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Trauma patients in the ICU need antimicrobial prophylaxis to prevent pneumonia: in reply

Sir, We thank Zandstra et al. for their comments and interest in our recent study; we will use this opportunity to respond to some of these comments. We agree that surveillance cultures are useful to study the chain of events, to explain why different pathogens cause pneumonia and for detection of antibiotic resistance. In contrast, we believe that the clinical usefulness of surveillance cultures from the lower respiratory tract when making treatment decisions in individual patients has important limitations and that there is even less data regarding cultures from other locations. We also agree that there is an important relationship between the duration of intensive care unit (ICU) care and the pathogens that are most likely to cause pneumonia. Depending on the causative pathogen’s first occurrence in surveillance cultures, Zandstra et al. differentiate pneumonias among ICU trauma patients as primary endogenous, secondary endogenous or exogenous. The terminology refers to a sequence of events and the duration of ICU care prior to the development of pneumonia. The relationship between the type of pneumonia and the causative pathogens is less specific. We find the related, but not identical, categorization in community-, hospitaland ICUacquired pneumonia easier to apply although it does not explain the pathophysiology in the same manner as the categorization used by Zandstra et al. We would also like to point out that trauma patients are different from other groups of ICU patients in that hospital care or antibiotic treatment prior to ICU admission are rare. For example, pneumonia caused by pathogens typical for secondary endogenous pneumonia might occur early after ICU admission for a patient with prior hospital care. In a previous study, we demonstrated that although there is a shift in pathogens found in the lower respiratory tract depending on the duration of ICU care, abnormal pathogens, using the terminology of Zandstra et al., e.g. Pseudomonas aeruginosa, might occur early after ICU admission. A full discussion of selective digestive decontamination (SDD) is far beyond the limits of this correspondence. We believe that several aspects of SDD need to be studied further before making it a widespread clinical routine. One such aspect is the effect on the spread of antibiotic resistance among Gramnegative bacteria in settings where this is common. We find the prophylactic use of polymyxin E (colistin) especially cumbersome since this is the only treatment option for an increasing number of ICU infections caused by multi-resistant Gramnegative pathogens, a situation very different from that when SDD was first used. SDD should therefore preferably be used within the framework of clinical studies. Responding to specific questions, among the patients included in our study, 20% underwent major surgery and received a single dose of pre-operative prophylactic antibiotic, few patients received a 24 h antibiotic treatment for open fractures and very few patients received a full course of antibiotic treatment due to severe contamination of the peritoneal cavity or deep wounds. Again, we thank Zandstra et al. for their interest in our work. Conflicts of interest: None.