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Prevention and Treatment of Hospital-acquired Pneumonia
range Acute Physiology And Chronic Health Evaluation (APACHE) II significantly. Comparative data from randomised trials suggest a
score on admission only.
52
In the other, larger, study, SDD administered trend towards reduced VAP with sucralfate, but there is a slightly
to 466 patients in one unit was associated with a relative risk of ICU higher rate of clinically significant gastric bleeding compared with
and hospital mortality of 0.65 and 0.78%, respectively, compared with H
2
antagonists. If needed, stress bleeding prophylaxis with either H
2
472 patients admitted in a control ward.
53
In addition, infections antagonists or sucralfate is acceptable.
44,66–71
caused by antibiotic-resistant micro-organisms occurred more
frequently in the control ward. Importantly, levels of antibiotic- A prospective, randomised trial comparing liberal and conservative
resistant pathogens were low in both wards, with complete absence ‘triggers’ to transfusion in ICU patients not exhibiting active
of methicillin-resistant Staphylococcus aureus (MRSA). Additionally, a bleeding and without underlying cardiac disease demonstrated that
small pre-existing difference in outcome between two wards and the awaiting a haemoglobin level of 7.0g/dl as opposed to a level of
absence of a cross-over design warrant confirmation of these 9.0g/dl before initiating transfusion resulted in less transfusion and
beneficial effects of SDD. no adverse effects on outcome.
72
The preventative effects of SDD for HAP have also been
considerably lower in ICUs with high endemic levels of antibiotic
resistance. In such a setting, SDD may increase the selective
Hyperglycaemia, relative insulin
pressure for antibiotic-resistant micro-organisms.
54–60
Although SDD
deficiency or both may directly
reduces HAP, routine prophylactic use of antibiotics should be
discouraged, especially in hospital settings where there are high
or indirectly increase the risk of
levels of antibiotic resistance.
complications and poor outcomes
Routine prophylaxis of HAP with SDD – with or without systemic
in critically ill patients.
antibiotics – reduces the incidence of ICU-acquired pneumonia and
has helped contain outbreaks of MDR bacteria, but is not
recommended for routine use, especially in patients who may be In those patients who were less severely ill, as judged by low APACHE
colonised with MDR pathogens. II scores, mortality was improved in the ‘restricted transfusion’ group,
a result thought to arise from the immunosuppressive effects of non-
The role of systemic antibiotics in the development of HAP is less leukocyte-depleted red blood cell units with consequent increased
clear. In one study, prior administration of antibiotics was risk of infection. Multiple studies have identified exposure to
associated with a three-fold increase in the risk of development of allogeneic blood products as a risk factor for post-operative infection
late-onset ICU-acquired pneumonia.
61
In addition, antibiotics clearly and post-operative pneumonia, and the length of time of blood
predispose patients to subsequent colonisation and infection with storage as another risk factor.
73–77
antibiotic-resistant pathogens.
62
In a prospective, randomised, controlled trial, the use of leukocyte-
In contrast, in another study prior antibiotic exposure conferred depleted red blood cell transfusions resulted in a reduced incidence
protection for ICU-acquired pneumonia.
63
It has been noted that of post-operative infections and, specifically, a reduced incidence of
antibiotic use at the time of emergent intubation may prevent post-operative pneumonia in patients undergoing colorectal
pneumonia within the first 48 hours of intubation.
64
The surgery.
75
Routine red blood cell transfusion should be conducted
preventative effects of intravenous antibiotics were evaluated in with a restricted transfusion trigger policy. Whether leukocyte-
only one randomised trial: administration of cefuroxime for 24 depleted red blood cell transfusions will further reduce the
hours at the time of intubation reduced the incidence of early- incidence of pneumonia in broad populations of patients at risk
onset ICU-acquired pneumonia in patients with closed head remains to be determined.
injuries.
65
However, its routine use is not recommended until more
data become available. Circumstantial evidence of the efficacy of Hyperglycaemia, relative insulin deficiency or both may directly or
systemic antibiotics also follows from the results of meta-analyses indirectly increase the risk of complications and poor outcomes in
of SDD, which have suggested that the intravenous component of critically ill patients. A randomised clinical trial in surgical ICU
the regimens was largely responsible for improved survival.
46
patients was designed to assess whether patients should receive
either intensive insulin therapy to maintain blood glucose levels
In summary, prior administration of systemic antibiotics has between 80 and 110mg/dl or conventional treatment.
78
The group
reduced the risk of nosocomial pneumonia in some patient groups, receiving intensive insulin therapy had reduced mortality and the
but if a history of prior administration is present at the time of onset difference was greater in patients who remained in the ICU for
of infection, there should be increased suspicion of infection with more than five days. Compared with the control group, those
MDR pathogens.
53–55,57–60
treated with intensive insulin therapy had a 46% reduction of
bloodstream infections, decreased frequency of acute renal failure
Stress Bleeding Prophylaxis, requiring dialysis by 41%, fewer antibiotic treatment days and a
Transfusion and Glucose Control significantly shorter length of mechanical ventilation and ICU stay.
Histamine type 2 (H
2
) antagonists and antacids have been identified Intensive insulin therapy is recommended to maintain serum
as independent risk factors for ICU-acquired pneumonia. Sucralfate glucose levels between 80 and 110mg/dl in ICU patients to reduce
has been used for stress bleeding prophylaxis as it does not nosocomial bloodstream infections, duration of mechanical
decrease intragastric acidity or increase gastric volume ventilation, ICU stay, morbidity and mortality.
EUROPEAN RESPIRATORY DISEASE 61
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