The incidence of bacteremia associated with emergent intubation: relevance to prophylaxis against bacterial endocarditis.
STUDY OBJECTIVE: To examine the incidence of bacteremia associated with emergent nasotracheal intubation. STUDY DESIGN: Non-randomized, controlled cohort trial during 30 minutes post-intubation with limited in-hospital follow-up. SETTING: Emergency care unit and inpatient setting of a tertiary care facility. PATIENTS: Emergency care unit patients with acute respiratory distress necessitating non-elective emergency airway placement. MEASUREMENTS AND MAIN RESULTS: We studied 84 blood cultures obtained from 21 patients intubated emergently. Fourteen patients were intubated by the nasotracheal (NT) route and seven patients were intubated orotracheally (OT) for comparison. Pre-intubation and post-intubation blood cultures were obtained at two to five, 10 to 15 and 30 minutes after intubation. Patients were excluded if they had strong clinical evidence of pre-existing bacterial infection, had received antibiotics within 48 hours of presentation or were less than 16 years of age. Of the patients that were NT intubated, 29% (4/14) of patients became bacteremic after intubation. All had negative pre-intubation cultures. Organisms isolated were nasopharyngeal florae and included: Streptococcus viridans, Veillonellae sp., aerobic diphtheroids, and other mouth florae. Of the seven patients with OT intubation, six were culture negative. One was excluded because of positive preintubation cultures secondary to urosepsis. No patients in our study developed complications that could be directly attributed to these organisms or to intubation alone. CONCLUSIONS: The risk of bacteremia associated with emergency nasotracheal intubation is substantial and is accompanied by organisms that may produce serious morbidity in the patient with valvular heart disease or compromised immunity. Our findings suggest that, whenever possible, the nasotracheal route should be avoided for emergency intubation in patients with valvular heart disease and if used, prophylactic antibiotics should be strongly considered.