在接受机械通气的危重成人患者中，选择性消化道脱污染(SDD)的效果尚不确定。研究目的旨在探讨SDD是否能降低重症监护病房(icu)接受机械通气的成人患者的死亡风险。

共纳入32项随机对照试验，包括24 389例患者。SDD与标准治疗相比，死亡率的合并估计风险比(RR)为0.91(95%可信区间[CrI]， 0.82 ~ 0.99;I2 = 33.9%;中度确定性)，且SDD降低医院死亡率的后验概率为99.3%。SDD的有益关联在静脉给药的试验中很明显(RR, 0.84 [95% CrI, 0.74-0.94])，但在不静脉给药的试验中并不明显(RR, 1.01 [95% CrI, 0.91-1.11])(亚组间交互作用的P值= .02)。SDD与呼吸机相关性肺炎(RR, 0.44 [95% CrI, 0.36 ~ 0.54])和icu获得性菌血症(RR, 0.68 [95% CrI, 0.57 ~ 0.81])的风险降低相关。

在ICU接受机械通气治疗的成人中，使用SDD与标准护理或安慰剂相比，与较低的医院死亡率相关。关于SDD对抗微生物药物耐药性影响的证据的确定性非常低

Abstract

Importance: The effectiveness of selective decontamination of the digestive tract (SDD) in critically ill adults receiving mechanical ventilation is uncertain.

Objective: To determine whether SDD is associated with reduced risk of death in adults receiving mechanical ventilation in intensive care units (ICUs) compared with standard care.

Data sources: The primary search was conducted using MEDLINE, EMBASE, and CENTRAL databases until September 2022.

Study selection: Randomized clinical trials including adults receiving mechanical ventilation in the ICU comparing SDD vs standard care or placebo.

Data extraction and synthesis: Data extraction and risk of bias assessments were performed in duplicate. The primary analysis was conducted using a bayesian framework.

Main outcomes and measures: The primary outcome was hospital mortality. Subgroups included SDD with an intravenous agent compared with SDD without an intravenous agent. There were 8 secondary outcomes including the incidence of ventilator-associated pneumonia, ICU-acquired bacteremia, and the incidence of positive cultures of antimicrobial-resistant organisms.

Results: There were 32 randomized clinical trials including 24 389 participants in the analysis. The median age of participants in the included studies was 54 years (IQR, 44-60), and the median proportion of female trial participants was 33% (IQR, 25%-38%). Data from 30 trials including 24 034 participants contributed to the primary outcome. The pooled estimated risk ratio (RR) for mortality for SDD compared with standard care was 0.91 (95% credible interval [CrI], 0.82-0.99; I2 = 33.9%; moderate certainty) with a 99.3% posterior probability that SDD reduced hospital mortality. The beneficial association of SDD was evident in trials with an intravenous agent (RR, 0.84 [95% CrI, 0.74-0.94]), but not in trials without an intravenous agent (RR, 1.01 [95% CrI, 0.91-1.11]) (P value for the interaction between subgroups = .02). SDD was associated with reduced risk of ventilator-associated pneumonia (RR, 0.44 [95% CrI, 0.36-0.54]) and ICU-acquired bacteremia (RR, 0.68 [95% CrI, 0.57-0.81]). Available data regarding the incidence of positive cultures of antimicrobial-resistant organisms were not amenable to pooling and were of very low certainty.

Conclusions and relevance: Among adults in the ICU treated with mechanical ventilation, the use of SDD compared with standard care or placebo was associated with lower hospital mortality. Evidence regarding the effect of SDD on antimicrobial resistance was of very low certainty.

文章连接：

www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)02074-8/fulltext

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