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• W2052643498 abstract "Infection and its major consequence, sepsis, are ever-increasing problems in the ICU environment. A recent study1Angus DC Llinde-Zwirble WT Lidicker J et al.Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care.Crit Care Med. 2001; 29: 1303-1310Crossref PubMed Scopus (6566) Google Scholar by Angus and coworkers suggest that there are > 750,000 episodes of severe sepsis each year in the United States. Their projections suggest that the incidence will continue to increase at a rate of 1.5%/yr.1Angus DC Llinde-Zwirble WT Lidicker J et al.Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care.Crit Care Med. 2001; 29: 1303-1310Crossref PubMed Scopus (6566) Google Scholar One of the most common ICU infections and the nosocomial infection associated with the highest mortality rate is hospital-acquired pneumonia.2Richards MJ Edwards JR Culver DH et al.Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System.Crit Care Med. 1999; 27: 887-892Crossref PubMed Scopus (1335) Google Scholar, 3Kollef MH Epidemiology and risk factors for nosocomial pneumonia: emphasis on prevention.Clin Chest Med. 1999; 20: 653-670Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Meduri GU Diagnosis and differential diagnosis of ventilator-associated pneumonia.Clin Chest Med. 1995; 16: 61-93PubMed Google Scholar, 5Campbell Jr, GD Niederman MS Broughton WA et al.Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies; a consensus statement. American Thoracic Society.Am J Respir Crit Care Med. 1995; 153: 1711-1725Google Scholar, 6Kollef MH The prevention of ventilator-associated pneumonia.N Engl J Med. 1999; 340: 627-634Crossref PubMed Scopus (405) Google Scholar Ventilator-associated pneumonia (VAP) is the term for hospital-acquired pneumonia that develops in an intubated patient receiving mechanical ventilatory support.3Kollef MH Epidemiology and risk factors for nosocomial pneumonia: emphasis on prevention.Clin Chest Med. 1999; 20: 653-670Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Meduri GU Diagnosis and differential diagnosis of ventilator-associated pneumonia.Clin Chest Med. 1995; 16: 61-93PubMed Google Scholar, 5Campbell Jr, GD Niederman MS Broughton WA et al.Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies; a consensus statement. American Thoracic Society.Am J Respir Crit Care Med. 1995; 153: 1711-1725Google Scholar VAP presents multiple diagnostic and therapeutic challenges for the clinician.3Kollef MH Epidemiology and risk factors for nosocomial pneumonia: emphasis on prevention.Clin Chest Med. 1999; 20: 653-670Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Meduri GU Diagnosis and differential diagnosis of ventilator-associated pneumonia.Clin Chest Med. 1995; 16: 61-93PubMed Google Scholar, 5Campbell Jr, GD Niederman MS Broughton WA et al.Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies; a consensus statement. American Thoracic Society.Am J Respir Crit Care Med. 1995; 153: 1711-1725Google Scholar One of the most controversial areas concerns the benefits of an aggressive diagnostic approach vs empiric treatment for VAP.7Ruiz M Torres A Ewig S et al.Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia.Am J Respir Crit Care Med. 2000; 162: 119-125Crossref PubMed Scopus (284) Google Scholar, 8Heyland DK Cook DJ Marshall J et al.The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia.Chest. 1999; 115: 1076-1084Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 9Fagon JY Chastre J Wolff M et al.Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: a randomized trial.Ann Intern Med. 2000; 132: 621-630Crossref PubMed Scopus (729) Google Scholar, 10Luna CM Vujacich P Niederman MS et al.Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.Chest. 1997; 111: 676-685Abstract Full Text Full Text PDF PubMed Scopus (819) Google Scholar, 11Meduri GU Mauldin GL Wunderink RG et al.Causes of fever and pulmonary densities in patients with clinical manifestations of ventilator-associated pneumonia.Chest. 1994; 106: 221-235Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar The aggressive diagnostic approach utilizes fiberoptic bronchoscopy along with a protected specimen brush or BAL coupled with quantitative cultures to ensure that sufficient thresholds of microorganisms are present.7Ruiz M Torres A Ewig S et al.Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia.Am J Respir Crit Care Med. 2000; 162: 119-125Crossref PubMed Scopus (284) Google Scholar, 8Heyland DK Cook DJ Marshall J et al.The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia.Chest. 1999; 115: 1076-1084Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar Advocates of this approach point out the poor specificity of the clinical diagnosis of VAP and our need to use antibiotics judiciously in this time of increasing antibiotic resistance.8Heyland DK Cook DJ Marshall J et al.The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia.Chest. 1999; 115: 1076-1084Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 9Fagon JY Chastre J Wolff M et al.Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: a randomized trial.Ann Intern Med. 2000; 132: 621-630Crossref PubMed Scopus (729) Google Scholar, 11Meduri GU Mauldin GL Wunderink RG et al.Causes of fever and pulmonary densities in patients with clinical manifestations of ventilator-associated pneumonia.Chest. 1994; 106: 221-235Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar, 12Kollef MH Fraser VJ Antibiotic resistance in the intensive care unit.Ann Intern Med. 2001; 134: 298-314Crossref PubMed Scopus (379) Google Scholar However, the supporters of empiric treatment contend that the aggressive invasive approach is more costly, and only defines treatment failure, and emphasize the need for additional randomized, prospective, multicentered controlled clinical trials to determine if either strategy is associated with a survival benefit.7Ruiz M Torres A Ewig S et al.Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia.Am J Respir Crit Care Med. 2000; 162: 119-125Crossref PubMed Scopus (284) Google Scholar, 10Luna CM Vujacich P Niederman MS et al.Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.Chest. 1997; 111: 676-685Abstract Full Text Full Text PDF PubMed Scopus (819) Google Scholar Another controversial area surrounds the determination of the attributable mortality of VAP that typically develops in patients with comorbid conditions that are associated with significant mortality.3Kollef MH Epidemiology and risk factors for nosocomial pneumonia: emphasis on prevention.Clin Chest Med. 1999; 20: 653-670Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Meduri GU Diagnosis and differential diagnosis of ventilator-associated pneumonia.Clin Chest Med. 1995; 16: 61-93PubMed Google Scholar, 5Campbell Jr, GD Niederman MS Broughton WA et al.Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies; a consensus statement. American Thoracic Society.Am J Respir Crit Care Med. 1995; 153: 1711-1725Google ScholarGiven the current difficulties with the clinical diagnosis, treatment, and assessment of attributable mortality of VAP, perhaps, the most prudent goal would be to channel our efforts toward prevention. Current prevention strategies include positioning patients with their heads elevated > 30°, selective digestive decontamination, rotational therapy, and continuous subglottic aspiration/suctioning, and early extubation with liberation from mechanical ventilatory support.6Kollef MH The prevention of ventilator-associated pneumonia.N Engl J Med. 1999; 340: 627-634Crossref PubMed Scopus (405) Google Scholar, 13Kollef MH The clinical use of selective digestive decontamination [opinion].Crit Care. 2000; 4: 327-332Crossref PubMed Scopus (24) Google Scholar, 14Nathens AB Marshall JC Selective decontamination of the digestive tract in surgical patients: a systematic review of the evidence.Arch Surg. 1999; 134: 170-176Crossref PubMed Scopus (269) Google Scholar, 15Anzueto A Peters JL Seidner SR et al.Effects of continuous bed rotation and prolonged mechanical ventilation on healthy adult baboons.Crit Care Med. 1995; 122: 179-186Google Scholar, 16Valles J Artigas A Rello J et al.Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia.Ann Intern Med. 1995; 122: 179-186Crossref PubMed Scopus (464) Google Scholar, 17Girous E Schortgen F Delclaux C et al.Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients.JAMA. 2000; 284: 2361-2367Crossref PubMed Scopus (388) Google Scholar Indwelling catheters, such as Foley and central venous catheters, invade the normal body barriers and subsequently become coated with a “biofilm.”18Costerton JW Stewart PS Greenberg EP Bacterial biofilms: a common cause of persistent infections.Science. 1999; 284: 1318-1322Crossref PubMed Scopus (8695) Google Scholar This biofilm is an excellent growth medium for bacteria and ultimately gives rise to infection. Specialized coatings have been used to retard the growth of the biofilm and to decrease the likelihood of subsequent colonization of the catheter surface with microorganisms.18Costerton JW Stewart PS Greenberg EP Bacterial biofilms: a common cause of persistent infections.Science. 1999; 284: 1318-1322Crossref PubMed Scopus (8695) Google Scholar, 19Mermel LA Farr BM Sherertz RJ et al.Guidelines for the management of intravascular catheter-related infections.Clin Infect Dis. 2001; 32: 1249-1272Crossref PubMed Scopus (128) Google Scholar Some common nosocomial infections, such as blood stream and urinary tract infections, have been prevented by the use of special coatings on the indwelling catheter.19Mermel LA Farr BM Sherertz RJ et al.Guidelines for the management of intravascular catheter-related infections.Clin Infect Dis. 2001; 32: 1249-1272Crossref PubMed Scopus (128) Google Scholar, 20Saint S Veenstra DL Sullivan SD et al.The potential clinical and economic benefits of silver alloy urinary catheters in preventing urinary tract infection.Arch Intern Med. 2000; 160: 2670-2675Crossref PubMed Scopus (114) Google Scholar, 21Karchmer TB Giannetta ET Muto CA et al.A randomized crossover study of silver-coated urinary catheters in hospitalized patients.Arch Intern Med. 2000; 160: 3294-3298Crossref PubMed Scopus (194) Google Scholar A natural extension of this technology would be to coat the endotracheal tube in an attempt to decrease the development of VAP.The report by Olson and coworkers in this issue of CHEST (see page 863) evaluated silver coated endotracheal tubes in an experimental animal model of VAP. The investigators evaluated the special coated endotracheal tube compared to a standard endotracheal tube in a prospective, randomized, double-blind, controlled trial in dogs receiving mechanical ventilation with Pseudomonas placed in the oropharynx. Serial swabs were obtained from the endotracheal tubes; at death, the endotracheal tube, tracheal, and lung parenchymal bacterial burdens were assessed. The silver coating was found to delay the appearance of bacteria on the inner surface of the endotracheal tube. In addition, there were significantly less aerobic bacteria in the lung parenchyma and less parenchymal inflammatory changes on histologic assessment.While this was a small study of relatively short duration, the results suggest that silver coating endotracheal tubes may offer some help in the battle to prevent VAP. The investigators attempted to recreate “life in the ICU,” where all too frequently patients are managed in a sedated, supine, flat position. The dogs involved in this trial were kept in this same state, which would tend to promote aspiration of the deposited oropharyngeal bacteria and potentiate the subsequent colonization of the lower airway and endotracheal tube. However, at present, there is little to no data to help us understand the significance of decreased numbers of colonizing bacteria on an endotracheal tube. It might be assumed that less is better, but it may be an all-or-none phenomenon. The same issues surround the implications of a decreased aerobic bacterial burden on the eventual development of pneumonia or, more importantly, on ultimate survival. Future trials will need to compare the coated endotracheal tube to our current preventive strategies (ie, elevated head of the bed, rotational/kinetic therapy, continuous subglottic suction, etc.) to see if there is continued or additional benefit. Nonetheless, VAP is an important cause of morbidity, mortality, and increased length and cost of care for the critically ill. If a strategy as simple and likely inexpensive as silver coating the endotracheal tube can prevent VAP, it is indeed the silver lining that we have been searching for. At this time, however, the data are far from complete, and further trials are both needed and warranted. Infection and its major consequence, sepsis, are ever-increasing problems in the ICU environment. A recent study1Angus DC Llinde-Zwirble WT Lidicker J et al.Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care.Crit Care Med. 2001; 29: 1303-1310Crossref PubMed Scopus (6566) Google Scholar by Angus and coworkers suggest that there are > 750,000 episodes of severe sepsis each year in the United States. Their projections suggest that the incidence will continue to increase at a rate of 1.5%/yr.1Angus DC Llinde-Zwirble WT Lidicker J et al.Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care.Crit Care Med. 2001; 29: 1303-1310Crossref PubMed Scopus (6566) Google Scholar One of the most common ICU infections and the nosocomial infection associated with the highest mortality rate is hospital-acquired pneumonia.2Richards MJ Edwards JR Culver DH et al.Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System.Crit Care Med. 1999; 27: 887-892Crossref PubMed Scopus (1335) Google Scholar, 3Kollef MH Epidemiology and risk factors for nosocomial pneumonia: emphasis on prevention.Clin Chest Med. 1999; 20: 653-670Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Meduri GU Diagnosis and differential diagnosis of ventilator-associated pneumonia.Clin Chest Med. 1995; 16: 61-93PubMed Google Scholar, 5Campbell Jr, GD Niederman MS Broughton WA et al.Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies; a consensus statement. American Thoracic Society.Am J Respir Crit Care Med. 1995; 153: 1711-1725Google Scholar, 6Kollef MH The prevention of ventilator-associated pneumonia.N Engl J Med. 1999; 340: 627-634Crossref PubMed Scopus (405) Google Scholar Ventilator-associated pneumonia (VAP) is the term for hospital-acquired pneumonia that develops in an intubated patient receiving mechanical ventilatory support.3Kollef MH Epidemiology and risk factors for nosocomial pneumonia: emphasis on prevention.Clin Chest Med. 1999; 20: 653-670Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Meduri GU Diagnosis and differential diagnosis of ventilator-associated pneumonia.Clin Chest Med. 1995; 16: 61-93PubMed Google Scholar, 5Campbell Jr, GD Niederman MS Broughton WA et al.Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies; a consensus statement. American Thoracic Society.Am J Respir Crit Care Med. 1995; 153: 1711-1725Google Scholar VAP presents multiple diagnostic and therapeutic challenges for the clinician.3Kollef MH Epidemiology and risk factors for nosocomial pneumonia: emphasis on prevention.Clin Chest Med. 1999; 20: 653-670Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Meduri GU Diagnosis and differential diagnosis of ventilator-associated pneumonia.Clin Chest Med. 1995; 16: 61-93PubMed Google Scholar, 5Campbell Jr, GD Niederman MS Broughton WA et al.Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies; a consensus statement. American Thoracic Society.Am J Respir Crit Care Med. 1995; 153: 1711-1725Google Scholar One of the most controversial areas concerns the benefits of an aggressive diagnostic approach vs empiric treatment for VAP.7Ruiz M Torres A Ewig S et al.Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia.Am J Respir Crit Care Med. 2000; 162: 119-125Crossref PubMed Scopus (284) Google Scholar, 8Heyland DK Cook DJ Marshall J et al.The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia.Chest. 1999; 115: 1076-1084Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 9Fagon JY Chastre J Wolff M et al.Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: a randomized trial.Ann Intern Med. 2000; 132: 621-630Crossref PubMed Scopus (729) Google Scholar, 10Luna CM Vujacich P Niederman MS et al.Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.Chest. 1997; 111: 676-685Abstract Full Text Full Text PDF PubMed Scopus (819) Google Scholar, 11Meduri GU Mauldin GL Wunderink RG et al.Causes of fever and pulmonary densities in patients with clinical manifestations of ventilator-associated pneumonia.Chest. 1994; 106: 221-235Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar The aggressive diagnostic approach utilizes fiberoptic bronchoscopy along with a protected specimen brush or BAL coupled with quantitative cultures to ensure that sufficient thresholds of microorganisms are present.7Ruiz M Torres A Ewig S et al.Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia.Am J Respir Crit Care Med. 2000; 162: 119-125Crossref PubMed Scopus (284) Google Scholar, 8Heyland DK Cook DJ Marshall J et al.The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia.Chest. 1999; 115: 1076-1084Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar Advocates of this approach point out the poor specificity of the clinical diagnosis of VAP and our need to use antibiotics judiciously in this time of increasing antibiotic resistance.8Heyland DK Cook DJ Marshall J et al.The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia.Chest. 1999; 115: 1076-1084Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 9Fagon JY Chastre J Wolff M et al.Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: a randomized trial.Ann Intern Med. 2000; 132: 621-630Crossref PubMed Scopus (729) Google Scholar, 11Meduri GU Mauldin GL Wunderink RG et al.Causes of fever and pulmonary densities in patients with clinical manifestations of ventilator-associated pneumonia.Chest. 1994; 106: 221-235Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar, 12Kollef MH Fraser VJ Antibiotic resistance in the intensive care unit.Ann Intern Med. 2001; 134: 298-314Crossref PubMed Scopus (379) Google Scholar However, the supporters of empiric treatment contend that the aggressive invasive approach is more costly, and only defines treatment failure, and emphasize the need for additional randomized, prospective, multicentered controlled clinical trials to determine if either strategy is associated with a survival benefit.7Ruiz M Torres A Ewig S et al.Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia.Am J Respir Crit Care Med. 2000; 162: 119-125Crossref PubMed Scopus (284) Google Scholar, 10Luna CM Vujacich P Niederman MS et al.Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.Chest. 1997; 111: 676-685Abstract Full Text Full Text PDF PubMed Scopus (819) Google Scholar Another controversial area surrounds the determination of the attributable mortality of VAP that typically develops in patients with comorbid conditions that are associated with significant mortality.3Kollef MH Epidemiology and risk factors for nosocomial pneumonia: emphasis on prevention.Clin Chest Med. 1999; 20: 653-670Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Meduri GU Diagnosis and differential diagnosis of ventilator-associated pneumonia.Clin Chest Med. 1995; 16: 61-93PubMed Google Scholar, 5Campbell Jr, GD Niederman MS Broughton WA et al.Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies; a consensus statement. American Thoracic Society.Am J Respir Crit Care Med. 1995; 153: 1711-1725Google Scholar Given the current difficulties with the clinical diagnosis, treatment, and assessment of attributable mortality of VAP, perhaps, the most prudent goal would be to channel our efforts toward prevention. Current prevention strategies include positioning patients with their heads elevated > 30°, selective digestive decontamination, rotational therapy, and continuous subglottic aspiration/suctioning, and early extubation with liberation from mechanical ventilatory support.6Kollef MH The prevention of ventilator-associated pneumonia.N Engl J Med. 1999; 340: 627-634Crossref PubMed Scopus (405) Google Scholar, 13Kollef MH The clinical use of selective digestive decontamination [opinion].Crit Care. 2000; 4: 327-332Crossref PubMed Scopus (24) Google Scholar, 14Nathens AB Marshall JC Selective decontamination of the digestive tract in surgical patients: a systematic review of the evidence.Arch Surg. 1999; 134: 170-176Crossref PubMed Scopus (269) Google Scholar, 15Anzueto A Peters JL Seidner SR et al.Effects of continuous bed rotation and prolonged mechanical ventilation on healthy adult baboons.Crit Care Med. 1995; 122: 179-186Google Scholar, 16Valles J Artigas A Rello J et al.Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia.Ann Intern Med. 1995; 122: 179-186Crossref PubMed Scopus (464) Google Scholar, 17Girous E Schortgen F Delclaux C et al.Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients.JAMA. 2000; 284: 2361-2367Crossref PubMed Scopus (388) Google Scholar Indwelling catheters, such as Foley and central venous catheters, invade the normal body barriers and subsequently become coated with a “biofilm.”18Costerton JW Stewart PS Greenberg EP Bacterial biofilms: a common cause of persistent infections.Science. 1999; 284: 1318-1322Crossref PubMed Scopus (8695) Google Scholar This biofilm is an excellent growth medium for bacteria and ultimately gives rise to infection. Specialized coatings have been used to retard the growth of the biofilm and to decrease the likelihood of subsequent colonization of the catheter surface with microorganisms.18Costerton JW Stewart PS Greenberg EP Bacterial biofilms: a common cause of persistent infections.Science. 1999; 284: 1318-1322Crossref PubMed Scopus (8695) Google Scholar, 19Mermel LA Farr BM Sherertz RJ et al.Guidelines for the management of intravascular catheter-related infections.Clin Infect Dis. 2001; 32: 1249-1272Crossref PubMed Scopus (128) Google Scholar Some common nosocomial infections, such as blood stream and urinary tract infections, have been prevented by the use of special coatings on the indwelling catheter.19Mermel LA Farr BM Sherertz RJ et al.Guidelines for the management of intravascular catheter-related infections.Clin Infect Dis. 2001; 32: 1249-1272Crossref PubMed Scopus (128) Google Scholar, 20Saint S Veenstra DL Sullivan SD et al.The potential clinical and economic benefits of silver alloy urinary catheters in preventing urinary tract infection.Arch Intern Med. 2000; 160: 2670-2675Crossref PubMed Scopus (114) Google Scholar, 21Karchmer TB Giannetta ET Muto CA et al.A randomized crossover study of silver-coated urinary catheters in hospitalized patients.Arch Intern Med. 2000; 160: 3294-3298Crossref PubMed Scopus (194) Google Scholar A natural extension of this technology would be to coat the endotracheal tube in an attempt to decrease the development of VAP. The report by Olson and coworkers in this issue of CHEST (see page 863) evaluated silver coated endotracheal tubes in an experimental animal model of VAP. The investigators evaluated the special coated endotracheal tube compared to a standard endotracheal tube in a prospective, randomized, double-blind, controlled trial in dogs receiving mechanical ventilation with Pseudomonas placed in the oropharynx. Serial swabs were obtained from the endotracheal tubes; at death, the endotracheal tube, tracheal, and lung parenchymal bacterial burdens were assessed. The silver coating was found to delay the appearance of bacteria on the inner surface of the endotracheal tube. In addition, there were significantly less aerobic bacteria in the lung parenchyma and less parenchymal inflammatory changes on histologic assessment. While this was a small study of relatively short duration, the results suggest that silver coating endotracheal tubes may offer some help in the battle to prevent VAP. The investigators attempted to recreate “life in the ICU,” where all too frequently patients are managed in a sedated, supine, flat position. The dogs involved in this trial were kept in this same state, which would tend to promote aspiration of the deposited oropharyngeal bacteria and potentiate the subsequent colonization of the lower airway and endotracheal tube. However, at present, there is little to no data to help us understand the significance of decreased numbers of colonizing bacteria on an endotracheal tube. It might be assumed that less is better, but it may be an all-or-none phenomenon. The same issues surround the implications of a decreased aerobic bacterial burden on the eventual development of pneumonia or, more importantly, on ultimate survival. Future trials will need to compare the coated endotracheal tube to our current preventive strategies (ie, elevated head of the bed, rotational/kinetic therapy, continuous subglottic suction, etc.) to see if there is continued or additional benefit. Nonetheless, VAP is an important cause of morbidity, mortality, and increased length and cost of care for the critically ill. If a strategy as simple and likely inexpensive as silver coating the endotracheal tube can prevent VAP, it is indeed the silver lining that we have been searching for. At this time, however, the data are far from complete, and further trials are both needed and warranted." @default.
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