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Ventilator-Associated Sinusitis Anesthesiology 2000; 93:1255–60 © 2000 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Ventilator-associated Sinusitis Microbiological Results of Sinus Aspirates in Patients on Antibiotics Bertrand Souweine, M.D.,* Thierry Mom, M.D., Ph.D.,† Ousmane Traore, M.D., Ph.D.,‡ Bruno Aublet-Cuvelier, M.D.,§ Laurent Bret, M.D., Ph.D.,ʈ Jacques Sirot, M.D., Ph.D.,# Patrice Deteix, M.D., Ph.D.,** Laurent Gilain, M.D., Ph.D.,†† Louis Boyer, M.D., Ph.D.‡‡ Background: The efficacy of systemic antibiotics on the treat- systematic search for and treatment of VAIMS was found ment of ventilator-associated infectious maxillary sinusitis to be associated with a decrease in overall mortality.2 (VAIMS) is debated. The objective of this study was to determine However, the explanations for this improved survival the etiologic diagnosis of VAIMS in patients receiving antibiotics. rate remain speculative.7 Methods: Patients mechanically ventilated for more than or Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/93/5/1255/400481/0000542-200011000-00019.pdf by guest on 29 September 2021 equal to 72 h, who had persistent fever while on antibiotics for The definition of VAIMS in the literature is elusive and more than or equal to 48 h, underwent computed tomography variable.8 Sinus aspiration and positive culture are re- scan followed by transnasal puncture of involved maxillary quired for accurate diagnosis.8 Some investigators have sinuses. VAIMS was defined as follows: fever greater than or recommended quantitative culture of sinus aspirate1,2,9 equal to 38°C, radiographic signs (air fluid level or opacification of maxillary sinuses on computed tomography scan), and a because of the risk of specimen contamination by nasal 1 quantitative culture of sinus aspirate yielding more than or flora. equal to 103 colony-forming units/ml. Opinions differ on the best therapeutic strategy for Results: Twenty-four patients had radiographic signs of si- VAIMS. Some investigators recommend intravenous an- ؎ nusitis. The mean SD prior durations of mechanical ventila- timicrobial treatment in addition to sinus aspiration,2,8,9 ,tion and antibiotic exposure were 9.5 ؎ 4.7 days and 6 ؎ 4 days respectively. Six unilateral and nine bilateral VAIMS were diag- whereas others have shown that successful treatment nosed in 15 patients. The median number of etiologic organ- can be achieved by sinus lavage using topical antibiot- isms per patient was two (range, one to four). The bacteriologic ics.1 Recent studies that focused on the concentration of gram-negative antibiotics in sinus secretions and mucosa in patients ,(21 ؍ cultures yielded gram-positive bacteria (n ؍ ؍ bacteria (n 22), and yeasts (n 5). Forty percent of causative treated with systemic antibiotics showed that adequate agents were susceptible to the antibiotics prescribed. Seven 10–12 patients with VAIMS developed 10 concomitant infections: ven- levels can be achieved. VAIMS has been reported in 1 -urinary tract infection patients on antibiotics. One may speculate that antibi ,(5 ؍ tilator-associated pneumonia (n ,In all cases of ventilator- otics predispose to the overgrowth of resistant bacteria .(2 ؍ catheter infections (n ,(3 ؍ n) associated pneumonia, the implicated agents were the causative or that antibiotics are only partially effective in suppress- agents of VAIMS. ing susceptible microorganisms caused by the presence of Conclusion: In VAIMS patients on antibiotics, quantitative cul- tures of sinus aspirates may contribute to establish the diagno- a closed space infection. We therefore studied the micro- sis. The frequent recovery of microorganisms susceptible to the biological results of sinus aspirate cultures in patients who antimicrobial treatment administered suggests that therapy of were receiving systemic antimicrobial treatment. VAIMS with systemic antibiotics may not be sufficient. (Key words: Microorgnisms; pneumonia; quantitative culture.) Methods VENTILATOR-ASSOCIATED infectious maxillary sinusitis (VAIMS) is a frequently unrecognized cause of fever in Study Population critically ill patients.1–6 Nasal intubation is an acknowl- This prospective study was conducted from April 1, edged risk factor.1 In a recent study, VAIMS was ob- 1995, to March 31, 1996, in a 10-bed medical–surgical served in 40% of patients with nasotracheal intubation.2 intensive care unit (ICU) at the teaching hospital of VAIMS may lead to sepsis, intracranial infections,3 bac- Clermont-Ferrand in France. Patients enrolled in the teremia,1,4,5 thoracic empyema,6 and pneumonia.2 The study fulfilled the following six criteria: (1) age more than 18 yr, (2) endotracheal intubation, (3) mechanical ventilation for more than 72 h, (4) temperature greater * Staff Intensivist, ** Professor, Service de Re´animation Me´dicale Polyvalente et Ne´phrologie, † Staff Surgeon, †† Professor, Service d’Otorhinolaryngologie, than 38°C, (5) leukocytosis greater than 12,000/␮l, and ‡ Staff in Prevention and Control of Infection, Service d’Hygie`ne Hospitalie`re, § Staff (6) antibiotic treatment for more than 2 days without in Epidemiology, De´partement d’Epide´miologie Me´dicale, ʈ Staff in Bacteriology, # Professor, Laboratoire de Bacte´riologie, ‡‡ Professor, Service d’Imagerie Me´dicale. change in the previous 48 h. All patients underwent a Received from the Services de Re´animation Me´dicale Polyvalente et Ne´phrolo- routine fever workup that included chest roentgeno- gie, d’Otorhinolaryngologie, d’Hygie`ne Hospitalie`re, d’Imagerie Me´dicale, and gram, urine analysis with culture, and blood cultures. De´partement d’Epide´miologie Me´dicale et Laboratoire de Bacte´riologie, Hoˆpital G. Montpied, Clermont-Ferrand, France. Submitted for publication February 25, When these studies failed to identify the source of the 2000. Accepted for publication June 20, 2000. Supported in part by a grant from fever or if fever was persistent despite administration of the Faculte´deMe´decine de Clermont-Ferrand, Clermont-Ferrand, France. Address reprint requests to Dr. Souweine: Service de Re´animation Me´dicale antibiotics effective against isolated causative organisms Polyvalente, Hoˆpital G. Montpied, rue Montalembert, BP69, 63003, Clermont- of a diagnosed infection, a computed tomography (CT) Ferrand Cedex 1, France. Address electronic mail to: [email protected]. Individual article reprints may be purchased through the Journal Web site, of the paranasal sinuses (5-mm incremental thickness www.anesthesiology.org. scans in the axial plane) was performed within 48 h. Anesthesiology, V 93, No 5, Nov 2000 1255 1256 SOUWEINE ET AL. Patients with CT maxillary sinusitis (CTMS) underwent a expressed in colony-forming units (cfu) per milliliter. transnasal puncture of the maxillary sinus involved and Isolated organisms were identified by standard tech- were included in the study. Patients were excluded from niques. Susceptibility to antibiotics was determined by the study if they met at least one of the following criteria: the disk diffusion test. (1) a history of sinusitis, (2) a transfer to the radiology department (considered by the attending physician as a Data Collection high risk of morbidity because of severe respiratory or The following data were collected on standardized hemodynamic instability), and (3) coagulation disorders forms designed for the purpose of the study: patient contraindicating transnasal puncture. name, date of birth, gender, date and time of admission Using protected-brush specimens obtained under fi- to the ICU, indication for ICU admission, simplified acute beroptic examination, lower respiratory tract secretions physiology score on admission,13 routes of endotracheal in the affected pulmonary lobe as seen on the chest and enteric intubations, date and time of insertion, dateDownloaded from http://pubs.asahq.org/anesthesiology/article-pdf/93/5/1255/400481/0000542-200011000-00019.pdf by guest on 29 September 2021 radiograph were obtained from patients with suspected and time of mechanical ventilation, type of antimicrobial ventilator-associated pneumonia. agents with course duration, indications for antimicro- Patients receiving mechanical ventilation in our ICU bial therapy, date of CT scans, date of sinus puncture, are usually placed in a semirecumbent position. There is infections diagnosed at sites other than sinuses, and no written protocol concerning the route for endotra- microbiological results within a week of sinus punc- cheal and nasal intubations, and the choice is left at the tures, date of discharge, or death. In the event of recur- discretion of the attending physician. In practice, rent sinusitis, only the first sinus puncture was taken into the oral route is mostly used for tracheal intubation and account. the nasal route for gastric intubation. In nasotracheally intubated patients, the nasogastric tube is inserted in the Definitions opposite naris to the nasotracheal tube. Computed tomography maxillary sinusitis was diag- The Ethics Committee of the hospital (Hoˆpital G. nosed by a team of senior physicians from the radiology Montpied, Clermont-Ferrand, France) approved the and the otolaryngology wards based on CT findings. study protocol. However, informed consent was not CTMS was defined as a total opacity of one or both requested because all procedures applied were consid- maxillary sinuses or as the presence of an air-fluid level ered routine medical practice. within one or both maxillary sinuses. Criteria for VAIMS were as follows: (1) CTMS, (2) Study Protocol macroscopic
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