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Appraisal Check List • 1. PICO • P: Adults receiving long-term hemodialysis using a central venous catheter • I: Use of an antibiotic applied topically to the catheter exit site or instilled intraluminally into the catheter • C: With another or no antimicrobial agent • O: Catheter-related bloodstream infection rate or secondary outcomes of interest
2．Is any study missed？ • ①Database？ • MEDLINE (1966 through October 2007) • EMBASE (1980 through October 2007) • Cochrane Central Register of Controlled Trials (1996 through October 2007) • ②Keywords? • Catheter-related bloodstream infection (searching for catheter-related bloodstream infection, bacteremia, or septicemia) • Dialysis (searching for renal dialysis) • Catheter (searching for indwelling catheter, catheterization, central venous catheter, or hemodialysis catheter)
Appraisal Check List • ③Reference list review: YES • ④Contact to Authors: YES • ⑤Unpublished studies: Eligible • ⑥Duplicate publications: Excluded • ⑦Language: regardless
Appraisal Check List • 3.Publication Bias: • Using funnel plots, the Begg test(P=0.001) for asymmetry, and an Egger test (P=0.085) for trials of intraluminal antibiotics • No test for trials of topical antimicrobial agents (∵ small number of these studies) • Funnel plot suggested an absence of publication of small studies that showed lesser benefits for intraluminal antibiotics than seen in the identified trials.
4. Reviewer numbers: • 2 reviewers independently evaluated articles for eligibility in a 2-stage procedure.
Apply • Both topical and intraluminal antibiotics reducedthe rate of bacteremia as well as the need for catheter removal secondary to complications. • Whether these strategies will lead to anti-microbial resistance and loss of efficacy over longer periods remains unclear.
Limitation • The evidence base included only 16 trials • Most had less than 6 months of follow-up • Only one third of studies were blinded. • Publication bias was evident.
Acquire (2) • A meta-analysis of hemodialysis catheter locking solutions in the prevention of catheter-related infection • American Journal of Kidney Diseases, Vol 51, No 2 (February), 2008: pp 233-241
Appraisal Check List • 1. PICO • P: Adults receiving long-term hemodialysis using a central venous catheter • I: Useantimicrobial lock solutions (ALSs) • C: Heparin only • O: CRI per 1,000 catheter-days
2．Is any study missed？ • ①Database？ • Cochrane Central Register of Controlled Trials • MEDLINE 1966 to 2005, • EMBASE (up to 2005 • CINAHL • ②Keywords? • end stage renal disease • h(a)emodialysis, • catheter related bacter(a)emia • antibiotic lock(ing) solution
Appraisal Check List • ③Reference list review: YES • ④Contact to Authors: not mention • ⑤Unpublished studies: Eligible • ⑥Duplicate publications: Nil • ⑦Language: English only
Appraisal Check List • 3.Publication Bias: Not mentioned • 4. Reviewer numbers: • 2 reviewers independently evaluated articles for eligibility in a 2-stage procedure. Differences were resolved by discussion
Apply • This meta-analysis of randomized controlled trials supports the effectiveness of ALSs as a successful strategy to decrease the incidence of CRI in HD patients. All ALSs studied were effective in this way, and the overall number needed to treat to prevent 1 CRI was small.
Acquire (3) • Preventing haemodialysis catheter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials • Nephrol Dial Transplant (2008) 23: 1666–1672
Appraisal Check List • 1. PICO • P: Adults receiving long-term hemodialysis using a central venous catheter • I: Useantimicrobial lock solutions (ALSs) • C: Heparin only • O: CRI per 1,000 catheter-days
2．Is any study missed？ • ①Database？ • Pubmed, from 1990 until March 2007. (same in below) • Medline • Web of Science • The Cochrane Library database • Major nephrology journals • ②Keywords? • Dialysis, Catheter lock, Bacteraemia, Sepsis, Septicaemia, Infection and prophylaxis
Appraisal Check List • ③Reference list review: YES • ④Contact to Authors: YES • ⑤Unpublished studies: Exclude • ⑥Duplicate publications: Exclude • ⑦Language: Regardless
Appraisal Check List • 3.Publication Bias: Funnel plot showed under-representation of small studies with a low or no effect. • 4. Reviewer numbers: • Not mentioned, perhaps only one (group of) reviewer
Apply • Catheter interdialytic locking with an ALS reduces the incidence of CRB. • Achieved incidence of CRB in the ALS groups is similar to published reports from units with low CRB incidence • Limit: follow-up of studies included in this meta-analysis does not exclude the onset of adverse events or bacterial resistance with longer use of ALS.
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