Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysisBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2743 (Published 13 June 2013) Cite this as: BMJ 2013;346:f2743
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Re: Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis
As a Cochrane system review, according to the Cochrane Handbook, this paper has some flaws in the methods:
1. Search strategy: It only includes articles in the English language and published after 1 January 1995. These are different criteria from the Cochrane Handbook (should be no language and date limitation).
2. Data synthesis of observational studies and random control trials (RCTs) is not right. Potential biases in observational studies are likely to be greater compared with randomized trials. Results from different study designs should be expected to differ systematically, resulting in increased heterogeneity. Therefore, The Cochrane Collaboration recommends that non-randomized studies which use different study designs (or which have different design features), or randomized trials and non-randomized studies, should not be combined in a meta-analysis.
For Cochrane reviews, when the question of interest cannot be answered by randomized trials, review authors may be justified in including other studies. Two issues in this review, “nasal decolonization to prevent surgical site infections caused by Gram positive bacteria” and “glycopeptide prophylaxis for all patients to prevent surgical site infections caused by Gram positive Bacteria” have enough RCT included. The data synthesis from RCTs can draw the conclusion: Neither nasal decolonization (pooled relative risk 0.63, 95% confidence interval 0.36 to1.13) nor glycopeptide prophylaxis (1.13, 0.90 to 1.42) can prevent surgical site infections caused by Gram positive Bacteria.
The review of decolonization and prophylaxis bundle includes only observational studies. So the conclusion “It was significantly protective against surgical site infections caused by both Gram positive bacteria and S aureus” needs more caution about potential biases.
In new update antibiotic prophylaxis guideline, for patients undergoing cardiac or orthopedic procedures, Mupirocin should be given intranasally to all patients with documented S. aureus colonization. This recommendation is based on another systematic review. This review shows decolonization can significantly reduce all kinds of nosocomial S. aureus infection rates. Like this paper's RCT result, this effect disappeared if the analysis included only surgical site infections caused by S. aureus. More studies are needed to understand why this happens.
Routine use of glycopeptide prophylaxis is not recommended for any procedure because of vancomycin resistance. Glycopeptide prophylaxis should be considered for patients with known MRSA colonization or at high risk for MRSA colonization in the absence of surveillance data.
The advantage of decolonization and glycopeptide prophylaxis is shown to be effective in specific patients. on this point, surveillance may be useful to select patients to perform proper prophylaxis. I agree with authors' conclusion that high quality randomized controlled trials or cluster randomized trials should be performed to further assess this issue. And further studies need to assess the potential side effects and verify the effectiveness of this intervention in health economics mode.
1. Higgins JPT GS (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration 2011. www.cochrane-handbook.org
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. American journal of health-system pharmacy 2013;70:195–283.
3. Van Rijen M, Bonten M, Wenzel R, et al. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev 2008;8:CD006216.
4. Hospital Infection Control Practices Advisory Committee. Recommendations for Preventing the Spread of Vancomycin Resistance Recommendations of the Hospital Infection Control Practices Advisory Committee(HICPAC). 1995.http://www.cdc.gov/mmwr/preview/mmwrhtml/00039349.htm
Competing interests: No competing interests