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Prophylactic antibiotics for burns patients: systematic review and meta-analysis

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c241 (Published 15 February 2010) Cite this as: BMJ 2010;340:c241

Selective decontamination of the digestive tract reduces mortality in burn patients

We read with interest the well conducted systematic review and meta-
analysis on prophylactic antibiotics in burn patients by Avni et al (1).
The authors did not find any significant impact of selective
decontamination of the digestive tract (SDD) on mortality. We believe that
this is due to both the inclusion of the Spanish SDD study (2) among the
randomized controlled trials (RCTs) using systemic antibiotics rather than
in the group of non-absorbable antibiotic prophylaxis, and the omission of
an Egyptian trial (3). Therefore, only the SDD study by Barret et al. (4)
was analysed by the authors in the group of non-absorbable antibiotic
prophylaxis. Not surprisingly, the Spanish trial (2) includes a four-day
course of parenteral cefotaxime, which is part of the full SDD regimen
including parenteral and enteral antimicrobials, high level of hygiene,
and surveillance cultures of throat and rectum. A meta-analysis of those
two RCTs (2, 4) demonstrates a survival benefit of SDD, albeit in a small
sample size (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.11-0.82;
p = 0.019). Remarkably, a recent meta-analysis of the three published SDD
RCTs in burn patients, recruiting 440 patients (289 SDD, 151 control),
confirmed that SDD significantly reduced mortality by 78% (OR 0.22; 95% CI
0.12-0.43; p<0.001) (5).

Only two SDD RCTs (2, 4) in burn patients reported data on the
endpoint of pneumonia. In the Spanish study (2) the rate of pneumonia/1000
ventilator-days was significantly reduced (38.8 vs 17, p= 0.03). Primary
endogenous pneumonias were completely prevented using SDD, whilst there
was no difference in the incidence of secondary endogenous pneumonias
which were mainly caused by methicillin-resistant Staphylococcus aureus
intrinsically resistant to the SDD antibiotics. In the small paediatric
study (4) pneumonia had similar incidence in test and control group.

We fully agree with the authors that SDD using parenteral and enteral
antimicrobials is the optimal regimen for infection control in burn
patients.

References

1. Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul M. Prophylactic
antibiotics for burns patients: systematic review and meta-analysis. BMJ
2010;340:c241.

2. de la Cal MA, Cerdá E, García-Hierro P, van Saene HKF, Gomez-
Santos D, Negro E, et al. Survival benefit in critically ill burned
patients receiving selective decontamination of the digestive tract: a
randomized, placebo-controlled, double-blind trial. Ann Surg 2005; 241:424
-430.

3. Abdel-Razek SM, Abdel-Khalek AH, Allam AM, Shalaby H, Mandoor S,
Higazi M. Impact of selective gastrointestinal decontamination on
mortality and morbidity in severely burned patients. Annals of Burns and
Fire Disasters 2000;13:213-215.

4. Barret JP, Jeschke MG, Herndon DN. Selective decontamination of
the digestive tract in severely burned pediatric patients. Burns
2001;27:439-445.

5. Silvestri L, de la Cal MA, Taylor N, van Saene HKF, Parodi PC.
Selective decontamination of the digestive tract in burn patients: an
evidence-based maneuver that reduces mortality. J Burn Care Res
2010;31:372-373.

Competing interests:
None declared

Competing interests: No competing interests

16 March 2010
Luciano Silvestri
Head, Department of Emergency and Unit of Anaesthesia and Intensive Care
Hendrick K.F. van Saene, Pier Camillo Parodi, and Miguel A. de la Cal
Presidio Ospedaliero, 34170 Gorizia, Italy