified six eligible studies, containing 5031 patients. Chlorhexidine reduced postoperative surgical-site infection compared with povidone-iodine (pooled odds ratio 0.68, 95 per cent confidence interval 0.50 to 0.94; P = 0.019) .
CONCLUSION
Chlorhexidine should be used preferentially for preoperative antisepsis in clean-contaminated surgery.
Topics: Adolescent; Adult; Anti-Infective Agents, Local; Chlorhexidine; Humans; Middle Aged; Povidone-Iodine; Surgical Wound Infection; Treatment Outcome; Young Adult
PubMed: 20878942
DOI: 10.1002/bjs.7214 -
Journal of Pharmacy & Pharmaceutical... 2009To review microbial contamination rates about preparation of individual and batch doses using aseptic techniques within pharmaceutical (controlled) and clinical (ward... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To review microbial contamination rates about preparation of individual and batch doses using aseptic techniques within pharmaceutical (controlled) and clinical (ward and theatre) environments.
METHODS
Systematic review, involving amalgamation of data using a random effect model and metaanalysis.
RESULTS
A total of 19 studies from 17 reports (7277 doses), mostly single arm studies, were identified for analysis. The overall contamination rates for doses prepared in clinical environments were found to be 5.0% (95% CI; 1.8%, 13.1%, n = 8 studies) for individual doses and 2.0% (95% CI; 0.3%, 13.1%; n = 5) for doses prepared as part of a batch. Rates for doses prepared in pharmaceutical environments were found to be 1.9% (95% CI; 0.8%, 4.2%; n = 5) for individual doses and 0.0% (95% CI; 0.0%, 0.8%; n= 1) for doses prepared as part of a batch. The results indicate greater overall contamination rates of doses prepared in clinical than pharmaceutical environments, in those prepared individually than in batch preparation, and in those in which additions rather than no additions were made. Significant differences were only found between pharmaceutical and clinical environments for batch doses, and between batch and individual doses prepared in a pharmaceutical environment. The studies differed substantially in sample size, interventions and comparison conditions, especially in the clinical setting. The quality of the data was judged to be low.
CONCLUSION
Contamination rates in clinical and pharmaceutical environments were commonly found to be unacceptably high. Intuitive recommendations for reducing contamination rates by carrying out the procedures in a pharmaceutical environment using batch doses are supported by an evidence base that needs to be strengthened further.
Topics: Asepsis; Drug Compounding; Drug Contamination; Environment, Controlled; Pharmaceutical Preparations; Pharmaceutical Services; Risk
PubMed: 19732500
DOI: 10.18433/j3jp4b -
The Cochrane Database of Systematic... Jan 2008Surgical hand antisepsis, to destroy transient micro-organisms and inhibit the growth of resident micro-organisms, is routinely carried out before undertaking invasive... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical hand antisepsis, to destroy transient micro-organisms and inhibit the growth of resident micro-organisms, is routinely carried out before undertaking invasive procedures. Antisepsis may reduce the risk of surgical site infections in patients.
OBJECTIVES
To determine the effects of surgical hand antisepsis on the number of surgical site infections (SSIs) in patients. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony forming units (CFUs) of bacteria on the hands of the surgical team.
SEARCH STRATEGY
We searched the Cochrane Wounds Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (Issue 2, 2007), MEDLINE (Week 5, 2007), CINAHL (June 2007), EMBASE (Week 23, 2007) and ZETOC (2005).
SELECTION CRITERIA
Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions.
DATA COLLECTION AND ANALYSIS
Three authors independently assessed studies for selection, trial quality and extracted data.
MAIN RESULTS
Ten trials were included in this review. Only one trial reported the primary outcome, rates of SSIs, and nine trials measured numbers of CFUs. One trial involving 4387 patients found alcohol rubs with additional active ingredients were as effective as aqueous scrubs in reducing SSIs. Four trials compared different alcohol rubs containing additional active ingredients with aqueous scrubs for numbers of CFUs on hands. One trial found N-duopropenide more effective than chlorhexidine and povidone iodine aqueous scrubs. One trial found 45% propanol-2, 30% propanol-1 with 0.2% ethylhexadecyldimethyl ammonium ethylsulfate more effective than chlorhexidine scrubs. One trial found no difference between 1% chlorhexidine gluconate in 61% ethyl alcohol or zinc pyrithione in 70% ethyl alcohol against aqueous povidone iodine. A fourth trial found 4% chlorhexidine gluconate scrubs more effective than chlorhexidine in 70% alcohol rubs. Four trials compared the relative effects of different aqueous scrubs in reducing CFUs on hands. Three trials found chlorhexidine gluconate scrubs were significantly more effective than povidone iodine scrubs. One trial found no difference between chlorhexidine gluconate scrubs and povidone iodine plus triclosan scrubs. Two trials found no evidence of a difference between alternative alcohol rubs in terms of the number of CFUs. Four trials compared the effect of different durations of scrubs and rubs on the numbers of CFUs on hands. One trial found no difference after the initial scrub but found subsequent three minute scrubs using chlorhexidine significantly more effective than subsequent scrubs lasting 30 seconds. One trial found that following a one minute hand wash, a three minute rub appears to be more effective than the five minute rub using alcohol disinfectant. The other comparisons demonstrated no difference.
AUTHORS' CONCLUSIONS
Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs however this evidence comes from only one, equivalence, cluster trial which did not appear to adjust for clustering. Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from 4 studies suggests that chlorhexidine gluconate based aqueous scrubs are more effective than povidone iodine based aqueous scrubs in terms of the numbers of CFUs on the hands. There is limited evidence regarding the effects on CFUs numbers of different scrub durations. There is no evidence regarding the effect of equipment such as brushes and sponges.
Topics: Anti-Infective Agents, Local; Antisepsis; Colony Count, Microbial; General Surgery; Hand; Humans; Randomized Controlled Trials as Topic; Surgical Wound Infection
PubMed: 18254046
DOI: 10.1002/14651858.CD004288.pub2 -
Journal of Vascular Surgery Jul 2007The aim of this systematic review and meta-analysis was to determine the effectiveness of perioperative strategies to prevent infection in patients undergoing peripheral... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The aim of this systematic review and meta-analysis was to determine the effectiveness of perioperative strategies to prevent infection in patients undergoing peripheral arterial reconstruction.
METHODS
All randomized controlled trials (RCTs) evaluating measures intended to reduce or prevent infection in arterial surgery were identified through searches of the Cochrane Peripheral Vascular Diseases Group specialized trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), and reference lists of relevant articles. Two authors independently selected and assessed the quality of included trials. Relative risk (RR) was used as a measure of effect for each dichotomous outcome.
RESULTS
The study included 34 RCTs. Of these, 22 were trials of prophylactic systemic antibiotics, 3 of rifampicin-bonded grafts, 3 of preoperative skin antisepsis, 2 of suction wound drainage, 2 of minimally invasive in situ bypass techniques, and individual trials of intraoperative glove change and wound closure techniques. Wound infection or early graft infection outcomes were recorded in all trials. Only two trials, both of rifampicin bonding, followed up graft infection outcomes to 2 years. Prophylactic systemic antibiotics reduced the risk of wound infection (RR, 0.25; 95% confidence interval [CI], 0.17 to 0.38) and early graft infection in a fixed-effect model (RR, 0.31; 95% CI, 0.11 to 0.85, P = .02). Antibiotic prophylaxis for >24 hours appeared to be of no added benefit (RR, 1.28; 95% CI, 0.82 to 1.98). There was no evidence that prophylactic rifampicin bonding to Dacron grafts reduced graft infection at 1 month (RR, 0.63; 95% CI, 0.27 to 1.49), or 2 years (RR, 1.05; 95% CI, 0.46 to 2.40). There was no evidence of a beneficial or detrimental effect on rates of wound infection with suction groin wound drainage (RR, 0.96; 95% CI, 0.50 to 1.86) or from preoperative bathing with antiseptic agents compared with unmedicated bathing (RR, 0.97; 95% CI, 0.70 to 1.36).
CONCLUSIONS
There is clear evidence of the benefit of prophylactic broad-spectrum antibiotics for vascular reconstruction. Many other interventions intended to reduce the risk of infection in arterial reconstruction lack evidence of effectiveness.
Topics: Anti-Infective Agents; Anti-Infective Agents, Local; Antibiotic Prophylaxis; Antisepsis; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Drug Administration Schedule; Humans; Peripheral Vascular Diseases; Prosthesis Design; Prosthesis-Related Infections; Rifampin; Risk Assessment; Risk Factors; Suction; Surgical Wound Infection; Treatment Outcome
PubMed: 17606135
DOI: 10.1016/j.jvs.2007.02.065 -
The Cochrane Database of Systematic... Jul 2006Arterial reconstructions with prosthetic graft materials or vein are susceptible to infection with a resultant high patient mortality and risk of limb loss. To reduce... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Arterial reconstructions with prosthetic graft materials or vein are susceptible to infection with a resultant high patient mortality and risk of limb loss. To reduce the risk of infection effective perioperative measures are essential.
OBJECTIVES
To determine the effectiveness of perioperative strategies to prevent infection in patients undergoing peripheral arterial reconstruction.
SEARCH STRATEGY
We searched the Cochrane Peripheral Vascular Diseases Group trials register (last searched May 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 2, 2006), and reference lists of relevant articles.
SELECTION CRITERIA
All randomised controlled trials (RCTs) evaluating measures intended to reduce or prevent infection in arterial surgery.
DATA COLLECTION AND ANALYSIS
AS and PSE independently selected and assessed the quality of included trials. Relative risk was used as a measure of effect for each dichotomous outcome.
MAIN RESULTS
Thirty-five RCTs were included. Of these, 23 were trials of prophylactic systemic antibiotics, three of rifampicin-bonded grafts, three of preoperative skin antisepsis, two of suction wound drainage, two of minimally invasive in situ bypass techniques, and individual trials of intraoperative glove change and wound closure techniques. Wound infection or early graft infection outcomes were recorded in all trials. Only two trials, both of rifampicin bonding, followed up graft infection outcomes to two years. Trials of antibiotics versus placebo were of highest quality with six double-blind studies of the ten included. Prophylactic systemic antibiotics reduced the risk of wound infection (Relative Risk (RR) 0.25, 95% Confidence Interval (CI) 0.17 to 0.38) and early graft infection in a fixed-effect model (RR 0.31, 95% CI 0.11 to 0.85, P = 0.02). Antibiotic prophylaxis for greater than 24 hours appears to be of no added benefit (RR 1.28, 95% CI 0.82 to 1.98). There was no evidence that prophylactic rifampicin bonding to dacron grafts reduced graft infection at either one month (RR 0.63, 95% CI 0.27 to 1.49) or two years (RR 1.05, 95% CI 0.46 to 2.40). There was no evidence of a beneficial or detrimental effect on rates of wound infection with suction groin-wound drainage (RR 0.96 95% CI 0.50 to 1.86) or of any benefit from a preoperative bathing or shower regimen with antiseptic agents over unmedicated bathing (RR 0.97, 95% CI 0.70 to 1.36).
AUTHORS' CONCLUSIONS
There is clear evidence of the benefits of prophylactic broad spectrum antibiotics. Many other interventions intended to reduce the risk of infection in arterial reconstruction lack evidence of effectiveness.
Topics: Antibiotic Prophylaxis; Arteries; Blood Vessel Prosthesis; Humans; Randomized Controlled Trials as Topic; Surgical Wound Infection
PubMed: 16855996
DOI: 10.1002/14651858.CD003073.pub2 -
Canadian Operating Room Nursing Journal Sep 2005Surgical face masks were originally developed to contain and filter droplets of microorganisms expelled from the mouth and nasopharynx of healthcare workers during... (Review)
Review
UNLABELLED
Surgical face masks were originally developed to contain and filter droplets of microorganisms expelled from the mouth and nasopharynx of healthcare workers during surgery, thereby providing protection for the patient. However, there are several ways in which surgical face masks could potentially contribute to contamination of the surgical wound. Surgical face masks have recently been advocated as a protective barrier between the surgical team and the patient, but the role of the surgical face mask as an effective measure in preventing surgical wound infections is questionable. The aim of the systematic review is to identify and review all randomised controlled trials evaluating disposable surgical face masks worn by the surgical team during clean surgery to prevent postoperative surgical wound infection. All relevant publications about disposable surgical face masks were sought through the Specialised Trials Register of the Cochrane Wounds Group (March 2001). Manufacturers and distributors of disposable surgical masks as well as professional organisations including the National Association of Theatre Nurses and the Association of Operating Room Nurses were contacted for details of unpublished and ongoing studies. Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing the use of disposable surgical masks with the use of no mask were included.
MAIN RESULTS
Two randomised controlled trials were included involving a total of 1453 patients. In a small trial there was a trend towards masks being associated with fewer infections, whereas in a large trial there was no difference in infection rates between the masked and unmasked group. Neither trial accounted for cluster randomisation in the analysis.
REVIEWERS' CONCLUSIONS
From the limited results it is unclear whether wearing surgical face masks results in any harm or benefit to the patient undergoing clean surgery.
Topics: Antisepsis; Bias; Cost of Illness; Cross Infection; Data Interpretation, Statistical; Disposable Equipment; Equipment Failure; Humans; Infection Control; Masks; Outcome Assessment, Health Care; Randomized Controlled Trials as Topic; Reproducibility of Results; Research Design; Research Support as Topic; Sample Size; Surgical Wound Infection
PubMed: 16295987
DOI: No ID Found