Ann Thorac Surg 2009;88:707. doi:10.1016/j.athoracsur.2009.03.021
© 2009 The Society of Thoracic Surgeons
Correspondence
Postoperative Pneumonia After Major Pulmonary Resections: Should We Try Alternative Ways to Antibiotic Change?
Alberto Terzi, MD,
Andrea Campione, MD,
Paolo Scanagatta, MD,
Giovanna Rizzardi, MD
Thoracic Surgery Unit, Azienda Ospedaliera S. Croce e Carle Cuneo, Via Coppino 26, Cuneo, 12100 Italy
(Email: alterzi{at}libero.it).
To the Editor:
We read with interest the article by Schussler and colleagues [1] about antibiotic prophylaxis to prevent postoperative pneumonia after major pulmonary resections, and we congratulate the authors. They reported a reduction of post-resection pulmonary infections from 25% to 13.7% (including documented and nondocumented pneumonia) and a reduction of related mortality changing antibiotic prophylaxis from cefamandole to amoxicillin-clavulanate.
We agree with the conclusion of the authors that there is a need for a prospective, randomized trial to confirm the results of their study; however, we think that a few considerations are important.
In their series, as well as what occurred in Eole study [2] and other reports [3], most cases of postoperative pneumonia occurred within the first postoperative days, suggesting that pulmonary infection in surgical patients can not be considered identical to other forms of nosocomial pneumonia. To focus on antibiotic prophylaxis only may be insufficient, because it does not take into consideration the possible role of gastroesophageal reflux and aspiration (during the intraoperative or the postoperative period), as well as that of bacteria colonizing the oropharynx with the development of pneumonia. Oral cavity is a potential reservoir for respiratory pathogens, and there is evidence of an association between pulmonary infection and oral health [4], and there is evidence that decontamination of the oropharynx with chlorhexidine gluconate results in important reductions in nosocomial pneumonia [5, 6].
Preemptive gastrointestinal tract management, as reported by Roberts and colleagues [7], paying attention to the fasting period before surgery, which may increase residual gastric volume and the risk of aspiration [8], decontamination of the oropharynx, which was reported to prevent lower respiratory tract infection in cardiac surgery [5–6], may be simple and inexpensive preventive measures to obtain a further reduction of postoperative pneumonia.
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References
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- Schussler O, Dermine H, Alifano M, et al. Should we change antibiotic prophylaxis for lung cancer?. Postoperative pneumonia is the critical issue. Ann Thorac Surg 2008;86:1727-1734.[Abstract/Free Full Text]
- Montravers P, Veber B, Auboyer C, et al. Diagnostic and therapeutic management of nosocomial pneumonia in surgical patients: results of the Eole study Crit Care Med 2002;30:368-375.[Medline]
- Radu DM, Jaurèguy F, Seguin A, et al. Postresection pneumonia after major pulmonary resections: an unsolved problem in thoracic surgery Ann Thorac Surg 2007;84:1669-1674.[Abstract/Free Full Text]
- Mojon P. Oral health and respiratory infection J Can Dent Assoc 2002;68:340-345.[Medline]
- Houston S, Hougland P, Anderson JJ, et al. Effectiveness of 12% chlorhexidine oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery Am J Crit Care 2002;11:567-570.[Abstract/Free Full Text]
- Segers P, Speekenbrink RGH, Ubbink DT, et al. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate. A randomized controlled trial. JAMA 2006;296:2460-2466.[Abstract/Free Full Text]
- Roberts JR, Shyr Y, Christian KR, Drinkwater D, Merrill W. Preemptive gastrointestinal tract management reduces aspiration and respiratory failure after thoracic operations J Thorac Cardiovasc Surg 2000;119:449-452.[Abstract/Free Full Text]
- Warner MA, Caplan RA, Epstein BS, et al. Practice guidelines on preoperative fasting and the use of pharmacological agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedure Anesthesiology 1999;90:896-905.[Medline]
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