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Empirical metronidazole for patients with severe bacterial infection: A systematic review with meta‐analysis and trial sequential analysis
Author(s) -
Petersen Marie Warrer,
Perner Anders,
Jonsson Andreas Bender,
Bahador Marjan,
Sjövall Fredrik,
Møller Morten Hylander
Publication year - 2019
Publication title -
acta anaesthesiologica scandinavica
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.738
H-Index - 107
eISSN - 1399-6576
pISSN - 0001-5172
DOI - 10.1111/aas.13327
Subject(s) - medicine , metronidazole , meta analysis , placebo , relative risk , randomized controlled trial , systematic review , confidence interval , medline , intensive care medicine , antibiotics , alternative medicine , pathology , political science , law , microbiology and biotechnology , biology
Background Metronidazole is the preferred empirical anti‐anaerobic agent for patients with suspected anaerobic infection. The balance between benefits and harms of empirical metronidazole is unclear. We aimed to assess patient‐important benefits and harms of empirical metronidazole vs placebo/no treatment in adult patients with severe bacterial infection of any origin. Methods We conducted a systematic review with meta‐analysis and trial sequential analysis of randomized clinical trials assessing empirical metronidazole vs placebo/no treatment in adult hospitalized patients with severe bacterial infection. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) statement, the Cochrane Handbook and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. A protocol and statistical analysis plan was published prior to conducting the review. Results We included a total of nine trials (n = 1753 patients), all of which were adjudicated as having high risk of bias. We found no difference in the primary outcome mortality within 90 days (relative risk 1.56, 95% confidence interval 0.39‐6.25). Fewer patients receiving metronidazole had secondary infections (relative risk 0.43, 95% CI: 0.27‐0.68). Trial sequential analysis indicated high risk of random errors due to lack of data, and the quality of evidence was very low for all outcomes. Conclusions There is low quantity and quality of evidence supporting the use of empirical metronidazole in adult patients with severe bacterial infections of any origin, and no firm evidence for benefit or harm.