Patients nosocomial pneumonia

Tod, M., Minozzi, C., Beaucaire, G., Ponsonnet, D., Gougnard, J., and Petitjean, O., Isepamicin in intensive care unit patients with nosocomial pneumonia population pharmacokinetic-pharmacodynamic study, /. Antimicrob. Chemother., 44, 99-108,1999. 

Nosocomial pneumonia - Start with 3.375 g every 4 hours plus an aminoglycoside. Continue the aminoglycoside in patients from whom Pseudomonas aeruginosa is isolated. 

Pneumonia - Do not use oral azithromycin in patients with pneumonia who are judged to be inappropriate for oral therapy because of moderate to severe illness or risk factors such as any of the following nosocomially acquired infections known or suspected bacteremia conditions requiring hospitalization cystic fibrosis significant underlying health problems that may compromise patients ability to respond to their illness (including immunodeficiency or functional asplenia) elderly or debilitated patients. 

H2 antagonists are extremely safe drugs. Adverse effects occur in less than 3% of patients and include diarrhea, headache, fatigue, myalgias, and constipation. Some studies suggest that intravenous H2 antagonists (or proton pump inhibitors) may increase the risk of nosocomial pneumonia in critically ill patients. 

Gastric acid is an important barrier to colonization and infection of the stomach and intestine from ingested bacteria. Increases in gastric bacterial concentrations are detected in patients taking proton pump inhibitors, which is of unknown clinical significance. Some studies have reported an increased risk of both community-acquired respiratory infections and nosocomial pneumonia among patients taking proton pump inhibitors. 

Chevret S., HemmerM., Carlet J., and LangerM. (1993) Incidence and risk factors of pneumonia acquired in intensive care units. Results from a multicenter prospective study on 996 patients. European Cooperative Group on Nosocomial Pneumonia. Intern. Care Med. 19, 256-264. 

In a multicenter, double-blind, randomized comparison of trovafloxacin 200 mg and clarithromycin 500 mg bd in 176 subjects with acute exacerbations of chronic bronchitis, the most common adverse effects of trovafloxacin were nausea (5%), dizziness (5%), vomiting (3%), and constipation (3%) (1). Because trovafloxacin is hepato-toxic, the list of appropriate indications has been limited to patients who have at least one of several specified infections, such as nosocomial pneumonia or complicated intra-abdominal infections that are serious and life- or limb-threatening in the physician s judgement. 

Joshi M, Bernstein J, Solomkin J, Wester BA, Kuye O. Piperacillin/tazobactam plus tobramycin versus ceftazidime plus tobramycin for the treatment of patients with nosocomial lower respiratory tract infection. Piperacillin/ Tazobactam Nosocomial Pneumonia Study Group. J Antimicrob Chemother 1999 43(3) 389-97. 

H2-receptor antagonists are preferred for prophylaxis of SRMB. A large landmark study demonstrated that intravenous ranitidine was superior to oral sucralfate in preventing SRMB. Moreover, ranitidine did not increase the risk for nosocomial pneumonia, as the incidence of pneumonia was no different between the two treatment groups. In itself, critical illness places the patient at risk for nosocomial pneumonia. Also there are potential problems associated with sucralfate therapy (e.g., constipation, clogging tubes, hypophosphatemia, and drug interactions). ... 

Ciprofloxacin is a fluoroquinolone antibiotic that interferes with microbial DNA synthesis. It is indicated in the treatment of infections of the lower respiratory tract, skin and skin structure, bones and joints, urinary tract gonorrhea, chancroid, and infectious diarrhea caused by susceptible strains of specific organisms typhoid fever uncomplicated cervical and urethral gonorrhea women with acute uncomplicated cystitis acute sinusitis nosocomial pneumonia chronic bacterial prostatitis complicated intra-abdominal infections reduction of incidence or progression of inhalational anthrax following exposure to aerosolized Bacillus anthracis. Cipro IV Used for empirical therapy for febrile neutropenic patients. 

THERAPEUTIC USES Because increased gastric pH may be a factor in the development of nosocomial pneumonia in critically iU patients, sucralfate may offer an advantage over proton pump inhibitors and H receptor antagonists for the prophylaxis of stress ulcers (see below). Due to its unique mechanism of action, sucralfate also has been used in several other conditions associated with mucosal inffammation/ulceration that may not respond to acid suppression, including oral mucositis (radiation and aphthous ulcers) and bile reflux gastropathy. Administered by rectal enema, sucralfate also has been used for radiation proctitis and solitary rectal ulcers. 

Cure rates with linezolid ( 60%) were similar to those with vancomycin for nosocomial pneumonia caused by methicillin-resistant or -susceptible S. aureus. Linezolid efficacy also was similar to that of either oxacillin or vancomycin for skin arul skin-structure infections, the majority of cases due to by 8. aureus. Linezolid appears comparable in efficacy to varwomycin for methicillin-resistant strains. Linezolid may be effective for patients with methicillin-resistant S. aureus infections who are failing varwomycin therapy or whose isolates have reduced susceptibility to vancomycin. Linezolid is bacteriostatic for staphylococci arul enterococci arul probably should not be used to treat suspected erulocarditis. 

Skin A 76-year-old patient developed toxic epidermal necrolysis while taking levofloxacin for a nosocomial pneumonia [36 ]. 

Mcmullin, B.B., Chittock, D.R., Roscoe, D.L., Garcha, H., Wang, L., Miller, C.C., 2005. The antimicrobial effect of nitric oxide on the bacteria that cause nosocomial pneumonia in mechanically ventilated patients in the intensive care unit Respiratory Care 50,1451-1456. 

Frequency Doripenem Doripenem has now been on the market for about 5 years. Of 263 patients with nosocomial pneumonia 10 had seizures. In patients with seizure-predisposing conditions, seizures occurred during treatment in two of 193 receiving doripenem and in six of II6 receiving imipenem + cilastatin [26 ]. 

Observational studies Stress ulcer prophylaxis with ranitidine has been associated with an increased risk of ventilator-associated pneumonia. The use of proton pump inhibitors has also been linked to an increased risk of community-acquired pneumonia, and pantoprazole is commonly used in stress ulcer prophylaxis. In a retrospective observational study the database of a cardiothoracic surgery unit was used to identify all patients who had received stress ulcer prophylaxis with pantoprazole or ranitidine 887 patients met the inclusion criteria [66% Nosocomial pneumonia was... 

Miano TA, Reichert MG, Houle TT, MacGregor DA, Kincaid EH, Bowton DL. Nosocomial pneumonia risk and stress ulcer prophylaxis. A comparison of pantoprazole vs ranitidine in car-diothoradc surgery patients. Chest 2009 136 440-7. 

Driks MR, Craven DE, Celli BR, et al. Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers The role of gastric colonization. N Engl J Med 1987 317 1376-1382. 

Fagon J, Chastre J, Domart Y, et al. Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 1989 139 877-884. 

Although reduction in pulmonary infections is one of the reasons for PT in the ICU, a combined intervention of postural drainage and manual hyperinflation resulted in only a slightly lower incidence of nosocomial pneumonia among MV patients, compared with a control group who received standard nursing care (13% vs. 16%, respectively) (18). 

Figure 1 Algorithm for the management of patients with nosocomial pneumonia. Abbreviations CXR, chest X ray CPIS, clinical pulmonary infection score TEAS, tracheobronchial aspirate BAL, bronchoalveolar lavage PSB, protected specimen bmsh PaOa, oxygen arterial pressure Fi02, inspired fraction of oxygen MODS, multiple organ dysfunction syndrome.

Prod hom G, Leuenberger P, Koerfer J, et al. Nosocomial pneumonia In mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. Ann Intern Med 1994 120 653-662. 

Torres A, Aznar R, Gatell JM, et al. Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 1990 142 523-528. Sopena N, Sabria M, and the Neumos Study Group. Multicenter study of hospital-acquired pneumonia in non-lCU patients. Chest 2005 127 213-219. 

Garrouste-Orgeas M, Chevret S, Arlet G, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med 1997 156 1647-1655. 

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(5) 1729-1734. 

Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients a randomised trial. Lancet 1999 354 (9193) 1851-1858. 

Tryba M. Risk of acute stress bleeding and nosocomial pneumonia in ventilated intensive care patients sucralfate versus antacids. Am J Med 1987 83 117-124. 

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