Incidence Of Nosocomial Pneumonia Research Articles

Risk factors for nosocomial pneumonia in a geriatric hospital: a control-case one-center study.

To determine the risk factors (RFs) and the incidence of nosocomial pneumonia (NP). Control/case study conducted from January 1 to April 15, 1999. Prospective enrollment. Geriatric university hospital with long-, intermediate-, and short-term care facilities. Inpatients aged 65 and older with NP. NP diagnosis relied on at least two clinical signs of respiratory infection and on chest radiography. Each NP case was randomly paired with two controls and followed up for 30 days to determine complication and mortality rates. RFs between cases and controls were compared (chi-square test, odds ratio (OR), 95% confidence interval, significance level P =.05). RFs that were significant in univariate analysis were tested using multivariate analysis and logistic regression. Seventy-five cases of NP were diagnosed in 2,142 patients. The average incidence rate was 3.5% (short-term facilities = 0.5%; intermediate-term facilities = 8.3%; long-term care facilities = 5.3%). The complication rate was 58.1%. The most frequent complications were recurrent NP, heart and respiratory failure, phlebitis, and pressure ulcers. The NP mortality rate was 12.2%. The independent RFs of NP were a history of NP during the previous 6 months (OR = 4.50) and oxygen therapy (OR = 16.15), P <.001. Additional RFs were severe malnutrition, heart failure, prescription of antibiotics during the month preceding the emerging NP, eating dependency, and feeding by nasogastric tube. The main RF for NP is a history of pneumonia. NP prevention in geriatrics should rely on early management of respiratory infections and malnutrition, surveillance of oxygen therapy and enteral feeding, rational use of antibiotics, and adaptation to the patient's dependency.

Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in the intensive care unit: a prospective multicenter study.

The authors prospectively evaluated the occurrence and outcomes of unplanned extubations (self-extubation and accidental extubation) and reintubation after weaning, and examined the hypothesis that these events may differ regarding their influence on the risk of nosocomial pneumonia. Data were taken from a prospective, 2-yr database including 750 mechanically ventilated patients from six intensive care units. One hundred five patients (14%) experienced at least one episode of these 3 events; 51 self-extubations occurred in 38 patients, 24 accidental extubations in 22 patients, and 56 reintubations after weaning in 45 patients. The incidence density of these 3 events was 16.4 per 1,000 mechanical ventilation days. Reintubation within 48 h was needed consistently after accidental extubation but was unnecessary in 37% of self-extubated patients. Unplanned extubation and reintubation after weaning were associated with longer total mechanical ventilation (17 vs. 6 days; P < 0.0001), intensive care unit stay (22 vs. 9 days; P < 0.0001), and hospital stay (34 vs. 18 days; P < 0.0001) than in control group, but did not influence intensive care unit or hospital mortality. The incidence of nosocomial pneumonia was significantly higher in patients with unplanned extubation or reintubation after weaning (27.6% vs. 13.8%; P = 0.002). In a Cox model adjusting on severity at admission, unplanned extubation and reintubation after weaning increased the risk of nosocomial pneumonia (relative risk, 1.80; 95% confidence interval, 1.15-2.80; P = 0.009). This risk increase was entirely ascribable to accidental extubation (relative risk, 5.3; 95% confidence interval, 2.8-9.9; P < 0.001). Accidental extubation but not self-extubation or reintubation after weaning increased the risk of nosocomial pneumonia. These 3 events may deserve evaluation as an indicator for quality-of-care studies.

Increased IL-10 production and HLA-DR suppression in the lungs of injured patients precede the development of nosocomial pneumonia.

The incidence of nosocomial pneumonia (NP) among injured patients is substantial. We hypothesize that traumatic injury induces alterations in local organ effector cell function that may predispose the lungs of injured patients to infection. It is the objective of this study to compare the systemic and alveolar effector cell response to injury and assess the relationship these have to the development of NP. Peripheral blood and bronchoalveolar lavage fluid (BAL) were collected from 10 elective surgery patients (controls) and 16 multitrauma patients at 12, 36, and 60 h post-injury. Systemic and alveolar levels of IL-8 and IL-10 were measured. CD11b expression on peripheral blood neutrophils (PBN) and alveolar neutrophils (AN) and HLA-DR expression on peripheral blood monocytes (PBM) and alveolar macrophages (AM) were measured. Alveolar levels of IL-8 and IL-10 were significantly higher than systemic levels after injury. HLA-DR expression was reduced on both PBM and AM after injury but was lowest on the AM. Six of 16 patients (38%) developed NP (NP+). There were no differences in cytokine levels (IL-8 and IL-10) or effector cell phenotype (CD11b and HLA-DR expression) within the systemic circulation of NP+ and NP- patients. In contrast, NP+ and NP- patients differed significantly in alveolar cytokine levels and alveolar effector cell phenotype. IL-8 was significantly higher in BAL form NP+ patients at all time points after injury. Furthermore, alveolar levels of IL-10 decreased in NP- patients but increased in NP+ patients. In all patients, AM HLA-DR expression was significantly reduced from normal controls 12 h post-injury. In NP-patients, AM HLA-DR expression returned to normal 60 h post-injury, whereas in NP+ patients, expression remained suppressed. These findings identify distinct trends in local organ cytokine production and alterations in effector cell phenotype that precede NP. The persistence of reduced HLA-DR expression amidst increasing levels of IL-10 in NP+ patients suggest that cell-mediated immune function is being suppressed. As such, local organ immunosuppression may be responsible for the development of nosocomial pneumonia in injured patients.

Incidence of and risk factors for nosocomial pneumonia in patients with tetanus.

From June 1998 through July 2000, 28 patients with tetanus admitted to the Intensive Care Unit for Tetanus and Infectious Diseases at the Hospital das Clínicas of University of Medicine at São Paulo, Brazil, were evaluated to establish what the incidence of nosocomial pneumonia was and what their risk factors were. The degree of severity of tetanus was assessed in all patients by means of APACHE II scores. The mortality rate was 3.6%. There were 63 hospital infections in 20 patients; among these, there were 10 cases of nosocomial pneumonia in 8 patients. Nosocomial pneumonia was associated in univariate analysis with the degree of severity of tetanus, dysautonomy, use of neuromuscular blockers, use of higher doses of diazepam, and lower arterial oxygen and oxygen fractions. In the multiple logistical regression, significance was found for dysautonomy (relative risk, 31.67; 95% confidence interval, 2.68-373.74; P=.006). Dysautonomy was an independent risk factor for pneumonia in patients with tetanus.

Nosocomial pneumonia during acute respiratory distress syndrome

The Acute Respiratory Distress Syndrome (ARDS) shares with nosocomial pneumonia aetiological, physiopathological and diagnostic properties. This report will focus on the importance of nosocomial pneumonia as a complication of ARDS and review data on prevalence, incidence and the impact of nosocomial pneumonia on outcome in patients with ARDS. Prevention strategies are imperative to protect ARDS patients for nosocomial pneumonia. The prevalence of nosocomial pneumonia seems to be at least 8%. The incidence varies largely with the study design but an estimate that every second patient with ARDS will suffer at least one episode of pneumonia during the course of mechanical ventilation, seems to reflect clinical experience and data. However, given the high incidence of nosocomial pneumonia during the course of ARDS and the impact of adequate antibiotic therapy on survival, microbiological surveillance seems to be appropriate even in the clinical routine.

Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial

Risk factors for nosocomial pneumonia, such as gastro-oesophageal reflux and subsequent aspiration, can be reduced by semirecumbent body position in intensive-care patients. The objective of this study was to assess whether the incidence of nosocomial pneumonia can also be reduced by this measure. This trial was stopped after the planned interim analysis. 86 intubated and mechanically ventilated patients of one medical and one respiratory intensive-care unit at a tertiary-care university hospital were randomly assigned to semirecumbent (n=39) or supine (n=47) body position. The frequency of clinically suspected and microbiologically confirmed nosocomial pneumonia (clinical plus quantitative bacteriological criteria) was assessed in both groups. Body position was analysed together with known risk factors for nosocomial pneumonia. The frequency of clinically suspected nosocomial pneumonia was lower in the semirecumbent group than in the supine group (three of 39 [8%] vs 16 of 47 [34%]; 95% CI for difference 10.0-42.0, p=0.003). This was also true for microbiologically confirmed pneumonia (semirecumbent 2/39 [5%] vs supine 11/47 [23%]; 4.2-31.8, p=0.018). Supine body position (odds ratio 6.8 [1.7-26.7], p=0.006) and enteral nutrition (5.7 [1.5-22.8], p=0.013) were independent risk factors for nosocomial pneumonia and the frequency was highest for patients receiving enteral nutrition in the supine body position (14/28, 50%). Mechanical ventilation for 7 days or more (10.9 [3.0-40.4], p=0.001) and a Glasgow coma scale score of less than 9 were additional risk factors. The semirecumbent body position reduces frequency and risk of nosocomial pneumonia, especially in patients who receive enteral nutrition. The risk of nosocomial pneumonia is increased by long-duration mechanical ventilation and decreased consciousness.

Prophylaxis for stress-related gastrointestinal hemorrhage

The incidence of clinically important stress-related gastrointestinal hemorrhage (SRGIH) has decreased without the use of prophylaxis. This decline is probably attributable to improved care in the modern intensive care unit: aggressive correction of hypovolemia, adequate respiratory support, maintenance of tissue perfusion, and improved nutritional support. The majority of patients admitted to intensive care units are not at risk of developing clinically important SRGIH. Patients who are at high risk for SRGIH, and who may, therefore, benefit from prophylaxis, are those with at least one of the factors listed in Table 1. Antacids, histamine type 2-receptor antago-nists (H2 RA), proton pump inhibitors, and sucralfate all provide comparable protection from SRGIH. The choice of pharmacologic agent for prophylaxis therefore depends on other considerations, such as cost, side effects, and ease of administration. In this regard, it is still unclear whether these prophylactic medications increase the inci-dence of nosocomial pneumonia when administered to intensive care unit patients. Antacids may pose the greatest risk for developing pneumonia, followed by H2RA, and sucralfate. More research is necessary to resolve this important issue. Pharmacologic prophylaxis for SRGIH is cost effective only in high- risk populations. Based on existing literature, the cost of using of routine prophylaxis is prohibitive for at least two-thirds of patients admitted to intensive care units who are at low risk of SRGIH. When prophylaxis is administered to high-risk patients, the cost-per-averted-bleeding episode for sucralfate is lower than for other medications.

Incidence of nosocomial pneumonia in a medical intensive care unit and general medical ward patients in a public hospital in Bombay, India

We prospectively studied the incidence of hospital-acquired pneumonia in 1886 consecutive admissions to an 1800 bed hospital in Bombay; 991 of them to general medical wards and 895 to a 17-bed medical intensive care unit (ICU). The average bed occupancy in the general wards was 56 patients in a ward with 40 beds. Staffing in the general ward was two nurses for 56 patients, and in the ICU three nurses for 17 beds. One hundred and sixty-eight patients developed nosocomial pneumonia: 18 (1·8%) in general wards and 150 (16·7%) in the ICU. Common isolates included Pseudomonas spp (44%) and Klebsiella spp (34%). The most frequently used antibiotics were cefotaxime (34%), amikacin (25%), gentamicin (23%) and ofloxacin (13%). Crude mortality in general ward patients was 88·9 vs 14·6% in patients without pneumonia. The corresponding figures for ICU patients were 67·4 vs 37·1%; 40% of the crude mortality in ICU patients with pneumonia was attributable to the infection. Infected patients stayed an additional 5·8 days in the ICU and 6·7 days in the general ward. Costs of additional stay and antibiotics accounted for 18·6% of the ICU budget. The incidence of nosocomial pneumonia was lower than expected, despite occupancy exceeding bed capacity, low nurse:patient ratios, and extensive reuse of disposable respiratory therapy equipment. Nevertheless, nosocomial pneumonia imposes a significant financial burden on the already scarce resources available for intensive care in developing countries like India.

Laboratory Abnormalities in Patients With Bacterial Pneumonia

This study was undertaken to evaluate the laboratory abnormalities observed in patients with bacterial pneumonia as predictors of the severity of illness. Retrospective analysis. Tertiary care hospital. We studied 302 consecutive patients who were admitted to the Long Island Jewish Medical Center from January through December 1993 and treated for bacterial pneumonia. The patients were subdivided into two groups based on their serum phosphorus level either on hospital admission or 4 days before the onset of pneumonia, if this was acquired in-hospital. Hypophosphatemia (group 1) was defined as serum phosphorus level of < or = 2.4 mg/dL and normophosphatemia > 2.4 mg/dL (group 2). Three hundred randomly selected hospitalized patients treated for conditions other than pneumonia comprised the control group (group 3). Groups 1 and 2 were compared with respect to laboratory data, mortality rate, and duration of hospitalization. The laboratory data of patients in group 3 were compared with those treated for bacterial pneumonia (groups 1 and 2). Stepwise multivariate logistic regression analysis was employed to identify the variables that best predicted the onset of pneumonia. In groups 1 and 2, a greater (p < 0.0001) number of patients (135 of 302 patients with pneumonia, 44.7%) developed hypophosphatemia compared with patients in group 3 (31 of 300 control subjects, 10.3%). Patients with pneumonia (groups 1 and 2) had higher levels (p < 0.01) of bicarbonate compared with control subjects. Moreover, patients with pneumonia demonstrated lower levels (p < 0.01) of calcium, phosphorus, albumin, cholesterol, and alanine aminotransferase compared with control patients (group 3). Among patients with pneumonia, those with hypophosphatemia (group 1) had significantly lower levels (p < 0.05) of potassium, calcium, and albumin compared to those subjects with normophosphatemia (group 2). Furthermore, hypophosphatemic subjects manifested higher levels of glucose (p < 0.01) and creatine phosphokinase (p < 0.05) compared to their normophosphatemic counterparts. In addition, hypophosphatemic patients experienced a longer duration of hospital stay (hypophosphatemia, 24.6 +/- 2.0 days, vs normophosphatemia, 14.1 +/- 1.0, p < 0.001) and higher (p < 0.001) mortality compared to normophosphatemic subjects. The incidence of nosocomial pneumonia was higher (p < 0.0001) in hypophosphatemic patients compared to those with normophosphatemia. We conclude that hypophosphatemia, hypocalcemia, hypokalemia, and hypoalbuminemia may be predictors of the severity of illness in patients admitted to the hospital with bacterial pneumonia.

Stress Ulcer Prophylaxis in Critically Ill Patients Resolving Discordant Meta-Analyses

Purpose. —To resolve discrepancies in previous systematic overviews and provide estimates of the effect of stress ulcer prophylaxis on gastrointestinal bleeding, pneumonia, and mortality in critically ill patients. Data Identification. —Computerized search of published and unpublished research, bibliographies, pharmaceutical and personal files, and conference abstract reports. Study Selection. —Independent review of 269 articles identified 63 relevant randomized trials for inclusion. Data Abstraction. —We made independent, duplicate assessment of the methodologic quality, population, intervention, and outcomes of each trial. Results. —The source of discrepancies between prior meta-analyses included incomplete identification of relevant studies, differential inclusion of non—English language and nonrandomized trials, different definitions of bleeding, provision of additional information through direct correspondence with authors, and different statistical methods. The current overview demonstrates that prophylaxis with histamine2-receptor antagonists decreases the incidence of overt gastrointestinal bleeding (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.42 to 0.79) and clinically important bleeding (OR, 0.44; 95% CI, 0.22 to 0.88). There is a trend toward decreased overt bleeding when antacids are compared with no therapy (OR, 0.66; 95% CI, 0.37 to 1.17). Histamine2-receptor antagonists and antacids are associated with a trend toward lower clinically important bleeding rates than sucralfate is. There is a trend toward an increased risk of pneumonia associated with histamine2-receptor antagonists as compared with no prophylaxis (OR, 1.25; 95% CI, 0.78 to 2.00). Sucralfate is associated with a lower incidence of nosocomial pneumonia when compared with antacids (OR, 0.80; 95% CI, 0.56 to 1.15) and histamine2-receptor antagonists (OR, 0.77; 95% CI, 0.60 to 1.01). Sucralfate is also associated with a reduced mortality rate (OR, 0.73; 95% CI, 0.54 to 0.97) relative to antacids and to histamine2-receptor antagonists (OR, 0.83; 95% CI, 0.63 to 1.09). Conclusions. —Our results emphasize the need for registries to include all randomized trials and demonstrate the importance of explicit methodology for systematic reviews. There is strong evidence of reduced clinically important gastrointestinal bleeding with histamine2-receptor antagonists. Sucralfate may be as effective in reducing bleeding as gastric pH—altering drugs and is associated with lower rates of pneumonia and mortality. However, the data are insufficient to determine the net effect of sucralfate compared with no prophylaxis. (JAMA. 1996;275:308-314)

Ranitidine Prophylaxis for Stress-Related Upper Gastrointestinal Bleeding in Patients with Severe Head Injury: Clinical and Pharmacoeconomic Outcome

A clinical program comprised of two randomized, double-blind, placebo-controlled studies was conducted to evaluate the effect of a 6.25 mg/h ranitidine continuous infusion on the development of stress-related upper gastrointestinal bleeding (SR-UGIB) and long-term patient resource utilization in a total of 201 patients with severe head injury. Ranitidine prophylaxis provided statistically significant, almost complete, protection from SR-UGIB in both studies without a corresponding increase in the incidence of nosocomial pneumonia. The development of SR-UGIB was associated with a median 2.5-day increase in intensive-care unit stay and a median 2-day increase in total duration of hospitalization.

Mechanical Ventilation with Heated Humidifiers or Heat and Moisture Exchangers: Effects on Patient Colonization and Incidence of Nosocomial Pneumonia

The contribution of ventilator circuit bacterial contamination to the occurrence of ventilator-associated pneumonia remains controversial. In a previous study, we found that the incidence of pneumonia was identical with ventilator circuit changes every 48 h and with no ventilator circuit changes. The present study prospectively assessed whether keeping ventilator circuits clean with a heat and moisture exchanger exhibiting antimicrobial barrier properties affects patient colonization and the incidence of nosocomial pneumonia in patients receiving mechanical ventilation for more than 48 h. Consecutive patients were randomly allocated to humidification with either a heat and moisture exchanger (Group 1, n = 61) or a heated humidifier (Group 2, n = 70). In both groups, no circuit changes were performed throughout ventilatory support. Duration of mechanical ventilation was identical in both groups (10 +/- 8.6 d (range: 2 to 47) in Group 1 and 12.5 +/- 14.2 d [range: 2 to 85] in Group 2). The incidence of pneumonia (positive quantitative culture of protected brush specimen) was similar in both groups (6/61 and 8/70 in Groups 1 and 2, respectively; p = 0.8), as was duration of ventilation prior to pneumonia (9 +/- 5.9 versus 8.2 +/- 5.7 d; p = 0.8). Ventilator tubing contamination was considerably reduced with the use of a heat and moisture exchanger. In contrast, bacterial colonization of the pharynx and trachea was identical in both groups. These results suggest that circuit colonization plays little or no role in the occurrence of ventilator-associated pneumonia, provided usual maintenance precautions are applied.(ABSTRACT TRUNCATED AT 250 WORDS)

Mechanical ventilation with heated humidifiers or heat and moisture exchangers: effects on patient colonization and incidence of nosocomial pneumonia.

Mechanical ventilation with heated humidifiers or heat and moisture exchangers: effects on patient colonization and incidence of nosocomial pneumonia.

Retrospective analysis of risk factors and prognosis in non-ventilated patients with nosocomial pneumonia

Although nosocomial pneumonia in non-ventilated patients continues to be frequent and have high mortality rates, knowledge of the associated risk and prognostic factors is still limited. This retrospective study was designed to analyze epidemiological characteristics, risk and prognostic factors in patients with nosocomial pneumonia admitted to a hospital internal medicine department. Data on epidemiological, clinical and microbiological factors as well as diagnosis and clinical course were obtained from the medical records of 104 patients diagnosed with nosocomial pneumonia, according to Centers for Disease Control criteria, and from 104 control subjects. The incidence of nosocomial pneumonia was 18.8 per 1000 admissions. Risk factors significantly associated with contracting the disease were female sex, hospital stay longer than 14 days, other admission in the previous month and use of antibiotics during the previous six weeks. The most frequent underlying diseases were cardiorespiratory in nature (59.4%). Prognostic factors significantly associated with increased mortality were serious underlying disease, initially critical clinical status, severe and moderate respiratory insufficiency and bilateral radiological signs. More epidemiological data are needed to improve the diagnosis, treatment and prevention of nosocomial pneumonia.

Some Recent Controversies in Intensive Care

The ability of dopamine to reverse oliguria has led to its ubiquitous renal protective use in patients at risk of acute renal failure. However, this diuresis is due primarily to inhibition of distal tubular sodium reabsorption and not renal vasodilation. Recent controlled clinical studies have been unable to demonstrate a renal protective effect independent of changes in cardiac output. Selective decontamination of the digestive tract (SDD) has the appealing theoretical ability to minimize upper gastrointestinal colonization with gram-negative bacteria and fungi, and subsequently reduce nosocomial infection and mortality. Such modification of flora does occur, but the initial studies showing a reduction in lower respiratory tract infections have not been supported by recent large double-blind randomized controlled trials. A reduction in mortality or length of stay of general intensive care patients given SDD has never been demonstrated, and it remains an experimental therapy with possible application for some patient subgroups. Upper gastrointestinal hemorrhage (UGH) in the critically ill is associated with prolonged ventilatory support and coagulopathy, but clinically important bleeding is now uncommon. Prophylaxis with agents that increase gastric pH is effective in reducing UGH, but may be associated with a higher incidence of nosocomial pneumonia than occurs with alternatives such as sucralfate. Prophylaxis does not alter mortality, and it is now controversial which patients, if any, should routinely receive such treatment.

Continuous Aspiration of Subglottic Secretions in Preventing Ventilator-Associated Pneumonia

To determine whether continuous subglottic aspiration prevents nosocomial pneumonia in mechanically ventilated patients. A randomized, controlled, blinded study. Medical-surgical intensive care unit. 190 patients who were admitted to the intensive care unit during a 33-month period and whose condition suggested the need for prolonged intubation (> 3 days). 76 patients were randomly allocated to receive continuous aspiration of subglottic secretions, and 77 control patients were allocated to receive usual care. The numbers of cases of ventilator-associated pneumonia, ventilated days, days in intensive care unit, and deaths were recorded. The amount of subglottic secretions aspirated daily and surveillance cultures in the subglottic secretions were also obtained periodically. Etiologic diagnosis was based on the quantitative culture of secretions obtained by protected specimen brush or bronchoalveolar lavage. The incidence rate of ventilator-associated pneumonia was 19.9 episodes/1000 ventilator days in the patients receiving continuous aspiration of subglottic secretions and 39.6 episodes/1000 ventilator days in the control patients (relative risk, 1.98; 95% CI, 1.03 to 3.82). This difference was due to a significant (P < 0.03) reduction in the number of gram-positive cocci and Haemophilus influenzae organisms in the patients receiving continuous aspiration. However, no differences were observed in the number of Pseudomonas aeruginosa or Enterobacteriaceae organisms. Episodes of ventilator-associated pneumonia occurred later in patients receiving continuous aspiration (12.0 +/- 7.1 days) than in the control patients (5.9 +/- 2.1 days) (P = 0.003). The same microorganisms isolated from protected specimen brush or bronchoalveolar lavage cultures in patients with ventilator-associated pneumonia were previously isolated from cultures of subglottic secretions in 85% of cases. No significant differences in outcome were found. The incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using a simple method that decreases the chronic microaspirations through the cuff of endotracheal tubes.

ANALYSIS OF CHARGES ASSOCIATED WITH DIAGNOSIS OF NOSOCOMIAL PNEUMONIA

Many ventilated trauma patients thought to have nosocomial pneumonia have pulmonary contusion or systemic inflammatory response syndrome with tracheobronchial colonization. Fiberoptic bronchoscopy with quantitative culture techniques of protected specimen brush (PSB; threshold 10(3) cfu/mL) or bronchoalveolar lavage (BAL; threshold 10(5) cfu/mL) can potentially eliminate the false positive cultures of the upper airway seen with routine sputum aspirates (RS). However, bronchoscopy is expensive, and routine use may not be cost effective. This prospective study evaluated the patient charges associated with bronchoscopy and quantitative cultures compared with RS for the diagnosis of nosocomial pneumonia. Specimens were obtained by RS, PSB, and BAL from the lower airway in 107 trauma patients (136 sets of triplicate cultures). All patients had clinical evidence suggestive of pneumonia (fever, leukocytosis, purulent sputum, abnormal roentgenographic findings). Typical oral flora were considered contaminants; no gram-negative specimens were excluded. Mean age was 40 years and mean ISS was 29. Seventy-eight percent had blunt injuries, 22% penetrating, and 42% had chest injuries. The incidence of nosocomial pneumonia according to each method was: RS-73%; PSB-34%; BAL-25%. Considering all charges involved (bronchoscopy, equipment, microbiologic analysis, and antibiotics), and based on a 14-day course of ceftazidime and vancomycin, the charges for PSB were 58% of RS, and charges for BAL were 43% of RS. We conclude that the charges associated with bronchoscopy are high, but can be offset by antibiotic savings. Side effects of unnecessary antibiotic therapy would be avoided. Further study is needed to determine the efficacy of PSB or BAL in trauma patients.

Prophylaxis for Stress-related Gastric Hemorrhage in the Medical Intensive Care Unit

To determine the efficacy and safety of cimetidine and sucralfate prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to a medical intensive care unit. Medical intensive care unit of a nonprofit, university-affiliated teaching hospital. 300 patients admitted to the medical intensive care unit during a 10-month period. Randomized, controlled, single-blind clinical trial. Patients were assigned to receive no prophylaxis (control), 1 g sucralfate given orally every 6 hours, or continuous intravenous cimetidine titrated to maintain gastric pH at 4.0, intervention was maintained until the occurrence of clinically severe hemorrhage, onset of drug-related complications, death, or discharge from the medical intensive care unit. The primary outcome measure was the incidence of clinically severe hemorrhage from endoscopically verified stress-related gastritis. Other outcome measures were transfusion requirements, duration of medical intensive care unit stay, incidence of nosocomial pneumonia, adverse drug reactions, and death. 100 patients were randomly assigned to each treatment. The three groups were similar with regard to demographic characteristics, intensive care unit admission diagnoses, and APACHE II scores. Stress-related hemorrhage was seen in 6% of control participants and in 5% of those receiving sucralfate or cimetidine (relative risk compared with control, 0.83 for each group; 95% CI, 0.26 to 2.64; P = 0.75). No statistically significant differences were found for transfusion requirements, duration of medical intensive care unit stay, and mortality rates among the three groups. Nosocomial pneumonia was diagnosed in 6%, 12%, and 13% of controls, sucralfate recipients, and cimetidine recipients, respectively (sucralfate: relative risk, 2.0 [CI, 0.79 to 5.01], P = 0.14; cimetidine: relative risk, 2.2 [CI, 0.88 to 5.33], P = 0.09). Prophylaxis caused no definite adverse drug reactions. The observed effects of cimetidine and sucralfate on the incidence and severity of hemorrhage from stress-related gastritis were not significant when compared with no treatment. Routine prophylaxis with these agents for patients entering the medical intensive care unit does not seem warranted.

COMPARISON OF ACID NEUTRALIZING AND NON-ACID NEUTRALIZING STRESS ULCER PROPHYLAXIS IN THERMALLY INJURED PATIENTS

We have compared the effectiveness of non-acid neutralizing stress ulcer prophylaxis (SUC) with sucralfate (n = 48) with that of acid neutralizing prophylaxis (AN) utilizing antacids and cimetidine (n = 48) in the prevention of stress ulcer bleeding and nosocomial pneumonia (PN) in thermally injured patients. In the subset of intubated patients, the incidence of PN was 17.8% and 42.8% in the AN and SUC groups, respectively (p < 0.05) despite a similar postburn time of onset of pneumonia. Ten patients in each group died. Three patients in the SUC group developed upper GI bleeding with one requiring gastrectomy. Bacterial colonization of the upper airway occurred in virtually all patients, whereas 83% (SUC) and 96% (AN) had colonization of gastric contents. Gram-negative colonization rates for the upper airway were not different (70%) whereas 48% of SUC patients compared with 60% of AN patients had gram-negative gastric colonization. In conclusion, SUC therapy was efficacious in the prevention of stress ulcer bleeding but did not alter the rate of bacterial colonization of the airway or gastric contents, and was associated with a higher incidence of nosocomial pneumonia in intubated patients.

Humidification in the Intensive Care Unit: Prospective Study of a New Protocol Utilizing Heated Humidification and a Hygroscopic Condenser Humidifier

Determine the utility of a proposed algorithm in allowing safe, efficient humidification in mechanically ventilated patients using both a hygroscopic condenser humidifier (HCH) and heated humidifier (HH). A prospective study using an algorithm to chose humidification devices based on physical examination and sputum characteristics. All patients admitted to the surgical ICU. One hundred twenty consecutive patients requiring mechanical ventilation (MV) were studied. Patients were examined by the attending respiratory care practitioner and given either an HCH or HH. If patients demonstrated any of the following--thick or tenacious secretions, core temperature < 32 degrees C, or bloody secretions--they were given an HH. All others used an HCH. If any of the above conditions occurred during HCH use, the patient was given an HH. Duration of ventilation, incidence of nosocomial pneumonia, ventilator circuit colonization, and mortality were determined for patients in each group. Cost of humidification devices, number of suctioning procedures per day, and volume of saline solution instilled were also recorded. Initially, 27 percent (32/120) of patients used an HH and 73 percent (88/120) used an HCH. During the study, ten patients required changing to an HH during HCH use. Patients in the HH group were more likely to have preexisting lung disease and had a longer duration of ventilation (83 +/- 21 h) and higher mortality (21 percent). Patients in the HCH group were more likely to be postoperative, had shorter durations of ventilation (38 +/- 14 h), and lower mortality (9 percent). There was no difference in the incidence of nosocomial pneumonia between the two groups (9 percent vs 6 percent) and endotracheal tube occlusion did not occur in either group. Circuit colonization was common in the HH group (64 percent) but rate in the HCH group (5 percent). Cost per day was significantly less for the HCH group ($4 vs $19.80). Patients who required a change from HCH to HH did so at a mean of 5 days. The proposed algorithm resulted in cost-efficient and safe application of humidification devices in patients in the surgical ICU.