Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Oct 2002
Pneumonia complicating the acute respiratory distress syndrome.
Ventilator-associated pneumonia (VAP) complicating the course of acute respiratory distress syndrome (ARDS) is one of the most challenging diagnostic and treatment dilemmas in critical care medicine. The VAP incidence rate ranges from 37 to 60% in ARDS patients, significantly greater than for other causes of respiratory failure. Although the normal risk factors for VAP are the same in ARDS patients, multiple aspects of the underlying disease and its management increase the risk compared with non-ARDS patients. ⋯ The multilobar but predominantly lower lobe pattern of pneumonia in ARDS makes use of quantitative cultures of lower respiratory secretions (sampled by various techniques) very accurate to confirm the presence of pneumonia. VAP in ARDS patients is usually late-onset and therefore caused by highly antibiotic-resistant microorganisms. Somewhat surprisingly, the mortality of ARDS patients with VAP is not significantly greater than that of ARDS patients without VAP, although subsequent duration of mechanical ventilation is consistently prolonged in patients with VAP.
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Semin Respir Crit Care Med · Oct 2002
Strategies for prevention of hospital-acquired pneumonia: oral and selective decontamination of the gastrointestinal tract.
The use of antimicrobial prophylaxis is the most extensively studied, though probably also the most controversial, method to prevent the development of ventilator-associated pneumonia (VAP). Selective decontamination of the digestive tract (SDD) includes the application of topical nonabsorbable antibiotics in the oropharynx, stomach, and intestines in combination with systemic antibiotics during the first days of ventilation. ⋯ Moreover, the significant reductions in incidences of VAP have, so far, not resulted in reductions of duration of ventilation and ICU-stay, and reductions in ICU-mortality were found only in meta-analysis. Selection of resistant bacteria is the most important drawback of antimicrobial prophylaxis, and the demonstrated benefits of antimicrobial prophylaxis should be carefully balanced with this potential risk.