Immune-modulating enteral nutrition does not reduce infections in the ICU

1. High protein enteral nutrition enriched with immune-modulating nutrients (IMHP) did not reduce infections in mechanically ventilated adults compared to high protein enteral nutrition (HP).

2. Compared to the HP group, a higher 6-month mortality rate was observed in IMHP group. 

Evidence Rating: 1 (Excellent) 

Study Rundown: Critically ill patients in the intensive care unit (ICU) require nutritional interventions to improve recovery. However, debate persists on whether these nutritional interventions should include immune-modulating nutrients such as glutamine, omega-3 fatty acids, selenium and antioxidants, which are thought to aid in recovery by modulating inflammatory and oxidative stress processes. This study was a randomized clinical trial comparing immune-modulating nutrients (IMHP) to high protein enteral nutrition (HP) in adult, mechanically-ventilated patients in the ICU who required at least 72 hours of enteral nutrition. The primary outcome was the incidence of new infections. There was no evidence that IMHP reduced the incidence of new infections compared to HP. Moreover, the study demonstrated a significant increase in 6-month mortality rate in patients who received IMHP.

The major strength of this investigation is the study design: an international, multi-center, double-blind, randomized controlled trial with an intention to treat analysis. One limitation was that IMHP combined multiple nutrients in the feed, which diminished the ability to discern a difference between any one component. Additionally, a lack of data on prescreened patients for inclusion may have led to selection bias. However, the authors note that baseline Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and mean ages were similar in their study compared to others, suggesting that the bias may be limited.

Click to read the study, published today in JAMA

Relevant Reading: Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

In-Depth [randomized controlled trial]: This study included 301 mechanically-ventilated adults in intensive care units that required enteral nutrition underwent randomization into two groups: high protein enteral nutrition with, or without, immune-modulating nutrients. The primary outcome was the incidence of infections. No differences were observed; 53% of patients in the IMHP group and 52% of patients in the HP group had new infections (95% CI 44-61%, p=0.96). Additionally, no differences were observed in the mean number of infections per patient, infections per patient per ICU-day, duration of infection, type of infection or incidence of infections by subgroups consisting of medical, surgical or trauma ICUs. However, when adjusted for age and APACHE II score, 6-month mortality was greater in the IMHP group compared to the HP group by Cox proportional hazard ratio (1.57, 95% CI 1.03-2.39, p=0.04).

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