Prevention of ventilator-associated pneumonia by oral decontamination: a prospective, randomized, double-blind, placebo-controlled study.
Colonization of the intestinal tract has been assumed to be important in the pathogenesis of ventilator-associated pneumonia (VAP), but relative impacts of oropharyngeal, gastric, or intestinal colonization have not been elucidated. Our aim was to prevent VAP by modulation of oropharyngeal colonization, without influencing gastric and intestinal colonization and without systemic prophylaxis. In a prospective, randomized, placebo-controlled, double-blind study, 87 patients received topical antimicrobial prophylaxis (gentamicin/ colistin/vancomycin 2% in Orabase, every 6 h) in the oropharynx and 139 patients, divided over two control groups, received placebo (78 patients were studied in the presence of patients receiving topical prophylaxis [control group A] and 61 patients were studied in an intensive care unit where no topical prophylaxis was used [control group B]). Baseline characteristics were comparable in all three groups. Topical prophylaxis eradicated colonization present on admission in oropharynx (75% in study group versus 0% in control group A [p < 0.00001] and 9% in control group B patients [p < 0.00001]) and in trachea (52% versus 22% in A [p = 0.03] and 7% in B [p = 0.004]). Moreover, topical prophylaxis prevented acquired oropharyngeal colonization (10% versus 59% in A [p < 0.00001] and 63% in B [p < 0.00001]). Colonization rates in stomach and intestine were not affected. Incidences of VAP were 10% in study patients, 31% in Group A, and 23% in Group B patients (p = 0.001 and p = 0.04, respectively). This was not associated with shorter durations of ventilation or ICU stay or better survival. Oropharyngeal colonization is of paramount importance in the pathogenesis of VAP, and a targeted approach to prevent colonization at this site is a very effective method of infection prevention.


BACKGROUND
cross infection, prevention and control; respiration, artificial, adverse effects; antibiotics, administration and dosage infection control methods; pneumonia, etiology, prevention and control; intubation, intratracheal, adverse effects
Bergmans
D C
DC
Department of Internal Medicine, University Hospital Maastricht, Maastricht, the Netherlands.
Bonten
M J
MJ
Gaillard
C A
CA
Paling
J C
JC
van der Geest
S
S
van Tiel
F H
FH
Beysens
A J
AJ
de Leeuw
P W
PW
Stobberingh
E E
EE
D000287:Administration, Topical; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000494:pharmacology*; D003091:Colistin / Q000008:administration & dosage / Q000494:pharmacology*; D004064:Digestive System / Q000382:microbiology; D004311:Double-Blind Method; D005260:Female; D005839:Gentamicins / Q000008:administration & dosage / Q000494:pharmacology*; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009960:Oropharynx / Q000382:microbiology*; D011014:Pneumonia / Q000209:etiology / Q000517:prevention & control*; D012121:Respiration, Artificial / Q000009:adverse effects*; D016019:Survival Analysis; D016896:Treatment Outcome; D014640:Vancomycin / Q000008:administration & dosage / Q000494:pharmacology*
D000900:Anti-Bacterial Agents; D005839:Gentamicins; D014640:Vancomycin; D003091:Colistin