Abstract
A high rate of nosocomial pneumonia exists among intubated patients receiving mechanical ventilation. Retrograde colonization of the oropharynx and trachea with bacteria from the stomach is not widely appreciated in the pathogenesis of pneumonia. Gastric colonization is affected by age, malnutrition, antibiotics, disease of the gastrointestinal tract, and changes in pH. The widespread use of antacids and/or histamine type 2 blockers as prophylaxis against stress bleeding in the ventilated patient may also increase gastric pH and the risk of colonization in the upper gastrointestinal tract. Migration of bacteria between the stomach, oropharynx and trachea in the intubated patient may be a dynamic system involving large numbers of bacteria. The high fatality rate of mechanically ventilated patients with pneumonia, which persists despite treatment of these patients with appropriate antimicrobial therapy, underscores the need for effective measures of prevention. Preventive measures include the appropriate use of antibiotics, proper decontamination of respiratory therapy equipment, the cautious use of drugs that alter the natural gastric acid barrier, or, possibly, the selective use of antibiotics to prevent or reduce gastric, oropharyngeal and tracheal colonization.
Similar content being viewed by others
References
Horan, T. C., White, J. W., Jarvis, W. R. Nosocomial infection surveillance, 1984. Morbidity & Mortality Weekly Report 1986, 35: 17–29.
Gross, P. A., Neu, H. C., Aswapokee, P., Van Antwerpen, C. V., Aswapokee, N. Deaths from nosocomial infection: experience in a university hospital and a community hospital. American Journal of Medicine 1980, 68: 219–223.
Cross, A. S., Roupe, B. Role of respiratory assistance devices in endemic nosocomial pneumonia. American Journal of Medicine 1981, 70: 681–685.
Haley, R. W., Hooton, T. M., Culter, D. H., Stanley, R. C., Emori, G., Hardison, C. D., Quade, D., Shaberg, D. R., Shah, B. V., Schatz, G. D. Nosocomial infections in U.S. hospitals, 1975–1976: estimated frequency by selected characteristics of patients. American Journal of Medicine 1981, 70: 947–959.
Stevens, R. M., Teres, D., Skillman, J. J., Feingold, D. S. Pneumonia in an intensive care unit: a thirty-month experience. Archives of Internal Medicine 1974, 134: 106–111.
du Moulin, G. C., Hedley-Whyte, J., Paterson, D. G., Lisbon, A. Aspiration of gastric bacteria in antacid-treated patients: a frequent cause of postoperative colonization of the airway. Lancet 1982, i: 242–245.
Craven, D. E., Kunches, L. M., Kilinsky, V., Lichtenberg, D. A., Make, B. J., McCabe, W. R. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. American Review of Respiratory Diseases 1986, 133: 792–796.
Daschner, F., Kappstein, I., Engels, I., Reuschenbach, K., Pfisterer, J., Krieg, N., Vogel, W. Stress ulcer prophylaxis and ventilation pneumonia: prevention by antibacterial cytoprotective agents. Infection Control Hospital Epidemiology 1988, 9: 59–65.
Johanson, W. G., Pierce, A. K., Sanford, J., Thomas, G. D. Nosocomial respiratory infections with gram-negative bacilli: the significance of colonization of the respiratory tract. Annals of Internal Medicine 1972, 77: 701–706.
Johanson, W. G., Pierce, A. K., Sanford, J. P. Changing pharyngeal bacterial flora of hospitalized patients. Emergence of gram-negative bacilli. New England Journal of Medicine 1969, 281: 1137–1140.
Driks, M. R., Craven, D. E., Celli, B. R., Manning, M., Burke, R. A., Garvin, G. G., Kunches, L. M., Farber, H. W., Wedel, S. A., McCabe, W. R. Nosocomial pneumonia in intubated patients given sucralfate as compared with antiacids or histamine type 2 blockers. New England Journal of Medicine 1987, 317: 1376–1382.
Atherton, S. T., White, D. J. Stomach as source of bacteria colonizing respiratory tract during artificial ventilation. Lancet 1978, ii: 968–969.
Tryba, M., Zevounou, F., Torok, M., Zenz, M. Prevention of acute stress bleeding with sucralfate, antacids, or cimetidine. American Journal of Medicine 1985, 79, Supplement 2C: 55–61.
Celis, R., Torres, A., Gatell, J. M., Almela, M., Rodriques-Roisin, R., Augusti-Vidas, A. Nosocomial pneumonia: a multivariate analysis of risk and prognosis, Chest 1988, 93: 318–324.
Garibaldi, R. A., Britt, M. R., Coleman, M. L., Reading, J. C., Page, N. L. Risk factors for postoperative pneumonia. American Journal of Medicine 1981, 70: 677–680.
Pennington, J. E. Nosocomial respiratory infection. In: Mandell, G. L., Douglas, R. G., Bennett, J. E. (ed.): Principles and practices of infectious disease. New York, Wiley, 1985, p. 1620–1625.
Sanford, J. P. Lower respiratory tract infections. In: Bennett, J. V., Brachman, P. S. (ed.): Hospital infections. Little Brown, Boston, 1986, p. 385–422.
Lepper, M. H. Opportunistic gram-negative rod pulmonary infection. Diseases of the Chest 1963, 44: 18–26.
Amberson, J. B. Aspiration bronchopneumonia. International Clinics 1937, 3: 126–134.
Huxley, E. J., Viroslav, J., Gray, W. R., Pierce, A. K. Pharyngeal aspiration in normal adults and patients with depressed consciousness. American Journal of Medicine 1978, 64: 564–568.
Wynne, J. M., Modell, J. H. Respiratory aspiration of stomach contents. Annals of Internal Medicine 1977, 87: 466–469.
Olivares, L., Segovia, A., Revuelta, R. Tube feeding and lethal aspiration in neurological patients: a review of 720 autopsy cases. Stroke 1974, 5: 654–656.
Cameron, J., Zuidema, G. Aspiration pneumonia: magnitude and frequency of the problem. Journal of the American Medical Association 1972, 219: 1194–1198.
Pierce, A. K., Sanford, J. P. Aerobic gram-negative bacillary pneumonias. American Review of Respiratory Disease 1974, 110: 647–658.
Kass, E. H., Schneiderman, L. J. Entry of bacteria into the urinary tracts of patients with inlying catheters. New England Journal of Medicine 1957, 256: 556–557.
Ramphal, R., Small, P. M., Shands, J. W., Fischelschweiger, W., Small, P. A. Adherence ofPseudomonas aeruginosa to tracheal cells injured by influenza infection or by endotracheal intubation. Infection & Immunity 1980, 27: 614–619.
Bernhard, W. N., Cottrell, J. E., Sivakumaran, C., Patel, K., Yost, L., Turndorf, H. Adjustment of intracuff pressure to prevent aspiration. Anesthesiology 1979, 50: 363–367.
LeFrock, J. L., Ellia, C. A., Weinstein, L. The relation between aerobic fecal and oropharyngeal microflora in hospitalized patients. American Journal of Medical Science 1979, 277: 275–280.
Louria, D. B., Kaminski, T. The effects of four antimicrobial drug regimens on sputum superinfection in hospitalized patients. American Review of Respiratory Disease 1962, 85: 649–665.
Sprunt, K., Redman, W. Evidence suggesting importance of role of antibacterial inhibition in maintaining balance of normal flora. Annals of Internal Medicine 1968, 68: 579–590.
Valenti, W. M., Trudell, R. G., Bentley, D. W. Risk factors predisposing to oropharyngeal colonization with gram-negative bacilli in the aged. New England Journal of Medicine 1978, 298: 1108–1111.
Higuchi, J. H., Chaudhui, T., Johanson, W. G. Determinants of postoperative respiratory tract colonization with gram-negative bacilli. American Review of Respiratory Disease 1978, 117: 274.
Mackowiak, P. A., Martin, R. M., Jones, S. R., Smith, J. W. Pharyngeal colonization by gram-negative bacilli in aspiration-prone persons. Archives of Internal Medicine 1978, 138: 1224–1227.
Penn, R. G., Sanders, W. E., Sanders, C. C. Colonization of the oropharynx with gram-negative bacilli: a major antecedent to nosocomial pneumonia. American Journal of Infection Control 1981, 9: 25–34.
Reynolds, H. Y. Bacterial adherence to respiratory tract mucosa: a dynamic interaction leading to colonization. Seminars in Respiratory Infection 1987, 2: 8–19.
Sprunt, K., Leidy, G. A., Redman, W. Prevention of bacterial overgrowth. Journal of Infectious Diseases 1971, 123: 1–10.
Schwartz, S. N., Dowling, J. N., Benkovic, C., DeQuittner-Buchanan, M., Prostko, T., Yee, R. Sources of gram-negative bacilli colonizing the trachea of intubated patients. Journal of Infectious Diseases 1978, 138: 227–231.
Seldon, R., Lee, S., Wong, W. L. L., Bennett, J., Eickhoff, T. NosocomialKlebsiella infections: intestinal colonization as a reservoir. Annals of Internal Medicine 1971, 74: 657–664.
Story, P. Proteus infections in hospital. Journal of Pathology 1954, 68: 55–62.
Garrod, L. P. A study of the bacterial power of hydrochloric acid and of gastric juice. St. Bartholomew's Hospital Reports 1939, 72: 145–167.
Arnold, I. The bacterial flora within the stomach and small intestine — the effect of experimental alterations of acid-base balance and the age of the subject. American Journal of Medical Science 1933, 186: 471–481.
Gracey, M., Suharjano, S., Stone, D. E. Microbial contamination of the gut: another feature of malnutrition. American Journal of Clinical Nutrition 1973, 26: 1170–1174.
Drasar, B. S., Shiner, M., McLeod, G. M. Studies on the intestinal flora. I. The bacterial flora of the gastrointestinal tract in healthy and achlorhydric persons. Gastroenterology 1969, 56: 71–79.
Gray, J. D., Shiner, M. Influence of gastric pH on gastric and jejeunal flora. Gut 1967, 8: 574–581.
Drasar, B. S., Shiner, M. Studies of the intestinal flora: II. Bacteria flora of the small intestine in patients with gastrointestinal disorders. Gut 1969, 10: 812–819.
Goldstein, F., Wirts, W., Dramar, S. The relationship of afferent limb stasis and bacterial flora to the production of post-gastrectomy steatorrhea. Gastroenterology 1961, 40: 47–55.
Bishop, R. F., Anderson, C. M. The bacterial flora of the stomach and small intestine in children with obstruction. Archives of Diseases of Children 1960, 35: 487–491.
Schwabacher, H., Salsbury, A. J., Loosemore, T. G. E. The bacteria flora of gastric lavages from patients undergoing partial gastrectomy. Journal of Clinical Pathology 1959, 12: 565–567.
Barber, M., Franklin, R. H. Bacteriology of stomach and duodenum in cases of peptic ulcers and gastric carcinoma. British Medical Journal 1946, i: 951–953.
Seley, G. P., Colp, R. The bacteriology of peptic ulcers and gastric malignancies: possible bearing on complications following gastric surgery. Surgery 1941, 10: 369–380.
Ruddell, W. S. J., Axon, A. T. R., Findlay, J. M., Bartholomew, B. A., Hill, M. J. Effect of cimetidine on the gastric bacterial flora. Lancet 1980, i: 672–674.
Goularte, T. A., Lichtenberg, D. A., Craven, D. E. Gastric colonization in patients receiving antacids and mechanical ventilation: a mechanism for pharyngeal colonization. American Journal of Infection Control 1986, 14: 88.
Pingleton, S. K., Hinthorn, D. R., Liu, C. Enteral nutrition in patients receiving mechanical ventilation: multiple sources of tracheal colonization include the stomach. American Journal of Medicine 1986, 80: 827–832.
Donowitz, G. L., Page, M. L., Mileur, B. L., Guenthner, S. H. Alteration of normal gastric flora in critical care patients receiving antacid and cimetidine therapy. Infection Control 1986, 7: 23–26.
Tryba, M. (ed.): Prevention of stress bleeding in critically ill patients — a new concept. Thieme Medical Publishers, New York, 1988, p. 1–162.
Schuman, R. B., Schuster, D. T., Zuckerman, G. R. Prophylactic treatment for stress ulcer bleeding: a reappraisal. Annals of Internal Medicine 1987, 106: 562–567.
Hotz, J. Antacids for the prevention of gastrointestinal stress bleeding. In: Tryba, M. (ed.): Prevention of stress bleeding in critically ill patients — a new concept. Thieme Medical Publishers, New York, 1988, p. 19–21.
Hastings, P. R., Skillman, J. J., Brushnell, L. S., Silen, W.: Antacid titration in the prevention of acute gastro-intestinal bleeding: a controlled, randomized trial in 100 critically ill patients. New England Journal of Medicine 1978, 1041–1045.
Zinner, M. J., Zuidema, G. D., Smith, P. L., Mignosa, M. The prevention of gastrointestinal tract bleeding in patients in an intensive care unit. Surgery Gynecology Obstetrics 1981, 153: 214–220.
Basso, N., Bagarani, M., Materia, A., Fiorani, S., Lunardi, P., Spernaza, V. Cimetidine and antacid prophylaxis of acute upper gastrointestinal bleeding in high risk patients: a controlled randomized trial. American Journal of Surgery 1981, 141: 339–341.
McAlhany, J. C., Czaya, A. J., Pruitt, B. A. Antacid control of complications from acute gastrointestinal disease after burns. Journal of Trauma 1976, 16: 645–649.
Huchzermeyer, H., Tryba, M. Efficacy of H2-receptor antagonists for the prevention of stress bleeding. In: Tryba, M. (ed.), Prevention of stress bleeding in critically ill patients — a new concept. Thieme Medical Publishers, New York, 1988, p. 22–27.
Holloran, L. G., Gayle, E., Wheeler, C. B., Miller, J. D. Prevention of acute gastrointestinal complications after severe head injury: a controlled trial of cimetidine. American Journal of Surgery 1980, 139: 44–48.
Priebe, H. J., Skillman, J. J., Bushnell, L. S. Antacid versus cimetidine in preventing acute gastrointestinal bleeding. New England Journal of Medicine 1980, 302: 426–430.
Bethge, H. Mechanism of action of sucralfate. In: Tryba, M. (ed.): Prevention of stress bleeding in critically ill patients — a new concept. Thieme Medical Publishers, New York, 1988, p. 1–12.
Bresalier, R. A., Grendell, J. H., Cello, J. P., Meyer, A. A. Sucralfate suspension versus titrated antacids for the prevention of acute stress-related gastrointestinal hemorrhage in critically ill patients. American Journal of Medicine 1987, 83: 110–116.
Cannon, L. A., Heiselman, D., Gardner, W., Jones, J. Prophylaxis of upper gastrointestinal tract bleeding in mechanically ventilated patients: a randomized study comparing the efficacy of sucralfate, cimetidine and antacids. Archives of Internal Medicine 1987, 147: 2101–2106.
Borrero, E., Bank, S., Margolis, I., Schulman, N., Chardavoyne, R. Comparison of antacid and sucralfate in the prevention of gastrointestinal bleeding in patients who are critically ill. American Journal of Medicine 1985, 79: 62–64.
Laggner, A. N., Lenz, K., Druml, W., Schneeweib, B., Grimm, G. Stressulcusprophylaxe auf einer internen Intensivstation. Wiener Klinische Wochenschrift 1987, 99: 12–13.
Borrero, E., Ciervo, J., Chang, J. B. Antacid versus sucralfate in preventing acute gastrointestinal tract bleeding in abdominal aortic surgery. Archives of Surgery 1986, 121: 810–812.
Mundinger, G. H., Hays, A., Allo, M., Lamy, P., Kitler, M. E., Zuidema, G. Effect of meciadanol and sucralfate as compared with antacid titration regimen on prevention of the gastrointestinal hemorrhage in postoperative intensive care patients. Surgical Forum 1985, 36: 121–123.
Tryba, M., Zevounou, F., Torok, M., Zenz, M. Prevention of acute stress bleeding with sucralfate, antacids or cimetidine: a controlled study with pirenzepine as a basic medication. American Journal of Medicine 1985, 79: 55–61.
Lundell, L., Persson, G. Does preoperative treatment with cimetidine increase the risk of postoperative infection? Annales Chirurgiae et Gynaecologiae 1983, 72: 312–316.
Cheadle, W. G., Vitale, G. C., Mackie, C. R., Cuschieri, A. Prophylactic postoperative nasogastric decompression: a prospective study of its requirement and the influence of cimetidine in 200 patients. Annals of Surgery 1985, 202: 361–366.
Mantey-Stiers, F., Tryba, M. Antibacterial activity of sucralfate in human gastric juice. American Journal of Medicine 1987, 87: 125–127.
Lepper, M. H., Kofman, S., Blatt, N., Dowling, H. F., Jackson, G. G. Effect of antibiotics used singly and in combination on the tracheal flora following tracheostomy in poliomyelitis. Antibiotics & Chemotherapy 1954, 4: 829–833.
Feeley, T. W., du Moulin, G. C., Hedley-Whyte, J., Bushnell, L. S., Gilbert, J. P., Feingold, D. S. Aerosol polymyxin and pneumonia in seriously ill patients. New England Journal of Medicine 1975, 293: 471–475.
Stoutenbeek, C. P., van Saene, H. K. F., Miranda, D. R., Andstra, D. F., Langrehr, D. Nosocomial gram-negative pneumonia in critically ill patients: a 3-year experience with a novel therapeutic regimen. Intensive Care Medicine 1986, 12: 419–423.
Stoutenbeek, C. P., van Saene, H. K. F., Miranda, D. R., Zandstra, D. F. The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intensive Care Medicine 1984, 10: 185–192.
Unertl, K., Ruckdeschel, G., Selmann, H. K., Jensen, U., Forst, H., Lenhart, F. P., Peter, K. Prevention of colonization and respiratory infections in long-term ventilated patients by local antimicrobial prophylaxis. Intensive Care Medicine 1987, 13: 106–113.
McA Ledingham, I., Alcock, S. R., Eastaway, A. T., McDonald, J. C., McKay, I. C., Ramsey, G. Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in intensive care. Lancet 1988, i: 785–790.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Craven, D.E., Daschner, F.D. Nosocomial pneumonia in the intubated patient: Role of gastric colonization. Eur. J. Clin. Microbiol. Infect. Dis. 8, 40–50 (1989). https://doi.org/10.1007/BF01964119
Issue Date:
DOI: https://doi.org/10.1007/BF01964119