Correspondence

Enterococcus faecalis Pneumonia Complicating Topical Antimicrobial Prophylaxis

N Engl J Med 1993; 328:209-210January 21, 1993

Article

To the Editor:

Selective decontamination of the digestive tract is widely used to prevent nosocomial pneumonia in patients receiving mechanical ventilation, although its benefits are unproved1. Objections to this procedure concern the possible selection of microorganisms resistant to the antibiotics used, rather than adverse effects2. We report eight cases of pneumonia or bacteremia caused by Enterococcus faecalis, as a possible side effect of the prophylactic use of nonabsorbable antimicrobial agents.

Sixty-one patients who were receiving mechanical ventilation in the intensive care unit were given topical antimicrobial prophylaxis for the oropharynx and stomach. Tobramycin (40 mg in a 5-ml solution), colistin (25 mg in 5 ml), and amphotericin B (250 mg in 2.5 ml) -- each given four times a day -- were administered in lower dosages than those used in conventional studies of selective decontamination of the digestive tract3. No systemic antibiotics were included as part of the prophylaxis. The diagnosis of pneumonia depended on clinical findings, culture of tracheal aspirate, and chest radiography in combination with quantitative cultures of samples obtained by the protected-specimen-brush technique and bronchoalveolar lavage.

The regimen eradicated enterobacteriaceae, pseudomonodaceae, and Staphylococcus aureus from the oropharynx and trachea, but colonization with E. faecalis, which is intrinsically resistant to tobramycin and colistin, occurred frequently at these sites. Colonization of the oropharynx or trachea (or both) occurred in 24 patients, whose ages ranged from 58 to 79 years. Eight cases of pneumonia or bacteremia developed that involved E. faecalis (Table 1Table 1Clinical and Bacteriologic Findings in Cases of Pneumonia and Bacteremia among Patients Given Topical Antimicrobial Prophylaxis.). Pneumonia involving E. faecalis was polymicrobial in all cases, with Pseudomonas aeruginosa (one case), S. epidermidis (three cases), acinetobacter species (three cases), and Alcaligenes denitrificans subsp. xylosoxydans (one case). In the first five cases the pneumonia was preceded by colonization of the oropharynx with E. faecalis, and in two cases it was accompanied by bacteremia (cases 1 and 2). Bacteremia with E. faecalis but without evidence of pneumonia was demonstrated in two cases (cases 7 and 8).

Although increased colonization by gram-positive cocci during selective decontamination of the digestive tract has been described,4 pneumonia due to E. faecalis has not been previously reported. The positive quantitative cultures obtained by the protected-specimen-brush technique and bronchoalveolar lavage, in some cases accompanied by bacteremia, strongly suggest that E. faecalis has an etiologic role in the development of pneumonia in our patients. We hypothesize that topical antimicrobial prophylaxis modified the bacterial flora of patients in the intensive care unit, resulting in increased colonization with species intrinsically resistant to the antibiotics used and leading to pneumonia caused by a microorganism generally considered not to cause respiratory tract infection.

Marc J.M. Bonten, M.D.
Frank H. van Tiel, M.D., Ph.D.
Siebe van der Geest, M.D., Ph.D.
Ellen E. Stobberingh, Ph.D.
Carlo A. Gaillard, M.D., Ph.D.
University Hospital Maastricht, 6202 AZ Maastricht, the Netherlands

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Citing Articles (18)

Citing Articles

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   Marta Ulldemolins, Marcos I. Restrepo, Jordi Rello. (2011) Medidas farmacológicas para la prevención de la neumonía asociada a la ventilación mecánica. Medicina Clínica 136:1, 21-25
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   Bert-Jan F. de Rooij, Bart van Hoek, W. Rogier ten Hove, Anja Roos, Lee H. Bouwman, Alexander F. Schaapherder, Robert J. Porte, Mohamed R. Daha, Johan J. van der Reijden, Minneke J. Coenraad, Jan Ringers, Andrzej G. Baranski, Bouke G. Hepkema, Daniel W. Hommes, Hein W. Verspaget. (2010) Lectin complement pathway gene profile of donor and recipient determine the risk of bacterial infections after orthotopic liver transplantation. Hepatology 52:3, 1100-1110
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   U Forslöw, M Remberger, A Nordlander, J Mattsson. (2010) The clinical importance of bronchoalveolar lavage in allogeneic SCT patients with pneumonia. Bone Marrow Transplantation 45:5, 945-950
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   R. Bergman, D. H. T. Tjan, M. A. Schouten, L. E. M. Haas, A. R. H. Zanten. (2009) Pleural Enterococcus faecalis Empyema: An Unusual Case. Infection 37:1, 56-59
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   M. J. M. Bonten. (2006) Selective Digestive Tract Decontamination--Will It Prevent Infection with Multidrug-Resistant Gram-Negative Pathogens but Still Be Applicable in Institutions where Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci Are Endemic?. Clinical Infectious Diseases 43:Supplement 2, S70-S74
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