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Nosocomial Pneumonia in Mechanically Ventilated Patients Receiving Antacid, Ranitidine, or Sucralfate as Prophylaxis for Stress Ulcer: A Randomized Controlled Trial

Guy Prod'hom, MD; Philippe Leuenberger, MD; Jacques Koerfer, MD; Andre Blum, MD; Rene Chiolero, MD; Marie-Denise Schaller, MD; Claude Perret, MD; Olivier Spinnler, MD; Jacques Blondel, MD; Hans Siegrist, MD; Laylee Saghafi, MPH; Dominique Blanc, PhD; and Patrick Francioli, MD
[+] Article, Author, and Disclosure Information

From the Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. Requests for Reprints: Patrick Francioli, MD, Division Autonome de Medecine Preventive Hospitaliere, Centre Hospitalier Universitaire Vaudois, CH-1011 Lausanne, Switzerland. Acknowledgments: The authors thank the staff of the Laboratory of Medical Microbiology (especially Dr. J. Bille); the staff of the medical and surgical intensive care units of the Centre Hospitalier Universitaire Vaudois of Lausanne for their support and assistance; Ms. M. Mottaz and Ms. G. Bossuat for their help in collecting the data; Ms. M. Roulet for secretarial assistance, and Drs. A. Cometta and M. P. Glauser for their valuable comments on the manuscript. Grant Support: By Merck and Co.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;120(8):653-662. doi:10.7326/0003-4819-120-8-199404150-00005
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Objective: To assess three anti-stress ulcer prophylaxis regimens in mechanically ventilated patients for bacterial colonization, early- and late-onset nosocomial pneumonia, and gastrointestinal bleeding.

Design: Randomized controlled trial.

Patients: Consecutive eligible patients with mechanical ventilation and a nasogastric tube. Of 258 eligible patients, 244 were assessable.

Setting: Medical and surgical intensive care units.

Intervention: At intubation, patients were randomly assigned to receive one of the following: antacid (a suspension of aluminum hydroxide and magnesium hydroxide), 20 mL every 2 hours; ranitidine, 150 mg as a continuous intravenous infusion; or sucralfate, 1 g every 4 hours.

Measurements: Using predetermined criteria, the incidence of gastric bleeding, gastric colonization, early-onset pneumonia, and late-onset pneumonia was assessed in patients intubated for more than 24 hours.

Results: Of 244 assessable patients, macroscopic gastric bleeding was observed in 10%, 4%, and 6% of patients assigned to receive sucralfate, antacid, and ranitidine, respectively (P > 0.2). The incidence of early-onset pneumonia was not statistically different among the three treatment groups (P > 0.2). Among the 213 patients observed for more than 4 days, late-onset pneumonia was observed in 5% of the patients who received sucralfate compared with 16% and 21% of the patients who received antacid or ranitidine, respectively (P = 0.022). Mortality was not statistically different among the three treatment groups. Patients who received sucralfate had a lower median gastric pH (P < 0.001) and less frequent gastric colonization compared with the other groups (P = 0.015). Using molecular typing, 84% of the patients with late-onset gram-negative bacillary pneumonia were found to have gastric colonization with the same bacteria before pneumonia developed.

Conclusion: Stress ulcer prophylaxis with sucralfate reduces the risk for late-onset pneumonia in ventilated patients compared with antacid or ranitidine.


Grahic Jump Location
Figure 1.
Median gastric pH.

Each symbol represents a patient's median gastric pH until the patient was extubated or late-onset pneumonia developed. The medians of these values are indicated by the horizontal bars.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Pneumonia in the three treatment groups according to the day of occurrence after intubation.

Each symbol represents one episode of pneumonia. The numbers of patients under observation and at risk for pneumonia are shown at the bottom.

Grahic Jump Location




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