Am. J. Respir. Crit. Care Med., Volume 159, Number 1, January 1999, 188-198

Bacterial Colonization Patterns in Mechanically Ventilated Patients with Traumatic and Medical Head Injury
Incidence, Risk Factors, and Association with Ventilator-associated Pneumonia

SANTIAGO EWIG, ANTONI TORRES, MUSTAFA EL-EBIARY, NEUS FÀBREGAS, CARMEN HERNÁNDEZ, JULIÀ GONZÁLEZ, JOSE MARIA NICOLÁS, and LUIS SOTO

Servei de Pneumologia i Al·lergia Respiratoria, Servei de Anestesia, Servei de Microbiologia, Area de Vigilancia Intensiva, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain

We prospectively evaluated the relation of upper airway, lower airway, and gastric colonization patterns with the development of pneumonia and its etiology in 48 patients with surgical (n = 25) and medical (n = 23) head injury. Initial colonization was assessed by cultures of nasal and pharyngeal swabs, tracheobronchial aspirates, gastric juice, and bronchoscopically retrieved protected specimen brush. Follow-up colonization was determined until the end points extubation, suspected ventilator-associated pneumonia (VAP), or death. The initial colonization rate at any site at ICU admission was 39/47 (83%). It mainly accounted for Group I pathogens (Streptococcus pneumoniae, Staphylococcus aureus, Hemophilus influenzae) of the upper and lower airways. At follow-up, colonization rates with Group II pathogens (Gram-negative enteric bacilli and Pseudomonas spp.) increased significantly. The high initial bacterial load with Group I pathogens of the upper airways and trachea decreased during Days 2 to 4, whereas that of Group II pathogens increased. Upper airway colonization was an independent predictor of follow-up tracheobronchial colonization (odds ratio [OR], 9.9; 95% confidence interval [CI], 1.8 to 56.3 for initial colonization with Group I pathogens; OR, 23.9; 95% CI, 3.8 to 153.3 for follow-up colonization with Group II pathogens). Previous (short-term) antibiotics had a protective effect against colonization with Group I pathogens of the lower respiratory tract (OR, 0.2; 95% CI, 0.05 to 0.86), but they were a risk factor for colonization with Group II pathogens (OR, 6.1; 95% CI, 1.3 to 29). Initial tracheobronchial colonization with Group I pathogens was associated with a higher probability of early onset pneumonia (OR, 4.1; 95% CI, 0.7 to 23.3), whereas prolonged antibiotic treatment (> 24 h) independently predicted late-onset pneumonia (OR, 9.2; 95% CI, 1.7 to 51.3). We conclude that patients with head injury are colonized in the airways mainly by Group I pathogens early in the evolution of illness. The upper airways represent the main reservoir for subsequent lower airway colonization with Group I pathogens. Previous (short-term) antibiotic treatment is protective against initial tracheobronchial colonization with Group I pathogens, but it represents a risk factor for subsequent lower airway colonization by Group II pathogens.

This article has been cited by other articles:

				P. Pelosi, A. Barassi, P. Severgnini, B. Gomiero, S. Finazzi, G. Merlini, G. M. d'Eril, M. Chiaranda, and M. S. Niederman Prognostic Role of Clinical and Laboratory Criteria To Identify Early Ventilator-Associated Pneumonia in Brain Injury Chest, July 1, 2008; 134(1): 101 - 108. [Abstract] [Full Text] [PDF]

				L. Lorente, S. Blot, and J. Rello Evidence on measures for the prevention of ventilator-associated pneumonia Eur. Respir. J., December 1, 2007; 30(6): 1193 - 1207. [Abstract] [Full Text] [PDF]

				O. Burkhardt, V. Kumar, D. Katterwe, J. Majcher-Peszynska, B. Drewelow, H. Derendorf, and T. Welte Ertapenem in critically ill patients with early-onset ventilator-associated pneumonia: pharmacokinetics with special consideration of free-drug concentration J. Antimicrob. Chemother., February 1, 2007; 59(2): 277 - 284. [Abstract] [Full Text] [PDF]

				K. A. Davis Ventilator-associated pneumonia: a review. J Intensive Care Med, July 1, 2006; 21(4): 211 - 226. [Abstract] [PDF]

				C. J. Cutler and N. Davis Improving Oral Care in Patients Receiving Mechanical Ventilation Am. J. Crit. Care., September 1, 2005; 14(5): 389 - 394. [Abstract] [Full Text] [PDF]

				J. Belda, M. Cavalcanti, M. Ferrer, M. Serra, J. Puig de la Bellacasa, E. Canalis, and A. Torres Bronchial Colonization and Postoperative Respiratory Infections in Patients Undergoing Lung Cancer Surgery Chest, September 1, 2005; 128(3): 1571 - 1579. [Abstract] [Full Text] [PDF]

				P. Corne, H. Marchandin, O. Jonquet, J. Campos, and A.-L. Banuls Molecular Evidence that Nasal Carriage of Staphylococcus aureus Plays a Role in Respiratory Tract Infections of Critically Ill Patients J. Clin. Microbiol., July 1, 2005; 43(7): 3491 - 3493. [Abstract] [Full Text] [PDF]

				C. M. Parker and D. K. Heyland Aspiration and the Risk of Ventilator-Associated Pneumonia Nutr Clin Pract, December 1, 2004; 19(6): 597 - 609. [Abstract] [Full Text] [PDF]

				G. B. Pier, D. Boyer, M. Preston, F. T. Coleman, N. Llosa, S. Mueschenborn-Koglin, C. Theilacker, H. Goldenberg, J. Uchin, G. P. Priebe, et al. Human Monoclonal Antibodies to Pseudomonas aeruginosa Alginate That Protect against Infection by Both Mucoid and Nonmucoid Strains J. Immunol., November 1, 2004; 173(9): 5671 - 5678. [Abstract] [Full Text] [PDF]

				L. Silvestri, H.K.F. van Saene, M. Milanese, F. Fontana, D. Gregori, L. Oblach, N. Piacente, and M. Blazic Prevention of MRSA pneumonia by oral vancomycin decontamination: a randomised trial Eur. Respir. J., June 1, 2004; 23(6): 921 - 926. [Abstract] [Full Text] [PDF]

				M. Leone, J. Albanese, S. Rousseau, F. Antonini, M. Dubuc, B. Alliez, and C. Martin Pulmonary Contusion in Severe Head Trauma Patients: Impact on Gas Exchange and Outcome Chest, December 1, 2003; 124(6): 2261 - 2266. [Abstract] [Full Text] [PDF]

				J. Chastre and J.-Y. Fagon Ventilator-associated Pneumonia Am. J. Respir. Crit. Care Med., April 1, 2002; 165(7): 867 - 903. [Abstract] [Full Text] [PDF]

				S Ewig, T Bauer, and A Torres The pulmonary physician in critical care * 4: Nosocomial pneumonia Thorax, April 1, 2002; 57(4): 366 - 371. [Abstract] [Full Text] [PDF]

				J. HAYON, C. FIGLIOLINI, A. COMBES, J.-L. TROUILLET, N. KASSIS, M. C. DOMBRET, C. GIBERT, and J. CHASTRE Role of Serial Routine Microbiologic Culture Results in the Initial Management of Ventilator-associated Pneumonia Am. J. Respir. Crit. Care Med., January 1, 2002; 165(1): 41 - 46. [Abstract] [Full Text] [PDF]

				Members of the Task Force:, E. Bouza, C. Brun-Buisson, J. Chastre, S. Ewig, J-Y. Fagon, C.H. Marquette, P. Munoz, M.S. Niederman, L. Papazian, et al. Ventilator-associated pneumonia: European Task Force on ventilator-associated pneumonia Chairmen of the Task Force: A. Torres and J. Carlet Eur. Respir. J., May 1, 2001; 17(5): 1034 - 1045. [Full Text] [PDF]

				A. CARLUCCI, J.-C. RICHARD, M. WYSOCKI, E. LEPAGE, L. BROCHARD, and the SRLF Collaborative Group o Noninvasive Versus Conventional Mechanical Ventilation . An Epidemiologic Survey Am. J. Respir. Crit. Care Med., March 15, 2001; 163(4): 874 - 880. [Abstract] [Full Text]

				A. M. NAMEN, E. WESLEY ELY, S. B. TATTER, L. DOUGLAS CASE, M. A. LUCIA, A. SMITH, S. LANDRY, J. A. WILSON, S. S. GLAZIER, C. L. BRANCH, et al. Predictors of Successful Extubation in Neurosurgical Patients Am. J. Respir. Crit. Care Med., March 1, 2001; 163(3): 658 - 664. [Abstract] [Full Text] [PDF]

				J. P. Lynch III Hospital-Acquired Pneumonia : Risk Factors, Microbiology, and Treatment Chest, February 1, 2001; 119(2_suppl): 373S - 384S. [Abstract] [Full Text] [PDF]