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Ventilator-Associated Pneumonia, Percutaneous Tracheostomy, and Antimicrobial Prophylaxis

Joan XXIII University Hospital, Rovira & Virgili University, Tarragona, Spain

Correspondence to: Jordi Rello, MD, PhD, Critical Care Department, Joan XXIII University Hospital, Rovira & Virgili University, 43007 Tarragona, Spain; e-mail: jrc{at}hjxxiii.scs.es

To the Editor:

Dr. Schultz raises pertinent concerns about the use of antimicrobial prophylaxis in patients who undergo percutaneous tracheostomies, and disagrees with our interpretation of the findings of ventilator-associated pneumonia (VAP) after percutaneous tracheostomy.¹ Tracheostomy is an elective surgical procedure in patients with contaminated tracheal mucosa (present in all intubated patients). Therefore, we believe that administration of a ß-lactam in the interval of 2 h before the time of surgical incision is a correct indication.²

Antimicrobial prophylaxis should cover potential pathogens to decrease surgery-related infections. The most frequent isolates colonizing our patients prior to tracheotomy were nonfermentative Gram-negative bacilli, with Pseudomonas aeruginosa being identified as the most frequent responsible pathogen. Another patient acquired bacteremia by P aeruginosa during the procedure.¹ Based on these findings, we suggested that surgical antimicrobials prescribed for tracheotomy prophylaxis in intubated patients should be active against P aeruginosa.

Dr. Schultz also expressed concern that the incidence of VAP in patients with tracheotomy was not compared to patients not receiving a tracheostoma. The overall incidence of VAP in our ICU was 9.6% of intubated patients in the study period. In the current article, 18.1% of patients acquired VAP after percutaneous tracheotomy. These episodes occurred a median of 7 days after intubation, and most episodes occurred within the first 5 days after the procedure (Table 2).¹ This percentage notably exceed the < 1% cumulative risk of acquiring pneumonia per day of mechanical ventilation, which is considered standard in intubated patients.³

Finally, Dr. Schultz indicates that antibiotic use in many patients before the procedure may have predisposed to the high incidence of VAP. However, in a cohort study⁴ focusing on episodes of pneumonia, prior antibiotic use showed a protective effect (relative risk, 0.1; 95% confidence interval, 0.01 to 0.71) within the first days after intubation. These findings agree with observations reported by Sirvent et al⁵ using a prophylactic antibiotic approach. Similarly, Cook et al⁶ estimated that exposure to antibiotics was associated with a risk ratio of 0.37 (95% confidence interval, 0.27 to 0.51) for development of VAP. A recent review article by Bonten et al⁷ confirmed these reports. Antibiotic exposure protects against pneumonia development within the first days of the intubation manipulation, especially against flora present in the colonized airways, suggesting that risk factors vary depending of the exposure to risk (ie, length of ventilation).⁸

Our opinion on antimicrobial prophylaxis for VAP has been clearly stated in a recent editorial,⁹ and a randomized clinical trial to assess the effect of single-dose antibiotic administration as prophylaxis for VAP is highly recommended. Unfortunately, such evidence is lacking. Dr. Schultz suggests not using antimicrobial prophylaxis for percutaneous tracheotomies. However, as indicated before, prophylaxis for surgical neck procedures in intubated patients with colonized tracheal mucosa has a level 1 evidence. Until such studies are available, the extremely high incidence of VAP in the first days after the procedure, the distribution of pathogens, and the low predictive value of tracheal aspirates prior to tracheostomy¹ suggest that prescription of a single dose of an antipseudomonal agent prior to the percutaneous tracheotomy is the most pertinent policy.

References

1. Rello, J, Lorente, C, Diaz, E, et al (2003) Incidence, etiology, and outcome of nosocomial pneumonia in ICU patients requiring percutaneous tracheotomy for mechanical ventilation. Chest 124,2239-2243[Abstract/Free Full Text]
2. Classen, DC, Evans, RS, Pestotnik, SL, et al The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326,281-286[Abstract]
3. Rello, J, Diaz, E Pneumonia in the ICU. Crit Care Med 2003;31,2544-2551[CrossRef][ISI][Medline]
4. Rello, J, Díaz, E, Roque, M, et al Risk factors for developing pneumonia within forty-eight hours of intubation. Am J Respir Crit Care Med 1999;159,1742-1746[Abstract/Free Full Text]
5. Sirvent, JM, Torres, A, El-Ebiary, M, et al Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma. Am J Respir Crit Care Med 1997;155,1729-1734[Abstract]
6. Cook, DJ, Walter, SD, Cook, RJ, et al Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 1998;129,433-440[Abstract/Free Full Text]
7. Bonten, MJM, Kollef, MH, Hall, JB Risk factors for ventilator-associated pneumonia: from epidemiology to patient management. Clin Infect Dis 2004;38,1141-1149[CrossRef][ISI][Medline]
8. Diaz, O, Diaz, E, Rello, J Risk factors for pneumonia in the intubated patient. Infect Dis Clin North Am 2003;17,697-705[CrossRef][ISI][Medline]
9. Diaz, E, Rello, J, Valles, J Antibiotic use and the risk of pneumonia: twenty years of studies, but where are we now? Clin Infect Dis 2004;38,1409-1411[CrossRef][ISI][Medline]

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