University of Amsterdam, Amsterdam, Netherlands
Correspondence to: Marcus J. Schultz, MD, PhD, Internist-Intensivist, Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Mail stop G3–206, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands; e-mail: firstname.lastname@example.org
I read with interest Dr. Rello’s report (December 2003)1 on the incidence, etiology, and outcome of nosocomial pneumonia in ICU patients requiring percutaneous tracheotomy for mechanical ventilation. He showed that as many as 18% of patients acquired ventilator-associated pneumonia (VAP) after tracheotomy, most of them in the first week after the procedure.
Unfortunately, the investigators did not compare the incidence of VAP in patients after tracheotomy with the incidence of nosocomial pneumonia in patients not receiving a tracheostoma. When the incidence of pneumonia in the latter group is as high as in the studied population, which very well might be the case, one can also say that prolonged mechanical ventilation predisposes to pneumonia. Thus, their conclusion—percutaneous tracheotomy predisposes to pneumonia—is not accurate.
Furthermore, I was very much surprised to see that antimicrobial prophylaxis before tracheotomy—a single dose of amoxicilline-clavunate—was recommended. In addition, many patients received antibiotics before the procedure (80%). Antibiotic use may have predisposed to the high incidence of VAP, more than the procedure itself. It is not correct to state that the current findings suggest the need to select an antipseudomonal agent for prophylaxis; one can also suggest not administering antimicrobial prophylaxis.
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