Dear Editor: We read with interest the special article ‘Defining, treating and preventing hospital acquired pneumonia: European perspective’ by Dr. Torres et al. [1]. We were particularly interested in two topics chosen by the European experts: definitions and prevention.
With regard to definitions, we fully agree with the experts that the term ventilator-associated pneumonia [VAP] is not appropriate and should be abandoned. The European experts suggest the terms intubation-associated pneumonia (IAP) be used for early onset pneumonia and tube-associated pneumonia (TAP) for late onset pneumonia. However, we would like to suggest that these terms do not define the problem adequately. We would argue that the severity of underlying disease is the major determinant of developing pneumonia on intensive care [2, 3], and, therefore, the term critical illness related pneumonia [CIRP] would be more descriptive.
The European experts also state that the preventive approach using selective decontamination of the digestive tract [SDD] plus short-term systemic intravenous antimicrobial treatment should not be called SDD. As two of the originators of SDD, we would humbly suggest that this is a little presumptuous and demonstrates a lack of insight into the philosophy of SDD. The SDD philosophy is based on the carrier state concept [4], which distinguishes among three different types of pneumonia (primary endogenous, secondary endogenous and exogenous) due to a limited range of potentially pathogenic micro-organisms (six ‘normal’ and nine ‘abnormal’). Each of the three types of pneumonia requires different prophylactic interventions. Parenteral antimicrobial agents control primary endogenous pneumonia, enteral antimicrobial agents prevent secondary endogenous pneumonia, and a high level of hygiene combined with topical antimicrobials can control exogenous pneumonia. SDD using hygiene, topical, parenteral and enteral antimicrobial agents is a prophylactic protocol that aims at the control of exogenous, primary endogenous, and secondary endogenous pneumonias resulting in a proven reduction in mortality.
With regard to prevention of IAP or TAP, Table 4 in the article outlines a series of recommended measures for their prevention. However, as far as we are aware none of the generally recommended measures are associated with evidenced based survival benefit. Amongst the additional measures, only one, SDD demonstrates unequivocal evidence based survival benefit [5].
In conclusion, this European exercise while well intentioned is not comprehensive and misses essential issues, notably evidence based practice.
References
Torres A, Ewig S, Lode H, Carlet J, for the European HAP working group (2009) Defining, treating and preventing hospital acquired pneumonia: European perspective. Intensive Care Med 35:9–29
Kerver AJ, Rommes JH, Mevissen-Verhage EA, Hulstaert PF, Vos A, Verhoef J, Wittebol P (1988) Prevention of colonization and infection in critically ill patients: a prospective randomized study. Crit Care Med 16:1087–1093
Sánchez García M, Cambronero Galache JA, López Diaz J, Cerdá Cerdá E, Rubio Blasco J, Gómez Aguinaga MA, Núnez Reiz A, Rogero Marín S, Onoro Canaveral JJ, Sacristán del Castillo JA (1998) Effectiveness and cost of selective decontamination of the digestive tract in critically ill intubated patients. A randomized, double-blind, placebo-controlled, multicenter trial. Am J Respir Crit Care Med 158:908–916
Silvestri L, van Saene HKF, de la Cal MA, de Gaudio AR (2009) Carriage classification of pneumonia rather than time improves survival. Chest 135 (in press)
van Saene HKF, Silvestri L, de la Cal MA, Baines PB (2009) The Emperor’s new clothes: the fairy tale continues. J Crit Care 24:149–152
Author information
Authors and Affiliations
Corresponding author
Additional information
An author’s reply to this comment is available at: doi:10.1007/s00134-009-1568-3.
Rights and permissions
About this article
Cite this article
Zandstra, D.F., Petros, A.J. & van Saene, H.K.F. The final gasp from the European experts. Intensive Care Med 35, 1816 (2009). https://doi.org/10.1007/s00134-009-1566-5
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00134-009-1566-5