Rev Pneumol Clin
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Nosocomial pneumonia is one of the primary causes of nosocomial infection in intensive care patients, leading to high mortality and prolonged hospitalization. Mechanical ventilation and its duration are major risk factors. When invasive ventilation is indispensable, preventive measures should aim at optimizing patient care by carefully applying basic rules of hygiene and recommended procedures for use of ventilation equipment. Different preventive measures have been proposed and should be considered in light of several criteria: the cost/benefit ratio, the level of proof (size of the study population, quality and pertinence of judgement criteria), feasibility, routine cost, and absence of secondary collateral adverse effects.
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In case of suspected nosocomial lung infection in an intensive care patient, a strictly "clinical" strategy based on the physical exam and qualitative culture of tracheal secretions has three potential drawbacks: i) Numerous patients are given unnecessary antibiotic regimens unwarranted on the sole basis of colonization of the upper airways. In addition to the high cost of such regimens, these antibiotics also have important adverse effects favoring the emergence of multiresistant strains, and in addition, considerably complicating the search for the real cause and the treatment of the fever and the new lung images. ii) This strategy exposes the patient to diagnostic errors by omission if all patients with suspected infection are not treated. iii) Finally, even if the diagnosis of pneumonia is exact, the antibiotic prescribed on the basis of necessarily imprecise information can be most inappropriate or non-optimal in many cases. It is particularly difficult or often impossible to taper off the regimen on day 3 when tracheal cultures become available since the prescription would have to cover all the germs present in the upper airways even though only certain strains are undoubtedly causing the infection in the lung parenchyma. ⋯ Thus, on the basis of the culture results, it would be possible to discontinue any unnecessary antibiotic in patients with negative samples and inversely to use the narrowest possible treatment spectrum for those with positive samples, adapting the regimen to the susceptibility pattern or identified strains. The strongest arguments favoring this invasive strategy come from a multicentric French study on 413 patients with clinically suspected nosocomial pneumonia under artificial ventilation. The results demonstrated lower mortality in the fibroscopy group associated with a major reduction in the consumption of antibiotics.
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Nosocomial infections are recognized as a major problem in patients with endotracheal ventilation, but the risk of nosocomial pneumonia is less well known and considered to be lower for patients on noninvasive ventilation. The risk factors for endotrachial ventilation involve the presence of the endoracheal canula and the direct consequences of the reclining position, use of a respirator, sedation, presence of a nosgastric tube, antiulcer treatment, etc. Most of these risk factors are not present in noninvasive ventilation while others, for example the use of a respirator and a ventilation circuit, persist. ⋯ The principal actions involve taking advantage of the noninvasive nature of the ventilation to reduce the risk factors and other invasive procedures indirectly related with the use of artificial ventilation. Patients should be mobilized as rapidly as possible and oral food intake instituted early. Certain measures concerning humidification of the ventilation circuit remain important as well as other nonspecific measures including hand washing, for the prevention of cross contamination.