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Treatment of Pneumonia in Mechanically Ventilated Trauma Patients: Results of a Prospective Trial

Treatment of Pneumonia in Mechanically Ventilated Trauma Patients: Results of a Prospective Trial Abstract Objectives: To determine the efficacy and magnitude of associated adverse effects of 2 different antibiotic regimens for the treatment of pneumonia in intubated surgical patients and to assay and compare blood samples and bronchoalveolar lavage fluid with respect to some host-defense parameters, especially in patients with unilateral pneumonia. Design: Randomized, prospective, unblinded clinical comparison of 2 treatment arms with respect to intent to treat and clinical and microbiologically evaluable patients. Setting: Six university surgical services in teaching hospitals with modern and well-staffed intensive care units. Interventions: The consistency and objectivity of the diagnosis of pneumonia was improved by the use of a grid of diagnostic parameters. Aggressive mechanical approaches to pneumonia in intubated surgical patients were supplemented by therapeutic use of aztreonam and vancomycin hydrochloride or combined imipenem and cilastatin sodium. Results: Patients randomized to the aztreonamvancomycin group were somewhat more ill, fared slightly better, and had fewer serious drug-related side effects than did those treated with imipenem-cilastatin (all P>.05). Immunologic parameters assessed by evaluation of bronchoalveolar lavage fluid showed differences between infected pulmonary lobes and noninfected ones; some changes were also noted in patients who recovered compared with those whose pneumonia persisted or recurred. Conclusions: Clinical studies of pneumonia in surgical patients need to be stratified to assure comparability, to identify patients in whom treatment is likely to fail, and to display differences between more and less effective therapies. Studies of blood and bronchoalveolar lavage samples showed that certain local and systemic immunologic parameters correlate with clinical status and outcome.Arch Surg. 1997;132:1086-1092 References 1. Naziri W, Cheadle WG, Pietsch JD, Appel S, Polk HC Jr. Pneumonia in the surgical intensive care unit: immunologic keys to the silent epidemic . Ann Surg . 1994; 219:632-642.Crossref 2. Pugliese G, Lichtenberg DA. Nosocomial bacterial pneumonia: an overview . Am J Infect Control . 1987;15:249-265.Crossref 3. Gross PA. Epidemiology of hospital-acquired pneumonia . Semin Respir Infect . 1987;2:2-7. 4. Scheld WM, Mandell GL. Nosocomial pneumonia: pathogenesis and recent advances in diagnosis and therapy . Rev Infect Dis . 1991;13( (suppl 9) ):S743-S751.Crossref 5. Driks MR, Craven DE, Bartalome R, et al. Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers . N Engl J Med . 1987;317:1376-1382.Crossref 6. Cook DJ, Reeve BK, Guyatt GH, et al. Stress ulcer prophylaxis in critically ill patients: resolving discordant meta-analysis . JAMA . 1996;275:308-314.Crossref 7. Voyles CR, Flint LM, DeMarco T, Fulton RL. Effect of limiting post-shock pulmonary edema on mortality from bacterial pneumonia . Am Surg . 1978;44:761-764. 8. Martin LF, Asher EF, Casey JM, Fry DE. Postoperative pneumonia: determinants of mortality . Arch Surg . 1984;119:379-383.Crossref 9. Malangoni MA, Crafton R, Mocek FC. Pneumonia in the surgical intensive care unit: factors determining successful outcome . Am J Surg . 1994;167:250-255.Crossref 10. Spain DA, Wilson MA, Boaz PW, Bar-Natan MF, Garrison RN. Haemophilus pneumonia is a common cause of early pulmonary dysfunction following trauma . Arch Surg . 1995;130:1228-1232.Crossref 11. Polk HC Jr, Cheadle WG, Livingston DH, et al. A randomized prospective clinical trial to determine the efficacy of interferon-gamma in severely injured patients . Am J Surg . 1992;163:191-196.Crossref 12. Bamberger DM. Diagnosis of nosocomial pneumonia . Semin Respir Infect 1988; 3:140-147. 13. Rodriguez JR, Ramirez-Ronda CH, Nevarez M. Efficacy and safety of aztreonamclindamycin versus tobramycin-clindamycin in the treatment of lower respiratory tract infections caused by aerobic gram-negative bacilli . Antimicrob Agents Chemother . 1985;27:246-251.Crossref 14. Schentag JJ, Vari AJ, Winslade NE, et al. Treatment with aztreonam or tobramycin in critical care patients with nosocomial gram-negative pneumonia . Am J Med . 1985;78:34-41.Crossref 15. Heyland D, Mandell LA. Gastric colonization by gram-negative bacilli and nosocomial pneumonia in the intensive care unit patient: evidence for causation . Chest . 1992;101:187-193.Crossref 16. Naziri W, Cheadle WG, Trachtenberg LS, Montgomery WD, Polk HC Jr. increased antibiotic effectiveness in a model of surgical infection through continuous infusion . Am Surg . 1995;61:11-15. 17. Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired pneumonia . JAMA . 1996;275:134-141.Crossref 18. Galandiuk S, Raque G, Appel S, Polk HC Jr. The two-edged sword of large-dose steroids for spinal cord trauma . Ann Surg . 1993;218:419-427.Crossref 19. Norrby SR, Finch RG, Glauser M, the European Study Group. Monotherapy in serious hospital-acquired infections: a clinical trial of ceftazidime versus imipenem/ cilastatin . J Antimicrob Chemother . 1993;31:927-937.Crossref 20. Mangi RJ, Peccerillo KM, Ryan J, et al. Cefoperazone versus ceftriaxone monotherapy of nosocomial pneumonia . Diagn Microbiol Infect Dis . 1992;15:441-447.Crossref 21. Hilf M, Yu VL, Sharp J, Zuravleff JJ, Korvick JA, Muder RR. Antibiotic therapy for Pseudomonas aeruginosa bacteremia: outcome correlations in a prospective study of 200 patients . Am J Med . 1989;87:540-546.Crossref 22. Fink MP, Snydman DR, Niederman MS, et al. Treatment of severe pneumonia in hospitalized patients: results of a multicenter, randomized, double-blind trial comparing intravenous ciprofloxacin with imipenem-cilastatin . Antimicrob Agents Chemother . 1994;38:547-557.Crossref 23. Croce MA, Fabian TC, Shaw B, et al. Analysis of charges associated with diagnosis of nosocomial pneumonia: can routine bronchoscopy be justified? J Trauma . 1994;37:721-727.Crossref 24. The MRSA Interagency Advisory Committee in conjunction with the Connecticut Department of Public Health and Addiction Services. Guidelines for management of patients with methicillin-resistant Staphylococcus aureus, in acute care hospitals and long-term care facilities. 1993;57:611-617. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Treatment of Pneumonia in Mechanically Ventilated Trauma Patients: Results of a Prospective Trial

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Publisher
American Medical Association
Copyright
Copyright © 1997 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1997.01430340040005
Publisher site
See Article on Publisher Site

Abstract

Abstract Objectives: To determine the efficacy and magnitude of associated adverse effects of 2 different antibiotic regimens for the treatment of pneumonia in intubated surgical patients and to assay and compare blood samples and bronchoalveolar lavage fluid with respect to some host-defense parameters, especially in patients with unilateral pneumonia. Design: Randomized, prospective, unblinded clinical comparison of 2 treatment arms with respect to intent to treat and clinical and microbiologically evaluable patients. Setting: Six university surgical services in teaching hospitals with modern and well-staffed intensive care units. Interventions: The consistency and objectivity of the diagnosis of pneumonia was improved by the use of a grid of diagnostic parameters. Aggressive mechanical approaches to pneumonia in intubated surgical patients were supplemented by therapeutic use of aztreonam and vancomycin hydrochloride or combined imipenem and cilastatin sodium. Results: Patients randomized to the aztreonamvancomycin group were somewhat more ill, fared slightly better, and had fewer serious drug-related side effects than did those treated with imipenem-cilastatin (all P>.05). Immunologic parameters assessed by evaluation of bronchoalveolar lavage fluid showed differences between infected pulmonary lobes and noninfected ones; some changes were also noted in patients who recovered compared with those whose pneumonia persisted or recurred. Conclusions: Clinical studies of pneumonia in surgical patients need to be stratified to assure comparability, to identify patients in whom treatment is likely to fail, and to display differences between more and less effective therapies. Studies of blood and bronchoalveolar lavage samples showed that certain local and systemic immunologic parameters correlate with clinical status and outcome.Arch Surg. 1997;132:1086-1092 References 1. Naziri W, Cheadle WG, Pietsch JD, Appel S, Polk HC Jr. Pneumonia in the surgical intensive care unit: immunologic keys to the silent epidemic . Ann Surg . 1994; 219:632-642.Crossref 2. Pugliese G, Lichtenberg DA. Nosocomial bacterial pneumonia: an overview . Am J Infect Control . 1987;15:249-265.Crossref 3. Gross PA. Epidemiology of hospital-acquired pneumonia . Semin Respir Infect . 1987;2:2-7. 4. Scheld WM, Mandell GL. Nosocomial pneumonia: pathogenesis and recent advances in diagnosis and therapy . Rev Infect Dis . 1991;13( (suppl 9) ):S743-S751.Crossref 5. Driks MR, Craven DE, Bartalome R, et al. Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers . N Engl J Med . 1987;317:1376-1382.Crossref 6. Cook DJ, Reeve BK, Guyatt GH, et al. Stress ulcer prophylaxis in critically ill patients: resolving discordant meta-analysis . JAMA . 1996;275:308-314.Crossref 7. Voyles CR, Flint LM, DeMarco T, Fulton RL. Effect of limiting post-shock pulmonary edema on mortality from bacterial pneumonia . Am Surg . 1978;44:761-764. 8. Martin LF, Asher EF, Casey JM, Fry DE. Postoperative pneumonia: determinants of mortality . Arch Surg . 1984;119:379-383.Crossref 9. Malangoni MA, Crafton R, Mocek FC. Pneumonia in the surgical intensive care unit: factors determining successful outcome . Am J Surg . 1994;167:250-255.Crossref 10. Spain DA, Wilson MA, Boaz PW, Bar-Natan MF, Garrison RN. Haemophilus pneumonia is a common cause of early pulmonary dysfunction following trauma . Arch Surg . 1995;130:1228-1232.Crossref 11. Polk HC Jr, Cheadle WG, Livingston DH, et al. A randomized prospective clinical trial to determine the efficacy of interferon-gamma in severely injured patients . Am J Surg . 1992;163:191-196.Crossref 12. Bamberger DM. Diagnosis of nosocomial pneumonia . Semin Respir Infect 1988; 3:140-147. 13. Rodriguez JR, Ramirez-Ronda CH, Nevarez M. Efficacy and safety of aztreonamclindamycin versus tobramycin-clindamycin in the treatment of lower respiratory tract infections caused by aerobic gram-negative bacilli . Antimicrob Agents Chemother . 1985;27:246-251.Crossref 14. Schentag JJ, Vari AJ, Winslade NE, et al. Treatment with aztreonam or tobramycin in critical care patients with nosocomial gram-negative pneumonia . Am J Med . 1985;78:34-41.Crossref 15. Heyland D, Mandell LA. Gastric colonization by gram-negative bacilli and nosocomial pneumonia in the intensive care unit patient: evidence for causation . Chest . 1992;101:187-193.Crossref 16. Naziri W, Cheadle WG, Trachtenberg LS, Montgomery WD, Polk HC Jr. increased antibiotic effectiveness in a model of surgical infection through continuous infusion . Am Surg . 1995;61:11-15. 17. Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired pneumonia . JAMA . 1996;275:134-141.Crossref 18. Galandiuk S, Raque G, Appel S, Polk HC Jr. The two-edged sword of large-dose steroids for spinal cord trauma . Ann Surg . 1993;218:419-427.Crossref 19. Norrby SR, Finch RG, Glauser M, the European Study Group. Monotherapy in serious hospital-acquired infections: a clinical trial of ceftazidime versus imipenem/ cilastatin . J Antimicrob Chemother . 1993;31:927-937.Crossref 20. Mangi RJ, Peccerillo KM, Ryan J, et al. Cefoperazone versus ceftriaxone monotherapy of nosocomial pneumonia . Diagn Microbiol Infect Dis . 1992;15:441-447.Crossref 21. Hilf M, Yu VL, Sharp J, Zuravleff JJ, Korvick JA, Muder RR. Antibiotic therapy for Pseudomonas aeruginosa bacteremia: outcome correlations in a prospective study of 200 patients . Am J Med . 1989;87:540-546.Crossref 22. Fink MP, Snydman DR, Niederman MS, et al. Treatment of severe pneumonia in hospitalized patients: results of a multicenter, randomized, double-blind trial comparing intravenous ciprofloxacin with imipenem-cilastatin . Antimicrob Agents Chemother . 1994;38:547-557.Crossref 23. Croce MA, Fabian TC, Shaw B, et al. Analysis of charges associated with diagnosis of nosocomial pneumonia: can routine bronchoscopy be justified? J Trauma . 1994;37:721-727.Crossref 24. The MRSA Interagency Advisory Committee in conjunction with the Connecticut Department of Public Health and Addiction Services. Guidelines for management of patients with methicillin-resistant Staphylococcus aureus, in acute care hospitals and long-term care facilities. 1993;57:611-617.

Journal

Archives of SurgeryAmerican Medical Association

Published: Oct 1, 1997

References

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