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Research ArticleConference Proceedings

The Gastrointestinal Tract and Ventilator-Associated Pneumonia

Richard H Kallet and Thomas E Quinn
Respiratory Care July 2005, 50 (7) 910-923;
Richard H Kallet
Cardiovascular Research Institute, University of California, San Francisco, California.
Respiratory Care Services, Department of Anesthesia, University of California, San Francisco at San Francisco General Hospital, San Francisco, California.
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  • For correspondence: [email protected]
Thomas E Quinn
Cardiovascular Research Institute, University of California, San Francisco, California.
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Abstract

The gastrointestinal tract is believed to play an important role in ventilator-associated pneumonia (VAP), because during critical illness the stomach often is colonized with enteric Gram-negative bacteria. These are the same bacteria that frequently are isolated from the sputum of patients with VAP. Interventions such as selective decontamination of the digestive tract (SDD), use of sucralfate for stress ulcer prophylaxis, and enteral feeding strategies that preserve gastric pH, or lessen the likelihood of pulmonary aspiration, are used to decrease the incidence of VAP. A review of both meta-analyses and large randomized controlled trials providing Level I evidence on these topics has led to the following conclusions. First, SDD substantially decreases the incidence of VAP and may have a modest positive effect on mortality. However, there is strong contravening evidence that SDD promotes infections by Gram-positive bacteria. In the context of an emerging public health crisis from the steady rise in drug-resistant Gram-positive bacteria, we cannot endorse the general use of SDD to prevent VAP. Rather, therapy should be focused on strategies other than antibiotic prophylaxis. Second, in patients who are at risk for clinically important gastrointestinal bleeding, a histamine-2 receptor antagonist should be used for stress ulcer prophylaxis, rather than sucralfate, because histamine-2 receptor antagonist provides substantially better protection without substantially increasing the risk of VAP. Third, post-pyloric enteral feeding may reduce the incidence of VAP.

  • ventilator-associated pneumonia
  • nosocomial pneumonia
  • selective decontamination of the digestive tract
  • stress ulcer prophylaxis

Footnotes

  • Correspondence: Richard H Kallet MSc RRT FAARC, Respiratory Care Services, San Francisco General Hospital, NH: GA-2, 1001 Potrero Ave, San Francisco CA 94110. E-mail: richkallet{at}earthlink.net.
  • Copyright © 2005 by Daedalus Enterprises Inc.
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Respiratory Care: 50 (7)
Respiratory Care
Vol. 50, Issue 7
1 Jul 2005
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The Gastrointestinal Tract and Ventilator-Associated Pneumonia
Richard H Kallet, Thomas E Quinn
Respiratory Care Jul 2005, 50 (7) 910-923;

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The Gastrointestinal Tract and Ventilator-Associated Pneumonia
Richard H Kallet, Thomas E Quinn
Respiratory Care Jul 2005, 50 (7) 910-923;
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Keywords

  • ventilator-associated pneumonia
  • nosocomial pneumonia
  • selective decontamination of the digestive tract
  • stress ulcer prophylaxis

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