Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. A randomized controlled trial.
OBJECTIVE
To assess three anti-stress ulcer prophylaxis regimens in mechanically ventilated patients for bacterial colonization, early- and late-onset nosocomial pneumonia, and gastrointestinal bleeding.


METHODS
Randomized controlled trial.


METHODS
Consecutive eligible patients with mechanical ventilation and a nasogastric tube. Of 258 eligible patients, 244 were assessable.


METHODS
Medical and surgical intensive care units.


METHODS
At intubation, patients were randomly assigned to receive one of the following: antacid (a suspension of aluminum hydroxide and magnesium hydroxide), 20 mL every 2 hours; ranitidine, 150 mg as a continuous intravenous infusion; or sucralfate, 1 g every 4 hours.


METHODS
Using predetermined criteria, the incidence of gastric bleeding, gastric colonization, early-onset pneumonia, and late-onset pneumonia was assessed in patients intubated for more than 24 hours.


RESULTS
Of 244 assessable patients, macroscopic gastric bleeding was observed in 10%, 4%, and 6% of patients assigned to receive sucralfate, antacid, and ranitidine, respectively (P > 0.2). The incidence of early-onset pneumonia was not statistically different among the three treatment groups (P > 0.2). Among the 213 patients observed for more than 4 days, late-onset pneumonia was observed in 5% of the patients who received sucralfate compared with 16% and 21% of the patients who received antacid or ranitidine, respectively (P = 0.022). Mortality was not statistically different among the three treatment groups. Patients who received sucralfate had a lower median gastric pH (P < 0.001) and less frequent gastric colonization compared with the other groups (P = 0.015). Using molecular typing, 84% of the patients with late-onset gram-negative bacillary pneumonia were found to have gastric colonization with the same bacteria before pneumonia developed.


CONCLUSIONS
Stress ulcer prophylaxis with sucralfate reduces the risk for late-onset pneumonia in ventilated patients compared with antacid or ranitidine.
Prod'hom
G
G
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
Leuenberger
P
P
Koerfer
J
J
Blum
A
A
Chiolero
R
R
Schaller
M D
MD
Perret
C
C
Spinnler
O
O
Blondel
J
J
Siegrist
H
H
Saghafi
L
L
Blanc
D
D
Francioli
P
P
D000328:Adult; D000368:Aged; D000863:Antacids / Q000627:therapeutic use*; D003428:Cross Infection / Q000209:etiology* / Q000401:mortality; D004866:Equipment Contamination; D005260:Female; D005745:Gastric Acidity Determination; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010438:Peptic Ulcer Hemorrhage / Q000209:etiology / Q000401:mortality; D011014:Pneumonia / Q000209:etiology* / Q000401:mortality; D011899:Ranitidine / Q000627:therapeutic use*; D012121:Respiration, Artificial / Q000009:adverse effects*; D013312:Stress, Physiological / Q000150:complications; D013392:Sucralfate / Q000627:therapeutic use*; D013997:Time Factors; D014456:Ulcer / Q000209:etiology / Q000517:prevention & control*
D000863:Antacids; D013392:Sucralfate; D011899:Ranitidine