According to current data, clinicians should not be concerned about increasing the risk of nosocomial pneumonia above baseline with the use of any prophylactic agent. However, current evidence supports the use of sucralfate over other agents, both because of a reduction in pneumonia and a possible reduction in mortality. In most settings, this agent is cheaper than alternative prophylactic drugs. Given the inaccuracy of the usual clinical criteria used to diagnose lung infection in previous trials, further trials, in which sucralfate is compared with gastric-pH-altering prophylaxis using sensitive and specific diagnostic approaches such as bronchoalveolar lavage and protected brush catheters, are needed to confirm the apparent reduction in pneumonia associated with sucralfate administration.

Enrolment of patients at risk of both stress ulcer bleeding and nosocomial pneumonia (those ventilated for at least 48 h and those likely to be exposed to study medication for at least 7 days) is also necessary. Whether the effect of sucralfate on ICU mortality is due to its impact on ventilator-associated lung infection or different rates of bacterial translocation remains to be determined. However, examination of both costs and consequences is necessary, and a full-scale economic evaluation is needed.

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