Network meta-analysis from a pairwise meta-analysis design: to assess the comparative effectiveness of oral care interventions in preventing ventilator-associated pneumonia in critically ill patients

Abstract: Objective: In this research, we assessed the usefulness of network meta-analysis (NMA), in creating a hierarchy to define the most effective oral care intervention for the prevention and management of ventilation-associated pneumonia (VAP). Materials and methods: We applied NMA to a previously published robust pairwise meta-analysis. Statistical analyses were based on comparing rates of total VAP events between intervention groups and placebo-usual care groups. We synthesized a netgraph, reported the ranking order of the interventions, and summarized output by a forest plot with a reference treatment placebo/usual care. Results: The results of this NMA are from the low and high risk of bias studies, and hence, we strongly recommend not to use findings of this NMA for clinical treatment needs, but based on results of the NMA, we highly recommend for future clinical trials. With our inclusion and exclusion criteria for the NMA, we extracted 25 studies (4473 subjects). The NMA included 16 treatments, 29 pairwise comparisons, and 15 designs. Based on results of NMA frequentist-ranking P scores, tooth brushing (P fixed-0.94, P random-0.89), tooth brushing with povidone-iodine (P fixed-0.90, P random-0.88), and furacillin (P fixed-0.88, P random-0.84) were the best three interventions for preventing VAP. Conclusions: Any conclusion drawn from this NMA should be taken with caution and recommend future clinical trials with the results. Clinical relevance: NMA appeared to be an effective platform from which multiple interventions reported in disparate clinical trials could be compared to derive a hierarchical assessment of efficacy in VAP intervention.