Nosocomial Pneumonia in Mechanically Ventilated Patients Receiving Antacid, Ranitidine, or Sucralfate as Prophylaxis for Stress Ulcer

A Randomized Controlled Trial

  1. Guy Prod'hom, MD;
  2. Philippe Leuenberger, MD;
  3. Jacques Koerfer, MD;
  4. Andre Blum, MD;
  5. Rene Chiolero, MD;
  6. Marie-Denise Schaller, MD;
  7. Claude Perret, MD;
  8. Olivier Spinnler, MD;
  9. Jacques Blondel, MD;
  10. Hans Siegrist, MD;
  11. Laylee Saghafi, MPH;
  12. Dominique Blanc, PhD; and
  13. Patrick Francioli, MD
  1. 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.

    Abstract

    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.

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    1. Ann Intern Med April 15, 1994 vol. 120 no. 8 653-662
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