Pneumonia in the critically ill hospitalized patient: part 9
Two recent randomized trials of mechanically ventilated intensive care unit patients given stress ulcer prophylaxis with sucralfate compared to conventional agents, found lower rates of pneumonia in patients given sucralfate. In Trybas study, rates of pneumonia were increased 3-fold for patients receiving antacids compared to those given sucralfate. In the study by Driks et al, 61 patients were randomized to sucralfate and 69 patients to conventional therapy; antacids (N = 39), H2-blockers (N = 17), and antacids and H2-blockers (N = 13). Rates of pneumonia were 12 percent in the sucralfate group compared to 23 percent for patients treated with antacids and/or H2- blockers. Of note, pneumonia occurred in only 1 of the 17 patients who received an H2-blocker alone as prophylaxis against stress bleeding. The low rate of pneumonia in the H2-blocker alone group suggests the need for additional randomized trials to assess risk and benefit compared to sucralfate. The H2-blocker group was comprised mostly of medical intensive care unit patients who may be at less risk for pneumonia.
Driks et al also reported that qualitative and quantitative gastric colonization with Gram-negative bacilli was significantly lower in patients given sucralfate compared to patients given conventional therapy. Laggener et al also reported colonization was significantly lower in the patients who received sucralfate compared to patients who were treated with ranitidine. Although the changes in gastric colonization were most likely related to gastric pH, two recent reports have suggested that sucralfate may have intrinsic bactericidal activity. cialis professional
Dr. Niederman: In addition to careful attention to gastrointestinal bleeding prophylaxis, how can pneumonia be prevented in patients at risk? Dr. Craven: Another approach to the prevention of pneumonia and other nosocomial infections has been selective decontamination of the trachea, oropharynx, and gastrointestinal tract with antobiotics. Stouten- beek et al applied polymyxin B, tobramycin, and amphotericin В (РТА) paste four times daily in the oropharnyx, along with the use of a solution of these antibiotics given via the nasogastric tube to eliminate colonization in the stomach and upper gastrointestinal tract. Systemic cefotaxime was also administered for variable periods to treat incubating infections. Using this regimen, nosocomial infections were reduced from 81 percent in 59 historic control subjects to 16 percent in 63 patients receiving the prophylactic antibiotic regimen, and “respiratory tract infection” was reduced from 59 percent in the control group compared to 8 percent for patients receiving prophylaxis,
Unertl et al administered a solution of polymyxin B, gentamicin, and amphotericin В to the nose, oropharynx, and stomach of 19 intubated patients who were expected to receive more than six days of mechanical ventilation and compared infection rates to 20 control patients. Colonization of the oropharynx and trachea were significantly lower (p <.001) in the group given antibiotic prophylaxis. Nine cases of pneumonia were identified in the control group compared to one case in the group given antibiotic prophylaxis.
In a more recent study of intensive care unit patients by Ledingham et al, selective decontamination with a regimen similar to that of Stoutenbeek et al reduced the number of respiratory infections 6-fold compared to historic control subjects (18 vs 3). There was also a significant reduction in the colonization rates with aerobic Gram-negative bacilli in the oropharynx and rectum of patients given prophylaxis compared to historical controls.
Flaherty et al randomized patients in a cardiac intensive care unit to receive sucralfate compared with selective decontamination of the oropharynx and stomach with gentamicin, nystatin, and polymyxin; no systemic third generation cephalosporin was included. Overall, rates of infection were 27 percent in the sucralfate group vs 12 percent in the selective decontamination group. Overall, there were five eposides of pneumonia in the sucralfate group compared to one in the antibiotic prophylaxis group. Patients in the sucralfate group had three Gram-negative pneumonias compared to none in the antiobiotic group. Although there were no significant differences in ICU stay or fatality rates, antibiotic use was increased 3-fold in the sucralfate group. Antibiotic resistance was not observed, but the duration of the study was short. suhagra 100
With the exception of the study of Flaherty et al, most of the data on selective decontamination of the oropharynx and gastrointestinal tract has been tried in multiple trauma patients with results compared to historic controls. Of note is the absence of any change in fatality rates despite the marked decrease in nosocomial infections. In addition, it is not clear if selective decontamination will be applicable to chronically ill patients who may develop colonization with more resistant nosocomial pathogens. Although the selection of antibiotic-resistant organisms was not encountered in these studies, more data collected over a longer time period are needed to definitively assess the risks, benefits, and cost effectiveness of antibiotic prophylaxis in the intensive care unit patient.