• Naomi E Hammond, John Myburgh, Ian Seppelt, Tessa Garside, Ruan Vlok, Sajeev Mahendran, Derick Adigbli, Simon Finfer, Ya Gao, Fiona Goodman, Gordon Guyatt, Joseph Alvin Santos, Balasubramanian Venkatesh, Liang Yao, Gian Luca Di Tanna, and Anthony Delaney.
• Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia.
• JAMA. 2022 Nov 15; 328 (19): 192219341922-1934.

ImportanceThe effectiveness of selective decontamination of the digestive tract (SDD) in critically ill adults receiving mechanical ventilation is uncertain.ObjectiveTo 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 SourcesThe primary search was conducted using MEDLINE, EMBASE, and CENTRAL databases until September 2022.Study SelectionRandomized clinical trials including adults receiving mechanical ventilation in the ICU comparing SDD vs standard care or placebo.Data Extraction And SynthesisData extraction and risk of bias assessments were performed in duplicate. The primary analysis was conducted using a bayesian framework.Main Outcomes And MeasuresThe 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.ResultsThere 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 RelevanceAmong 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.

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