NOSOCOMIAL PNEUMONIA IN MECHANICALLY VENTILATED PATIENTS RECEIVING ANTACID, RANITIDINE, OR SUCRALFATE AS PROPHYLAXIS FOR STRESS-ULCER - A RANDOMIZED CONTROLLED TRIAL

Objective: To assess three anti-stress ulcer prophylaxis regimens in m echanically ventilated patients for bacterial colonization, early- and late-onset nosocomial pneumonia, and gastrointestinal bleeding. Desig n: Randomized controlled trial. Patients: Consecutive eligible patient s 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 assig ned 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 lat e-onset pneumonia was assessed in patients intubated for more than 24 hours. Results: Of 244 assessable patients, macroscopic gastric bleedi ng was observed in 10%, 4%, and 6% of patients assigned to receive suc ralfate, antacid, and ranitidine, respectively (P > 0.2). The incidenc e of early-onset pneumonia was not statistically different among the t hree treatment groups (P > 0.2). Among the 213 patients observed for m ore than 4 days, late-onset pneumonia was observed in 5% of the patien ts who received sucralfate compared with 16% and 21% of the patients w ho received antacid or ranitidine, respectively (P = 0.022). Mortality was not statistically different among the three treatment groups. Pat ients who received sucralfate had a lower median gastric pH (P < 0.001 ) and less frequent gastric colonization compared with the other group s (P = 0.015). Using molecular typing, 84% of the patients with late-o nset gramnegative bacillary pneumonia were found to have gastric colon ization with the same bacteria before pneumonia developed. Conclusion: Stress ulcer prophylaxis with sucralfate reduces the risk for late-on set pneumonia in ventilated patients compared with antacid or ranitidi ne.