Advertisement

Prevention of Ventilator-Associated Pneumonia

  • Marin H. Kollef

Abstract

Nosocomial infections add significant costs to individual hospitalizations. They are estimated to involve more than two million patients annually at a cost of more than 4.5 billion dollars [1]. The Centers for Disease Control estimated that an episode of nosocomial pneumonia added 5.9 days to the average hospital stay and $5683 dollars in excess costs [1]. Other estimates put the excess hospital costs associated with nosocomial pneumonia at $4947 with excess hospital stays ranging from 6.8 to 30 days per episode of nosocomial pneumonia or ventilator-associated pneumonia (VAP) [2]. Boyce and colleagues also reported that among 31 of 33 Medicare patients who developed nosocomial pneumonia, hospital costs for the entire admission exceeded reimbursements with a net loss of $5800 per case [3]. Therefore, the occurrence of nosocomial infections, including VAP, are associated with excess medical care costs which may, in part, be preventable.

Keywords

Nosocomial Infection Respir Crit Nosocomial Pneumonia Stress Ulcer Prophylaxis Selective Digestive Decontamination 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Public health focus: Surveillance, prevention, and control of nosocomial infections. MMWR 41:783, 1992.Google Scholar
  2. 2.
    Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol 17:552, 1996.PubMedCrossRefGoogle Scholar
  3. 3.
    Boyce JM, Potter-Bynoe G, Dziobek L, Solomon SL. Nosocomial pneumonia in Medicare patients. Hospital costs and reimbursement patterns under the prospective payment system. Arch Intern Med 151:1109, 1991.PubMedCrossRefGoogle Scholar
  4. 4.
    Ascar JF. Consequences of bacterial resistance to antibiotics in medical practice. Clin Infect Dis 24:S17, 1997.CrossRefGoogle Scholar
  5. 5.
    Cohen ML. Epidemiology of drug resistance: implications for a post-antimicrobial era. Science 257:1050, 1992.PubMedCrossRefGoogle Scholar
  6. 6.
    Impacts of antibiotic-resistant bacteria: Thanks to Penicillin — He will home! Washington, DC; Office of Technology Assessment, Congress; 1995. Publication OTC-H-629.Google Scholar
  7. 7.
    Carmeli Y, Truillet N, Karchmer AW, Somore MH. Health and economic outcomes of antibiotic resistance in Pseudomonas aeruginosa. Arch Intern Med 159:1127, 1999.PubMedCrossRefGoogle Scholar
  8. 8.
    Holemberg SD, Solomon SL, Blake PA. Health and economic impact of antimicrobial resistance. Rev Infect Dis 9:1065, 1987.CrossRefGoogle Scholar
  9. 9.
    Phelps CE. Bug-drug resistance: Sometimes less is more. Med Care 27:194, 1989.PubMedCrossRefGoogle Scholar
  10. 10.
    Einarsson S, Kristjansson M, Kristinsson KG, Kjartansson G, Jonsson S. Pneumonia caused by penicillin-non-susceptible and penicillin-susceptible pneumococci in adults: a case-control study. Scand J Infect Dis 30:253, 1998.PubMedCrossRefGoogle Scholar
  11. 11.
    Moellering RC. A novel antimicrobial agent joins the battle against resistant bacteria. Ann Intern Med 130:155, 1999.PubMedCrossRefGoogle Scholar
  12. 12.
    Hancock RE. The role of fundamental research and biotechnology in finding solutions to the global problem of antibiotic resistance. Clin Infect Dis 24:Sl48, 1997.CrossRefGoogle Scholar
  13. 13.
    Bax RP. Antibiotic resistance: A view from the pharmaceutical industry. Clin Infect Dis 24:S151, 1997.CrossRefGoogle Scholar
  14. 14.
    Jones RN. The emergent needs for basic research, education, and surveillance of antimicrobial resistance. Problems facing the report from the American Society for Microbiology Task Force on Antibiotic Resistance. Diag Microbiol Infect Dis 25:153, 1996.CrossRefGoogle Scholar
  15. 15.
    Leu HS, Kaiser DL, Mori M, Woolson RF, Wenzel RP. Hospital-acquired pneumonia. Attributable mortality and morbidity. Am J Epidemiol 129:1258, 1989.PubMedGoogle Scholar
  16. 16.
    Pingleton SK, Fagon JY, Leeper KV Jr. Patient selection for clinical investigation of ventilator-associated pneumonia. Criteria for evaluating diagnostic techniques. Chest 102:553S, 1992.CrossRefGoogle Scholar
  17. 17.
    Niederman MS, Craven DE, Fein AM, Schultz DE. Pneumonia in the critically ill hospitalized patient. Chest 97:170, 1990.PubMedCrossRefGoogle Scholar
  18. 18.
    Kollef MH, Silver P, Murphy DM, Trovillion E. The effect of late-onset ventilator-associated pneumonia in determining patient mortality. Chest 108:1655, 1995.PubMedCrossRefGoogle Scholar
  19. 19.
    Rello J, Ausina V, Ricart M, Castella J, Prats G. Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest 104:1230, 1993.PubMedCrossRefGoogle Scholar
  20. 20.
    Craven DE, Steger KA. Epidemiology of nosocomial pneumonia. New perspectives on an old disease. Chest 108:1S, 1995.Google Scholar
  21. 21.
    Tablan OC, Anderson LJ, Arden NH, Breiman RF, Butler JC, McNeil MM. Guideline for prevention of nosocomial pneumonia. The Hospital Infection Control Practices Advisory committee, Centers for Disease Control and Prevention. Infect Control Hosp Epidemiol 15:587, 1994.PubMedCrossRefGoogle Scholar
  22. 22.
    Cook DJ, Kollef MH. Risk factors for ICU-acquired pneumonia. JAMA 279:1605, 1998.PubMedCrossRefGoogle Scholar
  23. 23.
    Kollef MH. Ventilator-associated pneumonia: a multivariate analysis. JAMA 270:1965, 1993.PubMedCrossRefGoogle Scholar
  24. 24.
    Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, Jaeschke RZ, Brun-Buison C. Incidence and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 129:433, 1998.PubMedCrossRefGoogle Scholar
  25. 25.
    Trouillet JL, Chastre J, Vuagnat A, Joly-Guillou ML, Combaux D, Dombret MC, Gibert C. Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med 157:531, 1998.PubMedCrossRefGoogle Scholar
  26. 26.
    Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C. Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94:281, 1993.PubMedCrossRefGoogle Scholar
  27. 27.
    Brewer SC, Wunderink RG, Jones CB, Leeper KV Jr. Ventilator-associated pneumonia due to Pseudomonas aeruginosa. Chest 109:1019, 1996.CrossRefGoogle Scholar
  28. 28.
    Papazian L, Bregeon F, Thirion X, Gregoire R, Saux P, Denis JP, Perin G, Charrel J, Dumon JF, Affray JP, Gouin F. Effect of ventilator-associated pneumonia on mortality and morbidity. Am J Respir Crit Care Med 154:91, 1996.PubMedCrossRefGoogle Scholar
  29. 29.
    Rello J, Gallego M, Mariscal D, Sonora R, Valles J. The value of routine microbial investigation in ventilator-associated pneumonia. Am J Respir Crit Care Med 156:196, 1997.PubMedCrossRefGoogle Scholar
  30. 30.
    Luna CM, Vujacich P, Niederman MS, Vay C, Gherardi C, Matera J, Jolly EC. Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest 111:676, 1997.PubMedCrossRefGoogle Scholar
  31. 31.
    Kollef MH, Ward S. The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia. Chest 113:412, 1998.PubMedCrossRefGoogle Scholar
  32. 32.
    Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: A risk factor for hospital mortality among critically ill patients. Chest 115:462, 1999.PubMedCrossRefGoogle Scholar
  33. 33.
    Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med 340:627, 1999.PubMedCrossRefGoogle Scholar
  34. 34.
    Goldmann DA, Weinstein RA, Wenzel RP, Tablan OC, Duma RJ, Gaynes RP, Schlosser J, Martone WJ. Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals. A challenge to hospital leadership. JAMA 275:234, 1996.PubMedCrossRefGoogle Scholar
  35. 35.
    Boyce JM, White RL, Spruill EY, Wall M. Cost-effective application of the Centers for Disease Control Guideline for Prevention of Nosocomial Pneumonia. Am J Infect Control 13:228, 1985.PubMedCrossRefGoogle Scholar
  36. 36.
    Joiner GA, Salisbury D, Bollin GE. Utilizing quality assurance as a tool for reducing the risk of nosocomial ventilator-associated pneumonia. Am J Medical Quality 11:100, 1996.CrossRefGoogle Scholar
  37. 37.
    Kelleghan SI, Salemi C, Padilla S, McCord M, Mermilliod G, Canola T, Becker L. An effective continuous quality improvement approach to the prevention of ventilator-associated pneumonia. Am J Infect Control 21:322, 1993.PubMedCrossRefGoogle Scholar
  38. 38.
    Gaynes RP, Solomon S. Improving hospital-acquired infection rates: the CDC experience. Joint Commission Journal on Quality Improvement 22:457, 1996.PubMedGoogle Scholar
  39. 39.
    Berwick DM. Continuous improvement as an idea in healthcare. N Engl J Med 320:53, 1989.PubMedCrossRefGoogle Scholar
  40. 40.
    Booth FV. ABCs of quality assurance. Crit Care Clin 9:477, 1993.PubMedGoogle Scholar
  41. 41.
    Kollef MH, Horst HM, Prang L, Brock WA. Reducing the duration of mechanical ventilation: Three examples of change in the intensive care unit. New Horizons 6:52, 1998.PubMedGoogle Scholar
  42. 42.
    Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelley PT, Johnson MM, Browder RW, Bowton DL, Haponik EF. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 335:1864, 1996.PubMedCrossRefGoogle Scholar
  43. 43.
    Kollef MH, Shapiro SD, Silver P, St. John RE, Prentice D, Sauer S, Ahrens TS, Shannon W, Baker-Clinkscale D. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med 25:567, 1997.PubMedCrossRefGoogle Scholar
  44. 44.
    Nava S, Ambrosino N, Clini E, Prato M, Orlando G, Vitacca M, Brigada P, Fracchia C, Rubini F. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. Ann Intern Med 128:721, 1998.PubMedCrossRefGoogle Scholar
  45. 45.
    Antonelli M, Conti G, Rocco M, Bun M, Deblasi RA, Vivino G, Gasparetto A, Meduri GV. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 339:429, 1998.PubMedCrossRefGoogle Scholar
  46. 46.
    Nourdine K, Combes P, Carton MJ, Beuret P, Cannamela A, Ducreux JC. Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey. Intensive Care Med 25:567, 1999.PubMedCrossRefGoogle Scholar
  47. 47.
    Nahum A, Hoyt J, Schmitz L, Schmitz L, Moody J, Shapiro R, Marini JJ. Effect of mechanical ventilation strategy on dissemination of intratracheally instilled Escherichia coli in dogs. Crit Care Med 25:1733, 1997.PubMedCrossRefGoogle Scholar
  48. 48.
    Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, Kairalla RA, Deheinzelin D, Munoz C, Oliveira R, Takagaki TY, Carvalho CR. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 338:347, 1998.PubMedCrossRefGoogle Scholar
  49. 49.
    Doebbeling BN, Stanley GL, Sheetz CT, Pfaller MA, Houston AK, Annis L, Li N, Wenzel RP. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med 327:88, 1992.PubMedCrossRefGoogle Scholar
  50. 50.
    Pittet D, Mourouga P, Perneger TV, and the Members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Ann Intern Med 130:126, 1999.PubMedCrossRefGoogle Scholar
  51. 51.
    Pereira LJ, Lee GM, Wade KJ. An evaluation of five protocols for surgical handwashing in relation to skin condition and microbial counts. J Hosp Infect 36:49, 1997.PubMedCrossRefGoogle Scholar
  52. 52.
    Klein BS, Perloff WH, Maki DG. Reduction of nosocomial infection during pediatric intensive care by protective isolation. N Engl J Med 320:1714, 1989.PubMedCrossRefGoogle Scholar
  53. 53.
    Torres A, Serra-Batlles J, Ros E, Piera C, Puig de la Bellacasa J, Cobos A, Lomena F, Rodriguez-Roisin R. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 116:540, 1992.PubMedCrossRefGoogle Scholar
  54. 54.
    Torres A, Gatell JM, Aznar E, el-Ebiary M, Puig de la Bellacasa J, Gonzalez J, Ferrer M, Rodriguez-Roisin R. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 152:137, 1995.PubMedCrossRefGoogle Scholar
  55. 55.
    Niederman MS, Craven DE. Devising strategies for preventing nosocomial pneumonia — should we ignore the stomach? Clin Infect Dis 24:320, 1997.PubMedCrossRefGoogle Scholar
  56. 56.
    Niederman MS, Mantovani R, Schoch P, Papas, J, Fein AM. Patterns and routes of tracheobronchial colonization in mechanically ventilated patients. The role of nutritional status in colonization of the lower airway by Pseudomonas species. Chest 95:155, 1989.PubMedCrossRefGoogle Scholar
  57. 57.
    Rouby JJ, Laurent P, Gosnach M, Cambau E, Lamas G, Zouaoui A, Leguillou JL, Bodin L, Khac TD, Marsault C. Risk factors and clinical relevance of nosocomial maxillary sinusitis in the critically ill. Am J Respir Crit Care Med 150:776, 1994.PubMedCrossRefGoogle Scholar
  58. 58.
    Holzapfel L, Chastang C, Demingeon G, Bohe J, Piralla B, Coupry A. A randomized study assessing the systematic search for maxillary sinusitis in nasotracheally mechanically ventilated patients. Influence of nosocomial maxillary sinusitis on the occurrence of ventilator-associated pneumonia. Am J Respir Crit Care Med 159:695, 1999.PubMedCrossRefGoogle Scholar
  59. 59.
    Kollef MH. Prolonged use of ventilator circuits and ventilator-associated pneumonia. A model for identifying the optimal clinical practice. Chest 113:267, 1998.PubMedCrossRefGoogle Scholar
  60. 60.
    Kollef MH, Prentice D, Shapiro SD, Fraser VJ, Silver P, Trovillion E, Weilitz P, von Harz B, St. John R. Mechanical ventilation with or without daily changes of in-line suction catheters. Am J Respir Crit Care Med 156:466, 1997.PubMedCrossRefGoogle Scholar
  61. 61.
    Craven DE, Goularte TA, Make BJ. Contaminated condensate in mechanical ventilator circuits. A risk factor for nosocomial pneumonia. Am Rev Respir Dis 129:625, 1984.PubMedGoogle Scholar
  62. 62.
    Valles J, Artigas A, Rello J, Bonsoms N, Fontanals D, Blanch L, Fernandez R, Baigorri F, Mestre J. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med 122:179, 1995.PubMedCrossRefGoogle Scholar
  63. 63.
    Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest 116:1339, 1999.PubMedCrossRefGoogle Scholar
  64. 64.
    Rello J, Soñora R, Jubert P, Artigas A, Rue M, Valles J. Pneumonia in intubated patients: role of respiratory airway care. Am J Respir Crit Care Med 154:111, 1996.PubMedCrossRefGoogle Scholar
  65. 65.
    Kirton OC, DeHaven B, Morgan J, Morejon O, Civetta J. A prospective randomized comparison of an in-line heat moisture exchange filter and heated wire humidifiers: rates of ventilator-associated early-onset (community-acquired) or late-onset (hospital acquired) pneumonia and incidence of endotracheal tube occlusion. Chest 112:1055, 1997.PubMedCrossRefGoogle Scholar
  66. 66.
    Kollef MH, Shapiro SD, Boyd V, Silver P, Von Harz B, Trovillion E, Prentice D. A randomized clinical trial comparing an extended-use hygroscopic condenser humidifier to heated water humidification in mechanically ventilated patients. Chest 113:759, 1998.PubMedCrossRefGoogle Scholar
  67. 67.
    Djedaini K, Billiard M, Mier L, Le Bourdelles G, Brun P, Markowicz P, Estagnasie P, Coste F, Boussougant Y, Dreyfuss D. Changing heat and moisture exchangers every 48 hours rather than 24 hours does not affect their efficacy and the incidence of nosocomial pneumonia. Am J Respir Crit Care Med 152:1562, 1995.PubMedCrossRefGoogle Scholar
  68. 68.
    Hall JC, Tarala RA, Tapper J, Hall JL. Prevention of respiratory complications after abdominal surgery: a randomized clinical trial. BMJ 312:148, 1996.PubMedCrossRefGoogle Scholar
  69. 69.
    Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 330:377, 1994.PubMedCrossRefGoogle Scholar
  70. 70.
    Cook DJ, Reeve BK, Guyatt GH, Heyland DK, Griffith LE, Buckingham L, Tryba M. Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analysis. JAMA 275:308, 1996.PubMedCrossRefGoogle Scholar
  71. 71.
    Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, Peters S, Rutledge F, Griffith L, McLellan A, Wood G, Kirby A. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. N Engl J Med 338:791, 1998.PubMedCrossRefGoogle Scholar
  72. 72.
    Johanson WG Jr, Pierce AK, Sandford JP, Thomas GD. Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tracet. Ann Intern Med 77:701, 1972.PubMedCrossRefGoogle Scholar
  73. 73.
    Garrouste-Orgeas M, Chevret S, Arlet G, Marie O, Rouveau M, Popoff N, Schlemmer B. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med 156:1647, 1997.PubMedCrossRefGoogle Scholar
  74. 74.
    Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme JF, Lloyd JF, Burke JP. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 338:232, 1998.PubMedCrossRefGoogle Scholar
  75. 75.
    Kollef MH, Vlasnik J, Sharpless L, Pasque C, Murphy D, Fraser V. Scheduled change of antibiotic classes: a strategy to decrease the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 156:1040, 1997.PubMedCrossRefGoogle Scholar
  76. 76.
    Rahal JJ, Urban C, Horn D, Freeman K, Segal-Maurer S, Maurer J, Mariano N, Marks S, Burns JM, Dominick D, Lim M. Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella. JAMA 280:1233, 1998.PubMedCrossRefGoogle Scholar
  77. 77.
    Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S. A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. The French Study Group of Selective Decontamination of the Digestive Tract. N Engl J Med 326:594, 1992.PubMedCrossRefGoogle Scholar
  78. 78.
    D’Amico R, Pifferi S, Leonetti C, Torri V, Tinazzi A, Liberati A. Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomized controlled trials. BMJ 316:1275, 1998.PubMedCrossRefGoogle Scholar
  79. 79.
    Tenover FC, McGowan JE Jr. Reasons for the emergence of antibiotic resistance. Am J Med Sci 311:9, 1996.PubMedCrossRefGoogle Scholar
  80. 80.
    Sirvent JM, Torres A, El-Ebiary M, Castro P, de Batlle J, Bonet A. Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma. Am J Respir Crit Care Med 155:1729, 1997.PubMedCrossRefGoogle Scholar
  81. 81.
    Rumbak MJ, Cancio MR. Significant reduction in methicillin-resistant Staphylococcus aureus ventilator-associated pneumonia associated with the institution of a prevention protocol. Crit Care Med 23:1200, 1995.PubMedCrossRefGoogle Scholar
  82. 82.
    DeRiso AJ II, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and non-prophylactic systemic antibiotic use in patients undergoing heart surgery. Chest 109:1556, 1996.PubMedCrossRefGoogle Scholar
  83. 83.
    Russell AD. Plasmids and bacterial resistance to biocides. J Appl Microbiol 83:155, 1997.PubMedCrossRefGoogle Scholar
  84. 84.
    Herceg A. The decline of Haemophilus influenza type b disease in Australia. Communicable Dis Intell 21:173, 1997.Google Scholar
  85. 85.
    Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowoski RA. The efficacy of influenza vaccine in elderly persons. A meta-analysis and review of the literature. Ann Intern Med 123:518, 1995.PubMedCrossRefGoogle Scholar
  86. 86.
    Nuorti JP, Butler JC, Crutcher JM, Guevara R, Welch D, Holder P, et al. An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents. N Engl J Med 338:1861, 1998.PubMedCrossRefGoogle Scholar
  87. 87.
    Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. Crit Care Med 27:887, 1999.PubMedCrossRefGoogle Scholar
  88. 88.
    Hanberger H, Garcia-Rodriguez J A, Gobernado M, Goossens H, Nilsson LE, Struelens MJ. Antibiotic susceptibility among aerobic gram-negative bacilli in intensive care units in 5 European Countries. JAMA 281:67, 1999.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2001

Authors and Affiliations

  • Marin H. Kollef

There are no affiliations available

Personalised recommendations