Selective decontamination of the digestive tract in burn patients: A systematic review with meta-analysis

Background: In mechanically ventilated adult patients in the intensive care unit (ICU), selective decontamination of the digestive tract (SDD) has been shown to reduce the risk of infections and improve survival. While the benefits of SDD have been documented in this population, it remains unclear whether burn patients, who are at increased risk of infection and have distinct clinical characteristics, may experience similar benefits. In this systematic review we aimed to assess the desirable and undesirable patient-important effects of administering SDD to burn patients. Methods/design: We conducted a systematic review with meta-analysis of randomized clinical trials (RCTs) assessing the effects of SDD versus placebo or no SDD in burn patients. The primary outcome was 30-day mortality. Secondary outcomes included serious adverse events, antimicrobial resistance, pneumonia, blood stream infections, ICU- and hospital-free days, and 90-day mortality. We searched all major databases and followed the recommendations provided by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The certainty of evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Results: We identified four RCTs with a total of 457 burn patients. All trials were assessed as having either ‘some concerns’ or ‘high risk’ of bias. The evidence was found to be very uncertain across all outcomes assessed. For mortality, the relative risk (RR) was 0.62 (95 % confidence interval (CI) 0.22–1.78, I² = 75 %, random-effects model (REM), very low certainty evidence). For pneumonia, the RR was 0.75 (95 % CI 0.48–1.19, I² = 0 %, fixed-effect model, very low certainty evidence). For bloodstream infections, the RR was 1.10 (95 % CI 0.71–1.69, I² = 0 %, REM, very low certainty evidence). For hospital length of stay, the mean difference was −2.03 days (95 % CI −9.64–5.59, I² = 51 %, REM, very low certainty evidence). We did not perform meta-analyses for the remaining secondary outcomes due to limited or no data. Trial sequential analysis could not be performed due to insufficient number of total participants and events in the included trials. Conclusion: We found that the certainty of evidence is very low about the effects of SDD on patient-important outcomes in burn patients. Extrapolating from the evidence on mechanically ventilated adult ICU patients may be reasonable until more data from RCTs in burn patients emerge.