Methods of preventing bacterial sepsis and wound complications for liver transplantation

  • Review
  • Intervention

Authors


Abstract

Background

Bacterial sepsis and wound complications after liver transplantation increase mortality, morbidity, hospital stay, and overall transplant costs.

Objectives

To assess the benefits and harms of different methods aimed at preventing bacterial sepsis and wound complications in patients undergoing liver transplantation.

Search methods

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until June 2007.

Selection criteria

We included only randomised clinical trials irrespective of language or publication status.

Data collection and analysis

We collected the data on infections, adverse effects of intervention, ITU (intensive therapy unit) stay, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis and risk ratio (RR) or weighted mean difference (WMD) with 95% confidence intervals (CI) based on intention-to-treat analysis.

Main results

We identified seven trials for inclusion including 614 patients. Four trials compared selective bowel decontamination versus placebo or no treatment. In one trial, patients were randomised to selective bowel decontamination, active lactobacillus with fibres (probiotic with prebiotic), or to inactivated lactobacillus with fibres (prebiotic). In another trial, different doses of granulocyte-colony stimulating factor and placebo were compared. The remaining two trials compared lactobacillus with fibres versus fibres alone and early enteral feeding versus no intervention. Only one trial was of low bias-risk. There was no statistically significant difference in any outcome between the selective bowel decontamination and the control groups. Selective bowel decontamination increased incidence of cholangitis (RR 4.84, 95% CI 1.15 to 20.35), incidence of bacterial infection (RR 3.63, 95% CI 1.36 to 9.74), and hospital stay (WMD 4.00, 95% CI 3.14 to 4.86) than the participants in the combined pre- and probiotic group. Hospital stay was prolonged in the selective bowel decontamination group compared to the prebiotic group. There was a statistically significant lower occurrence of urinary infection in the pre- and probiotic group than in the prebiotic group. The number of people experiencing gram-negative bacterial infection was not significantly lower in the probiotic group (RR 0.18, 95% CI 0.03 to 1.17). The ITU stay was lower in the probiotic group (WMD -1.41 days, 95% CI -2.09 to -0.73). There were no differences in any outcomes in the other comparisons.

Authors' conclusions

Currently, there is no clear evidence for any intervention offering significant benefits in the reduction of bacterial infections and wound complications in liver transplantation. Selective bowel decontamination increases the risk of infection and hospital stay compared to prebiotics and probiotics. The use of prebiotics and probiotics offers promise. Further randomised clinical trials are necessary.

摘要

背景

預防肝移植出現細菌性敗血症和傷口併發症的方法

肝移植之後出現的細菌性敗血症和傷口併發症提高死亡率、發病率、住院日和總體移植成本。

目標

評估各種方法預防肝移植病人出現細菌性敗血症傷口併發症的利弊。

搜尋策略

我們搜尋截至2007年6月The Cochrane HepatoBiliary Group Controlled Trials Register、Cochrane Library的Cochrane Central Register of Controlled Trials (CENTRAL)、 MEDLINE、EMBASE和Science Citation Index Expanded。

選擇標準

我們只收納隨機臨床試驗,不受語言或發表狀態的限制。

資料收集與分析

我們收集有關感染、治療的不良反應、加護病房停留時間和住院日等資料。我們以治療意向分析,使用RevMan 以固定效果模式和隨機效果模式分析資料,風險比率 (risk ratio,RR),加權平均差(weighted mean difference,WMD),及其95%信賴區間 (CI)。

主要結論

我們找出有7個試驗供收錄,包括614 位病人。4個試驗比較選擇性腸道清除細菌感染和安慰劑或無治療。一次試驗隨機挑選病人服用活性乳酸桿菌和纖維素(益生菌和益菌生)對照無活性乳酸桿菌和纖維素 (益菌生)。另外一次試驗比較各種劑量的顆粒細胞落刺激因子和安慰劑。 其餘的2次試驗分別比較乳酸菌聯合纖維素對照纖維素,早期腸道餵養對照無治療。只有1次試驗的偏差風險低。選擇性腸道清除細菌感染和控制組在任何結果上沒有統計上的顯著差異。和聯合益菌生和益生菌組的受試者相比,選擇性腸道清除細菌感染會增加膽管炎發病率 (RR 4.84, 95% CI 1.15 20.35),細菌感染發病率 (RR 3.63, 95% CI 1.36 9.74),延長住院日 (WMD 4.00, 95% CI 3.14 4.86)。和益菌生組相比,選擇性腸道清除細菌感染組延長住院日。添加益生菌益菌生組和益生菌組在尿道感染的發生率上沒有統計顯著性。 在益生菌組,患有革蘭氏陰性細菌感染的人數沒有明顯低於另一組(RR 0.18, 95% CI 0.03 1.17). 益生菌組的加護病房停留時間較短(WMD −1.41 天, 95% CI −2.09 – 0.73)。 其他比較結果沒有顯示差異。

作者結論

目前還沒有明確的證據指出任意一種治療法對降低肝移植引起的細菌感染和傷口併發症明顯有益。 和益菌生和益生菌組相比, 選擇性腸道清除細菌感染增加了感染風險和住院日。 需要進一步的隨機臨床試驗。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

沒有明確的證據指出任意一種治療法對降低肝移植引起的細菌感染和傷口併發症明顯有益: 肝移植之後引起的細菌性敗血症和傷口併發症增加死亡率、發病率、住院日和總體的移植成本。 有許多試圖減輕細菌性敗血和傷口併發症的方式。本次文獻回顧一共包括7個隨機臨床試驗,有614 位病人參加。4個試驗比較選擇性腸道清除細菌感染和(也就是,在腸道中延長使用抗生素清理器官)控制組(安慰劑或無治療治)。一個試驗比較選擇性腸道清除細菌感染,益生菌(纖維素),益菌生添加益生菌(活性乳酸桿菌)。一個試驗比較添加益生菌益菌生組和益生菌組。一個試驗評估顆粒細胞落刺激因子和安慰劑。沒有明確的證據指出何種治療法對病人有益。和添加益生菌益菌生組相比, 選擇性腸道清除細菌感染可能會增加感染風險,延長住院日。

Plain language summary

No clear evidence that any intervention is beneficial in reducing bacterial infectious complications and wound complications in liver transplantation

Bacterial sepsis and wound complications after liver transplantation increase mortality, morbidity, hospital stay, and overall transplant costs. Various methods have been attempted to decrease the bacterial sepsis and wound complications. A total of seven randomised clinical trials involving 614 patients were included in the review. Four trials compared selective bowel decontamination, ie, prolonged use of antibiotics to clear organisms in the gut) compared with control (placebo or no treatment). One trial compared selective bowel decontamination, prebiotics (fibres), and a combination of prebiotics and probiotics (living lactobacillus). One trial compared pre- and probiotics versus prebiotics. One trial assessed granulocyte-colony stimulating factor and placebo. There is no clear evidence that any of the interventions may benefit the patients. Selective bowel decontamination may even increase the risk of infection and hospital stay compared to pre- and probiotics.