American Journal of Respiratory and Critical Care Medicine

The objective of this randomized study was to compare the occurrence of nosocomial pneumonia in nasotracheally intubated patients who were randomly allocated either to a systematic search of sinusitis by CT scan (study group) or not (control group). A total of 399 patients were included: 272 male and 127 female; mean age, 61 ± 17 yr; SAPS: 12.6 ± 4.9. The study group consisted of 199 patients and the control group consisted of 200. In the study group, sinus CT scans were performed in case of fever at Days 4 and 8 and then every 7 d. Nosocomial sinusitis was defined as follows: fever of ⩾ 38 ° C, radiographic (sinusal air-fluid level or opacification on CT scan) signs, and presence of purulent aspirate from the involved sinus puncture with ⩾ 103 cfu/ml. Patients with sinusitis received sinus lavage and intravenously administered antibiotics. In the study group, 80 patients experienced nosocomial sinusitis. In the control group, no patient was treated for a sinusitis. Ventilator-associated bronchopneumonia (VAP) was observed in 88 patients: 37 in the study group (1 mo Kaplan-Meier estimate, 34%) versus 51 in the control group (1 mo Kaplan-Meier estimate, 47%); (p = 0.02, log-rank test; relative risk [RR] = 0.61; 95% confidence interval [CI], 0.40 to 0.93). Two months overall mortality was estimated at 36% in the study group versus 46% in the control group (p = 0.03, log-rank test; RR = 0.71; 95% CI, 0.52 to 0.97). We conclude that the occurrence of VAP in patients undergoing prolonged mechanical ventilation via a nasotracheal intubation can be prevented by the systematic search and treatment of nosocomial sinusitis. The effect on mortality should be confirmed.

Maxillary nosocomial sinusitis as a complication of endotracheal intubation has been reported (1). Clinical signs are not specific; sinusitis is usually searched for in patients with unexplained fever and is diagnosed by sinus radiography. Conventional sinus X-ray can be performed at the bedside, but its quality is poor. The performance of sinus computed tomograph (CT) scan is better, but patients have to be moved to the radiology department. Radiographic signs of sinusitis consist of air-fluid level and/or sinus opacification. In febrile patients with radiographic sinusitis, to confirm infectious sinusitis, sinus aspiration should be performed with bacteriologic culture. The incidence of infectious sinusitis is estimated at 20% after 8 d of mechanical ventilation in patients orotracheally or nasotracheally intubated (2). It has been suggested that nosocomial sinusitis could be prevented by oral tracheal intubation, but this is still controversial (2-5). Cultured bacteria from sinus are similar to those encountered in other nosocomial infections (1-11). The seriousness of this infection remains unclear (11). Treatment consists in sinus drainage, nasal tracheal tube removal or tracheotomy, nasal gastric tube removal, and parenteral antibiotics (3, 6-12). However, no prospective trial has been performed to assess the efficacy of such treatments. Several investigators have suggested that nosocomial sinusitis could be responsible for the development of ventilator-associated bronchopneumonia (VAP) (2, 3, 5, 6, 13), but this has not been clearly demonstrated. The effect of systematic search and treatment of nosocomial sinusitis remains to be established.

The aim of this randomized study was to assess the search and treatment of nosocomial sinusitis to prevent the occurrence of VAP in ICU nasally intubated patients undergoing prolonged mechanical ventilation.

Criteria for Eligibility

ICU patients were included in the study when tracheal intubation was decided if the following criteria were observed: (1) age > 15 yr, (2) nasotracheal intubation, and (3) foreseeable mechanical ventilation duration > 7 d. They were not included if at least one of the following criteria was present: pregnancy, tracheotomy in place, bleeding disorders (platelet count < 30,000/mm3, prothrombine time < 30%, activated partial thromboplastin time two times higher than the normal value, curative doses of heparin, and selective digestive tract decontamination.

Randomization

Eligible patients were randomly allocated to either the study group (systematic search for a sinusitis) or the control group (no systematic search for a sinusitis). A computer program was used to provide randomization between the two compared strategies with blocks of four patients. Sealed and numbered envelopes were available in the ICU.

Follow-up Examinations

Follow-up evaluations included measurement of body temperature every 4 h and daily chest radiographs. In the study group, if body temperature was ⩾ 38° C, a sinus CT scan was performed at Days 4 and 8 after tracheal intubation and then every 7 d. In the control group, no systematic sinus CT scan was performed. Blood culture was performed at least two times a day when body temperature was ⩾ 38° C. When CT scan showed an air-fluid level and/or an opacification within a maxillary sinus and if the patient had a body temperature ⩾ 38° C, a transnasal puncture was performed for (1) determination of the macroscopic aspect of the aspirated material and (2) aeroanaerobic culture with quantification of microorganisms present. Before transnasal puncture, a large disinfection of the nasal mucosa was performed using a povidone-iodine solution (Betadine ORL, Asta Medica, Mérignac, France). A drain was inserted in all punctured patients. Sinus aspirate cultures were performed on the following plates: blood agar for aerobic and anaerobic cultures, chocolate agar for culture in CO2 (5%) incubator, and Sabouraud's agar. When VAP was suspected, a specimen was obtained using a fibroscopic telescopic protected-specimen brush (PSB) (Ventimed, Marsannay la Cote, France) from the involved pulmonary lobe seen on the chest radiograph. Other procedures to identify the fever cause were standardized in the two groups: removal of catheters, blood culturing, urine culturing, and abdominal ultrasound.

End Points

The main end point was the time of occurrence of VAP. Two secondary criteria were also defined, namely, the time of occurrence of nosocomial septicemia and overall survival. All end points were calculated from the date of randomization. Patients who were discharged from the ICU or who died without developing the event were censored at the time of their discharge.

Criteria for nosocomial sinusitis were as follows: (1) sinus CT scan findings consistent with sinusitis (air-fluid level and/or opacification); (2) mechanical ventilation for at least 48 h; (3) macroscopic purulent sinus aspiration; (4) quantitative culture of the aspirated material with ⩾ 103 colony-forming units (cfu)/ml.

Criteria for nosocomial pneumonia were as follows: (1) a new infiltrate on chest radiograph consistent with pneumonia; (2) rectal temperature of > 38.4° C or < 36° C; (3) leukocyte count of > 12,000 cells/mm3 or < 5,000 cells/mm3 and/or grossly purulent tracheobronchial secretions; (4) a PSB with ⩾ 103 cfu/ml.

Nosocomial septicemia was defined as two separate blood cultures yielding the same microorganism or as a single blood culture associated with tachycardia > 90 /min, fever > 38.4° C, or hypothermia < 36° C.

Treatment Procedures

All tracheal and gastric tubes were inserted via the nasal route. Endotracheal tubes had low-pressure, high-volume cuffs with an internal diameter of 7 or 7.5 mm. No patient received a stress ulcer prophylactic regimen. Selective digestive decontamination was not used. Care of the patient's mouth was performed three times a day using an antiseptic solution (Givalex; Norgan, Paris, France). No special care was given to the nares. Patients were reintubated only in case of a ruptured endotracheal tube cuff or an unsuccessful extubation. In the study group, treatment of sinusitis consisted of the intravenous administration of antibiotics and sinus lavage every 8 h using Albertini drains. Nasotracheal and nasogastric tubes were not removed. VAP and septicemia were treated with antibiotics adapted to cultured microbiologic agents susceptibility. Patients with sepsis of unknown source were given broad-spectrum antibiotics. Empiric antibiotic treatment was standardized for both groups. Doses of antibiotics were recorded daily and it was also recorded if they were given to treat (1) a sepsis present before or in the first 48 h of intubation and admission in the ICU, (2) a sepsis developed at least 48 h after intubation and admission in the ICU (nosocomial infection), and (3) a documented or a nondocumented infection. This protocol was approved by the Ethics Committee of Lyon University.

Sample Size

Sample size was based on the main end point that is VAP. Although statistical analysis planned the use of failure time data methods, we dealt with the anticipated rates of occurrence of VAP at 1 mo (as the long-term occurrence of VAP is without sense). Thus, we considered that the 1-mo rate of VAP would be 45% in the control group and 30% in the study group. Thus, with a type I error of 0.05 and a type II error of 0.10, the sample size should be 217 patients per group.

Statistical Analysis

Statistical analysis was performed on an intent-to-treat basis. End points were estimated using the Kaplan-Meier method (14) and compared by the log-rank test (15). Tests were two-sided with a 5% type I error. Statistical analysis used the SAS software (SAS Institute, Raleigh, NC). In the study group, Cox's time-dependent model was used to estimate the relationship between the occurrence of sinusitis and the occurrence of VAP or nosocomial septicemia. For each censored end point, the relative risk of the strategy of diagnosis and treatment of sinusitis or control was estimated by using Cox's model, and 95% confidence was calculated.

A total of 399 patients were included, 272 male and 127 female, with a mean age of 61 ± 17 yr, and the simplified acute physiologic score was 12.6 ± 4.9. Of the 399 patients, 199 were randomly allocated to the study group and 200 to the control group. Baseline characteristics of these 399 patients according to the treatment group are displayed in Table 1. No imbalances were observed between the two groups. During the follow-up period, the number of sinus CT scans performed in patients of the study group was 270: 53 patients had no CT scan, 81 patients had one CT scan, and 65 patients had more than two CT scans. Radiographic evidence of sinusitis was observed in 110 patients (55%) of the study group. Among these 110 patients, 78 fulfilled the microbiologic sinusitis criteria. This criteria was also observed in two patients who did not have a sinus CT scan performed but presented an unexplained fever and thus had a sinus puncture. Finally 80 patients among the 199 study group patients were found to have infectious nosocomial maxillary sinusitis, and the 1 mo Kaplan-Meier estimate of sinusitis occurrence was 58% (95% confidence interval [CI], 48 to 69%) (Figure 1A). Among the 110 patients who demonstrated radiographic evidence of sinusitis, 32 did not fulfill the microbiologic sinusitis criteria: (1) 16 had sterile sinus aspiration, (2) seven had sinus aspiration with < 103 cfu/ml, and (3) sinus puncture was not performed in nine patients: six had no more fever, two died, and one was extubated. Among the 80 patients with sinusitis, infection was due to polymicrobial flora in 44 patients and 138 microorganisms were isolated. Isolated microorganisms are shown in Table 2. Among the patients' characteristics, a Cox's model selected as risk factors for infectious sinusitis coma as admission diagnosis (relative risk [RR] = 1.79, p = 0.03) and sex (male) (RR = 1.61, p = 0.06).

Table 1. BASELINE CHARACTERISTICS ACCORDING TO RANDOMIZATION

Study Group (n = 199)Control Group (n = 200)All Patients (n = 399)
Age, yr* 60.7 ± 17.260.8 ± 17.860.8 ± 17
Male137 (69%)135 (67%)272 (68%)
Simplified Acute Physiologic Score* 12.4 ± 4.912.7 ± 4.812.6 ± 4.9
Admission diagnosis
 Coma 51 (26%) 51 (25%)102 (25%)
 Pneumonia 48 (24%) 32 (16%) 80 (20%)
 Surgery 30 (15%) 41 (20%) 71 (18%)
 Infection 27 (14%)15 (7%) 42 (10%)
 Multiple trauma 5 (2%)19 (9%)24 (6%)
 Others 38 (19%) 42 (21%) 80 (20%)
Chronic obstructive pulmonary   disease 48 (24%) 50 (25%) 98 (25%)
Cardiac insufficiency 29 (15%) 39 (19%) 68 (17%)
Immunodepression 8 (4%) 8 (4%)16 (4%)

*Values are mean ± SD.

Table 2. NUMBER OF MICROORGANISMS ISOLATED FROM SINUS, LUNGS, AND BLOOD

SinusLungsBlood
Study GroupControl GroupStudy GroupControl GroupStudy GroupControl Group
Gram negative bacilli
Escherichia coli 12 3 5 1 1
Proteus 10 2 2 2 0
Providencia  0 0 0 0 0
Citrobacter  1 0 0 0 0
Klebsiella  6 1 0 1 1
Enterobacter  6 4 1 2 0
Serratia  1 0 1 0 0
Acinetobacter  4 4 3 1 0
Pseudomonas 1210 6 2 0
Hemophilus  7 4 8 0 0
 Other gram negative bacilli 5 0 0 0 0
Gram positive cocci
Staphylococcus aureus 10 721 2 2
Staphylococcus epidermidis  9 2 22229
Streptococcus 301114 5 9
 Anaerobes15  1 0 0 1
Candida albicans 10 1 3 1 1

In the control group, no sinus CT scan was performed to search for a sinusitis, thus no patient had a sinus punctured or received antibiotics to treat a sinusitis.

VAP was observed in 88 patients: 37 in the study group (1-mo Kaplan-Meier estimate, 34%) versus 51 in the control group (1-mo Kaplan-Meier estimate, 47%); (p = 0.02, log-rank test; RR = 0.61, 95% CI, 0.40 to 0.93) (Figure 1B). Among the 80 study group patients with sinusitis, VAP occurred before diagnosis of sinusitis in seven patients, the same day in five patients, and after in 11 patients. Among the 119 study group patients without sinusitis, 14 developed VAP. In the study group, a Cox's model considering sinusitis as a time-dependent event found that sinusitis increased by 1.69 (95% CI = 0.80 to 3.56), but not significantly (p = 0.17) the risk of VAP.

Isolated microorganisms from the PSB culture are shown in Table 2. Multiple microorganisms were isolated in 25 patients. The distribution of microorganisms isolated in both groups showed no marked imbalances, except for Staphylococcus aureus, which was isolated in seven patients in the study group versus 21 patients in the control group. In the study group, among the 80 patients with nosocomial sinusitis, 23 developed VAP and the same organism was isolated from the lung and sinus in 10 of the 23 cases.

Nosocomial septicemia was observed in 82 patients, 36 in the study group (1-mo Kaplan-Meier estimate, 30%) versus 46 in the control group (1-mo Kaplan-Meier estimate, 35%); (p = 0.11, log-rank test; RR = 0.71; 95% CI, 0.46 to 1.09) (Figure 1C). In the study group, a Cox's model considering sinusitis as a time-dependent factor estimated that sinusitis increased by 2.29 (85% CI = 1.10 to 4.74, p = 0.03) the risk of nosocomial septicemia. Multiple microorganisms were isolated in eight patients. Isolated bacterial microorganisms are shown in Table 2. In the study group, among the 80 patients with nosocomial sinusitis, septicemia was observed in 24, and the same organism was isolated from blood and sinus in nine of these 24.

In the study group, antibiotics were more frequently given to treat a nosocomial infection developed in the ICU than to the control group, and antibiotics were more often given on a documented microbiologic basis (Table 3). The time to antibiotics treatment for nosocomial infection in both groups (p = 0.03, log-rank test) is displayed in Figure 2.

Table 3. ANTIBIOTICS PRESCRIPTION FOR A NOSOCOMIAL INFECTION DEVELOPED IN THE ICU IN THE TWO RANDOMIZED GROUPS

Study Group (n = 199)Control Group (n = 200)p Value
Length of antibiotherapy, d* 8.1 ± 10.55.4 ± 8.50.008
Number of antibiotics prescriptions for
 Documented infection146950.03
 Nondocumented infection 44400.71

*Values are means ± SD.

Kruskal-Wallis test.

Length of mechanical ventilation was 15.7 ± 14.4 d in the study group versus 14.2 ± 14.3 d in the control group (p = 0.31, Kruskal-Wallis test). Length of stay in the ICU was 16.5 ± 14.5 d in the study group versus 14.6 ± 14.5 d in the control group (p = 0.10, Kruskal-Wallis test).

Follow-up of all patients was performed until 60 d after inclusion; 2 mo overall mortality was estimated at 36% in the study group versus 46% in the control group (p = 0.03, log-rank test; RR = 0.71; 95% CI, 0.52 to 0.97) (Figure 1D).

In the literature, the definition of maxillary sinusitis varies. Some investigators reported radiographic evidence of sinusitis, which is defined by the presence of air-fluid levels or opacification within the maxillary sinuses on radiographs (3, 9, 16) or CT scans (5, 17-19). Other investigators (1, 7, 10, 12, 20) reported infectious sinusitis defined by the presence of radiographic evidence of sinusitis associated with fever and a purulent sinus puncture. In our study, infectious maxillary sinusitis (IMS) was defined as a positive culture of sinus aspirate with a quantitative threshold of 103 cfu/ml. This IMS definition has already been used in other studies (2, 5). If we had considered only the growth of bacteria in the liquid material drained from the sinus, the results would have been close (seven more patients with sinusitis).

Unexplained fever is probably the most constant clinical sign that draws attention toward the sinuses (10-12, 16). But ICU patients present multiple sources of infection, and fever can be due to sinusitis and/or other simultaneous infections. A fever related to peritonitis, pneumonia, or meningitis does not exclude the possibility of an associated sinusitis. Thus, in our study, sinusitis was systematically searched in the study group in patients with unexplained or explained fever. The microorganisms cultured from sinus aspirates were similar to the microorganisms identified in other studies (1-3, 5, 7, 9-12).

In our study, the patients were intubated via the nasal route. It was suggested that nosocomial sinusitis could be prevented by oral tracheal intubation, but this is still controversial (2-5). Salord and colleagues (3) randomly assigned 111 patients to receive either orotracheal or nasotracheal intubation. Radiographic evidence of sinusitis was assessed by sinus radiograph at bedside. The incidence of radiographic sinusitis was lower in the orotracheal group than in the nasotracheal group (p < 0.001). Rouby and colleagues (5) randomly assigned 40 patients to receive either orotracheal or nasotracheal intubation. Radiographic evidence of sinusitis was assessed by sinus CT scans on Day 7. The incidence of CT scan sinusitis was lower in the orotracheal group than in the nasotracheal group (p < 0.001). But in these two studies, the occurrence of IMS was not evaluated. In a prospective study (2), 300 patients undergoing prolonged mechanical ventilation were randomly assigned to receive either orotracheal or nasotracheal intubation. A sinus CT scan was performed every 7 d or earlier in febrile patients. The total number of CT scans was 335, performed in 121 patients still intubated at Day 7. A trend (p = 0.08, log-rank test) suggested less radiographic evidence of sinusitis in the orotracheal group, which was consistent with the two previous studies (3, 5), but no statistically significant difference was found in the occurrence rate of IMS between patients undergoing tracheal intubation via nasal route versus oral route (p = 0.75, log-rank test).

Treatment of sinusitis consists in sinus drainage, nasal tracheal tube removal or tracheotomy, nasal gastric tube removal, and parenteral antibiotics (3, 6-12). However, no prospective study has been yet performed to assess the efficacy of each of these procedures. In our study, patients were initially nasally intubated, and nasal tubes were not removed when sinusitis was diagnosed because the nasal route for intubation as risk factor for maxillary sinusitis is still controversial (2).

The nares were carefully disinfected before the insertion of the Albertini drains, because this is a critical element for an accurate diagnosis of infectious maxillary sinusitis. As the endotracheal tube and the gastric tube were kept in place when puncturing the sinus cavities, disinfection was difficult in some cases and particular attention was given to these cases.

The aim of this randomized study was to assess the clinical interest of the search by sinus CT scan and treatment of maxillary sinusitis. In the literature, sinusitis is a recognized cause of sepsis and is supposed to favor the occurrence of nosocomial pneumonia (11, 21). But no study has been performed to evaluate the interest of performing sinus CT scan in case of fever in order to detect and treat a sinusitis. In our study, end points were occurrence of nosocomial pneumonia and overall survival.

In this study we used the PSB as a diagnostic test for VAP. Two recent human studies in which the gold standard was the histology and the bacteriology of the lung itself estimated the sensitivity of the PSB at 42% (22) and 57% (23). Therefore, in both groups, the true incidence of VAP was likely underestimated.

Several studies have demonstrated that nosocomial sinusitis episodes are frequently associated with nosocomial pneumonia with similar microorganisms often isolated from both sites. Guérin and colleagues (7) reported 34 episodes of nosocomial pneumonia in 42 patients with nosocomial sinusitis. Meyer and colleagues (13) observed 11 patients with nosocomial pneumonia associated with nosocomial sinusitis, and in 10 cases, the same microorganism was cultured from both sites. In our study, among 23 patients with nosocomial pneumonia and sinusitis, 10 had the same microorganisms isolated from sinus and lungs. The data obtained in four previous studies and in the present study, concerning the occurrence rate of pneumonia and sinusitis in ventilated patients, are summarized in Table 4. In all studies, the occurrence of pneumonia was higher in patients with sinusitis than in patients without sinusitis. Three interpretations could be proposed: (1) nosocomial sinusitis and pneumonia occur in patients at risk for nosocomial infections without determinist relationship between the two infections, (2) nosocomial sinusitis favors the occurrence of nosocomial pneumonia, and (3) nosocomial pneumonia favors the occurrence of nosocomial sinusitis. In the studies summarized in Table 4, the chronology of the two infections was not given. Their frequent association does not allow the conclusion that one favors the occurrence of the other. Only a time-dependent model can firmly assess a relationship between one complication and another occurring over time. In a previous study (2), among 54 patients with nosocomial sinusitis, pneumonia was observed in 16 (30%), and a Cox's model considering sinusitis as a time-dependent variable estimated that sinusitis increased by 3.8 the risk of nosocomial pneumonia. Our present study supports the hypothesis that sinusitis favors the occurrence of nosocomial pneumonia: in the study group, nosocomial pneumonia was prevented by the treatment of sinusitis, and the occurrence rate of nosocomial pneumonia was lower in the study group compared with the control group. It can be seen in Table 2 that the distribution of microorganisms isolated in both groups showed no marked imbalances, except for Staphylococcus aureus, which was isolated in seven patients in the study group versus 21 patients in the control group. These results suggest that the treatment of sinusitis was particularly efficient to prevent VAP caused by this microorganism.

Table 4. OCCURRENCE RATE OF PNEUMONIA AND SINUSITIS IN VENTILATED PATIENTS

References
Boles*(6)Salord*(3)Holzapfel(2)Rouby*(5)This Study
Occurrence of nosocomial pneumonia
 Patients with sinusitis33/5014/2616/5429/4323/80
(66%)(54%)(30%)(67%)(29%)
 Patients without sinusitis 7/43 4/8510/24623/5314/119
(16%) (5%) (5%)(43%)(12%)
Same organisms isolated from lung and sinus 8/209/1611/2910/23
(40%)(56%)(38%)(43%)

*Radiographic evidence of sinusitis.

Infectious maxillary sinusitis.

Septicemia has been documented in patients with nosocomial sinusitis with the same microorganisms isolated from the blood and from the sinuses. Deutschman and colleagues (9) reported two cases of septicemia among 17 patients (12%) with sinusitis, with the same organism isolated in both sites, O'Reilly and coworkers (17) reported two cases among six patients (33%), Füssle and colleagues (8) reported 11 cases among 43 patients (26%), our previous study (2) reported nine cases among 21 patients (43%), and the present study reported nine cases among 24 patients (37%). In these studies, isolated microorganisms were most often gram-positive cocci (Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus sp.) as in the present study. In our previous study (2), among 54 patients with nosocomial sinusitis, septicemia was recorded in 21, and in the present study, among the 80 patients with nosocomial sinusitis, septicemia was observed in 24. In the study group, a Cox's model considering sinusitis as a time-dependent factor estimated that sinusitis increased by 2.29 (95% CI = 1.10 to 4.74, p = 0.03) the risk of nosocomial septicemia.

In the study group, antibiotic prescriptions given to treat a nosocomial infection developed in the ICU were more frequent when compared with the control group, and antibiotics were more often given on a documented microbiologic basis (Table 3 and Figure 2). ICU patients are often given antibiotics either to treat a documented infection (pneumonia, septicemia, peritonitis) or a nondocumented infection, with or without severe sepsis. We can assume that, in the control group, patients presented the same occurrence of infectious sinusitis as in the study group, but these infections were not treated, unless patients developed nosocomial pneumonia and/or septicemia or serious sepsis, requiring documented or nondocumented antibiotics prescription. In the study group, infections were treated as in the control group, but more antibiotics were given to treat sinusitis. The administration of antibiotics intravenously for treating nosocomial sinusitis in mechanically ventilated patients is recommended by most investigators (3, 6– 12). One investigator (5) did not recommend the intravenous use of antibiotics but instead recommended the administration of topical antibiotics directly into the sinus cavity after drainage. Recently, one study (24) demonstrated that oral amoxycillin treatment did not change the course of acute maxillary sinusitis in patients presenting on general practice.

The mortality was lower in the study group than in the control group. We can assume that this was related to the lower occurrence rate of nosocomial pneumonia in the study group. Another hypothesis is that infectious sinusitis was a serious infection responsible for severe sepsis, and its treatment improved the patient's outcome. We were unable to find in the literature data dealing with the seriousness of this nosocomial infection. Another hypothesis is that, in our study, antibiotics given to treat sinusitis improved also an undiagnosed sepsis.

We conclude that the systematic search and treatment of nosocomial sinusitis decreases the occurrence rate of nosocomial pneumonia in nasally intubated patients undergoing prolonged mechanical ventilation. The effect on mortality should be confirmed by other studies.

1. Linden B. E., Aguilar E. A., Allen S. J.Sinusitis in the nasotracheally intubated patient. Arch. Otolaryngol. Head Neck Surg.1141988860861
2. Holzapfel L., Chevret S., Madinier G., Onen F., Demingeon G., Coupry A., Chaudet M.Incidence of long term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a randomized clinical trial (300 patients). Crit. Care Med.21199311321138
3. Salord F., Gaussorgues P., Marti-Flich J., Sirodot M., Allimant C., Lyonnet D., Robert D.Nosocomial maxillary sinusitis during mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal route for intubation. Intensive Care Med.161990390393
4. Bach A., Boehrer H., Schmidt H., Geiss H. K.Nosocomial sinusitis in ventilated patients: nasotracheal versus orotracheal intubation. Anaesthesia471992335339
5. Rouby J. J., Laurent P., Gosnach M., Cambau E., Lamas G., Zouaoui A., Leguillou J. L., Bodin L., Khac T. D., Marsault C., Poete P., Nicolas M. H., Jarlier V., Viars P.Risk factors and clinical relevance of nosocomial maxillary sinusitis in the critically ill. Am. J. Respir. Crit. Care Med.1501994776783
6. Boles, J. M., B. Garo, and M. Garre. 1988. Nosocomial sinusitis in intensive care patients. In J. L. Vincent, editor. Update in Intensive Care, Springer-Verlag, Heidelberg. 133–140.
7. Guérin J. M., Lustman C., Meyer P., Barbotin-Larrieau F.Nosocomial sinusitis in pediatric intensive care patients. Crit. Care Med.181990902
8. Füssle R., Biscoping J., Michaelis G.Paranasal sinusitis in ventilated patients: aspects of infection. Clin. Intensive Care21991351355
9. Deutschman C. S., Wilton P., Sinow J., Thienprasit P., Konstantinides F. N., Cerra F. B.Paranasal sinusitis associated with nasotracheal intubation: a frequently unrecognized and treatable source of sepsis. Crit. Care Med.141986111114
10. Grindlinger G. A., Niehoff J., Hughes L., Humphrey M. A., Simpson G.Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients. Crit. Care Med.151987214217
11. Talmor M., Li P., Barie P. S.Acute paranasal sinusitis in critically ill patients: guidelines for prevention, diagnosis and treatment. Clin. Infect. Dis.25199714411446
12. Kronberg F. G., Goodwin W. J.Sinusitis in intensive care unit patients. Laryngoscope951985936938
13. Meyer P., Guérin J. M., Habib Y., Levy C.Pneumopathies secondaires du sujet intubé par voie naso-trachéale: rôle des sinusites nosocomiales. Ann. Fr. Anesth. Réanim.719882630
14. Kaplan E., Meier P.Non parametric estimation from incomplete observations. J. Am. Statist. Assoc.531958457481
15. Peto R., Peto J.Asymptotically efficient rank invariant test procedures (with discussion). J. R. Statist. Soc. A1351972185206
16. Arens J. F., Lejeune F. E., Webre D. R.Maxillary sinusitis, a complication of nasotracheal intubation. Anesthesiology4041974415416
17. O'Reilly M. J., Reddick E. J., Black W., Carter P. L., Erhardt J., Fill W., Maughn D., Sado A., Klatt G. R.Sepsis from sinusitis in nasotracheally intubated patients. Am. J. Surg.1471984601604
18. Fassoulaki A., Pamouktsoglou P.Prolonged nasotracheal intubation and its association with inflammation of paranasal sinuses. Anesth. Analg.6919895052
19. Hansen M., Poulsen M. R., Bendixen D. K., Hartmann-Andersen F.Incidence of sinusitis in patients with nasotracheal intubation. Br. J. Anaesth.611988231232
20. Aebert H., Hünefeld G., Regel G.Paranasal sinusitis and sepsis in ICU patients with nasotracheal intubation. Intensive Care Med.1519882730
21. Meduri G. U., Mauldin G. L., Wunderink R. G., Leeper K. V., Jones C. B., Tolley E., Mayhall G.Causes of fever and pulmonary densities in patients with clinical manifestations of ventilator- associated pneumonia. Chest1061994221235
22. Papazian L., Thomas P., Garbe L., Guignon I., Thirion X., Charrel J., Bollet C., Fuentes P., Goin F.Bronchoscopic or blind sampling techniques for the diagnosis of ventilator-associated pneumonia. Am. J. Respir. Crit. Care Med.152199519821991
23. Marquette C. H., Copin M. C., Wallet F., Neviere R., Saulnier F., Mathieu D., Durocher A., Ramon P., Tonnel A. B.Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard. Am. J. Respir. Crit. Care Med.151199518781888
24. van Buchem F. L., Knottnerus J. A., Schrijnemaekers V. J. J., Peeters M. F.Primary-care-based randomized placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis. Lancet3491997693687
Correspondence and requests for reprints should be addressed to Laurent Holzapfel, M.D., Service de Réanimation, Centre Hospitalier, 01012 - Bourg en Bresse, France. E-mail:

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