Prevention of ventilator-associated pneumonia by oral decontamination - A prospective, randomized, double-blind, placebo-controlled study

Colonization of the intestinal tract has been assumed to be important in th e pathogenesis of ventilator-associated pneumonia (VAP), but relative Impac ts of oropharyngeal, gastric, or intestinal colonization have not been eluc idated. Our aim was to prevent VAP by modulation of oropharyngeal colonizat ion, without influencing gastric and Intestinal colonization and without sy stemic prophylaxis. In a prospective, randomized, placebo-controlled, doubl e-blind study, 87 patients received topical antimicrobial prophylaxis (gent amicin/ colistin/vancomycin 2% in Orabase, every 6 h) in the oropharynx and 139 patients, divided over two control groups, received placebo (78 patien ts were studied in the presence of patients receiving topical prophylaxis [ control group A] and 61 patients were studied In an intensive care unit whe re no topical prophylaxis was used [control group B]). Baseline characteris tics were comparable in all three groups. Topical prophylaxis eradicated co lonization present on admission in oropharynx (75% in study group versus 0% in control group A [p < 0.00001] and 9% in control group B patients [p < 0 .00001]) and In trachea (52% versus 22% in A [p = 0.03] and 7% in 8 [p = 0. 004]). Moreover, topical prophylaxis prevented acquired oropharyngeal colon ization (10% versus 59% in A [p < 0.00001] and 63% in B [p < 0.00001]). Col onization rates In stomach and intestine were not affected. Incidences of V AP were 10% in study patients, 31% in Group A, and 23% in Group B patients (p = 0.001 and p = 0.04 respectively). This was not associated with shorter durations of ventilation or ICU stay or better survival. Oropharyngeal col onization is of paramount importance in the pathogenesis of VAP, and a targ eted approach to prevent colonization at this site is a very effective meth od of infection prevention.