Impaired carriage defense and the abnormal carrier state

Carriage defense is the first line of defense to fail in critically ill patients. The adherence of Gram-negative bacilli to mucosal cells is greatly increased. Stasis, an increase in gastric pH, and mucosal atrophy all lead to an explosive overgrowth of aerobic Gram-negative bacilli. The intravenous administration of broad-spectrum antibiotics excreted via saliva, bile, and mucus may eradicate both the indigenous flora and the sensitive 'community' potentially pathogenic micro-organisms. Consequently, resistant Gram-negative bacilli, Staph. aureus, and Candida species are selected, followed by overgrowth in the oropharynx and gastrointestinal tract.

From a microbiological point of view, the impairment of carriage defense is associated with an abnormal carrier state. The incidence of abnormal carriage in mechanically ventilated patients is 60 to 90 per cent. High concentrations of mostly Gram-negative bacilli (>10 8/ml), but also Staph. aureus and Candida species, can be found in saliva, stomach, and gut as soon as 48 h after admission to the ICU.

Abnormal carriage predisposes to (secondary endogenous) infections and emergence of resistance, and is associated with multiple organ failure. The pathophysiological mechanisms by which infections and multiple organ failure may develop are (micro)aspiration, continuous spreading of potentially pathogenic micro-organisms to neighboring organ systems, translocation, and absorption of endotoxin.

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