Summary
In a prospective case study we investigated whether the application of barbiturates in artificially ventilated patients with brain oedema has dose-dependent effects on the rate of nosocomial pneumonia. Pneumonia developed within the first seven days of controlled ventilation in patients receiving barbiturates; furthermore, the rate of nosocomial pneumonia was significantly higher in patients receiving barbiturates than in the control group without barbiturates (7.7%; p<0.0181); thus a clear dose dependency was shown (high-dose group: 43.8%, low-dose group: 21.4%). In all patients with pneumonia, colonization of the respiratory tract with pathogenic organisms preceded the pulmonary infection by four days. Under barbiturate therapy colonization of the respiratory tract occurred in all patients and one or two days earlier than in the control group, in which only 70% of the patients were colonized. These differences were significant for each of the first six days after hospitalization (p<0.0001 -0.013). While in the high-dose group both colonization and pneumonia were caused mainly by gram-positive pathogens, mixed gram-positive and gram-negative pathogens were isolated in groups 2 and 3. Thus the higher rate of pneumonia of 43.8% in the high-dose group suggests a need for regular and semiquantitative monitoring of the causative agents and their antibiogram. Such measures could lead to early recognition with high predictability of the development of nosocomial pneumonia in colonized patients, allowing for timely application of the most appropriate antibiotics.
Zusammenfassung
In einer prospektiven Fallstudie untersuchten wir die Frage, ob künstlich beatmete Patienten mit Hirnödem eine erhöhte Quote nosokomialer Pneumonien entwickeln, wenn sie eine hohe bzw. eine niedere Dosis von Barbituraten erhalten, als wenn sie ohne Barbiturate sediert werden. Die Untersuchung zeigte, daß sich nosokomiale Pneumonien innerhalb von sieben Tagen nach Beginn der Beatmung entwickelten, und daß die Quote signifikant höher lag bei der Gruppe der Patienten mit hoher Barbituratdosis (43,8%) gegenüber der Gruppe mit niedriger Barbituratdosis (21,4%) und der Kontrollgruppe ohne Barbituratapplikation (7,7%, p<0,0181). Bei allen Pneumonie-Patienten war eine Kolonisation der Atemwege mit pathogenen Keimen der Infektion um vier Tage vorausgegangen. Unter der Barbiturat-Therapie erschien die 100%ige Kolonisation der Atemwege ein bis zwei Tage früher als bei der Kontrollgruppe. Letztere wurde nur zu 70% kolonisiert. Unterschiede sind für jeden der ersten sechs Tage nach der Hospitalisierung mit p<0,0001 - 0,013 signifikant. Während in der Hochdosis-Gruppe sowohl die Kolonisation wie die Infektion der tiefen Atemwege hauptsächlich durch grampositive Erreger verursacht wurde, lag bei den Gruppen 2 und 3 meist eine Mischflora aus grampositiven und gramnegativen Erregern vor. Die hohe Pneumonierate von 43,8% in der Hochdosis-Gruppe verlangt in Zukunft nach einem regelmäßigen semiquantitativen Monitoring der ursächlichen Erreger und ihres Antibiogramms. Dies ermöglicht ein frühzeitiges Erkennen mit hoher Voraussagekraft einer sich entwickelnden nosokomialen Pneumonie aus der Gruppe der kolonisierten Patienten und den zeitgerechten Einsatz der geeigneten Antibiotika.
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Eberhardt, K.E.W., Spring, A., Maskos, W. et al. Dose-dependent rate of nosocomial pulmonary infection in mechanically ventilated patients with brain oedema receiving barbiturates: A prospective case study. Infection 20, 12–18 (1992). https://doi.org/10.1007/BF01704886
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DOI: https://doi.org/10.1007/BF01704886