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1.文献信息：
Title:Comparative efficacy of different concentrations of chlorhexidine for prevention of ventilator-associated pneumonia in intensive care units: A systematic review and network meta-analysis.
不同浓度氯己定预防重症监护病房呼吸机相关性肺炎的疗效比较：系统综述和网状荟萃分析。
Journal:Nursing in Critical Care .
IF//JCR分区: 3.0/Q1.
Keyword:chlorhexidine ; ventilator-associated pneumonia ; network meta-analysis ; randomized controlled trials.
氯己定；呼吸机相关肺炎；网状meta分析；随机对照实验。
Design:A systematic review and network meta-analysis.
系统回顾和网状荟萃分析。
2. 摘要 Abstract：
（译文仅供参考）
Background: Ventilator-associated pneumonia is a common type of hospital-acquired infection in critically ill patients. The implementation of effective oral care with chlorhexidine is known to be an effective intervention to prevent ventilator-associated pneumonia. Nonetheless, no well-supported evidence exists yet to rank the efficacy of various concentrations of chlorhexidine.
背景：呼吸机相关性肺炎是危重患者常见的医院获得性感染类型。使用氯己定进行有效的口腔护理是预防呼吸机相关性肺炎的有效干预措施。然而，目前还没有得到充分的证据来支持对不同浓度氯己定的疗效进行排序。
Study Design: Electronic databases, as well as bibliographies, were systematically searched to find relevant studies published in English from inception until January 1, 2022. We included randomized controlled trials of mechanically ventilated adult patients in intensive care settings comparing at least two of the following treatments: 0.12% chlorhexidine, 0.2% chlorhexidine, 2.0% chlorhexidine, or placebo. The selected outcome was the incidence of ventilator-associated pneumonia. A frequentist network meta-analysis was performed. We ranked the concentrations of chlorhexidine for the selected outcome by p score (estimate of the probability of being the best treatment).
研究设计：系统检索电子数据库和参考书目，查找从研究开始到2022年1月1日发表的相关英文研究。我们纳入了在重症监护环境中进行机械通气的成年患者的随机对照试验，比较了至少两种治疗方法：0.12%氯己定、0.2%氯己定、2.0%氯己定或安慰剂。选择的结局是呼吸机相关性肺炎的发生率。进行频率网状荟萃分析。我们将氯己定的浓度按p值（作为最佳治疗的估计概率）排序。
Results: We included 19 trials with 3183 participants, conducted across nine countries. The use of 2.0% chlorhexidine and 0.12% chlorhexidine decreased the risk of ventilator-associated pneumonia compared with placebo (OR 0.46, 95% CI = 0.28– 0.75; OR 0.49, 95% CI = 0.33–0.71, respectively), whereas the effect resulting from 0.02% chlorhexidine remains unclear (OR 0.78, 95% CI = 0.54–1.13). Our network meta-analysis ranked the 2.0% concentration as the most beneficial for ventilatorassociated pneumonia prevention (p score: 0.92).
结果：我们纳入了19项试验，共有3183名参与者，在9个国家进行。与安慰剂相比，使用2.0%氯己定和0.12%氯己定可降低呼吸机相关肺炎的风险(OR 0.46, 95% CI = 0.28 - 0.75；OR 0.49, 95% CI = 0.33-0.71)，而0.02%氯己定的效果尚不清楚（OR 0.78, 95% CI = 0.54-1.13）。我们的网状荟萃分析将2.0%的浓度列为预防呼吸机相关肺炎最佳的浓度（p值：0.92）。
Conclusion: The 2.0% chlorhexidine and the 0.12% chlorhexidine reduce the risk of ventilator-associated pneumonia in mechanically ventilated patients. According to the results of our network meta-analysis, 2.0% chlorhexidine seems more beneficial.Chlorhexidine needs to be further evaluated in large-scale controlled trials.
结论：2.0%氯己定和0.12%氯己定可降低机械通气患者发生呼吸机相关性肺炎的风险。根据我们网络荟萃分析的结果，2.0%的氯己定似乎更有益。氯己定需要在大规模对照试验中进一步验证。
3.文献新知扩展：
①网状meta结果图分析
原文原句：All of the included studies were two-arm RCTs, comparing different concentrations of CHX with placebo (n = 17)12,15–18,30–41 or against each other (n = 2).11,42 The network of eligible comparisons for VAP is provided in Figure 3a. The 0.12% CHX versus Placebo comparison was the most common comparison (N = 8). Compared with placebo, 2.0% CHX (OR = 0.35; 95% CI = 0.17%–0.70%; p = .003) and 0.12% CHX (OR = 0.52; 95% CI = 0.31%- 0.86%; p = .01) showed a significant reduction in VAP among critically ill patients. However, 0.2% CHX did not show a significant reduction in the odds of VAP compared with placebo (Figure 3b). Ranking analysis revealed that the hierarchy for efficacy in preventing VAP (highest to lowest rank) was 2.0% CHX (p-score: .92), followed by 0.12% CHX (p-score: .65) and then 0.2% CHX (p-score: .34).
所有纳入的研究均为两臂随机对照试验，比较不同浓度的CHX与安慰剂（n = 17）、12、15-18、30-41或相互对照（n = 2）。图3a提供了VAP的合格比较网络。与安慰剂相比，0.12% CHX是最常见的比较（N = 8）。与安慰剂相比，2.0% CHX (OR = 0.35；95% ci = 0.17%-0.70%；p = 0.003)和0.12% CHX (OR = 0.52；95% ci = 0.31%- 0.86%；p = 0.01)显示危重患者的VAP显著降低。然而，与安慰剂相比，0.2% CHX并没有显示出VAP发生几率的显著降低（图3b）。排序分析显示，预防VAP的有效性从最高到最低为2.0% CHX (p-score: 0.92)，其次为0.12% CHX (p-score: 0.65)，最后为0.2% CHX （p-score: 0.34）。
②建议、评估、发展和评价分级（GRADE）框架
原文原句：We applied the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework for rating the certainty in the estimates of the direct and network analyses.
我们应用建议、评估、发展和评价分级（GRADE）框架对直接和网络分析估计的确定性进行评级。
GRADE（Grading of Recommendations Assessment, Development and Evaluation）框架是一种用于评估医疗证据质量和制定临床实践指南的系统方法。它最初由GRADE工作组在2004年提出，并逐渐成为国际上广泛认可和使用的标准。
GRADE框架包括以下几个核心组成部分：
1、证据质量评估：将证据质量分为高、中、低、极低四个等级，以反映研究结果的可信度。
2、推荐强度：根据证据质量和其他考量因素（如患者价值观、资源利用等），将推荐分为“强”或“弱”。
3、证据质量的升降级：初始基于随机对照试验（RCTs）的高质量证据可能因研究限制、不一致性、间接证据、不精确性或发表偏倚而降级；反之，观察性研究可能因设计优势而升级。
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