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Evidence-Based Medicine in ICU

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Infection Control in the Intensive Care Unit

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Abstract

In intensive care, there have been many clinical trials evaluating numerous new therapies and much data generated. How is all this data to be evaluated and which specific treatment options should be chosen? This is where evidenced-based medicine comes to the fore. It involves integrating clinical expertise, best research evidence and patient values. Clinical expertise involves the ability to use clinical skills and past experience to identify risks and benefits of potential interventions. Best research evidence includes relevant clinical research into accuracy and specificity of diagnostic tests and the power of the prediction of these tests, either science based or patient centred. Patient values involve concerns and expectations of each patient, which must be best integrated into clinical decisions. We screened intensive care unit literature using these Grading of Recommendations Assessment, Development and Evaluation rules for manoeuvres that may impact on infectious morbidity and mortality. We classified the most common manoeuvres according to levels of evidence and grades of recommendations.

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References

  1. Atkins D, Best D, Briss PA et al, for the GRADE working group (2004) Grading quality of evidence and strength of recommendations. BMJ 328:1490–1495

    Article  PubMed  Google Scholar 

  2. Schünemann HJ, Oxman AD, Brozek J et al, for the GRADE working group (2008) Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 336:1106–1110

    Article  PubMed  Google Scholar 

  3. Jaeschke R, Guyatt GH, Dellinger P et al, for the GRADE working group (2008) Use of GRADE grid to reach decisions on clinical practice guidelines when consensus is elusive. BMJ 337:a744

    Article  PubMed  Google Scholar 

  4. Guyatt GH, Oxman AD, Vist GE et al, for the GRADE working group (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. 336:924–926

    Google Scholar 

  5. Casewell M, Philips I (1977) Hands as route of transmission for Klebsiella species. BMJ 2:1315–1317

    Article  PubMed  CAS  Google Scholar 

  6. Massanari RM, Hierholzer J (1984) A cross-over comparison of antiseptic soaps on nosocomial infection rates in the intensive care units. Am J Infect Control 12:247–248

    Google Scholar 

  7. Maki DG (1989) The use of antiseptics for handwashing by medical personnel. J Chemother 1(Suppl 1):3–11

    PubMed  Google Scholar 

  8. Simmons B, Bryant J, Neiman K et al (1990) The role of handwashing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol 11:589–594

    Article  PubMed  CAS  Google Scholar 

  9. Doebbeling RN, Stanley G, Sheetz CT et al (1992) Comparative efficacy of alternative handwashing agents in reducing nosocomial infections in intensive care units. New Engl J Med 327:88–93

    Article  PubMed  CAS  Google Scholar 

  10. Webster J, Faogali JL, Cartwright D (1994) Elimination of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit after handwashing with tricloson. J Paediatr Child Health 30:59–64

    Article  PubMed  CAS  Google Scholar 

  11. Koss WG, Khalili TM, Lemus JF et al (2001) Nosocomial pneumonia is not prevented by protective contact isolation in the surgical intensive care unit. Am Surg 67:1140–1144

    PubMed  CAS  Google Scholar 

  12. Slota M, Green M, Farley A et al (2001) The role of gown and glove isolation and strict handwashing in the reduction of nosocomial infection in children with solid organ transplantation. Crit Care Med 29:405–412

    Article  PubMed  CAS  Google Scholar 

  13. Silvestri L, Petros AJ, Sarginson RE et al (2005) Handwashing in the intensive care unit: a big measure with modest effects. J Hosp Infect 59:172–179

    Article  PubMed  CAS  Google Scholar 

  14. Choi SC, Nelson LD (1992) Kinetic therapy in critically ill patients: combined results based on meta-analysis. J Crit Care 7:57–62

    Article  Google Scholar 

  15. Summer WR, Curry P, Haponik EF et al (1989) Continuous mechanical turning of intensive care unit patients shortens length of stay in some diagnostic-related groups. J Crit Care 4:45–53

    Article  Google Scholar 

  16. Traver GA, Tyler ML, Hudson LD et al (1995) Continuous oscillation: outcome in critically ill patients. J Crit Care 10:97–103

    Article  PubMed  CAS  Google Scholar 

  17. Craven DE, Steger KA (1996) Nosocomial pneumonia in mechanically ventilated patients: epidemiology and prevention in 1996. Semin Respir Infect 11:32–53

    PubMed  CAS  Google Scholar 

  18. Drakulovic MB, Torres A, Bauer TT et al (1999) Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 354:1851–1858

    Article  PubMed  CAS  Google Scholar 

  19. van Nieuwenhoven CA, van Tiel FH, Vandenbroucke-Grauls C et al (2002) The effect of semi-recumbent position on development of ventilator-associated pneumonia (VAP). Intensive Care Med 27(Suppl 2):S285, Abstract 585

    Google Scholar 

  20. Keeley L (2007) Reducing the risk of ventilator-acquired pneumonia through head of bed elevation. Nurs Crit Care 12:287–294

    Article  PubMed  Google Scholar 

  21. Silvestri L, Gregori D, van Saene HKF, Belli R (2010) Semirecumbent position to prevent ventilator-associated pneumonia is not evidence based. J Critical Care 25:152–153

    Article  Google Scholar 

  22. Mahul P, Auboyer C, Jaspe R et al (1992) Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Med 18:20–25

    Article  PubMed  CAS  Google Scholar 

  23. Valles J, Artigas A, Rello J et al (1995) Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med 122:179–186

    PubMed  CAS  Google Scholar 

  24. Kollef MH, Skubas NJ, Sundt TM (1999) A randomised clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest 116:1339–1346

    Article  PubMed  CAS  Google Scholar 

  25. Smulders K, van der Hoeven H, Weers-Pothoff I et al (2002) A randomised clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest 121:858–862

    Article  PubMed  Google Scholar 

  26. Metz C, Linde HJ, Gobel L et al (1998) Influence of intermittent subglottic lavage on subglottic colonization and ventilator associated pneumonia. Clin Intensive Care 9:20–24

    Article  Google Scholar 

  27. Bo H, He L, Qu J et al (2000) Influence of the subglottic secretion drainage on the morbidity of ventilator associated pneumonia in mechanically ventilated patients. Zhonghua Jie He He Hu Xi Za Zhi 23:472–474

    PubMed  CAS  Google Scholar 

  28. Liu SH, Yan XX, Cao SQ et al (2006) The effect of subglottic secretion drainage on prevention of ventilator-associated lower airway infection. Zhonghua Jie He He Hu Xi Za Zhi 29:19–22

    PubMed  CAS  Google Scholar 

  29. Lorente L, Lecuona M, Jimenez A et al (2007) Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am J Respir Crit Care Med 176:1079–1083

    Article  PubMed  Google Scholar 

  30. Zheng RQ, Lin H, Shao J et al (2008) A clinical study of subglottic secretion drainage for prevention of ventilator associated pneumonia. Zhongguo Wie Zhong Bing Ji Jiu Yi Xue 20:338–340

    Google Scholar 

  31. Bouza E, Perez MJ, Munoz P et al (2008) Continuous aspiration of subglottic secretions (CASS) in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest 134:938–946

    Article  PubMed  Google Scholar 

  32. Dezfulian C, Shojania K, Collard HR et al (2005) Subglottic secretion drainage for preventing ventilator associated pneumonia: a meta-analysis. Am J Med 118:11–18

    Article  PubMed  Google Scholar 

  33. Silvestri L, Milanese M, van Saene HKF et al (2008) Impact of subglottic secretion drainage on ventilator-associated pneumonia and mortality: systematic review of randomized controlled trials. In: Proceedings of the 21st anesthesia and ICU symposium Alpe Adria. Udine, 5–6 Sept 2008, pp 26–29

    Google Scholar 

  34. De Riso AJII, Ladowski JS, Dillon TA et al (1996) Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest 109:1556–1561

    Article  Google Scholar 

  35. Fourrier F, Cau-Pottier E, Boutigny H et al (2000) Effects of dental plaque on antiseptic decontamination on bacterial colonisation and nosocomial infections in critically ill patients. Intensive Care Med 26:1239–1247

    Article  PubMed  CAS  Google Scholar 

  36. Houston S, Houghland P, Anderson JJ et al (2002) Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care 11:567–570

    PubMed  Google Scholar 

  37. MacNaughton PD, Bailey J, Donlin N et al (2004) A randomised controlled trial assessing the efficacy of oral chlorhexidine in ventilated patients. Intensive Care Med 30(Suppl 1):S12 Abstract 029

    Google Scholar 

  38. Grap MJ, Munro CL, Elswick RE et al (2004) Duration of action of a single early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: a pilot study. Heart Lung 33:83–91

    Article  PubMed  Google Scholar 

  39. Fourrier F, Dubois D, P Pronnier et al (2005) Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med 33:1728–1735

    Article  PubMed  Google Scholar 

  40. Segers P, Speckenbrink RGH, Ubbink DT et al (2006) Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate. JAMA 296:2460–2466

    Article  PubMed  CAS  Google Scholar 

  41. Koeman M, van der Ven AJAM, Hak E et al (2006) Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 173:1348–1355

    Article  PubMed  CAS  Google Scholar 

  42. Bopp M, Darby M, Loftin KC et al (2006) Effects of daily oral care with 0.12% chlorhexidine gluconate and a standard care protocol on the development of nosocomial pneumonia in intubated patients: a pilot study. J Dent Hyg 80:9

    Google Scholar 

  43. Tad YD (2007) Efficacy of Chlorhexidine oral decontamination in the prevention of VAP. Chest 51:498S

    Google Scholar 

  44. Tantipong H, Morkchareonpong C, Jaiyindee S et al (2008) Randomised controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol 29:131–136

    Article  PubMed  Google Scholar 

  45. Panchabhai TS, Dangayach NS, Krishnan A et al (2009) Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients. Chest 135:1150–1156

    Article  PubMed  CAS  Google Scholar 

  46. Scannapieco FA, Yu J, Raghavendran K et al (2009) A randomised trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Crit Care 13:R117

    Article  PubMed  Google Scholar 

  47. Munro CL, Grap MJ, Jones DJ et al (2009) Chlorhexidine, toothbrushing, and ventilator-associated pneumonia in critically ill adults. Am J Crit Care 18:428–438

    Article  PubMed  Google Scholar 

  48. Bellissimo-Rodrigues F, Bellissimo-Rodrigues WT et al (2009) Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infect Control Hosp Epidemiol 30:952–958

    Article  PubMed  Google Scholar 

  49. Cabov T, Macan D, Husedzinovic I et al (2010) The impact of oral health and 0.2% chlorhexidine oral gel on the prevalence of nosocomial infections in surgical intensive-care patients: a randomized placebo-controlled study. Wien Klin Wochenschr 122:397–404

    Article  PubMed  CAS  Google Scholar 

  50. Pineda LA, Saliba RG, El Solh AA (2006) Effects of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Crit Care 10:R35

    Article  PubMed  Google Scholar 

  51. Chlebicki MP, Safdar N (2007) Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 35:595–602

    Article  PubMed  CAS  Google Scholar 

  52. Chan EY, Ruest A, O’Meade M et al (2007) Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 334:889–893

    Article  PubMed  Google Scholar 

  53. Kola A, Gastmeier P (2007) Efficacy of oral chlorhexidine in preventing lower respiratory tract infections: meta-analysis of randomised controlled trials. J Hosp Infect 66:207–216

    Article  PubMed  CAS  Google Scholar 

  54. van Saene HKF, Silvestri L, de la Cal MA et al (2009) The emperor’s new clothes: the fairy tale continues. J Crit Care 24:149–152

    Article  PubMed  Google Scholar 

  55. Carvajal C, Pobo A, Diaz E et al (2010) Oral hygiene with chlorhexidine on the prevention of ventilator-associated pneumonia in intubated patients: a systematic review of randomized clinical trials. Med Clin (Barc) 135:491–497

    Article  Google Scholar 

  56. Beale RJ, Bryg DJ, Bihari DJ (1999) Immunonutrition in the critically ill: a systematic review of clinical outcome. Crit Care Med 27:2799–2805

    Article  PubMed  CAS  Google Scholar 

  57. Heyland DK, Novak F, Drover JW et al (2001) Should immunonutrition become routine in critically ill patients? a systematic review of the evidence. JAMA 286:944–953

    Article  PubMed  CAS  Google Scholar 

  58. Cronin L, Cook DJ, Carlet J et al (1995) Corticosteroid treatment for sepsis: a critical appraisal and meta-analysis of the literature. Crit Care Med 23:1430–1439

    Article  PubMed  CAS  Google Scholar 

  59. Lefering R, Neugebauer EAM (1995) Steroid controversy in sepsis and septic shock: a meta-analysis. Crit Care Med 23:1294–1303

    Article  PubMed  CAS  Google Scholar 

  60. Bollaert PE, Charpentier C, Levy B et al (1998) Reversal of late septic shock with supraphysiologic doses of hydrocortisone. Crit Care Med 26:645–650

    Article  PubMed  CAS  Google Scholar 

  61. Briegel J, Forst H, Haller M et al (1999) Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomised, double-blind, single-center study. Crit Care Med 27:723–732

    Article  PubMed  CAS  Google Scholar 

  62. Annane D, Sebille V, Charpentier C et al (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871

    Article  PubMed  CAS  Google Scholar 

  63. Annane D, Bellissant E, Bollaert PE et al (2009) Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review. JAMA 301:2362–2375

    Article  PubMed  CAS  Google Scholar 

  64. Annane D, Cariou A, Maxime V et al, for the COIITSS study investigators (2010) Corticosteroid treatment and intensive insulin therapy for septic shock in adults: a randomized controlled trial. JAMA 303:341–348

    Article  PubMed  Google Scholar 

  65. Alejandria MM, Lansang MA, Dans LF, Mantaring JBV (2000) Intravenous immunoglobulin for treating sepsis and septic shock (Cochrane review). In: The Cochrane library, issue 3. Update Software, Oxford

    Google Scholar 

  66. Bernard GR, Vincent JL, Laterre PF et al (2001) Efficacy and safety of recombinant human activated protein C for severe sepsis. New Engl J Med 344:699–709

    Article  PubMed  CAS  Google Scholar 

  67. Marshall J (2000) Clinical trials of mediator-directed therapy in sepsis: what have we learned? Intensive Care Med 26:575–583

    Article  Google Scholar 

  68. Zeni F, Freeman B, Natanson C (1997) Anti-inflammatory therapies to treat sepsis and septic shock: a reassessment. Crit Care Med 25:1095–1100

    Article  PubMed  CAS  Google Scholar 

  69. van den Berghe G, Wouters P, Weekers F et al (2001) Intensive insulin therapy in the critically ill patients. N Engl J Med 345:1359–1367

    Article  PubMed  Google Scholar 

  70. Van den Berghe G, Wilmer A, Hermans G (2006) Intensive insulin therapy in the medical ICU. N Engl J Med 354:449–461

    Article  PubMed  Google Scholar 

  71. Wiener RS, Wiener DC, Larson RJ (2008) Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA 300:933–944

    Article  PubMed  CAS  Google Scholar 

  72. Vlasselaers D, Milants I, Desmet L et al (2009) Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study. Lancet 373:547–556

    Article  PubMed  CAS  Google Scholar 

  73. Beardsall K, Vanhaesebrouck S, Ogilvy-Stuart AL et al (2007) A randomised controlled trial of early insulin therapy in very low birth weight infants, NIRTURE (neonatal insulin replacement therapy in Europe). BMC Pediatr 7:29

    Article  PubMed  Google Scholar 

  74. Hermanides J, Bosman RJ, Vriesendorp TM (2010) Hypoglycemia is associated with intensive care unit mortality. Crit Care Med 38:1430–1434

    Article  PubMed  Google Scholar 

  75. Stoutenbeek CP, van Saene HKF, Miranda DR et al (1984) The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intensive Care Med 10:185–192

    Article  PubMed  CAS  Google Scholar 

  76. Vandenbroucke-Grauls CMJ, Vandenbroucke JP (1991) Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in the intensive care unit. Lancet 338:859–862

    Article  PubMed  CAS  Google Scholar 

  77. D’Amico R, Pifferi S, Leonetti C et al, on behalf of the study investigators (1998) Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials. BMJ 316:1275–1285

    Article  PubMed  Google Scholar 

  78. Safdar N, Said A, Lucey MR (2004) The role of selective decontamination for reducing infection in patients undergoing liver transplantation: a systematic review and meta-analysis. Liver Transpl 10:817–827

    Article  PubMed  Google Scholar 

  79. Liberati A, D’Amico R, Pifferi S et al (2004) Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care (Cochrane review). In: The Cochrane library, issue 1. Wiley, Chichester

    Google Scholar 

  80. Silvestri L, van Saene HKF, Milanese M, Gregori D (2005) Impact of selective decontamination of the digestive tract on fungal carriage and infection: systematic review of randomized controlled trials. Intensive Care Med 31:898–910

    Article  PubMed  Google Scholar 

  81. Silvestri L, van Saene HKF, Milanese M et al (2007) Selective decontamination of the digestive tract reduces bloodstream infections and mortality in critically ill patients: a systematic review of randomized controlled trials. J Hosp Infect 65:187–203

    Article  PubMed  CAS  Google Scholar 

  82. Silvestri L, van Saene HKF, Casarin AL et al (2008) Impact of selective decontamination of the digestive tract on carriage and infection due to Gram-negative and Gram-positive bacteria: systematic review of randomized controlled trials. Anaesths Intens Care 36:324–338

    CAS  Google Scholar 

  83. Silvestri L, van Saene HKF, Weir I, Gullo A (2009) Survival benefit of the full selective digestive decontamination regimen. J Crit Care 24:474.e7–474.e14

    Google Scholar 

  84. Liberati A, D’Amico R, Pifferi S (2009) Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev 4:CD000022

    Google Scholar 

  85. Silvestri L, van Saene HKF, Zandstra DF et al (2010) Selective decontamination of the digestive tract reduces multiple organ failure and mortality in critically ill patients: systematic review of randomized controlled trials. Crit Care Med 38:1370–1376

    PubMed  Google Scholar 

  86. Silvestri L, van Saene HKF, Zandstra DF (2010) Selective digestive decontamination reduces ventilator-associated tracheobronchitis. Respir Med 104:1953–1955

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. PICU, Great Ormond Street Hospital, London, UK

    A. J. Petros

  2. Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland, UK

    K. G. Lowry

  3. Institute of Ageing and Chronic Diseases, University of Liverpool, Duncan Building, Daulby Street, Liverpool, L69 3GA, UK

    H. K. F. van Saene

  4. Department of Surgery and Intensive Care, St Michael’s Hospital, Ontario, Canada

    J. C. Marshall

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  1. A. J. Petros
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  2. K. G. Lowry
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  3. H. K. F. van Saene
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  4. J. C. Marshall
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Correspondence to A. J. Petros .

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Editors and Affiliations

  1. , Institute of Aging and Chronic Diseases, University Liverpool, Daulby Street, Liverpool, L69 3GA, United Kingdom

    Hendrick K.F. van Saene

  2. , Dept. Emergency, Hospital Gorizia, Via Vittorio Veneto 171, Gorizia, 34170, Italy

    Luciano Silvestri

  3. , Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo km 12.5, Getafe, 28045, Spain

    Miguel A. de la Cal

  4. Policlinico di Catania, UCO di Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria, Via Santa Sofia 78, Catania, 95100, Italy

    Antonino Gullo

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Petros, A.J., Lowry, K.G., van Saene, H.K.F., Marshall, J.C. (2011). Evidence-Based Medicine in ICU. In: van Saene, H., Silvestri, L., de la Cal, M., Gullo, A. (eds) Infection Control in the Intensive Care Unit. Springer, Milano. https://doi.org/10.1007/978-88-470-1601-9_30

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