*2.3.3. Prevention*

Measures for prevention of osteomyelitis are in fact those that were mentioned in Section 2.3.1 for prevention of pressure ulcer and skin and soft tissue infection. The main preventive measures are pressure relief, regular change of position, and frequent observation of the skin over bony prominences.

#### **2.4. Pneumonia**

Pulmonary complications in SCI patients are important, as they may be life threatening. Pneumonia, pulmonary infarction, pulmonary thromboembolism, chest injury, and atelectasis are the most frequent and important complications in these patients. Pneumonia is one of the most important pulmonary complications. It may have developed shortly after spinal cord injury, during hospitalization or even in rehabilitation periods. The risk of pneumonia is greater in post-injury period. In this phase, the patients usually do not have effective cough. If the phrenic and intercostal nerves have been damaged, the respiration cycle may be influenced and the patients may be prone to pneumonia [48]. After intubation and mechanical ventilation, ventilator-associated pneumonia (VAP) may develop. VAP is in fact the occurrence of pneumonia in patients with mechanical ventilation, occurring more than 48 h after endotracheal intubation [49]. VAP is the most frequent nosocomial infection in patients with mechanical ventilation and is associated with longer intensive care unit stay, longer duration of mechanical ventilation, and high morbidity and mortality [4].

#### *2.4.1. Diagnosis*

Pneumonia is diagnosed by signs and symptoms of respiratory infection and according to criteria for diagnosis of nosocomial pneumonia and VAP. By endotracheal culture, the causative organism is found and an antibiotic is chosen according to the result of culture. The most common organisms are *Pseudomonas aeruginosa*, *Klebsiella pneumonia*, *Acinetobacter baumannii* [50], *Serratia marcescens* [51] and methicillin-resistant *Staphylococcus aureus* [52]. Chest radiograph accompanied by clinical and laboratory findings are required for diagnosis of patients with suspected VAP [53].
