3 Ask 圖書資訊學檢索 H的思考：who how when what why where 實證醫學思考：PICO Patient who dialyzed through permanent cathetersIProphylactic antibioticsCPlacebo or without antibioticsOPrevention of catheter related infection and other complication圖書資訊學檢索H的思考：who how when what why where實證醫學思考：PICOPatient: Patient Basic BackgroundIntervention or Indicator: 預後-預測以後Comparator: 比較Outcome: 預期效益
4 Evidence-Based Practice Tools Summary Cochrane LibraryCochrane Database of Systematic Reviews (Cochrane Reviews)Database of Abstracts of Reviews of Effects (Other Reviews - DARE)PubMed MEDLINE - Systematic ReviewsBMJ Clinical EvidenceDynaMedUSPSTF Guidelines | AHRQ Evidence Reports | FPIN Clinical Inquiries included in Journal of Family Practice and American Family Physician Indexed in PrimeAnswersPubMed Clinical QueriesCochrane LibraryCochrane Central Register of Controlled Trials (Clinical Trials)ACP Journal ClubPOEMS (Patient Oriented Evidence that Matters)Bandolier | BestBETsNatural Medicines Comprehensive DatabasePubMedNational Guideline ClearinghousePrimeAnswers | Care Provider Toolkit
5 Acquire The Cochrane Library (www.thecochranelibrary.com) Main search keywords:H*emodialysisCatheter*Infection*Advanced Search:(Cochrane or meta-analysis or Systematic review)
6 No related topics was found ! AcquireCochrane Database of Systematic Reviews(Cochrane Reviews)No related topics was found !
7 3 related topics was found ! AcquireDatabase of Abstracts of Reviews of Effects (Other Reviews - DARE)3 related topics was found !
8 Acquired Journal (1)Meta-analysis: Antibiotics for Prophylaxis against Hemodialysis Catheter–Related InfectionsAnn Intern Med. 2008;148:
11 Appraisal Check List 1. PICO P: Adults receiving long-term hemodialysis using a central venous catheterI: Use of an antibiotic applied topically to the catheter exit site or instilled intraluminally into the catheterC: With another or no antimicrobial agentO: Catheter-related bloodstream infection rate or secondary outcomes of interest
12 2．Is any study missed？ ①Database？ ②Keywords? 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)
13 Appraisal Check List③Reference list review: YES④Contact to Authors: YES⑤Unpublished studies: Eligible⑥Duplicate publications: Excluded⑦Language: regardless
14 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 antibioticsNo 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.
15 4. Reviewer numbers:2 reviewers independently evaluated articles for eligibility in a 2-stage procedure.
25 ApplyBoth topical and intraluminal antibiotics reduced the 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.
26 Limitation The evidence base included only 16 trials Most had less than 6 months of follow-upOnly one third of studies were blinded.Publication bias was evident.
28 Acquire (2)A meta-analysis of hemodialysis catheter locking solutions in the prevention of catheter-related infectionAmerican Journal of Kidney Diseases, Vol 51, No 2 (February), 2008: pp
29 Appraisal Check List 1. PICO P: Adults receiving long-term hemodialysis using a central venous catheterI: Use antimicrobial lock solutions (ALSs)C: Heparin onlyO: CRI per 1,000 catheter-days
30 2．Is any study missed？ ①Database？ ②Keywords? Cochrane Central Register of Controlled TrialsMEDLINE to 2005,EMBASE (up to 2005CINAHL②Keywords?end stage renal diseaseh(a)emodialysis,catheter related bacter(a)emiaantibiotic lock(ing) solution
31 Appraisal Check List③Reference list review: YES④Contact to Authors: not mention⑤Unpublished studies: Eligible⑥Duplicate publications: Nil⑦Language: English only
32 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
38 ApplyThis 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.
40 Acquire (3)Preventing haemodialysis catheter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trialsNephrol Dial Transplant (2008) 23: 1666–1672
41 Appraisal Check List 1. PICO P: Adults receiving long-term hemodialysis using a central venous catheterI: Use antimicrobial lock solutions (ALSs)C: Heparin onlyO: CRI per 1,000 catheter-days
42 2．Is any study missed？ ①Database？ ②Keywords? Pubmed, from 1990 until March (same in below)MedlineWeb of ScienceThe Cochrane Library databaseMajor nephrology journals②Keywords?Dialysis, Catheter lock, Bacteraemia, Sepsis, Septicaemia, Infection and prophylaxis
43 Appraisal Check List③Reference list review: YES④Contact to Authors: YES⑤Unpublished studies: Exclude⑥Duplicate publications: Exclude⑦Language: Regardless
44 Appraisal Check List3.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
50 ApplyCatheter 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 incidenceLimit: 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.
51 Kidney International (2006) 70, 1629–1635 Tunneled catheters’ outcome optimization among diabetics on dialysis through antibiotic-lock placementKidney International (2006) 70, 1629–1635
52 PICO of this studyP: Diabetics dialyzed through tunneled-cuffed cathetersI: ‘locked’ with cefotaxime/heparinC: filled with standard heparin onlyO: prevention of thrombotic and infectious complication-related morbidity and mortality
53 Appraisal Patient: Include criteria: All the diabetic ESRD patients were eligible for the study if they required insertion of a TCC (SC or IJC) for the maintenance or initiation of HD between March 2002 and February at our Tertiary Care CenterReinsertion of a TCC through a new access site were also included
55 Appraisal Exclude criteria: Active sepsis/receiving prolonged (more than 7 days) antibiotic therapy (oral/parenteral)Allergy to cephalosporinsPatients who could not be randomized within three dialysis sessions of new TCC insertionHad the exchange over guidewire of a TCC through the same exit site
56 Appraisal Intervention: Group I with cefotaxime–heparin lock (cefotaxime, 10 mg/ml and heparin, 5000 U/ml)Comparison:Group II with standard heparin lock (5000 U/ml)
57 AppraisalOutcome:Thrombosis: inability to use the catheter at a blood ﬂow of 200 ml/min; No respond to intraluminal thrombolysis with t-plasminogen activator.Catheter infection: growth of ≥15 colony-forming units (by semiquantitative roll-plate technique)
58 Catheter exit-site infection: Positive (semi-)quantitative culture of the drainage material with local signs of inﬂammation.Catheter-related bloodstream infections (CRBSI):The same organism (i.e. identical species, antibiogram) from a quantitative culture of the distal segment of catheter and from the blood
59 Randomize qualityThe randomization was performed using sequentially numbered, opaque, sealed envelopes.The sequence of interventions was obtained from a computer-generated random number list to ensure the concealment of the patient’s assignment to a particular group.
62 Masking Double blind Patient: randomized, consealment All the authors/investigators, including microbiologists and HD staff involved in the study, were blinded to the patient’s allocation to the treatment groups
63 Enough sample? The sample size:110 TCCs (55 in each group) Calculated to be of power to detect 30% difference in the two treatments at a one-sided 0.05 level of signiﬁcanceBased on baseline risk of 2.5 CRBSI episodes/1000 catheter daysα error: 5% / β error: 70%