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Correspondence |

Carriage Classification of Pneumonia Rather Than Time Improves Survival FREE TO VIEW

Luciano Silvestri, MD; Hendrick K. F. van Saene, MD, PhD; Miguel A. de la Cal, MD; Angelo Raffaele De Gaudio, MD
Author and Funding Information

Affiliations: Dr. Silvestri is affiliated with Presidio Ospedaliero. Dr. van Saene is affiliated with the University of Liverpool. Dr. de la Cal is affiliated with University Hospital. Dr. De Gaudio is affiliated with the University of Florence.

Correspondence to: Luciano Silvestri, MD, Department of Emergency and Unit of Anesthesia and Intensive Care, Presidio Ospedaliero, Via Fatebenefratelli 34, 34170 Gorizia, Italy; e-mail: lucianosilvestri@yahoo.it


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(4):1188-1189. doi:10.1378/chest.08-2910
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We always enjoy Craven's editorials1,2 on pneumonia prevention as they are accurate and constructive. In his previous editorial in CHEST (July 2006),1 Craven acknowledged that antibiotic prophylaxis with selective digestive decontamination (SDD) is a valid strategy that reduces mortality. The SDD philosophy is based on the carrier state concept, which distinguishes among three different types of pneumonia (primary endogenous, secondary endogenous, and exogenous pneumonia), due to a limited range of potentially pathogenic microorganisms (six “normal” organisms and nine “abnormal” organisms). Each of the three types of pneumonia requires different prophylactic interventions. Parenteral antimicrobial agents control primary endogenous pneumonia, enteral antimicrobial agents prevent secondary endogenous pneumonia, and only a high level of hygiene can control exogenous pneumonia. SDD using hygiene, and parenteral and enteral antimicrobial agents is a prophylactic protocol that aims at the control of exogenous, primary endogenous, and secondary endogenous pneumonias, and at a reduction in mortality.

In line with the SDD philosophy, Craven, in his recent editorial in CHEST (November 2008),2 acknowledged that different prophylactic interventions are required to control the different types of pneumonia. He suggested the use of subglottic drainage to control early-onset pneumonia,3 although parenteral agents are required to control lower airway infections due to respiratory pathogens present in the flora at hospital admission, and silver-coated tubes to control late-onset pneumonia.4

This proposal is puzzling, as neither subglottic drainage nor silver-coated tubes have been associated with a survival benefit,3,4 while therapy with parenteral antimicrobial agents without enteral antimicrobial agents promotes the emergence of resistance.5 Additionally, in the subglottic drainage study3 pneumonia was not significantly reduced when all randomized patients were considered or when the intention-to-treat analysis was used. Only a post hoc analysis of a small subset of patients who had received ventilation for > 48 h demonstrated a significant, albeit borderline, impact from subglottic drainage (relative risk, 0.40; 95% confidence interval, 0.16 to 0.99; p = 0.04).

Similarly, in the silver-coated endotracheal tube study4 the difference in pneumonia rate was marginally significant in the intention-to-treat analysis, and the exclusion of pneumonia episodes due to coagulase-negative staphylococci and enterococci, which usually do not cause pneumonia, might importantly change the results. Finally, exogenous pneumonias, in which microorganisms are introduced directly into the lower airways due to poor hygiene, bypassing the oropharynx, is an inherent limitation in the use of silver-coated tubes and subglottic suctioning devices.

Due to the absence of any significant survival benefit from the use of subglottic drainage and silver-coated tubes, we continue to prevent pneumonia in ventilated patients with SDD, which is associated with a significant 8% reduction in mortality.

Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Craven DE. Preventing ventilator associated pneumonia in adults: sowing seeds of change. Chest. 2006;130:251-260. [PubMed] [CrossRef]
 
Craven DE, Hjalmarson K. Prophylaxis of ventilator associated pneumonia: changing culture and strategies to trump disease. Chest. 2008;134:898-900. [PubMed]
 
Bouza E, Perez MJ, Munoz P, et al. Continuous aspiration of subglottic secretions in the prevention of ventilator associated pneumonia in the postoperative period of major heart surgery. Chest. 2008;134:938-946. [PubMed]
 
Kollef MH, Bekele A, Anzueto A, et al. Silver coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300:805-813. [PubMed]
 
van Saene HKF, Taylor N, Damjanovic V, et al. Microbial gut overgrowth guarantees increased spontaneous mutation leading to polyclonality and antibiotic resistance in the critically ill. Curr Drug Targets. 2008;9:419-421. [PubMed]
 

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References

Craven DE. Preventing ventilator associated pneumonia in adults: sowing seeds of change. Chest. 2006;130:251-260. [PubMed] [CrossRef]
 
Craven DE, Hjalmarson K. Prophylaxis of ventilator associated pneumonia: changing culture and strategies to trump disease. Chest. 2008;134:898-900. [PubMed]
 
Bouza E, Perez MJ, Munoz P, et al. Continuous aspiration of subglottic secretions in the prevention of ventilator associated pneumonia in the postoperative period of major heart surgery. Chest. 2008;134:938-946. [PubMed]
 
Kollef MH, Bekele A, Anzueto A, et al. Silver coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300:805-813. [PubMed]
 
van Saene HKF, Taylor N, Damjanovic V, et al. Microbial gut overgrowth guarantees increased spontaneous mutation leading to polyclonality and antibiotic resistance in the critically ill. Curr Drug Targets. 2008;9:419-421. [PubMed]
 
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