Retrospective Application of New Pediatric Ventilator-Associated Pneumonia Criteria Identifies a High-Risk Population.

PubMed

Gionfriddo, Ashley; Nonoyama, Mika L; Laussen, Peter C; Cox, Peter N; Clarke, Megan; Floh, Alejandro A

2018-06-01

To promote standardization, the Centers for Disease Control and Prevention introduced a new ventilator-associated pneumonia classification, which was modified for pediatrics (pediatric ventilator-associated pneumonia according to proposed criteria [PVAP]). We evaluated the frequency of PVAP in a cohort of children diagnosed with ventilator-associated pneumonia according to traditional criteria and compared their strength of association with clinically relevant outcomes. Retrospective cohort study. Tertiary care pediatric hospital. Critically ill children (0-18 yr) diagnosed with ventilator-associated pneumonia between January 2006 and December 2015 were identified from an infection control database. Patients were excluded if on high frequency ventilation, extracorporeal membrane oxygenation, or reintubated 24 hours following extubation. None. Patients were assessed for PVAP diagnosis. Primary outcome was the proportion of subjects diagnosed with PVAP. Secondary outcomes included association with intervals of care. Two hundred seventy-seven children who had been diagnosed with ventilator-associated pneumonia were eligible for review; 46 were excluded for being ventilated under 48 hours (n = 16), on high frequency ventilation (n = 12), on extracorporeal membrane oxygenation (n = 8), ineligible bacteria isolated from culture (n = 8), and other causes (n = 4). ICU admission diagnoses included congenital heart disease (47%), neurological (16%), trauma (7%), respiratory (7%), posttransplant (4%), neuromuscular (3%), and cardiomyopathy (3%). Only 16% of subjects (n = 45) met the new PVAP definition, with 18% (n = 49) having any ventilator-associated condition. Failure to fulfill new definitions was based on inadequate increase in mean airway pressure in 90% or FIO2 in 92%. PVAP was associated with prolonged ventilation (median [interquartile range], 29 d [13-51 d] vs 16 d [8-34.5 d]; p = 0.002), ICU (median [interquartile range], 40 d [20-100 d] vs 25 d [14-61 d]; p = 0

Pathogenic Link Between Postextubation Pneumonia and Ventilator-Associated Pneumonia: An Experimental Study.

PubMed

Rezoagli, Emanuele; Zanella, Alberto; Cressoni, Massimo; De Marchi, Lorenzo; Kolobow, Theodor; Berra, Lorenzo

2017-04-01

The presence of an endotracheal tube is the main cause for developing ventilator-associated pneumonia (VAP), but pneumonia can still develop in hospitalized patients after endotracheal tube removal (postextubation pneumonia [PEP]). We hypothesized that short-term intubation (24 hours) can play a role in the pathogenesis of PEP. To test such hypothesis, we initially evaluated the occurrence of lung colonization and VAP in sheep that were intubated and mechanically ventilated for 24 hours. Subsequently, we assessed the incidence of lung colonization and PEP at 48 hours after extubation in sheep previously ventilated for 24 hours. To simulate intubated intensive care unit patients placed in semirecumbent position, 14 sheep were intubated and mechanically ventilated with the head elevated 30° above horizontal. Seven of them were euthanized after 24 hours (Control Group), whereas the remaining were euthanized after being awaken, extubated, and left spontaneously breathing for 48 hours after extubation (Awake Group). Criteria of clinical diagnosis of pneumonia were tested. Microbiological evaluation was performed on autopsy in all sheep. Only 1 sheep in the Control Group met the criteria of VAP after 24 hours of mechanical ventilation. However, heavy pathogenic bacteria colonization of trachea, bronchi, and lungs (range, 10-10 colony-forming unit [CFU]/g) was reported in 4 of 7 sheep (57%). In the Awake Group, 1 sheep was diagnosed with VAP and 3 developed PEP within 48 hours after extubation (42%), with 1 euthanized at 30 hours because of respiratory failure. On autopsy, 5 sheep (71%) confirmed pathogenic bacterial growth in the lower respiratory tract (range, 10-10 CFU/g). Twenty-four hours of intubation and mechanical ventilation in semirecumbent position leads to significant pathogenic colonization of the lower airways, which can promote the development of PEP. Strategies directed to prevent pathogenic microbiological colonization before and after mechanical

75 FR 73107 - Draft Guidance for Industry on Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-29

...] Draft Guidance for Industry on Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia: Developing Drugs for Treatment; Availability AGENCY: Food and Drug Administration, HHS. ACTION... guidance for industry entitled ``Hospital- Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial...

Adherence to the items in a bundle for the prevention of ventilator-associated pneumonia.

PubMed

Sachetti, Amanda; Rech, Viviane; Dias, Alexandre Simões; Fontana, Caroline; Barbosa, Gilberto da Luz; Schlichting, Dionara

2014-01-01

To assess adherence to a ventilator care bundle in an intensive care unit and to determine the impact of adherence on the rates of ventilator-associated pneumonia. A total of 198 beds were assessed for 60 days using a checklist that consisted of the following items: bed head elevation to 30 to 45º; position of the humidifier filter; lack of fluid in the ventilator circuit; oral hygiene; cuff pressure; and physical therapy. Next, an educational lecture was delivered, and 235 beds were assessed for the following 60 days. Data were also collected on the incidence of ventilator-acquired pneumonia. Adherence to the following ventilator care bundle items increased: bed head elevation from 18.7% to 34.5%; lack of fluid in the ventilator circuit from 55.6% to 72.8%; oral hygiene from 48.5% to 77.8%; and cuff pressure from 29.8% to 51.5%. The incidence of ventilator-associated pneumonia was statistically similar before and after intervention (p=0.389). The educational intervention performed in this study increased the adherence to the ventilator care bundle, but the incidence of ventilator-associated pneumonia did not decrease in the small sample that was assessed.

Use of elastin fibre detection in the diagnosis of ventilator associated pneumonia.

PubMed

el-Ebiary, M; Torres, A; González, J; Martos, A; Puig de la Bellacasa, J; Ferrer, M; Rodriguez-Roisin, R

1995-01-01

Elastin fibre detection could be a simple and reliable marker of ventilator associated pneumonia. To confirm this, a prospective study was undertaken to evaluate the diagnostic yield of elastin fibre detection in the diagnosis of ventilator associated pneumonia. Seventy eight mechanically ventilated patients were evaluated by examining endotracheal aspirates for the presence of elastin fibres. All patients were previously treated with antibiotics. Quantitative bacterial cultures of endotracheal aspirates and protected specimen brush samples were also performed. Patients were classified into three diagnostic categories: group 1, definite pneumonia (n = 25); group 2, probable pneumonia (n = 35); and group 3, controls (n = 18). Patients with definite and probable pneumonia were grouped together. The presence of elastin fibres in endotracheal aspirate samples was more frequent in groups 1 and 2, being found in 19 of the 60 patients compared with five of the control group. Although the presence of elastin fibres had a low sensitivity (32%), it was a reasonably specific marker (72%) of pneumonia. This specificity increased to 86% and 81% respectively when only Gram negative bacilli and Pseudomonas aeruginosa pneumonia were considered. Again, calculated sensitivity was 43% and 44% when analysing cases infected by Gram negative bacilli and Ps aeruginosa, respectively. The negative predictive value of the detection of elastin fibres in pneumonia caused by Ps aeruginosa was 81%. Detection was more frequent with infection by Gram negative bacilli (14/19), particularly with Ps aeruginosa (8/14). By contrast, pneumonia due to Gram positive cocci or non-bacterial agents uncommonly resulted in positive elastin fibre preparations (4/19, 21%). When analysing patients with and without chronic obstructive pulmonary disease, the diagnostic value of elastin fibre detection did not change. Potassium hydroxide preparation of elastin fibres is a rapid and simple specific marker of

Strategies for prevention of ventilator-associated pneumonia: bundles, devices, and medications for improved patient outcomes.

PubMed

Alroumi, Fahad; Sarwar, Akmal; Grgurich, Philip E; Lei, Yuxiu; Hudcova, Jana; Craven, Donald E

2012-02-01

Ventilator-associated pneumonia is associated with significant patient morbidity, mortality, and increased health care costs. In the current economic climate, it is crucial to implement cost-effective prevention strategies that have proven efficacy. Multiple prevention measures have been proposed by various expert panels. Global strategies have focused on infection control, and reduction of lower airway colonization with bacterial pathogens, intubation, duration of mechanical ventilation, and length of stay in the intensive care unit. Routine use of the Institute for Healthcare Improvement ventilator care bundle is widespread, and has been clearly demonstrated to be an effective method for reducing the incidence of ventilator-associated pneumonia. In this article, we examine specific aspects of the Institute for Healthcare Improvement bundle, better-designed endotracheal tubes, use of antibiotics and probiotics, and treatment of ventilator-associated tracheobronchitis to prevent ventilator-associated pneumonia.

Significance of Prior Digestive Colonization With Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Patients With Ventilator-Associated Pneumonia.

PubMed

Bruyère, Rémi; Vigneron, Clara; Bador, Julien; Aho, Serge; Toitot, Amaury; Quenot, Jean-Pierre; Prin, Sébastien; Charles, Pierre Emmanuel

2016-04-01

Ventilator-associated pneumonia is frequent in ICUs. Extended-spectrum β-lactamase-producing Enterobacteriaceae are difficult-to-treat pathogens likely to cause ventilator-associated pneumonia. We sought to assess the interest of screening for extended-spectrum β-lactamase-producing Enterobacteriaceae rectal carriage as a way to predict their involvement in ventilator-associated pneumonia. A retrospective cohort study of patients with suspected ventilator-associated pneumonia in a medical ICU was conducted. Every patient admitted between January 2006 and August 2013 was eligible if subjected to mechanical ventilation for more than 48 hours. Each patient with suspected ventilator-associated pneumonia was included in the cohort. Active surveillance culture for extended-spectrum β-lactamase-producing Enterobacteriaceae detection was routinely performed in all patients at admission and then weekly throughout the study period. Extended-spectrum β-lactamase colonization was defined by the isolation of at least one extended-spectrum β-lactamase-producing Enterobacteriaceae from rectal swab culture. None. Among 587 patients with suspected ventilator-associated pneumonia, 40 (6.8%) were colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae prior to the development of pneumonia. Over the study period, 20 patients (3.4%) had ventilator-associated pneumonia caused by extended-spectrum β-lactamase-producing Enterobacteriaceae; of whom, 17 were previously detected as being colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae. Sensitivity and specificity of prior extended-spectrum β-lactamase-producing Enterobacteriaceae colonization as a predictor of extended-spectrum β-lactamase-producing Enterobacteriaceae involvement in ventilator-associated pneumonia were 85.0% and 95.7%, respectively. The positive and negative predictive values were 41.5% and 99.4%, respectively. The positive likelihood ratio was 19.8. Screening for

Diagnosis of bacterial ventilator-associated pneumonia in children: reproducibility of blind bronchial sampling.

PubMed

Sachdev, Anil; Chugh, Krishan; Raghunathan, Veena; Gupta, Dhiren; Wattal, Chand; Menon, Geetha R

2013-01-01

To evaluate the reproducibility of blind bronchial sampling in patients with suspected diagnosis of bacterial ventilator-associated pneumonia. Prospective study. Pediatric intensive care unit of a tertiary care, multidisciplinary, teaching hospital in Northern India. All consecutive patients on mechanical ventilation for >48 hrs were evaluated clinically for ventilator-associated pneumonia. Children with clinical ventilator-associated pneumonia were subjected to blind bronchial sampling twice. Sixty-eight blind bronchial sampling samples from 34 patients were analyzed for polymorphonuclear cells, the presence, type, and number of bacteria. Acinetobacter baumannii was the most common organism grown from distal respiratory secretions. For polymorphonuclear cells, the concordance between two blind bronchial samples was 85.3% and kappa coefficient was 0.65. The concordance for the presence and type of bacteria in Gram staining in two samples was 85.3% and kappa coefficient was 0.68. The intraclass coefficients for bacterial index and predominant species index were 0.82 (95% confidence interval 0.65-0.91) and 0.89 (95% confidence interval 0.78-0.94), respectively. The use of prior antibiotics did not adversely affect the reproducibility of blind bronchial sampling. No major complications were recorded during the procedure. Blind bronchial sampling of lower respiratory tract secretions in mechanically ventilated patients generates reproducible results of quantitative and qualitative cultures. We suggest that blind bronchial sampling may provide valuable clue to the bacterial etiology in ventilated child with suspected clinical ventilator-associated pneumonia.

Ventilator-associated pneumonia improvement program.

PubMed

Murray, Theresa; Goodyear-Bruch, Caryl

2007-01-01

Ventilator-associated pneumonia (VAP) is a significant clinical problem associated with increased intensive care unit and hospital length of stay and substantial increases in delivery cost and associated morbidity and mortality. With system changes and management of the environment of care, the incidence of VAP was reduced in seven of our intensive care units across the system. Steps necessary to reduce VAP were identified and put into place in all the intensive care units. Patient positioning, oral care, nutrition, and management of comfort drugs are a few of the processes addressed to reduce VAP. Standardization of these essential care practices can reduce the incidence of this nosocomial infection and its associated increases in the cost of care delivery and mortality.

Cost of treating ventilator-associated pneumonia post cardiac surgery in the National Health Service: Results from a propensity-matched cohort study.

PubMed

Luckraz, Heyman; Manga, Na'ngono; Senanayake, Eshan L; Abdelaziz, Mahmoud; Gopal, Shameer; Charman, Susan C; Giri, Ramesh; Oppong, Raymond; Andronis, Lazaros

2018-05-01

Ventilator-associated pneumonia is associated with significant morbidity, mortality and healthcare costs. Most of the cost data that are available relate to general intensive care patients in privately remunerated institutions. This study assessed the cost of managing ventilator-associated pneumonia in a cardiac intensive care unit in the National Health Service in the United Kingdom. Propensity-matched study of prospectively collected data from the cardiac surgical database between April 2011 and December 2014 in all patients undergoing cardiac surgery (n = 3416). Patients who were diagnosed as developing ventilator-associated pneumonia, as per the surveillance definition for ventilator-associated pneumonia (n = 338), were propensity score matched with those who did not (n = 338). Costs of treating post-op cardiac surgery patients in intensive care and cost difference if ventilator-associated pneumonia occurred based on Healthcare Resource Group categories were assessed. Secondary outcomes included differences in morbidity, mortality and cardiac intensive care unit and in-hospital length of stay. There were no significant differences in the pre-operative characteristics or procedures between the groups. Ventilator-associated pneumonia developed in 10% of post-cardiac surgery patients. Post-operatively, the ventilator-associated pneumonia group required longer ventilation (p < 0.01), more respiratory support, longer cardiac intensive care unit (8 vs 3, p < 0.001) and in-hospital stay (16 vs 9) days. The overall cost for post-operative recovery after cardiac surgery for ventilator-associated pneumonia patients was £15,124 compared to £6295 for non-ventilator-associated pneumonia (p < 0.01). The additional cost of treating patients with ventilator-associated pneumonia was £8829. Ventilator-associated pneumonia was associated with significant morbidity to the patients, generating significant costs. This cost was nearer to the lower end for

Gravity predominates over ventilatory pattern in the prevention of ventilator-associated pneumonia.

PubMed

Li Bassi, Gianluigi; Marti, Joan Daniel; Saucedo, Lina; Rigol, Montserrat; Roca, Ignasi; Cabanas, Maria; Muñoz, Laura; Ranzani, Otavio Tavares; Giunta, Valeria; Luque, Nestor; Esperatti, Mariano; Gabarrus, Albert; Fernandez, Laia; Rinaudo, Mariano; Ferrer, Miguel; Ramirez, Jose; Vila, Jordi; Torres, Antoni

2014-09-01

In the semirecumbent position, gravity-dependent dissemination of pathogens has been implicated in the pathogenesis of ventilator-associated pneumonia. We compared the preventive effects of a ventilatory strategy, aimed at decreasing pulmonary aspiration and enhancing mucus clearance versus the Trendelenburg position. Prospective randomized animal study. Animal research facility, University of Barcelona, Spain. Twenty-four Large White-Landrace pigs. Pigs were intubated and on mechanical ventilation for 72 hours. Following surgical preparation, pigs were randomized to be positioned: 1) in semirecumbent/prone position, ventilated with a duty cycle (TITTOT) of 0.33 and without positive end-expiratory pressure (control); 2) as in the control group, positive end-expiratory pressure of 5 cm H2O and TITTOT to achieve a mean expiratory-inspiratory flow bias of 10 L/min (treatment); 3) in Trendelenburg/prone position and ventilated as in the control group (Trendelenburg). Following randomization, Pseudomonas aeruginosa was instilled into the oropharynx. Mucus clearance rate was measured through fluoroscopic tracking of tracheal markers. Microspheres were instilled into the subglottic trachea to assess pulmonary aspiration. Ventilator-associated pneumonia was confirmed by histological/microbiological studies. The mean expiratory-inspiratory flow in the treatment, control, and Trendelenburg groups were 10.7 ± 1.7, 1.8 ± 3.7 and 4.3 ± 2.8 L/min, respectively (p < 0.001). Mucus clearance rate was 11.3 ± 9.9 mm/min in the Trendelenburg group versus 0.1 ± 1.0 in the control and 0.2 ± 1.0 in the treatment groups (p = 0.002). In the control group, we recovered 1.35% ± 1.24% of the instilled microspheres per gram of tracheal secretions, whereas 0.22% ± 0.25% and 0.97% ± 1.44% were recovered in the treatment and Trendelenburg groups, respectively (p = 0.031). Ventilator-associated pneumonia developed in 66.67%, 85.71%, and 0% of the animals in

Ventilator-associated pneumonia in surgical emergency intensive care unit.

PubMed

Ertugrul, Bulent M; Yildirim, Ayse; Ay, Pinar; Oncu, Serkan; Cagatay, Atahan; Cakar, Nahit; Ertekin, Cemalettin; Ozsut, Halit; Eraksoy, Haluk; Calangu, Semra

2006-01-01

To investigate the incidence, risk factors and the etiology of ventilator-associated pneumonia (VAP) in surgical emergency intensive care unit (ICU) patients. We conducted this prospective cohort study in the surgical emergency ICU of Istanbul Medical Faculty between December 1999 and May 2001. We included 100 mechanically ventilated patients in this study. We diagnosed VAP according to the current diagnostic criteria. We identified the etiology of VAP cases by both quantitative cultures of endotracheal aspiration and blood cultures. To analyze the predisposing factors for the development of VAP, we recorded the following variables: age, gender, acute physiology and chronic health evaluation (APACHE) II score, Glasgow coma scale (GCS), sequential organ failure assessment (SOFA) score, serum albumin level, duration of mechanical ventilation (MV) prior to the development of VAP, and underlying diseases. We determined the VAP incidence rate as 28%. We found the APACHE II score and the duration of MV to be statistically significant variables for the development of VAP. There were no significant differences regarding age, gender, GCS, SOFA score, albumin level, or underlying diseases for the development of VAP. The isolated bacteria among VAP cases were as follows: Staphylococcus aureus (n=12, 43%), Acinetobacter spp. (n=6, 21%), coagulase-negative Staphylococci (n=4, 15%), Pseudomonas aeruginosa (n=3, 10.7%) and Klebsiella pneumoniae (n=3, 10.7%). Ventilator-associated pneumonia is a common infection, and certain interventions might affect the incidence of VAP. The ICU clinicians should be aware of the risk factors for VAP, which could prove useful in identifying patients at high risk for VAP, and modifying patient care to minimize the risk of VAP.

Patient positioning and ventilator-associated pneumonia.

PubMed

Hess, Dean R

2005-07-01

Rotational beds, prone position, and semi-recumbent position have been proposed as procedures to prevent ventilator-associated pneumonia (VAP). Rotational therapy uses a special bed designed to turn continuously, or nearly continuously, the patient from side to side; specific designs include kinetic therapy and continuous lateral rotation therapy. A meta-analysis of studies evaluating the effect of rotational bed therapy shows a decrease in the risk of pneumonia but no effect on mortality. Two studies reported a lower risk of VAP in patients placed in a prone position, with no effect on mortality. Studies using radiolabeled enteral feeding solutions in mechanically ventilated patients have reported that aspiration of gastric contents occurs to a greater degree when patients are in the supine position, compared with the semirecumbent position. One study reported a lower rate of VAP in patients randomized to semi-recumbent compared to supine position. Although each of the techniques discussed in this paper has been shown to reduce the risk of VAP, none has been shown to affect mortality. The available evidence suggests that semi-recumbent position should be used routinely, rotational therapy should be considered in selected patients, and prone position should not be used as a technique to reduce the risk of VAP.

Ventilator-associated pneumonia management in critical illness.

PubMed

Albertos, Raquel; Caralt, Berta; Rello, Jordi

2011-03-01

Ventilator-associated pneumonia (VAP) is a frequent adverse event in the intensive care unit.We review recent publications about the management and prevention of VAP. The latest care bundles introduced standard interventions to facilitate implementation of evidence-based clinical guidelines and to improve the outcome of patients. Recent studies find that prevention management of ventilated patients decreases the risk of VAP. Enteral feeding, considered a risk factor for VAP, currently has been recommended, with appropriate administration, for all critical ill patients if no contraindications exist. In view of the recently available data, it can be concluded that the implementation of care bundles on the general management of ventilated patients in daily practice has reduced the VAP rates. The main pharmacological measures to prevent VAP are proper hands hygiene, high nurse-to-patient ratio, avoid unnecessary transfer of ventilated patients, use of noninvasive mechanical ventilation, shortening weaning period, avoid the use of nasal intubation, prevent bio-film deposition in endotracheal tube, aspiration of subglottic secretions, maintenance of adequate pressure of endotracheal cuffs, avoid manipulation of ventilator circuits, semi-recumbent position and adequate enteral feeding.In addition, updated guidelines incorporate more comprehensive diagnostic protocols to the evidence-based management of VAP.

[Role of plasma procalcitonin in the diagnosis of ventilator-associated pneumonia: systematic review and metaanalysis].

PubMed

Sotillo-Díaz, J C; Bermejo-López, E; García-Olivares, P; Peral-Gutiérrez, J A; Sancho-González, M; Guerrero-Sanz, J E

2014-01-01

To determine the role of plasma procalcitonin (PCT) levels in diagnosing ventilator-associated pneumonia. A systematic review of publications prospectively assessing the diagnostic role of PCT in ventilator-associated pneumonia was carried out. The search was performed using Medline, Embase, the Cochrane Collaboration and MEDION, with reviewing of the references of retrieved articles. We extracted data that allowed the calculation of sensitivity, specificity, likelihood ratios and diagnostic odds ratio. Intervention Metaregression was performed to determine whether exposure to previous antibiotic treatment, the time to occurrence of ventilator-associated pneumonia and the type of patients had an impact upon the diagnostic performance of procalcitonin. Seven studies were considered (373 patients, 434 episodes). We found no publication bias or threshold effect. High plasma PCT levels were associated to an increased risk of suffering ventilator-associated pneumonia (OR: 8.39; 95% CI: 5.4-12.6). The pooled data on sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio found were 76% (69-82), 79% (74-84), 4.35 (2.48-7.62), 0.26 (0.15-0.46) and 17.9 (10.1-31.7), respectively. Diagnostic yield was modified by prior exposure to antibiotics (rDOR 0.11, 0.02-0.069), but not by the type of critically ill patient or the time to occurrence of ventilator-associated pneumonia. Our results suggest that PCT provides additional information on the risk of VAP. Inclusion of PCT in diagnostic algorithms could improve their effectiveness. Copyright © 2013 Elsevier España, S.L. and SEMICYUC. All rights reserved.

Ventilator-associated pneumonia, like real estate: location really matters.

PubMed

Eckert, Matthew J; Davis, Kimberly A; Reed, R Lawrence; Esposito, Thomas J; Santaniello, John M; Poulakidas, Stathis; Gamelli, Richard L; Luchette, Fred A

2006-01-01

Previous work has demonstrated an increased risk of ventilator-associated pneumonia (VAP) in trauma patients after prehospital (field) intubation as compared with emergency department (ED) intubations. However, this population was not compared with patients intubated as inpatients, making data interpretation difficult. We sought to further examine predictors for the development of VAP after trauma. A 10-year retrospective review of all patients mechanically ventilated greater than 24 hours after injury was performed. In all, 1,628 patients were identified, of which 1,213 (75%) were intubated as inpatients and 415 were emergently intubated (353 ED, 62 field). Overall, those intubated emergently were younger (p = 0.03) and less injured as seen by higher Glasgow Coma Scale scores (p = 0.0002), lower Injury Severity Scores (p = 0.01) and higher Revised Trauma Scores (p < 0.0001). Despite a lower injury severity, those patients emergently intubated were more likely to develop pneumonia as 22% of ED intubations and 15% of field intubations developed pneumonia, as compared with the inpatient rate of 6.5%. Pneumonia after field intubation was more likely to be community-acquired (p < 0.0001) with a significantly lower percentage of infecting enteric gram-negative rods (p < 0.0001) as compared with the inpatient and ED groups. Forward logistic regression analysis (with VAP = 1) identified inpatient intubation as protective against VAP (odds ratio 0.28, 95% CI = 0.2-0.4). Backwards logistic regression analysis further identified both field airway (odds ratio 2.29, 95% CI = 1.1-4.9) and ED airway (odds ratio 3.61, 95% CI = 2.5-5.2) as predictive of VAP. Compared with a population of trauma patients as inpatients, and excluding those patients mechanically ventilated less than 24 hours, patients intubated in the ED or field have a higher incidence of pneumonia, despite equivalent or lower injury severity.

The barriers to the prevention of ventilator-associated pneumonia from the perspective of critical care nurses: A qualitative descriptive study.

PubMed

Atashi, Vajihe; Yousefi, Hojatollah; Mahjobipoor, Hosein; Yazdannik, Ahmadreza

2018-03-01

The aim of this study was to explore the perspectives of Iranian critical care nurses on the barriers to ventilator-associated pneumonia prevention in intensive care units. Most patients hospitalized in intensive care units need mechanical ventilation. One of the most prevalent and serious complications of mechanical ventilation is ventilator-associated pneumonia. There are different barriers to the prevention of this kind of pneumonia. Qualitative descriptive design was used. In this qualitative study, 23 critical care nurses were recruited via purposive sampling. Semi-structured interviews were done for data collection. The interviews were recorded digitally, transcribed word by word, and analyzed using the inductive content analysis approach. The barriers to the prevention of ventilator-associated pneumonia fell into three main categories, namely nurses' limited professional competence, unfavorable environmental conditions, and passive human resource management. The 10 subcategories of these main categories were unfavorable professional attitude, limited professional knowledge, low job motivation, limited professional accountability, non-standard physical structure, inadequate or inappropriate equipment, heavy workload, staff shortage, inadequate staff training, and ineffective supervision. The barriers to the prevention of ventilator-associated pneumonia in intensive care units are very diverse and complex and include a wide range of interrelated personal, environmental, and organizational barriers. This study created a better understanding of the barriers to ventilator-associated pneumonia prevention. Moreover, highlighted the importance of sufficient resources, adequate staffing level, and contextually-appropriate evidence-based guidelines for effective ventilator-associated pneumonia prevention. © 2017 John Wiley & Sons Ltd.

A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting

PubMed Central

2012-01-01

Background Ventilator-associated pneumonia (VAP) is a common infection in the intensive care unit (ICU) and associated with a high mortality. Methods A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed from October 2008 to December 2010. All of these processes, including the Institute for Healthcare Improvement’s (IHI) ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions (CASS), were adopted for patients undergoing mechanical ventilation. Results We evaluated a total of 21,984 patient-days, and a total of 6,052 ventilator-days (ventilator utilization rate of 0.27). We found VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero incidence of VAP several times during 12 months, whenever VAP bundle compliance was over 90%. Conclusion These results suggest that it is possible to reduce VAP rates to near zero and sustain these rates, but it requires a complex process involving multiple performance measures and interventions that must be permanently monitored. PMID:23020101

Ventilator associated pneumonia: risk factors and preventive measures.

PubMed

Vincent, J L; Lobo, S; Struelens, M

2001-11-01

Ventilator-associated pneumonia (VAP) is a common nosocomial infection associated with considerable morbidity and mortality. Various risk factors for VAP have been identified and include the duration of ICU stay and of mechanical ventilation, a diagnosis of trauma, and severity of illness. Knowledge of these factors can promote early diagnosis and hence treatment. In addition to simple, but very effective, basic hygiene, different preventative strategies have been suggested, and can be divided into those that aim to limit airway colonization, and those that improve host defense mechanisms. Of the former, non-invasive ventilation is effective but not always applicable or available, nursing the patient in the semi-recumbent position is also associated with a reduced incidence of VAP but carries its own problems, stress ulcer prophylaxis remains controversial, and selective digestive decontamination is probably only relevant to certain subgroups of patients. Methods to improve host defense include early nutrition. Immunostimulatory therapies, such as interferon and granulocyte colony stimulating factor, require further research to confirm their place in the prevention or management of VAP.

Histopathology of ventilator-associated pneumonia (VAP) and its clinical implications.

PubMed

Torres, A; Fábregas, N; Arce, Y; López-Boado, M A

1999-01-01

Ventilator-associated pneumonia (VAP) is a diffuse polymicrobial and dynamic process, with heterogeneous distribution of lesions, showing different degrees of histological evolution predominating in the dependent lung zones, in which microbiology and histology can be dissociated. This might explain why blind endobronchial techniques to collect respiratory secretions have similar accuracy compared to visually guided samples, explaining the difficulties in validating any methods for its diagnosis. In the clinical setting the association of acute lung injury (ALI) and pneumonia is controversial. However, it is rare to detect diffuse alveolar damage (DAD) in absence of histological signs of pneumonia, probably evidencing that ALI favors the development of pneumonia. Histopathologically, it is difficult to distinguish initial and resolution phases of DAD from pneumonia and vice versa. On the other hand, there is a clear relationship between antimicrobial treatment and the decreased lung bacterial burden which strengthens the importance of distal airway sampling before starting antibiotic therapy.

Prevention of ventilator-associated pneumonia through aspiration of subglottic secretions: a systematic review and meta-analysis.

PubMed

Leasure, A Renee; Stirlen, Joan; Lu, Shu Hua

2012-01-01

Ventilator-associated pneumonia (VAP) is a subset of hospital-acquired pneumonias and is a serious, sometimes fatal, complication in patients who need mechanical ventilation. In addition, pay-for-performance initiative has placed increased emphasis on preventing nosocomial infections including VAP. Facilities may not be reimbursed for costs associated with prevalence infections. This article presents a review and meta-analysis of the prevention of VAP through the aspiration of subglottic secretion.

Ventilator-associated pneumonia: the influence of bacterial resistance, prescription errors, and de-escalation of antimicrobial therapy on mortality rates.

PubMed

Souza-Oliveira, Ana Carolina; Cunha, Thúlio Marquez; Passos, Liliane Barbosa da Silva; Lopes, Gustavo Camargo; Gomes, Fabiola Alves; Röder, Denise Von Dolinger de Brito

2016-01-01

Ventilator-associated pneumonia is the most prevalent nosocomial infection in intensive care units and is associated with high mortality rates (14-70%). This study evaluated factors influencing mortality of patients with Ventilator-associated pneumonia (VAP), including bacterial resistance, prescription errors, and de-escalation of antibiotic therapy. This retrospective study included 120 cases of Ventilator-associated pneumonia admitted to the adult adult intensive care unit of the Federal University of Uberlândia. The chi-square test was used to compare qualitative variables. Student's t-test was used for quantitative variables and multiple logistic regression analysis to identify independent predictors of mortality. De-escalation of antibiotic therapy and resistant bacteria did not influence mortality. Mortality was 4 times and 3 times higher, respectively, in patients who received an inappropriate antibiotic loading dose and in patients whose antibiotic dose was not adjusted for renal function. Multiple logistic regression analysis revealed the incorrect adjustment for renal function was the only independent factor associated with increased mortality. Prescription errors influenced mortality of patients with Ventilator-associated pneumonia, underscoring the challenge of proper Ventilator-associated pneumonia treatment, which requires continuous reevaluation to ensure that clinical response to therapy meets expectations. Copyright © 2016. Published by Elsevier Editora Ltda.

The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study.

PubMed

Eom, Joong Sik; Lee, Mi-Suk; Chun, Hee-Kyung; Choi, Hee Jung; Jung, Sun-Young; Kim, Yeon-Sook; Yoon, Seon Jin; Kwak, Yee Gyung; Oh, Gang-Bok; Jeon, Min-Hyok; Park, Sun-Young; Koo, Hyun-Sook; Ju, Young-Su; Lee, Jin Seo

2014-01-01

For prevention of ventilator-associated pneumonia (VAP), a bundle approach was applied to patients receiving mechanical ventilation in intensive care units. The incidence of VAP and the preventive efficacy of the VAP bundle were investigated. A quasi-experimental study was conducted in adult intensive care units of 6 university hospitals with similar VAP rates. We implemented the VAP bundle between March 2011 and June 2011, then compared the rate of VAP after implementation of the VAP bundle with the rate in the previous 8 months. Our ventilator bundle included head of bed elevation, peptic ulcer disease prophylaxis, deep venous thrombosis prophylaxis, and oral decontamination with chlorhexidine 0.12%. Continuous aspiration of subglottic secretions was an option. Implementation of the VAP bundle reduced the VAP rate from a mean of 4.08 cases per 1,000 ventilator-days to 1.16 cases per 1,000 ventilator-days. The incidence density ratio (rate) was 0.28 (95% confidence interval, 0.275-0.292). Implementing the appropriate VAP bundle significantly decreased the incidence of VAP in patients with mechanical ventilation. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

Aspiration and the risk of ventilator-associated pneumonia.

PubMed

Parker, Chris M; Heyland, Daren K

2004-12-01

Ventilator-associated pneumonia (VAP) is a major concern in the intensive care unit. It is estimated that the risk of developing VAP may be as high as 1% per ventilated day, and the attributable mortality approaches 50% in some series. A growing body of evidence implicates the role of microaspiration of contaminated oropharyngeal and perhaps gastroesophageal secretions into the airways as an integral step in the pathogenesis of VAP. In patients who have been intubated and mechanically ventilated for >72 hours, the majority of VAP is caused by enteric gram-negative organisms, presumably of gastrointestinal origin. As a result, strategies designed to minimize the risk of these contaminated secretions into the normally sterile airways are of paramount importance in terms of VAP prevention. This review highlights the important etiological role of the gut in the development of VAP and also discusses the evidence behind interventions that may modulate the risk of both aspiration and subsequent VAP.

Bundles to prevent ventilator-associated pneumonia: how valuable are they?

PubMed

Wip, Charity; Napolitano, Lena

2009-04-01

To review the value of care bundles to prevent ventilator-associated pneumonia (VAP). The Ventilator Bundle contains four components, elevation of the head of the bed to 30-45 degrees, daily 'sedation vacation' and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep venous thrombosis prophylaxis, aimed to improve outcome in mechanically ventilated patients, but not all are associated with VAP prevention. Daily spontaneous awakening and breathing trials are associated with early liberation from mechanical ventilation and VAP reduction. Although a small prospective, randomized clinical study documented that the semirecumbent position was associated with a significant reduction in VAP, more recent studies have documented that the semirecumbent position is difficult to maintain in mechanically ventilated patients and may not impact VAP reduction. Prophylaxis for peptic ulcer disease and deep venous thrombosis do not directly impact VAP reduction. Other methods to reduce VAP, such as oral care and hygiene, chlorhexidine in the posterior pharynx, and specialized endotracheal tubes (continuous aspiration of subglottic secretions, silver-coated), should be considered for inclusion in a revised Ventilator Bundle more specifically aimed at VAP prevention. The Ventilator Bundle is an effective method to reduce VAP rates in ICUs. The ventilator bundle should be modified and expanded to include specific processes of care that have been definitively demonstrated to be effective in VAP reduction or a specific VAP bundle created to focus on VAP prevention.

Ventilator-associated pneumonia: the importance of oral care in intubated adults.

PubMed

Stonecypher, Karen

2010-01-01

Ventilator-associated pneumonia (VAP) occurs within 24 hours of intubation and mechanical ventilation. Health care costs related to increased patient mortality, extended length of stay, and patient well-being make treatment of VAP a priority in all health care settings. The Institute for Healthcare Improvements has developed the Ventilator Bundle as a group of interventions linked to ventilator care with demonstrated outcome improvements; removal of subglottic secretions is one of these recommendations. Dental plaque and bacterial colonization of pathogens is directly related to microaspiration of bacteria into the lungs. A moist environment in the mouth maintains normal oropharyngeal bacteria, preventing overgrowth of pathogenic bacteria. Frequent oral care to include twice-a-day brushing of the teeth found a 69% reduction in respiratory tract infections.

Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit.

PubMed

Blamoun, John; Alfakir, Maria; Rella, Marie E; Wojcik, Janice M; Solis, Roberto A; Anees Khan, M; DeBari, Vincent A

2009-03-01

The ventilator bundle (VB) includes a group of clinical maneuvers (head-of-bed elevation, "sedation vacation," deep vein thrombosis prophylaxis, and peptic ulcer disease prophylaxis) to improve outcomes in patients undergoing mechanical ventilation. We modified the standard VB in our medical intensive care unit to include a group of respiratory therapist-driven protocols and, postimplementation, observed a statistically significant (P = .0006) reduction in ventilator-associated pneumonia (VAP), from a median of 14.1 cases/10(3) ventilator-days (interquartile range [IQR] = 12.1 to 20.6) to 0 cases/10(3) ventilator-days (IQR = 0 to 1.1).

Stomach as a source of colonization of the respiratory tract during mechanical ventilation: association with ventilator-associated pneumonia.

PubMed

Torres, A; El-Ebiary, M; Soler, N; Montón, C; Fàbregas, N; Hernández, C

1996-08-01

The aetiopathogenesis of ventilator-associated pneumonia (VAP) requires abnormal oropharyngeal and gastric colonization and the further aspiration of their contents to the lower airways. VAP develops easily if aspiration or inoculation of microorganisms occur in patients with artificial airways, in whom mechanical, cellular and/or humoral defences are altered. Well-known risk factors for gastric colonization include: alterations in gastric juice secretion; alkalinization of gastric contents; administration of enteral nutrition; and the presence of bilirubin. However, the role of the colonized gastric reservoir in the development of VAP remains debatable. Evidence in favour of the role of the stomach in the development of VAP comes mainly from randomized, controlled trials of selective gut decontamination and stress ulcer prophylaxis in the intensive care unit (ICU), in which reducing the bacterial burden of the stomach decreases the incidence of nosocomial respiratory infections. However, at least three studies of flora have found an absence of stomach origin of pneumonia occurring during mechanical ventilation. Prophylactic measures suggested to prevent VAP in relation to the gastric reservoir include: treatment for stress ulcers with sucralfate; prevention of duodenal reflux with metoclopramide; reduction of gastric burden and bacterial translocation by selective digestive decontamination; acidification of enteral feeding; and jejunal feeding. Gastro-oesophageal reflux can be prevented by using small bore nasogastric tubes and jejunal feeding. The aspiration of gastric contents can be reduced by positioning patients in a semirecumbent position, checking the patency of the tube cuff, and aspiration of subglottic secretions. The role of the stomach as a reservoir for microorganisms causing ventilator-associated pneumonia is still controversial but despite the debate, there is major evidence in the literature in favour of the gastric origin of part of these

[Diagnostic value of quantitative cultures of endotracheal aspirate in ventilator-associated pneumonia: a multicenter study].

PubMed

Valencia Arango, M; Torres Martí, A; Insausti Ordeñana, J; Alvarez Lerma, F; Carrasco Joaquinet, N; Herranz Casado, M; Tirapu León, J P

2003-09-01

To study the validity of quantitative cultures of tracheal aspirate (TA) in comparison with the plugged telescoping catheter (PTC) for the diagnosis of mechanical ventilator-associated pneumonia. Prospective multicenter study enrolling patients undergoing mechanical ventilation for longer than 72 hours. TA samples were collected from patients with suspected ventilator-associated pneumonia, followed by PTC sampling. Quantitative cultures were performed on all samples. Patients were classified according to the presence or not of pneumonia, based on clinical and radiologic criteria, clinical course and autopsy findings. The cutoff points were > or = 103 colony-forming units (cfu)/mL for PTC cultures; the TA cutoffs analyzed were > or = 105 and > or = 106 cfu/mL. Of the 120 patients studied, 84 had diagnoses of pneumonia and 36 did not (controls). The sensitivity values for TA > or = 106, TA > or = 105, and PTC, respectively, were 54% (95% confidence interval [CI], 42%-64%), 71% (95% CI, 60%-81%), and 68% (95% CI, 57%-78%). The specificity values were 75% (95% CI, 58%-88%), 58% (95% CI, 41%-74%), and 75% (95% CI, 58%-88%), respectively. Staphylococcus aureus was the microorganism most frequently isolated in both TA and PTC samples, followed in frequency by Pseudomomonas aeruginosa in TA samples and Haemophilus influenzae in PTC samples. No significant differences were found between the sensitivity of TA > or = 105 and that of PTC, nor between the specificities of TA > or = 106 and PTC. No differences in the specificities of PTC and TA were found when a TA cutoff of > or = 106 cfu/ml was used. Moreover, at a cutoff of > or = 105 the sensitivity of TA was not statistically different from that of PTC. Quantitative cultures of TA can be considered acceptable for the diagnosis of ventilator-associated pneumonia.

Ventilator-associated pneumonia: a review.

PubMed

Ashraf, Madiha; Ostrosky-Zeichner, Luis

2012-02-01

Ventilator-associated pneumonia (VAP) is the most common infection seen in intensive care units (ICUs); it accounts for one-fourth of the infections occurring in critically ill patients and is the reason for half of antibiotic prescriptions in mechanically ventilated patients. In addition to being a financial burden on ICUs, it continues to contribute significantly to the morbidity and mortality of ICU patients, with an estimated attributable mortality rate of 8% to 15%. While the pathophysiology of VAP remains relatively unchanged, diagnostic techniques and preventive measures are constantly evolving. The focus of this article is on recent trends in VAP epidemiology, modifiable risk factors, diagnostic techniques, challenges in management, and current data on the prevention of VAP. Important messages that the reader should take away include: 1) There is no gold standard for the diagnosis of VAP; whenever VAP is suspected, if feasible, a quantitative culture should be obtained by invasive or noninvasive methods (whichever is more readily available before initiation of antibiotics); 2) Suspicion based on clinical features should prompt the initiation of a broad spectrum of antibiotics depending on suspected pathogens; 3) Close attention should be paid to de-escalation of antibiotics once microbiological results become available or as the patient starts responding clinically; the ideal duration of treatment should be 8 days instead of the conventional 10 to 14 days, except in situations where Pseudomonas may be suspected or the patient's comorbidities dictate otherwise; and 4) Prevention remains the key to reducing the burden of VAP. We promote the proven preventive measures of using noninvasive ventilation when possible, semirecumbent patient positioning, continuous aspiration of subglottic secretions, and oral chlorhexidine washes along with stress ulcer prophylaxis only after careful assessment of the risks versus benefits.

Comparison between a clinical diagnosis method and the surveillance technique of the Center for Disease Control and Prevention for identification of mechanical ventilator-associated pneumonia.

PubMed

Waltrick, Renata; Possamai, Dimitri Sauter; de Aguiar, Fernanda Perito; Dadam, Micheli; de Souza Filho, Valmir João; Ramos, Lucas Rocker; Laurett, Renata da Silva; Fujiwara, Kênia; Caldeira Filho, Milton; Koenig, Álvaro; Westphal, Glauco Adrieno

2015-01-01

>To evaluate the agreement between a new epidemiological surveillance method of the Center for Disease Control and Prevention and the clinical pulmonary infection score for mechanical ventilator-associated pneumonia detection. This was a prospective cohort study that evaluated patients in the intensive care units of two hospitals who were intubated for more than 48 hours between August 2013 and June 2014. Patients were evaluated daily by physical therapist using the clinical pulmonary infection score. A nurse independently applied the new surveillance method proposed by the Center for Disease Control and Prevention. The diagnostic agreement between the methods was evaluated. A clinical pulmonary infection score of ≥ 7 indicated a clinical diagnosis of mechanical ventilator-associated pneumonia, and the association of a clinical pulmonary infection score ≥ 7 with an isolated semiquantitative culture consisting of ≥ 104 colony-forming units indicated a definitive diagnosis. Of the 801 patients admitted to the intensive care units, 198 required mechanical ventilation. Of these, 168 were intubated for more than 48 hours. A total of 18 (10.7%) cases of mechanical ventilation-associated infectious conditions were identified, 14 (8.3%) of which exhibited possible or probable mechanical ventilator-associated pneumonia, which represented 35% (14/38) of mechanical ventilator-associated pneumonia cases. The Center for Disease Control and Prevention method identified cases of mechanical ventilator-associated pneumonia with a sensitivity of 0.37, specificity of 1.0, positive predictive value of 1.0, and negative predictive value of 0.84. The differences resulted in discrepancies in the mechanical ventilator-associated pneumonia incidence density (CDC, 5.2/1000 days of mechanical ventilation; clinical pulmonary infection score ≥ 7, 13.1/1000 days of mechanical ventilation). The Center for Disease Control and Prevention method failed to detect mechanical ventilator-associated

Ultra-Short-Course Antibiotics for Patients With Suspected Ventilator-Associated Pneumonia but Minimal and Stable Ventilator Settings.

PubMed

Klompas, Michael; Li, Lingling; Menchaca, John T; Gruber, Susan

2017-04-01

Many patients started on antibiotics for possible ventilator-associated pneumonia (VAP) do not have pneumonia. Patients with minimal and stable ventilator settings may be suitable candidates for early antibiotic discontinuation. We compared outcomes among patients with suspected VAP but minimal and stable ventilator settings treated with 1-3 days vs >3 days of antibiotics. We identified consecutive adult patients started on antibiotics for possible VAP with daily minimum positive end-expiratory pressure of ≤5 cm H2O and fraction of inspired oxygen ≤40% for at least 3 days within a large tertiary care hospital between 2006 and 2014. We compared time to extubation alive vs ventilator death and time to hospital discharge alive vs hospital death using competing risks models among patients prescribed 1-3 days vs >3 days of antibiotics. All models were adjusted for patient demographics, comorbidities, severity of illness, clinical signs of infection, and pathogens. There were 1290 eligible patients, 259 treated for 1-3 days and 1031 treated for >3 days. The 2 groups had similar demographics, comorbidities, and clinical signs. There were no significant differences between groups in time to extubation alive (hazard ratio [HR], 1.16 for short- vs long-course treatment; 95% confidence interval [CI], .98-1.36), ventilator death (HR, 0.82 [95% CI, .55-1.22]), time to hospital discharge alive (HR, 1.07 [95% CI, .91-1.26]), or hospital death (HR, 0.99 [95% CI, .75-1.31]). Very short antibiotic courses (1-3 days) were associated with outcomes similar to longer courses (>3 days) in patients with suspected VAP but minimal and stable ventilator settings. Assessing serial ventilator settings may help clinicians identify candidates for early antibiotic discontinuation. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.

Quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia.

PubMed

el-Ebiary, M; Torres, A; González, J; de la Bellacasa, J P; García, C; Jiménez de Anta, M T; Ferrer, M; Rodriguez-Roisin, R

1993-12-01

Bronchoalveolar lavage (BAL) and protected specimen brushing (PSB) are the most commonly used methods for diagnosing ventilator-associated (VA) pneumonia although they require bronchoscopy. Endotracheal aspiration (EA) is a simple and less costly technique than PSB or BAL. The purpose of our study was to investigate the diagnostic value of EA quantitative cultures and to compare the results obtained using EA with those obtained using PSB and BAL in mechanically ventilated patients with or without pneumonia. We prospectively studied 102 intubated patients divided into three diagnostic categories: Group I (definite pneumonia, n = 26), Group II (uncertain status, n = 48), and Group III (control group, n = 28). All patients received prior antibiotic treatment. EA, PSB, and BAL were obtained sequentially in all patients. When comparing Group I with Group III and using 10(5) cfu/ml as a threshold, we found that EA quantitative cultures represented a relatively sensitive (70%) and relatively specific (72%) method to diagnose VA pneumonia. The specificity of BAL and PSB (87% and 93%, respectively) was better than that of EA. The negative predictive value of EA cultures was higher (72%) when compared with that obtained using PSB (34%) (p < 0.05). EA quantitative cultures correlated with PSB and BAL quantitative cultures in patients with definite pneumonia. Although EA quantitative cultures are less specific than PSB and BAL for diagnosing VA pneumonia, our results suggest that the former approach may be used to treat these patients when bronchoscopic procedures are not available.

Antibiotic therapy in ventilator-associated tracheobronchitis: a literature review.

PubMed

Alves, Abel Eduardo; Pereira, José Manuel

2018-03-01

The concept of ventilator-associated tracheobronchitis is controversial; its definition is not unanimously accepted and often overlaps with ventilator-associated pneumonia. Ventilator-associated tracheobronchitis has an incidence similar to that of ventilator-associated pneumonia, with a high prevalence of isolated multiresistant agents, resulting in an increase in the time of mechanical ventilation and hospitalization but without an impact on mortality. The performance of quantitative cultures may allow better diagnostic definition of tracheobronchitis associated with mechanical ventilation, possibly avoiding the overdiagnosis of this condition. One of the major difficulties in differentiating between ventilator-associated tracheobronchitis and ventilator-associated pneumonia is the exclusion of a pulmonary infiltrate by chest radiography; thoracic computed tomography, thoracic ultrasonography, or invasive specimen collection may also be required. The institution of systemic antibiotic therapy does not improve the clinical impact of ventilator-associated tracheobronchitis, particularly in reducing time of mechanical ventilation, hospitalization or mortality, despite the possible reduced progression to ventilator-associated pneumonia. However, there are doubts regarding the methodology used. Thus, considering the high prevalence of tracheobronchitis associated with mechanical ventilation, routine treatment of this condition would result in high antibiotic usage without clear benefits. However, we suggest the institution of antibiotic therapy in patients with tracheobronchitis associated with mechanical ventilation and septic shock and/or worsening of oxygenation, and other auxiliary diagnostic tests should be simultaneously performed to exclude ventilator-associated pneumonia. This review provides a better understanding of the differentiation between tracheobronchitis associated with mechanical ventilation and pneumonia associated with mechanical ventilation, which

Amoeba-Resisting Bacteria and Ventilator-Associated Pneumonia

PubMed Central

La Scola, Bernard; Boyadjiev, Ioanna; Greub, Gilbert; Khamis, Atieh; Martin, Claude

2003-01-01

To evaluate the role of amoeba-associated bacteria as agents of ventilator-associated pneumonia (VAP), we tested the water from an intensive care unit (ICU) every week for 6 months for such bacteria isolates; serum samples and bronchoalveolar lavage samples (BAL) were also obtained from 30 ICU patients. BAL samples were examined for amoeba-associated bacteria DNA by suicide-polymerase chain reaction, and serum samples were tested against ICU amoeba-associated bacteria. A total of 310 amoeba-associated bacteria from10 species were isolated. Twelve of 30 serum samples seroconverted to one amoeba-associated bacterium isolated in the ICU, mainly Legionella anisa and Bosea massiliensis, the most common isolates from water (p=0.021). Amoeba-associated bacteria DNA was detected in BAL samples from two patients whose samples later seroconverted. Seroconversion was significantly associated with VAP and systemic inflammatory response syndrome, especially in patients for whom no etiologic agent was found by usual microbiologic investigations. Amoeba-associated bacteria might be a cause of VAP in ICUs, especially when microbiologic investigations are negative. PMID:12890321

Ventilator-associated nosocomial pneumonia in intensive care units in Malaysia.

PubMed

Gopal Katherason, Supaletchimi; Naing, Lin; Jaalam, Kamarudin; Imran Musa, Kamarul; Nik Mohamad, Nik Abdullah; Aiyar, Subramaniar; Bhojani, Kavita; Harussani, Najah; Abdul Rahman, Aisai; Ismail, Asma

2009-10-22

The outcome indicator of nosocomial infection (NI) in the intensive care unit (ICU) is used to benchmark the quality of patient care in Malaysia. We conducted a three-year prospective study on the incidences of ventilator-associated pneumonia (VAP), risk factors, and patterns of the microorganisms isolated in three ICUs. A follow-up in prospective cohort surveillance was conducted on patients admitted to an adult medical-surgical ICU of a university hospital and two governmental hospitals in Malaysia from October 2003 to December 2006. VAP was detected using CDC criteria which included clinical manifestation and confirmed endotracheal secretion culture results. In total, 215 patients (2,306 patient-days) were enrolled into the study. The incidence of ICU-acquired device-related NI was 29.3 % (n = 63). The device-related VAP infection rate was 27.0 % (n = 58), with a mechanical ventilator utilization rate of 88.7%. The death rate due to all ICU-acquired NI including sepsis was 6.5%. The most common causative pathogen was Klebsiella pneumoniae (n = 27). Multivariate analysis using Cox regression showed that the risk factors identified were aspiration pneumonia (HR = 4.09; 95% CI = 1.24, 13.51; P = 0.021), cancer (HR = 2.51; 95% CI = 1.27, 4.97; P = 0.008), leucocytosis (HR=3.43; 95% CI= 1.60, 7.37; P=0.002) and duration of mechanical ventilation (HR=1.04; 95% CI = 1.00, 1.08; P = 0.030). Age, gender and race were not identified as risk factors in the multivariable analysis performed. The incidence of VAP was comparable to that found in the National Nosocomial Infection Surveillance (NNIS) System report of June 1998. The incidence of VAP was considered high for the three hospitals studied.

Prevalence and test characteristics of national health safety network ventilator-associated events.

PubMed

Lilly, Craig M; Landry, Karen E; Sood, Rahul N; Dunnington, Cheryl H; Ellison, Richard T; Bagley, Peter H; Baker, Stephen P; Cody, Shawn; Irwin, Richard S

2014-09-01

The primary aim of the study was to measure the test characteristics of the National Health Safety Network ventilator-associated event/ventilator-associated condition constructs for detecting ventilator-associated pneumonia. Its secondary aims were to report the clinical features of patients with National Health Safety Network ventilator-associated event/ventilator-associated condition, measure costs of surveillance, and its susceptibility to manipulation. Prospective cohort study. Two inpatient campuses of an academic medical center. Eight thousand four hundred eight mechanically ventilated adults discharged from an ICU. None. The National Health Safety Network ventilator-associated event/ventilator-associated condition constructs detected less than a third of ventilator-associated pneumonia cases with a sensitivity of 0.325 and a positive predictive value of 0.07. Most National Health Safety Network ventilator-associated event/ventilator-associated condition cases (93%) did not have ventilator-associated pneumonia or other hospital-acquired complications; 71% met the definition for acute respiratory distress syndrome. Similarly, most patients with National Health Safety Network probable ventilator-associated pneumonia did not have ventilator-associated pneumonia because radiographic criteria were not met. National Health Safety Network ventilator-associated event/ventilator-associated condition rates were reduced 93% by an unsophisticated manipulation of ventilator management protocols. The National Health Safety Network ventilator-associated event/ventilator-associated condition constructs failed to detect many patients who had ventilator-associated pneumonia, detected many cases that did not have a hospital complication, and were susceptible to manipulation. National Health Safety Network ventilator-associated event/ventilator-associated condition surveillance did not perform as well as ventilator-associated pneumonia surveillance and had several undesirable

Tracheal Tube Design and Ventilator-Associated Pneumonia.

PubMed

Rouzé, Anahita; Jaillette, Emmanuelle; Poissy, Julien; Préau, Sébastien; Nseir, Saad

2017-10-01

Microaspiration of contaminated oropharyngeal and gastric secretions is the main mechanism for ventilator-associated pneumonia (VAP) in critically ill patients. Improving the performance of tracheal tubes in reducing microaspiration is one potential means to prevent VAP. The aim of this narrative review is to discuss recent findings on the impact of tracheal tube design on VAP prevention. Several randomized controlled studies have reported that subglottic secretion drainage (SSD) is efficient in VAP prevention. Meta-analyses have reported conflicting results regarding the impact of SSD on duration of mechanical ventilation, and one animal study raised concern about SSD-related tracheal lesions. However, this measure appears to be cost-effective. Therefore, SSD should probably be used in all patients with expected duration of mechanical ventilation > 48 h. Three randomized controlled trials have shown that tapered-cuff tracheal tubes are not useful to prevent VAP and should probably not be used in critically ill patients. Further studies are required to confirm the promising effects of continuous control of cuff pressure, polyurethane-cuffed, silver-coated, and low-volume low-pressure tracheal tubes. There is moderate evidence for the use of SSD and strong evidence against the use of tapered-cuff tracheal tubes in critically ill patients for VAP prevention. However, more data on the safety and cost-effectiveness of these measures are needed. Other tracheal tube-related preventive measures require further investigation. Copyright © 2017 by Daedalus Enterprises.

Early Discrimination Of Microorganisms Involved In Ventilator Associated Pneumonia Using Qualitative Volatile Fingerprints

NASA Astrophysics Data System (ADS)

Planas, Neus; Kendall, Catherine; Barr, Hugh; Magan, Naresh

2009-05-01

This study has examined the use of an electronic nose for the detection of volatile organic compounds produced by different microorganisms responsible for ventilator-associated pneumonia (VAP), an important disease among patients who require mechanical ventilation. Based on the analysis of the volatile organic compounds, electronic nose technology is being evaluated for the early detection and identification of many diseases. It has been shown that effective discrimination of two bacteria (Enterobacter cloacae and Klebsiella pneumoniae) and yeast (Candida albicans), could be obtained after 24 h and filamentous fungus (Aspergillus fumigatus) after 72 h. Discrimination between blank samples and those with as initial concentration of 102 CFU ml-1 was shown with 24 h incubation for bacteria and 48 h for fungi. Effective discrimination between all the species was achieved 72 h after incubation. Initial studies with mixtures of microorganisms involved in VAP suggest that complex interactions between species occur which influences the ability to differentiate dominant species using volatile production patterns. A nutrient agar base medium was found to be optimum for early discrimination between two microorganisms (Klebsiella pneumoniae and Candida albicans).

Nosocomial and ventilator-associated pneumonia in a community hospital intensive care unit: a retrospective review and analysis.

PubMed

Behnia, Mehrdad; Logan, Sharon C; Fallen, Linda; Catalano, Philip

2014-04-11

Nosocomial and ventilator-associated pneumonia (VAP) are causes of significant morbidity and mortality in hospitalized patients. We analyzed a) the incidence and the outcome of pneumonias caused by different pathogens in the intensive care unit (ICU) of a medium-sized twenty-four bed community hospital and b) the incidence of complications of such pneumonias requiring surgical intervention such as thoracotomy and decortication. We retrospectively reviewed the charts of patients diagnosed with nosocomial and ventilator-associated pneumonia in our ICU. Their bronchoalveolar lavage (BAL) and sputum cultures, antibiograms, and other clinical characteristics, including complications and need for tracheostomy, thoracotomy and decortication were studied. In a span of one year (2011-12), 43 patients were diagnosed with nosocomial pneumonia in our ICU. The median simplified acute physiology score (SAPS II) was 39. One or more gram negative organisms as the causative agents were present in 85% of microbiologic samples. The three most prevalent gram negatives were Stenotrophomonas maltophilia (34%), Pseudomonas aeurginosa (40%), and Acinetobacter baumannii (32%). Twenty eight percent of bronchoalveolar samples contained Staphylococcus aureus. Eight three percent of patients required mechanical ventilation postoperatively and 37% underwent tracheostony. Thirty five percent underwent thoracotomy and decortication because of further complications such as empyema and non-resolving parapneumonic effusions. A. baumannii, Klebsiella pneumonia extended spectrum beta lactam (ESBL) and P. aeurginosa had the highest prevalence of multi drug resistance (MDR). Fifteen patients required surgical intervention. Mortality from pneumonia was 37% and from surgery was 2%. Nosocomial pneumonias, in particular the ones that were caused by gram negative drug resistant organisms and their ensuing complications which required thoracotomy and decortication, were the cause of significant morbidity in

Prevention of ventilator-associated pneumonia.

PubMed

Li Bassi, Gianluigi; Senussi, Tarek; Aguilera Xiol, Eli

2017-04-01

Ventilator-associated pneumonia (VAP) is an iatrogenic disease. Here we appraise recent advancements in the development and testing of strategies to prevent VAP. We also provide recommendations on the most promising interventions that should be applied. In the last year, preventive bundles have consistently let to a reduction of VAP. A few trials on endotracheal tubes (ETTs) with novel cuffs failed to translate positive bench findings into clinical settings. In addition, meta-analyses confirmed the primary role of subglottic secretion aspiration in VAP prevention. A relatively new ETT, with an innovative cuff design, has been tested in clinical trials confirming potential value. Meta-analyses confirmed reduction of VAP with the use of chlorhexidine for oropharyngeal decontamination. However, prophylactic inhaled or oral antibiotics are ineffective. Finally, there is growing interest in orally ingested probiotics to prevent VAP. The results of ongoing studies on probiotics are much-awaited. In conclusion, in the past year, new evidence elucidated limitations of new ETT cuffs in the prevention of VAP; whereas, subglottic secretion aspiration proved consistent benefits. Modulation of oropharyngeal colonization with chlorhexidine decreases risks of VAP and should be widely implemented. Finally, preventive measures with proven preventive value should be grouped into bundles.

Incidence and risk factors of ventilator associated pneumonia in a tertiary care hospital.

PubMed

Charles, Mv Pravin; Easow, Joshy M; Joseph, Noyal M; Ravishankar, M; Kumar, Shailesh; Umadevi, Sivaraman

2013-01-01

Ventilator associated pneumonia (VAP) is a type of nosocomial pneumonia associated with increased morbidity and mortality. Knowledge about the incidence and risk factors is necessary to implement preventive measures to reduce mortality in these patients. A prospective study was conducted at a tertiary care teaching hospital for a period of 20 months from November 2009 to July 2011. Patients who were on mechanical ventilation (MV) for more than 48 hours were monitored at frequent intervals for development of VAP using clinical and microbiological criteria until discharge or death. Of the 76 patients, 18 (23.7%) developed VAP during their ICU stay. The incidence of VAP was 53.25 per 1,000 ventilator days. About 94% of VAP cases occurred within the first week of MV. Early-onset and late-onset VAP was observed in 72.2% and 27.8%, respectively. Univariate analysis showed chronic lung failure, H2 blockers usage, and supine head position were significant risk factors for VAP. Logistic regression revealed supine head position as an independent risk factor for VAP. VAP occurred in a sizeable number of patients on MV. Chronic lung failure, H2 blockers usage, and supine head position were the risk factors associated with VAP. Awareness about these risk factors can be used to inform simple and effective preventive measures.

Cost Drivers of a Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia Phase 3 Clinical Trial

PubMed Central

Stergiopoulos, Stella; Calvert, Sara B; Brown, Carrie A; Awatin, Josephine; Tenaerts, Pamela; Holland, Thomas L; DiMasi, Joseph A; Getz, Kenneth A

2018-01-01

Abstract Background Studies indicate that the prevalence of multidrug-resistant infections, including hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (HABP/VABP), has been rising. There are many challenges associated with these disease conditions and the ability to develop new treatments. Additionally, HABP/VABP clinical trials are very costly to conduct given their complex protocol designs and the difficulty in recruiting and retaining patients. Methods With input from clinicians, representatives from industry, and the US Food and Drug Administration, we conducted a study to (1) evaluate the drivers of HABP/VABP phase 3 direct and indirect clinical trial costs; (2) to identify opportunities to lower these costs; and (3) to compare (1) and (2) to endocrine and oncology clinical trials. Benchmark data were gathered from proprietary and commercial databases and used to create a model that calculates the fully loaded (direct and indirect) cost of typical phase 3 HABP/VABP endocrine and oncology clinical trials. Results Results indicate that the cost per patient for a 200-site, 1000-patient phase 3 HABP/VABP study is $89600 per patient. The cost of screen failures and screen failure rates are the main cost drivers. Conclusions Results indicate that biopharmaceutical companies and regulatory agencies should consider strategies to improve screening and recruitment to decrease HABP/VABP clinical trial costs. PMID:29020279

Knowledge of Pediatric Critical Care Nurses Regarding Evidence Based Guidelines for Prevention of Ventilator Associated Pneumonia (VAP)

ERIC Educational Resources Information Center

Ahmed, Gehan EL Nabawy; Abosamra, Omyma Mostafa

2015-01-01

Ventilator associated pneumonia (VAP) is a costly, preventable, and often fatal consequence of medical therapy that increases hospital and intensive care stays in mechanically ventilated patients. The prevention of VAP is primarily the responsibility of the bedside nurse whose knowledge, beliefs, and practices influence the health outcome of ICU…

A translational approach to ventilator associated pneumonia

PubMed Central

2014-01-01

The management of Ventilator Associated Pneumonia (VAP) presents many difficulties because of the heterogeneity of the disease; the way the immunocompromised host and the aggressive ICU environment interact is only partially discovered, the available biomarkers for diagnosis are not sufficient to ensure prompt differentiation between sick patients and patients at risk, the microbiological cultures require invasive techniques and time consuming methods. A translational medicine and bio-informatics approach can enable the identification of the main players of pathology, which may represent novel therapeutic targets or biomarker candidates. Analysis of proteome i.e. allows to individuate proteins that act as biomarkers, for patient-centered research strategies. Similarly, the genomic approach has proved useful to individuate those patients who are prone to develop VAP, and, in the future, we could be able to immunomodulate their responses to save them from nosocomial infections. PMID:25097729

Oral hygiene is an important factor for prevention of ventilator-associated pneumonia.

PubMed

Par, Matej; Badovinac, Ana; Plancak, Darije

2014-03-01

Inadequate oral hygiene in intensive care units (ICUs) has been recognized as a critical issue, for it is an important risk factor for ventilator associated pneumonia (VAP). VAP is an aspiration pneumonia that occurs in mechanically ventilated patients, mostly caused by bacteria colonizing the oral cavity and dental plaque. It is the second most common nosocomial infection and the leading cause of complications and death in mechanically ventilated patients. It has been suggested that improvement of oral hygiene in ICU patients could lead to a reduced incidence of VAP. Although diverse oral care measures for ICU patients have been proposed in the literature, there is no evidence that could identify the most efficient ones. Although there are several evidence-based protocols, oral care measures are still performed inconsistently and differ greatly between individual ICUs. This paper lists the oral care measures most commonly performed in ICUs, indicating their advantages and disadvantages. Brushing with regular toothbrush and rinsing with chlorhexidine are considered optimal measures of oral hygiene in critically ill patients. To date, there is no definitive agreement about the most effective oral care protocol, but evidence demonstrates that consistent performance of oral care may lower the incidence of VAP in critically ill patients.

Prevention of Ventilator-Associated Pneumonia in the Intensive Care Unit: Beyond the Basics.

PubMed

Larrow, Vickie; Klich-Heartt, Eira I

2016-06-01

Ventilated-associated pneumonia (VAP) is a major concern for hospitals and a major problem for ventilated patients in the intensive care unit. Included in the basics are hand hygiene, wearing gloves, endotracheal tube suctioning, head of bed at 30°, stress ulcer prophylaxis, turning patient side to side at least every two hours, and giving the patient a sedation vacation each morning. Beyond the basics included here are oral hygiene, oral suctioning, endotracheal tube cuff pressure, artificial humidification, the difference in practice between registered nurses and respiratory therapists, using the beach chair position and early mobilization, and the VAP bundle. The prevention of VAP becomes the focus for both nurses and respiratory therapists working with patients who are ventilated.

Tracheo-bronchitis and pneumonia associated with mechanical ventilation by Chryseobacterium indologenes.

PubMed

González-Castro, A; Alsasua, A; Peñasco, Y; Rodríguez, J C; Duerto, J

2017-05-01

The development of nosocomial infections by germs resistant to carbapenems inherently increases mortality, and causes an increase in health spending. The knowledge and study of these infections is important in improving epidemiological and therapeutic performance protocols. We present a descriptive study of eight patients diagnosed with tracheobronchitis (TAVM) and pneumonia (NAVM) associated with mechanical ventilation Chryseobacterium indologenes (CBI), over a period of five years. CBI isolation occurred at 11 days on average (rank 7-18) of remaining patients connected to mechanical ventilation. The average length of patients on mechanical ventilation was 36 days (range 10-140). The average ICU stay was 49 days (range 14-180). There was no death at 28 days, but the intra-hospital mortality was 2 cases (25%). Nosocomial respiratory infection secondary to CBI in mechanically ventilated patients has increased in recent years, so that should be included in the differential diagnostic of NAMV. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Incidence of Ventilator-Associated Pneumonia in Critically Ill Children Undergoing Mechanical Ventilation in Pediatric Intensive Care Unit

PubMed Central

Amanati, Ali; Karimi, Abdollah; Fahimzad, Alireza; Shamshiri, Ahmad Reza; Fallah, Fatemeh; Mahdavi, Alireza; Talebian, Mahshid

2017-01-01

Background: Among hospital-acquired infections (HAIs) in children, ventilator-associated pneumonia (VAP) is the most common after blood stream infection (BSI). VAP can prolong length of ventilation and hospitalization, increase mortality rate, and directly change a patient’s outcome in Pediatric Intensive Care Units (PICU). Objectives: The research on VAP in children is limited, especially in Iran; therefore, the identification of VAP incidence and mortality rate will be important for both clinical and epidemiological implications. Materials and Methods: Mechanically ventilated pediatric patients were assessed for development of VAP during hospital course on the basis of clinical, laboratory and imaging criteria. We matched VAP group with control group for assessment of VAP related mortality in the critically ill ventilated children. Results: VAP developed in 22.9% of critically ill children undergoing mechanical ventilation. Early VAP and late VAP were found in 19.3% and 8.4% of VAP cases, respectively. Among the known VAP risk factors that were investigated, immunodeficiency was significantly greater in the VAP group (p = 0.014). No significant differences were found between the two groups regarding use of corticosteroids, antibiotics, PH (potential of hydrogen) modifying agents (such as ranitidine or pantoprazole), presence of nasogastric tube and total or partial parenteral nutrition administration. A substantial number of patients in the VAP group had more than four risk factors for development of VAP, compared to those without VAP (p = 0.087). Mortality rate was not statistically different between the VAP and control groups (p = 0.477). Conclusion: VAP is still one of the major causes of mortality in PICUs. It is found that altered immune status is a significant risk factor for acquiring VAP. Also, occurrence of VAP was high in the first week after admission in PICU. PMID:28671616

Early non-invasive ventilation treatment for severe influenza pneumonia.

PubMed

Masclans, J R; Pérez, M; Almirall, J; Lorente, L; Marqués, A; Socias, L; Vidaur, L; Rello, J

2013-03-01

The role of non-invasive ventilation (NIV) in acute respiratory failure caused by viral pneumonia remains controversial. Our objective was to evaluate the use of NIV in a cohort of (H1N1)v pneumonia. Usefulness and success of NIV were assessed in a prospective, observational registry of patients with influenza A (H1N1) virus pneumonia in 148 Spanish intensive care units (ICUs) in 2009-10. Significant variables for NIV success were included in a multivariate analysis. In all, 685 patients with confirmed influenza A (H1N1)v viral pneumonia were admitted to participating ICUs; 489 were ventilated, 177 with NIV. The NIV was successful in 72 patients (40.7%), the rest required intubation. Low Acute Physiology and Chronic Health Evaluation (APACHE) II, low Sequential Organ Failure Assessment (SOFA) and absence of renal failure were associated with NIV success. Success of NIV was independently associated with fewer than two chest X-ray quadrant opacities (OR 3.5) and no vasopressor requirement (OR 8.1). However, among patients with two or more quadrant opacities, a SOFA score ≤7 presented a higher success rate than those with SOFA score >7 (OR 10.7). Patients in whom NIV was successful required shorter ventilation time, shorter ICU stay and hospital stay than NIV failure. In patients in whom NIV failed, the delay in intubation did not increase mortality (26.5% versus 24.2%). Clinicians used NIV in 25.8% of influenza A (H1N1)v viral pneumonia admitted to ICU, and treatment was effective in 40.6% of them. NIV success was associated with shorter hospital stay and mortality similar to non-ventilated patients. NIV failure was associated with a mortality similar to those who were intubated from the start. © 2012 The Authors. Clinical Microbiology and Infection © 2012 European Society of Clinical Microbiology and Infectious Diseases.

Staff education aimed at reducing ventilator-associated pneumonia.

PubMed

Yilmaz, Gurdal; Aydin, Hava; Aydin, Mustafa; Saylan, Sedat; Ulusoy, Hulya; Koksal, Iftihar

2016-12-01

Mechanical ventilation is a life-saving invasive procedure performed in intensive care units (ICUs) where critical patients are given advanced support. The purpose of this study was to assess the effect of personnel training on the incidence of ventilator-associated pneumonia (VAP). The study, performed prospectively in the ICU, was planned in two periods. In both periods, patient characteristics were recorded on patient data forms. In the second period, ICU physicians and assistant health personnel were given regular theoretical and practical training. Twenty-two cases of VAP developed in the pre-training period, an incidence of 31.2. Nineteen cases of VAP developed in the post-training period, an incidence of 21.0 (P<0.001). Training reduced development of VAP by 31.7 %. Crude VAP mortality was 69 % in the first period and 26 % in the second (P<0.001). Statistically significant risk factors for VAP in both periods were prolonged hospitalization, increased number of days on mechanical ventilation, and enteral nutrition; risk factors determined in the first period were re-intubation, central venous catheter use and heart failure and, in the second period, erythrocyte transfusion >5 units (P<0.05). Prior to training, compliance with hand washing (before and after procedure), appropriate aseptic endotracheal aspiration and adequate oral hygiene in particular were very low. An improvement was observed after training (P<0.001). The training of personnel who will apply infection control procedures for the prevention of healthcare-associated infections is highly important. Hand hygiene and other infection control measures must be emphasized in training programmes, and standard procedures in patient interventions must be revised.

Should Aerosolized Antibiotics Be Used to Treat Ventilator-Associated Pneumonia?

PubMed

Zhang, Changsheng; Berra, Lorenzo; Klompas, Michael

2016-06-01

In patients with ventilator-associated pneumonia, systemic use of antibiotics is the cornerstone of medical management. Supplemental use of aerosolized antibiotics with intravenous antibiotics in both experimental and clinical studies has been shown to have the following pharmacologic benefits: (1) aerosolized antibiotics reach the infected lung parenchyma without crossing the pulmonary alveolar capillary barrier; (2) aerosolized antibiotics increase anti-bacterial efficacy through increased local antibiotic concentration; and (3) aerosolized antibiotics decrease systemic toxicity. These benefits may be particularly beneficial to treat pneumonia caused by multidrug-resistant pathogens. Clinical data on the benefits of aerosolized antibiotics are more limited. Studies to date have not clearly shown improvements in time to extubation, mortality, or other patient-centered outcomes. At present, amikacin, colistin, and ceftazidime are the most frequently used and studied aerosolized antibiotics. This review summarizes the characteristics of aerosolized antibiotics, reviews the advantages and disadvantages of using aerosolized antibiotics, and calls for future investigations based on animal study data. Copyright © 2016 by Daedalus Enterprises.

Alternative approaches to ventilator-associated pneumonia prevention.

PubMed

Berra, L; Sampson, J; Fumagalli, J; Panigada, M; Kolobow, T

2011-03-01

Ventilator-associated pneumonia (VAP), which develops in patients receiving mechanical ventilation, is the most common nosocomial infection in patients with acute respiratory failure. The major mechanism of lower respiratory tract colonization is aspiration of bacteria-colonized secretions from the oropharynx into the lower airways. The hydrostatic pressure of the secretions that collect in the subglottic space, which is the area above the endotracheal tube (ETT) cuff, or aerosolization of bacteria from the secretions collected within the respiratory tubing may facilitate the leakage into the lower airways. Ideally, the elimination of the mechanisms responsible for aspiration would decrease the incidence of VAP. Several preventive measures have been tested in clinical trials with little success.Here we present the results of our efforts to develop novel approaches for the prevention of VAP. Specifically, we found that keeping ventilated patients in a lateral position, which eliminates gravitational forces, is feasible and possibly advantageous. Additionally, several novel medical devices have been recently developed to prevent bacterial biofilm formation from the ETT and breathing tubing. These devices include coated ETTs, mucus shavers and mucus slurpers. Prevention of ETT bacterial colonization showed decreased bacterial colonization of the respiratory circuit and of the lower respiratory tract in laboratory studies and clinical trials. Future large studies should be designed to test the hypothesis that VAP can be prevented with these novel strategies. While there is a current focus on the use of respiratory devices to prevent biofilm formation and microaspiration, it is important to remember that lower respiratory tract colonization is multifactorial. Prevention of VAP cannot be achieved solely by eliminating bacterial biofilm on respiratory devices, and more comprehensive care of the intubated patient needs to be implemented.

Sustained Reduction of Ventilator-Associated Pneumonia Rates Using Real-Time Course Correction With a Ventilator Bundle Compliance Dashboard.

PubMed

Talbot, Thomas R; Carr, Devin; Parmley, C Lee; Martin, Barbara J; Gray, Barbara; Ambrose, Anna; Starmer, Jack

2015-11-01

The effectiveness of practice bundles on reducing ventilator-associated pneumonia (VAP) has been questioned. To implement a comprehensive program that included a real-time bundle compliance dashboard to improve compliance and reduce ventilator-associated complications. DESIGN Before-and-after quasi-experimental study with interrupted time-series analysis. SETTING Academic medical center. In 2007 a comprehensive institutional ventilator bundle program was developed. To assess bundle compliance and stimulate instant course correction of noncompliant parameters, a real-time computerized dashboard was developed. Program impact in 6 adult intensive care units (ICUs) was assessed. Bundle compliance was noted as an overall cumulative bundle adherence assessment, reflecting the percentage of time all elements were concurrently in compliance for all patients. The VAP rate in all ICUs combined decreased from 19.5 to 9.2 VAPs per 1,000 ventilator-days following program implementation (P<.001). Bundle compliance significantly increased (Z100 score of 23% in August 2007 to 83% in June 2011 [P<.001]). The implementation resulted in a significant monthly decrease in the overall ICU VAP rate of 3.28/1,000 ventilator-days (95% CI, 2.64-3.92/1,000 ventilator-days). Following the intervention, the VAP rate decreased significantly at a rate of 0.20/1,000 ventilator-days per month (95% CI, 0.14-0.30/1,000 ventilator-days per month). Among all adult ICUs combined, improved bundle compliance was moderately correlated with monthly VAP rate reductions (Pearson correlation coefficient, -0.32). A prevention program using a real-time bundle adherence dashboard was associated with significant sustained decreases in VAP rates and an increase in bundle compliance among adult ICU patients.

Efficacy of Hi-Lo Evac Endotracheal Tube in Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Poisoned Patients.

PubMed

Ghoochani Khorasani, Ahmad; Shadnia, Shahin; Mashayekhian, Mohammad; Rahimi, Mitra; Aghabiklooei, Abbas

2016-01-01

Background. Ventilator-associated pneumonia (VAP) is the most common health care-associated infection. To prevent this complication, aspiration of subglottic secretions using Hi-Lo Evac endotracheal tube (Evac ETT) is a recommended intervention. However, there are some reports on Evac ETT dysfunction. We aimed to compare the incidence of VAP (per ventilated patients) in severely ill poisoned patients who were intubated using Evac ETT versus conventional endotracheal tubes (C-ETT) in our toxicology ICU. Materials and Methods. In this clinical randomized trial, 91 eligible patients with an expected duration of mechanical ventilation of more than 48 hours were recruited and randomly assigned into two groups: (1) subglottic secretion drainage (SSD) group who were intubated by Evac ETT (n = 43) and (2) control group who were intubated by C-ETT (n = 48). Results. Of the 91 eligible patients, 56 (61.5%) were male. VAP was detected in 24 of 43 (55.8%) patients in the case group and 23 of 48 (47.9%) patients in the control group (P = 0.45). The most frequently isolated microorganisms were S. aureus (54.10%) and Acinetobacter spp. (19.68%). The incidence of VAP and ICU length of stay were not significantly different between the two groups, but duration of intubation was statistically different and was longer in the SSD group. Mortality rate was less in SSD group but without a significant difference (P = 0.68). Conclusion. The SSD procedure was performed intermittently with one-hour intervals using 10 mL syringe. Subglottic secretion drainage does not significantly reduce the incidence of VAP in patients receiving MV. This strategy appears to be ineffective in preventing VAP among ICU patients.

Guidelines-concordant empiric antimicrobial therapy and mortality in patients with severe community-acquired pneumonia requiring mechanical ventilation.

PubMed

Sakamoto, Yukiyo; Yamauchi, Yasuhiro; Yasunaga, Hideo; Takeshima, Hideyuki; Hasegawa, Wakae; Jo, Taisuke; Matsui, Hiroki; Fushimi, Kiyohide; Nagase, Takahide

2017-01-01

Community-acquired pneumonia (CAP) has high morbidity and mortality among adults. Several clinical guidelines recommend prompt administration of combined antimicrobial therapy. However, the association between guidelines concordance and mortality in patients with severe pneumonia remains unclear. The present study aimed to examine the impact of guidelines-concordant empiric antimicrobial therapy on 7-day mortality in patients with extremely severe pneumonia who required mechanical ventilation at admission, using a nationwide inpatient database in Japan. Data of CAP patients aged over 20 years who required mechanical ventilation at admission between April 2012 and March 2014 were retrospectively analyzed. Multivariable logistic regression analysis was performed to examine the association between guidelines-concordant empiric antimicrobial therapy and all-cause 7-day mortality, with adjustment for patient backgrounds and pneumonia severity. There were a total of 3719 eligible patients, 836 (22.5%) of whom received guidelines-concordant combination therapy. Overall, 7-day mortality was 29.5%. Higher 7-day mortality was associated with advanced age, confusion, lower systolic blood pressure, malignant tumor or immunocompromised state, and C-reactive protein ≥20mg/dl or infiltration occupying two-thirds of one lung on chest radiography. After adjustment for these variables, guidelines-concordant combined antimicrobial therapy was associated with significantly lower 7-day mortality (odds ratio: 0.78; 95% confidence interval: 0.65-0.95; P=0.013). Adherence to initial empiric treatment as recommended by the guidelines was associated with better short-term prognosis in patients with extremely severe pneumonia who required mechanical ventilation on hospital admission. Copyright © 2016 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.

A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting.

PubMed

Caserta, Raquel A; Marra, Alexandre R; Durão, Marcelino S; Silva, Cláudia Vallone; Pavao dos Santos, Oscar Fernando; Neves, Henrique Sutton de Sousa; Edmond, Michael B; Timenetsky, Karina Tavares

2012-09-29

Ventilator-associated pneumonia (VAP) is a common infection in the intensive care unit (ICU) and associated with a high mortality. A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed from October 2008 to December 2010. All of these processes, including the Institute for Healthcare Improvement's (IHI) ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions (CASS), were adopted for patients undergoing mechanical ventilation. We evaluated a total of 21,984 patient-days, and a total of 6,052 ventilator-days (ventilator utilization rate of 0.27). We found VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero incidence of VAP several times during 12 months, whenever VAP bundle compliance was over 90%. These results suggest that it is possible to reduce VAP rates to near zero and sustain these rates, but it requires a complex process involving multiple performance measures and interventions that must be permanently monitored.

Risk factors for ventilator-associated pneumonia: among trauma patients with and without brain injury.

PubMed

Gianakis, Anastasia; McNett, Molly; Belle, Josie; Moran, Cristina; Grimm, Dawn

2015-01-01

Ventilator-associated pneumonia (VAP) rates remain highest among trauma and brain injured patients; yet, no research compares VAP risk factors between the 2 groups. This retrospective, case-controlled study identified risk factors for VAP among critically ill trauma patients with and without brain injury. Data were abstracted on trauma patients with (cases) and without (controls) brain injury. Data gathered on n = 157 subjects. Trauma patients with brain injury had more emergent and field intubations. Age was strongest predictor of VAP in cases, and ventilator days predicted VAP in controls. Trauma patients with brain injury may be at higher risk for VAP.

Aerophagia increases the risk of ventilator-associated pneumonia in critically-ill patients.

PubMed

Destrebecq, A L; Elia, G; Terzoni, S; Angelastri, G; Brenna, G; Ricci, C; Spanu, P; Umbrello, M; Iapichino, G

2014-04-01

Gastric residual volume in ventilated critically ill may complicate gut function. Over the years studies suggested to tolerate progressively higher residuals. The relationship between such volumes and the development of ventilator-associated pneumonia (VAP) is still under debate. No reports deal with the relevant anecdotal finding of air in the stomach. Aim of the present study is to test the role of air in the development of VAPs. Prospective observational trial in consecutive patients with a predicted length of ICU stay >3 days. The first 8 days of stay were studied. Sedation was targeted to have awake/cooperative patients. Early enteral nutrition was attempted. Gastric content was measured every 4 hours by 60 mL-syringe suction. Upper digestive intolerance (UDI) was defined as >2 consecutive findings of liquid >200 mL, aerophagia was defined as >2 consecutive findings of air >150 mL. Three hundred sixty-four patients enrolled, 43 developed VAP (11.8%). Patients were sedated with enteral (76% total time), intravenous (6%) or both (28%) drugs. Conscious sedation was achieved in 54% of the observations. 326 patients began enteral nutrition during the first 24 hours (1000 kcal median calorie intake). 10% developed UDI, 15% had aerophagia. No association was found between VAP and UDI (P=0.78), while significant association was found between VAP and aerophagia (OR=2.88, P<0.01). A sensitivity analysis, excluding patients admitted with respiratory infection, confirmed the results. High volumes of air in the stomach significantly increased the risk of developing VAP, while gastric residual volumes were not associated with the incidence of pneumonia.

Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy

PubMed Central

2012-01-01

Introduction Ventilator-associated pneumonia (VAP) may contribute to the mortality associated with acute respiratory distress syndrome (ARDS). We aimed to determine the incidence, outcome, and risk factors of bacterial VAP complicating severe ARDS in patients ventilated by using a strictly standardized lung-protective strategy. Methods This prospective epidemiologic study was done in all the 339 patients with severe ARDS included in a multicenter randomized, placebo-controlled double-blind trial of cisatracurium besylate in severe ARDS patients. Patients with suspected VAP underwent bronchoalveolar lavage to confirm the diagnosis. Results Ninety-eight (28.9%) patients had at least one episode of microbiologically documented bacterial VAP, including 41 (41.8%) who died in the ICU, compared with 74 (30.7%) of the 241 patients without VAP (P = 0.05). After adjustment, age and severity at baseline, but not VAP, were associated with ICU death. Cisatracurium besylate therapy within 2 days of ARDS onset decreased the risk of ICU death. Factors independently associated with an increased risk to develop a VAP were male sex and worse admission Glasgow Coma Scale score. Tracheostomy, enteral nutrition, and the use of a subglottic secretion-drainage device were protective. Conclusions In patients with severe ARDS receiving lung-protective ventilation, VAP was associated with an increased crude ICU mortality which did not remain significant after adjustment. PMID:22524447

Effect of frequency of ventilator circuit changes (3 vs 7 days) on the rate of ventilator-associated pneumonia in PICU.

PubMed

Samransamruajkit, Rujipat; Jirapaiboonsuk, Suree; Siritantiwat, Sirirush; Tungsrijitdee, Ornanong; Deerojanawong, Jitladda; Sritippayawan, Suchada; Prapphal, Nuanchan

2010-03-01

Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality in pediatric intensive care unit (PICU). Our purpose was to evaluate the effects of ventilator circuit change on the rate of VAP in the PICU. A prospective randomized controlled trial was conducted at a university hospital PICU. Children (younger than 18 years) who received mechanical ventilation from December 2006 to November 2007 were randomly assigned to receive ventilator circuit changes every 3 or 7 days. Of 176 patients, 88 were assigned to receive ventilator circuit every 3 days and 88 patients had a change weekly. The rate of VAP was 13.9/1000 ventilator days for the 3-day circuit change (n = 12) vs 11.5/1000 ventilator days (n = 10) for the 7-day circuit change (odds ratio, 0.8; confidence interval, 0.3-1.9; P = .6). There was a trend toward decreased PICU stay and mortality rate in 7-day change group compared to 3-day change group but did not reach statistical significance. Furthermore, switching from a 3-day to a 7-day change policy could save costs up to US $22,000/y. The 7-day ventilator circuit change did not contribute to increased rates of VAP in our PICU. Thus, it may be used as a guide to save workload and supply costs. Crown Copyright 2010. Published by Elsevier Inc. All rights reserved.

Backrest position in prevention of pressure ulcers and ventilator-associated pneumonia: Conflicting recommendations

PubMed Central

Burk, Ruth Srednicki; Jo Grap, Mary

2013-01-01

Pressure ulcers and ventilator-associated pneumonia (VAP) are both common in acute and critical care settings and are considerable sources of morbidity, mortality, and health care costs. To prevent pressure ulcers, guidelines limit bed backrest elevation to less than 30 degrees, whereas recommendations to reduce VAP include use of backrest elevations of 30 degrees or more. Although a variety of risk factors beyond patient position have been identified for both pressure ulcers and VAP, this article will focus on summarizing the major evidence for each of these apparently conflicting positioning strategies and discuss implications for practice in managing mechanically ventilated patients with risk factors for both pressure ulcers and VAP. PMID:22819601

Backrest position in prevention of pressure ulcers and ventilator-associated pneumonia: conflicting recommendations.

PubMed

Burk, Ruth Srednicki; Grap, Mary Jo

2012-01-01

Pressure ulcers and ventilator-associated pneumonia (VAP) are both common in acute and critical care settings and are considerable sources of morbidity, mortality, and health care costs. To prevent pressure ulcers, guidelines limit bed backrest elevation to less than 30 degrees, whereas recommendations to reduce VAP include use of backrest elevations of 30 degrees or more. Although a variety of risk factors beyond patient position have been identified for both pressure ulcers and VAP, this article will focus on summarizing the major evidence for each of these apparently conflicting positioning strategies and discuss implications for practice in managing mechanically ventilated patients with risk factors for both pressure ulcers and VAP. Copyright © 2012 Elsevier Inc. All rights reserved.

The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study.

PubMed

Marik, P E; Careau, P

1999-01-01

Aspiration of oropharyngeal material, with its high concentration of anaerobic bacteria, has been implicated in the pathogenesis of both ventilator-associated pneumonia (VAP) and aspiration pneumonitis (AP). Consequently, patients with these disorders are usually treated with antimicrobial agents with anaerobic activity. To determine the incidence of anaerobic bacteria in patients with VAP and AP. Prospective, nonrandomized, interventional study. University-affiliated community teaching hospital. We performed sequential blind protected specimen brush (PSB) sampling and mini-BAL in 143 patients with 185 episodes of suspected VAP and 25 patients with AP who required mechanical ventilation. Quantitative aerobic and anaerobic cultures were performed on all specimens. Pneumonia was considered to be present when either > 500 cfu/mL cultured from blind PSB sampling or > 5,000 cfu/mL cultured from mini-BAL were present. Using the predefined criteria, bacterial pneumonia was diagnosed in 63 of 185 suspected VAP episodes (34%) and 12 of 25 patients with AP (48%). At least one dose of an antibiotic was given in the 24 h prior to bacteriologic sampling in 106 suspected VAP episodes (57%) and in 12 patients with AP (48%). More than one pathogen was isolated from 11 VAP and four AP patients. Pseudomonas aeruginosa, Staphylococcus aureus, and enteric Gram-negative organisms were isolated most frequently from patients with VAP. In the patients with AP, enteric Gram-negative organisms were isolated in patients with GI disorders and Streptococcus pneumoniae and Haemophilus influenzae predominated in patients with "community-acquired" aspiration. Only one anaerobic organism was isolated from the entire group of patients; Veillonella paravula was isolated from a blind PSB specimen in a patient with suspected aspiration pneumonia. Despite painstaking effort, we were able to isolate only one anaerobic organism (nonpathogenic) from this group of patients. The spectrum of aerobes in

Ventilator-associated pneumonia caused by ESKAPE organisms: cause, clinical features, and management.

PubMed

Sandiumenge, Alberto; Rello, Jordi

2012-05-01

Despite important geographical variations, Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species (ESKAPE) pathogens constitute more than 80% of ventilator-associated pneumonia (VAP) episodes. Their clinical importance relies on their virulence and ability in developing mechanisms to decrease susceptibility to antimicrobials, increasing inappropriate therapy and affecting negatively on ICU patients' outcome. This review updates information on VAP due to ESKAPE pathogens. Although methicillin-resistant Staphylococcus aureus VAP may be clinically similar to that caused by susceptible strains, it is associated with poorer outcomes despite adequate treatment. Local colonization determines treatment options. The contribution of tracheobronchitis is an important issue. Minimum inhibitory concentration should be considered for nonfermentative Gram-negative bacteria VAP to prescribe extended infusion β-lactam treatment due to an increase of resistant strains. Strategies promoting antimicrobial diversity may protect against emergence and spread of resistance by ESKAPE pathogens. VAP due to ESKAPE pathogens represents a global challenge that can be prevented using stewardship programmes promoting diversity.

Technologic advances in endotracheal tubes for prevention of ventilator-associated pneumonia.

PubMed

Fernandez, Juan F; Levine, Stephanie M; Restrepo, Marcos I

2012-07-01

Ventilator-associated pneumonia (VAP) is associated with high morbidity, mortality, and costs. Interventions to prevent VAP are a high priority in the care of critically ill patients requiring mechanical ventilation (MV). Multiple interventions are recommended by evidence-based practice guidelines to prevent VAP, but there is a growing interest in those related to the endotracheal tube (ETT) as the main target linked to VAP. Microaspiration and biofilm formation are the two most important mechanisms implicated in the colonization of the tracheal bronchial tree and the development of VAP. Microaspiration occurs when there is distal migration of microorganisms present in the secretions accumulated above the ETT cuff. Biofilm formation has been described as the development of a network of secretions and attached microorganisms that migrate along the ETT cuff polymer and inside the lumen, facilitating the transfer to the sterile bronchial tree. Therefore, our objective was to review the literature related to recent advances in ETT technologies regarding their impact on the control of microaspiration and biofilm formation in patients on MV, and the subsequent impact on VAP.

Implementation of a real-time compliance dashboard to help reduce SICU ventilator-associated pneumonia with the ventilator bundle.

PubMed

Zaydfudim, Victor; Dossett, Lesly A; Starmer, John M; Arbogast, Patrick G; Feurer, Irene D; Ray, Wayne A; May, Addison K; Pinson, C Wright

2009-07-01

Ventilator-associated pneumonia (VAP) causes significant morbidity and mortality in critically ill surgical patients. Recent studies suggest that the success of preventive measures is dependent on compliance with ventilator bundle parameters. Implementation of an electronic dashboard will improve compliance with the bundle parameters and reduce rates of VAP in our surgical intensive care unit (SICU). Time series analysis of VAP rates between January 2005 and July 2008, with dashboard implementation in July 2007. Multidisciplinary SICU at a tertiary-care referral center with a stable case mix during the study period. Patients admitted to the SICU between January 2005 and July 2008. Infection control data were used to establish rates of VAP and total ventilator days. For the time series analysis, VAP rates were calculated as quarterly VAP events per 1000 ventilator days. Ventilator bundle compliance was analyzed after dashboard implementation. Differences between expected and observed VAP rates based on time series analysis were used to estimate the effect of intervention. Average compliance with the ventilator bundle improved from 39% in August 2007 to 89% in July 2008 (P < .001). Rates of VAP decreased from a mean (SD) of 15.2 (7.0) to 9.3 (4.9) events per 1000 ventilator days after introduction of the dashboard (P = .01). Quarterly VAP rates were significantly reduced in the November 2007 through January 2008 and February through April 2008 periods (P < .05). For the August through October 2007 and May through July 2008 quarters, the observed rate reduction was not statistically significant. Implementation of an electronic dashboard improved compliance with ventilator bundle measures and is associated with reduced rates of VAP in our SICU.

Bile acid aspiration in suspected ventilator-associated pneumonia.

PubMed

Wu, Yu-Chung; Hsu, Po-Kuei; Su, Kang-Cheng; Liu, Lung-Yu; Tsai, Cheng-Chien; Tsai, Shu-Ho; Hsu, Wen-Hu; Lee, Yu-Chin; Perng, Diahn-Warng

2009-07-01

The aims of this study were to measure the levels of bile acids in patients with suspected ventilator-associated pneumonia (VAP) and provide a possible pathway for neutrophilic inflammation to explain its proinflammatory effect on the airway. Bile acid levels were measured by spectrophotometric enzymatic assay, and liquid chromatography mass spectrometry was used to quantify the major bile acids. Alveolar cells were grown on modified air-liquid interface culture inserts, and bile acids were then employed to stimulate the cells. Reverse transcriptase polymerase chain reaction and Western blots were used to determine the involved gene expression and protein levels. The mean (+/- SE) concentration of total bile acids in tracheal aspirates was 6.2 +/- 2.1 and 1.1 +/- 0.4 mumol/L/g sputum, respectively, for patients with and without VAP (p < 0.05). The interleukin (IL)-8 level was significantly higher in the VAP group (p < 0.05). The major bile acid, chenodeoxycholic acid, stimulated alveolar epithelial cells to increase IL-8 production at both the messenger RNA and protein level through p38 and c-Jun N-terminal kinase (JNK) activation. The selective p38 and JNK inhibitors, as well as dexamethasone, successfully inhibited IL-8 production. These data suggest that early intervention to prevent bile acid aspiration may reduce the intensity of neutrophilic inflammation in intubated and mechanically ventilated patients in the ICU.

Ventilation-associated pneumonia after intubation in the prehospital or the emergency unit.

PubMed

Decelle, Lydie; Thys, Frédéric; Zech, Francis; Verschuren, Franck

2013-02-01

The aim of the study was to evaluate the prevalence and the risk factors of ventilation-associated pneumonia (VAP) for out-of-hospital or in the emergency department intubated patients. This was a retrospective descriptive study. All intubated adults subsequently admitted to the ICU over 1-year period were included. Among 75 patients, 15 patients developed VAP (20%; 95% CI 12-31%). A multivariate analysis revealed three variables independently associated with VAP: cardiorespiratory arrest as the reason of intubation (P=0.001), out-of-hospital as the location of intubation (P=0.011), and clinical macroaspiration as clinical characteristic at the time of intubation (P=0.024). Death rate was 17% and was not significantly higher for patients with VAP (P=0.9; 95% CI 0.32-4.95%). Emergency care workers should be aware of the potential 20% occurrence of VAP when they intubate and ventilate a patient. Preventive strategies, which have been proven effective in ICUs, should be implemented in the emergency setting.

Non-invasive mechanical ventilation and mortality in elderly immunocompromised patients hospitalized with pneumonia: a retrospective cohort study.

PubMed

Johnson, Christopher S; Frei, Christopher R; Metersky, Mark L; Anzueto, Antonio R; Mortensen, Eric M

2014-01-27

Mortality after pneumonia in immunocompromised patients is higher than for immunocompetent patients. The use of non-invasive mechanical ventilation for patients with severe pneumonia may provide beneficial outcomes while circumventing potential complications associated with invasive mechanical ventilation. The aim of our study was to determine if the use of non-invasive mechanical ventilation in elderly immunocompromised patients with pneumonia is associated with higher all-cause mortality. In this retrospective cohort study, data were obtained from the Department of Veterans Affairs administrative databases. We included veterans age ≥65 years who were immunocompromised and hospitalized due to pneumonia. Multilevel logistic regression analysis was used to determine the relationship between the use of invasive versus non-invasive mechanical ventilation and 30-day and 90-day mortality. Of 1,946 patients in our cohort, 717 received non-invasive mechanical ventilation and 1,229 received invasive mechanical ventilation. There was no significant association between all-cause 30-day mortality and non-invasive versus invasive mechanical ventilation in our adjusted model (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.66-1.10). However, those patients who received non-invasive mechanical ventilation had decreased 90-day mortality (OR 0.66, 95% CI 0.52-0.84). Additionally, receipt of guideline-concordant antibiotics in our immunocompromised cohort was significantly associated with decreased odds of 30-day mortality (OR 0.31, 95% CI 0.24-0.39) and 90-day mortality (OR 0.41, 95% CI 0.31-0.53). Our findings suggest that physicians should consider the use of non-invasive mechanical ventilation, when appropriate, for elderly immunocompromised patients hospitalized with pneumonia.

Increased risk of pneumonia among ventilated patients with traumatic brain injury: every day counts!

PubMed

Hui, Xuan; Haider, Adil H; Hashmi, Zain G; Rushing, Amy P; Dhiman, Nitasha; Scott, Valerie K; Selvarajah, Shalini; Haut, Elliott R; Efron, David T; Schneider, Eric B

2013-09-01

Patients with traumatic brain injury (TBI) frequently require mechanical ventilation (MV). The objective of this study was to examine the association between time spent on MV and the development of pneumonia among patients with TBI. Patients older than 18 y with head abbreviated injury scale (AIS) scores coded 1-6 requiring MV in the National Trauma Data Bank 2007-2010 data set were included. The study was limited to hospitals reporting pneumonia cases. AIS scores were calculated using ICDMAP-90 software. Patients with injuries in any other region with AIS score >3, significant burns, or a hospital length of stay >30 d were excluded. A generalized linear model was used to determine the approximate relative risk of developing all-cause pneumonia (aspiration pneumonia, ventilator-associated pneumonia [VAP], and infectious pneumonia identified by the International Classification of Disease, Ninth Revision, diagnosis code) for each day of MV, controlling for age, gender, Glasgow coma scale motor score, comorbidity (Charlson comorbidity index) score, insurance status, and injury type and severity. Among the 24,525 patients with TBI who required MV included in this study, 1593 (6.5%) developed all-cause pneumonia. After controlling for demographic and injury factors, each additional day on the ventilator was associated with a 7% increase in the risk of pneumonia (risk ratio 1.07, 95% confidence interval 1.07-1.08). Patients who have sustained TBIs and require MV are at higher risk for VAP than individuals extubated earlier; therefore, shortening MV exposure will likely reduce the risk of VAP. As patients with TBI frequently require MV because of neurologic impairment, it is key to develop aggressive strategies to expedite ventilator independence. Copyright © 2013 Elsevier Inc. All rights reserved.

Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients.

PubMed

Foglia, Elizabeth; Meier, Mary Dawn; Elward, Alexis

2007-07-01

Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is associated with an estimated $30,000 in attributable cost. Surveillance for VAP is complex and usually performed using clinical definitions established by the CDC. Invasive testing via bronchoalveolar lavage increases the sensitivity and specificity of the diagnosis. The pathogenesis in children is poorly understood, but several prospective cohort studies suggest that aspiration and immunodeficiency are risk factors. Educational interventions and efforts to improve adherence to hand hygiene for children have been associated with decreased VAP rates. Studies of antibiotic cycling in pediatric patients have not consistently shown this measure to prevent colonization with multidrug-resistant gram-negative rods. More consistent and precise approaches to the diagnosis of pediatric VAP are needed to better define the attributable morbidity and mortality, pathophysiology, and appropriate interventions to prevent this disease.

Use of probiotics to prevent ventilator-associated pneumonia: A survey of pharmacists' attitudes.

PubMed

Wheeler, Kathleen E; Cook, Deborah J; Mehta, Sangeeta; Calce, Adriana; Guenette, Melanie; Perreault, Marc M; Thiboutot, Zoé; Duffett, Mark; Burry, Lisa

2016-02-01

The primary objective of this survey was to describe pharmacists' attitudes regarding probiotic use in the intensive care unit (ICU); secondary objectives were to evaluate pharmacists' knowledge and use of probiotics for critically ill patients. The survey instrument was rigorously designed and pretested, then distributed in both English and French to Canadian ICU pharmacists. The online survey was open for 5 weeks, and 3 follow-up emails were sent to maximize response rates. Of 303 eligible surveys, 191 were returned (63.0%). Probiotics were available in the hospitals of 69.8% (113/162) of respondents, and 62.0% (101/163) indicated that they had used probiotics for at least 1 ICU patient in the previous year. Most pharmacists (137/171, 80.1%) said that they would "never" consider recommending probiotics for prevention of ventilator-associated pneumonia in ICU patients, and this response was more common (P = .0074) among pharmacists who were "unsure" about the safety of probiotics in this population when compared to those who felt that they knew how safe probiotics are. Most Canadian ICU pharmacists have used probiotics at least once in the ICU in the last year. However, based on uncertain efficacy and safety, most ICU pharmacists would not currently recommend probiotics for the prevention of ventilator-associated pneumonia. Copyright © 2015 Elsevier Inc. All rights reserved.

An Update on Aerosolized Antibiotics for Treating Hospital-Acquired and Ventilator-Associated Pneumonia in Adults.

PubMed

Wood, G Christopher; Swanson, Joseph M

2017-12-01

A significant percentage of patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) have poor outcomes with intravenous antibiotics. It is not clear if adding aerosolized antibiotics improves treatment. This review is an update on using aerosolized antibiotics for treating HAP/VAP in adults. PubMed search using the terms "aerosolized antibiotics pneumonia," "nebulized antibiotics pneumonia," and "inhaled antibiotics pneumonia." Reference lists from identified articles were also searched. Clinical studies of aerosolized antibiotics for treating HAP/VAP in adults from July 2010 to March 2017. This article updates a previous review on this topic written in mid-2010. The size and quality of studies have improved dramatically in the recent time period compared to previous studies. However, there still are not large randomized controlled trials available. Colistin and aminoglycosides were the most commonly studied agents, and the most common pathogens were Pseudomonas and Acinetobacter. The clinical efficacy of adding aerosolized antibiotics was mixed. Approximately half of the studies showed better outcomes, and none showed worse outcomes. Aerosolized antibiotics appear to be relatively safe, though pulmonary adverse events can occur. Attention to proper administration technique in mechanically ventilated patients is required, including the use of vibrating plate nebulizers. Adding aerosolized antibiotics to intravenous antibiotics may improve the outcomes of adult patients with HAP/VAP in some settings. It seems reasonable to add aerosolized antibiotics in patients with multidrug-resistant organisms or who appear to be failing therapy. Clinicians should pay attention to potential adverse events and proper administration technique.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis

PubMed Central

Arumugam, Suresh Kumar; Mudali, Insolvisagan; Strandvik, Gustav; El-Menyar, Ayman; Al-Hassani, Ammar; Al-Thani, Hassan

2018-01-01

BACKGROUND: We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. METHODS: Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients’ demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. RESULTS: Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. CONCLUSION: In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role. PMID:29796145

Effects of tracheal orientation on development of ventilator-associated pneumonia: an experimental study.

PubMed

Zanella, Alberto; Cressoni, Massimo; Epp, Myra; Hoffmann, Viktoria; Stylianou, Mario; Kolobow, Theodor

2012-04-01

Orientation of the trachea and tracheal tube below horizontal may prevent aspiration of oropharyngeal secretions into the lungs, which is a pivotal pathway in the pathogenesis of ventilator-associated pneumonia (VAP). The incidence of VAP was evaluated in swine with orientation of trachea and tracheal tube above horizontal (model of semirecumbent position, currently recommended in patients) and below horizontal. Twenty-six mini-pigs were randomized into four groups: (A) eight mechanically ventilated with orientation of trachea 45° above horizontal for 72 h. In the remaining groups (B, C, D) the trachea was oriented 10° below horizontal, with (B) six mechanically ventilated for 72 h, (C) six mechanically ventilated for 72 h with enteral feeding, and (D) six mechanically ventilated for 168 h with enteral feeding. At the end of the study period, all pigs were sacrificed and the clinical diagnosis of VAP was microbiologically evaluated. No antibiotics were administered. All eight pigs kept orientated with the trachea 45° above horizontal developed VAP and respiratory failure (PaO(2)/F(i)O(2) = 132 ± 139 mmHg) with a median of 5.5 pulmonary lobes out of 6 colonized with average colonization of 9.3 × 10(7) CFU/g. None of the 18 pigs kept oriented with the trachea below horizontal developed VAP; 16 had sterile lungs, while 2, ventilated for 7 days, developed a low level of colonization. Orientation of the trachea above horizontal was uniformly associated with VAP and respiratory failure; positioning the trachea below horizontal consistently prevented development of VAP.

Impact of ventilator-associated pneumonia in patients with severe head injury.

PubMed

Rincón-Ferrari, M Dolores; Flores-Cordero, Juan M; Leal-Noval, S Ramón; Murillo-Cabezas, Francisco; Cayuelas, Aurelio; Muñoz-Sánchez, M Angeles; Sánchez-Olmedo, J Ignacio

2004-12-01

The impact of ventilator-associated pneumonia (VAP) on outcome seems to vary depending on the critically ill patients we analyze. Our objective, therefore, has been to evaluate the influence of VAP on the mortality and morbidity in patients with severe head injury (Glasgow Coma Scale score ventilation. VAP was diagnosed on the basis of quantitative microbiologic criteria. Mortality did not differ significantly between cases and matched control subjects (15 [20.8%] vs. 11 [15.3%], p = 0.54). However, patients with VAP had a significantly longer duration of mechanical ventilation (median, 14 vs. 10 days; p = 0.015) and ICU stay (median, 21 vs. 15.5 days; p = 0.008). The occurrence of multiple organ failure was also significantly more frequent among the case group (33.3% vs. 12.5%, p = 0.004) during the overall ICU stay. VAP does not seem to be associated with a significantly increased risk of death in patients with severe HI, but it may be associated with greater morbidity during the ICU stay.

Ventilator-associated pneumonia: role of positioning.

PubMed

Li Bassi, Gianluigi; Torres, Antoni

2011-02-01

Ventilator-associated pneumonia (VAP) is a lung infection commonly acquired following tracheal intubation. This review assesses the role of the supine semirecumbent and the prone position as VAP preventive strategies and calls attention for further investigation on novel body positions that could potentially reduce risks of VAP. The most recent studies on the semirecumbent position failed to achieve an orientation of the head of the bed higher than 30° and did not corroborate any benefit of the semirecumbent position on VAP, as reported in earlier studies. To date, there is clear evidence that the supine horizontal body position increases risks of pulmonary aspiration and VAP, particularly when patients are enterally fed. Laboratory reports are emphasizing the importance of an endotracheal tube-oropharynx-trachea axis below horizontal to avoid VAP. The prone position potentially increases drainage of oropharyngeal and airways secretions and recent evidence is supporting its beneficial effects. However, several associated adverse effects preclude its regular use as a VAP preventive strategy for patients other than those with acute respiratory distress syndrome. Body position greatly affects several pathogenetic mechanisms of VAP. The current evidence recommends avoidance of supine horizontal position in order to prevent aspiration of colonized gastric contents. The semirecumbent position has proven benefits and should be routinely used but there is still limited evidence to recommend the lowest orientation of the bed at which the patient can be safely maintained. Results from pioneering laboratory investigation call attention to new possible positions, that is lateral Trendelenburg position, aimed to avoid pulmonary aspiration and to enhance mucus clearance in intubated patients.

Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study.

PubMed

Martin-Loeches, Ignacio; Povoa, Pedro; Rodríguez, Alejandro; Curcio, Daniel; Suarez, David; Mira, Jean-Paul; Cordero, Maria Lourdes; Lepecq, Raphaël; Girault, Christophe; Candeias, Carlos; Seguin, Philippe; Paulino, Carolina; Messika, Jonathan; Castro, Alejandro G; Valles, Jordi; Coelho, Luis; Rabello, Ligia; Lisboa, Thiago; Collins, Daniel; Torres, Antonio; Salluh, Jorge; Nseir, Saad

2015-11-01

Ventilator-associated tracheobronchitis has been suggested as an intermediate process between tracheobronchial colonisation and ventilator-associated pneumonia in patients receiving mechanical ventilation. We aimed to establish the incidence and effect of ventilator-associated tracheobronchitis in a large, international patient cohort. We did a multicentre, prospective, observational study in 114 intensive care units (ICU) in Spain, France, Portugal, Brazil, Argentina, Ecuador, Bolivia, and Colombia over a preplanned time of 10 months. All patients older than 18 years admitted to an ICU who received invasive mechanical ventilation for more than 48 h were eligible. We prospectively obtained data for incidence of ventilator-associated lower respiratory tract infections, defined as ventilator-associated tracheobronchitis or ventilator-associated pneumonia. We grouped patients according to the presence or absence of such infections, and obtained data for the effect of appropriate antibiotics on progression of tracheobronchitis to pneumonia. Patients were followed up until death or discharge from hospital. To account for centre effects with a binary outcome, we fitted a generalised estimating equation model with a logit link, exchangeable correlation structure, and non-robust standard errors. This trial is registered with ClinicalTrials.gov, number NCT01791530. Between Sept 1, 2013, and July 31, 2014, we obtained data for 2960 eligible patients, of whom 689 (23%) developed ventilator-associated lower respiratory tract infections. The incidence of ventilator-associated tracheobronchitis and that of ventilator-associated pneumonia at baseline were similar (320 [11%; 10·2 of 1000 mechanically ventilated days] vs 369 [12%; 8·8 of 1000 mechanically ventilated days], p=0·48). Of the 320 patients with tracheobronchitis, 250 received appropriate antibiotic treatment and 70 received inappropriate antibiotics. 39 patients with tracheobronchitis progressed to pneumonia; however

Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates.

PubMed

Leonard, Kenji L; Borst, Gregory M; Davies, Stephen W; Coogan, Michael; Waibel, Brett H; Poulin, Nathaniel R; Bard, Michael R; Goettler, Claudia E; Rinehart, Shane M; Toschlog, Eric A

2016-06-01

No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients. A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients. Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41). The lack of

Levofloxacin for treatment of ventilator-associated pneumonia: a subgroup analysis from a randomized trial.

PubMed

Shorr, Andrew F; Zadeikis, Neringa; Jackson, William L; Ramage, Anthony S; Wu, Shu-Chen; Tennenberg, Alan M; Kollef, Marin H

2005-02-15

Ventilator-associated pneumonia (VAP) remains a significant challenge in critical care. We conducted a secondary analysis of a multicenter, prospective, randomized trial comparing levofloxacin (750 mg iv q24h) with imipenem-cilastatin (500-1000 mg iv q6-8h) for treatment of nosocomial pneumonia and focused on the subgroup of patients with VAP. The study cohort included 222 patients, with half (111) of the patients assigned to each treatment group. The patients in both groups were similar with respect to age, severity of illness, and duration of mechanical ventilation before the onset of VAP. Among the intention-to-treat population, clinical success was achieved in 58.6% of patients receiving levofloxacin, compared with 63.1% of patients receiving imipenem-cilastatin (P=.49; 95% confidence interval for the difference, -8.77% to 17.79%). Microbiological success and 28-day mortality rates were also comparable. Multivariate analysis demonstrated that assignment to antibiotic treatment (i.e., levofloxacin vs. imipenem-cilastatin) was not predictive of outcomes, thus suggesting that the treatment regimens were equivalent. Both levofloxacin and imipenem-cilastatin regimens were well tolerated and had similar adverse event profiles.

Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate.

PubMed

Weber, Carla D

2016-06-01

Ventilator-associated pneumonia (VAP) in neonates can be reduced by implementing preventive care practices. Implementation of a group, or bundle, of evidence-based practices that improve processes of care has been shown to be cost-effective and to have better outcomes than implementation of individual single practices. The purpose of this article is to describe a safe, effective, and efficient neonatal VAP prevention protocol developed for caregivers in the neonatal intensive care unit (NICU). Improved understanding of VAP causes, effects of care practices, and rationale for interventions can help reduce VAP risk to neonatal patients. In order to improve care practices to affect VAP rates, initial and annual education occurred on improved protocol components after surveying staff practices and auditing documentation compliance. In 2009, a tertiary care level III NICU in the Midwestern United States had 14 VAP cases. Lacking evidence-based VAP prevention practices for neonates, effective adult strategies were modified to meet the complex needs of the ventilated neonate. A protocol was developed over time and resulted in an annual decrease in VAP until rates were zero for 20 consecutive months from October 2012 to May 2014. This article describes a VAP prevention protocol developed to address care practices surrounding hand hygiene, intubation, feeding, suctioning, positioning, oral care, and respiratory equipment in the NICU. Implementation of this VAP prevention protocol in other facilities with appropriate monitoring and tracking would provide broader support for standardization of care. Individual components of this VAP protocol could be studied to strengthen the inclusion of each; however, bundled interventions are often considered stronger when implemented as a whole.

Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome.

PubMed

Ruiz, M; Torres, A; Ewig, S; Marcos, M A; Alcón, A; Lledó, R; Asenjo, M A; Maldonaldo, A

2000-07-01

Noninvasive and invasive diagnostic techniques have been shown to achieve comparable performances in the evaluation of suspected ventilator-associated pneumonia (VAP). We studied the impact of both approaches on outcome in a prospective, open, and randomized study in three intensive care units (ICUs) of a 1,000-bed tertiary care university hospital. Patients with suspected VAP were randomly assigned to noninvasive (Group 1) versus invasive (Group 2) investigation (tracheobronchial aspirates [TBAS] versus bronchoscopically retrieved protected specimen brush [PSB] and bronchoalveolar lavage [BAL]. Samples were cultured quantitatively, and BAL fluid (BALF) was examined for intracellular organisms (ICO) additionally. Initial empiric antimicrobial treatment was administered following the guidelines of the American Thoracic Society (ATS) and adjusted according to culture results (and ICO counts in Group 2). Outcome variables included length of ICU stay and mechanical ventilation as well as mortality. Overall, 76 patients (39 noninvasive, 37 invasive) were investigated. VAP was microbiologically confirmed in 23 of 39 (59%) and 23 of 37 (62%) (p = 0.78). There were no differences with regard to the frequencies of community-acquired and potentially drug-resistant microorganisms (PDRM). Antimicrobial treatment was changed in seven patients (18%) of Group 1 and 10 patients (27%) of Group 2 because of etiologic findings (including five of 17 with ICO = 2% (p = not significant [NS]). Length of ICU stay and mechanical ventilation were also not significantly different in both groups. Crude 30-d mortality was 31 of 76 (41%), and 18 of 39 (46%) in Group 1 and 14 of 37 (38%) in Group 2 (p = 0.46). Adjusted mortality was 16% versus 11% (p = 0.53), and mortality of microbiologically confirmed pneumonia 10 of 23 (44%) in both groups (p = 1.0). We conclude that the outcome of VAP was not influenced by the techniques used for microbial investigation.

Antibiotic consumption and ventilator-associated pneumonia rates, some parallelism but some discrepancies

PubMed Central

Póvoa, Pedro

2017-01-01

Ventilator-associated pneumonia (VAP) is a common infection in intensive care units (ICUs) but its clinical definition is neither sensitive nor specific and lacks accuracy and objectivity. New defining criteria were proposed in 2013 by the National Healthcare Safety Network (NHSN) in order to more accurately conduct surveillance and track prevention progress. Although there is a consistent trend towards a decrease in VAP incidence during the last decade, significant differences in VAP rates have been reported and are persistently lower in NHSN and other American reports (0.0 to 4.4 VAP per 1,000 ventilator-days in 2012) compared to the European Centre for Disease Prevention and Control (ECDC) data (10 VAP per 1,000 ventilator-days in 2014). In the United States, VAP has been proposed as an indicator of quality of care in public reporting, and the threat of financial penalties for this diagnosis has put pressure on hospitals to minimize VAP rates that may lead to artificial lower values, independently of patient care. Although prevention bundles may contribute for encouraging reductions in VAP incidence, both pathophysiologic and epidemiologic factors preclude a zero-VAP rate. It would be expected from the trend of reduction of VAP incidence that the consumption of antibiotics would also decrease in particular in those hospitals with lowest VAP rates. However, ICU reports show a steadily use of antibiotics for nosocomial pneumonia in 15% of patients and both ECDC and NHSN data on antibiotic consumption showed no significant trend. Knowledge of bacterial epidemiology and resistance profiles for each ICU has great relevance in order to understand trends of antibiotic use. The new NHSN criteria provide a more objective and quantitative data based VAP definition, including an antibiotic administration criterion, allowing, in theory, a more comprehensive assessment and a reportable benchmark of the observed VAP and antibiotic consumption variability. PMID:29264367

Antibiotic consumption and ventilator-associated pneumonia rates, some parallelism but some discrepancies.

PubMed

Nora, David; Póvoa, Pedro

2017-11-01

Ventilator-associated pneumonia (VAP) is a common infection in intensive care units (ICUs) but its clinical definition is neither sensitive nor specific and lacks accuracy and objectivity. New defining criteria were proposed in 2013 by the National Healthcare Safety Network (NHSN) in order to more accurately conduct surveillance and track prevention progress. Although there is a consistent trend towards a decrease in VAP incidence during the last decade, significant differences in VAP rates have been reported and are persistently lower in NHSN and other American reports (0.0 to 4.4 VAP per 1,000 ventilator-days in 2012) compared to the European Centre for Disease Prevention and Control (ECDC) data (10 VAP per 1,000 ventilator-days in 2014). In the United States, VAP has been proposed as an indicator of quality of care in public reporting, and the threat of financial penalties for this diagnosis has put pressure on hospitals to minimize VAP rates that may lead to artificial lower values, independently of patient care. Although prevention bundles may contribute for encouraging reductions in VAP incidence, both pathophysiologic and epidemiologic factors preclude a zero-VAP rate. It would be expected from the trend of reduction of VAP incidence that the consumption of antibiotics would also decrease in particular in those hospitals with lowest VAP rates. However, ICU reports show a steadily use of antibiotics for nosocomial pneumonia in 15% of patients and both ECDC and NHSN data on antibiotic consumption showed no significant trend. Knowledge of bacterial epidemiology and resistance profiles for each ICU has great relevance in order to understand trends of antibiotic use. The new NHSN criteria provide a more objective and quantitative data based VAP definition, including an antibiotic administration criterion, allowing, in theory, a more comprehensive assessment and a reportable benchmark of the observed VAP and antibiotic consumption variability.

Glutamine supplemented parenteral nutrition to prevent ventilator-associated pneumonia in the intensive care unit.

PubMed

Aydoğmuş, Meltem Türkay; Tomak, Yakup; Tekin, Murat; Katı, Ismail; Hüseyinoğlu, Urfettin

2012-12-01

Ventilator-associated pneumonia (VAP) is a form of nosocomial pneumonia that increases patient morbidity and mortality, length of hospital stay, and healthcare costs. Glutamine preserves the intestinal mucosal structure, increases immune function, and reduces harmful changes in gut permeability in patients receiving total parenteral nutrition (TPN). We hypothesized that TPN supplemented by glutamine might prevent the development of VAP in patients on mechanical ventilator support in the intensive care unit (ICU). With the approval of the ethics committee and informed consent from relatives, 60 patients who were followed in the ICU with mechanical ventilator support were included in our study. Patients were divided into three groups. The first group received enteral nutrition (n=20), and the second was prescribed TPN (n=20) while the third group was given glutamine-supplemented TPN (n=20). C-reactive protein (CRP), sedimentation rate, body temperature, development of purulent secretions, increase in the amount of secretions, changes in the characteristics of secretions and an increase in requirement of deep tracheal aspiration were monitored for seven days by daily examination and radiographs. No statistically significant difference was found among groups in terms of development of VAP (p=0.622). Although VAP developed at a lower rate in the glutamine-supplemented TPN group, no statistically significant difference was found among any of the groups. Glutamine-supplemented TPN may have no superiority over unsupplemented enteral and TPN in preventing VAP.

Duration of antibiotic therapy for ventilator-associated pneumonia in burn patients.

PubMed

Wahl, Wendy L; Taddonio, Michael A; Arbabi, Saman; Hemmila, Mark R

2009-01-01

Shorter compared with longer courses of antibiotic therapy for ventilator-associated pneumonia (VAP) in mixed medical-surgical intensive care units (ICUs) have been reported to produce equivalent outcomes. There have been few studies on the duration of antibiotic therapy for VAP in the burn population. We hypothesized that a shorter duration of antibiotic therapy for VAP would produce similar outcomes in our burn ICU. All burn patients from July 2001 to December 2006 admitted to the burn ICU requiring mechanical ventilation were studied. VAP was diagnosed prospectively by our Infection Control Liaison using bronchoalveolar lavage for cultures. Patients were cohorted into two groups: before July 1, 2004, antibiotic therapy duration was directed by the discretion of the attending physician (preprotocol), and after, the goal was 8 days of appropriate therapy or longer based on physician discretion (postprotocol). There were 98 patients treated for VAP with similar rates of inhalation injury, %TBSA burn size, age, and need for mechanical ventilation between the groups. The incidence of recurrent VAP was the same: 17% for the preprotocol and 15% for the postprotocol periods. The overall duration of antibiotic therapy did not change from 11 +/- 4 to 12 +/- 6 days. For patients treated longer than the target of 8 days, 66% had positive respiratory cultures at 4 days after initiation of antibiotic therapy. For the majority of patients with aspiration-type organisms or nonvirulent strains, there were fewer antibiotic days overall at 10 +/- 5 days (P < .05), with no episodes of recurrent VAP with the same bacteria. Despite a focused effort to decrease antibiotic usage for VAP in burn patients, the overall duration of therapy did not change. The majority of patients with virulent organisms such as methicillin-resistant Staphylococcus aureus or nonfermenting Gram-negative rods still had clinical signs of pneumonia and positive cultures, leading clinicians to continue

Validation of different techniques for the diagnosis of ventilator-associated pneumonia. Comparison with immediate postmortem pulmonary biopsy.

PubMed

Torres, A; el-Ebiary, M; Padró, L; Gonzalez, J; de la Bellacasa, J P; Ramirez, J; Xaubet, A; Ferrer, M; Rodriguez-Roisin, R

1994-02-01

To assess the accuracy of clinical parameters for the diagnosis of ventilator-associated (VA) pneumonia, as well as the diagnostic value of several invasive techniques, such as protected specimen brush (PSB), bronchoalveolar lavage (BAL), fiberoptic bronchial aspirates (FBAS), and percutaneous lung needle aspiration (PLNA), we compared the results of these techniques with the histopathology of immediate postmortem pulmonary biopsies, considered the "gold standard" reference test. We studied 30 mechanically ventilated patients (age 52 +/- 21 yr; mechanical ventilation period 9 +/- 7 days) who died in an intensive care unit. All patients received prior antibiotic treatment. The following procedures were performed immediately after death: bilateral PSB, BAL, FBAS, and PLNA, as well as bilateral minithoracotomies to obtain pulmonary biopsies as close as possible to the area sampled with the other techniques. According to the histopathology 18 patients had pneumonia and 12 did not. The presence of fever (sensitivity 55%, specificity 58%), purulent secretions (sensitivity 83%, specificity 33%), and chest radiograph infiltrates (sensitivity 78%, specificity 42%) could not differentiate in all instances presence from absence of pneumonia. Quantitative bacterial cultures of lung biopsies using 10(3) cfu/g as a cutoff point had low sensitivity (40%) and low specificity (45%) and could not differentiate the histologic absence or presence of pneumonia. Considering the histopathology of pulmonary biopsies as a gold standard, we found the following sensitivities for PSB, BAL, FBAS, and PLNA: 36, 50, 44, and 25%. The specificities were 50, 45, 48, and 79%, respectively. The sensitivities and specificities of different invasive techniques are much lower than those reported in clinical studies.(ABSTRACT TRUNCATED AT 250 WORDS)

World-Wide Variation in Incidence of Staphylococcus aureus Associated Ventilator-Associated Pneumonia: A Meta-Regression

PubMed Central

2018-01-01

Staphylococcus aureus (S. aureus) is a common Ventilator-Associated Pneumonia (VAP) isolate. The objective here is to define the extent and possible reasons for geographic variation in the incidences of S. aureus-associated VAP, MRSA-VAP and overall VAP. A meta-regression model of S. aureus-associated VAP incidence per 1000 Mechanical Ventilation Days (MVD) was undertaken using random effects methods among publications obtained from a search of the English language literature. This model incorporated group level factors such as admission to a trauma ICU, year of publication and use of bronchoscopic sampling towards VAP diagnosis. The search identified 133 publications from seven worldwide regions published over three decades. The summary S. aureus-associated VAP incidence was 4.5 (3.9–5.3) per 1000 MVD. The highest S. aureus-associated VAP incidence is amongst reports from the Mediterranean (mean; 95% confidence interval; 6.1; 4.1–8.5) versus that from Asian ICUs (2.1; 1.5–3.0). The incidence of S. aureus-associated VAP varies by up to three-fold (for the lowest versus highest incidence) among seven geographic regions worldwide, whereas the incidence of VAP varies by less than two-fold. Admission to a trauma unit is the most important group level correlate for S. aureus-associated VAP. PMID:29495472

Ventilator Associated Pneumonia in a Military Deployed Setting: The Impact of an Aggressive Infection Control Program

DTIC Science & Technology

2008-02-01

methicillin - resistant Staphylococcus aureus ; patient and staff cohorting whenever possible; elevating the head of the bed to at least 30 degrees unless... resistant bacterial infections among combat casualties. We describe the rates of ventilator-associated pneumonia (VAP) before and after the implementation...seen within these hospitals in Iraq,2 but the sources remain to be definitively described. Recent publications along with other circumstantial data

Treatment of Chryseobacterium indologenes ventilator-associated pneumonia in a critically ill trauma patient.

PubMed

Monteen, Megan R; Ponnapula, Supriya; Wood, G Christopher; Croce, Martin A; Swanson, Joseph M; Boucher, Bradley A; Fabian, Timothy C

2013-12-01

To report a case of Chryseobacterium indologenes ventilator-associated pneumonia (VAP) in a critically ill trauma patient. This report describes a 66-year-old critically ill trauma patient who developed VAP, which was caused by C indologenes. The patient was injured in a riding lawn mower accident that trapped him underwater in a pond. The patient required surgery for intra-abdominal injuries and was mechanically ventilated in the trauma intensive care unit. On hospital day 5, the patient developed signs and symptoms of VAP. A diagnosis of C indologenes VAP was confirmed based on a quantitative culture from a bronchoscopic bronchoalveolar lavage. The patient's infection was successfully treated with moxifloxacin for 2 days followed by cefepime for 7 days. Formally known as Flavobacterium indologenes, C indologenes is a Gram-negative bacillus normally found in plants, soil, foodstuffs, and fresh and marine water sources. Recently, worldwide reports of C indologenes infections in humans have been increasing, though reports from the United States are still rare. Bacteremia and pneumonia are the most commonly reported infections, and most patients are immunocompromised. The current case differs from most previous reports because this patient was in the United States and did not have any traditional immunocompromised states (eg, transplant, cancer, HIV/AIDS, or corticosteroid use). This case report demonstrates that C indologenes can cause VAP in a trauma ICU patient.

Are specialized endotracheal tubes and heat-and-moisture exchangers cost-effective in preventing ventilator associated pneumonia?

PubMed

Gentile, Michael A; Siobal, Mark S

2010-02-01

Ventilator-associated pneumonia (VAP) is a common and serious complication of mechanical ventilation via an artificial airway. As with all nosocomial infections, VAP increases costs, morbidity, and mortality in the intensive care unit (ICU). VAP prevention is a multifaceted priority of the intensive care team, and can include the use of specialized artificial airways and heat-and-moisture exchangers (HME). Substantial evidence supports the use of endotracheal tubes (ETTs) that allow subglottic suctioning; silver-coated and antiseptic-impregnated ETTs; ETTs with thin-walled polyurethane cuffs; and HMEs, but these devices also can have adverse effects. Controversy still exists regarding the evidence, cost-effectiveness, and disadvantages and risks of these devices.

Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit.

PubMed

Fields, Lorraine B

2008-10-01

Ventilator-associated pneumonia (VAP) is a preventable secondary consequence of intubation and mechanical ventilation. VAP is pneumonia that develops in an intubated patient after 48 hours or more of mechanical ventilator support. Mechanically ventilated patients in neurologic and other intensive care units (ICUs) are at an increased risk of VAP due to factors such as decreased level of consciousness; dry, open mouth; and microaspiration of secretions. VAP can be prevented by initiating interventions from the Institute of Healthcare Improvement's VAP bundle, including (a) elevating the head of the bed of ventilated patients to 30 degrees, (b) preventing venous thromboembolism through use of sequential compression devices or anticoagulation, (c) administering gastric acid histamine2 blockers, (d) practicing good hand hygiene, (e) initiating early mobilization, and (f) performing daily sedation interruption at 10 am to evaluate neurologic status. The one intervention not included in the IHI bundle is oral hygiene. The purpose of this project is to support the premise that oral care, including timed toothbrushing, combined with the VAP bundle can mitigate and prevent the occurrence of VAP. Our project specifically addressed timed oral care of mechanically ventilated patients on a 24-bed stroke, neurologic, and medical ICU. Patients were randomized into a control group that performed usual oral care or an intervention group that brushed teeth every 8 hours. The results were immediate and startling, as the VAP rate dropped to zero within a week of beginning the every-8-hours toothbrushing regimen in the intervention group. The study was so successful that the control group was dropped after 6 months, and all intubated patients' teeth were brushed every 8 hours, maintaining the zero rate until the end of the study.

A Pilot Study of the Noninvasive Assessment of the Lung Microbiota as a Potential Tool for the Early Diagnosis of Ventilator-Associated Pneumonia

PubMed Central

Brady, Jacob S.; Romano-Keeler, Joann; Drake, Wonder P.; Norris, Patrick R.; Jenkins, Judith M.; Isaacs, Richard J.; Boczko, Erik M.

2015-01-01

BACKGROUND: Ventilator-associated pneumonia (VAP) remains a common complication in critically ill surgical patients, and its diagnosis remains problematic. Exhaled breath contains aerosolized droplets that reflect the lung microbiota. We hypothesized that exhaled breath condensate fluid (EBCF) in hygroscopic condenser humidifier/heat and moisture exchanger (HCH/HME) filters would contain bacterial DNA that qualitatively and quantitatively correlate with pathogens isolated from quantitative BAL samples obtained for clinical suspicion of pneumonia. METHODS: Forty-eight adult patients who were mechanically ventilated and undergoing quantitative BAL (n = 51) for suspected pneumonia in the surgical ICU were enrolled. Per protocol, patients fulfilling VAP clinical criteria undergo quantitative BAL bacterial culture. Immediately prior to BAL, time-matched HCH/HME filters were collected for study of EBCF by real-time polymerase chain reaction. Additionally, convenience samples of serially collected filters in patients with BAL-diagnosed VAP were analyzed. RESULTS: Forty-nine of 51 time-matched EBCF/BAL fluid samples were fully concordant (concordance > 95% by κ statistic) relative to identified pathogens and strongly correlated with clinical cultures. Regression analysis of quantitative bacterial DNA in paired samples revealed a statistically significant positive correlation (r = 0.85). In a convenience sample, qualitative and quantitative polymerase chain reaction analysis of serial HCH/HME samples for bacterial DNA demonstrated an increase in load that preceded the suspicion of pneumonia. CONCLUSIONS: Bacterial DNA within EBCF demonstrates a high correlation with BAL fluid and clinical cultures. Bacterial DNA within EBCF increases prior to the suspicion of pneumonia. Further study of this novel approach may allow development of a noninvasive tool for the early diagnosis of VAP. PMID:25474571

A comparison of Listerine® and sodium bicarbonate oral cleansing solutions on dental plaque colonisation and incidence of ventilator associated pneumonia in mechanically ventilated patients: a randomised control trial.

PubMed

Berry, A M

2013-10-01

Effective oral hygiene has been proposed as a key factor in the reduction of dental plaque colonisation and subsequent development of ventilator associated pneumonia (VAP). Listerine(®) oral rinse, while used extensively in dental practice has rarely been tested in mechanically ventilated patients. Sodium bicarbonate as an oral rinse has been more commonly utilised in oral hygiene regimens in intensive care patients. To test the efficacies of the essential oil mouth rinse, Listerine(®) (Pfizer) and sodium bicarbonate in the reduction of dental plaque colonisation with respiratory pathogens and the subsequent development of VAP. The study design was a prospective, single blind randomised comparative study of adult patients mechanically ventilated for at least 4 days. Patients were randomised to Listerine(®) (Pfizer) oral rinse twice daily, sodium bicarbonate oral rinse 2/24 or sterile water 2/24 (control group). All groups received tooth brushing 3 times a day. Dental plaque colonisation (primary outcome) and incidence of ventilator associated pneumonia (secondary outcome) were studied. Three hundred and ninety-eight patients were randomised to either the Listerine group (127), sodium bicarbonate group (133) or the control group (138). Baseline characteristics were similar for all groups. There were no significant differences between the control and study groups in colonisation of dental plaque at Day 4 (p=0.243). Ventilator associated pneumonia was diagnosed in 18 patients. The incidence was, Listerine(®) group 4.7%, sodium bicarbonate group 4.5% and control 4.3% [OR, 0.99; 95% CI, 0.31 to 3.16; p=0.92]. Compared to the control group, Listerine(®) or sodium bicarbonate oral rinses were not more effective in the reduction of colonisation of dental plaque or the incidence of VAP. Given the low incidence of VAP, the common factor of a small, soft toothbrush as part of an oral hygiene regimen suggests possible benefit in mechanically ventilated patients. Crown

The role of surveillance cultures in guiding ventilator-associated pneumonia therapy.

PubMed

Luna, Carlos M; Bledel, Ignacio; Raimondi, Alejandro

2014-04-01

Ventilator-associated pneumonia (VAP) is the most frequent cause of death among the nosocomial infections acquired in the ICU. Routine surveillance endotracheal aspirate (ETA) cultures in patients on mechanical ventilation have been proposed to predict the cause of VAP. Our aim is to review the available experience regarding the role of surveillance ETA cultures in guiding VAP antimicrobial therapy. Microorganisms arrive in the lower respiratory tract by aspiration from the oropharynx or gastric reflux, extension from a contiguous infection, air contamination or by hematogenous seeding. Bacterial colonization of the airway leads to the development of VAP and may result from the aspiration of oropharyngeal or gastric secretions. Recent studies have suggested that surveillance cultures could provide a rationale for prescribing appropriate antibiotics, while waiting for culture results, in up to 95% of patients in whom VAP is ultimately diagnosed by bronchoalveolar lavage fluid culture. However, some authors observed that guiding therapy with those routine surveillance cultures leads to unacceptably low coverage of the pathogens producing VAP. This article describes the evidence supporting the use of routine ETA cultures to prescribe appropriate initial empirical therapy compared with the current practice dictated by guidelines.

Imipenem, meropenem, or doripenem to treat patients with Pseudomonas aeruginosa ventilator-associated pneumonia.

PubMed

Luyt, Charles-Edouard; Aubry, Alexandra; Lu, Qin; Micaelo, Maïté; Bréchot, Nicolas; Brossier, Florence; Brisson, Hélène; Rouby, Jean-Jacques; Trouillet, Jean-Louis; Combes, Alain; Jarlier, Vincent; Chastre, Jean

2014-01-01

Only limited data exist on Pseudomonas aeruginosa ventilator-associated pneumonia (VAP) treated with imipenem, meropenem, or doripenem. Therefore, we conducted a prospective observational study in 169 patients who developed Pseudomonas aeruginosa VAP. Imipenem, meropenem, and doripenem MICs for Pseudomonas aeruginosa isolates were determined using Etests and compared according to the carbapenem received. Among the 169 isolates responsible for the first VAP episode, doripenem MICs were lower (P<0.0001) than those of imipenem and meropenem (MIC50s, 0.25, 2, and 0.38, respectively); 61%, 64%, and 70% were susceptible to imipenem, meropenem, and doripenem, respectively (P was not statistically significant). Factors independently associated with carbapenem resistance were previous carbapenem use (within 15 days) and mechanical ventilation duration before VAP onset. Fifty-six (33%) patients had at least one VAP recurrence, and 56 (33%) died. Factors independently associated with an unfavorable outcome (recurrence or death) were a high day 7 sequential organ failure assessment score and mechanical ventilation dependency on day 7. Physicians freely prescribed a carbapenem to 88 patients: imipenem for 32, meropenem for 24, and doripenem for 32. The remaining 81 patients were treated with various antibiotics. Imipenem-, meropenem-, and doripenem-treated patients had similar VAP recurrence rates (41%, 25%, and 22%, respectively; P=0.15) and mortality rates (47%, 25%, and 22%, respectively; P=0.07). Carbapenem resistance emerged similarly among patients treated with any carbapenem. No carbapenem was superior to another for preventing carbapenem resistance emergence.

Imipenem, Meropenem, or Doripenem To Treat Patients with Pseudomonas aeruginosa Ventilator-Associated Pneumonia

PubMed Central

Aubry, Alexandra; Lu, Qin; Micaelo, Maïté; Bréchot, Nicolas; Brossier, Florence; Brisson, Hélène; Rouby, Jean-Jacques; Trouillet, Jean-Louis; Combes, Alain; Jarlier, Vincent; Chastre, Jean

2014-01-01

Only limited data exist on Pseudomonas aeruginosa ventilator-associated pneumonia (VAP) treated with imipenem, meropenem, or doripenem. Therefore, we conducted a prospective observational study in 169 patients who developed Pseudomonas aeruginosa VAP. Imipenem, meropenem, and doripenem MICs for Pseudomonas aeruginosa isolates were determined using Etests and compared according to the carbapenem received. Among the 169 isolates responsible for the first VAP episode, doripenem MICs were lower (P < 0.0001) than those of imipenem and meropenem (MIC50s, 0.25, 2, and 0.38, respectively); 61%, 64%, and 70% were susceptible to imipenem, meropenem, and doripenem, respectively (P was not statistically significant). Factors independently associated with carbapenem resistance were previous carbapenem use (within 15 days) and mechanical ventilation duration before VAP onset. Fifty-six (33%) patients had at least one VAP recurrence, and 56 (33%) died. Factors independently associated with an unfavorable outcome (recurrence or death) were a high day 7 sequential organ failure assessment score and mechanical ventilation dependency on day 7. Physicians freely prescribed a carbapenem to 88 patients: imipenem for 32, meropenem for 24, and doripenem for 32. The remaining 81 patients were treated with various antibiotics. Imipenem-, meropenem-, and doripenem-treated patients had similar VAP recurrence rates (41%, 25%, and 22%, respectively; P = 0.15) and mortality rates (47%, 25%, and 22%, respectively; P = 0.07). Carbapenem resistance emerged similarly among patients treated with any carbapenem. No carbapenem was superior to another for preventing carbapenem resistance emergence. PMID:24342638

Successful prevention of ventilator-associated pneumonia in an intensive care setting.

PubMed

Marra, Alexandre R; Cal, Ruy Guilherme Rodrigues; Silva, Cláudia Vallone; Caserta, Raquel Afonso; Paes, Angela Tavares; Moura, Denis Faria; dos Santos, Oscar Fernando Pavão; Edmond, Michael B; Durão, Marcelino Souza

2009-10-01

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections (HAIs) in critical care settings. Our objective was to examine the effect of a series of interventions, implemented in 3 different periods to reduce the incidence of VAP in an intensive care unit (ICU). A quasiexperimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed during different phases. From March 2001 to December 2002 (phase 1: P1), some Centers for Disease Control and Prevention (CDC) evidence-based practices were implemented. From January 2003 to December 2006 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and, from January 2007 to September 2008 (P3), we continued P2 interventions and implemented the Institute for Healthcare Improvement's ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions. The incidence density of VAP in the ICU per 1000 patient-days was 16.4 in phase 1, 15.0 in phase 2, and 10.4 in phase 3, P=.05. Getting to zero VAP was possible only in P3 when compliance with all interventions exceeded 95%. These results suggest that reducing VAP rates to zero is a complex process that involves multiple performance measures and interventions.

Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review.

PubMed

Pássaro, Leonor; Harbarth, Stephan; Landelle, Caroline

2016-01-01

Pneumonia is one of the leading hospital-acquired infections worldwide and has an important impact. Although preventive measures for ventilator-associated pneumonia (VAP) are well known, less is known about appropriate measures for prevention of hospital-acquired pneumonia (HAP). The purpose of this narrative review is to provide an overview of the current standards for preventing HAP in non-ventilated adult patients. A search of the literature up to May 2015 was conducted using Medline for guidelines published by national professional societies or professional medical associations. In addition, a comprehensive search for the following preventive measures was performed: hand hygiene, oral care, bed position, mobilization, diagnosis and treatment of dysphagia, aspiration prevention, viral infections and stress bleeding prophylaxis. Regarding international guidelines, several measures were recommended for VAP, whilst no specific recommendations for HAP prevention in non-ventilated patients are available. There is reasonable evidence available that oral care is associated with a reduction in HAP. Early mobilization interventions, swift diagnosis and treatment of dysphagia, and multimodal programmes for the prevention of nosocomial influenza cross-infection, have a positive impact on HAP reduction. The impact of bed position and stress bleeding prophylaxis remains uncertain. Systematic antibiotic prophylaxis for HAP prevention should be avoided. Scant literature and little guidance is available for the prevention of HAP among non-ventilated adult patients. In addition, the criteria used for the diagnosis of HAP and the populations targeted in the studies selected are heterogeneous. Oral care was the most studied measure and was commonly associated with a decrease in HAP rate, although a broad range of interventions are proposed. No robust evidence is available for other measures. Further high-quality studies are required to evaluate the impact of specific measures on

A multifaceted program to prevent ventilator-associated pneumonia: impact on compliance with preventive measures.

PubMed

Bouadma, Lila; Mourvillier, Bruno; Deiler, Véronique; Le Corre, Bertrand; Lolom, Isabelle; Régnier, Bernard; Wolff, Michel; Lucet, Jean-Christophe

2010-03-01

To determine the effect of a 2-yr multifaceted program aimed at preventing ventilator-acquired pneumonia on compliance with eight targeted preventive measures. Pre- and postintervention observational study. A 20-bed medical intensive care unit in a teaching hospital. A total of 1649 ventilator-days were observed. The program involved all healthcare workers and included a multidisciplinary task force, an educational session, direct observations with performance feedback, technical improvements, and reminders. It focused on eight targeted measures based on well-recognized published guidelines, easily and precisely defined acts, and directly concerned healthcare workers' bedside behavior. Compliance assessment consisted of five 4-wk periods (before the intervention and 1 month, 6 months, 12 months, and 24 months thereafter). Hand-hygiene and glove-and-gown use compliances were initially high (68% and 80%) and remained stable over time. Compliance with all other preventive measures was initially low and increased steadily over time (before 2-yr level, p < .0001): backrest elevation (5% to 58%) and tracheal cuff pressure maintenance (40% to 89%), which improved after simple technical equipment implementation; orogastric tube use (52% to 96%); gastric overdistension avoidance (20% to 68%); good oral hygiene (47% to 90%); and nonessential tracheal suction elimination (41% to 92%). To assess overall performance of the last six preventive measures, using ventilator-days as the unit of analysis, a composite score for preventive measures applied (range, 0-6) was developed. The median (interquartile range) composite scores for the five successive assessments were 2 (1-3), 4 (3-5), 4 (4-5), 5 (4-6), and 5 (4-6) points; they increased significantly over time (p < .0001). Ventilator-acquired pneumonia prevalence rate decreased by 51% after intervention (p < .0001). Our active, long-lasting program for preventing ventilator-acquired pneumonia successfully increased compliance with

Can routine surveillance samples from tracheal aspirate predict bacterial flora in cases of ventilator-associated pneumonia?

PubMed

Lampati, L; Maggioni, E; Langer, M; Malacarne, P; Mozzo, R; Pesenti, A; Fumagalli, R

2009-10-01

The aim of this study was to investigate the hypothesis that periodical sampling of the tracheo-bronchial tree in the absence of clinical suspicion of pneumonia is useful to identify bacteria responsible for subsequent late ventilator associated pneumonia (VAP). This was a retrospective observational human study carried out in two medical-surgical intensive care units of two different hospitals. From January 1999 to December 2000, 559 patients, who received invasive respiratory support for more than 48 hours, were screened. Tracheal aspiration (TA) was performed once or twice weekly in all mechanically ventilated patients. The microbiological findings from TA surveillance cultures done in the eight days before suspicion of VAP were compared to those isolated from the positive diagnostic samples done for late onset VAP (after more than four days of mechanical ventilation). The sensitivity, specificity, and positive/negative predictive values of the ability of the surveillance sample to anticipate the VAP pathogen were calculated. Among the microorganisms isolated from TA, 68% were retrieved from diagnostic samples. All VAP pathogens previously isolated were from 43% of the TA samples. If TA was collected 2-4 days before the clinical diagnosis of VAP, pathogens were detected in 58% of samples. In contrast, only 27% were collected more than four days earlier (P<0.05). The positive predictive values for Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus from routine TA samples were 92% and 90%, respectively. The negative predictive values for Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus from routine TA samples were 75% and 89%, respectively. TA cultures in ventilated patients may help to predict pathogens. Early detection may lead to earlier treatment in long term ventilated patients when VAP is suspected.

Supine position and nonmodifiable risk factors for ventilator-associated pneumonia in trauma patients.

PubMed

Michetti, Christopher P; Prentice, Heather A; Rodriguez, Jennifer; Newcomb, Anna

2017-02-01

We studied trauma-specific conditions precluding semiupright positioning and other nonmodifiable risk factors for their influence on ventilator-associated pneumonia (VAP). We performed a retrospective study at a Level I trauma center from 2008 to 2012 on ICU patients aged ≥15, who were intubated for more than 2 days. Using backward logistic regression, a composite of 4 factors (open abdomen, acute spinal cord injury, spine fracture, spine surgery) that preclude semiupright positioning (supine composite) and other variables were analyzed. In total, 77 of 374 (21%) patients had VAP. Abbreviated Injury Score head/neck greater than 2 (odds ratio [OR] 2.79, P = .006), esophageal obturator airway (OR 4.25, P = .015), red cell/plasma transfusion in the first 2 intensive care unit days (OR 2.59, P = .003), and 11 or more ventilator days (OR 17.38, P < .0001) were significant VAP risk factors, whereas supine composite, scene vs emergency department airway intervention, brain injury, and coma were not. Factors that may temporarily preclude semiupright positioning in intubated trauma patients were not associated with a higher risk for VAP. Copyright © 2016 Elsevier Inc. All rights reserved.

An assessment of ventilator-associated pneumonias and risk factors identified in the Intensive Care Unit

PubMed Central

Karatas, Mevlut; Saylan, Sedat; Kostakoglu, Ugur; Yilmaz, Gurdal

2016-01-01

Objectives: Ventilator-associated pneumonia (VAP) is a significant cause of hospital-related infections, one that must be prevented due to its high morbidity and mortality. The purpose of this study was to evaluate the incidence and risk factors in patients developing VAP in our intensive care units (ICUs). Methods: This retrospective cohort study involved in mechanically ventilated patients hospitalized for more than 48 hours. VAP diagnosed patients were divided into two groups, those developing pneumonia (VAP(+)) and those not (VAP(-)).\\ Results: We researched 1560 patients in adult ICUs, 1152 (73.8%) of whom were mechanically ventilated. The MV use rate was 52%. VAP developed in 15.4% of patients. The VAP rate was calculated as 15.7/1000 ventilator days. Mean length of stay in the ICU for VAP(+) and VAP(-) patients were (26.7±16.3 and 18.1±12.7 days (p<0.001)) and mean length of MV use was (23.5±10.3 and 12.6±7.4 days (p<0.001)). High APACHE II and Charlson co-morbidity index scores, extended length of hospitalization and MV time, previous history of hospitalization and antibiotherapy, reintubation, enteral nutrition, chronic obstructive pulmonary disease, cerebrovascular disease, diabetes mellitus and organ failure were determined as significant risk factors for VAP. The mortality rate in the VAP(+) was 65.2%, with 23.6% being attributed to VAP. Conclusion: VAPs are prominent nosocomial infections that can cause considerable morbidity and mortality in ICUs. Patient care procedures for the early diagnosis of patients with a high risk of VAP and for the reduction of risk factors must be implemented by providing training concerning risk factors related to VAP for ICU personnel, and preventable risk factors must be reduced to a minimum. PMID:27648020

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia.

PubMed

Hua, Fang; Xie, Huixu; Worthington, Helen V; Furness, Susan; Zhang, Qi; Li, Chunjie

2016-10-25

Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in people who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions, may reduce the risk of VAP in these patients. To assess the effects of oral hygiene care on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs). We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 17 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 11), MEDLINE Ovid (1946 to 17 December 2015), Embase Ovid (1980 to 17 December 2015), LILACS BIREME Virtual Health Library (1982 to 17 December 2015), CINAHL EBSCO (1937 to 17 December 2016), Chinese Biomedical Literature Database (1978 to 14 January 2013), China National Knowledge Infrastructure (1994 to 14 January 2013), Wan Fang Database (January 1984 to 14 January 2013) and VIP Database (January 2012 to 4 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 17 December 2015. We placed no restrictions on the language or date of publication when searching the electronic databases. We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours. At least two review authors independently assessed search results, extracted data and assessed risk of bias in included studies. We contacted study authors for additional information. We pooled data from trials with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous

Effectiveness of heat and moisture exchangers in preventing ventilator-associated pneumonia in critically ill patients: a meta-analysis.

PubMed

Menegueti, Mayra Gonçalves; Auxiliadora-Martins, Maria; Nunes, Altacílio Aparecido

2014-01-01

Patients may acquire ventilator-associated pneumonia (VAP) by aspirating the condensate that originates in the ventilator circuit upon use of a conventional humidifier. The bacteria that colonize the patients themselves can proliferate in the condensate and then return to the airways and lungs when the patient aspirates this contaminated material. Therefore, the use of HME might contribute to preventing pneumonia and lowering the VAP incidence. The aim of this study was to evaluate how the use of HME impacts the probability of VAP occurrence in critically ill patients. On the basis of the acronym "PICO" (Patient, Intervention, Comparison, Outcome), the question that guided this review was "Do critically ill patients under invasive mechanical ventilation present lower VAP incidence when they use HME as compared with HH?". Two of the authors of this review searched the databases PUBMED/Medline, The Cochrane Library, and Latin-American and Caribbean Literature in Health Sciences, LILACS independently; they used the following keywords: "heat and moisture exchanger", AND "heated humidifier", AND "ventilator-associated pneumonia prevention". This review included papers in the English language published from January 1990 to December 2012. This review included ten studies. Comparison between the use of HME and HH did not reveal any differences in terms of VAP occurrence (OR = 0.998; 95% CI: 0.778-1.281). Together, the ten studies corresponded to a total sample of 1077 and 953 patients in the HME and HH groups, respectively; heterogeneity among the investigations was low (I(2) < 50%). Information about the outcome mortality was available in only eight of the ten studies. The use of HME and HH did not afford different results in terms of mortality (OR = 1.09; 95% CI: 0.864-1.376). The total sample size was 884 and 762 patients, respectively. Heterogeneity among the studies was low (I(2) = 0.0%). Current meta-analysis was not sufficient to definitely exclude an associate

The dynamics of the pulmonary microbiome during mechanical ventilation in the intensive care unit and the association with occurrence of pneumonia.

PubMed

Zakharkina, Tetyana; Martin-Loeches, Ignacio; Matamoros, Sébastien; Povoa, Pedro; Torres, Antoni; Kastelijn, Janine B; Hofstra, Jorrit J; de Wever, B; de Jong, Menno; Schultz, Marcus J; Sterk, Peter J; Artigas, Antonio; Bos, Lieuwe D J

2017-09-01

Ventilator-associated pneumonia (VAP) is the most common nosocomial infections in patients admitted to the ICU. The adapted island model predicts several changes in the respiratory microbiome during intubation and mechanical ventilation. We hypothesised that mechanical ventilation and antibiotic administration decrease the diversity of the respiratory microbiome and that these changes are more profound in patients who develop VAP. Intubated and mechanically ventilated ICU-patients were included. Tracheal aspirates were obtained three times a week. 16S rRNA gene sequencing with the Roche 454 platform was used to measure the composition of the respiratory microbiome. Associations were tested with linear mixed model analysis and principal coordinate analysis. 111 tracheal aspirates were obtained from 35 patients; 11 had VAP, 18 did not have VAP. Six additional patients developed pneumonia within the first 48 hours after intubation. Duration of mechanical ventilation was associated with a decrease in α diversity (Shannon index; fixed-effect regression coefficient (β): -0.03 (95% CI -0.05 to -0.005)), but the administration of antibiotic therapy was not (fixed-effect β: 0.06; 95% CI -0.17 to 0.30). There was a significant difference in change of β diversity between patients who developed VAP and control patients for Bray-Curtis distances (p=0.03) and for Manhattan distances (p=0.04). Burkholderia, Bacillales and, to a lesser extent, Pseudomonadales positively correlated with the change in β diversity. Mechanical ventilation, but not antibiotic administration, was associated with changes in the respiratory microbiome. Dysbiosis of microbial communities in the respiratory tract was most profound in patients who developed VAP. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

The gastrointestinal tract and ventilator-associated pneumonia.

PubMed

Kallet, Richard H; Quinn, Thomas E

2005-07-01

The gastrointestinal tract is believed to play an important role in ventilator-associated pneumonia (VAP), because during critical illness the stomach often is colonized with enteric Gram-negative bacteria. These are the same bacteria that frequently are isolated from the sputum of patients with VAP. Interventions such as selective decontamination of the digestive tract (SDD), use of sucralfate for stress ulcer prophylaxis, and enteral feeding strategies that preserve gastric pH, or lessen the likelihood of pulmonary aspiration, are used to decrease the incidence of VAP. A review of both meta-analyses and large randomized controlled trials providing Level I evidence on these topics has led to the following conclusions. First, SDD substantially decreases the incidence of VAP and may have a modest positive effect on mortality. However, there is strong contravening evidence that SDD promotes infections by Gram-positive bacteria. In the context of an emerging public health crisis from the steady rise in drug-resistant Gram-positive bacteria, we cannot endorse the general use of SDD to prevent VAP. Rather, therapy should be focused on strategies other than antibiotic prophylaxis. Second, in patients who are at risk for clinically important gastrointestinal bleeding, a histamine-2 receptor antagonist should be used for stress ulcer prophylaxis, rather than sucralfate, because histamine-2 receptor antagonist provides substantially better protection without substantially increasing the risk of VAP. Third, post-pyloric enteral feeding may reduce the incidence of VAP.

A prospective randomized trial of tapered-cuff endotracheal tubes with intermittent subglottic suctioning in preventing ventilator-associated pneumonia in critically ill patients.

PubMed

Mahmoodpoor, Ata; Hamishehkar, Hadi; Hamidi, Masoud; Shadvar, Kamran; Sanaie, Sarvin; Golzari, Samad Ej; Khan, Zahid Hussain; Nader, Nader D

2017-04-01

Endotracheal tube placement is necessary for the control of the airway in patients who are mechanically ventilated. However, prolonged duration of endotracheal tube placement contributes to the development of ventilator-associated pneumonias (VAPs). The aim of this study was to evaluate whether subglottic suctioning using TaperGuard EVAC tubes was effective in decreasing the frequency of VAP. A total of 276 mechanically ventilated patients for more than 72 hours were randomly assigned to group E (EVAC tube) and group C (conventional tube). All patients received routine care including VAP prevention measures during their intensive care unit stay. In group E, subglottic suctioning was performed every 6 hours. Outcome variables included incidence VAP, intensive care unit length of stay, and mortality. Frequency of intraluminal suction, mechanical ventilation-free days, reintubation, the ratio of arterial oxygen partial pressure to fractional inspired oxygen and mortality rate were similar between the 2 groups (P > .05). The mean cuff pressure in group E was significantly less than that in group C (P < .001). Ventilator-associated pneumonia was significantly less in group E compared with group C (P = .015). The use of intermittent subglottic secretion suctioning was associated with a significant decrease in the incidence of the VAP in critically ill patients. However, larger multicenter trials are required to arrive at a concrete decision on routine usage of TaperGuard tubes in critical care settings. Published by Elsevier Inc.

Effect of heat and moisture exchangers on the prevention of ventilator-associated pneumonia in critically ill patients.

PubMed

Auxiliadora-Martins, M; Menegueti, M G; Nicolini, E A; Alkmim-Teixeira, G C; Bellissimo-Rodrigues, F; Martins-Filho, O A; Basile-Filho, A

2012-12-01

Ventilator-associated pneumonia (VAP) remains one of the major causes of infection in the intensive care unit (ICU) and is associated with the length of hospital stay, duration of mechanical ventilation, and use of broad-spectrum antibiotics. We compared the frequency of VAP 10 months prior to (pre-intervention group) and 13 months after (post-intervention group) initiation of the use of a heat and moisture exchanger (HME) filter. This is a study with prospective before-and-after design performed in the ICU in a tertiary university hospital. Three hundred and fourteen patients were admitted to the ICU under mechanical ventilation, 168 of whom were included in group HH (heated humidifier) and 146 in group HME. The frequency of VAP per 1000 ventilator-days was similar for both the HH and HME groups (18.7 vs 17.4, respectively; P = 0.97). Duration of mechanical ventilation (11 vs 12 days, respectively; P = 0.48) and length of ICU stay (11 vs 12 days, respectively; P = 0.39) did not differ between the HH and HME groups. The chance of developing VAP was higher in patients with a longer ICU stay and longer duration of mechanical ventilation. This finding was similar when adjusted for the use of HME. The use of HME in intensive care did not reduce the incidence of VAP, the duration of mechanical ventilation, or the length of stay in the ICU in the study population.

Effect of heat and moisture exchangers on the prevention of ventilator-associated pneumonia in critically ill patients

PubMed Central

Auxiliadora-Martins, M.; Menegueti, M.G.; Nicolini, E.A.; Alkmim-Teixeira, G.C.; Bellissimo-Rodrigues, F.; Martins-Filho, O.A.; Basile-Filho, A.

2012-01-01

Ventilator-associated pneumonia (VAP) remains one of the major causes of infection in the intensive care unit (ICU) and is associated with the length of hospital stay, duration of mechanical ventilation, and use of broad-spectrum antibiotics. We compared the frequency of VAP 10 months prior to (pre-intervention group) and 13 months after (post-intervention group) initiation of the use of a heat and moisture exchanger (HME) filter. This is a study with prospective before-and-after design performed in the ICU in a tertiary university hospital. Three hundred and fourteen patients were admitted to the ICU under mechanical ventilation, 168 of whom were included in group HH (heated humidifier) and 146 in group HME. The frequency of VAP per 1000 ventilator-days was similar for both the HH and HME groups (18.7 vs 17.4, respectively; P = 0.97). Duration of mechanical ventilation (11 vs 12 days, respectively; P = 0.48) and length of ICU stay (11 vs 12 days, respectively; P = 0.39) did not differ between the HH and HME groups. The chance of developing VAP was higher in patients with a longer ICU stay and longer duration of mechanical ventilation. This finding was similar when adjusted for the use of HME. The use of HME in intensive care did not reduce the incidence of VAP, the duration of mechanical ventilation, or the length of stay in the ICU in the study population. PMID:23044627

Antibiotic Therapy in Comatose Mechanically Ventilated Patients Following Aspiration: Differentiating Pneumonia From Pneumonitis.

PubMed

Lascarrou, Jean Baptiste; Lissonde, Floriane; Le Thuaut, Aurélie; Bachoumas, Konstantinos; Colin, Gwenhael; Henry Lagarrigue, Matthieu; Vinatier, Isabelle; Fiancette, Maud; Lacherade, Jean Claude; Yehia, Aihem; Joret, Aurélie; Lebert, Christine; Bourdon, Sandra; Martin Lefèvre, Laurent; Reignier, Jean

2017-08-01

To determine the proportion of patients with documented bacterial aspiration pneumonia among comatose ICU patients with symptoms suggesting either bacterial aspiration pneumonia or non-bacterial aspiration pneumonitis. Prospective observational study. University-affiliated 30-bed ICU. Prospective cohort of 250 patients admitted to the ICU with coma (Glasgow Coma Scale score ≤ 8) and treated with invasive mechanical ventilation. None. The primary outcome was the proportion of patients with microbiologically documented bacterial aspiration pneumonia. Patients meeting predefined criteria for aspiration syndrome routinely underwent telescopic plugged catheter sampling during bronchoscopy before starting probabilistic antibiotic treatment. When cultures were negative, the antibiotic treatment was stopped. Of 250 included patients, 98 (39.2%) had aspiration syndrome, including 92 before mechanical ventilation discontinuation. Telescopic plugged catheter in these 92 patients showed bacterial aspiration pneumonia in 43 patients (46.7%). Among the remaining 49 patients, 16 continued to receive antibiotics, usually for infections other than pneumonia; of the 33 patients whose antibiotics were discontinued, only two subsequently showed signs of lung infection. In the six patients with aspiration syndrome after mechanical ventilation, and therefore without telescopic plugged catheter, antibiotic treatment was continued for 7 days. Mechanical ventilation duration, ICU length of stay, and mortality did not differ between the 43 patients with bacterial aspiration pneumonia and the 49 patients with non-bacterial aspiration pneumonitis. The 152 patients without aspiration syndrome did not receive antibiotics. Among comatose patients receiving mechanical ventilation, those without clinical, laboratory, or radiologic evidence of bacterial aspiration pneumonia did not require antibiotics. In those with suspected bacterial aspiration pneumonia, stopping empirical antibiotic therapy

[Nursing role in prevention of Ventilator Associated Pneumonia: Spanish project "Neumonìa Zero"].

PubMed

Pinto, Cristina; Reig Valero, Roberto; Iadeluca, Antonio; Lomuscio, Sonia; Caldarulo, Tiziana; Sponton, Anna

2015-01-01

The incidence of Ventilator Associated Pneumonia (VAP) varies between 8 and 28% on patients with invasive mechanical ventilation, and it is associated with high mortality rates. The international literature indicates that the VAP has some risk factors that cannot be changed and some other that are closely related to nursing care procedures. The aim of this study is to analyze compliance level to the protocol of nursing prevention of the VAP in the ICU of "General Hospital" in Castellon de la Plana (Spain) within the project "Neumonía Zero". The data were collected during the months of May and June 2012 through direct observation which lasted 33 days. 5 check lists based on international recommendations were used for the objective evaluation on the adoption of preventive treatments. 58 patients in invasive mechanical ventilation and 43 ICU nurses were enrolled. Compliance procedure showed no significant differences among each other with an average adhesion of 78% of the observations. The observations trend shows a tendency of improvement in accordance with the checklists of cuff pressure and of the inclination of the bed head. An incidence rate of VAP 13,37/1000 was observed. In conclusion, direct observation showed good compliance to the protocols used in the ward. The obtained data allows to re-direct educational choices and assume a systematic application of this methodology with an important contribution to nursing.

Effect of antibiotic diversity on ventilator-associated pneumonia caused by ESKAPE Organisms.

PubMed

Sandiumenge, Alberto; Lisboa, Thiago; Gomez, Frederic; Hernandez, Pilar; Canadell, Laura; Rello, Jordi

2011-09-01

The aim of this study was to test in the clinic whether antimicrobial diversity affects resistance of Enterococcus faecium, Staphylococcus aureus, Klebsiella species, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species (ESKAPE) pathogens in ventilator-associated pneumonia (VAP). Three different strategies of empirical antimicrobial prescription for VAP were consecutively implemented in an ICU: patient specific (10 months); scheduling, including sequential quarterly prioritization (12 months) and restriction (12 months) of antimicrobials; and mixing (10 months). Periods were compared, measuring the antimicrobial heterogeneity index (AHI). Incidence and resistance patterns of VAP caused by ESKAPE were compared. Overall, 127 microbiologic VAP episodes were documented. ESKAPE VAP increased significantly during scheduling (AHI, 0.65) compared with patient-specific (AHI, 0.88) and mixing (AHI, 0.87) periods (relative risk, 2.67 and 3.84, respectively). This finding was associated with a significant (P < .05) increase of carbapenem-resistant A baumannii during the scheduling period (15.0%) compared with the patient-specific (2.4%) and mixing (0%) periods. ICU mortality of resistant patients with ESKAPE VAP was doubled that of patients without ESKAPE VAP (relative risk, 2.25; 95% CI, 1.67-9.48). Thirty-day mechanical ventilation-free days was significantly increased (5 days) in patients with resistant ESKAPE VAP. Antibiotic strategies promoting diversity may prevent the emergence of resistance of ESKAPE organisms, improving use of health-care resources.

[The role of endotracheal aspiration in the diagnosis of ventilator associated pneumonia].

PubMed

Gürgün, Alev; Korkmaz Ekren, Pervin; Bacakoğlu, Feza; Başoğlu, Ozen Kaçmaz; Dirican, Nigar; Aydemir, Şöhret; Nart, Deniz; Sayıner, Abdullah

2013-01-01

Ventilator associated pneumonia (VAP) is one of the most important causes of mortality in patients treated with invasive mechanical ventilation (IMV) in intensive care unit (ICU). Microbiological examinations are required as clinical and radiological findings are usually insufficient in the diagnosis. Twenty four patients who were receiving IMV because of respiratory failure, had a Clinical Pulmonary Infection Score (CPIS) of ≥ 6 in the follow-up and died with the suspicion of VAP were enrolled in our study. Six patients were excluded as post-mortem biopsy could not be performed. The patients who had pre-mortem CPIS ≥ 6, in whom a causative organism was identified from the culture of post-mortem lung biopsy and/or histopathological examination of lung biopsy was compatible with pneumonia were diagnosed as VAP. In the 18 patients in whom a post-mortem lung biopsy was performed, quantitative culture results of endotracheal aspirate performed 48 hours prior to death were compared with microbiological and histopathological results of post-mortem lung biopsy specimens, and the role of endotracheal aspirate in the diagnosis of VAP was evaluated retrospectively. Out of 18 patients (12 men, mean age 67.0 ± 13.0 years) included in the study, 11 (61.1%) were diagnosed as VAP. The quantitative culture of endotracheal aspirate was positive in 9 (81.8%) out of 11 patients diagnosed as VAP. The sensitivity, specificity, positive and negative predictive values of endotracheal aspirate culture for identifying VAP were found to be 81.8%, 14.3%, 60.0% and 33.3%, respectively. Our study shown that quantitative culture of endotracheal aspirate is a practical and reliable method that can be used for the diagnosis of VAP in patients receiving IMV in ICU and having CPIS ≥ 6.

Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates.

PubMed

Roberts, Nesta; Moule, Pam

2011-01-01

Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation after endotracheal intubation. The role of chlorhexidine and tooth-brushing has been considered as a clinical intervention to reduce infection rates, however, evidence to inform this needs appraising. This paper presents a critical review on the effect of chlorhexidine gluconate (CHX) and tooth-brushing in decreasing rates of VAP in mechanically ventilated adult patients cared for in intensive care settings. A literature search was conducted using a number of bibliographic databases (n = 6). A number of parameters were used to exclude irrelevant papers. A total n = 17 papers were located and accessed, which were directly related to the field. Eight studies that met the criteria and addressed the study aims were reviewed. CHX was successful in reducing the rate of VAP and using a combination of CHX and colistine resulted in better oropharyngeal decontamination which reduced and delayed VAP. Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive care and had the potential to reduce nosocomial infections. Results of studies investigating the use of tooth-brushing in reducing VAP incidence proved inconsistent, although all recommend tooth-brushing as important in maintaining good oral hygiene. The use of chlorhexidine has been proven to be of some value in reducing VAP, although may be more effective when used with a solution which targets gram-negative bacteria. Tooth-brushing is recommended in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study design and inconsistency in results suggest that further research is required into the effects of tooth-brushing. © 2011 The Authors. Nursing in Critical Care © 2011 British Association of Critical Care Nurses.

Comparison of ventilator-associated pneumonia (VAP) rates between different ICUs: Implications of a zero VAP rate.

PubMed

Sundar, Krishna M; Nielsen, David; Sperry, Paul

2012-02-01

Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality. Measures to reduce the incidence of VAP have resulted in institutions reporting a zero or near-zero VAP rates. The implications of zero VAP rates are unclear. This study was done to compare outcomes between two intensive care units (ICU) with one of them reporting a zero VAP rate. This study retrospectively compared VAP rates between two ICUs: Utah Valley Regional Medical Center (UVRMC) with 25 ICU beds and American Fork Hospital (AFH) with 9 ICU beds. Both facilities are under the same management and attended by a single group of intensivists. Both ICUs have similar nursing and respiratory staffing patterns. Both ICUs use the same intensive care program for reduction of VAP rates. ICU outcomes between AFH (reporting zero VAP rate) and UVRMC (VAP rate of 2.41/1000 ventilator days) were compared for the years 2007-2008. UVRMC VAP rates during 2007 and 2008 were 2.31/1000 ventilator days and 2.5/1000 ventilator days respectively compared to a zero VAP rate at AFH. The total days of ventilation, mean days of ventilation per patient and mean duration of ICU stay per patient was higher in the UVRMC group as compared to AFH ICU group. There was no significant difference in mean age and APACHE II score between ICU patients at UVRMC and AFH. There was no statistical difference in rates of VAP and mortality between UVRMC and AFH. During comparisons of VAP rate between institutions, a zero VAP rate needs to be considered in the context of overall ventilator days, mean durations of ventilator stay and ICU mortality. Copyright © 2012 Elsevier Inc. All rights reserved.

Probiotics for preventing ventilator-associated pneumonia

PubMed Central

Bo, Lulong; Li, Jinbao; Tao, Tianzhu; Bai, Yu; Ye, Xiaofei; Hotchkiss, Richard S; Kollef, Marin H; Crooks, Neil H; Deng, Xiaoming

2014-01-01

Background Ventilator-associated pneumonia (VAP) is common in intensive care units (ICUs). Some evidence indicates that probiotics may reduce the incidence of VAP. Several additional published studies have demonstrated that probiotics are safe and efficacious in preventing VAP in ICUs. We aimed to systematically summarise the results of all available data to generate the best evidence for the prevention of VAP. Objectives To evaluate the effectiveness and safety of probiotics for preventing VAP. Search methods We searched CENTRAL (2014, Issue 8), MEDLINE (1948 to September week 1, 2014) and EMBASE (2010 to September 2014). Selection criteria Randomised controlled trials (RCTs) comparing probiotics with placebo or another control (excluding RCTs that use probiotics in both study groups) to prevent VAP. Data collection and analysis Two review authors independently assessed eligibility and the quality of trials, and extracted data. Main results We included eight RCTs, with 1083 participants. All studies compared a form of probiotic (Lactobacillus casei rhamnosus; Lactobacillus plantarum; Synbiotic 2000FORTE; Ergyphilus; combination Bifidobacterium longum + Lactobacillus bulgaricus + Streptococcus thermophilus) versus a control group (placebo; glutamine; fermentable fibre; peptide; chlorhexidine). The analysis of all RCTs showed that the use of probiotics decreased the incidence of VAP (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.52 to 0.95, low quality evidence). However, the aggregated results were uncertain for ICU mortality (OR 0.84, 95% CI 0.58 to 1.22 very low quality evidence), in-hospital mortality (OR 0.78, 95% CI 0.54 to 1.14, very low quality evidence), incidence of diarrhoea (OR 0.72, 95% CI 0.47 to 1.09, very low quality evidence), length of ICU stay (mean difference (MD) −1.60, 95% CI −6.53 to 3.33, very low quality evidence), duration of mechanical ventilation (MD −6.15, 95% CI −18.77 to 6.47, very low quality evidence) and antibiotic

[Comparison of endotracheal aspiration and mini-BAL culture results in the diagnosis of ventilator-associated pneumonia].

PubMed

Artuk, Cumhur; Gül, Hanefi Cem; Mert, Gürkan; Karakaş, Ahmet; Bedir, Orhan; Eyigün, Can Polat

2012-07-01

The objective of this study was to compare the results of cultures obtained by mini-bronchoalveolar lavage (BAL) and endotracheal aspiration (ETA) techniques, used for rapid and accurate determination of pathogens causing ventilator-associated pneumonia (VAP) in intensive care units. Of the 92 patients on mechanical ventilation followed at the emergency intensive care unit of our hospital between June 2010 and June 2011, 30 (32.2%) patients were diagnosed as VAP and they were included in this study. VAP diagnosis were based on the clinical and radiological findings. Clinical pulmonary infection score (CPIS) of > 6 was accepted as the clinical criteria of VAP. Initially ETA samples were collected from the patients followed by mini-BAL sampling 15 minutes later, together with urine and two blood cultures. Microbiological evaluation and identification were performed by conventional methods and Phoenix 100 (BD Diagnostic Systems, ABD) automated system. In quantitative culture analysis, > 10.000 cfu/ml for BAL and > 100.000 cfu/ml for ETA were accepted as the positive result. The mean ages of VAP-developed (n= 30; 18 were male) and nondeveloped (n= 62; 39 were male) patients were 68.23 ± 16.19 and 52.16 ± 10.41 years, respectively, and the mean durations of mechanical ventilation were 29.57 ± 15.78 and 12.11 ± 6.01 days, respectively. Multivariate logistic regression analysis showed that older age (p< 0.001) and duration of mechanical ventilation (p< 0.001) were independent risk factors for VAP development. There was also a statistically significant difference in CPIS values between patients who developed VAP and not (6.8 ± 1.15 and 2.71 ± 1.06, respectively; p< 0.001). The use of CPIS for VAP diagnosis was found to be useful in patients on mechanical ventilation. In our study, a total of 16 strains (six A.baumannii, three P.aeruginosa, one K.pneumoniae, six S.aureus) were isolated from ETA cultures, while 34 strains (16 A.baumannii, six P.aeruginosa, four K.pneumoniae

Improved outcome of ventilator-associated pneumonia caused by methicillin-resistant Staphylococcus aureus in a trauma population.

PubMed

Gonzalez, Richard P; Rostas, Jack; Simmons, Jon D; Allen, John; Frotan, Mohammad A; Brevard, Sidney B

2013-03-01

The treatment of ventilator-associated pneumonia (VAP) secondary to methicillin-resistant Staphylococcus aureus (MRSA) remains controversial. We performed a review of all blunt trauma patients diagnosed with MRSA VAP from June 2005 to June 2011. VAP for the first 3 years was diagnosed by sputum aspiration and treated with vancomycin. For the last 3 years of the study period, VAP was diagnosed with bronchoalveolar lavage and treated with linezolid. MRSA VAP patients treated with vancomycin had an average hospital length of stay (LOS) of 49 days (range 9-99 days), an average intensive care unit (ICU) LOS of 43 days (range 6-98 days), and average ventilator days of 34.4 (range 3-76 days). Seventeen MRSA VAP patients treated with linezolid had an average hospital LOS of 27 days (range 11-61), an average ICU LOS of 22 days (range 10-42) days, and average ventilator days of 16.6 (range 2-42). Trauma patients who develop MRSA VAP appear to have fewer ventilator days and shorter ICU and hospital LOS when treated with linezolid. Copyright © 2013 Elsevier Inc. All rights reserved.

Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury. Incidence, risk factors, and association with ventilator-associated pneumonia.

PubMed

Ewig, S; Torres, A; El-Ebiary, M; Fábregas, N; Hernández, C; González, J; Nicolás, J M; Soto, L

1999-01-01

We prospectively evaluated the relation of upper airway, lower airway, and gastric colonization patterns with the development of pneumonia and its etiology in 48 patients with surgical (n = 25) and medical (n = 23) head injury. Initial colonization was assessed by cultures of nasal and pharyngeal swabs, tracheobronchial aspirates, gastric juice, and bronchoscopically retrieved protected specimen brush. Follow-up colonization was determined until the end points extubation, suspected ventilator-associated pneumonia (VAP), or death. The initial colonization rate at any site at ICU admission was 39/47 (83%). It mainly accounted for Group I pathogens (Streptococcus pneumoniae, Staphylococcus aureus, Hemophilus influenzae) of the upper and lower airways. At follow-up, colonization rates with Group II pathogens (Gram-negative enteric bacilli and Pseudomonas spp.) increased significantly. The high initial bacterial load with Group I pathogens of the upper airways and trachea decreased during Days 2 to 4, whereas that of Group II pathogens increased. Upper airway colonization was an independent predictor of follow-up tracheobronchial colonization (odds ratio [OR], 9.9; 95% confidence interval [CI], 1.8 to 56.3 for initial colonization with Group I pathogens; OR, 23.9; 95% CI, 3.8 to 153.3 for follow-up colonization with Group II pathogens). Previous (short-term) antibiotics had a protective effect against colonization with Group I pathogens of the lower respiratory tract (OR, 0.2; 95% CI, 0.05 to 0.86), but they were a risk factor for colonization with Group II pathogens (OR, 6.1; 95% CI, 1.3 to 29). Initial tracheobronchial colonization with Group I pathogens was associated with a higher probability of early onset pneumonia (OR, 4. 1; 95% CI, 0.7 to 23.3), whereas prolonged antibiotic treatment (> 24 h) independently predicted late-onset pneumonia (OR, 9.2; 95% CI, 1.7 to 51.3). We conclude that patients with head injury are colonized in the airways mainly by Group I

[Prevention of ventilator-associated pneumonia: a comparison of level of knowledge in three critical care units].

PubMed

Pujante-Palazón, I; Rodríguez-Mondéjar, J J; Armero-Barranco, D; Sáez-Paredes, P

2016-01-01

To determine the level of knowledge of the prevention of ventilator-associated pneumonia guidelines of nurses working in three intensive care units (ICU) in 3 university hospitals in a Spanish region, and evaluate the relationship between this level of knowledge and years worked in the ICU. A descriptive, prospective, cross-sectional, multicentre study was conducted using a validated and reliable questionnaire, made up by 9 questions with closed answers drawn from the EVIDENCE study. A total of 98 questionnaires were collected from ICU nurses of the three university hospitals (A, B, and C) from January to April 2014. The sample from hospital A responded the most, in contrast with the sample from hospital B, which was the one with the less participation. The Pearson correlation was calculated in order to determine the relationship between nurse years worked in ICU and level of knowledge. Hospital A obtained in the best mean score in the questionnaire, 6.33 (SD 1.4) points, followed by hospital C with 6.21 (SD 1.4), and finally, the hospital B with 6.06 (SD 1.5) points. A p=.08 was obtained on relating years worked with the level of knowledge. The results showed a high level of knowledge compared other studies. There was a tendency between the years worked in the unit and the level of knowledge in ventilator-associated pneumonia prevention. Copyright © 2016 Elsevier España, S.L.U. y SEEIUC. All rights reserved.

[The role of endotracheal aspirate culture in the diagnosis of ventilator-associated pneumonia: a meta analysis].

PubMed

Wang, Fei; He, Bei

2013-01-01

To investigate the role of endotracheal aspirate (EA) culture in the diagnosis and antibiotic management in ventilator-associated pneumonia (VAP). We searched CNKI, Wanfang, PUBMED and EMBASE databases published from January 1990 to December 2011, to find relevant literatures on VAP microbiological diagnostic techniques including EA and bronchoalveolar lavage (BALF). The following key words were used: ventilator associated pneumonia, diagnosis and adult. Meta-analysis was performed and the sensitivity and specificity of EA on VAP diagnosis were calculated. Our literature search identified 1665 potential articles, 8 of which fulfilled our selection criteria including 561 patients with paired cultures. Using BALF quantitative culture as reference standard, the sensitivity and specificity of EA were 72% and 71%. When considering quantitative culture of EA only, the sensitivity and specificity improved to 90% and 65%, while the positive and the negative predictive values were 68% and 89% respectively. However, the sensitivity and specificity of semi-quantitative culture of EA were only 50% and 80%, with a positive predictive value of 77% and a negative predictive value of 58% respectively. EA culture had relatively poor sensitivity and specificity, although quantitative culture of EA only could improve the sensitivity. Initiating therapy on the basis of EA quantitative culture may still result in excessive antibiotic usage. Our data suggested that EA could provide some information for clinical decision but could not replace the role of BALF quantitative culture in VAP diagnosis.

The multistep road to ventilator-associated lung abscess: A retrospective study of S.aureus ventilator-associated pneumonia.

PubMed

Mounier, Roman; Lobo, David; Voulgaropoulos, Julia; Martin, Mathieu; Aït-Mamar, Bouziane; Bitot, Valérie; Jost, Paul-Henri; Birnbaum, Ron; Nebbad, Biba; Cook, Fabrice; Dhonneur, Gilles

2017-01-01

We observed some cases of lung abscess (LA) in ICU patients suffering S.aureus ventilator-associated pneumonia (S.aureus-VAP). We aimed to assess which of the host and/or bacteria-related features are associated with LA. We conducted a retrospective study from January 2009 to July 2013 in a trauma surgical ICU within a teaching hospital. All adult patients presenting with S.aureus-VAP were included. We compared two groups of patients according to the formation or not of LA concomitantly to S.aureus-VAP. Seventy-nine S.aureus-VAP patients, predominantly males (85%) of rather young age (mean [SD]: 35yr [21-64]) with severe trauma (initial Simplified Acute Score II = 42 [32-52]) related-ICU admission, were included. Among them, 10 (14%) developed LA. Patient's characteristics significantly associated with LA development were: a younger age (p = 0.003), road traffic accidents admission (p = 0.017), head injury (p = 0.002), lower Glasgow Coma Scale (p = 0.009), blunt chest trauma (p = 0.01) pneumothorax (p = 0.01) and lung contusions (p = 0.002). No microbiological factors were significantly associated with LA formation. Abscesses were mostly bilateral, ≥5 cm of diameter and with a posterior location. Our results do not favor a specific virulence of S.aureus, but rather highlight the role of multiple insults to the lung, promoting LA formation. Despite a similar severity score, patients with LA had more serious trauma, combining severe both chest and head insults.

Extended infusion versus intermittent infusion of imipenem in the treatment of ventilator-associated pneumonia.

PubMed

Ibrahim, Mohamed M; Tammam, Tarek Fouad; Ebaed, Mohy El Deen; Sarhan, Hatem A; Gad, Gamal F; Hussein, Amal K

2017-01-01

Mechanical ventilation support can be the main source of ventilator-associated pneumonia (VAP). VAP is a serious infection that may be associated with dangerous gram-negative bacteria mainly, and it leads to an increase in the mortality in the intensive care unit (ICU). Imipenem is one of the strongest antibiotics now available for treating VAP which is associated with gram-negative and gram-positive bacteria, and it belongs to beta-lactam antibiotic group (carbapenem). This study tried to investigate the efficacy of imipenem against VAP when it was infused within 180 min versus the efficacy when it was infused within 30-60 min. This study was conducted in main ICU in general hospital which consists of surgical and medical beds within 2 years. One hundred and eighty-seven patients were enrolled on it. This study is a retrospective cohort which was conducted within 2 years. The efficacy of imipenem which was administered by intermittent infusion (30-60 min) within first year was compared with the efficacy of imipenem which was administered by extended infusion (180 min) within second year in the field of VAP curing and cost reduction. All data were collected retrospectively from patient medical files and were statistically analyzed by SPSS version 20. The study was designed to measure clinical and cost reduction outcomes, mortality and hospital stay. The results indicated that there is a significant decrease in mortality, number of recurrent infection, and ICU stay length, and the number of mechanical ventilator days was associated with extended imipenem infusion during the second year of the study. The use of imipenem with extended infusion over 3 hours enhances its clinical outcomes in the treatment of VAP.

Mechanical ventilation drives pneumococcal pneumonia into lung injury and sepsis in mice: protection by adrenomedullin.

PubMed

Müller-Redetzky, Holger C; Will, Daniel; Hellwig, Katharina; Kummer, Wolfgang; Tschernig, Thomas; Pfeil, Uwe; Paddenberg, Renate; Menger, Michael D; Kershaw, Olivia; Gruber, Achim D; Weissmann, Norbert; Hippenstiel, Stefan; Suttorp, Norbert; Witzenrath, Martin

2014-04-14

Ventilator-induced lung injury (VILI) contributes to morbidity and mortality in acute respiratory distress syndrome (ARDS). Particularly pre-injured lungs are susceptible to VILI despite protective ventilation. In a previous study, the endogenous peptide adrenomedullin (AM) protected murine lungs from VILI. We hypothesized that mechanical ventilation (MV) contributes to lung injury and sepsis in pneumonia, and that AM may reduce lung injury and multiple organ failure in ventilated mice with pneumococcal pneumonia. We analyzed in mice the impact of MV in established pneumonia on lung injury, inflammation, bacterial burden, hemodynamics and extrapulmonary organ injury, and assessed the therapeutic potential of AM by starting treatment at intubation. In pneumococcal pneumonia, MV increased lung permeability, and worsened lung mechanics and oxygenation failure. MV dramatically increased lung and blood cytokines but not lung leukocyte counts in pneumonia. MV induced systemic leukocytopenia and liver, gut and kidney injury in mice with pneumonia. Lung and blood bacterial burden was not affected by MV pneumonia and MV increased lung AM expression, whereas receptor activity modifying protein (RAMP) 1-3 expression was increased in pneumonia and reduced by MV. Infusion of AM protected against MV-induced lung injury (66% reduction of pulmonary permeability p < 0.01; prevention of pulmonary restriction) and against VILI-induced liver and gut injury in pneumonia (91% reduction of AST levels p < 0.05, 96% reduction of alanine aminotransaminase (ALT) levels p < 0.05, abrogation of histopathological changes and parenchymal apoptosis in liver and gut). MV paved the way for the progression of pneumonia towards ARDS and sepsis by aggravating lung injury and systemic hyperinflammation leading to liver, kidney and gut injury. AM may be a promising therapeutic option to protect against development of lung injury, sepsis and extrapulmonary organ injury in mechanically

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia.

PubMed

Shi, Zongdao; Xie, Huixu; Wang, Ping; Zhang, Qi; Wu, Yan; Chen, E; Ng, Linda; Worthington, Helen V; Needleman, Ian; Furness, Susan

2013-08-13

Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in persons who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions may reduce the risk of VAP in these patients. To assess the effects of OHC on the incidence of VAP in critically ill patients receiving mechanical ventilation in intensive care units (ICUs) in hospitals. We searched the Cochrane Oral Health Group's Trials Register (to 14 January 2013), CENTRAL (The Cochrane Library 2012, Issue 12), MEDLINE (OVID) (1946 to 14 January 2013), EMBASE (OVID) (1980 to 14 January 2013), LILACS (BIREME) (1982 to 14 January 2013), CINAHL (EBSCO) (1980 to 14 January 2013), Chinese Biomedical Literature Database (1978 to 14 January 2013), China National Knowledge Infrastructure (1994 to 14 January 2013), Wan Fang Database (January 1984 to 14 January 2013), OpenGrey and ClinicalTrials.gov (to 14 January 2013). There were no restrictions regarding language or date of publication. We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation. Two review authors independently assessed all search results, extracted data and undertook risk of bias. We contacted study authors for additional information. Trials with similar interventions and outcomes were pooled reporting odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes using random-effects models unless there were fewer than four studies. Thirty-five RCTs (5374 participants) were included. Five trials (14%) were assessed at low risk of bias, 17 studies (49%) were at high risk of bias, and 13 studies (37%) were assessed at unclear risk of bias in at least one domain. There were

Infection control in intensive care units and prevention of ventilator-associated pneumonia.

PubMed

Bonten, M J; Weinstein, R A

2000-12-01

Ventilator-associated pneumonia (VAP) is considered the most frequent infection in the intensive care unit (ICU), although incidence rates depend on the diagnostic methods. Because VAP has been associated with increased mortality and greater costs for medical care, prevention remains an important goal for intensive care medicine. Selective digestive decontamination (SDD), the most frequently studied method of infection prevention, is still controversial despite more than 30 prospective randomized trials and 6 metaanalyses. SDD reduces the incidence of VAP diagnoses, but beneficial effects on duration of ventilation or ICU stay, antibiotic use, and patient survival have not been shown unequivocally. Although recent metaanalyses suggest a 20% to 40% decrease in ICU mortality for SDD used with systemic prophylaxis, this benefit should be confirmed in a large, prospective, randomized study, preferably with a cost-benefit analysis. Selection of pathogens resistant to the antibiotics used in SDD remains the most important drawback of SDD, rendering SDD contraindicated in wards with endemic resistant problems. Other methods of infection prevention that do not create a selective growth advantage for resistant microorganisms may be more useful. Among these are the use of endotracheal tubes with the possibility of continuous aspiration of subglottic secretions, oropharyngeal decontamination with antiseptics, or the semirecumbent treatment position of patients. Although these methods were successful in single studies, more data are needed. Notwithstanding the potential benefits of these interventions, such classic infection control measures as handwashing remain the cornerstone of infection prevention.

Paradoxical ventilator associated pneumonia incidences among selective digestive decontamination studies versus other studies of mechanically ventilated patients: benchmarking the evidence base

PubMed Central

2011-01-01

Introduction Selective digestive decontamination (SDD) appears to have a more compelling evidence base than non-antimicrobial methods for the prevention of ventilator associated pneumonia (VAP). However, the striking variability in ventilator associated pneumonia-incidence proportion (VAP-IP) among the SDD studies remains unexplained and a postulated contextual effect remains untested for. Methods Nine reviews were used to source 45 observational (benchmark) groups and 137 component (control and intervention) groups of studies of SDD and studies of three non-antimicrobial methods of VAP prevention. The logit VAP-IP data were summarized by meta-analysis using random effects methods and the associated heterogeneity (tau2) was measured. As group level predictors of logit VAP-IP, the mode of VAP diagnosis, proportion of trauma admissions, the proportion receiving prolonged ventilation and the intervention method under study were examined in meta-regression models containing the benchmark groups together with either the control (models 1 to 3) or intervention (models 4 to 6) groups of the prevention studies. Results The VAP-IP benchmark derived here is 22.1% (95% confidence interval; 95% CI; 19.2 to 25.5; tau2 0.34) whereas the mean VAP-IP of control groups from studies of SDD and of non-antimicrobial methods, is 35.7 (29.7 to 41.8; tau2 0.63) versus 20.4 (17.2 to 24.0; tau2 0.41), respectively (P < 0.001). The disparity between the benchmark groups and the control groups of the SDD studies, which was most apparent for the highest quality studies, could not be explained in the meta-regression models after adjusting for various group level factors. The mean VAP-IP (95% CI) of intervention groups is 16.0 (12.6 to 20.3; tau2 0.59) and 17.1 (14.2 to 20.3; tau2 0.35) for SDD studies versus studies of non-antimicrobial methods, respectively. Conclusions The VAP-IP among the intervention groups within the SDD evidence base is less variable and more similar to the benchmark

A Retrospective Study of Non-Ventilator-Associated Hospital Acquired Pneumonia Incidence and Missed Opportunities for Nursing Care.

PubMed

Tesoro, Mary; Peyser, Diane J; Villarente, Farley

2018-05-01

To determine non-ventilator-associated hospital-acquired pneumonia (NV-HAP) incidence, assess negative impacts on patient outcomes and cost, and identify missed preventive nursing care opportunities. NV-HAP is inadequately studied and underreported. Missed nursing care opportunities, particularly oral care, may aid NV-HAP prevention. This descriptive, observational, retrospective chart review identified adult NV-HAP cases and associated demographic and hospital care data. Two hundred five NV-HAP cases occurred in 1 year at Montefiore Medical Center, equating to an incidence of 0.47 per 1000 patient-days and an estimated excess cost of $8.2 million. ICU transfer following pneumonia occurred in 15.6% of cases. Care requirements from specialist nursing facilities increased at discharge (26.8%), as compared with care requirements on admission (17.6%). Complete nursing care documentation was missing for most patients, with oral care undocumented 60.5% of the time. Preventable NV-HAP cases and their negative impact on cost and patient outcomes may decrease through improved basic nursing care.

Hospital-acquired pneumonia

MedlinePlus

... pneumonia; HCAP Patient Instructions Pneumonia in adults - discharge Images Hospital-acquired pneumonia Respiratory system References Chastre J, Luyt C-E. Ventilator-associated pneumonia. In: Broaddus ...

Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies.

PubMed

Fàbregas, N; Ewig, S; Torres, A; El-Ebiary, M; Ramirez, J; de La Bellacasa, J P; Bauer, T; Cabello, H

1999-10-01

A study was undertaken to assess the diagnostic value of different clinical criteria and the impact of microbiological testing on the accuracy of clinical diagnosis of suspected ventilator associated pneumonia (VAP). Twenty five deceased mechanically ventilated patients were studied prospectively. Immediately after death, multiple bilateral lung biopsy specimens (16 specimens/patient) were obtained for histological examination and quantitative lung cultures. The presence of both histological pneumonia and positive lung cultures was used as a reference test. The presence of infiltrates on the chest radiograph and two of three clinical criteria (leucocytosis, purulent secretions, fever) had a sensitivity of 69% and a specificity of 75%; the corresponding numbers for the clinical pulmonary infection score (CPIS) were 77% and 42%. Non-invasive as well as invasive sampling techniques had comparable values. The combination of all techniques achieved a sensitivity of 85% and a specificity of 50%, and these values remained virtually unchanged despite the presence of previous treatment with antibiotics. When microbiological results were added to clinical criteria, adequate diagnoses originating from microbiological results which might have corrected false positive and false negative clinical judgements (n = 5) were countered by a similar proportion of inadequate diagnoses (n = 6). Clinical criteria had reasonable diagnostic values. CPIS was not superior to conventional clinical criteria. Non-invasive and invasive sampling techniques had diagnostic values comparable to clinical criteria. An algorithm guiding antibiotic treatment exclusively by microbiological results does not increase the overall diagnostic accuracy and carries the risk of undertreatment.

Use of ventilator associated pneumonia bundle and statistical process control chart to decrease VAP rate in Syria.

PubMed

Alsadat, Reem; Al-Bardan, Hussam; Mazloum, Mona N; Shamah, Asem A; Eltayeb, Mohamed F E; Marie, Ali; Dakkak, Abdulrahman; Naes, Ola; Esber, Faten; Betelmal, Ibrahim; Kherallah, Mazen

2012-10-01

Implementation of ventilator associated pneumonia (VAP) bundle as a performance improvement project in the critical care units for all mechanically ventilated patients aiming to decrease the VAP rates. VAP bundle was implemented in 4 teaching hospitals after educational sessions and compliance rates along with VAP rates were monitored using statistical process control charts. VAP bundle compliance rates were steadily increasing from 33 to 80% in hospital 1, from 33 to 86% in hospital 2 and from 83 to 100% in hospital 3 during the study period. The VAP bundle was not applied in hospital 4 therefore no data was available. A target level of 95% was reached only in hospital 3. This correlated with a decrease in VAP rates from 30 to 6.4 per 1000 ventilator days in hospital 1, from 12 to 4.9 per 1000 ventilator days in hospital 3, whereas VAP rate failed to decrease in hospital 2 (despite better compliance) and it remained high around 33 per 1000 ventilator days in hospital 4 where VAP bundle was not implemented. VAP bundle has performed differently in different hospitals in our study. Prevention of VAP requires a multidimensional strategy that includes strict infection control interventions, VAP bundle implementation, process and outcome surveillance and education.

Ventilator associated pneumonia: perspectives on the burden of illness.

PubMed

Cook, D

2000-01-01

The objective of this narrative review is to summarize selected current concepts and clinical evidence regarding the burden of illness of VAP, including its epidemiology, diagnosis, attributable mortality and risk factors. Studies were identified through MEDLINE, EMBASE, bibliographies of primary and review articles and personal files. While cross sectional studies inform us about VAP prevalence, longitudinal studies inform us of the cumulative risk and conditional risk of developing VAP. Reported VAP rates are modulated by factors related to case mix, causative microorganisms, interventions that influence risk over time, and VAP definitions employed. Population-specific and organism-specific VAP rates are needed to avoid misleading benchmarking between different ICUs, and to minimize inappropriate between-study comparisons. Observational studies have shown that invasive sampling techniques versus non-invasive approaches to diagnose VAP facilitates more targeted antibiotic treatment; however, the influence of the diagnostic method on endpoints such as mortality is less clear. VAP is associated with approximately a 4 day increase in length of ICU stay and an attributable mortality of approximately 20-30%. Fixed VAP risk factors include underlying cardiorespiratory disease, neurologic injury and trauma. Modifiable VAP risk factors include supine body position, witnessed aspiration, paralytic agents and antibiotic exposure. If modifiable risk factors tested in randomized trials lower VAP rates, such as semirecumbency versus supine positioning, these represent effective VAP prevention strategies. Ventilator-associated pneumonia is a major morbid outcome among critically ill patients. Studies evaluating more effective prevention and treatment strategies are needed.

Effect of multimodality chest physiotherapy in prevention of ventilator-associated pneumonia: A randomized clinical trial.

PubMed

Pattanshetty, Renu B; Gaude, G S

2010-04-01

Despite remarkable progress that has been achieved in the recent years in the diagnosis, prevention, and therapy for ventilator-associated pneumonia (VAP), this disease continues to create complication during the course of treatment in a significant proportion of patients while receiving mechanical ventilation. This study was designed to evaluate the effect of multimodality chest physiotherapy in intubated and mechanically ventilated patients undergoing treatment in the intensive care units (ICUs) for prevention of VAP. A total of 101 adult intubated and mechanically ventilated patients were included in this study. Manual hyperinflation (MH) and suctioning were administered to patients in the control group (n = 51), and positioning and chest wall vibrations in addition to MH plus suctioning (multimodality chest physiotherapy) were administered to patients in the study group (n = 50) till they were extubated. Both the groups were subjected to treatment twice a day. Standard care in the form of routine nursing care, pharmacological therapy, inhalation therapy, as advised by the concerned physician/surgeon was strictly implemented throughout the intervention period. Data were analyzed using SPSS window version 9.0. The Clinical Pulmonary infection Score (CPIS) Score showed significant decrease at the end of extubation/successful outcome or discharge in both the groups (P = 0.00). In addition, significant decrease in mortality rate was noted in the study group (24%) as compared to the control group (49%) (P = 0.007). It was observed in this study that twice-daily multimodality chest physiotherapy was associated with a significant decrease in the CPIS Scores in the study group as compared to the control group suggesting a decrease in the occurrence of VAP. There was also a significant reduction in the mortality rates with the use of multimodality chest physiotherapy in mechanically ventilated patients.

The use of inhaled antibiotic therapy in the treatment of ventilator-associated pneumonia and tracheobronchitis: a systematic review.

PubMed

Russell, Christopher J; Shiroishi, Mark S; Siantz, Elizabeth; Wu, Brian W; Patino, Cecilia M

2016-03-08

Ventilator-associated respiratory infections (tracheobronchitis, pneumonia) contribute significant morbidity and mortality to adults receiving care in intensive care units (ICU). Administration of broad-spectrum intravenous antibiotics, the current standard of care, may have systemic adverse effects. The efficacy of aerosolized antibiotics for treatment of ventilator-associated respiratory infections remains unclear. Our objective was to conduct a systematic review of the efficacy of aerosolized antibiotics in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT), using the Cochrane Collaboration guidelines. We conducted a search of three databases (PubMed, Web of Knowledge and the Cochrane Collaboration) for randomized, controlled trials studying the use of nebulized antibiotics in VAP and VAT that measured clinical cure (e.g., change in Clinical Pulmonary Infection Score) as an outcome measurement. We augmented the electronic searches with hand searches of the references for any narrative review articles as well as any article included in the systematic review. Included studies were examined for risk of bias using the Cochrane Handbook's "Risk of Bias" assessment tool. Six studies met full inclusion criteria. For the systemic review's primary outcome (clinical cure), two studies found clinically and statistically significant improvements in measures of VAP cure while four found no statistically significant difference in measurements of cure. No studies found inferiority of aerosolized antibiotics. The included studies had various degrees of biases, particularly in the performance and detection bias domains. Given that outcome measures of clinical cure were not uniform, we were unable to conduct a meta-analysis. There is insufficient evidence for the use of inhaled antibiotic therapy as primary or adjuvant treatment of VAP or VAT. Additional, better-powered randomized-controlled trials are needed to assess the efficacy of inhaled

The multistep road to ventilator-associated lung abscess: A retrospective study of S.aureus ventilator-associated pneumonia

PubMed Central

Mounier, Roman; Lobo, David; Voulgaropoulos, Julia; Martin, Mathieu; Aït-Mamar, Bouziane; Bitot, Valérie; Jost, Paul-Henri; Birnbaum, Ron; Nebbad, Biba; Cook, Fabrice; Dhonneur, Gilles

2017-01-01

Object We observed some cases of lung abscess (LA) in ICU patients suffering S.aureus ventilator-associated pneumonia (S.aureus-VAP). We aimed to assess which of the host and/or bacteria-related features are associated with LA. Methods We conducted a retrospective study from January 2009 to July 2013 in a trauma surgical ICU within a teaching hospital. All adult patients presenting with S.aureus-VAP were included. We compared two groups of patients according to the formation or not of LA concomitantly to S.aureus-VAP. Results Seventy-nine S.aureus-VAP patients, predominantly males (85%) of rather young age (mean [SD]: 35yr [21–64]) with severe trauma (initial Simplified Acute Score II = 42 [32–52]) related-ICU admission, were included. Among them, 10 (14%) developed LA. Patient’s characteristics significantly associated with LA development were: a younger age (p = 0.003), road traffic accidents admission (p = 0.017), head injury (p = 0.002), lower Glasgow Coma Scale (p = 0.009), blunt chest trauma (p = 0.01) pneumothorax (p = 0.01) and lung contusions (p = 0.002). No microbiological factors were significantly associated with LA formation. Abscesses were mostly bilateral, ≥5 cm of diameter and with a posterior location. Conclusions Our results do not favor a specific virulence of S.aureus, but rather highlight the role of multiple insults to the lung, promoting LA formation. Despite a similar severity score, patients with LA had more serious trauma, combining severe both chest and head insults. PMID:29261721

Antibody response to Prevotella spp. in patients with ventilator-associated pneumonia.

PubMed Central

Grollier, G; Doré, P; Robert, R; Ingrand, P; Gréjon, C; Fauchere, J L

1996-01-01

Although anaerobic bacteria are frequently isolated from the oropharyngeal flora, their potential pathogenic role in ventilator-associated pneumonia (VAP) has been poorly investigated. In order to evaluate the pathogenic role of Prevotella spp. isolated from protected specimen brushes, we investigated the systemic humoral response with the enzyme-linked immunosorbent assay (ELISA) and Western blot (immunoblot) in 13 patients who developed a VAP associated with Prevotella species (group I). The antigen used was a mixture of whole-cell proteins taken from four reference Prevotella strains. We compared the antibody levels observed in these patients with those measured in 30 patients who developed a VAP unrelated to anaerobic bacteria (group II), in 27 patients with dental stumps (group III), and in 30 healthy patients (group IV) who had Prevotella species on dental plaque. The ELISA levels obtained in the four groups showed significant differences between group I and each of the three control groups (P < 0.05). The antibody profiles obtained by Western blot showed an intensity of response roughly superposable over levels obtained by ELISA and a species specificity. These findings suggested that colonization of these patients with Prevotella species may have been associated with an infectious process leading to a systemic humoral response and that these bacteria could play a role in VAP. PMID:8770505

The value of pretest probability and modified clinical pulmonary infection score to diagnose ventilator-associated pneumonia.

PubMed

Lauzier, François; Ruest, Annie; Cook, Deborah; Dodek, Peter; Albert, Martin; Shorr, Andrew F; Day, Andrew; Jiang, Xuran; Heyland, Daren

2008-03-01

The aim of the study was to assess the utility of pretest probability and modified clinical pulmonary infection score CPIS in the diagnosis of late-onset ventilator-associated pneumonia (VAP). In 740 adults enrolled in a multicenter randomized trial, intensivists prospectively rated the pretest probability of VAP as low, moderate, or high based on their clinical judgment. The modified CPIS was calculated without considering culture results. Ventilator-associated pneumonia diagnosis was determined by 2 adjudicators using standardized definitions. We analyzed the relationship between pretest likelihood, CPIS, and VAP diagnosis. Among the 739 patients analyzed, 14.5%, 39.6%, and 45.9% had low, moderate, and high pretest probability of VAP. Patients with high pretest probability had a lower PaO2/FiO2 ratio and a larger volume of secretions. High or moderate vs low pretest probability had high sensitivity (0.88; 95% confidence interval [CI], 0.87-0.89) and positive predictive value (0.87; 95% CI, 0.86-0.88) but low specificity (0.27; 95% CI, 0.21-0.35) and negative predictive value (0.29; 95% C,: 0.22-0.37) for the diagnosis of VAP. Therefore, 71% of patients who had a low pretest probability were actually infected (1 - negative predictive value). The area under the receiver operating characteristic curve for the modified CPIS was not significant (0.47; 95% CI, 0.42-0.53), meaning that no score threshold was clinically useful. Pretest probability and a modified CPIS, which excludes culture results, are of limited utility in the diagnosis of late-onset VAP.

Ventilator-associated pneumonia: current status and future recommendations.

PubMed

Efrati, Shai; Deutsch, Israel; Antonelli, Massimo; Hockey, Peter M; Rozenblum, Ronen; Gurman, Gabriel M

2010-04-01

Ventilator-associated pneumonia (VAP) is a common hazardous complication in ICU patients. The aim of the current review is to give an update on the current status and future recommendations for VAP prevention. This article gives an updated review of the current literature on VAP. The first part briefly reviews pathogenesis and epidemiology while the second includes an in-depth review of evidence-based practice guidelines (EBPG) and new technologies developed for prevention of VAP. VAP remains a frequent and costly complication of critical illness with a pooled relative risk of 9-27% and mortality of 25-50%. Strikingly, VAP adds an estimated cost of more than $40,000 to a typical hospital admission. An important aetiological mechanism of VAP is gross or micro-aspiration of oropharyngeal organisms around the cuff of the endotracheal tube (ETT) into the distal bronchi. Prevention of VAP is preferable. Preventative measures can be divided into two main groups: the implemen- tation of EBPGs and use of device-based technologies. EBPGs have been authored jointly by the American Thoracic Society and the Infectious Diseases Society of America. The Canadian Critical Care Trials group also published VAP Guidelines in 2008. Their recommendations are detailed in this review. The current device-based technologies include drainage of subglottic secretions, silver coated ETTs aiming to influence the internal bio-layer of the ETT, better sealing of the lower airways with ultrathin cuffs and loops for optimal cuff pressure control. EBPG consensus includes: elevation of the head of the bed, use of daily "sedation vacations" and decontamination of the oropharynx. Technological solutions should aim to use the most comprehensive combination of subglottic suction of secretions, optimization of ETT cuff pressure and ultrathin cuffs. VAP is a type of hospital-acquired pneumonia that develops more than 48 h after endotracheal intubation. Its incidence is estimated to be 9-27%, with a

Does educating nurses with ventilator-associated pneumonia prevention guidelines improve their compliance?

PubMed

Aloush, Sami M

2017-09-01

This study aimed to compare the compliance with ventilator-associated pneumonia (VAP)-prevention guidelines between nurses who underwent an intensive educational program and those who did not, and to investigate other factors that influence nurses' compliance. A 2-group posttest design was used to examine the effect of the VAP-prevention guidelines education on nurses' compliance. Participants were randomly assigned to experimental and control groups. The overall nurses' compliance scores were moderate. There was no statistically significant difference in compliance between the nurses who received VAP education and those who did not (t[100] = -1.43; P = .15). The number of beds in the unit and the nurse-patient ratio were found to influence nurses' compliance. Education in VAP-prevention guidelines will not improve nurses' compliance unless other confounding factors, such as their workload, are controlled. It is imperative to reduce nurses' workload to improve their compliance and enhance the effectiveness of education. Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Antibiotic susceptibility patterns of different bacteria isolated from patients with ventilator associated pneumonia (vap).

PubMed

Alqurashi, Abdulrahman M

2005-09-01

Ventilator associated pneumonia (VAP) is a frequent complication of mechanical ventilation (MV) and it is a leading cause of death in MV patients. The development of VAP has been demonstrated as being due to aspiration of oropharyngeal secretion, ventilator tubing condensate, or gastric contents that are colonized with pathogenic microorganisms. The aim of the present study is to isolate and identify bacteria that cause VAP and to study antibiotic susceptibility. This study was carried out on 95 patients who fulfilled the diagnostic criteria for VAP. Quantitative cultures of endotracheal aspirates (EA) using a cut-off point of 10(6) cfu/ml was done. The microbiological results revealed that gram negative bacilli were the most common bacterial agents responsible for VAP and accounted for 78.8% of all the causative agents. The most common isolated organisms were Klebsiella pnemouniae (30.9 %) followed by Pseudomonas aeruginosa (22.5%), Staphylococcus aureus (21.2%), Eschericia coli (12.8 %), Proteus spp. (9.8%), and Citrobacter spp. (2.8%). Blood cultures were positive in 25.9% of patients with Klebsiella pnemouniae in about 33.3%. From this study, it can be concluded that VAP is an important nosocomial infection. EA is a simple procedure to obtain respiratory samples and perform sensitivity testing in patients with VAP. Also, the commonest cause of VAP is gram negative bacilli.

Ventilator-associated pneumonia in a pediatric intensive care unit in Saudi Arabia: a 30-month prospective surveillance.

PubMed

Almuneef, Maha; Memish, Ziad A; Balkhy, Hanan H; Alalem, Hala; Abutaleb, Abdulrahman

2004-09-01

To describe the rate, risk factors, and outcome of ventilator-associated pneumonia (VAP) in pediatric patients. This prospective surveillance study of VAP among all patients receiving mechanical ventilation for 48 hours or more admitted to a pediatric intensive care unit (PICU) in Saudi Arabia from May 2000 to November 2002 used National Nosocomial Infections Surveillance (NNIS) System definitions. Three hundred sixty-one eligible patients were enrolled. Most were Saudi with a mean age of 28.6 months. Thirty-seven developed VAP. The mean VAP rate was 8.87 per 1,000 ventilation-days with a ventilation utilization rate of 47%. The mean duration of mechanical ventilation was 21 days for VAP patients and 10 days for non-VAP patients. The mean PICU stay was 34 days for VAP patients and 15 days for non-VAP patients. Among VAP patients, Pseudomonas aeruginosa was the most common organism, followed by Staphylococcus aureus. Other gram-negative organisms were also encountered. There was no significant difference between VAP and non-VAP patients regarding mortality rate. Witnessed aspiration, reintubation, prior antibiotic therapy, continuous enteral feeding, and bronchoscopy were associated with VAP. On multiple logistic regression analysis, only prior antibiotic therapy, continuous enteral feeding, and bronchoscopy were independent predictors of VAP. The mean VAP rate in this hospital was higher than that reported by NNIS System surveillance of PICUs. This study has established a benchmark for future studies of VAP in the pediatric intensive care population in Saudi Arabia. Additional studies from the region are necessary for comparison and development of preventive measures.

Healthcare-associated Pneumonia: Clinical Features and Retrospective Analysis Over 10 Years

PubMed Central

Qi, Fei; Zhang, Guo-Xin; She, Dan-Yang; Liang, Zhi-Xin; Wang, Ren-Tao; Yang, Zhen; Chen, Liang-An; Cui, Jun-Chang

2015-01-01

Background: Healthcare-associated pneumonia (HCAP) is associated with drug-resistant pathogens and high mortality, and there is no clear evidence that this is due to inappropriate antibiotic therapy. This study was to elucidate the clinical features, pathogens, therapy, and outcomes of HCAP, and to clarify the risk factors for drug-resistant pathogens and prognosis. Methods: Retrospective observational study among hospitalized patients with HCAP over 10 years. The primary outcome was 30-day all-cause hospital mortality after admission. Demographics (age, gender, clinical features, and comorbidities), dates of admission, discharge and/or death, hospitalization costs, microbiological results, chest imaging studies, and CURB-65 were analyzed. Antibiotics, admission to Intensive Care Unit (ICU), mechanical ventilation, and pneumonia prognosis were recorded. Patients were dichotomized based on CURB-65 (low- vs. high-risk). Results: Among 612 patients (mean age of 70.7 years), 88.4% had at least one comorbidity. Commonly detected pathogens were Acinetobacter baumannii, Pseudomonas aeruginosa, and coagulase-negative staphylococci. Initial monotherapy with β-lactam antibiotics was the most common initial therapy (50%). Mean age, length of stay, hospitalization expenses, ICU admission, mechanical ventilation use, malignancies, and detection rate for P. aeruginosa, and Staphylococcus aureus were higher in the high-risk group compared with the low-risk group. CURB-65 ≥3, malignancies, and mechanical ventilation were associated with an increased mortality. Logistic regression analysis showed that cerebrovascular diseases and being bedridden were independent risk factors for HCAP. Conclusion: Initial treatment of HCAP with broad-spectrum antibiotics could be an appropriate approach. CURB-65 ≥3, malignancies, and mechanical ventilation may result in an increased mortality. PMID:26481734

Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies

PubMed Central

Fabregas, N.; Ewig, S.; Torres, A.; El-Ebiary, M.; Ramirez, J.; de la Bellacasa, J. P.; Bauer, T.; Cabello, H.

1999-01-01

BACKGROUND—A study was undertaken to assess the diagnostic value of different clinical criteria and the impact of microbiological testing on the accuracy of clinical diagnosis of suspected ventilator associated pneumonia (VAP).
METHODS—Twenty five deceased mechanically ventilated patients were studied prospectively. Immediately after death, multiple bilateral lung biopsy specimens (16 specimens/patient) were obtained for histological examination and quantitative lung cultures. The presence of both histological pneumonia and positive lung cultures was used as a reference test.
RESULTS—The presence of infiltrates on the chest radiograph and two of three clinical criteria (leucocytosis, purulent secretions, fever) had a sensitivity of 69% and a specificity of 75%; the corresponding numbers for the clinical pulmonary infection score (CPIS) were 77% and 42%. Non-invasive as well as invasive sampling techniques had comparable values. The combination of all techniques achieved a sensitivity of 85% and a specificity of 50%, and these values remained virtually unchanged despite the presence of previous treatment with antibiotics. When microbiological results were added to clinical criteria, adequate diagnoses originating from microbiological results which might have corrected false positive and false negative clinical judgements (n = 5) were countered by a similar proportion of inadequate diagnoses (n =6).
CONCLUSIONS—Clinical criteria had reasonable diagnostic values. CPIS was not superior to conventional clinical criteria. Non-invasive and invasive sampling techniques had diagnostic values comparable to clinical criteria. An algorithm guiding antibiotic treatment exclusively by microbiological results does not increase the overall diagnostic accuracy and carries the risk of undertreatment.

 PMID:10491448

Efficacy of continuous versus intermittent subglottic secretion drainage in preventing ventilator-associated pneumonia in patients requiring mechanical ventilation: A single-center randomized controlled trial.

PubMed

Fujimoto, Hiroko; Yamaguchi, Osamu; Hayami, Hajime; Shimosaka, Mika; Tsuboi, Sayaka; Sato, Mitsunori; Takebayashi, Shigeo; Morita, Satoshi; Saito, Mari; Goto, Takahisa; Kurahashi, Kiyoyasu

2018-03-23

Aspiration of subglottic secretion is a widely used intervention to prevent ventilator-associated pneumonia (VAP). This study aimed to compare the efficacy of continuous and intermittent subglottic secretion drainage (SSD) in preventing VAP. A single-center randomized controlled trial was conducted on adult postoperative patients who were expected to undergo mechanical ventilation for more than 48 hours. Primary outcome measure was incidence of VAP and secondary outcome measures were length of mechanical ventilation and intensive-care unit (ICU) stay. Fifty-nine patients received continuous SSD, while 60 patients received intermittent SSD. Of these 119 patients, 88 (74%) were excluded and 15 and 16 patients were allocated to receive continuous and intermittent SSD, respectively. VAP was detected in 4 (26.7%) and 7 (43.8%) patients in the continuous and intermittent groups, respectively, (p=0.320). The length of mechanical ventilation was significantly shorter (p=0.034) in the continuous group (99.5±47.1 h) than in the intermittent group (159.9±94.5 h). The length of ICU stay was also shorter (p=0.0097) in the continuous group (6.3±2.1 days) than the intermittent group (9.8±4.8 days). Although continuous SSD did not reduce the incidence of VAP, it reduced the length of mechanical ventilation and ICU stay when compared to intermittent SSD.

Genetic polymorphisms within tumor necrosis factor gene promoter region: a role for susceptibility to ventilator-associated pneumonia.

PubMed

Kotsaki, Antigoni; Raftogiannis, Maria; Routsi, Christina; Baziaka, Fotini; Kotanidou, Anastasia; Antonopoulou, Anastasia; Orfanos, Stylianos E; Katsenos, Chrisostomos; Koutoukas, Pantelis; Plachouras, Diamantis; Mandragos, Konstantinos; Giamarellos-Bourboulis, Evangelos J

2012-08-01

Debatable findings exist among various studies regarding the impact of single nucleotide polymorphisms (SNPs) within the promoter region of the tumor necrosis factor (TNF) gene for susceptibility to infections. Their impact was investigated in a cohort of mechanically ventilated patients who developed ventilator-associated pneumonia (VAP). Two-hundred and thirteen mechanically ventilated patients who developed VAP were enrolled. Genomic DNA was extracted and SNPs at the -376, -308 and -238 position of the promoter region of the TNF gene were assessed by restriction fragment length polymorphisms. Monocytes were isolated from 47 patients when they developed sepsis and stimulated by bacterial endotoxin for the production of TNFα and of interleukin-6 (IL-6). Patients were divided into two groups; 166 patients bearing only wild-type alleles of all three studied polymorphisms; and 47 patients carrying at least one A allele of the three studied SNPs. Time between start of mechanical ventilation and advent of VAP was significantly shorter in the second group than in the first group (log-rank: 4.416, p: 0.041). When VAP supervened, disease severity did not differ between groups. Stimulation of TNFα and of IL-6 was much greater by monocytes for patients carrying A alleles. Carriage of at least one A allele of the three studied SNPs at the promoter region of the TNF-gene is associated with shorter time to development of VAP but it is not associated with disease severity. Findings may be related with a role of the studied SNPs in the production of pro-inflammatory cytokines. Copyright © 2012 Elsevier Ltd. All rights reserved.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis.

PubMed

Arumugam, Suresh Kumar; Mudali, Insolvisagan; Strandvik, Gustav; El-Menyar, Ayman; Al-Hassani, Ammar; Al-Thani, Hassan

2018-01-01

We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS ( P =0.001), respiratory rate ( P =0.001), and higher frequency of head ( P =0.02) and chest injuries ( P =0.04). The rate of VAP in PHI group was comparable to the TRI group ( P =0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia.

PubMed

Caruso, Pedro; Denari, Silvia; Ruiz, Soraia A L; Demarzo, Sergio E; Deheinzelin, Daniel

2009-01-01

To compare the incidence of ventilator-associated pneumonia (VAP) with or without isotonic saline instillation before tracheal suctioning. As a secondary objective, we compared the incidence of endotracheal tube occlusion and atelectasis. Randomized clinical trial. The study was conducted in a medical surgical intensive care unit of an oncologic hospital. We selected consecutive patients needing mechanical ventilation for >72 hrs. Patients were allocated into two groups: a saline group that received instillation of 8 mL of saline before tracheal suctioning and a control group which did not. VAP was diagnosed based on clinical suspicion and confirmed by bronchoalveolar lavage quantitative culture. The incidence of atelectasis on daily chest radiography and endotracheal tube occlusions were recorded. The sample size was calculated to a power of 80% and a type I error probability of 5%. One hundred thirty patients were assigned to the saline group and 132 to the control group. The baseline demographic variables were similar between groups. The rate of clinically suspected VAP was similar in both groups. The incidence of microbiological proven VAP was significantly lower in the saline group (23.5% x 10.8%; p = 0.008) (incidence density/1.000 days of ventilation 21.22 x 9.62; p < 0.01). Using the Kaplan-Meier curve analysis, the proportion of patients remaining without VAP was higher in the saline group (p = 0.02, log-rank test). The relative risk reduction of VAP in the saline instillation group was 54% (95% confidence interval, 18%-74%) and the number needed to treat was eight (95% confidence interval, 5-27). The incidence of atelectases and endotracheal tube occlusion were similar between groups. Instillation of isotonic saline before tracheal suctioning decreases the incidence of microbiological proven VAP.

Inadequate treatment of ventilator-associated pneumonia: risk factors and impact on outcomes.

PubMed

Teixeira, P J Z; Seligman, R; Hertz, F T; Cruz, D B; Fachel, J M G

2007-04-01

Initial antibiotic therapy is an important determinant of clinical outcomes in ventilator-associated pneumonia (VAP). Several studies have investigated this issue, with conflicting results. This study investigated risk factors of inadequate empirical antimicrobial therapy and its impact on outcomes for patients with a clinical diagnosis of VAP. The primary outcome was adequacy of antimicrobial therapy. Secondary outcomes were duration of mechanical ventilation, hospital and intensive care unit (ICU) lengths of stay, and mortality due to VAP. Mean age was 62.9+/-15.2 years, mean APACHE (Acute Physiological Assessment and Chronic Health Evaluation) II score was 20.1+/-8.1 and mean MODS (Multiple Organ Dysfunction Score) was 3.7+/-2.5. Sixty-nine (45.7%) of 151 patients with a clinical diagnosis of VAP received inadequate antimicrobial treatment for VAP initially. There were 100 (66.2%) episodes of VAP caused by multidrug-resistant pathogens, of which 56% were inadequately treated, whereas the rate of inadequate antimicrobial therapy for VAP caused by susceptible-drug pathogens was 25.5% (P<0.001). Multiple logistic regression analysis revealed that the risk of inadequate antimicrobial treatment was more than twice as great for patients with late-onset VAP [odds ratio (OR), 2.93; 95% confidence interval (CI), 1.30-6.64; P=0.01], and more than three times for patients with VAP caused by multidrug-resistant pathogens (OR, 3.07; 95% CI, 1.29-7.30; P=0.01) or with polymicrobial VAP (OR, 3.67; 95% CI, 1.21-11.12; P=0.02). Inadequate antimicrobial treatment was associated with higher mortality for patients with VAP. Two of three independent risk factors for treatment inadequacy were associated with the isolation and identification of micro-organisms.

Pro/con clinical debate: The use of a protected specimen brush in the diagnosis of ventilator associated pneumonia

PubMed Central

Heyland, Daren; Ewig, Santiago; Torres, Antoni

2002-01-01

Although mechanical ventilation is instituted as a life-saving technique, it may lead to complications that can negatively impact on patients' morbidity and/or mortality. Ventilator associated pneumonia (VAP) is one such complication that is a common challenge to intensivists. Although most experts would agree that early 'appropriate' antibiotic use is essential in patients who develop VAP, the best diagnostic test to guide decision-making is far from clear. One diagnostic test that is capable of providing microbiological samples from the lower respiratory tree is invasive bronchoscopy with a protected specimen brush. Such a procedure has long been available to intensivists and is frequently employed in many intensive care units. However, this procedure has associated costs and potential complications, and its utility in VAP has been challenged. In this issue of Critical Care Forum, the two sides of this debate are brought forward with compelling arguments. The authors' arguments should fuel future trials. PMID:11983035

Incidence and risk factors for ventilator-associated pneumonia in 4 multidisciplinary intensive care units in Athens, Greece.

PubMed

Apostolopoulou, Eleni; Bakakos, Petros; Katostaras, Theophanis; Gregorakos, Leonides

2003-07-01

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection among intensive care unit (ICU) patients. Prospectively identify the factors associated with development of VAP and examine the incidence of VAP. Over a 6-month period we had 175 patients who required mechanical ventilation for longer than 24 hours. VAP occurred in 56 patients (32%). Stepwise logistic regression analysis identified 5 factors independently associated with VAP (p < 0.05): bronchoscopy (adjusted odds ratio [AOR] = 2.95; 95% confidence interval [CI], 1.1-8.3; p = 0.036); tube thoracostomy (AOR = 2.78; 95% CI, 1.1-6.6; p = 0.023); tracheostomy (AOR = 3.56; 95% CI, 1.7-8.4; p = 0.002); Acute Physiology and Chronic Health Evaluation (APACHE II) score >/= 18 (AOR = 2.33; 95% CI, 1.1-5.1; p = 0.033); and enteral feeding (AOR = 2.89; 95% CI, 1.3-7.7; p = 0.026). The duration of mechanical ventilation was longer among patients who developed VAP (p < 0.001). VAP was not associated with the cause of ICU admission. VAP is a common infection and certain interventions might affect the incidence of VAP. ICU clinicians should be aware of the risk factors for VAP, which could prove useful in identifying patients at high risk for VAP and modifying patient care to minimize the risk of VAP, such as avoiding unnecessary bronchoscopy or modulating enteral feeding.

Use of Ketorolac Is Associated with Decreased Pneumonia Following Rib Fractures

PubMed Central

Yang, Yifan; Young, Jason B.; Schermer, Carol R.; Utter, Garth H.

2015-01-01

Background The effectiveness of the non-steroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity following rib fractures remains largely unknown. Methods We conducted a retrospective cohort study spanning January, 2003 to June, 2011, comparing pneumonia within 30 days and potential adverse effects of ketorolac among all patients with rib fractures who received ketorolac within four days post-injury to a random sample of those who did not. Results Among 202 patients who received ketorolac and 417 who did not, ketorolac use was associated with decreased pneumonia [odds ratio 0.14 (95% confidence interval 0.04–0.46)] and increased ventilator- and intensive care unit-free days [1.8 (95% confidence interval 1.1–2.5) and 2.1 (95% confidence interval 1.3–3.0) days, respectively] within 30 days. The rates of acute kidney injury, gastrointestinal hemorrhage, and fracture non-union were not different. Conclusions Early administration of ketorolac to patients with rib fractures is associated with a decreased likelihood of pneumonia, without apparent risks. PMID:24112670

[Comparision of risk factors and pathogens in patients with early- and late-onset ventilator-associated pneumonia in intensive care unit].

PubMed

Liang, Y J; Li, Z L; Wang, L; Liu, B Y; Ding, R Y; Ma, X C

2017-10-01

Objective: To compare risk factors and bacterial etiology in patients with early-onset versus late-onset ventilator-associated pneumonia (VAP) in intensive care unit (ICU). Methods: This prospective cohort study enrolled mechanically ventilated patients hospitalized for more than 48 hours in the first affiliated hospital, China Medical University from Jan 2012 to Jun 2016. Subjects were classified by ventilator status: early-onset VAP (< 5 d ventilation, E-VAP) or late-onset VAP (≥ 5 d ventilation, L-VAP). Potential risk factors and pathogen were evaluated. Results: A total of 4 179 patients in adult ICU were screened, 3 989 (95.5%) of whom were mechanically ventilated, 962 patients with mechanical ventilation time ≥ 48 h. VAP developed in 142 patients. E-VAP and L-VAP had different potential risk factors based on statistical analysis.Independent risk factors for E-VAP included male ( OR =1.825, 95% CI 1.006-3.310), chronic obstructive pulmonary disease (COPD; OR =3.746, 95% CI 1.795-7.818), emergency intubation ( OR =1.932, 95% CI 1.139-3.276), aspiration ( OR =3.324, 95% CI 1.359-8.130). Whereas independent risk factors for L-VAP were coma ( OR =2.335, 95% CI 1.300-4.194), renal dysfunction ( OR =0.524, 95% CI 0.290-0.947), emergency intubation ( OR =2.184, 95% CI 1.334-3.574). Mortality in E-VAP and L-VAP group were both higher than the non-VAP group[30.2%(19/63)vs 19.8%(162/820), P =0.044; 29.1%(23/79) vs 19.8%(162/820), P =0.046]. The pathogens isolated from early-onset versus late-onset VAP were not significantly different between groups, which the most common ones were acinetobacter baumannii, pseudomonas aeruginosa and klebsiella pneumoniae. Conclusion: E-VAP and L-VAP have different risk factors, however related pathogens are similar. Different specific preventive strategies are suggested based on different onset of VAP.

Assessment of a training programme for the prevention of ventilator-associated pneumonia.

PubMed

Jam Gatell, M Rosa; Santé Roig, Montserrat; Hernández Vian, Óscar; Carrillo Santín, Esther; Turégano Duaso, Concepción; Fernández Moreno, Inmaculada; Vallés Daunis, Jordi

2012-01-01

Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in intensive care units (ICUs). Most published studies have analysed nurses' theoretical knowledge about a specific procedure; however, the transfer of this knowledge to the practice has received little attention. To assess the impact of training session on nurses' knowledge regarding VAP, compliance with VAP preventive measures, VAP incidence and determining whether nursing workload affects compliance. A prospective, quasiexperimental, pre- and post-study of the nursing team in a 16-bed medical/surgical ICU. Pre-intervention phase: a questionnaire to assess nurses' knowledge of VAP prevention measures, direct observation and review of clinical records to assess compliance. Intervention phase: eight training sessions for nurses. The post-intervention phase mirrored the pre-intervention phase. Nurses answered more questions correctly on the post-intervention questionnaire than on the pre-intervention (17·87 ± 2·69 versus 15·91 ± 2·68, p = 0·002). Compliance with the following measures was better during the post-intervention period (p = 0·001): use of the smallest possible nasogastric tube, controlled aspiration of subglottic secretions and endotracheal tube cuff pressure, use of oral chlorhexidine and recording the endotracheal tube fixation number. VAP incidence remained unchanged throughout the study. However, a trend towards lower incidence of late (>4 days after intubation) VAP was observed (4·6 versus 3·1 episodes/1000 ventilation days, p = 0·37). The programme improved both knowledge of and compliance with VAP preventive measures, although improved knowledge did not always result in improved compliance. © 2012 The Authors. Nursing in Critical Care © 2012 British Association of Critical Care Nurses.

Study of prone positioning to reduce ventilator-associated pneumonia in hypoxaemic patients.

PubMed

Mounier, R; Adrie, C; Français, A; Garrouste-Orgeas, M; Cheval, C; Allaouchiche, B; Jamali, S; Dinh-Xuan, A T; Goldgran-Toledano, D; Cohen, Y; Azoulay, E; Timsit, J-F; Ricard, J-D

2010-04-01

The aim of the present study was to examine whether prone positioning (PP) affects ventilator associated-pneumonia (VAP) and mortality in patients with acute lung injury/adult respiratory distress syndrome. 2,409 prospectively included patients were admitted over 9 yrs (2000-2008) to 12 French intensive care units (ICUs) (OUTCOMEREA). The patients required invasive mechanical ventilation (MV) and had arterial oxygen tension/inspiratory oxygen fraction ratios <300 during the first 48 h. Controls were matched to PP patients on the PP propensity score (+/-10%), MV duration longer than that in PP patients before the first turn prone, and centre. VAP incidence was similar in the PP and control groups (24 versus 13 episodes.1,000 patient-days MV(-1) respectively, p = 0.14). After adjustment, PP did not decrease VAP occurrence (HR 1.64 (95% CI 0.70-3.84); p = 0.25) but significantly delayed hospital mortality (HR 0.56 (95% CI 0.39-0.79); p = 0.001), without decreasing 28-day mortality (37% in both groups). Post hoc analyses indicated that PP did not protect against VAP but, when used for >1 day, might decrease mortality and benefit the sickest patients (Simplified Acute Physiology Score >50). In ICU patients with hypoxaemic acute respiratory failure, PP had no effect on the risk of VAP. PP delayed mortality without decreasing 28-day mortality. PP >1 day might decrease mortality, particularly in the sickest patients.

Reducing the risk of ventilator-acquired pneumonia through head of bed elevation.

PubMed

Keeley, Libby

2007-01-01

It has been suggested that placing critically ill ventilated patients in a semirecumbent position minimizes the likelihood of nosocomial pneumonia. This pilot study explores whether the incidence of ventilator-acquired pneumonia (VAP) can be reduced by elevating the head of the bed to 45 degrees. The design is quantitative in nature, using a randomized controlled trial. The method involves adult ventilated patients being randomly assigned to one of two positions, i.e. 45 degrees raised head of bed (treatment group) or 25 degrees raised head of bed (control group). Data collection relied upon the diagnosis of clinically suspected and microbiologically confirmed pneumonia defined by the Consensus Conference on VAP. Thirty patients were included in the study--17 in the treatment group and 13 in the control group. Results showed that 29% (five) in the treatment group and 54% (seven) in the control group contracted VAP (P < 0.176). There was a trend towards a reduction in VAP in the patients nursed at 45 degrees. However, because of the sample size this difference did not reach statistical significance.

Inhaled Antibiotics for Ventilator-Associated Infections.

PubMed

Palmer, Lucy B

2017-09-01

Multidrug-resistant organisms are creating a challenge for physicians treating the critically ill. As new antibiotics lag behind the emergence of worsening resistance, intensivists in countries with high rates of extensively drug-resistant bacteria are turning to inhaled antibiotics as adjunctive therapy. These drugs can provide high concentrations of drug in the lung that could not be achieved with intravenous antibiotics without significant systemic toxicity. This article summarizes current evidence describing the use of inhaled antibiotics for the treatment of bacterial ventilator-associated pneumonia and ventilator-associated tracheobronchitis. Preliminary data suggest aerosolized antimicrobials may effectively treat resistant pathogens with high minimum inhibitory concentrations. Copyright © 2017 Elsevier Inc. All rights reserved.

Timing of intubation and ventilator-associated pneumonia following injury.

PubMed

Evans, Heather L; Zonies, David H; Warner, Keir J; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph

2010-11-01

In an emergency medical system with established rapid-sequence intubation protocols, prehospital (PH) intubation of patients with trauma is not associated with a higher rate of ventilator-associated pneumonia (VAP) than emergency department (ED) intubation. Retrospective observational cohort. Level I trauma center. Adult patients with trauma intubated in a PH or an ED setting from July 1, 2007, through July 31, 2008. Diagnosis of VAP by means of bronchoscopic alveolar lavage or clinical assessment when bronchoscopic alveolar lavage was impossible. Secondary outcomes included time to VAP, length of hospitalization, and in-hospital mortality. Of 572 patients, 412 (72.0%) underwent PH intubation. The ED group was older than the PH group (mean ages, 46.4 vs 39.1 years; P < .001) and had a higher incidence of blunt injury (142 [88.8%] vs 322 [78.2%]; P = .002). The mean (SD) lowest recorded ED systolic blood pressure was lower in the ED group (102.8 [1.9] vs 111.4 [1.2] mm Hg; P < .001), despite similar mean injury severity scores in both groups (27.2 [0.7] vs 27.0 [1.1]; P = .94). There was no difference in the mean rate of VAP (30 [18.8%] vs 71 [17.2%]; P = .66) or mean time to diagnosis (8.1 [1.2] vs 7.8 [1.0] days; P = .89). Logistic regression analysis identified history of drug abuse, lowest recorded ED systolic blood pressure, and injury severity score as 3 independent factors predictive of VAP. Prehospital intubation of patients with trauma is not associated with higher risk of VAP. Further investigation of intubation factors and the incidence and timing of aspiration is required to identify potentially modifiable factors to prevent VAP.

4G/5G Polymorphism of Plasminogen Activator Inhibitor -1 Gene Is Associated with Mortality in Intensive Care Unit Patients with Severe Pneumonia

PubMed Central

Sapru, Anil; Hansen, Helen; Ajayi, Temitayo; Brown, Ron; Garcia, Oscar; Zhuo, HanJing; Wiemels, Joseph; Matthay, Michael A.; Wiener-Kronish, Jeanine

2011-01-01

Background Higher plasma and pulmonary edema fluid levels of plasminogen activator inhibitor-1 (PAI-1) are associated with increased mortality in patients with pneumonia and acute lung injury. The 4G allele of the 4G/5G polymorphism of the PAI-1 gene is associated with higher PAI-1 levels and an increased incidence of hospitalizations for pneumonia. The authors hypothesized that the 4G allele would be associated with worse clinical outcomes (mortality and ventilator-free days) in patients with severe pneumonia. Methods The authors enrolled patients admitted with severe pneumonia in a prospective cohort. Patients were followed until hospital discharge. DNA was isolated from blood samples, and genotyping detection for the PAI-1 4G/5G polymorphism was carried out using Taqman-based allelic discrimination. Results A total of 111 patients were available for analysis. Distribution of genotypes was 4G/4G 26 of 111 (23%), 4G/5G 59 of 111 (53%), and 5G/5G 26 of 111 (23%). Of 111 patients, 32 (29%) died before hospital discharge and 105 patients (94%) received mechanical ventilation. Patients with the 4G/4G and the 4G/5G genotypes had higher mortality (35% vs. 8%, P = 0.007) and fewer ventilator-free days (median 4 vs. 13, P = 0.04) compared to patients with the 5G/5G genotype. Conclusions The 4G allele of the 4G/5G polymorphism in the PAI-1 gene is associated with fewer ventilator-free days and increased mortality in hospitalized patients with severe pneumonia. These findings suggest that PAI-1 may have a role in pathogenesis and that the 4G/5G polymorphism may be an important biomarker of risk in patients with severe pneumonia. PMID:19387177

Candida spp. airway colonization: A potential risk factor for Acinetobacter baumannii ventilator-associated pneumonia.

PubMed

Tan, Xiaojiang; Zhu, Song; Yan, Dongxing; Chen, Weiping; Chen, Ruilan; Zou, Jian; Yan, Jingdong; Zhang, Xiangdong; Farmakiotis, Dimitrios; Mylonakis, Eleftherios

2016-08-01

This retrospective study was conducted to identify potential risk factors for Acinetobacter baumannii (A. baumannii) ventilator-associated pneumonia (VAP) and evaluate the association between Candida spp. airway colonization and A. baumannii VAP. Intensive care unit (ICU) patients who were on mechanical ventilation (MV) for ≥48 hours were divided into the following groups: patients with and without Candida spp. airway colonization; colonized patients receiving antifungal treatment or not; patients with A. baumannii VAP and those without VAP. Logistic regression analysis and propensity score matching were used to identify factors independently associated with A. baumannii VAP. Among 618 eligible patients, 264 (43%) had Candida spp. airway colonization and 114 (18%) developed A. baumannii VAP. Along with MV for ≥7 days (adjusted odds ratio [aOR] 8.9, 95% confidence intervals [95% CI] 4.9-15.8) and presence of a central venous catheter (aOR 3.2, 95% CI 1.1-9), Candida spp. airway colonization (aOR 2.6, 95% CI 1.6-4.3) was identified as an independent risk factor for A. baumannii VAP. Patients with Candida spp. airway colonization were more likely to develop A. baumannii VAP than non-colonized patients (23% vs 15%, P=.01 and 34% vs. 15%, P<.001 in propensity score-matched subgroups). Administration of antifungal agents was not associated with A. baumannii VAP (29% vs. 21%, P=.153) but with higher in-hospital mortality (53% vs. 39%, P=.037). Candida spp. airway colonization (43%) and A. baumannii VAP (18%) were common in ICU patients who were on mechanical ventilation for at least 48 hours. Candida spp. airway colonization was an independent risk factor for subsequent A. baumannii VAP. © The Author 2016. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Ventilator-associated pneumonia rates in critical care units in 3 Arabian Gulf countries: A 6-year surveillance study.

PubMed

El-Saed, Aiman; Al-Jardani, Amina; Althaqafi, Abdulhakeem; Alansari, Huda; Alsalman, Jameela; Al Maskari, Zaina; El Gammal, Ayman; Al Nasser, Wafa; Al-Abri, Seif S; Balkhy, Hanan H

2016-07-01

Data estimating the rates of ventilator-associated pneumonia (VAP) in critical patients in Gulf Cooperation Council (GCC) countries are very limited. The aim of this study was to estimate VAP rates in GCC hospitals and to compare rates with published reports of the U.S. National Healthcare Safety Network (NHSN) and International Nosocomial Infection Control Consortium (INICC). VAP rates and ventilator utilization between 2008 and 2013 were calculated from aggregate VAP surveillance data using NHSN methodology pooled from 6 hospitals in 3 GCC countries: Saudi Arabia, Oman, and Bahrain. The standardized infection ratios of VAP in GCC hospitals were compared with published reports of the NHSN and INICC. A total of 368 VAP events were diagnosed during a 6-year period covering 76,749 ventilator days and 134,994 patient days. The overall VAP rate was 4.8 per 1,000 ventilator days (95% confidence interval, 4.3-5.3), with an overall ventilator utilization of 0.57. The VAP rates showed a wide variability between different types of intensive care units (ICUs) and were decreasing over time. After adjusting for the differences in ICU type, the risk of VAP in GCC hospitals was 217% higher than NHSN hospitals and 69% lower than INICC hospitals. The risk of VAP in ICU patients in GCC countries is higher than pooled U.S. VAP rates but lower than pooled rates from developing countries participating in the INICC. Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

[Ventilator bundle guided by context of JCI settings can effectively reduce the morbidity of ventilator-associated pneumonia].

PubMed

Zhao, Lili; Liu, Lili; Chen, Jing; Yang, Caili; Nie, Jianjian; Zhang, Minwei

2017-07-01

To observe the impact of improving the compliance of ventilator bundle on morbidity of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients undergoing mechanical ventilation (MV) guided by context of Joint Commission International (JCI) settings, and to study the oral care efficacy of suction tube sponge brush. A prospective study was conducted. The patients who needed MV admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Xiamen University from January 2013 to December 2016 were enrolled. In the context of JCI settings, necessary measurements were taken to enhance the compliance of ventilator bundle each year. In 2013, the preventive measures were set up and the education was strengthened. In 2014, the compliance of hand hygiene and bedside elevation was strengthened. In 2015, a control study was conducted to evaluate the effect between the traditional cotton dipped in chlorhexidine and the suction tube sponge brush rinsed with chlorhexidine on oral health impact parameters. The suction tube sponge brush rinsed with chlorhexidine oral care was introduced to improve compliance. In 2016, electronic bundle checklist for daily self-audits was conducted. The annually morbidity of VAP through the software of hospital and ICU was collected and calculated. The annual incidence of VAP was indicated by the VAP cases per 1 000 MV days. Based on the VAP incidence rate in 2013 as 1, the VAP incidence-rate ratio (IRR) of each year was calculated. During the study period, a total of 2 733 patients admitted to the ICU, including 1 403 patients undergoing MV. Ninety-four of the 1 403 patients with community-acquired pneumonia (CAP), aspiration pneumonia, back elevation ban, incomplete information, and withdrew from the study were excluded. 1 399 patients undergoing MV were enrolled in the final analysis, with total MV days of 11 012 days, and 94 patients occurred VAP. The annual incidence of VAP was progressively declined

The impact of hospital-wide use of a tapered-cuff endotracheal tube on the incidence of ventilator-associated pneumonia.

PubMed

Bowton, David L; Hite, R Duncan; Martin, R Shayn; Sherertz, Robert

2013-10-01

Aspiration of colonized oropharyngeal secretions is a major factor in the pathogenesis of ventilator-associated pneumonia (VAP). A tapered-cuff endotracheal tube (ETT) has been demonstrated to reduce aspiration around the cuff. Whether these properties are efficacious in reducing VAP is not known. This 2-period, investigator-initiated observational study was designed to assess the efficacy of a tapered-cuff ETT to reduce the VAP rate. All intubated, mechanically ventilated patients over the age of 18 were included. During the baseline period a standard, barrel-shaped-cuff ETT (Mallinckrodt Hi-Lo) was used. All ETTs throughout the hospital were then replaced with a tapered-cuff ETT (TaperGuard). The primary outcome variable was the incidence of VAP per 1,000 ventilator days. We included 2,849 subjects, encompassing 15,250 ventilator days. The mean ± SD monthly VAP rate was 3.29 ± 1.79/1,000 ventilator days in the standard-cuff group and 2.77 ± 2.00/1,000 ventilator days in the tapered-cuff group (P = .65). While adherence to the VAP prevention bundle was high throughout the study, bundle adherence was significantly higher during the standard-cuff period (96.5 ± 2.7%) than in the tapered-cuff period (90.3 ± 3.5%, P = .01). In the setting of a VAP rate very near the average of ICUs in the United States, and where there was high adherence to a VAP prevention bundle, the use of a tapered-cuff ETT was not associated with a reduction in the VAP rate.

Gastropulmonary Route of Infection and the Prevalence of Microaspiration in the Elderly Patients with Ventilator-Associated Pneumonia Verified by Molecular Microbiology-GM-PFGE.

PubMed

Liu, Qing-hua; Zhang, Jing; Lin, Dian-jie; Mou, Xiao-yan; He, Li-xian; Qu, Jie-ming; Li, Hua-yin; Hu, Bi-jie; Zhu, Ying-min; Zhu, Du-ming; Gao, Xiao-dong

2015-04-01

Gastropulmonary route of infection was considered to be an important mechanism of ventilator-associated pneumonia (VAP). However there is little evidence to support this assumption. Moreover, the prevalence of microaspiration in elderly ventilated patients was not well understood. To confirm gastropulmonary infection route and investigate the prevalence of microaspiration in elderly ventilated patients using genome macrorestriction-pulsed field gel electrophoresis (GM-PFGE). Patients over 60 years old, expected to receive mechanical ventilation longer than 48 h, were prospectively enrolled from October 2009 to January 2012. Clinical data were collected and recorded until they died, developed pneumonia, or were extubated. Samples from gastric fluid, subglottic secretion and lower respiratory tract (LRT) were collected during the follow-up for microbiological examination. To evaluate the homogeneity, GM-PFGE was performed on strains responsible for VAP that had the same biochemical phenotype as those isolated from gastric juice and subglottic secretions sequentially. Among 44 VAP patients, 76 strains were isolated from LRT and considered responsible for VAP. Twenty-two isolates had the same biochemical phenotype with the corresponding gastric isolates. The homology was further confirmed using GM-PFGE in 12 episodes of VAP. Nearly 30% of VAPs were caused by microaspiration based on the analysis of bacterial phenotype or GM-PFGE. In addition, 58.3% patients with gastric colonization developed VAP, especially late-onset VAP (LOP). Gastropulmonary infection route exists in VAP especially LOP in elderly ventilated patients. It is one of the important mechanisms in the development of VAP.

Efficacy of a bundle approach in preventing the incidence of ventilator associated pneumonia (VAP)

PubMed Central

Burja, Sandra; Belec, Tina; Bizjak, Nika; Mori, Jernej; Markota, Andrej; Sinkovič, Andreja

2018-01-01

Ventilator-associated pneumonia (VAP) is a potentially preventable iatrogenic illness that may develop following mechanical ventilation. A bundle for the prevention of VAP consists of different measures which may vary between institutions, and may include: elevation of the head of the bed, oral care with chlorhexidine, subglottic suctioning, daily assessment for extubation and the need for proton-pump inhibitors, use of closed suction systems, and maintaining endotracheal cuff pressure at 25 cmH2O. Our aim was to determine the efficacy of a VAP prevention bundle, consisting of the above-mentioned measures, by evaluating the incidence of VAP before (no-VAP-B group) and after (VAP-B group) the introduction of the bundle. We retrospectively evaluated the data for patients who were mechanically ventilated with an endotracheal tube, in the period between 1 September and 31 December 2014 (no-VAP-B group, n = 55, 54.5% males, mean age 67.8 ± 14.5 years) and between 1 January to 30 April 2015 (VAP-B group, n = 74, 62.1% males, mean age 64.8 ± 13.7 years). There were no statistically significant differences between no-VAP-B and VAP-B groups in demographic data, intensive care unit (ICU) mortality, hospital mortality, duration of ICU treatment, and duration of mechanical ventilation. No significant differences in the rates of VAP and early VAP (onset ≤7 days after intubation) were found between no-VAP-B and VAP-B groups (41.8% versus 25.7%, p = 0.06 and 10.9% versus 12.2%, p > 0.99, respectively). However, a significant decrease in the late VAP (onset >8 days after intubation) was found in VAP-B group compared to no-VAP-B group (13.5% versus 30.9%, p = 0.027). Overall, our results support the use of VAP prevention bundle in clinical practice. PMID:28976870

Healthcare-Associated Pneumonia among United States Combat Casualties, 2009–2010

PubMed Central

Yun, Heather C.; Weintrob, Amy C.; Conger, Nicholas G.; Li, Ping; Lu, Dan; Tribble, David R.; Murray, Clinton K.

2014-01-01

Although there is literature evaluating infectious complications associated with combat-related injuries from Iraq and Afghanistan, none have evaluated pneumonia specifically. Therefore, we assessed a series of pneumonia cases among wounded military personnel admitted to Landstuhl Regional Medical Center, and then evacuated further to participating U.S. military hospitals. Of the 423 casualties evacuated to the U.S., 36 developed pneumonia (8.5%) and 30 of these (83.3%) were ventilator-associated. Restricting to 162 subjects admitted to intensive care, 30 patients had pneumonia (18.5%). The median Injury Severity Score was higher among subjects with pneumonia (23.0, versus 6.0; p<0.01). There were 61 first-isolate respiratory specimens recovered from 31 pneumonia subjects, of which 56.1% were gram-negative, 18.2% were gram-positive, and 18.2% were fungal. Staphylococcus aureus and Pseudomonas aeruginosa were most commonly recovered (10.6%, and 9.1%, respectively). Thirteen bacterial isolates (26.5%) were multidrug-resistant. Outcome data were available for 32 patients, of which 26 resolved their infection without progression, 5 resolved after initial progression, and 1 died. Overall, combat-injured casualties suffer a relatively high rate of pneumonia, particularly those requiring mechanical ventilation. Although gram-negative pathogens were common, S. aureus was most frequently isolated. Continued focus on pneumonia prevention strategies is necessary for improving combat care. PMID:25562865

Antibiotic therapy prior to hospital admission is associated with reduced septic shock and need for mechanical ventilation in patients with community-acquired pneumonia.

PubMed

Amaro, Rosanel; Sellarés, Jacobo; Polverino, Eva; Cillóniz, Catia; Ferrer, Miquel; Fernández-Barat, Laia; Mensa, Josep; Niederman, Michael S; Torres, Antoni

2017-05-01

A subgroup of patients admitted to the hospital with a diagnosis of community-acquired pneumonia (CAP) have received antibiotic therapy prior to admission for the current episode of pneumonia. The objective of this study was to assess the clinical course of patients receiving antibiotics prior to admission, compared to patients not previously treated. An observational cohort of 3364 CAP patients consecutively admitted to our hospital, and prospectively included, were studied. We collected clinical, microbiological and biochemical parameters, focusing on recent antibiotics received prior to admission. 610 (18%) patients received antibiotics prior to hospital admission for the current CAP episode. Patients with previous antibiotic use developed septic shock less frequently (4% vs. 7%, p = 0.007) and required invasive ventilation less often (3% vs. 6%, p = 0.002). After adjustment by different covariate factors and propensity score, antibiotic therapy was still independently associated with a lower incidence of septic shock at admission (OR 0.54 [95% CI 0.31-0.95], p = 0.03) and less need for invasive ventilation (OR 0.38 [95% CI 0.16-0.91], p = 0.03). In this cohort, recent use of antibiotics before hospital admission in CAP seems to be associated with a lower incidence of septic shock on admission and a lower need for invasive ventilation. Copyright © 2017 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Temporal Trends of Ventilator-Associated Pneumonia Incidence and the Effect of Implementing Health-care Bundles in a Suburban Community

PubMed Central

Ding, Shifang; Kilickaya, Oguz; Senkal, Serkan; Gajic, Ognjen; Hubmayr, Rolf D.

2013-01-01

Background: Recent changes in critical care delivery, including the widespread implementation of health-care bundles, were aimed at reducing complications of critical illness, in particular ventilator-associated pneumonia (VAP), but no population-based study evaluated its effectiveness. Methods: Using a previously validated electronic medical record database, we identified adult (≥ 18 years old) critically ill patients from Olmsted County, Minnesota, requiring mechanical ventilation for ≥ 48 h from January 2003 to December 2009. Trained intensivists identified cases of VAP according to different established clinical definitions. The incidence and outcome of VAP was compared before and after implementation of the so-called “VAP bundle.” Results: The median age, severity of illness, proportion of surgical patients, and patients with neurologic disease increased over time (P < .05 for trend in all). Regardless of the definition used, the VAP rate remained similar throughout the study period and did not change with the introduction of the VAP bundle. According to previous Centers for Disease Control and Prevention criteria, the yearly estimates of the VAP incidence ranged between 7.1 and 10.4 cases per 1,000 ventilator-days, with an age-adjusted incidence of 3.1 vs 5.6 per 100,000 population (P = .54 for trends). Standardized hospital mortality ratio of patients at high risk to develop VAP significantly decreased from 1.7 (95% CI, 0.8-3.0) to 0.7 (95% CI, 0.3-1.4; P = .0003 for trend). Conclusions: The incidence of VAP was unaffected by the implementation of the VAP bundle. Secular changes in hospital mortality are unlikely to be attributed to the VAP bundle per se. PMID:23907411

Routine aspiration of subglottic secretions after major heart surgery: impact on the incidence of ventilator-associated pneumonia.

PubMed

Pérez Granda, M J; Barrio, J M; Hortal, J; Muñoz, P; Rincón, C; Bouza, E

2013-12-01

Aspiration of subglottic secretions (ASS) is recommended in patients requiring mechanical ventilation for ≥48h. We assessed the impact of the introduction of ASS routinely in all patients after major heart surgery in an ecological study comparing ventilator-acquired pneumonia (VAP) incidence, days of mechanical ventilation, and cost of antimicrobial agents before and after the implementation of ASS. Before and after the intervention the results (per 1000 days) were: VAP incidence, 23.92 vs 16.46 (P = 0.04); cost of antimicrobials, €71,384 vs €63,446 (P = 0.002); and days of mechanical ventilation, 507.5 vs 377.5 (P = 0.009). From the moment of induction of anaesthesia all patients undergoing major heart surgery should routinely receive ASS. Copyright © 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Could soluble urokinase plasminogen receptor (suPAR) be used as a diagnostic biomarker for ventilator-associated pneumonia?

PubMed

Sunnetcioglu, Aysel; Sunnetcioglu, Mahmut; Adıyaman, Fırat; Binici, Irfan; Soyoral, Lokman

2017-11-01

Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker that is increasingly used for evaluation of systemic inflammation. This study was performed to investigate whether suPAR may possess a diagnostic value in patients with ventilator-associated pneumonia (VAP). This clinical study was performed in the anesthesia intensive care units (ICUs) of our university. In addition to descriptive data, WBC, serum levels of C-reactive protein (CRP) and suPAR prior to and after development of VAP were noted and compared in 31 patients (22 men, 9 women) diagnosed with VAP (Study Group) and 19 patients without VAP (Control Group) in ICU (14 men, 5 women). The suPAR (P = 0.023), CRP (P = 0.037), WBCs (P = 0.024) in patients with VAP were significantly higher than patients without VAP. There was no remarkable difference in terms of WBCs (P = 0.052) and suPAR levels (P = 0.616) between groups on the first day of connection to mechanical ventilator. The suPAR and CRP levels in patients with VAP were significantly higher than prior to development of VAP (P = 0.001 for both). Area under curve value after diagnosis of pneumonia was found 0.248 (P = 0.002). To conclude, our results suggest that suPAR can be a useful diagnostic biomarker in patients with VAP. However, clinical trials on larger series are warranted to explore the clinical significance more accurately. © 2016 John Wiley & Sons Ltd.

Role of First-Line Noninvasive Ventilation in Non-COPD Subjects With Pneumonia.

PubMed

Rialp, Gemma; Forteza, Catalina; Muñiz, Daniel; Romero, Maria

2017-09-01

The use of noninvasive ventilation (NIV) in non-COPD patients with pneumonia is controversial due to its high rate of failure and the potentially harmful effects when NIV fails. The purpose of the study was to evaluate outcomes of the first ventilatory treatment applied, NIV or invasive mechanical ventilation (MV), and to identify predictors of NIV failure. Historical cohort study of 159 non-COPD patients with pneumonia admitted to the ICU with ventilatory support. Subjects were divided into 2 groups: invasive MV or NIV. Univariate and multivariate analyses with demographic and clinical data were performed. Analysis of mortality was adjusted for the propensity of receiving first-line invasive MV. One hundred and thirteen subjects received first-line invasive MV and 46 received first-line NIV, of which 27 needed intubation. Hospital mortality was 35, 37 and 56%, respectively, with no significant differences among groups. In the propensity-adjusted analysis (expressed as OR [95% CI]), hospital mortality was associated with age (1.05 [1.02-1.08]), SAPS3 (1.03 [1.00-1.07]), immunosuppression (2.52 [1.02-6.27]) and NIV failure compared to first-line invasive MV (4.3 [1.33-13.94]). Compared with invasive MV, NIV failure delayed intubation (p=.004), and prolonged the length of invasive MV (p=.007) and ICU stay (p=.001). NIV failure was associated with need for vasoactive drugs (OR 7.8 [95% CI, 1.8-33.2], p=.006). In non-COPD subjects with pneumonia, first-line NIV was not associated with better outcome compared with first-line invasive MV. NIV failure was associated with longer duration of MV and hospital stay, and with increased hospital mortality. The use of vasoactive drugs predicted NIV failure. Copyright © 2016 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.

BreathDx - molecular analysis of exhaled breath as a diagnostic test for ventilator-associated pneumonia: protocol for a European multicentre observational study.

PubMed

van Oort, Pouline M P; Nijsen, Tamara; Weda, Hans; Knobel, Hugo; Dark, Paul; Felton, Timothy; Rattray, Nicholas J W; Lawal, Oluwasola; Ahmed, Waqar; Portsmouth, Craig; Sterk, Peter J; Schultz, Marcus J; Zakharkina, Tetyana; Artigas, Antonio; Povoa, Pedro; Martin-Loeches, Ignacio; Fowler, Stephen J; Bos, Lieuwe D J

2017-01-03

The diagnosis of ventilator-associated pneumonia (VAP) remains time-consuming and costly, the clinical tools lack specificity and a bedside test to exclude infection in suspected patients is unavailable. Breath contains hundreds to thousands of volatile organic compounds (VOCs) that result from host and microbial metabolism as well as the environment. The present study aims to use breath VOC analysis to develop a model that can discriminate between patients who have positive cultures and who have negative cultures with a high sensitivity. The Molecular Analysis of Exhaled Breath as Diagnostic Test for Ventilator-Associated Pneumonia (BreathDx) study is a multicentre observational study. Breath and bronchial lavage samples will be collected from 100 and 53 intubated and ventilated patients suspected of VAP. Breath will be analysed using Thermal Desorption - Gas Chromatography - Mass Spectrometry (TD-GC-MS). The primary endpoint is the accuracy of cross-validated prediction for positive respiratory cultures in patients that are suspected of VAP, with a sensitivity of at least 99% (high negative predictive value). To our knowledge, BreathDx is the first study powered to investigate whether molecular analysis of breath can be used to classify suspected VAP patients with and without positive microbiological cultures with 99% sensitivity. UKCRN ID number 19086, registered May 2015; as well as registration at www.trialregister.nl under the acronym 'BreathDx' with trial ID number NTR 6114 (retrospectively registered on 28 October 2016).

Ventilator associated pneumonia: evolving definitions and preventive strategies.

PubMed

Mietto, Cristina; Pinciroli, Riccardo; Patel, Niti; Berra, Lorenzo

2013-06-01

Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections occurring in intubated patients. Because VAP is associated with higher mortality, morbidity, and costs, there is a need to solicit further research for effective preventive measures. VAP has been proposed as an indicator of quality of care. Clinical diagnosis has been criticized to have poor accuracy and reliability. Thus, the Centers for Disease Control and Prevention has introduced a new definition based upon objective and recordable data. Institutions are nowadays reporting a VAP zero rate in surveillance programs, which is in discrepancy with clinical data. This reduction has been highlighted in epidemiological studies, but it can only be attributed to a difference in patient selection, since no additional intervention has been taken to modify pathogenic mechanisms in these studies. The principal determinant of VAP development is the presence of the endotracheal tube (ETT). Contaminated oropharyngeal secretions pool over the ETT cuff and subsequently leak down to the lungs through a hydrostatic gradient. Impairment of mucociliary motility and cough reflex cannot counterbalance with a proper clearance of secretions. Lastly, biofilm develops on the inner ETT surface and acts as a reservoir for microorganism inoculum to the lungs. New preventive strategies are focused on the improvement of secretions drainage and prevention of bacterial colonization. The influence of gravity on mucus flow and body positioning can facilitate the clearance of distal airways, with decreased colonization of the respiratory tract. A different approach proposes ETT modifications to limit the leakage of oropharyngeal secretions: subglottic secretion drainage and cuffs innovations have been addressed to reduce VAP incidence. Moreover, coated-ETTs have been shown to prevent biofilm formation, although there is evidence that ETT clearance devices (Mucus Shaver) are required to preserve the

Predictive value of α-amylase in tracheal aspirates for ventilator-associated pneumonia in elderly patients.

PubMed

Qu, Ge-Ping; Fang, Xiang-Qun; Xu, Ya-Ping; Shi, Min; Wang, Yang; Gong, Mei-Liang; Fang, Hao-Ming

2018-04-01

This study aims to investigate the correlation between α-amylase in tracheal aspirates and risk factors of aspiration, as well as ventilator-associated pneumonia (VAP), in elderly patients undergoing mechanical ventilation and explore the clinical value of α-amylase for predicting VAP. Tracheal aspirates were collected from elderly patients within 2 weeks after tracheal intubation in mechanical ventilation, and α-amylase was detected. Patients were grouped according to the presence of VAP. The correlation between α-amylase and risk factors of aspiration before intubation, as well as VAP, were analyzed. The sample of this study comprised 147 patients. The average age of these patients was 86.9 years. The incidence of VAP was 21% during the study period. Tracheal aspirate α-amylase level increased with the increase in the number of risk factors for aspiration before intubation, α-amylase level was significantly higher in the VAP group than in the non-VAP group, the area under the receiver operating characteristic curve (ROC) of the diagnostic value of α-amylase for VAP was 0.813 (95% CI: 0.721-0.896), threshold value was 4,681.5 U/L, sensitivity was 0.801 and specificity was 0.793. Logistic multivariate analysis revealed the following risk factors for VAP: a number of risk factors before intubation of ≥3, a Glasgow score of <8 points, the absence of continuous aspiration of subglottic secretion and a tracheal aspirate α-amylase level of >4681.5 U/L. Tracheal aspirate α-amylase can serve as a biomarker for predicting VAP in elderly patients undergoing mechanical ventilation. © 2017 John Wiley & Sons Ltd.

Pneumomediastinum and Pneumothorax Associated with Herpes Simplex Virus (HSV) Pneumonia.

PubMed

López-Rivera, Fermín; Colón Rivera, Xavier; González Monroig, Hernán A; Garcia Puebla, Juan

2018-01-30

BACKGROUND Pneumonia is one of the most common causes of death from infectious disease in the United States (US). Although most cases of community-acquired pneumonia (CAP) are secondary to bacterial infection, up to one-third of cases are secondary to viral infection, most commonly due to rhinovirus and influenza virus. Pneumonia due to herpes simplex virus (HSV) is rare, and there is limited knowledge of the pathogenesis and clinical complications. This report is of a fatal case of HSV pneumonia associated with bilateral pneumothorax and pneumomediastinum. CASE REPORT A 36-year-old homeless male Hispanic patient, who was a chronic smoker, with a history of intravenous drug abuse and a medical history of chronic hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection, not on highly active antiretroviral therapy (HAART), was admitted to hospital as an emergency with a seven-day history of productive purulent cough. The patient was admitted to the medical intensive care unit (MICU) with a diagnosis of CAP, with intubation and mechanical ventilation. Broncho-alveolar lavage (BAL) was performed and was positive for HSV. The patient developed bilateral pneumothorax with pneumomediastinum, which was fatal, despite aggressive clinical management. CONCLUSIONS Pneumonia due to HSV infection is uncommon but has a high mortality. Although HSV pneumonia has been described in immunocompromised patients, further studies are required to determine the pathogenesis, early detection, identification of patients who are at risk and to determine the most effective approaches to prophylaxis and treatment for HSV pneumonia.

The function of probiotics on the treatment of ventilator-associated pneumonia (VAP): facts and gaps.

PubMed

Karacaer, Feride; Hamed, Imen; Özogul, Fatih; Glew, Robert H; Özcengiz, Dilek

2017-09-01

Probiotics have been used for centuries in making fermented dairy products. The health benefits related to probiotics consumption are well recognized and they are generally regarded as safe (GRAS). Their therapeutic effects are due to the production of a variety of antimicrobial compounds, such as short-chain fatty acids, organic acids (such as lactic, acetic, formic, propionic and butyric acids), ethanol, hydrogen peroxide and bacteriocins. Ventilator-associated pneumonia (VAP) is a nosocomial infection associated with high mortality in intensive care units. VAP can result from endotracheal intubation and mechanical ventilation. These interventions increase the risk of infection as patients lose the natural barrier between the oropharynx and the trachea, which in turn facilitates the entry of pathogens through the aspiration of oropharyngeal secretions containing bacteria into the lung. In order to prevent this, probiotics have been used extensively against VAP. This review is an update containing information extracted from recent studies on the use of probiotics to treat VAP. In addition, probiotic safety, the therapeutic properties of probiotics, the probiotic strains used and the action of the probiotics mechanism are reviewed. Furthermore, the therapeutic effects of probiotic treatment procedures for VAP are compared to those of antibiotics. Finally, the influences of bacteriocin on the growth of human pathogens, and the side-effects and limitations of using probiotics for the treatment of VAP are addressed.

Effect of enhanced ultraviolet germicidal irradiation in the heating ventilation and air conditioning system on ventilator-associated pneumonia in a neonatal intensive care unit.

PubMed

Ryan, R M; Wilding, G E; Wynn, R J; Welliver, R C; Holm, B A; Leach, C L

2011-09-01

The objective of this study was to test the hypothesis that enhanced ultraviolet germicidal irradiation (eUVGI) installed in our neonatal intensive care unit (NICU) heating ventilation and air conditioning system (HVAC) would decrease HVAC and NICU environment microbes, tracheal colonization and ventilator-associated pneumonia (VAP). The study was designed as a prospective interventional pre- and post-single-center study. University-affiliated Regional Perinatal Center NICU. Intubated patients in the NICU were evaluated for colonization, and a high-risk sub-population of infants <30 weeks gestation ventilated for ≥ 14 days was studied for VAP. eUVGI was installed in the NICU's remote HVACs. The HVACs, NICU environment and intubated patients' tracheas were cultured pre- and post-eUVGI for 12 months. The high-risk patients were studied for VAP (positive bacterial tracheal culture, increased ventilator support, worsening chest radiograph and ≥ 7 days of antibiotics). Pseudomonas, Klebsiella, Serratia, Acinetobacter, Staphylococcus aureus and Coagulase-negative Staphylococcus species were cultured from all sites. eUVGI significantly decreased HVAC organisms (baseline 500,000 CFU cm(-2); P=0.015) and NICU environmental microbes (P<0.0001). Tracheal microbial loads decreased 45% (P=0.004), and fewer patients became colonized. VAP in the high-risk cohort fell from 74% (n=31) to 39% (n=18), P=0.04. VAP episodes per patient decreased (Control: 1.2 to eUVGI: 0.4; P=0.004), and antibiotic usage was 62% less (P=0.013). eUVGI decreased HVAC microbial colonization and was associated with reduced NICU environment and tracheal microbial colonization. Significant reductions in VAP and antibiotic use were also associated with eUVGI in this single-center study. Large randomized multicenter trials are needed.

Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study.

PubMed

van Nieuwenhoven, Christianne A; Vandenbroucke-Grauls, Christine; van Tiel, Frank H; Joore, Hans C A; van Schijndel, Rob J M Strack; van der Tweel, Ingeborg; Ramsay, Graham; Bonten, Marc J M

2006-02-01

Reducing aspiration of gastric contents by placing mechanically ventilated patients in a semirecumbent position has been associated with lower incidences of ventilator-associated pneumonia (VAP). The feasibility and efficacy of this intervention in a larger patient population, however, are unknown. Assessment of the feasibility of the semirecumbent position for intensive care unit patients and its influence on development of VAP. In a prospective multicentered trial, critically ill patients undergoing mechanical ventilation were randomly assigned to the semirecumbent position, with a target backrest elevation of 45 degrees , or standard care (i.e., supine position) with a backrest elevation of 10 degrees . Backrest elevation was measured continuously during the first week of ventilation with a monitor-linked device. A deviation of position was defined as a change of the randomized position >5 degrees . Diagnosis of VAP was made by quantitative cultures of samples obtained by bronchoscopic techniques. One hundred nine patients were assigned to the supine group and 112 to the semirecumbent group. Baseline characteristics were comparable for both groups. Average elevations were 9.8 degrees and 16.1 degrees at day 1 and day 7, respectively, for the supine group and 28.1 degrees and 22.6 degrees at day 1 and day 7, respectively, for the semirecumbent group (p < .001). The target semirecumbent position of 45 degrees was not achieved for 85% of the study time, and these patients more frequently changed position than supine-positioned patients. VAP was diagnosed in eight patients (6.5%) in the supine group and in 13 (10.7%) in the semirecumbent group (NS), after a mean of 6 (range, 3-9) and 7 (range, 3-12) days, respectively. There were no differences in numbers of patients undergoing enteral feeding, receiving stress ulcer prophylaxis, or developing pressure sores or in mortality rates or duration of ventilation and intensive care unit stay between the groups. The

Prevention and diagnosis of ventilator-associated pneumonia: a survey on current practices in Southern Spanish ICUs.

PubMed

Sierra, Rafael; Benítez, Encarnación; León, Cristóbal; Rello, Jordi

2005-09-01

To assess the implementation of selected ventilator-associated pneumonia (VAP) prevention strategies, and to learn how VAP is diagnosed in the ICUs of Southern Spain. Multicentric survey. The ICUs of 32 hospitals of the public health-care system of Southern Spain. Directors of ICUs. None. Twenty-eight ICUs (87.5%) returned completed questionnaires. Ventilator circuits were changed every 72 h or longer in 75% of ICUs. Use of heat and moisture exchangers and open endotracheal suction systems were reported in 96% of ICUs. Subglottic secretion drainage was never used, and 57% of ICUs checked endotracheal tube cuff pressure at least daily. Semi-recumbent position was common (93%), and 67.5% of ICUs used frequently noninvasive ventilation. Continuous enteral feeding was reported in all ICUs. Sedative infusions were usually interrupted every day in 11% of ICUs. Seventy-five percent of ICUs had specific guidelines for antibiotic therapy of VAP, but rotation of antibiotics was uncommon (11%). Twenty-nine percent of ICUs diagnosed VAP without microbiological confirmation. The most used technique for microbiologic diagnosis was qualitative culture of endotracheal aspirates (42.8%). The centers with a larger structural complexity reported using VAP therapy guidelines more frequently than the smaller centers, but they did not utilized bronchoscopic techniques for diagnosing VAP. Common prevention and diagnostic procedures in clinical practice, including large teaching institutions, significantly differed from evidence-based recommendations and reports by research groups of excellence. In addition, our study suggests that clinical practice for preventing and diagnosing VAP is variable and many opportunities exist to improve the care of patients receiving mechanical ventilation.

Alternative diagnosis in the putative ventilator-associated pneumonia patient not meeting lavage-based diagnostic criteria.

PubMed

Schoemakers, Rik J; Schnabel, Ronny; Oudhuis, Guy J; Linssen, Catharina F M; van Mook, Walther N K A; Verbon, Annelies; Bergmans, Dennis C J J

2014-12-01

The clinical picture of ventilator-associated pneumonia (VAP) can be mimicked by other infectious and non-infectious diseases. The aim of this study was to determine the alternative diagnoses and to develop a diagnostic flow chart for patients suspected of having VAP not meeting the diagnostic broncho-alveolar lavage (BAL) criteria. Adult intensive care patients with a clinical suspicion of VAP and negative BAL results were included. The clinical suspicion of VAP was based on the combination of clinical, radiological, and microbiological criteria. BAL was considered positive if cell differentiation revealed ≥ 2% cells with intracellular organisms and/or quantitative culture results of ≥ 10(4) cfu/ml. The most likely alternative diagnosis of fever and pulmonary densities was retrospectively determined by two authors independently. In all, 110 of 207 patients with suspected VAP did not meet the diagnostic BAL criteria and required further diagnostic evaluation. In 67 patients an alternative diagnosis for fever could be found. In 51 patients an alternative diagnosis of both fever and pulmonary densities could be established. In almost 40% of patients no alternative diagnosis could be provided. Non-bacterial pneumonia was diagnosed in 10 patients with Herpes simplex virus 1 (HSV-1) as the most common pathogen. In eight patients non-infectious pneumonitis was diagnosed. Due to the wide range of alternative diagnoses and applied tests the diagnostic work-up proved to be necessarily individualized and guided by repeated clinical assessment. The most frequently found alternative diagnoses were viral pneumonia and non-infectious pneumonitis.

Antimicrobial-resistant Pseudomonas aeruginosa and Acinetobacter baumannii From Patients With Hospital-acquired or Ventilator-associated Pneumonia in Vietnam.

PubMed

Biedenbach, Douglas J; Giao, Phan Trong; Hung Van, Pham; Su Minh Tuyet, Nguyen; Thi Thanh Nga, Tran; Phuong, Doan Mai; Vu Trung, Nguyen; Badal, Robert E

2016-09-01

Multidrug-resistant bacterial pathogens are becoming a significant problem worldwide. Acinetobacter baumannii and Pseudomonas aeruginosa are problematic multidrug-resistant pathogens. This multicenter study in Vietnam determined the level of resistance to antimicrobial agents used to treat A baumannii and P aeruginosa infections in this country. Five medical centers in Vietnam provided 529 P aeruginosa and 971 Acinetobacter species (904 A baumannii) isolates from patients with hospital-acquired or ventilator-associated pneumonia from 2012 to 2014. A central laboratory verified identification of the isolates and performed susceptibility testing using Clinical and Laboratory Standards Institute methods. Resistance to cephalosporins, β-lactam/β-lactamase inhibitors, carbapenems, and fluoroquinolones was >90% against A baumannii. Aminoglycosides had only slightly better activity, with amikacin resistance >80%. Only colistin (MIC90, ≤0.25 mg/L) and tigecycline (MIC90, 4 mg/L) had appreciable activity against A baumannii. Similar activity was observed among the β-lactams tested against P aeruginosa. Cefepime demonstrated the highest activity (60.1% susceptible), which was similar to doripenem (58.6% susceptible), the most active carbapenem tested. Amikacin was the most active aminoglycoside tested against P aeruginosa, with susceptibility of 81.7% compared with tobramycin (58.0%) and gentamicin (56.5%). Fluoroquinolones had limited activity against P aeruginosa with susceptibility to ciprofloxacin (55.0%). All P aeruginosa isolates had colistin MIC values ≤2 mg/L. The data from this 3-year longitudinal study in Vietnam demonstrate that 2 of the most common nonfermentative gram-negative pathogens associated with hospital-acquired and ventilator-associated pneumonia are significantly resistant to most of the available treatment options and require combination therapies unless new antimicrobial agents become available. Copyright © 2016. Published by Elsevier Inc.

Unusually High Incidences of Staphylococcus aureus Infection within Studies of Ventilator Associated Pneumonia Prevention Using Topical Antibiotics: Benchmarking the Evidence Base

PubMed Central

2018-01-01

Selective digestive decontamination (SDD, topical antibiotic regimens applied to the respiratory tract) appears effective for preventing ventilator associated pneumonia (VAP) in intensive care unit (ICU) patients. However, potential contextual effects of SDD on Staphylococcus aureus infections in the ICU remain unclear. The S. aureus ventilator associated pneumonia (S. aureus VAP), VAP overall and S. aureus bacteremia incidences within component (control and intervention) groups within 27 SDD studies were benchmarked against 115 observational groups. Component groups from 66 studies of various interventions other than SDD provided additional points of reference. In 27 SDD study control groups, the mean S. aureus VAP incidence is 9.6% (95% CI; 6.9–13.2) versus a benchmark derived from 115 observational groups being 4.8% (95% CI; 4.2–5.6). In nine SDD study control groups the mean S. aureus bacteremia incidence is 3.8% (95% CI; 2.1–5.7) versus a benchmark derived from 10 observational groups being 2.1% (95% CI; 1.1–4.1). The incidences of S. aureus VAP and S. aureus bacteremia within the control groups of SDD studies are each higher than literature derived benchmarks. Paradoxically, within the SDD intervention groups, the incidences of both S. aureus VAP and VAP overall are more similar to the benchmarks. PMID:29300363

[Prospective study on the gastro-pulmonary infection route of ventilator-associated pneumonia].

PubMed

Zhang, Qing-ling; Liu, Ming-hua; Liu, Yu-fu; Wang, Xian-yuan; Fu, Wei-ling

2004-02-01

To explore the role of gastro-pulmonary infection route in the development of ventilator-associated pneumonia (VAP), so as to improve the management of VAP. Forty-three patients who received mechanical ventilation (MV) were enrolled in the study. Intra-gastric contents were labeled with (99)mTc-DTPA. Randomized two-period crossover trial was employed to determine the radioactive level in the oropharyngeal and bronchial secretion when patients were in supine or semi-reclining position. Gastric juice, oropharyngeal secretion and tracheal lavage fluid were collected for bacterial culture every other day. Bronchoalveolar lavage fluid (BALF) was harvested from those suspected of VAP for quantitative bacterial culture. Infrequent-restriction site amplification (IRS-PCR) was employed in the identification of the identity of the bacteria from intra-gastric colonization with those causing VAP. The sIgA content in the BALF was determined. The gastroesophageal regurgitation rate was higher (89.7%) with lower aspiration rate (28.5%) in patients receiving MV. Moreover, the aspiration rate and the radioactivity of deep tracheal aspirates in patients in supine position were significantly higher than those in semi-reclining position (P < 0.01). There was high homology of the bacteria isolated from intra-gastric colonization with that causing VAP (55.8%). The sIgA content in BALF in VAP patients was evidently lower than that in non-VAP patients (P < 0.01). Regurgitation and aspiration of stomach contents are very common in patients receiving MV. Intra-gastric colonized bacteria might be one of the important origins causing VAP. The lowering of sIgA in BALF in patients with MV could be a risk factor for VAP.

[Pulmonary complications associated with mechanical ventilation in neonates].

PubMed

Torres-Castro, Cristabel; Valle-Leal, Jaime; Martínez-Limón, Alba J; Lastra-Jiménez, Zaira; Delgado-Bojórquez, Lesvia Carmina

To determine the incidence of0 associated with mechanical ventilation in patients admitted to a service in a second level hospital NICU. Retrospective analytical study records of newborns admitted to NICU room and receiving mechanical ventilation in a secondary hospital health care. Demographic data, of mechanical ventilation, intubation and complications reported in the clinical record were collected and analyzed in SPSS 20. 53 patients selected a total of 40 complications found. The annual incidence of pulmonary complications associated with mechanical ventilation in the area of service neonatology NICU, at a second level hospital at Sonora was 49.05% (95% CI 0.35 to 0.62). The most frequent pulmonary complications were atelectasis 35%, pneumonia 27.5%, pneumothorax 15%, bronchopulmonary dysplasia 15%, pneumomediastinum 15% and pulmonary hemorrhage 2.5%. The presentation of pulmonary complications secondary to mechanical ventilation in neonatal patients is similar to that reported in developing countries. Atelectasis is the most common pulmonary complication in neonatal patients undergoing mechanical ventilation. Copyright © 2016 Hospital Infantil de México Federico Gómez. Publicado por Masson Doyma México S.A. All rights reserved.

Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults requiring mechanical ventilation.

PubMed

Wang, Li; Li, Xiao; Yang, Zongxia; Tang, Xueli; Yuan, Qiang; Deng, Lijing; Sun, Xin

2016-01-08

Ventilator-associated pneumonia (VAP) is associated with increased mortality, prolonged length of hospital stay and increased healthcare costs in critically ill patients. Guidelines recommend a semi-recumbent position (30º to 45º) for preventing VAP among patients requiring mechanical ventilation. However, due to methodological limitations in existing systematic reviews, uncertainty remains regarding the benefits and harms of the semi-recumbent position for preventing VAP. To assess the effectiveness and safety of semi-recumbent positioning versus supine positioning to prevent ventilator-associated pneumonia (VAP) in adults requiring mechanical ventilation. We searched CENTRAL (2015, Issue 10), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1946 to October 2015), EMBASE (2010 to October 2015), CINAHL (1981 to October 2015) and the Chinese Biomedical Literature Database (CBM) (1978 to October 2015). We included randomised controlled trials (RCTs) comparing semi-recumbent versus supine positioning (0º to 10º), or RCTs comparing alternative degrees of positioning in mechanically ventilated patients. Our outcomes included clinically suspected VAP, microbiologically confirmed VAP, intensive care unit (ICU) mortality, hospital mortality, length of ICU stay, length of hospital stay, duration of ventilation, antibiotic use and any adverse events. Two review authors independently and in duplicate screened titles, abstracts and full texts, assessed risk of bias and extracted data using standardised forms. We calculated the mean difference (MD) and 95% confidence interval (95% CI) for continuous data and the risk ratio (RR) and 95% CI for binary data. We performed meta-analysis using the random-effects model. We used the grading of recommendations, assessment, development and evaluation (GRADE) approach to grade the quality of evidence. We included 10 trials involving 878 participants, among which 28 participants in two

Mechanical Ventilation Alters the Development of Staphylococcus aureus Pneumonia in Rabbit

PubMed Central

Barbar, Saber-Davide; Pauchard, Laure-Anne; Bruyère, Rémi; Bruillard, Caroline; Hayez, Davy; Croisier, Delphine; Pugin, Jérôme; Charles, Pierre-Emmanuel

2016-01-01

Ventilator-associated pneumonia (VAP) is common during mechanical ventilation (MV). Beside obvious deleterious effects on muco-ciliary clearance, MV could adversely shift the host immune response towards a pro-inflammatory pattern through toll-like receptor (TLRs) up-regulation. We tested this hypothesis in a rabbit model of Staphylococcus aureus VAP. Pneumonia was caused by airway challenge with S. aureus, in either spontaneously breathing (SB) or MV rabbits (n = 13 and 17, respectively). Pneumonia assessment regarding pulmonary and systemic bacterial burden, as well as inflammatory response was done 8 and 24 hours after S. aureus challenge. In addition, ex vivo stimulations of whole blood taken from SB or MV rabbits (n = 7 and 5, respectively) with TLR2 agonist or heat-killed S. aureus were performed. Data were expressed as mean±standard deviation. After 8 hours of infection, lung injury was more severe in MV animals (1.40±0.33 versus [vs] 2.40±0.55, p = 0.007), along with greater bacterial concentrations (6.13±0.63 vs. 4.96±1.31 colony forming units/gram, p = 0.002). Interleukin (IL)-8 and tumor necrosis factor (TNF)-αserum concentrations reached higher levels in MV animals (p = 0.010). Whole blood obtained from MV animals released larger amounts of cytokines if stimulated with TLR2 agonist or heat-killed S. aureus (e.g., TNF-α: 1656±166 vs. 1005±89; p = 0.014). Moreover, MV induced TLR2 overexpression in both lung and spleen tissue. MV hastened tissue injury, impaired lung bacterial clearance, and promoted a systemic inflammatory response, maybe through TLR2 overexpression. PMID:27391952

Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish "Zero-VAP" bundle.

PubMed

Álvarez Lerma, F; Sánchez García, M; Lorente, L; Gordo, F; Añón, J M; Álvarez, J; Palomar, M; García, R; Arias, S; Vázquez-Calatayud, M; Jam, R

2014-05-01

"Zero-VAP" is a proposal for the implementation of a simultaneous multimodal intervention in Spanish intensive care units (ICU) consisting of a bundle of ventilator-associated pneumonia (VAP) prevention measures. An initiative of the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses, the project is supported by the Spanish Ministry of Health, and participation is voluntary. In addition to guidelines for VAP prevention, the "Zero-VAP" Project incorporates an integral patient safety program and continuous online validation of the application of the bundle. For the latter, VAP episodes and participation indices are entered into the web-based Spanish ICU Infection Surveillance Program "ENVIN-HELICS" database, which provides continuous information about local, regional and national VAP incidence rates. Implementation of the guidelines aims at the reduction of VAP to less than 9 episodes per 1000 days of mechanical ventilation. A total of 35 preventive measures were initially selected. A task force of experts used the Grading of Recommendations, Assessment, Development and Evaluation Working Group methodology to generate a list of 7 basic "mandatory" recommendations (education and training in airway management, strict hand hygiene for airway management, cuff pressure control, oral hygiene with chlorhexidine, semi-recumbent positioning, promoting measures that safely avoid or reduce time on ventilator, and discouraging scheduled changes of ventilator circuits, humidifiers and endotracheal tubes) and 3 additional "highly recommended" measures (selective decontamination of the digestive tract, aspiration of subglottic secretions, and a short course of iv antibiotic). We present the Spanish VAP prevention guidelines and describe the methodology used for the selection and implementation of the recommendations and the organizational structure of the project. Compared to conventional guideline documents, the associated safety assurance program, the

The methodological quality of guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia: A systematic review.

PubMed

Ambaras Khan, R; Aziz, Z

2018-05-02

Clinical practice guidelines serve as a framework for physicians to make decisions and to support best practice for optimizing patient care. However, if the guidelines do not address all the important components of optimal care sufficiently, the quality and validity of the guidelines can be reduced. The objectives of this study were to systematically review current guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), evaluate their methodological quality and highlight the similarities and differences in their recommendations for empirical antibiotic and antibiotic de-escalation strategies. This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Electronic databases including MEDLINE, CINAHL, PubMed and EMBASE were searched up to September 2017 for relevant guidelines. Other databases such as NICE, Scottish Intercollegiate Guidelines Network (SIGN) and the websites of professional societies were also searched for relevant guidelines. The quality and reporting of included guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument. Six guidelines were eligible for inclusion in our review. Among 6 domains of AGREE-II, "clarity of presentation" scored the highest (80.6%), whereas "applicability" scored the lowest (11.8%). All the guidelines supported the antibiotic de-escalation strategy, whereas the majority of the guidelines (5 of 6) recommended that empirical antibiotic therapy should be implemented in accordance with local microbiological data. All the guidelines suggested that for early-onset HAP/VAP, therapy should start with a narrow spectrum empirical antibiotic such as penicillin or cephalosporins, whereas for late-onset HAP/VAP, the guidelines recommended the use of a broader spectrum empirical antibiotic such as the penicillin extended spectrum carbapenems and glycopeptides. Expert guidelines

Association between presence of pneumonia and pressure ulcer formation following traumatic spinal cord injury.

PubMed

Krishnan, Shilpa; Karg, Patricia E; Boninger, Michael L; Brienza, David M

2017-07-01

To determine if the presence of pneumonia and pressure ulcers are associated in individuals with an acute spinal cord injury during acute care and rehabilitation hospitalizations. Retrospective, secondary analyses of data obtained from the Spinal Cord Injury Model Systems enrolled from 1993 until 2006 Setting: Acute care hospitalization and inpatient rehabilitation facilities Participants: A cohort of individuals hospitalized in acute care (n = 3,098) and inpatient rehabilitation (n = 1,768) was included in the analysis. Frequencies of pressure ulcer formation and episodes of pneumonia were noted in both settings. Not applicable. Pressure ulcer formation and diagnosis of pneumonia Results: The development of pressure ulcers, including stage I, was 20.3% acute care and 21.1% during in inpatient rehabilitation. Multivariate logistic regression analyses revealed a significant association of pneumonia with occurrence of pressure ulcers (P ≤ 0.001, OR = 2.3 and 2.2 respectively), the American Spinal Injury Association Impairment Scale grades (P < 0.001), and utilization of mechanical ventilation (P < 0.01) in both settings. A higher presence of pressure ulcers was found in individuals with pneumonia, after adjusting for injury severity, age, sex, and utilization of mechanical ventilation. Impaired inflammatory response and decreased mobility in individuals with pneumonia may predispose these individuals to develop pressure ulcers. Surveillance and preventive measures for pressure ulcers should be rigorous in individuals with SCI and pneumonia.

Comparison of endotracheal aspirate and non-bronchoscopic bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia in a pediatric intensive care unit.

PubMed

Yıldız-Atıkan, Başak; Karapınar, Bülent; Aydemir, Şöhret; Vardar, Fadıl

2015-01-01

Ventilator-associated pneumonia (VAP) is defined as pneumonia occuring in any period of mechanical ventilation. There is no optimal diagnostic method in current use and in this study we aimed to compare two non-invasive diagnostic methods used in diagnosis of VAP in children. This prospective study was conducted in 8 bedded Pediatric Intensive Care Unit at Ege University Children´s Hospital. Endotracheal aspiration (ETA) and non-bronchoscopic bronchoalveolar lavage (BAL) were performed in case of developing VIP after 48 hours of ventilation. Quantitative cultures were examined in Ege University Department of Diagnostic Microbiology, Bacteriology Laboratory. Fourty-one patients were enrolled in the study. The mean age of study subjects was 47.2±53.6 months. A total of 28 in 82 specimens taken with both methods were negative/negative; 28 had positive result with ETA and a negative result with non-bronchoscopic BAL and both results were negative in 26 specimens. There were no patients whose respiratory specimen culture was negative with ETA and positive with non-bronchoscopic BAL. These results imply that there is a significant difference between two diagnostic methods (p < 0.001). Negative non-bronchoscopic BAL results are recognized as absence of VAP; therefore, ETA results were compared with this method. ETA's sensitivity, specificity, negative and positive predictive values were 100%, 50%, 100% and 48% respectively. The study revealed the ease of usability and the sensitivity of non-bronchoscopic BAL, in comparison with ETA.

Determining the Ideal Strategy for Ventilator-associated Pneumonia Prevention. Cost-Benefit Analysis.

PubMed

Branch-Elliman, Westyn; Wright, Sharon B; Howell, Michael D

2015-07-01

Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection with high associated cost and poor patient outcomes. Many strategies for VAP reduction have been evaluated. However, the combination of strategies with the optimal cost-benefit ratio remains unknown. To determine the preferred VAP prevention strategy, both from the hospital and societal perspectives. A cost-benefit decision model with a Markov model was constructed. Baseline probability of VAP, death, reintubation, and discharge from the intensive care unit (ICU) alive were ascertained from clinical trial data. Model inputs were obtained from the medical literature and the U.S. Department of Labor; a device cost was obtained from the manufacturer. Sensitivity analyses were completed to test the robustness of model results. Overall least expensive strategy and the strategy with the best cost-benefit ratio, up to a willingness to pay threshold of $50,000-100,000 per case of VAP averted was sought. We examined a total of 120 unique combinations of VAP prevention strategies. The preferred strategy from the hospital perspective included subglottic suction endotracheal tubes, probiotics, and the Institute for Healthcare Improvement VAP Prevention Bundle. The preferred strategy from the point of view of society also included additional prevention measures (oral care with chlorhexidine and selective oral decontamination). No preferred strategies included silver endotracheal tubes or selective gut decontamination. Despite their infrequent use, current data suggest that the use of prophylactic probiotics and subglottic endotracheal tubes are cost-effective for preventing VAP from the societal and hospital perspectives.

The LoTrach system: its role in the prevention of ventilator-associated pneumonia.

PubMed

Fletcher, Andrew J W; Ruffell, Alison J; Young, Peter J

2008-01-01

To discuss the development of the LoTrach system in light of current evidence around the prevention of ventilator-associated pneumonia (VAP) and its practical application in the intensive care setting. VAP causes substantial morbidity and mortality in ventilated patients in the Intensive Care Unit (ICU), increases length of stay in ICU and is extremely costly. Strategies are needed to reduce the risk of VAP. We examine the need for an endotracheal tube (ETT) specifically designed for the critically-ill patient, the development of the LoTrach system from conception to production, and the role of the various components of the system in preventing VAP. Early issues in implementing this revolutionary equipment into ICU are explored and three case studies highlight advantages of this system. The LoTrach system has been designed to facilitate the provision of a number of evidence-based interventions that have been shown to reduce VAP. Pulmonary aspiration is ubiquitous with conventional cuffs but prevented by the cuff of the LoTrach system when held at a constant and safe pressure against the tracheal wall with a cuff pressure controller. Other aspects incorporated in the ETT are aimed at clearing the secretions from the subglottic space, preventing tube occlusion and accidental extubation, and avoiding damage to the airway. In this way the LoTrach system employs a multifactorial approach to the prevention of VAP and the cost savings from LoTrach rather than a standard ETT will be considerable because of an average 3 day reduction in ICU length of stay related to this. It thus has the potential to be a very useful tool in the ICU setting in the prevention of VAP.

Trimethoprim/sulfamethoxazole versus vancomycin in the treatment of healthcare/ventilator-associated MRSA pneumonia: a case-control study.

PubMed

Eliakim-Raz, Noa; Hellerman, Moran; Yahav, Dafna; Cohen, Jonathan; Margalit, Ili; Fisher, Sharon; Zusman, Oren; Shaked, Hila; Bishara, Jihad

2017-03-01

Therapeutic options available to treat MRSA pneumonia are limited. Trimethoprim/sulfamethoxazole is an attractive treatment because of its bactericidal anti-MRSA activity, oral and parenteral formulations and good penetration to the lung tissue. We aimed to compare the efficacy and safety of trimethoprim/sulfamethoxazole with vancomycin in the treatment of healthcare/ventilator-associated MRSA pneumonia. We carried out a retrospective case-control study of all consecutive hospitalized adult patients diagnosed with MRSA pneumonia at Beilinson Hospital during 2010-15 and treated with either vancomycin or trimethoprim/sulfamethoxazole. The primary outcomes were all-cause mortality at 30 days and clinical failure at the end of treatment. In order to reduce bias affecting the decision to use a specific antibiotic and as a sensitivity analysis, a propensity-score model for choosing between vancomycin and trimethoprim/sulfamethoxazole was used. We identified 42 patients with MRSA pneumonia treated with trimethoprim/sulfamethoxazole and 39 treated with vancomycin. There were no significant differences in the baseline characteristics between the groups. Vancomycin-treated patients showed significantly higher 30 day mortality on both multivariate analysis (HR = 5.28; 95% CI = 1.50-18.60; P  < 0.05) and sensitivity analysis with propensity score [vancomycin 13/24 (54.1%) versus trimethoprim/sulfamethoxazole 4/24 (16.7%); P  < 0.05], and higher clinical failure rates [vancomycin 23/39 (59%) versus trimethoprim/sulfamethoxazole 15/42 (35.7%); P  < 0.05], also in the sensitivity analysis with propensity score [vancomycin 14/24 (58.3%) versus trimethoprim/sulfamethoxazole 6/24 (25%); P  < 0.05]. The rates of side effects in both arms were comparable. Trimethoprim/sulfamethoxazole appears to be superior to vancomycin in the treatment of MRSA pneumonia. A large-scale randomized controlled trial is needed to evaluate these findings. © The Author 2016

[Effect of 45 degree angle semirecumbent position on ventilator-associated pneumonia in mechanical ventilated patients: a meta-analysis].

PubMed

Leng, Yu-xin; Song, Ya-han; Yao, Zhi-yuan; Zhu, Xi

2012-10-01

To systemically analyze the effect of 45 degree angle semirecumbent position on the incidence of ventilator-associated pneumonia (VAP) and other outcomes in mechanical ventilated patients, and to evaluate whether 45 degree angle semirecumbent position is superior to 25 degree angle-30 degree angle head of bed (HOB). The randomized controlled trials (RCTs) comparing the effect of different HOB on the outcomes of mechanical ventilated patients were searched (from 1st January 1990 to 20th July 2012) from five databases including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, China Knowledge Resource Integrated Database (CNKI), and Wanfang Database. Meta analysis was conducted using RevMan 5.0 software. Data extracted from five RCTs with a total of 427 patients were analyzed. The risks of developing clinically diagnosed VAP were significantly lower among the patients in semirecumbent 45 degree angle position compared to the patients in lower position [15.96% (34/213) vs. 26.64% (57/214), relative risk (RR)=0.57, 95% confidence interval (95%CI) 0.39 to 0.83, P=0.003], while no significant differences were detected between the two groups regarding the mortality rate [27.04% (53/196) vs. 28.22% (57/202), RR=0.93, 95%CI 0.68 to 1.27, P=0.66], the length of intensive care unit (ICU) stay [weighted mean difference (WMD)=-0.45, 95%CI -1.08 to 0.18, P=0.16] and the percentage of antibiotics treatment [71.11% (32/45) vs. 60.87% (28/46), RR=1.14, 95%CI 0.85 to 1.53, P=0.37]. Two of the five trials (91 patients) were included in the sub-analysis between 45 degree angle group (45 patients) and 25 degree angle-30 degree angle group (46 patients). The results showed that comparing with 25 degree angle-30 degree angle, 45 degree angle semirecumbent position had no significance in improving patients' clinical outcomes. This study proved that the clinically preferred semirecumbent 45 degree angle position did have effect in reducing the incidence of VAP

Protective ventilation reduces Pseudomonas aeruginosa growth in lung tissue in a porcine pneumonia model.

PubMed

Sperber, Jesper; Nyberg, Axel; Lipcsey, Miklos; Melhus, Åsa; Larsson, Anders; Sjölin, Jan; Castegren, Markus

2017-08-31

Mechanical ventilation with positive end expiratory pressure and low tidal volume, i.e. protective ventilation, is recommended in patients with acute respiratory distress syndrome. However, the effect of protective ventilation on bacterial growth during early pneumonia in non-injured lungs is not extensively studied. The main objectives were to compare two different ventilator settings on Pseudomonas aeruginosa growth in lung tissue and the development of lung injury. A porcine model of severe pneumonia was used. The protective group (n = 10) had an end expiratory pressure of 10 cm H 2 O and a tidal volume of 6 ml x kg -1 . The control group (n = 10) had an end expiratory pressure of 5 cm H 2 O and a tidal volume of 10 ml x kg -1 . 10 11 colony forming units of Pseudomonas aeruginosa were inoculated intra-tracheally at baseline, after which the experiment continued for 6 h. Two animals from each group received only saline, and served as sham animals. Lung tissue samples from each animal were used for bacterial cultures and wet-to-dry weight ratio measurements. The protective group displayed lower numbers of Pseudomonas aeruginosa (p < 0.05) in the lung tissue, and a lower wet-to-dry ratio (p < 0.01) than the control group. The control group deteriorated in arterial oxygen tension/inspired oxygen fraction, whereas the protective group was unchanged (p < 0.01). In early phase pneumonia, protective ventilation with lower tidal volume and higher end expiratory pressure has the potential to reduce the pulmonary bacterial burden and the development of lung injury.

Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial.

PubMed

Drakulovic, M B; Torres, A; Bauer, T T; Nicolas, J M; Nogué, S; Ferrer, M

1999-11-27

Risk factors for nosocomial pneumonia, such as gastro-oesophageal reflux and subsequent aspiration, can be reduced by semirecumbent body position in intensive-care patients. The objective of this study was to assess whether the incidence of nosocomial pneumonia can also be reduced by this measure. This trial was stopped after the planned interim analysis. 86 intubated and mechanically ventilated patients of one medical and one respiratory intensive-care unit at a tertiary-care university hospital were randomly assigned to semirecumbent (n=39) or supine (n=47) body position. The frequency of clinically suspected and microbiologically confirmed nosocomial pneumonia (clinical plus quantitative bacteriological criteria) was assessed in both groups. Body position was analysed together with known risk factors for nosocomial pneumonia. The frequency of clinically suspected nosocomial pneumonia was lower in the semirecumbent group than in the supine group (three of 39 [8%] vs 16 of 47 [34%]; 95% CI for difference 10.0-42.0, p=0.003). This was also true for microbiologically confirmed pneumonia (semirecumbent 2/39 [5%] vs supine 11/47 [23%]; 4.2-31.8, p=0.018). Supine body position (odds ratio 6.8 [1.7-26.7], p=0.006) and enteral nutrition (5.7 [1.5-22.8], p=0.013) were independent risk factors for nosocomial pneumonia and the frequency was highest for patients receiving enteral nutrition in the supine body position (14/28, 50%). Mechanical ventilation for 7 days or more (10.9 [3.0-40.4], p=0.001) and a Glasgow coma scale score of less than 9 were additional risk factors. The semirecumbent body position reduces frequency and risk of nosocomial pneumonia, especially in patients who receive enteral nutrition. The risk of nosocomial pneumonia is increased by long-duration mechanical ventilation and decreased consciousness.

A novel porcine model of ventilator-associated pneumonia caused by oropharyngeal challenge with Pseudomonas aeruginosa.

PubMed

Li Bassi, Gianluigi; Rigol, Montserrat; Marti, Joan-Daniel; Saucedo, Lina; Ranzani, Otavio T; Roca, Ignasi; Cabanas, Maria; Muñoz, Laura; Giunta, Valeria; Luque, Nestor; Rinaudo, Mariano; Esperatti, Mariano; Fernandez-Barat, Laia; Ferrer, Miquel; Vila, Jordi; Ramirez, Jose; Torres, Antoni

2014-05-01

Animal models of ventilator-associated pneumonia (VAP) in primates, sheep, and pigs differ in the underlying pulmonary injury, etiology, bacterial inoculation methods, and time to onset. The most common ovine and porcine models do not reproduce the primary pathogenic mechanism of the disease, through the aspiration of oropharyngeal pathogens, or the most prevalent human etiology. Herein the authors characterize a novel porcine model of VAP due to aspiration of oropharyngeal secretions colonized by Pseudomonas aeruginosa. Ten healthy pigs were intubated, positioned in anti-Trendelenburg, and mechanically ventilated for 72 h. Three animals did not receive bacterial challenge, whereas in seven animals, a P. aeruginosa suspension was instilled into the oropharynx. Tracheal aspirates were cultured and respiratory mechanics were recorded. On autopsy, lobar samples were obtained to corroborate VAP through microbiological and histological studies. In animals not challenged, diverse bacterial colonization of the airways was found and monolobar VAP rarely developed. In animals with P. aeruginosa challenge, colonization of tracheal secretion increased up to 6.39 ± 0.34 log colony-forming unit (cfu)/ml (P < 0.001). VAP was confirmed in six of seven pigs, in 78% of the cases developed in the dependent lung segments (right medium and lower lobes, P = 0.032). The static respiratory system elastance worsened to 41.5 ± 5.8 cm H2O/l (P = 0.001). The authors devised a VAP model caused by aspiration of oropharyngeal P. aeruginosa, a frequent causative pathogen of human VAP. The model also overcomes the practical and legislative limitations associated with the use of primates. The authors' model could be employed to study pathophysiologic mechanisms, as well as novel diagnostic/preventive strategies.

A prospective, randomized comparison of an in-line heat moisture exchange filter and heated wire humidifiers: rates of ventilator-associated early-onset (community-acquired) or late-onset (hospital-acquired) pneumonia and incidence of endotracheal tube occlusion.

PubMed

Kirton, O C; DeHaven, B; Morgan, J; Morejon, O; Civetta, J

1997-10-01

To compare the performance of an in-line heat moisture exchanging filter (HMEF) (Pall BB-100; Pall Corporation; East Hills, NY) to a conventional heated wire humidifier (H-wH) (Marquest Medical Products Inc., Englewood, Colo) in the mechanical ventilator circuit on the incidence of ventilator-associated pneumonia (VAP) and the rate of endotracheal tube occlusion. This report describes a prospective, randomized trial of 280 consecutive trauma patients in a 20-bed trauma ICU (TICU). All intubated patients not ventilated elsewhere in the medical center prior to their TICU admission were randomized to either an in-line HMEF or a H-wH in the breathing circuit. Ventilator circuits were changed routinely every 7 days, and closed system suction catheters were changed every 3 days. HMEFs were changed every 24 h, or more frequently if necessary. A specific endotracheal tube suction and lavage protocol was not employed. Patients were dropped from the HMEF group if the filter was changed more than three times a day or the patient was placed on a regimen of ultra high-frequency ventilation. The Centers for Disease Control and Prevention (CDC) criteria for diagnosis of pneumonia were used; early-onset, community-acquired pneumonia was defined if CDC criteria were met in < or =3 days, and late-onset, hospital-acquired pneumonia was defined if criteria were met in >3 days. Laboratory and chest radiograph interpretation were blinded. The patient ages ranged from 15 to 95 years in the HMEF group and 16 to 87 years in the H-wH group (p=not significant), with a mean age of 46 years and 48 years, respectively. The male to female ratio ranged between 78 to 82%/22 to 18%, respectively, and 55% of all admissions were related to blunt trauma, 40% secondary to penetrating trauma, and 5% to major burns. There was no difference in Injury Severity Score (ISS) between the two groups. Moreover, there was no significant difference in mean ISS among those who did not develop pneumonia and those

Randomized, multicenter trial of lateral Trendelenburg versus semirecumbent body position for the prevention of ventilator-associated pneumonia.

PubMed

Li Bassi, Gianluigi; Panigada, Mauro; Ranzani, Otavio T; Zanella, Alberto; Berra, Lorenzo; Cressoni, Massimo; Parrini, Vieri; Kandil, Hassan; Salati, Giovanni; Selvaggi, Paola; Amatu, Alessandro; Sanz-Moncosi, Miquel; Biagioni, Emanuela; Tagliaferri, Fernanda; Furia, Mirella; Mercurio, Giovanna; Costa, Antonietta; Manca, Tullio; Lindau, Simone; Babel, Jaksa; Cavana, Marco; Chiurazzi, Chiara; Marti, Joan-Daniel; Consonni, Dario; Gattinoni, Luciano; Pesenti, Antonio; Wiener-Kronish, Janine; Bruschi, Cecilia; Ballotta, Andrea; Salsi, Pierpaolo; Livigni, Sergio; Iotti, Giorgio; Fernandez, Javier; Girardis, Massimo; Barbagallo, Maria; Moise, Gabriella; Antonelli, Massimo; Caspani, Maria Luisa; Vezzani, Antonella; Meybohm, Patrick; Gasparovic, Vladimir; Geat, Edoardo; Amato, Marcelo; Niederman, Michael; Kolobow, Theodor; Torres, Antoni

2017-11-01

The lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP). This was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two preplanned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay. At the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to-treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02-1.03, p = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86-1.60, p = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients (p = 0.01 vs. SRP). The LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted; however, at this time, the LTP cannot be recommended as a VAP preventive measure. CLINICALTRIALS. NCT01138540.

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

PubMed Central

Kalil, Andre C.; Metersky, Mark L.; Klompas, Michael; Muscedere, John; Sweeney, Daniel A.; Palmer, Lucy B.; Napolitano, Lena M.; O'Grady, Naomi P.; Bartlett, John G.; Carratalà, Jordi; El Solh, Ali A.; Ewig, Santiago; Fey, Paul D.; File, Thomas M.; Restrepo, Marcos I.; Roberts, Jason A.; Waterer, Grant W.; Cruse, Peggy; Knight, Shandra L.; Brozek, Jan L.

2016-01-01

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances. These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews. PMID:27418577

Assessment of Critical Care Provider's Application of Preventive Measures for Ventilator-Associated Pneumonia in Intensive Care Units.

PubMed

Bagheri-Nesami, Masoumeh; Amiri-Abchuyeh, Maryam; Gholipour-Baradari, Afshin; Yazdani-Cherati, Jamshid; Nikkhah, Attieh

2015-08-01

The implementation of guidelines for the prevention of Ventilator-associated pneumonia has been shown to have a significant effect in reducing the incidence of VAP. The aim of the present study was to evaluate the implementation of the preventive strategies for VAP in ICUs of university hospitals of Sari, Iran. This cross-sectional study was carried out in 600 beds/day in the ICUs of university hospitals of Sari from April to June 2012. Sampling was done by availability technique in patients receiving mechanical ventilation in the ICU. The implementation of the preventive measures was assessed by a standard checklist with previously approved validity and reliability. The percentage of implementing each of the measures was as follows: sterile suction, 88.44%; semi-recumbent position, 76.8%; oral hygiene, 58.45%; using heat and moisture exchanges (HMEs), 58%; controlling cuff pressure, 46.8%; hand hygiene, 32.8%; using anti-coagulants, 26.8% and physiotherapy, 25.5%. Closed suction system, continuous drainage of subglottic secretions and kinetic beds were not used at all. The overall mean percentage of implementing preventive measures was low and required designing integrated guidelines by considering the conditions of the ICUs in each country, as well as educating and encouraging the staffs to use the recommended guidelines.

Efficacy of intermittent sub-glottic suctioning in prevention of ventilator-associated pneumonia- A preliminary study of 100 patients.

PubMed

Vijai, M N; Ravi, Parli R; Setlur, Rangaraj; Vardhan, Harsh

2016-05-01

Oropharyngeal colonisation followed by aspiration of contaminated secretions is the major cause for ventilator-associated pneumonia (VAP). Pooled secretions present in the sub-glottic area above inflated endotracheal tube cuff may be aspirated into the lower airways. It was hypothesised that intermittent suctioning of sub-glottic secretions would prevent VAP. Group I (n = 50) patients were intubated with HiLo Evac™ endotracheal (ET) tube with facility for sub-glottic suctioning, and Group II (n = 50) patients were intubated with HiLo Contour™ ET tube without such facility. In the Group I, sub-glottic suctioning was performed every 2 h. Incidence of VAP, mean ventilator days, Intensive Care Unit (ICU) stay and mortality were compared. Qualitative variables were reported as percentages and were compared by Chi-square test or unpaired two-tailed, Fisher's exact test, as appropriate, to analyse the significance of difference between the two groups. The two groups were similar with respect to demographic characteristics. VAP was seen in 6% of patients in Group I and 22% of patients in Group II (P = 0.021). Both early- and late-onset VAPs were significantly reduced in Group I. Both ventilator days (8.0 vs. 6.45; P = 0.001) and ICU stay (8.33 vs. 6.33; P = 0.001) on the day of onset of VAP were significantly more in the Group I. Total ventilator days were significantly less (6.52 vs. 8.32; P = 0.006) with lower incidence of mortality (36% vs. 48%; P = 0.224) in the Group I. Intermittent sub-glottic suctioning reduces the incidence of VAP including late-onset VAP.

Effect of continuous oral suctioning on the development of ventilator-associated pneumonia: a pilot randomized controlled trial.

PubMed

Chow, Meyrick C M; Kwok, Shu-Man; Luk, Hing-Wah; Law, Jenny W H; Leung, Bartholomew P K

2012-11-01

Both continuous and intermittent aspiration of subglottic secretions by means of specially designed endotracheal tubes containing a separate dorsal lumen that opens into the subglottic region have been shown to be useful in reducing ventilator-associated pneumonia (VAP). However, the high cost of these tubes restricts their use. The aim of this pilot randomized controlled trial was to test the effect of a low-cost device (saliva ejector) for continuous oral suctioning (COS) on the incidence of VAP in patients receiving mechanical ventilation. The study was conducted in the six-bed medical-surgical ICU of a hospital with over 400 beds that provides comprehensive medical services to the public. The design of this study was a parallel-group randomized controlled trial. While both the experimental and control groups used the conventional endotracheal tube, the saliva ejector was only applied to patients assigned to the experimental group. The device was put between the patient's cheek and teeth, and then connected to 100mmHg of suction for the continuous drainage of saliva. Fourteen patients were randomized to receive COS and 13 patients were randomized to the control group. The two groups were similar in demographics, reasons for intubation, co-morbidity, and risk factors for acquiring VAP. VAP was found in 3 patients (23.1%; 71 episodes of VAP per 1000 ventilation days) receiving COS and in 10 patients (83.3%; 141 episodes of VAP per 1000 ventilation days) in the control group (relative risk, 0.28; 95% confidence interval, 0.10-0.77; p=0.003). The duration of mechanical ventilation in the experimental group was 3.2 days (SD 1.3), while that in the control group was 5.9 days (SD 2.8) (p=0.009); and the length of ICU stay was 4.8 days (SD 1.6) versus 9.8 days (SD 6.3) for the experimental and control groups, respectively (p=0.019). Continuous clearance of oral secretion by the saliva ejector may have an important role to play in reducing the rate of VAP, decreasing the

Ventilator-associated pneumonia using a heated humidifier or a heat and moisture exchanger: a randomized controlled trial [ISRCTN88724583].

PubMed

Lorente, Leonardo; Lecuona, María; Jiménez, Alejandro; Mora, María L; Sierra, Antonio

2006-01-01

Some guidelines to prevent ventilator-associated pneumonia (VAP) do not establish a recommendation for the preferential use of either heat and moisture exchangers (HMEs) or heated humidifiers (HHs), while other guidelines clearly advocate the use of HMEs. The aim of this study was to determine the incidence of VAP associated with HHs or HMEs. A randomized study was conducted in the intensive care unit of a university hospital involving patients expected to require mechanical ventilation for >5 days. Patients were assigned to two groups; one group received HH and the other group received HME. Tracheal aspirate samples were obtained on endotracheal intubation, then twice a week, and finally on extubation, in order to diagnose VAP. Throat swabs were taken on admission to the intensive care unit, then twice a week, and finally at discharge from the intensive care unit in order to classify VAP as primary endogenous, secondary endogenous, or exogenous. A total of 120 patients were assigned to HMEs (60 patients) and HHs (60 patients); 16 patients received mechanical ventilation for less than five days and were excluded from the analysis. Data analysis of the remaining 104 patients (53 HMEs and 51 HHs) showed no significant differences between groups regarding sex, age, Acute Physiology and Chronic Health Evaluation II score, pre-VAP use of antibiotics, days on mechanical ventilation, and diagnosis group. VAP was found in eight of 51 (15.69%) patients in the HH group and in 21 of 53 (39.62%) patients in the HME group (P = 0.006). The median time free of VAP was 20 days (95% confidence interval, 13.34-26.66) for the HH group and was 42 days (95% confidence interval, 35.62-48.37) for the HME group (P <0.001). Cox regression analysis showed the HME as a risk factor for VAP (hazard rate, 16.2; 95% confidence interval, 4.54-58.04; P < 0.001). The patients mechanically ventilated during more than 5 days developed a lower incidence of VAP with a heated humidifier than heat and

Population pharmacokinetics of imipenem in critically ill patients with suspected ventilator-associated pneumonia and evaluation of dosage regimens

PubMed Central

Couffignal, Camille; Pajot, Olivier; Laouénan, Cédric; Burdet, Charles; Foucrier, Arnaud; Wolff, Michel; Armand-Lefevre, Laurence; Mentré, France; Massias, Laurent

2014-01-01

Aims Significant alterations in the pharmacokinetics (PK) of antimicrobials have been reported in critically ill patients. We describe PK parameters of imipenem in intensive care unit (ICU) patients with suspected ventilator-associated pneumonia and evaluate several dosage regimens. Methods This French multicentre, prospective, open-label study was conducted in ICU patients with a presumptive diagnosis of ventilator-associated pneumonia caused by Gram-negative bacilli, who empirically received imipenem intravenously every 8 h. Plasma imipenem concentrations were measured during the fourth imipenem infusion using six samples (trough, 0.5, 1, 2, 5 and 8 h). Data were analysed with a population approach using the stochastic approximation expectation maximization algorithm in Monolix 4.2. A Monte Carlo simulation was performed to evaluate the following six dosage regimens: 500, 750 or 1000 mg with administration every 6 or 8 h. The pharmacodynamic target was defined as the probability of achieving a fractional time above the minimal inhibitory concentration (MIC) of >40%. Results Fifty-one patients were included in the PK analysis. Imipenem concentration data were best described by a two-compartment model with three covariates (creatinine clearance, total bodyweight and serum albumin). Estimated clearance (between-subject variability) was 13.2 l h−1 (38%) and estimated central volume 20.4 l (31%). At an MIC of 4 μg ml−1, the probability of achieving 40% fractional time > MIC was 91.8% for 0.5 h infusions of 750 mg every 6 h, 86.0% for 1000 mg every 8 h and 96.9% for 1000 mg every 6 h. Conclusions This population PK model accurately estimated imipenem concentrations in ICU patients. The simulation showed that for these patients, the best dosage regimen of imipenem is 750 mg every 6 h and not 1000 mg every 8 h. PMID:24903189

Population pharmacokinetics of imipenem in critically ill patients with suspected ventilator-associated pneumonia and evaluation of dosage regimens.

PubMed

Couffignal, Camille; Pajot, Olivier; Laouénan, Cédric; Burdet, Charles; Foucrier, Arnaud; Wolff, Michel; Armand-Lefevre, Laurence; Mentré, France; Massias, Laurent

2014-11-01

Significant alterations in the pharmacokinetics (PK) of antimicrobials have been reported in critically ill patients. We describe PK parameters of imipenem in intensive care unit (ICU) patients with suspected ventilator-associated pneumonia and evaluate several dosage regimens. This French multicentre, prospective, open-label study was conducted in ICU patients with a presumptive diagnosis of ventilator-associated pneumonia caused by Gram-negative bacilli, who empirically received imipenem intravenously every 8 h. Plasma imipenem concentrations were measured during the fourth imipenem infusion using six samples (trough, 0.5, 1, 2, 5 and 8 h). Data were analysed with a population approach using the stochastic approximation expectation maximization algorithm in Monolix 4.2. A Monte Carlo simulation was performed to evaluate the following six dosage regimens: 500, 750 or 1000 mg with administration every 6 or 8 h. The pharmacodynamic target was defined as the probability of achieving a fractional time above the minimal inhibitory concentration (MIC) of >40%. Fifty-one patients were included in the PK analysis. Imipenem concentration data were best described by a two-compartment model with three covariates (creatinine clearance, total bodyweight and serum albumin). Estimated clearance (between-subject variability) was 13.2 l h(-1) (38%) and estimated central volume 20.4 l (31%). At an MIC of 4 μg ml(-1) , the probability of achieving 40% fractional time > MIC was 91.8% for 0.5 h infusions of 750 mg every 6 h, 86.0% for 1000 mg every 8 h and 96.9% for 1000 mg every 6 h. This population PK model accurately estimated imipenem concentrations in ICU patients. The simulation showed that for these patients, the best dosage regimen of imipenem is 750 mg every 6 h and not 1000 mg every 8 h. © 2014 The British Pharmacological Society.

Nurses' knowledge of evidence-based guidelines for prevention of ventilator-associated pneumonia in critical care areas: a pre and post test design.

PubMed

Meherali, Salima Moez; Parpio, Yasmin; Ali, Tazeen S; Javed, Fawad

2011-01-01

Ventilator associated pneumonia (VAP) is a common hospital acquired pneumonia in ventilated patients. VAP is associated with increased morbidity, mortality duration of hospitalization and cost of treatment. Critical care nurses are usually unaware of evidence based preventive guidelines for VAP, resulting in negative impact on all aspects of patient care. This study investigated the impact of a 5-hour teaching module on nurses' knowledge to practice evidence based guidelines for the prevention of VAP. This study was conducted at a private tertiary care teaching hospital in Karachi, Pakistan. Single group pre-test design was used. Forty nurses were included in the study. The knowledge of nurses was assessed before, immediately after and 4 weeks after the intervention. The final sample (n=40) was selected on the basis of the set inclusion criteria. The demographic data sheet was used to collect relevant information about the participants. Knowledge was assessed through a self-developed validated tool, consisting of multiple choice questions. The difference in knowledge was analysed through repeated measures of analysis of variance. The mean scores at 3 time points were compared using the Tukey's multiple comparison procedure. Knowledge scores of participants increased significantly after the educational intervention in the first post-test; however, there was a decline in the score in post-test 2. the 5-hour teaching module significantly enhanced nurses' knowledge towards evidence based guidelines for the prevention of VAP. Further research is needed to assess the impact of training on nursing practice and to explore factors affecting attitudinal change.

Mechanical ventilation weaning and extubation after spinal cord injury: a Western Trauma Association multicenter study.

PubMed

Kornblith, Lucy Z; Kutcher, Matthew E; Callcut, Rachael A; Redick, Brittney J; Hu, Charles K; Cogbill, Thomas H; Baker, Christopher C; Shapiro, Mark L; Burlew, Clay C; Kaups, Krista L; DeMoya, Marc A; Haan, James M; Koontz, Christopher H; Zolin, Samuel J; Gordy, Stephanie D; Shatz, David V; Paul, Doug B; Cohen, Mitchell J

2013-12-01

Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05). While many patients with SCI require short-term mechanical ventilation, the majority can be successfully

International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT).

PubMed

Torres, Antoni; Niederman, Michael S; Chastre, Jean; Ewig, Santiago; Fernandez-Vandellos, Patricia; Hanberger, Hakan; Kollef, Marin; Li Bassi, Gianluigi; Luna, Carlos M; Martin-Loeches, Ignacio; Paiva, J Artur; Read, Robert C; Rigau, David; Timsit, Jean François; Welte, Tobias; Wunderink, Richard

2017-09-01

The most recent European guidelines and task force reports on hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) were published almost 10 years ago. Since then, further randomised clinical trials of HAP and VAP have been conducted and new information has become available. Studies of epidemiology, diagnosis, empiric treatment, response to treatment, new antibiotics or new forms of antibiotic administration and disease prevention have changed old paradigms. In addition, important differences between approaches in Europe and the USA have become apparent.The European Respiratory Society launched a project to develop new international guidelines for HAP and VAP. Other European societies, including the European Society of Intensive Care Medicine and the European Society of Clinical Microbiology and Infectious Diseases, were invited to participate and appointed their representatives. The Latin American Thoracic Association was also invited.A total of 15 experts and two methodologists made up the panel. Three experts from the USA were also invited (Michael S. Niederman, Marin Kollef and Richard Wunderink).Applying the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology, the panel selected seven PICO (population-intervention-comparison-outcome) questions that generated a series of recommendations for HAP/VAP diagnosis, treatment and prevention. Copyright ©ERS 2017.

Severe community-acquired Enterobacter pneumonia: a plea for greater awareness of the concept of health-care-associated pneumonia

PubMed Central

2011-01-01

Background Patients with Enterobacter community-acquired pneumonia (EnCAP) were admitted to our intensive care unit (ICU). Our primary aim was to describe them as few data are available on EnCAP. A comparison with CAP due to common and typical bacteria was performed. Methods Baseline clinical, biological and radiographic characteristics, criteria for health-care-associated pneumonia (HCAP) were compared between each case of EnCAP and thirty age-matched typical CAP cases. A univariate and multivariate logistic regression analysis was performed to determine factors independently associated with ENCAP. Their outcome was also compared. Results In comparison with CAP due to common bacteria, a lower leukocytosis and constant HCAP criteria were associated with EnCAP. Empiric antibiotic therapy was less effective in EnCAP (20%) than in typical CAP (97%) (p < 0.01). A delay in the initiation of appropriate antibiotic therapy (3.3 ± 1.6 vs. 1.2 ± 0.6 days; p < 0.01) and an increase in duration of mechanical ventilation (8.4 ± 5.2 vs. 4.0 ± 4.3 days; p = 0.01) and ICU stay were observed in EnCAP patients. Conclusions EnCAP is a severe infection which is more consistent with HCAP than with typical CAP. This retrospectively suggests that the application of HCAP guidelines should have improved EnCAP management. PMID:21569334

A Case-Control Study on the Impact of Ventilator-Associated Tracheobronchitis in the PICU.

PubMed

Wheeler, Derek S; Whitt, John D; Lake, Michael; Butcher, John; Schulte, Marion; Stalets, Erika

2015-07-01

Hospital-acquired infections increase morbidity, mortality, and charges in the PICU. We implemented a quality improvement bundle directed at ventilator-associated pneumonia in our PICU in 2005. We observed an increase in ventilator-associated tracheobronchitis coincident with the near-elimination of ventilator-associated pneumonia. The impact of ventilator-associated tracheobronchitis on critically ill children has not been previously described. Accordingly, we hypothesized that ventilator-associated tracheobronchitisis associated with increased length of stay, mortality, and hospital charge. Retrospective case-control study. Critically ill children admitted to a quaternary PICU at a free-standing academic children's hospital in the United States. None. We conducted a retrospective case control study, with institutional review board approval, of 77 consecutive cases of ventilator-associated tracheobronchitis admitted to our PICU from 2004-2010. We matched each case with a control based on the following criteria (in rank order): age range (< 30 d, 30 d to 24 mo, 24 mo to 12 yr, > 12 yr), admission Pediatric Risk of Mortality III score ± 10, number of ventilator days of control group (> 75% of days until development of ventilator-associated tracheobronchitis), primary diagnosis, underlying organ system dysfunction, surgical procedure, and gender. The primary outcome measured was PICU length of stay. Secondary outcomes included ventilator days, hospital length of stay, mortality, and PICU and hospital charges. Data was analyzed using chi square analysis and p less than 0.05 was considered significant. We successfully matched 45 of 77 ventilator-associated tracheobronchitis patients with controls. There were no significant differences in age, gender, diagnosis, or Pediatric Risk of Mortality III score between groups. Ventilator-associated tracheobronchitis patients had a longer PICU length of stay (median, 21.5 d, interquartile range, 24 d) compared to controls

Extra corporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe Pneumocystis pneumonia with pneumomediastinum: a case report and short literature review.

PubMed

Ali, Husain Shabbir; Hassan, Ibrahim Fawzy; George, Saibu

2016-04-14

Pulmonary infections caused by Pneumocystis jirovecii in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraxes. In such cases, it can be challenging to maintain adequate gas exchange by conventional mechanical ventilation and at the same time prevent further ventilator-induced lung injury. We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis infection, rescued with veno-venous extra corporeal membrane oxygenation (V-V ECMO). A 26 year old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation for respiratory failure. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients' pulmonary parameters worsened necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-protective lung ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus infection. Patient was successfully treated with appropriate antimicrobials and de-cannulated after six days of ECMO support. ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia and air leak syndrome.

Incidence and clinical implication of nosocomial infections associated with implantable biomaterials – catheters, ventilator-associated pneumonia, urinary tract infections

PubMed Central

Guggenbichler, Josef Peter; Assadian, Ojan; Boeswald, Michael; Kramer, Axel

2012-01-01

Health care associated infections, the fourth leading cause of disease in industrialised countries, are a major health issue. One part of this condition is based on the increasing insertion and implantation of prosthetic medical devices, since presence of a foreign body significantly reduces the number of bacteria required to produce infection. The most significant hospital-acquired infections, based on frequency and potential severity, are those related to procedures e.g. surgical site infections and medical devices, including urinary tract infection in catheterized patients, pneumonia in patients intubated on a ventilator and bacteraemia related to intravascular catheter use. At least half of all cases of nosocomial infections are associated with medical devices. Modern medical and surgical practices have increasingly utilized implantable medical devices of various kinds. Such devices may be utilized only short-time or intermittently, for months, years or permanently. They improve the therapeutic outcome, save human lives and greatly enhance the quality of life of these patients. However, plastic devices are easily colonized with bacteria and fungi, able to be colonized by microorganisms at a rate of up to 0.5 cm per hour. A thick biofilm is formed within 24 hours on the entire surface of these plastic devices once inoculated even with a small initial number of bacteria. The aim of the present work is to review the current literature on causes, frequency and preventive measures against infections associated with intravascular devices, catheter-related urinary tract infection, ventilator-associated infection, and infections of other implantable medical devices. Raising awareness for infection associated with implanted medical devices, teaching and training skills of staff, and establishment of surveillance systems monitoring device-related infection seem to be the principal strategies used to achieve reduction and prevention of such infections. The intelligent use

A study of ventilator-associated pneumonia: Incidence, outcome, risk factors and measures to be taken for prevention.

PubMed

Gadani, Hina; Vyas, Arun; Kar, Akhya Kumar

2010-11-01

Ventilator-associated pneumonia (VAP) is a major cause of hospital morbidity and mortality despite recent advances in diagnosis and accuracy of management. However, as taught in medical science, prevention is better than cure is probably more appropriate as concerned to VAP because of the fact that it is a well preventable disease and a proper approach decreases the hospital stay, cost, morbidity and mortality. The aim of the study is to critically review the incidence and outcome, identify various risk factors and conclude specific measures that should be undertaken to prevent VAP. We studied 100 patients randomly, kept on ventilatory support for more than 48 h. After excluding those who developed pneumonia within 48 h, VAP was diagnosed when a score of ≥6 was obtained in the clinical pulmonary infection scoring system having six variables and a maximum score of 12. After evaluating, the data were subjected to univariate analysis using the chi-square test. The level of significance was set at P<0.05. It was found that 37 patients developed VAP. The risk factor significantly associated with VAP in our study was found to be duration of ventilator support, reintubation, supine position, advanced age and altered consciousness. Declining ratio of partial pressure to inspired fraction of oxygen (PaO(2)/FiO(2) ratio) was found to be the earliest indicator of VAP. The most common organism isolated in our institution was Pseudomonas. The incidence of early-onset VAP (within 96 h) was found to be 27% while the late-onset type (>96 h) was 73%. Late-onset VAP had poor prognosis in terms of mortality (66%) as compared to the early-onset type (20%). The mortality of patients of the non-VAP group was found to be 41% while that of VAP patients was 54%. Targeted strategies aimed at preventing VAP should be implemented to improve patient outcome and reduce length of intensive care unit stay and costs. Above all, everyone of the critical care unit should understand the factors

Ventilator-associated pneumonia risk decreased by use of oral moisture gel in oral health care.

PubMed

Takeyasu, Yoshihiro; Yamane, Gen-Yuki; Tonogi, Morio; Watanabe, Yutaka; Nishikubo, Shuichi; Serita, Ryohei; Imura, Kumiko

2014-01-01

Although oral health care has a preventive effect against ventilator-associated pneumonia (VAP), the most effective method of oral health care in this respect remains to be established. The objective of this single-center, randomized, controlled trial was to investigate the relationship between VAP and various methods of oral health care. All patients included in the study (n=142) were on mechanical ventilation with oral intubation at the intensive care unit of the Tokyo Dental College Ichikawa General Hospital. They were divided into two groups, one receiving standard oral health care (Standard group), and the other receiving oral health care using an oral moisture gel instead of water (Gel group). After removal of the intubation tube, biofilm on cuff of the tube was stained with a disclosing agent to determine the contamination level. Factors investigated included sex, age, number of remaining teeth, intubation time, fever ≥38.5°C, VAP, cuff contamination level, and time required for one oral health care session. No VAP occurred in either group during the study period. The level of cuff contamination was significantly lower in the Gel group than the Standard group, and the time required for one session of oral health care was shorter (p<0.001). Multivariate analysis revealed use of the oral moisture gel as a factor affecting cuff contamination level. Use of an oral moisture gel decreased invasion of the pharynx by bacteria and contaminants together with biofilm formation on the intubation tube cuff. These results suggest that oral health care using an oral moisture gel is effective in preventing cuff contamination.

Developing a new, national approach to surveillance for ventilator-associated events*.

PubMed

Magill, Shelley S; Klompas, Michael; Balk, Robert; Burns, Suzanne M; Deutschman, Clifford S; Diekema, Daniel; Fridkin, Scott; Greene, Linda; Guh, Alice; Gutterman, David; Hammer, Beth; Henderson, David; Hess, Dean; Hill, Nicholas S; Horan, Teresa; Kollef, Marin; Levy, Mitchell; Septimus, Edward; VanAntwerpen, Carole; Wright, Don; Lipsett, Pamela

2013-11-01

To develop and implement an objective, reliable approach to surveillance for ventilator-associated events in adult patients. The Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group in September 2011. Working Group members included representatives of stakeholder societies and organizations and federal partners. The Working Group finalized a three-tier, adult surveillance definition algorithm for ventilator-associated events. The algorithm uses objective, readily available data elements and can identify a broad range of conditions and complications occurring in mechanically ventilated adult patients, including but not limited to VAP. The first tier definition, ventilator-associated condition (VAC), identifies patients with a period of sustained respiratory deterioration following a sustained period of stability or improvement on the ventilator, defined by changes in the daily minimum fraction of inspired oxygen or positive end-expiratory pressure. The second tier definition, infection-related ventilator-associated complication (IVAC), requires that patients with VAC also have an abnormal temperature or white blood cell count, and be started on a new antimicrobial agent. The third tier definitions, possible and probable VAP, require that patients with IVAC also have laboratory and/or microbiological evidence of respiratory infection. Ventilator-associated events surveillance was implemented in January 2013 in the CDC's National Healthcare Safety Network. Modifications to improve surveillance may be made as additional data become available and users gain experience with the new definitions.

Healthcare-associated Pneumonia: Clinical Features and Retrospective Analysis Over 10 Years.

PubMed

Qi, Fei; Zhang, Guo-Xin; She, Dan-Yang; Liang, Zhi-Xin; Wang, Ren-Tao; Yang, Zhen; Chen, Liang-An; Cui, Jun-Chang

2015-10-20

Healthcare-associated pneumonia (HCAP) is associated with drug-resistant pathogens and high mortality, and there is no clear evidence that this is due to inappropriate antibiotic therapy. This study was to elucidate the clinical features, pathogens, therapy, and outcomes of HCAP, and to clarify the risk factors for drug-resistant pathogens and prognosis. Retrospective observational study among hospitalized patients with HCAP over 10 years. The primary outcome was 30-day all-cause hospital mortality after admission. Demographics (age, gender, clinical features, and comorbidities), dates of admission, discharge and/or death, hospitalization costs, microbiological results, chest imaging studies, and CURB-65 were analyzed. Antibiotics, admission to Intensive Care Unit (ICU), mechanical ventilation, and pneumonia prognosis were recorded. Patients were dichotomized based on CURB-65 (low- vs. high-risk). Among 612 patients (mean age of 70.7 years), 88.4% had at least one comorbidity. Commonly detected pathogens were Acinetobacter baumannii, Pseudomonas aeruginosa, and coagulase-negative staphylococci. Initial monotherapy with β-lactam antibiotics was the most common initial therapy (50%). Mean age, length of stay, hospitalization expenses, ICU admission, mechanical ventilation use, malignancies, and detection rate for P. aeruginosa, and Staphylococcus aureus were higher in the high-risk group compared with the low-risk group. CURB-65 ≥3, malignancies, and mechanical ventilation were associated with an increased mortality. Logistic regression analysis showed that cerebrovascular diseases and being bedridden were independent risk factors for HCAP. Initial treatment of HCAP with broad-spectrum antibiotics could be an appropriate approach. CURB-65 ≥3, malignancies, and mechanical ventilation may result in an increased mortality.

Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials.

PubMed

Alexiou, Vangelis G; Ierodiakonou, Vrettos; Dimopoulos, George; Falagas, Matthew E

2009-12-01

The aim of this study is to summarize the effect of position (prone and semirecumbent 45 degrees ) of mechanically ventilated patients on the incidence of ventilator-associated pneumonia (VAP) and other outcomes. A systematic search for randomized control trials (RCTs) was done. We estimated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using fixed effects model or random effects model, where appropriate. For continuous variables, we calculated the estimation of weighted mean differences. We analyzed data extracted from 3 RCTs studying the semirecumbent 45 degrees and 4 RCTs studying the prone position with a total of 337 and 1018 patients, respectively. The odds of developing clinically diagnosed VAP were significantly lower among patients in the semirecumbent 45 degrees position compared to patients in the supine position (OR = 0.47; 95% CI, 0.27-0.82; 337 patients). The comparison of prone vs supine position group showed a moderate trend toward better outcomes regarding the incidence of clinically diagnosed VAP among patients in the prone position (OR = 0.80; 95% CI, 0.60-1.08; 1018 patients). The subanalysis regarding the incidence of microbiologically documented VAP, the length of intensive care unit stay, and the duration of mechanical ventilation showed that patients in the semirecumbent 45 degrees position have a moderate trend toward better clinical outcomes. This meta-analysis provides additional evidence that the usual practice of back-rest elevation of 15 degrees to 30 degrees is not sufficient to prevent VAP in mechanically ventilated patients. Patients positioned semirecumbently 45 degrees have significantly lower incidence of clinically diagnosed VAP compared to patients positioned supinely. On the other hand, the incidence of clinically diagnosed VAP among patients positioned pronely does not differ significantly from the incidence of clinically diagnosed VAP among patients positioned supinely.

Evaluation of the New Centers for Disease Control and Prevention Ventilator-Associated Event Module and Criteria in Critically Ill Children in Greece.

PubMed

Iosifidis, Elias; Chochliourou, Elpis; Violaki, Asimenia; Chorafa, Elisavet; Psachna, Stavroula; Roumpou, Afroditi; Sdougka, Maria; Roilides, Emmanuel

2016-10-01

OBJECTIVE To evaluate the new adult Centers for Disease Control and Prevention (CDC) ventilator-associated event (VAE) module in critically ill children and compare with the traditionally used CDC definition for ventilator-associated pneumonia (VAP). DESIGN Retrospective observational study of mechanically ventilated children in a pediatric intensive care unit in Greece January 1-December 31, 2011. METHODS Assessment of new adult CDC VAE module including 3 definition tiers: ventilator-associated condition (VAC), infection-related VAC, and possible/probable ventilator-associated pneumonia (VAE-VAP); comparison with traditional CDC criteria for clinically defined pneumonia in mechanically ventilated children (PNEU-VAP). We recorded Pediatric Risk of Mortality score at admission (PRISM III), number of ventilator-days, and outcome. RESULTS Among 119 patients with mechanical ventilation (median [range] number of ventilator-days, 7 [1-183]), 19 patients experienced VAC. Criteria for VAE-VAP were fulfilled in 12 of 19 patients with VAC (63%). Children with either VAC or VAE-VAP were on ventilation more days than patients without these conditions (16.5 vs 5 d, P=.0006 and 18 vs 5 d, P<.001, respectively), whereas PRISM-III score was similar between them. Mortality was significant higher in patients with new VAE-VAP definition (50%), but not in patients with VAC (31.6%), than the patients without new VAE-VAP (14%, P=.007) or VAC (15%, P=.1), respectively. No significant association was found between PNEU-VAP and death. Incidences of PNEU-VAP and VAE-VAP were similar, but the agreement was poor. CONCLUSIONS VAE-VAP and PNEU-VAP found similar prevalence in critically ill children but with poor agreement. However, excess of death was significantly associated only with VAE-VAP. Infect Control Hosp Epidemiol 2016:1-5.

Nursing workload and adherence to non-pharmacological measures in the prevention of ventilator-associated pneumonia. A pilot study.

PubMed

Jam, R; Hernández, O; Mesquida, J; Turégano, C; Carrillo, E; Pedragosa, R; Gómez, V; Martí, L; Vallés, J; Delgado-Hito, P

To analyse whether adherence to non-pharmacological measures in the prevention of ventilator-associated pneumonia (VAP) is associated with nursing workload. A prospective observational study performed in a single medical-surgical ICU. Nurses in charge of patients under ventilator support were assessed. knowledge questionnaire, application of non-pharmacological VAP prevention measures, and workload (Nine Equivalents of Nursing Manpower Use Score). Phases: 1) the nurses carried out a educational programme, consisting of 60-minute lectures on non-pharmacological measures for VAP prevention, and at the end completed a questionnaire knowledge; 2) observation period; 3) knowledge questionnaire. Among 67 ICU-staff nurses, 54 completed the educational programme and were observed. A total of 160 observations of 49 nurses were made. Adequate knowledge was confirmed in both the initial and final questionnaires. Application of preventive measures ranged from 11% for hand washing pre-aspiration to 97% for the use of a sterile aspiration probe. The Nine Equivalents of Nursing Manpower Use Score was 50±13. No significant differences were observed between the association of the nurses' knowledge and the application of preventive measures or between workload and the application of preventive measures. Nurses' knowledge of VAP prevention measures is not necessarily applied in daily practice. Failure to follow these measures is not subject to lack of knowledge or to increased workload, but presumably to contextual factors. Copyright © 2017 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.

Postoperative infections after major heart surgery and prevention of ventilator-associated pneumonia: a one-day European prevalence study (ESGNI-008).

PubMed

Bouza, E; Hortal, J; Muñoz, P; Pascau, J; Pérez, M J; Hiesmayr, M

2006-11-01

Few data have been published on the prevalence of postoperative infection in patients undergoing major heart surgery (MHS). The degree of compliance with standard measures used to prevent them is unknown. This study assessed the prevalence of infections, particularly ventilator-associated pneumonia (VAP), in patients undergoing MHS in 42 institutions from 13 European countries. On the study day, there were 321 postoperative MHS patients, of whom 164 (51%) were mechanically ventilated. The overall prevalence of infection was 26.8%. Lower respiratory tract infections represented 57% of all the infections present on the study day. Other infections included intravenous-catheter-related bloodstream infections (2.8%), surgical site infections (2.2%), urinary tract infections (0.9%) and postoperative mediastinitis (0.9%). Of the mechanically ventilated patients, 55 (33.5%) were not being nursed in a semi-recumbent position, 36 (22%) had heat-moisture exchangers with no antibacterial filters, and intracuff pressure was not monitored in 78 patients (47.6%). Only 13 patients (8%) were given continuous subglottic suctioning, 64 patients (39%) did not receive postural oscillation, and gastric overdistension was not actively prevented in 23 patients (14%). In conclusion, these data from intensive care units across Europe provide information on postoperative infections in an important subset of the patient population, and stress the need for active interventions to prevent VAP in patients undergoing MHS.

Executive Summary: Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

PubMed Central

Kalil, Andre C.; Metersky, Mark L.; Klompas, Michael; Muscedere, John; Sweeney, Daniel A.; Palmer, Lucy B.; Napolitano, Lena M.; O'Grady, Naomi P.; Bartlett, John G.; Carratalà, Jordi; El Solh, Ali A.; Ewig, Santiago; Fey, Paul D.; File, Thomas M.; Restrepo, Marcos I.; Roberts, Jason A.; Waterer, Grant W.; Cruse, Peggy; Knight, Shandra L.; Brozek, Jan L.

2016-01-01

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances. These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews. PMID:27521441

Predictors of physician confidence to diagnose pneumonia and determine illness severity in ventilated patients. Australian and New Zealand practice in intensive care (ANZPIC II).

PubMed

Boots, R J; Lipman, J; Bellomo, R; Stephens, D; Heller, R E

2005-02-01

The manner in which elements of clinical history, physical examination and investigations influence subjectively assessed illness severity and outcome prediction is poorly understood. This study investigates the relationship between clinician and objectively assessed illness severity and the factors influencing clinician's diagnostic confidence and illness severity rating for ventilated patients with suspected pneumonia in the intensive care unit (ICU). A prospective study of fourteen ICUs included all ventilated admissions with a clinical diagnosis of pneumonia. Data collection included pneumonia type - community-acquired (CAP), hospital-acquired (HAP) and ventilator-associated (VAP), clinician determined illness severity (CDIS), diagnostic methods, clinical diagnostic confidence (CDC), microbiological isolates and antibiotic use. For 476 episodes of pneumonia (48% CAP, 24% HAP, 28% VAP), CDC was greatest for CAP (64% CAP, 50% HAP and 49% VAP, P<0.01) or when pneumonia was considered "life-threatening" (84% high CDC, 13% medium CDC and 3% low CDC, P<0. 001). "Life-threatening" pneumonia was predicted by worsening gas exchange (OR 4.8, CI 95% 2.3-10.2, P<0.001), clinical signs of consolidation (OR 2.0, CI 95% 1.2-3.2, P<0.01) and the Sepsis-Related Organ Failure Assessment (SOFA) Score (OR 1.1, CI 95% 1.1-1.2, P<0.001). Diagnostic confidence increased with CDIS (OR 16.3, CI 95% 8.4-31.4, P<0.001), definite pathogen isolation (OR 3.3, CI 95% 2.0-5.6) and clinical signs of consolidation (OR 2.1, CI 95% 1.3-3.3, P=0.001). Although the CDIS, SOFA Score and the Simplified Acute Physiologic Score (SAPS II) were all associated with mortality, the SAPS II Score was the best predictor of mortality (P = 0. 02). Diagnostic confidence for pneumonia is moderate but increases with more classical presentations. A small set of clinical parameters influence subjective assessment. Objective assessment using SAPS II Scoring is a better predictor of mortality.

Multidrug Resistance Acinetobacter Bacteremia Secondary to Ventilator-Associated Pneumonia: Risk Factors and Outcome.

PubMed

Brotfain, Evgeni; Borer, Abraham; Koyfman, Leonid; Saidel-Odes, Lisa; Frenkel, Amit; Gruenbaum, Shaun E; Rosenzweig, Vsevolod; Zlotnik, Alexander; Klein, Moti

2017-10-01

Acinetobacter baumannii is a multidrug resistant (MDR), gram-negative bacterium commonly implicated in ventilator-associated pneumonia (VAP) in critically ill patients. Patients in the intensive care unit (ICU) with VAP often subsequently develop A baumannii bacteremia, which may significantly worsen outcomes. In this study, we retrospectively reviewed the clinical and laboratory records of 129 ICU patients spanning 6 years with MDR A baumannii VAP; 46 (35%) of these patients had concomitant MDR A baumannii bacteremia. The ICU mortality rate was higher in patients with VAP having A baumannii bacteremia compared to nonbacteremic patients (32.4% vs 9.6% respectively, P < .005). Age >65 years, an Acute Physiology and Chronic Health Evaluation II (APACHE-II) score higher than 20, a Sequential Organ Failure Assessment (SOFA) score higher than 7 on the day of bacteremia, and the presence of comorbid disease (chronic obstructive pulmonary disease [COPD] and chronic renal failure) were found to be independent risk factors for in-hospital mortality in this population. Multidrug resistant A baumannii was not an independent risk factor for mortality. Although the presence of comorbid diseases (COPD and chronic renal failure) and severity of disease (APACHE > 20 and SOFA >7) were found to be independent risk factors for ICU mortality, MDR A baumannii bacteremia was not an independent risk factor for mortality in our critically ill population.

Ventilator-associated pneumonia using a heated humidifier or a heat and moisture exchanger: a randomized controlled trial [ISRCTN88724583

PubMed Central

Lorente, Leonardo; Lecuona, María; Jiménez, Alejandro; Mora, María L; Sierra, Antonio

2006-01-01

Introduction Some guidelines to prevent ventilator-associated pneumonia (VAP) do not establish a recommendation for the preferential use of either heat and moisture exchangers (HMEs) or heated humidifiers (HHs), while other guidelines clearly advocate the use of HMEs. The aim of this study was to determine the incidence of VAP associated with HHs or HMEs. Methods A randomized study was conducted in the intensive care unit of a university hospital involving patients expected to require mechanical ventilation for >5 days. Patients were assigned to two groups; one group received HH and the other group received HME. Tracheal aspirate samples were obtained on endotracheal intubation, then twice a week, and finally on extubation, in order to diagnose VAP. Throat swabs were taken on admission to the intensive care unit, then twice a week, and finally at discharge from the intensive care unit in order to classify VAP as primary endogenous, secondary endogenous, or exogenous. Results A total of 120 patients were assigned to HMEs (60 patients) and HHs (60 patients); 16 patients received mechanical ventilation for less than five days and were excluded from the analysis. Data analysis of the remaining 104 patients (53 HMEs and 51 HHs) showed no significant differences between groups regarding sex, age, Acute Physiology and Chronic Health Evaluation II score, pre-VAP use of antibiotics, days on mechanical ventilation, and diagnosis group. VAP was found in eight of 51 (15.69%) patients in the HH group and in 21 of 53 (39.62%) patients in the HME group (P = 0.006). The median time free of VAP was 20 days (95% confidence interval, 13.34–26.66) for the HH group and was 42 days (95% confidence interval, 35.62–48.37) for the HME group (P <0.001). Cox regression analysis showed the HME as a risk factor for VAP (hazard rate, 16.2; 95% confidence interval, 4.54–58.04; P < 0.001). Conclusion The patients mechanically ventilated for more than five days developed a lower incidence of

Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis.

PubMed

Siempos, Ilias I; Ntaidou, Theodora K; Filippidis, Filippos T; Choi, Augustine M K

2015-02-01

Delay of tracheostomy for roughly 2 weeks after translaryngeal intubation of critically ill patients is the presently recommended practice and is supported by findings from large trials. However, these trials were suboptimally powered to detect small but clinically important effects on mortality. We aimed to assess the benefit of early versus late or no tracheostomy on mortality and pneumonia in critically ill patients who need mechanical ventilation. We systematically searched PubMed, CINAHL, Embase, Web of Science, DOAJ, the Cochrane Library, references of relevant articles, scientific conference proceedings, and grey literature up to Aug 31, 2013, to identify randomised controlled trials comparing early tracheostomy (done within 1 week after translaryngeal intubation) with late (done any time after the first week of mechanical ventilation) or no tracheostomy and reporting on mortality or incidence of pneumonia in critically ill patients under mechanical ventilation. Our primary outcomes were all-cause mortality during the stay in the intensive-care unit and incidence of ventilator-associated pneumonia. Mortality during the stay in the intensive-care unit was a composite endpoint of definite intensive-care-unit mortality, presumed intensive-care-unit mortality, and 28-day mortality. We calculated pooled odds ratios (OR), pooled risk ratios (RR), and 95% CIs with a random-effects model. All but complications analyses were done on an intention-to-treat basis. Analyses of 13 trials (2434 patients, 648 deaths) showed that all-cause mortality in the intensive-care unit was not significantly lower in patients assigned to the early versus the late or no tracheostomy group (OR 0·80, 95% CI 0·59-1·09; p=0·16). This result persisted when we considered only trials with a low risk of bias (511 deaths; OR 0·80, 95% CI 0·59-1·09; p=0·16; eight trials with 1934 patients). Incidence of ventilator-associated pneumonia was lower in mechanically ventilated patients assigned

Impact of oral care with versus without toothbrushing on the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials

PubMed Central

2012-01-01

Introduction Ventilator-associated pneumonia (VAP) remains a common hazardous complication in mechanically ventilated patients and is associated with increased morbidity and mortality. We undertook a systematic review and meta-analysis of randomized controlled trials to assess the effect of toothbrushing as a component of oral care on the prevention of VAP in adult critically ill patients. Methods A systematic literature search of PubMed and Embase (up to April 2012) was conducted. Eligible studies were randomized controlled trials of mechanically ventilated adult patients receiving oral care with toothbrushing. Relative risks (RRs), weighted mean differences (WMDs), and 95% confidence intervals (CIs) were calculated and heterogeneity was assessed with the I2 test. Results Four studies with a total of 828 patients met the inclusion criteria. Toothbrushing did not significantly reduce the incidence of VAP (RR, 0.77; 95% CI, 0.50 to 1.21) and intensive care unit mortality (RR, 0.88; 95% CI, 0.70 to 1.10). Toothbrushing was not associated with a statistically significant reduction in duration of mechanical ventilation (WMD, -0.88 days; 95% CI, -2.58 to 0.82), length of intensive care unit stay (WMD, -1.48 days; 95% CI, -3.40 to 0.45), antibiotic-free day (WMD, -0.52 days; 95% CI, -2.82 to 1.79), or mechanical ventilation-free day (WMD, -0.43 days; 95% CI, -1.23 to 0.36). Conclusions Oral care with toothbrushing versus without toothbrushing does not significantly reduce the incidence of VAP and alter other important clinical outcomes in mechanically ventilated patients. However, the results should be interpreted cautiously since relevant evidence is still limited, although accumulating. Further large-scale, well-designed randomized controlled trials are urgently needed. PMID:23062250

[Efficacy of heat and moisture exchangers and heated humidifiers in preventing ventilator-associated pneumonia: a meta-analysis].

PubMed

Mo, Min; Liu, Song-qiao; Yang, Yi

2011-09-01

To demonstrate the effects of heat and moisture exchangers (HME) and heated humidifiers(HH) in preventing ventilator-associated pneumonia (VAP). PubMed and Cochrane databases were searched by computer retrieval and manual retrieval to identify relevant randomized controlled trials (RCTs) using HMEs and HHs in preventing VAP from January 1st 1990 to September 1st 2010. Meta-analysis of HME and HH in preventing VAP was conducted using the methods recommended by the Cochrane Collaboration. Eleven RCTs were included. 1 121 in HME group and 1 101 in HH group. In total, the rate of VAP in HME group and HH group was 14.2% (159/1 121) and 15.9% (175/1 101) respectively, the total relative risk (RR) was 0.88, and 95% confidence interval (95%CI) 0.72-1.07, P=0.21. Compared with HH group, there was not a reduction in the risk ratio of VAP in the HME group. Even in mechanical ventilation(MV) with a duration of at least 7 days for subgroup analysis (8 RCTs, sample size: 834 in HME group and 859 in HH group), the rate of VAP in HME group and HH group was 15.2% (127/834) and 17.5% (150/859) respectively, the total RR was 0.84, 95%CI 0. 58-1.23, P=0.37, suggesting that in MV with a duration at least 7 days, there was also no reduction in the risk ratio of VAP in the HME group. This study suggests there is not a significant reduction in the incidence of VAP in patients humidified with HMEs during MV, even in patients ventilated for 7 days or longer. This finding is limited by lack of enough RCTs and blinding. Further large sample of high quality RCTs is necessary to examine the wider applicability of HMEs and their extended use.

The accuracy of Gram stain of respiratory specimens in excluding Staphylococcus aureus in ventilator-associated pneumonia.

PubMed

Gottesman, Tamar; Yossepowitch, Orit; Lerner, Evgenia; Schwartz-Harari, Orna; Soroksky, Arie; Yekutieli, Daniel; Dan, Michael

2014-10-01

To evaluate the Gram stain of deep tracheal aspirate as a tool to direct empiric antibiotic therapy, and more specifically as a tool to exclude the need for empiric antibiotic coverage against Staphylococcus aureus in ventilator-associated pneumonia (VAP). A prospective, single-center, observational, cohort study. All wards at a community hospital. Adult patients requiring mechanical ventilation, identified as having VAP in a 54-month prospective surveillance database. Sampling of lower airway secretions by deep endotracheal aspiration was taken from each patient who developed VAP. Samples were sent immediately for Gram stain and qualitative bacterial cultures. Demographic and relevant clinical data were collected; Gram stain, culture, and antibiotic susceptibility results were documented; and outcome was followed prospectively. The analysis included 114 consecutive patients with 115 episodes of VAP from June 2007 to January 2012. Sensitivity of Gram stain compared with culture was 90.47% for gram-positive cocci, 69.6% for gram-negative rods, and 50% for sterile cultures. Specificity was 82.5%, 77.8%, and 79%, respectively. Negative predictive value was high for gram-positive cocci (97%) and sterile cultures (96%) but low for gram-negative rods (20%). Acinetobacter baumanii (45%) and Pseudomonas aeruginosa (38 %) were the prevailing isolates. S aureus was found in 18.3% of the patients. Most isolates were multiresistant. Absence of gram-positive bacteria on Gram stain had a high negative predictive value. These data can be used to narrow the initial empiric antibiotic regimen and to avoid unnecessary exposure of patients to vancomycin and other antistaphyloccocal agents. Copyright © 2014 Elsevier Inc. All rights reserved.

Impact of invasive and noninvasive quantitative culture sampling on outcome of ventilator-associated pneumonia: a pilot study.

PubMed

Sanchez-Nieto, J M; Torres, A; Garcia-Cordoba, F; El-Ebiary, M; Carrillo, A; Ruiz, J; Nuñez, M L; Niederman, M

1998-02-01

We performed an open, prospective, randomized clinical trial in 51 patients receiving mechanical ventilation for more than 72 h, in order to evaluate the impact of using either invasive (protected specimen brush [PSB] and bronchoalveolar lavage [BAL] via fiberoptic bronchoscopy) or noninvasive (quantitative endotracheal aspirates [QEA]) diagnostic methods on the morbidity and mortality of ventilator-associated pneumonia (VAP). Patients were randomly assigned to two groups: Group A patients (n = 24) underwent QEA, PSB, and BAL; Group B patients (n = 27) underwent only QEA cultures. Empiric antibiotic treatment was given according to the attending physician and was modified according to the results of cultures and sensitivity in Group A using PSB and BAL results and in Group B based upon QEA cultures. Bacteriologic cultures were done quantitatively for EA, PSB, and BAL. Thresholds of > or = 10(5), > or = 10(3), and > or = 10(4) CFU/ml were used for QEA, PSB, and BAL, respectively. Microbial cultures from Group A patients were positive in 16 (67%) BAL samples, 14 (58%) PSB samples, and 16 (67%) QEA samples. In Group B patients, QEA microbial cultures yielded positive results in 20 of 27 (74%) samples. In Group A, there was total agreement between culture results of the three techniques on 17 (71%) occasions. In five (21%) cases, QEA coincided with either BAL or PBS. In only two (8%) cases, QEA cultures did not coincide with either PSB or BAL. No cases of positive BAL or PSB cultures had negative QEA cultures. Initial antibiotic treatment was modified in 10 (42%) patients from Group A and in four (16%) patients from Group B (p < 0.05). The observed crude mortality rate was 11 of 24 (46%) in Group A, and 7 of 27 (26%) in Group B, whereas the adjusted mortality rates (observed crude minus predicted at admission) for Groups A and B were 29 and 10%, respectively. There were no statistically significant differences when comparing crude and adjusted mortality rates of Groups

Impact of immunosuppression on incidence, aetiology and outcome of ventilator-associated lower respiratory tract infections.

PubMed

Moreau, Anne-Sophie; Martin-Loeches, Ignacio; Povoa, Pedro; Salluh, Jorge; Rodriguez, Alejandro; Thille, Arnaud W; Diaz Santos, Emilio; Vedes, Elisa; Lobo, Suzana Margareth; Mégarbane, Bruno; Molero Silvero, Esperanza; Coelho, Luis; Argaud, Laurent; Sanchez Iniesta, Rafael; Labreuche, Julien; Rouzé, Anahita; Nseir, Saad

2018-03-01

The aim of this planned analysis of the prospective multinational TAVeM database was to determine the incidence, aetiology and impact on outcome of ventilator-associated lower respiratory tract infections (VA-LRTI) in immunocompromised patients.All patients receiving mechanical ventilation for >48 h were included. Immunocompromised patients (n=663) were compared with non-immunocompromised patients (n=2297).The incidence of VA-LRTI was significantly lower among immunocompromised than among non-immunocompromised patients (16.6% versus 24.2%; sub-hazard ratio 0.65, 95% CI 0.53-0.80; p<0.0001). Similar results were found regarding ventilator-associated tracheobronchitis (7.3% versus 11.6%; sub-hazard ratio 0.61, 95% CI 0.45-0.84; p=0.002) and ventilator-associated pneumonia (9.3% versus 12.7%; sub-hazard ratio 0.72, 95% CI 0.54-0.95; p=0.019). Among patients with VA-LRTI, the rates of multidrug-resistant bacteria (72% versus 59%; p=0.011) and intensive care unit mortality were significantly higher among immunocompromised than among non-immunocompromised patients (54% versus 30%; OR 2.68, 95% CI 1.78-4.02; p<0.0001). In patients with ventilator-associated pneumonia, mortality rates were higher among immunocompromised than among non-immunocompromised patients (64% versus 34%; p<0.001).Incidence of VA-LRTI was significantly lower among immunocompromised patients, but it was associated with a significantly higher mortality rate. Multidrug-resistant pathogens were more frequently found in immunocompromised patients with VA-LRTI. Copyright ©ERS 2018.

Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated.

PubMed

Vallés, Jordi; Peredo, Raquel; Burgueño, Maria Jose; Rodrigues de Freitas, A Patrícia; Millán, Susana; Espasa, Mateu; Martín-Loeches, Ignacio; Ferrer, Ricard; Suarez, David; Artigas, Antonio

2013-05-01

Comatose patients present a high risk of early-onset ventilator-associated pneumonia (EO-VAP) for which antibiotic prophylaxis has been proposed. Comatose patients were studied to evaluate the efficacy of a single-dose of antibiotic prophylaxis at intubation against EO-VAP. A prospective cohort of comatose patients (Glasgow Coma Score ≤ 8) who were admitted in 2009-2010 and administered a single-dose of antibiotic within 4 h of intubation was compared with comatose patients (admitted ≥ 4 h after intubation in 2009-2010 or admitted in 2007-2008) who did not receive antibiotic prophylaxis. We analyzed the incidence of EO-VAP, late-onset VAP, and ventilator-associated tracheobronchitis in both groups. Propensity scores for receiving antibiotic prophylaxis were derived on the basis of patients' characteristics (eg, age and severity) to assess its impact on EO-VAP development. We included 129 patients (71 in the prophylaxis group and 58 in the control group). The global incidence of VAP and incidence of EO-VAP were lower in the prophylaxis group: 10.8 vs 28.4 episodes/1,000 days on mechanical ventilation (P = .015) and 4.4 vs 23.1 episodes/1,000 days on mechanical ventilation (P = .02), respectively. The incidence of late-onset VAP did not differ. The prophylaxis group tended toward lower incidence of ventilator-associated tracheobronchitis (15.5% vs 25.9%, P = .14). No differences in mortality were found between groups. The propensity-score regression analysis confirmed that a single dose of antibiotic prophylaxis was independently associated with lower incidence of EO-VAP (OR, 0.11; 95% CI, 0.02-0.58; P = .009). A single dose of antibiotic prophylaxis at intubation might lower the incidence of EO-VAP. However, a randomized clinical trial should be conducted to confirm our findings.

Effectiveness of Intraoral Chlorhexidine Protocols in the Prevention of Ventilator-Associated Pneumonia: Meta-Analysis and Systematic Review.

PubMed

Villar, Cristina C; Pannuti, Claudio M; Nery, Danielle M; Morillo, Carlos M R; Carmona, Maria José C; Romito, Giuseppe A

2016-09-01

Ventilator-associated pneumonia (VAP) is common in critical patients and related with increased morbidity and mortality. We conducted a systematic review and meta-analysis, with intention-to-treat analysis, of randomized controlled clinical trials that assessed the effectiveness of different intraoral chlorhexidine protocols for the prevention of VAP. Search strategies were developed for the MEDLINE, EMBASE, and LILACS databases. MeSH terms were combined with Boolean operators and used to search the databases. Eligible studies were randomized controlled trials of mechanically ventilated subjects receiving oral care with chlorhexidine or standard oral care protocols consisting of or associated with the use of a placebo or no chemicals. Pooled estimates of the relative risk and corresponding 95% CIs were calculated with random effects models, and heterogeneity was assessed with the Cochran Q statistic and I(2). The 13 included studies provided data on 1,640 subjects that were randomly allocated to chlorhexidine (n = 834) or control (n = 806) treatments. A preliminary analysis revealed that oral application of chlorhexidine fails to promote a significant reduction in VAP incidence (relative risk 0.80, 95% CI 0.59-1.07, I(2) = 45%). However, subgroup analyses showed that chlorhexidine prevents VAP development when used at 2% concentration (relative risk 0.53, 95% CI 0.31-0.91, I(2) = 0%) or 4 times/d (relative risk 0.56, 95% CI 0.38-0.81, I(2) = 0%). We found that oral care with chlorhexidine is effective in reducing VAP incidence in the adult population if administered at 2% concentration or 4 times/d. Copyright © 2016 by Daedalus Enterprises.

A case-control study on the clinical impact of ventilator associated tracheobronchitis in adult patients who did not develop ventilator associated pneumonia.

PubMed

Cantón-Bulnes, María Luisa; González-García, María Ascensión; García-Sánchez, Manuela; Arenzana-Seisdedos, Ángel; Garnacho-Montero, José

2018-02-05

The main objective was to determine whether ventilator-associated tracheobronchitis (VAT) is related to increased length of ICU stay. Secondary endpoints included prolongation of hospital stay, as well as, ICU and hospital mortality. A retrospective matched case-control study. Each case was matched with a control for duration of ventilation (± 2 days until development of ventilator-associated tracheobronchitis), disease severity (Acute Physiology and Chronic Health Evaluation II) at admission ± 3, diagnostic category and age ±10 years. Critically ill adults admitted to a polyvalent 30-beds ICU with the diagnosis of VAT in the period 2013-2016. We identified 76 cases of VAT admitted to our ICU during the study period. No adequate controls were found for 3 patients with VAT. There were no significant differences in demographic characteristics, reasons for admission and comorbidities. Patients with VAT had a longer ICU length of stay, median 22 days (14-35), compared to controls, median 15 days (8-27), p=.02. Ventilator days were also significantly increased in VAT patients, median 18 (9-28) versus 9 days (5-16), p=.03. There was no significant difference in total hospital length of stay 40 (28-61) vs. 35days (23-54), p=.32; ICU mortality (20.5 vs. 31.5% p=.13) and hospital mortality (30.1 vs. 43.8% p=.09). We performed a subanalysis of patients with microbiologically proven VAT receiving adequate antimicrobial treatment and did not observe significant differences between cases and the corresponding controls. VAT is associated with increased length of intensive care unit stay and longer duration of mechanical ventilation. This effect disappears when patients receive appropriate empirical treatment. Copyright © 2018 Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.

Effect of Intensive Education and Training of Nurses on Ventilator-associated Pneumonia and Central Line-associated Bloodstream Infection Incidence in Intensive Care Unit at a Tertiary Care Center in North India.

PubMed

Sahni, Neeru; Biswal, Manisha; Gandhi, Komal; Kaur, Kulbeer; Saini, Vikas; Yaddanapudi, Lakshminarayana N

2017-11-01

The aim was to analyze the impact of education and training of nurses on the incidence of ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI). A prospective observational study at a tertiary care hospital included adult patients with Intensive Care Unit stay >48 h. The study was done in three phases: in Phase 1, baseline VAP and CLABSI incidence was calculated; in Phase 2, education and training of nurses; and in Phase 3, data were recollected for the incidence of VAP and CLABSI. The baseline incidence of VAP in Phase 1 was 28.86/1000 ventilator days and that of CLABSI was 7.89/1000 central-line days. In Phase 3, the incidence of VAP increased to 35.06 and that of CLABSI decreased significantly, 1.73. Intensive education and training sessions with feedback from nurses over a period of 6 months led to significant reduction in the incidence of CLABSI; however, the incidence of VAP increased.

Comparing influence of intermittent subglottic secretions drainage with/without closed suction systems on the incidence of ventilator associated pneumonia.

PubMed

Juneja, Deven; Javeri, Yash; Singh, Omender; Nasa, Prashant; Pandey, Rameshwar; Uniyal, Bhupesh

2011-07-01

Intermittent subglottic drainage (ISD) of secretions is recommended for prevention of ventilator-associated pneumonia (VAP) as it reduces microaspiration from the area around the cuff. Poor suction techniques can contribute to VAP, hence closed suction system (CSS) may have theoretical benefit in VAP prevention. Combination of these two techniques may provide added advantage. To study the influence of ISD with/without CSS on the incidence of VAP. Data from 311 patients requiring mechanical ventilation (MV) for more than 72 hours were collected retrospectively. They were divided into four groups as follows: group A, no intervention; group B, only CSS; group C, only ISD; and group D, ISD with CSS. These groups were compared with respect to incidence of VAP, duration of MV, length of ICU and hospital stay and ICU mortality. Patients in the four groups were comparable with respect to age, sex ratio and admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores. Incidence of VAP per 1000 ventilator days in groups A, B, C, and D were 25, 23.9, 15.7 and 14.3, respectively (P=0.04). There was no significant difference in the duration of MV (P=0.33), length of ICU (P=0.55) and hospital stay (P=0.36) and ICU mortality (P=0.9) among the four groups. ISD of secretions reduces the incidence of VAP. CSS alone or in combination with ISD has no significant effect on VAP incidence. Hence, ISD may be recommended for VAP prevention, but indications other than VAP prevention should determine the type of the suction system.

Treatment of Highly Virulent Extraintestinal Pathogenic Escherichia coli Pneumonia With Bacteriophages.

PubMed

Dufour, Nicolas; Debarbieux, Laurent; Fromentin, Mélanie; Ricard, Jean-Damien

2015-06-01

To study the effect of bacteriophage treatment on highly virulent extraintestinal Escherichia coli pneumonia in mice and compare it with conventional antimicrobial treatment. Animal investigation. University research laboratory. Pathogen-free 8-week-old Balb/cJRj male mice. Two bacteriophages (536_P1 and 536_P7) were isolated from sewage using strain 536, a highly virulent extraintestinal E. coli. Their in vitro and in vivo efficacy against strain 536 and a ventilator-associated pneumonia E. coli were tested. The first group of mice were infected by intranasal instillation of bioluminescent strain 536 and received 536_P1 intranasally, ceftriaxone, or control. The second group of mice was infected with the ventilator-associated pneumonia strain and received 536_P7. Adaptation of 536_P7 to this clinical isolate was also evaluated in vitro and in vivo. In vivo efficacy of bacteriophage and antibiotic treatment were assessed by recording bioluminescence for short-time periods and by recording body weight and survival of mice for longer periods. Both treatments improved survival compared with control (100% vs 0%), and in vivo bioluminescence recordings showed a similar rapid decrease of emitted light, suggesting prompt bacterial clearance. The majority of mice infected by the ventilator-associated pneumonia strain were not rescued by treatment with 536_P7; however, in vitro adaptation of this bacteriophage toward the ventilator-associated pneumonia strain led to isolate a variant which significantly improved in vivo treatment efficacy (animal survival increased from 20% to 75%). Bacteriophage treatment was as effective as antibiotherapy to provide 100% survival rate in a lethal model of highly virulent E. coli pneumonia. Adaptation of a bacteriophage is a rapid solution to improve its efficacy toward specific strains. These results suggest that phage therapy could be a promising therapeutic strategy for ventilator-associated pneumonia.

Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among European intensive care nurses.

PubMed

Labeau, S; Vandijck, D; Rello, J; Adam, S; Rosa, A; Wenisch, C; Bäckman, C; Agbaht, K; Csomos, A; Seha, M; Dimopoulos, G; Vandewoude, K H; Blot, S

2008-10-01

As part of a needs analysis preceding the development of an e-learning platform on infection prevention, European intensive care unit (ICU) nurses were subjected to a knowledge test on evidence-based guidelines for preventing ventilator-associated pneumonia (VAP). A validated multiple-choice questionnaire was distributed to 22 European countries between October 2006 and March 2007. Demographics included nationality, gender, ICU experience, number of ICU beds and acquisition of a specialised degree in intensive care. We collected 3329 questionnaires (response rate 69.1%). The average score was 45.1%. Fifty-five percent of respondents knew that the oral route is recommended for intubation; 35% knew that ventilator circuits should be changed for each new patient; 38% knew that heat and moisture exchangers were the recommended humidifier type, but only 21% knew that these should be changed once weekly; closed suctioning systems were recommended by 46%, and 18% knew that these must be changed for each new patient only; 51% and 57%, respectively, recognised that subglottic drainage and kinetic beds reduce VAP incidence. Most (85%) knew that semi-recumbent positioning prevents VAP. Professional seniority and number of ICU beds were shown to be independently associated with better test scores. Further research may determine whether low scores are related to a lack of knowledge, deficiencies in training, differences in what is regarded as good practice, and/or a lack of consistent policy.

Impact of a monitored program of care on incidence of ventilator-associated pneumonia: results of a longterm performance-improvement project.

PubMed

Weireter, Leonard J; Collins, J N; Britt, Rebecca C; Reed, Scott F; Novosel, T J; Britt, L D

2009-05-01

Ventilator-associated pneumonia (VAP) remains a major source of morbidity, mortality, and expense in the ICU despite therapies directed against it. A retrospective review of a prospectively developed performance-improvement project monitoring the incidence of VAP in two adjacent ICUs was conducted. In response to an excessive VAP rate, weekly multidisciplinary team meetings were instituted to review data, develop care protocols, and modify care routines. Protocol compliance was monitored daily and feedback provided weekly to the care teams. VAP rates were determined by the institutional Infection Control Committee and reviewed monthly with the ICU multidisciplinary team. Duration of the investigational period was 10 years. A standardized ventilator-weaning protocol was instituted with confirmed 95% use. Additional modifications of care, such as patient positioning, use of specific endotracheal tubes to minimize aspiration of supraglottic secretions, an oral-care regimen, and aggressive antibiotic stewardship were standardized, with a compliance rate >90%. VAP rates dropped from 12.8 per 1,000 patient-days in 1998 to 1.1 in 2007 in the burn trauma ICU and from 21.2 to <1 in the neurotrauma ICU in the same time frame. Also, mean ventilator length of stay decreased from 6 days to 4.2 and from 5.8 days to 4.75 simultaneously in the respective ICUs. Such performance improvement has been sustained since implementation of the program. A systematic, monitored program of standardized care protocols can markedly reduce VAP rate in the ICU.

4G/5G polymorphism of plasminogen activator inhibitor-1 gene is associated with mortality in intensive care unit patients with severe pneumonia.

PubMed

Sapru, Anil; Hansen, Helen; Ajayi, Temitayo; Brown, Ron; Garcia, Oscar; Zhuo, HanJing; Wiemels, Joseph; Matthay, Michael A; Wiener-Kronish, Jeanine

2009-05-01

Higher plasma and pulmonary edema fluid levels of plasminogen activator inhibitor-1 (PAI-1) are associated with increased mortality in patients with pneumonia and acute lung injury. The 4G allele of the 4G/5G polymorphism of the PAI-1 gene is associated with higher PAI-1 levels and an increased incidence of hospitalizations for pneumonia. The authors hypothesized that the 4G allele would be associated with worse clinical outcomes (mortality and ventilator-free days) in patients with severe pneumonia. The authors enrolled patients admitted with severe pneumonia in a prospective cohort. Patients were followed until hospital discharge. DNA was isolated from blood samples, and genotyping detection for the PAI-1 4G/5G polymorphism was carried out using Taqman-based allelic discrimination. A total of 111 patients were available for analysis. Distribution of genotypes was 4G/4G 26 of 111 (23%), 4G/5G 59 of 111 (53%), and 5G/5G 26 of 111 (23%). Of 111 patients, 32 (29%) died before hospital discharge and 105 patients (94%) received mechanical ventilation. Patients with the 4G/4G and the 4G/5G genotypes had higher mortality (35% vs. 8%, P = 0.007) and fewer ventilator-free days (median 4 vs. 13, P = 0.04) compared to patients with the 5G/5G genotype. The 4G allele of the 4G/5G polymorphism in the PAI-1 gene is associated with fewer ventilator-free days and increased mortality in hospitalized patients with severe pneumonia. These findings suggest that PAI-1 may have a role in pathogenesis and that the 4G/5G polymorphism may be an important biomarker of risk in patients with severe pneumonia.

Animal models of hospital-acquired pneumonia: current practices and future perspectives

PubMed Central

Bielen, Kenny; ’S Jongers, Bart; Malhotra-Kumar, Surbhi; Jorens, Philippe G.; Goossens, Herman

2017-01-01

Lower respiratory tract infections are amongst the leading causes of mortality and morbidity worldwide. Especially in hospital settings and more particularly in critically ill ventilated patients, nosocomial pneumonia is one of the most serious infectious complications frequently caused by opportunistic pathogens. Pseudomonas aeruginosa is one of the most important causes of ventilator-associated pneumonia as well as the major cause of chronic pneumonia in cystic fibrosis patients. Animal models of pneumonia allow us to investigate distinct types of pneumonia at various disease stages, studies that are not possible in patients. Different animal models of pneumonia such as one-hit acute pneumonia models, ventilator-associated pneumonia models and biofilm pneumonia models associated with cystic fibrosis have been extensively studied and have considerably aided our understanding of disease pathogenesis and testing and developing new treatment strategies. The present review aims to guide investigators in choosing appropriate animal pneumonia models by describing and comparing the relevant characteristics of each model using P. aeruginosa as a model etiology for hospital-acquired pneumonia. Key to establishing and studying these animal models of infection are well-defined end-points that allow precise monitoring and characterization of disease development that could ultimately aid in translating these findings to patient populations in order to guide therapy. In this respect, and discussed here, is the development of humanized animal models of bacterial pneumonia that could offer unique advantages to study bacterial virulence factor expression and host cytokine production for translational purposes. PMID:28462212

Tumor necrosis factor receptor 1 (TNFRI) for ventilator-associated pneumonia diagnosis by cytokine multiplex analysis.

PubMed

Martin-Loeches, Ignacio; Bos, Lieuwe D; Povoa, Pedro; Ramirez, Paula; Schultz, Marcus J; Torres, Antoni; Artigas, Antonio

2015-12-01

The diagnosis of ventilator-associated pneumonia (VAP) is challenging. An important aspect to improve outcome is early recognition of VAP and the initiation of the appropriate empirical treatment. We hypothesized that biological markers in plasma can rule out VAP at the moment of clinical suspicion and could rule in VAP before the diagnosis can be made clinically. In this prospective study, patients with VAP (n = 24, microbiology confirmed) were compared to controls (n = 19) with a similar duration of mechanical ventilation. Blood samples from the day of VAP diagnosis and 1 and 3 days before were analyzed with a multiplex array for markers of inflammation, coagulation, and apoptosis. The best biomarker combination was selected and the diagnostic accuracy was given by the area under the receiver operating characteristic curve (ROC-AUC). TNF-receptor 1 (TNFRI) and granulocyte colony-stimulating factor (GCSF) were selected as optimal biomarkers at the day of VAP diagnosis, which resulted in a ROC-AUC of 0.96, with excellent sensitivity. Three days before the diagnosis TNFRI and plasminogen activator inhibitor-1 (PAI-1) levels in plasma predicted VAP with a ROC-AUC of 0.79. The slope of IL-10 and PAI-1 resulted in a ROC-AUC of 0.77. These biomarkers improved the classification of the clinical pulmonary infection score when combined. Concentration of TNFRI and PAI-1 and the slope of PAI-1 and IL-10 may be used to predict the development of VAP as early as 3 days before the diagnosis made clinically. TNFRI and GCSF may be used to exclude VAP at the moment of clinical suspicion. Especially TNFRI seems to be a promising marker for the prediction and diagnosis of VAP.

[Effect of continuous aspiration of subglottic secretions on the prevention of ventilator-associated pneumonia in mechanically ventilated patients: a prospective, randomized, controlled clinical trial].

PubMed

Yang, Cong-shan; Qiu, Hai-bo; Zhu, Yan-ping; Huang, Ying-zi; Xu, Xiao-ting; Gao, Liang

2008-08-01

To evaluate the effect of continuous aspiration of subglottic secretions (CASS) on the prevention of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Patients ventilated mechanically at the ICU from October, 2004 to April, 2006 were randomly divided into 2 groups: one group received CASS and the other did not (NASS group). CASS was performed immediately after admission for patients in the CASS group. The diagnosis of VAP was made based on clinical presentations, and the evaluation of VAP was done using simplified version of the clinical pulmonary infection score (CPIS). The general status of the patients, days of ventilated treatment, the volume of daily aspirated subglottic secretions, the morbidity and timing of VAP, days of stay in ICU and mortality within 28 days of hospitalization were recorded. One hundred and one patients were included in the study. There were 48 patients in the CASS group who were treated with mechanical ventilation more than 48 hours, and 43 patients in the NASS group. There was no significant difference in the general status of the patients and days of ventilation between 2 groups with the averaged score of APACHE II being 20.8 +/- 6.1. The average of CPIS was of 5.6 +/- 1.0 when VAP was diagnosed. The mean volume of aspirated subglottic secretions within the first 24 hours in the CASS group (n = 48) was (27.2 +/- 21.2) ml. The morbidity of VAP in the CASS and the NASS groups was 25.0% and 46.5% respectively (P = 0.032), and the length of time before the onset of VAP in these 2 groups was (7.3 +/- 4.2) days and (5.1 +/- 3.0) days respectively (P = 0.100). There was a significant increase in the percentage of gram-positive cocci from the lower respiratory tracts in the NASS group compared with that in the CASS group (P = 0.004). In the CASS group, the volume of the first daily aspirated subglottic secretions in patients with VAP was significantly less than that in patients without VAP (P = 0.006). The morbidity of

Postoperative pneumonia following cardiac surgery in non-ventilated patients versus mechanically ventilated patients: is there any difference?

PubMed

Allou, Nicolas; Allyn, Jerome; Snauwaert, Aurélie; Welsch, Camille; Lucet, Jean Christophe; Kortbaoui, Rita; Desmard, Mathieu; Augustin, Pascal; Montravers, Philippe

2015-03-11

No studies have compared ventilator-associated pneumonia (VAP) and non-VAP following cardiac surgery (CS). The aim of this study was to assess the incidence, clinical and microbiologic features, treatment characteristics and prognosis of postoperative pneumonia following CS with a special focus on non-VAP. This was a retrospective cohort study based on a prospectively collected database. We compared cases of non-VAP and VAP following CS observed between January 2005 and December 2012. Statistical analysis consisted of bivariate and multivariate analysis. A total of 257 (3.5%) of 7,439 consecutive CS patients developed postoperative pneumonia, including 120 (47%) cases of non-VAP. Patients with VAP had more frequent history of congestive heart failure (31% vs. 17%, P = 0.006) and longer duration of cardiopulmonary bypass (105 vs 76 min, P < 0.0001), than patients with non-VAP. No significant differences were observed between the 2 groups in terms of the types of microorganisms isolated with high proportions of Enterobacteriaceae (35%), Pseudomonas aeruginosa (20.2%) and Haemophilus spp (20.2%), except for a lower proportion of Methicillin-susceptible S. aureus in the non-VAP group (3.2% vs 7.9%, P = 0.03). In the intensive care unit, patients with non-VAP had lower sequential organ failure assessment scores than patients with VAP (8 ± 3 versus 9 ± 3, P = 0.004). On multivariate analysis, in-hospital mortality was similar in both groups (32% in the non-VAP group and 42% in the VAP group, adjusted Odds Ratio (aOR): 1.4; 95% confidence intervals (CI): 0.7-2.5; P = 0.34) and appropriate empiric antibiotic therapy was associated with a reduction of in-hospital mortality (aOR: 0.4; 95% CI: 0.2-1; P = 0.05). Piperacillin/tazobactam or imipenem monotherapy constituted appropriate empiric therapy in the two groups, with values reaching 93% and 95% with no differences between VAP and non-VAP cases. Intensive care patients with VAP are more

Comparison of suction above cuff and standard endotracheal tubes in neurological patients for the incidence of ventilator-associated pneumonia and in-hospital outcome: A randomized controlled pilot study

PubMed Central

Jena, Sritam; Kamath, Sriganesh; Masapu, Dheeraj; Veenakumari, H. B.; Ramesh, Venkatapura J.; Bhadrinarayan, Varadarajan; Ravikumar, R.

2016-01-01

Background: Ventilator-associated pneumonia (VAP) is a common complication with endotracheal intubation. The occurrence of VAP results in significant mortality and morbidity. Earlier studies have shown reduction in the incidence of VAP with subglottic secretion drainage. The incidence of VAP in neurologically injured patients is higher and can impact the neurological outcome. This study aimed to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurologically ill patients and its impact on clinical outcome. Methods: Fifty-four patients with neurological illnesses aged ≥18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT. All the VAP preventive measures were similar between two groups except for the difference in type of tube. Results: The data of 50 patients were analyzed. The incidence of clinical VAP was 20% in SETT group and 12% in SACETT group; (P = 0.70). The incidence of microbiological VAP was higher in the SETT group (52%) as compared to SACETT group (44%) but not statistically significant; (P = 0.78). There was no difference between the two groups for measured outcomes such as duration of intubation, mechanical ventilation, and Intensive Care Unit stay. Conclusions: In this pilot study in neurological population, a there was no significant difference in incidence of clinical and microbiological VAP was seen between SETT and SACETT, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation. PMID:27275073

Trauma patients meeting both Centers for Disease Control and Prevention's definitions for ventilator-associated pneumonia had worse outcomes than those meeting only one.

PubMed

Younan, Duraid; Griffin, Russell; Swain, Thomas; Pittet, Jean-Francois; Camins, Bernard

2017-08-01

The Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) replaced its old definition for ventilator-associated pneumonia (VAP) with the ventilator-associated events algorithm in 2013. We sought to compare the outcome of trauma patients meeting the definitions for VAP in the two modules. Trauma patients with blunt or penetrating injuries and with at least 2 d of ventilator support were identified from the trauma registry from 2013 to 2014. VAP was determined using two methods: (1) VAP as defined by the "old," clinically based NHSN definition and (2) possible VAP as defined by the updated "new" NHSN definition. Cohen's kappa statistic was determined to compare the two definitions for VAP. To compare demographic and clinical outcomes, the chi-square and Student's t-tests were used for categorical and continuous variables, respectively. From 2013 to 2014, there were 1165 trauma patients admitted who had at least 2 d of ventilator support. Seventy-eight patients (6.6%) met the "new" NHSN definition for possible VAP, 361 patients (30.9%) met the "old" definition of VAP, and 68 patients (5.8%) met both definitions. The kappa statistic between VAP as defined by the "new" and "old" definitions was 0.22 (95% confidence interval, 0.17-0.27). There were no differences in age, gender, race, or injury severity score when comparing patients who met the different definitions. Those satisfying both definitions had longer ventilator support days (P = 0.0009), intensive care unit length of stay (LOS; P = 0.0003), and hospital LOS (P = 0.0344) when compared with those meeting only one definition. There was no difference in mortality for those meeting both and those meeting the old definition for VAP; patients meeting both definitions had higher respiratory rate at arrival (P = 0.0178). There was no difference in mortality between patients meeting the "old" and "new" NHSN definitions for VAP; those who met "both" definitions had longer

Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe.

PubMed

Hortal, Javier; Muñoz, Patricia; Cuerpo, Gregorio; Litvan, Hector; Rosseel, Peter M; Bouza, Emilio

2009-01-01

Patients undergoing major heart surgery (MHS) represent a special subpopulation at risk for nosocomial infections. Postoperative infection is the main non-cardiac complication after MHS and has been clearly related to increased morbidity, use of hospital resources and mortality. Our aim was to determine the incidence, aetiology, risk factors and outcome of ventilator-associated pneumonia (VAP) in patients who have undergone MHS in Europe. Our study was a prospective study of patients undergoing MHS in Europe who developed suspicion of VAP. During a one-month period, participating units submitted a protocol of all patients admitted to their units who had undergone MHS. Overall, 25 hospitals in eight different European countries participated in the study. The number of patients intervened for MHS was 986. Fifteen patients were excluded because of protocol violations. One or more nosocomial infections were detected in 43 (4.4%) patients. VAP was the most frequent nosocomial infection (2.1%; 13.9 episodes per 1000 days of mechanical ventilation). The microorganisms responsible for VAP in this study were: Enterobacteriaceae (45%), Pseudomonas aeruginosa (20%), methicillin-resistant Staphylococcus aureus (10%) and a range of other microorganisms. We identified the following significant independent risk factors for VAP: ascending aorta surgery (odds ratio (OR) = 6.22; 95% confidence interval (CI) = 1.69 to 22.89), number of blood units transfused (OR = 1.08 per unit transfused; 95% CI = 1.04 to 1.13) and need for re-intervention (OR = 6.65; 95% CI = 2.10 to 21.01). The median length of stay in the intensive care unit was significantly longer (P < 0.001) in patients with VAP than in patients without VAP (23 days versus 2 days). Death was significantly more frequent (P < 0.001) in patients with VAP (35% versus 2.3%). Patients undergoing aortic surgery and those with complicated post-intervention courses, requiring multiple transfusions or re-intervention, constitute a high

Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia.

PubMed

Berton, Danilo Cortozi; Kalil, Andre C; Cavalcanti, Manuela; Teixeira, Paulo José Zimermann

2008-10-08

Ventilator-associated pneumonia (VAP) is a common infectious disease in intensive care units (ICUs). The best diagnostic approach to resolve this condition remains uncertain. To evaluate whether quantitative cultures of respiratory secretions are effective in reducing mortality in immunocompetent patients with VAP, compared with qualitative cultures. We also considered changes in antibiotic use, length of ICU stay and mechanical ventilation. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 4), which contains the Acute Respiratory Infections Group's Specialized Register; MEDLINE (1966 to December 2007); EMBASE (1974 to December 2007); and LILACS (1982 to December 2007). Randomized controlled trials (RCTs) comparing respiratory samples processed quantitatively or qualitatively, obtained by invasive or non-invasive methods from immunocompetent patients with VAP, and which analyzed the impact of these methods on antibiotic use and mortality rates. Two review authors independently reviewed and selected trials from the search results, and assessed studies for suitability, methodology and quality. We analyzed data using Review Manager software. We pooled the included studies to yield the risk ratio (RR) for mortality and antibiotic change with 95% confidence intervals (CI). Of the 3931 references identified from the electronic databases, five RCTs (1367 patients) met the inclusion criteria. Three studies compared invasive methods using quantitative cultures versus non-invasive methods using qualitative cultures, and were used to answer the main objective of this review. The other two studies compared invasive versus non-invasive methods, both using quantitative cultures. All five studies were combined to compare invasive versus non-invasive interventions for diagnosing VAP. The studies that compared quantitative and qualitative cultures (1240 patients) showed no statistically significant differences in mortality

[Aspirative pneumonia associated to swallowing dysfunction: case report].

PubMed

Toufen Junior, Carlos; Camargo, Fernanda Pereira de; Carvalho, Carlos Roberto Ribeiro

2007-03-01

Critically ill patients represent a population with multiple risk factors for aspiration. Features such as decreased level of consciousness, mechanical ventilation, and comorbities as stroke, correlate with this increased threat in intensive care unit (ICU) patients. Recognition of deglutition dysfunction may identify patients at high risk of aspiration, and thereby help to avoid pulmonary complications such as recurrent pneumonia. The goal of our report is show a severe case of recurrent aspirative pneumonia after acute stroke and intubation, alerting to appropriate diagnosis and treatment of this condition. A male patient, 57 year old, was admitted to the hospital because of acute stroke. Ten days later, the patient began to have fever and severe shortness of breath. He was admitted to the ICU necessitating of intratracheal intubation. Four days after intubation he was extubated, however, he had a new aspirative pneumonia in ICU, newly treated. An evaluation of swallowing demonstrated a severe deglutition dysfunction with a high risk of aspiration. The patient was transferred, but aspirative pneumonia was diagnosed eight days after his ICU discharge and he was readmitted, stayed for a long time in ICU and presenting severe morbidity. ICU patients who are at risk for swallowing dysfunction and aspiration should be identified to prevent their associated morbidity and mortality.

Antibiotics or probiotics as preventive measures against ventilator-associated pneumonia: a literature review

PubMed Central

2011-01-01

Introduction Mechanically ventilated critically ill patients frequently develop ventilator-associated pneumonia (VAP), a life-threatening complication. Proposed preventive measures against VAP include, but are not restricted to, selective decontamination of the digestive tract (SDD), selective oropharyngeal decontamination (SOD) and the use of probiotics. Probiotics are live bacteria that could have beneficial effects on the host by altering gastrointestinal flora. Similar to SDD and SOD, a prescription of probiotics aims at the prevention of secondary colonization of the upper and/or lower digestive tract. Methods We performed a literature review to describe the differences and similarities between SDD/SOD and probiotic preventive strategies, focusing on (a) efficacy, (b) risks, and (c) the routing of these strategies. Results Reductions in the incidence of VAP have been achieved with SDD and SOD. Two large randomized controlled trials even showed reduced mortality with these preventive strategies. Randomized controlled trials of probiotic strategies also showed a reduction of the incidence of VAP, but trials were too small to draw firm conclusions. Preventive strategies with antibiotics and probiotics may be limited due to the risk of emerging resistance to the locally applied antibiotics and the risk of probiotic-related infections, respectively. The majority of trials of SDD and SOD did not exhaustively address the issue of emerging resistance. Likewise, trials of probiotic strategies did not adequately address the risk of colonization with probiotics and probiotic-related infection. In studies of SDD and SOD the preventive strategy aimed at decontamination of the oral cavity, throat, stomach and intestines, and the oral cavity and throat, respectively. In the vast majority of studies of probiotic therapy the preventive strategy aimed at decontamination of the stomach and intestines. Conclusions Prophylactic use of antibiotics in critically ill patients is

Ventilator-Associated Pneumonia: Incidence, Risk Factors and Outcome in Paediatric Intensive Care Units at Cairo University Hospital

PubMed Central

Galal, Yasmine S.; Ibrahiem, Sally K.

2016-01-01

Introduction Ventilator-Associated Pneumonia (VAP) is a major cause of hospital morbidity, mortality and increased health care costs. Although the epidemiology, pathogenesis and outcome of VAP are well described in adults; few data exist regarding VAP in paediatric patients, especially in developing countries. Aim To determine the incidence, risk factors and outcome of VAP in two Paediatric Intensive Care Units (PICUs) at Cairo University Hospital. Materials and Methods A total of 427 patients who received Mechanical Ventilation (MV) were included in this prospective study during the period from September 2014 till September 2015. Patients were observed daily till VAP occurrence, discharge from the unit or death, whichever came first. Demographic, clinical characteristics, laboratory results, radiographic and microbiological reports were recorded for all patients. Results Nearly 31% patients developed VAP among the entire cohort. The incidence density was 21.3 per 1000 ventilator days. The most frequently isolated organisms from VAP patients were Pseudomonas aeruginosa (47.7%), Acinetobacter (18.2%) and Methicillin-resistant Staphylococcus aureus (MRSA) (14.4%). VAP patients were significantly younger than non-VAP ones. The incidence of VAP in comatose patients and those with MOSF was significantly higher. Prior antibiotic use for > 48 h before MV, supine body positioning and reintubation were significantly associated with VAP. On multiple logistic regression analysis, MOSF; prior antibiotic use > 48h; reintubation; coma; and age remained independent predictors of VAP. Mortality rate among the VAP group was significantly higher compared to the non-VAP one (68.2% vs. 48.5%, p<0.001). Survival curve analysis showed a shorter median survival time in VAP patients. Conclusion Identification of risk factors and outcome of VAP in PICUs may help in reducing the incidence and improving patients’ outcomes. The incidence of VAP in this study was relatively high. The most

Metabolic Profiling in Patients with Pneumonia on Intensive Care.

PubMed

Antcliffe, David; Jiménez, Beatriz; Veselkov, Kirill; Holmes, Elaine; Gordon, Anthony C

2017-04-01

Clinical features and investigations lack predictive value when diagnosing pneumonia, especially when patients are ventilated and when patients develop ventilator associated pneumonia (VAP). New tools to aid diagnosis are important to improve outcomes. This pilot study examines the potential for metabolic profiling to aid the diagnosis in critical care. In this prospective observational study ventilated patients with brain injuries or pneumonia were recruited in the intensive care unit and serum samples were collected soon after the start of ventilation. Metabolic profiles were produced using 1D 1 H NMR spectra. Metabolic data were compared using multivariate statistical techniques including Principal Component Analysis (PCA) and Orthogonal Partial Least Squares Discriminant Analysis (OPLS-DA). We recruited 15 patients with pneumonia and 26 with brain injuries, seven of whom went on to develop VAP. Comparison of metabolic profiles using OPLS-DA differentiated those with pneumonia from those with brain injuries (R 2 Y=0.91, Q 2 Y=0.28, p=0.02) and those with VAP from those without (R 2 Y=0.94, Q 2 Y=0.27, p=0.05). Metabolites that differentiated patients with pneumonia included lipid species, amino acids and glycoproteins. Metabolic profiling shows promise to aid in the diagnosis of pneumonia in ventilated patients and may allow a more timely diagnosis and better use of antibiotics. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Ventilator-associated pneumonia at a tertiary-care center in a developing country: incidence, microbiology, and susceptibility patterns of isolated microorganisms.

PubMed

Kanafani, Zeina A; Kara, Layla; Hayek, Shady; Kanj, Souha S

2003-11-01

Ventilator-associated pneumonia (VAP) complicates the course of up to 24% of intubated patients. Data from the Middle East are scarce. The objective of this study was to evaluate the incidence, microbiology, and antimicrobial susceptibility patterns of isolated microorganisms in VAP in a developing country. Prospective observational cohort study. The American University of Beirut Medical Center, a tertiary-care center that serves as a major referral center for Lebanon and neighboring countries. All patients admitted to the intensive care and respiratory care units from March to September 2001, and who had been receiving mechanical ventilation for at least 48 hours, were included in the study. Results of samples submitted for culture were recorded and antimicrobial susceptibility testing of isolated pathogens was performed. Seventy patients were entered into the study. The incidence of VAP was 47%. Gram-negative bacilli accounted for 83% of all isolates. The most commonly identified organism was Acinetobacter anitratus, followed by Pseudomonas aeruginosa. Fifty percent of all gram-negative bacterial isolates were classified as antibiotic resistant. Compared with patients without VAP, patients with VAP remained intubated for a longer period and stayed in the intensive care unit longer. VAP was not associated with an increased mortality rate. Compared with other studies, the results from this referral center in Lebanon indicate a higher incidence of VAP and a high prevalence of resistant organisms. These data are relevant because they direct the choice of empiric antibiotic therapy for VAP.

Risk Factors for the Mortality of Pneumocystis jirovecii Pneumonia in Non-HIV Patients Who Required Mechanical Ventilation: A Retrospective Case Series Study.

PubMed

Kotani, Toru; Katayama, Shinshu; Miyazaki, Yuya; Fukuda, Satoshi; Sato, Yoko; Ohsugi, Koichi

2017-01-01

The risk factors for the mortality rate of Pneumocystis jirovecii pneumonia (PCP) who required mechanical ventilation (MV) remained unknown. A retrospective chart review was performed of all PCP patients admitted to our intensive care unit and treated for acute hypoxemic respiratory failure to assess the risk factors for the high mortality. Twenty patients without human immunodeficiency virus infection required mechanical ventilation; 19 received noninvasive ventilation; and 11 were intubated. PEEP was incrementally increased and titrated to maintain FIO 2 as low as possible. No mandatory ventilation was used. Sixteen patients (80%) survived. Pneumothorax developed in one patient with rheumatoid arthritis (RA). Median PEEP level in the first 5 days was 10.0 cmH 2 O and not associated with death. Multivariate analysis showed the association of incidence of interstitial lung disease and increase in serum KL-6 with 90-day mortality. We found MV strategies to prevent pneumothorax including liberal use of noninvasive ventilation, and PEEP titration and disuse of mandatory ventilation may improve mortality in this setting. Underlying disease of interstitial lung disease was a risk factor and KL-6 may be a useful predictor associated with mortality in patients with RA. These findings will need to be validated in larger studies.

Pediatric Ventilator-Associated Infections: The Ventilator-Associated INfection Study.

PubMed

Willson, Douglas F; Hoot, Michelle; Khemani, Robinder; Carrol, Christopher; Kirby, Aileen; Schwarz, Adam; Gedeit, Rainer; Nett, Sholeen T; Erickson, Simon; Flori, Heidi; Hays, Spencer; Hall, Mark

2017-01-01

Suspected ventilator-associated infection is the most common reason for antibiotics in the PICU. We sought to characterize the clinical variables associated with continuing antibiotics after initial evaluation for suspected ventilator-associated infection and to determine whether clinical variables or antibiotic treatment influenced outcomes. Prospective, observational cohort study conducted in 47 PICUs in the United States, Canada, and Australia. Two hundred twenty-nine pediatric patients ventilated more than 48 hours undergoing respiratory secretion cultures were enrolled as "suspected ventilator-associated infection" in a prospective cohort study, those receiving antibiotics of less than or equal to 3 days were categorized as "evaluation only," and greater than 3 days as "treated." Demographics, diagnoses, comorbidities, culture results, and clinical data were compared between evaluation only and treated subjects and between subjects with positive versus negative cultures. PICUs in 47 hospitals in the United States, Canada, and Australia. All patients undergoing respiratory secretion cultures during the 6 study periods. None. Treated subjects differed from evaluation-only subjects only in frequency of positive cultures (79% vs 36%; p < 0.0001). Subjects with positive cultures were more likely to have chronic lung disease, tracheostomy, and shorter PICU stay, but there were no differences in ventilator days or mortality. Outcomes were similar in subjects with positive or negative cultures irrespective of antibiotic treatment. Immunocompromise and higher Pediatric Logistic Organ Dysfunction scores were the only variables associated with mortality in the overall population, but treated subjects with endotracheal tubes had significantly lower mortality. Positive respiratory cultures were the primary determinant of continued antibiotic treatment in children with suspected ventilator-associated infection. Positive cultures were not associated with worse outcomes

Multicentre randomised controlled trial to investigate the usefulness of continuous pneumatic regulation of tracheal cuff pressure for reducing ventilator-associated pneumonia in mechanically ventilated severe trauma patients: the AGATE study protocol

PubMed Central

Marjanovic, Nicolas; Frasca, Denis; Asehnoune, Karim; Paugam, Catherine; Lasocki, Sigismond; Ichai, Carole; Lefrant, Jean-Yves; Leone, Marc; Dahyot-Fizelier, Claire; Pottecher, Julien; Falcon, Dominique; Veber, Benoit; Constantin, Jean-Michel; Seguin, Sabrina; Guénézan, Jérémy; Mimoz, Olivier

2017-01-01

Introduction Severe trauma represents the leading cause of mortality worldwide. While 80% of deaths occur within the first 24 hours after trauma, 20% occur later and are mainly due to healthcare-associated infections, including ventilator-associated pneumonia (VAP). Preventing underinflation of the tracheal cuff is recommended to reduce microaspiration, which plays a major role in the pathogenesis of VAP. Automatic devices facilitate the regulation of tracheal cuff pressure, and their implementation has the potential to reduce VAP. The objective of this work is to determine whether continuous regulation of tracheal cuff pressure using a pneumatic device reduces the incidence of VAP compared with intermittent control in severe trauma patients. Methods and analysis This multicentre randomised controlled and open-label trial will include patients suffering from severe trauma who are admitted within the first 24 hours, who require invasive mechanical ventilation to longer than 48 hours. Their tracheal cuff pressure will be monitored either once every 8 hours (control group) or continuously using a pneumatic device (intervention group). The primary end point is the proportion of patients that develop VAP in the intensive care unit (ICU) at day 28. The secondary end points include the proportion of patients that develop VAP in the ICU, early (≤7 days) or late (>7 days) VAP, time until the first VAP diagnosis, the number of ventilator-free days and antibiotic-free days, the length of stay in the ICU, the proportion of patients with ventilator-associated events and that die during their ICU stay. Ethics and dissemination This protocol has been approved by the ethics committee of Poitiers University Hospital, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer

Multicentre randomised controlled trial to investigate the usefulness of continuous pneumatic regulation of tracheal cuff pressure for reducing ventilator-associated pneumonia in mechanically ventilated severe trauma patients: the AGATE study protocol.

PubMed

Marjanovic, Nicolas; Frasca, Denis; Asehnoune, Karim; Paugam, Catherine; Lasocki, Sigismond; Ichai, Carole; Lefrant, Jean-Yves; Leone, Marc; Dahyot-Fizelier, Claire; Pottecher, Julien; Falcon, Dominique; Veber, Benoit; Constantin, Jean-Michel; Seguin, Sabrina; Guénézan, Jérémy; Mimoz, Olivier

2017-08-07

Severe trauma represents the leading cause of mortality worldwide. While 80% of deaths occur within the first 24 hours after trauma, 20% occur later and are mainly due to healthcare-associated infections, including ventilator-associated pneumonia (VAP). Preventing underinflation of the tracheal cuff is recommended to reduce microaspiration, which plays a major role in the pathogenesis of VAP. Automatic devices facilitate the regulation of tracheal cuff pressure, and their implementation has the potential to reduce VAP. The objective of this work is to determine whether continuous regulation of tracheal cuff pressure using a pneumatic device reduces the incidence of VAP compared with intermittent control in severe trauma patients. This multicentre randomised controlled and open-label trial will include patients suffering from severe trauma who are admitted within the first 24 hours, who require invasive mechanical ventilation to longer than 48 hours. Their tracheal cuff pressure will be monitored either once every 8 hours (control group) or continuously using a pneumatic device (intervention group). The primary end point is the proportion of patients that develop VAP in the intensive care unit (ICU) at day 28. The secondary end points include the proportion of patients that develop VAP in the ICU, early (≤7 days) or late (>7 days) VAP, time until the first VAP diagnosis, the number of ventilator-free days and antibiotic-free days, the length of stay in the ICU, the proportion of patients with ventilator-associated events and that die during their ICU stay. This protocol has been approved by the ethics committee of Poitiers University Hospital, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. Clinical Trials NCT02534974. © Article author(s) (or

Early antibiotic treatment for BAL-confirmed ventilator-associated pneumonia: a role for routine endotracheal aspirate cultures.

PubMed

Michel, Fabrice; Franceschini, Bruno; Berger, Pierre; Arnal, Jean-Michel; Gainnier, Marc; Sainty, Jean-Marie; Papazian, Laurent

2005-02-01

To test whether routine quantitative cultures of endotracheal aspirates obtained before the onset of ventilator-associated pneumonia (VAP) could help to predict the causative microorganisms and to select early appropriate antimicrobial therapy before obtaining BAL culture results. Prospective observational study. French medical ICU. A total of 299 patients received mechanical ventilation for at least 48 h. Endotracheal aspiration (EA) was performed twice weekly in all mechanically ventilated patients. A diagnosis of VAP was made by BAL culture. Only the EA performed just before the suspicion of VAP (EA-pre) were evaluated. This strategy (ie, the EA-pre-based strategy) was compared with an antibiotic therapy that would have been prescribed if the recommendations of both the American Thoracic Society (ATS) and Trouillet et al (Am J Respir Crit Care Med 1998; 157:531-539) had been applied. VAP was diagnosed (by BAL culture) in 41 of the 75 patients in whom BAL was performed. Among the 41 BAL specimens that were positive for VAP, EA-pre had identified the same microorganisms (with the same antibiotic resistance patterns) in 34 cases (83%). In one case, EA-pre was not available at the time BAL was performed (a case of early-onset VAP), but the empiric antibiotic therapy was adequate. While EA-pre did not give the same results as the BAL culture, the antibiotic therapy based on the results of the EA-pre was adequate in four other cases. Finally, antibiotic therapy was delayed in only two cases. Antibiotic treatment was therefore adequate in 38 of the 40 assessable cases (95%). If the Trouillet-based strategy had been used, the antibiotic treatment would have been adequate in 34 of the 41 cases (83%; p = 0.15 [vs EA-pre strategy]). Based on the ATS classification, the antibiotic treatment would have been adequately prescribed in only 28 of the 41 cases (68%; p = 0.005 [vs EA-pre strategy]). Routine EA performed twice a week makes it possible to prescribe adequate

Age-specific Mycoplasma pneumoniae pneumonia-associated myocardial damage in children.

PubMed

Li, Cheng-Mei; Gu, Li; Yin, Shao-Jun; Yang, Rong; Xie, Yuan; Guo, Xiao-Zhi; Fu, Yu-Xuan; Cheng, Dan

2013-10-01

To measure Mycoplasma pneumoniae pneumonia (MPP)-associated myocardial damage in different age groups of children with pneumonia. Children aged 0-14 years with pneumonia and myocardial damage (serum creatine kinase isoenzyme-MB [CK-MB] concentration >25 U/l) were enrolled in the study. The children were classified as Mycoplasma pneumoniae immunoglobulin M positive (M. pneumoniae IgM+) or negative (M. pneumoniae IgM-) based on a serological test. Children were stratified into four age groups in order to analyse age-specific MPP-associated myocardial damage. The incidence of fever was significantly higher in children who were M. pneumoniae IgM+ compared with M. pneumoniae IgM- children. The median serum CK-MB concentration was significantly higher in children who were M. pneumoniae IgM+ compared with those who were M. pneumoniae IgM-. Children who were M. pneumoniae IgM+ in the 13-36 months and 72 months-14 years age groups had significantly higher median serum CK-MB concentrations than those who were M. pneumoniae IgM- in the same age group. M. pneumoniae infection was associated with greater myocardial damage in children aged 13-36 months and 72 months-14 years. This suggests age-specific immune responses to M. pneumoniae.

Use of ketorolac is associated with decreased pneumonia following rib fractures.

PubMed

Yang, Yifan; Young, Jason B; Schermer, Carol R; Utter, Garth H

2014-04-01

The effectiveness of the nonsteroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity after rib fractures remains largely unknown. A retrospective cohort study was conducted spanning January 2003 to June 2011 assessing pneumonia within 30 days and potential adverse effects of ketorolac among all patients with rib fractures who received ketorolac <4 days after injury compared with a random sample of those who did not. Among 202 patients who received ketorolac and 417 who did not, ketorolac use was associated with decreased pneumonia (odds ratio, .14; 95% confidence interval, .04 to .46) and increased ventilator-free days (difference, 1.8 days; 95% confidence interval, 1.1 to 2.5) and intensive care unit-free days (difference, 2.1 days; 95% confidence interval, 1.3 to 3.0) within 30 days. The rates of acute kidney injury, gastrointestinal hemorrhage, and fracture nonunion were not different. Early administration of ketorolac to patients with rib fractures is associated with a decreased likelihood of pneumonia, without apparent risks. Copyright © 2014 Elsevier Inc. All rights reserved.

Association between pathogens from tracheal aspirate and oral biofilm of patients on mechanical ventilation.

PubMed

Souza, Luana Carneiro Diniz; Mota, Vanise Barros Rodrigues da; Carvalho, Alícia Valéria Dos Santos Zaranza de; Corrêa, Rita da Graça Carvalhal Frazão; Libério, Silvana Amado; Lopes, Fernanda Ferreira

2017-06-05

The aim of this study was to detect possible associations between respiratory pathogens from tracheal aspirate and oral biofilm samples in intubated patients in an intensive care unit (ICU), and to identify the most common respiratory pathogens in oral biofilm, particularly in patients that developed ventilator-associated pneumonia (VAP). Two oral biofilm samples were collected from the tongue of intubated patients (at admission and after 48 hours) and analyzed by culture with the Antibiotic Sensitivity Test. The results from the tongue biofilm samples were compared with the tracheal secretions samples. A total of 59.37% of patients exhibited the same species of pathogens in their tracheal aspirate and oral biofilm, of which 8 (42.1%) developed VAP, 10 (52.63%) did not develop pneumonia and one (5.26%) had aspiration pneumonia. There was a statistically significant association between presence of microorganisms in the tracheal and mouth samples for the following pathogens: Klebsiella pneumoniae, Candida albicans, Pseudomonas aeruginosa, Enterobacter gergoviae, Streptococcus spp and Serratia marcescens (p < 0.05). Pathogens that are present in tracheal aspirates of intubated patients can be detected in their oral cavity, especially in those who developed VAP or aspiration pneumonia. Thus, the results indicate that an improved oral care in these patients could decrease ICU pneumonia rates.

A history of Panton-Valentine leukocidin (PVL)-associated infection protects against death in PVL-associated pneumonia.

PubMed

Rasigade, Jean-Philippe; Sicot, Nicolas; Laurent, Frederic; Lina, Gerard; Vandenesch, François; Etienne, Jerome

2011-06-06

Panton-Valentine leukocidin (PVL) is a Staphylococcus aureus toxin associated with skin and soft-tissue infections (SSTIs) and life-threatening necrotizing pneumonia in humans. Recent reports have demonstrated that neutralizing antibody to PVL is not protective against SSTI recurrence, thus raising a controversy about the expected clinical benefits from the use of PVL as a vaccine target. To investigate the impact of pre-existing immunity to PVL on the outcome of necrotizing pneumonia, we conducted a retrospective study of 114 cases and searched for an association between the history of PVL-associated infection and outcome. Death and severity factors, such as the need for mechanical ventilation and inotrope support, were significantly less frequent in patients with prior PVL-associated infection than in those without. These findings indicate a protective role of PVL-directed immunity in severe systemic PVL-associated disease, suggesting that anti-PVL vaccine could provide strong clinical benefits in this setting. Copyright © 2011 Elsevier Ltd. All rights reserved.

Effect of probiotics on the incidence of ventilator-associated pneumonia in critically ill patients: a randomized controlled multicenter trial.

PubMed

Zeng, Juan; Wang, Chun-Ting; Zhang, Fu-Shen; Qi, Feng; Wang, Shi-Fu; Ma, Shuang; Wu, Tie-Jun; Tian, Hui; Tian, Zhao-Tao; Zhang, Shu-Liu; Qu, Yan; Liu, Lu-Yi; Li, Yuan-Zhong; Cui, Song; Zhao, He-Ling; Du, Quan-Sheng; Ma, Zhuang; Li, Chun-Hua; Li, Yun; Si, Min; Chu, Yu-Feng; Meng, Mei; Ren, Hong-Sheng; Zhang, Ji-Cheng; Jiang, Jin-Jiao; Ding, Min; Wang, Yu-Ping

2016-06-01

To evaluate the potential preventive effect of probiotics on ventilator-associated pneumonia (VAP). This was an open-label, randomized, controlled multicenter trial involving 235 critically ill adult patients who were expected to receive mechanical ventilation for ≥48 h. The patients were randomized to receive (1) a probiotics capsule containing live Bacillus subtilis and Enterococcus faecalis (Medilac-S) 0.5 g three times daily through a nasogastric feeding tube plus standard preventive strategies or (2) standard preventive strategies alone, for a maximum of 14 days. The development of VAP was evaluated daily, and throat swabs and gastric aspirate were cultured at baseline and once or twice weekly thereafter. The incidence of microbiologically confirmed VAP in the probiotics group was significantly lower than that in the control patients (36.4 vs. 50.4 %, respectively; P = 0.031). The mean time to develop VAP was significantly longer in the probiotics group than in the control group (10.4 vs. 7.5 days, respectively; P = 0.022). The proportion of patients with acquisition of gastric colonization of potentially pathogenic microorganisms (PPMOs) was lower in the probiotics group (24 %) than the control group (44 %) (P = 0.004). However, the proportion of patients with eradication PPMO colonization on both sites of the oropharynx and stomach were not significantly different between the two groups. The administration of probiotics did not result in any improvement in the incidence of clinically suspected VAP, antimicrobial consumption, duration of mechanical ventilation, mortality and length of hospital stay. Therapy with the probiotic bacteria B. Subtilis and E. faecalis are an effective and safe means for preventing VAP and the acquisition of PPMO colonization in the stomach.

Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery.

PubMed

Bouza, Emilio; Pérez, María Jesús; Muñoz, Patricia; Rincón, Cristina; Barrio, José María; Hortal, Javier

2008-11-01

Aspiration of endotracheal secretions is a major step in the prevention of ventilator-associated pneumonia (VAP). We compared conventional and continuous aspiration of subglottic secretions (CASS) procedures in ventilated patients after major heart surgery (MHS). Randomized comparison during a 2-year period. A total of 714 patients were randomized (24 patients were excluded from the study; 359 CASS patients; 331 control subjects). The results for CASS patients and control subjects (per protocol and intention-to-treat analysis) were as follows: VAP incidence, 3.6% vs 5.3% (p = 0.2) and 3.8% vs 5.1%, respectively; incidence density, 17.9 vs 27.6 episodes per 1,000 days of mechanical ventilation (MV) [p = 0.18] and 18.9 vs 28.7 episodes per 1,000 days of MV, respectively; hospital antibiotic use in daily defined doses (DDDs), 1,213 vs 1,932 (p < 0.001) and 1,392 vs 1,932, respectively (p < 0.001). In patients who had received mechanical ventilation for > 48 h, the comparisons of CASS patients and control subjects were as follows: VAP incidence, 26.7% vs 47.5% (p = 0.04), respectively; incidence density, 31.5 vs 51.6 episodes per 1,000 days of MV, respectively (p = 0.03); median length of ICU stay, 7 vs 16.5 days (p = 0.01), respectively; hospital antibiotic use, 1,206 vs 1,877 DDD (p < 0.001), respectively; Clostridium difficile-associated diarrhea, 6.7% vs 12.5% (p = 0.3), respectively; and overall mortality rate, 44.4% vs 52.5% (p = 0.3), respectively. Reintubation increased the risk of VAP (relative risk [RR], 6.07; 95% confidence interval [CI], 2.20 to 16.60; p < 0.001), while CASS was the only significant protective factor (RR, 0.40; 95% CI, 0.16 to 0.99; p = 0.04). No complications related to CASS were observed. The cost of the CASS tube was 9 vs 1.5 euro for the conventional tube. CASS is a safe procedure that reduces the use of antimicrobial agents in the overall population and the incidence of VAP in patients who are at risk. CASS use should be encouraged, at

Hospital acquired pneumonia with high-risk bacteria is associated with increased pulmonary matrix metalloproteinase activity

PubMed Central

Schaaf, Bernhard; Liebau, Cornelia; Kurowski, Volkhard; Droemann, Daniel; Dalhoff, Klaus

2008-01-01

Background Neutrophil products like matrix metalloproteinases (MMP), involved in bacterial defence mechanisms, possibly induce lung damage and are elevated locally during hospital- acquired pneumonia (HAP). In HAP the virulence of bacterial species is known to be different. The aim of this study was to investigate the influence of high-risk bacteria like S. aureus and pseudomonas species on pulmonary MMPconcentration in human pneumonia. Methods In 37 patients with HAP and 16 controls, MMP-8, MMP-9 and tissue inhibitors of MMP (TIMP) were analysed by ELISA and MMP-9 activity using zymography in bronchoalveolar lavage (BAL). Results MMP-9 activity in mini-BAL was increased in HAP patients versus controls (149 ± 41 vs. 34 ± 11, p < 0.0001). In subgroup analysis, the highest MMP concentrations and activity were seen in patients with high-risk bacteria: patients with high-risk bacteria MMP-9 1168 ± 266 vs. patients with low-risk bacteria 224 ± 119 ng/ml p < 0.0001, MMP-9 gelatinolytic activity 325 ± 106 vs. 67 ± 14, p < 0.0002. In addition, the MMP-8 and MMP-9 concentration was associated with the state of ventilation and systemic inflammatory marker like CRP. Conclusion Pulmonary MMP concentrations and MMP activity are elevated in patients with HAP. This effect is most pronounced in patients with high-risk bacteria. Artificial ventilation may play an additional role in protease activation. PMID:18700005

Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT): A Feasibility Clinical Trial

ClinicalTrials.gov

2018-03-23

Ventilator Associated Pneumonia (VAP); Other Infections; Antibiotic-Associated Diarrhea; C-Difficile; Duration of Mechanical Ventilation; Length of ICU Stay; Length of Hospital Stay; ICU and Hospital Mortality

16S pan-bacterial PCR can accurately identify patients with ventilator-associated pneumonia.

PubMed

Conway Morris, Andrew; Gadsby, Naomi; McKenna, James P; Hellyer, Thomas P; Dark, Paul; Singh, Suveer; Walsh, Timothy S; McAuley, Danny F; Templeton, Kate; Simpson, A John; McMullan, Ronan

2017-11-01

Ventilator-associated pneumonia (VAP) remains a challenge to intensive care units, with secure diagnosis relying on microbiological cultures that take up to 72 hours to provide a result. We sought to derive and validate a novel, real-time 16S rRNA gene PCR for rapid exclusion of VAP. Bronchoalveolar lavage (BAL) was obtained from two independent cohorts of patients with suspected VAP. Patients were recruited in a 2-centre derivation cohort and a 12-centre confirmation cohort. Confirmed VAP was defined as growth of >10 4 colony forming units/ml on semiquantitative culture and compared with a 16S PCR assay. Samples were tested from 67 patients in the derivation cohort, 10 (15%) of whom had confirmed VAP. Using cycles to cross threshold (C t ) values as the result of the 16S PCR test, the area under the receiver operating characteristic (ROC) curve (AUROC) was 0.94 (95% CI 0.86 to 1.0, p<0.0001). Samples from 92 patients were available from the confirmation cohort, 26 (28%) of whom had confirmed VAP. The AUROC for C t in this cohort was 0.89 (95% CI 0.83 to 0.95, p<0.0001). This study has derived and assessed the diagnostic accuracy of a novel application for 16S PCR. This suggests that 16S PCR in BAL could be used as a rapid test in suspected VAP and may allow better stewardship of antibiotics. VAPRAPID trial ref NCT01972425. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Artificial humidification for the mechanically ventilated patient.

PubMed

Selvaraj, N

Caring for patients who are mechanically ventilated poses many challenges for critical care nurses. It is important to humidify the patient's airways artificially to prevent complications such as ventilator-associated pneumonia. There is no gold standard to determine which type of humidification is best for patients who are artificially ventilated. This article provides an overview of commonly used artificial humidification for mechanically ventilated patients and discusses nurses' responsibilities in caring for patients receiving artificial humidification.

Biomarkers kinetics in the assessment of ventilator-associated pneumonia response to antibiotics - results from the BioVAP study.

PubMed

Póvoa, Pedro; Martin-Loeches, Ignacio; Ramirez, Paula; Bos, Lieuwe D; Esperatti, Mariano; Silvestre, Joana; Gili, Gisela; Goma, Gemma; Berlanga, Eugenio; Espasa, Mateu; Gonçalves, Elsa; Torres, Antoni; Artigas, Antonio

2017-10-01

Our aim was to evaluate the role of biomarker kinetics in the assessment of ventilator-associated pneumonia (VAP) response to antibiotics. We performed a prospective, multicenter, observational study to evaluate in 37 microbiologically documented VAP, the kinetics of C-reactive protein (CRP), procalcitonin (PCT), mid-region fragment of pro-adrenomedullin (MR-proADM). The kinetics of each variable, from day 1 to 6 of therapy, was assessed with a time dependent analysis comparing survivors and non-survivors. During the study period kinetics of CRP as well as its relative changes, CRP-ratio, was significantly different between survivors and non-survivors (p=0.026 and p=0.005, respectively). On day 4 of antibiotic therapy, CRP of survivors was 47% of the initial value while it was 96% in non-survivors. The kinetics of other studied variables did not distinguish between survivors and non-survivors. In survivors the bacterial load also decreased markedly. Adequate initial antibiotic therapy was associated with lower mortality (p=0.025) and faster CRP decrease (p=0.029). C-reactive protein kinetics can be used to identify VAP patients with poor outcome as soon as four days after the initiation of treatment. (Trial registration - NCT02078999; registered 3 August 2012). Copyright © 2017 Elsevier Inc. All rights reserved.

How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients.

PubMed

Blot, Stijn I; Poelaert, Jan; Kollef, Marin

2014-11-28

Microaspiration of subglottic secretions through channels formed by folds in high volume-low pressure poly-vinyl chloride cuffs of endotracheal tubes is considered a significant pathogenic mechanism of ventilator-associated pneumonia (VAP). Therefore a series of prevention measures target the avoidance of microaspiration. However, although some of these can minimize microaspiration, benefits in terms of VAP prevention are not always obvious. Polyurethane-cuffed endotracheal tubes successfully reduce microaspiration but high quality data demonstrating VAP rate reduction are lacking. An analogous conclusion can be made regarding taper-shaped cuffs compared with classic barrel-shaped cuffs. More clinical data regarding these endotracheal tube designs are needed to demonstrate clinical value in addition to in vitro-based evidence. The clinical usefulness of endotracheal tubes developed for subglottic secretions drainage is established in multiple studies and confirmed by meta-analysis. Any change in cuff design will fail to prevent microaspiration if the cuff is insufficiently inflated. At least one well-designed trial demonstrated that continuous cuff pressure monitoring and control decrease the risk of VAP. Gel lubrication of the cuff prior to intubation temporarily hampers microaspiration through sludging the channels formed by folds in high volume-low pressure cuffs. As the beneficial effect of gel lubrication is temporarily, its potential to reduce VAP risk is probably nonsignificant. A minimum positive end-expiratory pressure of at least 5 cmH2O can be recommended as it reduces the risk of microaspiration in vitro and in vivo. One randomized controlled study demonstrated a reduced risk of VAP in patients ventilated with PEEP (5-8 cmH2O). Regarding head-of-bed elevation, it can be recommended to avoid supine positioning. Whether a 45° head-of-bed elevation is to be preferred above 25-30° head-of-bed elevation remains unproven. Finally, the routine monitoring of

Ventilator-associated pneumonia in ARDS patients: the impact of prone positioning. A secondary analysis of the PROSEVA trial.

PubMed

Ayzac, L; Girard, R; Baboi, L; Beuret, P; Rabilloud, M; Richard, J C; Guérin, C

2016-05-01

The goal of this study was to assess the impact of prone positioning on the incidence of ventilator-associated pneumonia (VAP) and the role of VAP in mortality in a recent multicenter trial performed on patients with severe ARDS. An ancillary study of a prospective multicenter randomized controlled trial on early prone positioning in patients with severe ARDS. In suspected cases of VAP the diagnosis was based on positive quantitative cultures of bronchoalveolar lavage fluid or tracheal aspirate at the 10(4) and 10(7) CFU/ml thresholds, respectively. The VAP cases were then subject to central, independent adjudication. The cumulative probabilities of VAP were estimated in each position group using the Aalen-Johansen estimator and compared using Gray's test. A univariate and a multivariate Cox model was performed to assess the impact of VAP, used as a time-dependent covariate for mortality hazard during the ICU stay. In the supine and prone position groups, the incidence rate for VAP was 1.18 (0.86-1.60) and 1.54 (1.15-2.02) per 100 days of invasive mechanical ventilation (p = 0.10), respectively. The cumulative probability of VAP at 90 days was estimated at 46.5 % (27-66) in the prone group and at 33.5 % (23-44) in the supine group. The difference between the two cumulative probability curves was not statistically significant (p = 0.11). In the univariate Cox model, VAP was associated with an increase in the mortality rate during the ICU stay [HR 1.65 (1.05-2.61), p = 0.03]. HR increased to 2.2 (1.39-3.52) (p < 0.001) after adjustment for position group, age, SOFA score, McCabe score, and immunodeficiency. In severe ARDS patients prone positioning did not reduce the incidence of VAP and VAP was associated with higher mortality.

Association of Systemic Inflammatory Response Syndrome with Clinical Outcomes of Pediatric Patients with Pneumonia.

PubMed

Frazier, Steven Barron; Sepanski, Robert; Mangum, Christopher; Bovat, Christine; Zaritsky, Arno; Godambe, Sandip

2015-11-01

Systemic inflammatory response syndrome (SIRS) may complicate pneumonia. When present, it suggests that the patient's pneumonia is more severe. As such, recognition of SIRS among patients with pneumonia may be helpful in identifying those requiring more careful evaluation. Our objective was to examine the relation between the presence of SIRS and adverse clinical outcomes among children with pneumonia seen in the emergency department (ED). A retrospective chart review was performed on children diagnosed as having community-acquired pneumonia who presented to a children's hospital ED during a 3-month period. SIRS was determined by using a modification of the International Consensus Conference on Pediatric Sepsis criteria. Specifically, the SIRS criteria require an abnormal temperature-corrected heart rate or respiratory rate and either an abnormal temperature or white blood cell count. The threshold for abnormal vital signs and white blood cell counts used to determine SIRS was adjusted based on the patient's age. Morbidity endpoints included progression to inpatient or observation status or subsequent return to the ED for pneumonia, need for video-assisted thoracoscopic surgery, and total hospital length of stay as measured from ED triage assessment to final discharge from the hospital (ED, observation, or inpatient), and the need for mechanical ventilation. A total of 276 children were included in the analysis. Pneumonia patients with SIRS (n = 38) had a greater rate of hospital admission or ED return compared with SIRS-negative patients (n = 238; 79% vs 34.5%, respectively; P < 0.0001). Children with SIRS-positive pneumonia were at greater risk of requiring video-assisted thoracoscopic surgery (18.4% vs 0.8%; P < 0.0001). In addition, pneumonia patients with SIRS had a significantly longer median length of stay compared with pneumonia patients without SIRS (2.7 vs 0.19 days, P < 0.0001) and also had a significantly higher risk of mechanical ventilation (10.5% vs

Successful treatment of Panton-Valentine leukocidin-expressing Staphylococcus aureus-associated pneumonia co-infected with influenza using extracorporeal membrane oxygenation.

PubMed

Fujisaki, Noritomo; Takahashi, Azusa; Arima, Takahiro; Mizushima, Tomoya; Ikeda, Katsuki; Kakuchi, Hiroyuki; Nakao, Atsunori; Kotani, Joji; Sakaida, Koji

2014-01-01

Panton-Valentine leukocidin (PVL) is a cytotoxin that causes leukocyte destruction and lung necrosis. Managing respiratory failure and acute respiratory distress syndrome secondary to PVL-expressing Staphylococcus aureus pneumonia and its associated lung necrosis with mechanical ventilation is challenging. We report a patient with life-threatening PVL-expressing S. aureus-associated pneumonia who was rescued using extracorporeal membrane oxygenation (ECMO). We examined the case of a woman who presented to our Emergency Department with septic shock due to PVL-expressing S. aureus-associated pneumonia. A 27-year-old Filipino woman was transferred to our hospital due to severe dyspnea, hemosputum, and high-grade fever. She had a medical history of osteosarcoma of the leg and hyperthyroidism. On arrival, her vital signs indicated septic shock, with a white blood cell count of 3.5×10(3)/μl. Because a Gram stain of her sputum indicated SA, therapy with antibiotics, including meropenem and vancomycin, was started. Hypoxemia necessitated intubation and ventilation. Because the patient's PaO2/FiO2 remained less than 60 mmHg and her blood pressure was unstable despite aggressive conventional management, venoarterial ECMO was administered approximately 11 h after her arrival. The ECMO circuit was changed to veno-venous ECMO on day 7 and the patient was successfully weaned off ECMO after 12 days of treatment. She was discharged from the hospital 104 days after admission. This case demonstrates that early induction of ECMO support can be a reasonable therapeutic option for PVL-S. aureus-associated pneumonia. This patient's successful outcome might be attributable to early establishment of ECMO to prevent ventilation-induced lung injury. Copyright © 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.

Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trial.

PubMed

Valencia, Mauricio; Ferrer, Miquel; Farre, Ramon; Navajas, Daniel; Badia, Joan Ramon; Nicolas, Josep Maria; Torres, Antoni

2007-06-01

The aspiration of subglottic secretions colonized by bacteria pooled around the tracheal tube cuff due to inadvertent deflation (<20 cm H2O) of the cuff plays a relevant role in the pathogenesis of ventilator-associated pneumonia. We assessed the efficacy of an automatic, validated device for the continuous regulation of tracheal tube cuff pressure in preventing ventilator-associated pneumonia. Prospective randomized controlled trial. Respiratory intensive care unit and general medical intensive care unit. One hundred and forty-two mechanically ventilated patients (age, 64 +/- 17 yrs; Acute Physiology and Chronic Health Evaluation II score, 18 +/- 6) without pneumonia or aspiration at admission. Within 24 hrs of intubation, patients were randomly allocated to undergo continuous regulation of the cuff pressure with the automatic device (n = 73) or routine care of the cuff pressure (control group, n = 69). Patients remained in a semirecumbent position in bed. The primary end point variable was the incidence of ventilator-associated pneumonia. Main causes for intubation were decreased consciousness (43, 30%) and exacerbation of chronic respiratory diseases (38, 27%). Cuff pressure <20 cm H2O was more frequently observed in the control than the automatic group (45.3 vs. 0.7% determinations, p < .001). However, the rate of ventilator-associated pneumonia with clinical criteria (16, 22% vs. 20, 29%) and microbiological confirmation (11, 15% vs. 10, 15%), the distribution of early and late onset, the causative microorganisms, and intensive care unit (20, 27% vs. 16, 23%) and hospital mortality (30, 41% vs. 23, 33%) were similar for the automatic and control groups, respectively. Cuff pressure is better controlled with the automatic device. However, it did not result in additional benefits to the semirecumbent position in preventing ventilator-associated pneumonia.

Nosocomial pneumonia.

PubMed

Myrianthefs, Pavlos M; Kalafati, Maria; Samara, Irini; Baltopoulos, George J

2004-01-01

Nosocomial pneumonia (NP) is defined as pneumonia that develops within 48 hours or more of hospital admission and which was not developing at the time of admission. Nosocomial pneumonia, also known as hospital-acquired pneumonia (HAP), is the second most common hospital infection, while ventilator-associated pneumonia represents the most common intensive care unit (ICU) infection. Nosocomial pneumonia significantly contributes to morbidity, mortality, and escalating healthcare costs because of increases in antibiotic prescription and administration, length of ICU stay, and length of hospital stay. Aspiration and colonization of the upper respiratory tract seem to be the major pathogenetic mechanisms for the development of NP, either in intubated or spontaneously breathing patients. The microbiology of NP depends on the timing of onset. In early-onset NP, the responsible pathogens are generally endogenous community-acquired pathogens. In late-onset NP, the responsible microbes include potentially multi-drug-resistant nosocomial organisms residing in oropharyngeal or gastric contents. Important risk factors for development of NP include coma, intubation, prolonged mechanical ventilation, repeated intubations, supine positioning, and long-term antibiotic use. The most significant preventive measures include routine hand washing and avoidance of (1) the supine position, (2) inappropriate antibiotics, and (3) overuse of H2-antagonists for stress ulcer prophylaxis. Accurate diagnosis of NP is difficult and controversial, warranting consideration for the application of invasive quantitative culture techniques over tracheal aspirates. Empiric antibiotic treatment should be prompt, starting on clinical suspicion, and based on local ICU pathogen epidemiology and antibiotic resistance patterns and on a deescalating antibiotic strategy. Innovative antibiotic strategies, such as antibiotic rotation, to help prevent the emergence of multi-drug-resistant pathogens and improve

Quantitative cultures of bronchoscopically obtained specimens should be performed for optimal management of ventilator-associated pneumonia.

PubMed

Baselski, Vickie; Klutts, J Stacey; Baselski, Vickie; Klutts, J Stacey

2013-03-01

Ventilator-associated pneumonia (VAP) is a leading cause of health care-associated infection. It has a high rate of attributed mortality, and this mortality is increased in patients who do not receive appropriate empirical antimicrobial therapy. As a result of the overuse of broad-spectrum antimicrobials such as the carbapenems, strains of Acinetobacter, Enterobacteriaceae, and Pseudomonas aeruginosa susceptible only to polymyxins and tigecycline have emerged as important causes of VAP. The need to accurately diagnose VAP so that appropriate discontinuation or de-escalation of antimicrobial therapy can be initiated to reduce this antimicrobial pressure is essential. Practice guidelines for the diagnosis of VAP advocate the use of bronchoalveolar lavage (BAL) fluid obtained either bronchoscopically or by the use of a catheter passed through the endotracheal tube. The CDC recommends that quantitative cultures be performed on these specimens, using ≥ 10(4) CFU/ml to designate a positive culture (http://www.cdc.gov/nhsn/TOC_PSCManual.html, accessed 30 October 2012). However, there is no consensus in the clinical microbiology community as to whether these specimens should be cultured quantitatively, using the aforementioned designated bacterial cell count to designate infection, or by a semiquantitative approach. We have asked Vickie Baselski, University of Tennessee Health Science Center, who was the lead author on one of the seminal papers on quantitative BAL fluid culture, to explain why she believes that quantitative BAL fluid cultures are the optimal strategy for VAP diagnosis. We have Stacey Klutts, University of Iowa, to advocate the semiquantitative approach.

Rapid MRSA PCR on respiratory specimens from ventilated patients with suspected pneumonia: a tool to facilitate antimicrobial stewardship.

PubMed

Trevino, S E; Pence, M A; Marschall, J; Kollef, M H; Babcock, H M; Burnham, C-A D

2017-05-01

Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of pneumonia in ventilated patients. Our objective was to evaluate the GeneXpert MRSA/SA SSTI Assay (Xpert MRSA/SA) (Cepheid, Sunnyvale, CA) for use in lower respiratory tract (LRT) specimens for rapid MRSA detection and to determine the potentially saved antibiotic-days if a culture-based identification method was replaced by this assay. Remnant LRT samples from ventilated patients submitted to the microbiology laboratory for routine culture were tested using conventional culture and Xpert MRSA/SA. One hundred of 310 LRT specimens met the inclusion criteria. Ten samples were positive for MRSA by Xpert MRSA/SA, while six were positive by routine culture methods. Xpert MRSA/SA correctly identified 5/6 positive and 89/94 negative MRSA specimens, for a sensitivity of 83.3%, specificity of 94.7%, positive predictive value of 45.6%, and negative predictive value of 98.9%. The assay also correctly detected 3/3 positive and 90/97 negative methicillin-susceptible S. aureus (MSSA) specimens, for a sensitivity of 100%, specificity of 92.8%, positive predictive value of 30%, and negative predictive value of 100%. A total of 748 vancomycin and 305 linezolid antibiotic-days were associated with the enrolled specimens. Vancomycin and linezolid utilization could decrease by 68.4% and 83%, respectively, if discontinued 1 day after negative polymerase chain reaction (PCR) results. The Xpert MRSA/SA SSTI rapid MRSA PCR assay performed well in respiratory samples from ventilated patients with suspected pneumonia and has the potential to facilitate stewardship efforts such as reducing empiric vancomycin and linezolid therapy.

Procedural and educational interventions to reduce ventilator-associated pneumonia rate and central line-associated blood stream infection rate.

PubMed

Kellie, Scott P; Scott, Michael J; Cavallazzi, Rodrigo; Wiemken, Tim L; Goss, Linda; Parker, Deanna; Saad, Mohamed

2014-01-01

Implementing best practice guidelines for ventilator-associated pneumonia (VAP) and central line-associated blood stream infection (CLA-BSI) has variable success. Our institution was concerned with high rates of VAP and CLA-BSI. This retrospective study was undertaken to see whether implementation of the below practices would reduce the rates of VAP and CLA-BSI without resorting to more expensive interventions such as subglottic endotracheal (ET) tube suctioning or silver-impregnated ET tubes. We utilized easily collectable data (standardized infection ratios [SIRs]) to rapidly assess whether interventions already in place were successful. This avoided cumbersome data collection and review. Retrospective data review calculated SIRs using National Healthcare Safety Network benchmarks. Rates and SIRs were compared using z tests with P values <.05 considered statistically significant. This data review attempted to examine the impact of education campaigns, staff meetings, in-services, physician checklist, nurse checklist, charge nurse checklist implementation, and chlorhexidine gluconate oral care addition to the VAP bundle. Additionally, central line insertion required nursing supervision, a checklist, and physician signature. The incidence rate of VAP went from 9.88 occurrences/1000 vent days in 2009 to 0 occurrences/1000 vent days in 2010 (P < .001). The CLA-BSI occurrences/1000 line days were 2.86 in 2009 and 0.97 in 2010 (P = .0187). The SIR for VAP was 4.12 in 2009 and 0 in 2010 (P < .001). For CLA-BSI, the SIR was 1.1 in 2009 and 0.37 in 2010 (P = .04). Efforts to improve physician, patient, and staff education, and checklist implementation resulted in a decrease in VAP and CLA-BSI. This study confirms the applicability of best practice guidelines and suggests a benefit to the use of checklists. We utilize a practical approach for examining the success of these changes.

Poor clinical outcomes among pneumonia patients with depressive disorder.

PubMed

Kao, Li-Ting; Liu, Shih-Ping; Lin, Herng-Ching; Lee, Hsin-Chien; Tsai, Ming-Chieh; Chung, Shiu-Dong

2014-01-01

Some studies suggested that psychological stress may be associated with the severity and duration of infectious diseases. In this population-based study, we investigated associations between depressive disorder (DD) and pneumonia outcomes in Taiwan with a large-scale database from the National Health Insurance. Our study defined 112,198 patients who were hospitalized with a principal diagnosis of pneumonia. We defined their admission date for treatment of pneumonia as the index date. Subsequently, we selected 2,394 patients with DD within 3 years prior to their index date and 11,970 matched patients without DD. We carried out separate conditional logistic regressions to explore the association of clinical pneumonia treatment outcome (ICU admission, use of mechanical ventilation, acute respiratory failure and in-hospital death) with previously diagnosed DD. Patients with DD had a significantly higher probability of an intensive care unit admission (18.1% vs. 12.9%; p<0.001), need for mechanical ventilation (21.9% vs. 18.1%; p<0.001) and in-hospital death (10.4% vs. 9.0%; p = 0.025) than patients without DD. The study showed that pneumonia patients with DD were respectively 1.41- (95% CI: 1.25∼1.59, p<0.001), 1.28- (95% CI: 1.14∼1.43, p<0.001), and 1.17- times (95% CI: 1.01∼1.36, p = 0.039) greater odds of being admitted to the ICU, need for mechanical ventilation, and in-hospital death than patients without DD after adjusting for monthly income, urbanization level, geographic region and Charlson Comorbidity Index score. In conclusion, we found that pneumonia patients with DD were associated with poor treatment outcomes compared to patients without DD.

Conservative Fluid Management Prevents Age-Associated Ventilator Induced Mortality

PubMed Central

Herbert, Joseph A.; Valentine, Michael S.; Saravanan, Nivi; Schneck, Matthew B.; Pidaparti, Ramana; Fowler, Alpha A.; Reynolds, Angela M.; Heise, Rebecca L.

2017-01-01

Background Approximately 800 thousand patients require mechanical ventilation in the United States annually with an in-hospital mortality rate of over 30%. The majority of patients requiring mechanical ventilation are over the age of 65 and advanced age is known to increase the severity of ventilator-induced lung injury (VILI) and in-hosptial mortality rates. However, the mechanisms which predispose aging ventilator patients to increased mortality rates are not fully understood. Ventilation with conservative fluid management decreases mortality rates in acute respiratory distress patients, but to date there has been no investigation of the effect of conservative fluid management on VILI and ventilator associated mortality rates. We hypothesized that age-associated increases in susceptibility and incidence of pulmonary edema strongly promote age-related increases in ventilator associated mortality. Methods 2 month old and 20 month old male C57BL6 mice were mechanically ventilated with either high tidal volume (HVT) or low tidal volume (LVT) for up to 4 hours with either liberal or conservative fluid support. During ventilation, lung compliance, total lung capacity, and hysteresis curves were quantified. Following ventilation, bronchoalveolar lavage fluid was analyzed for total protein content and inflammatory cell infiltration. Wet to dry ratios were used to directly measure edema in excised lungs. Lung histology was performed to quantify alveolar barrier damage/destruction. Age matched non-ventilated mice were used as controls. Results At 4hrs, both advanced age and HVT ventilation significantly increased markers of inflammation and injury, degraded pulmonary mechanics, and decreased survival rates. Conservative fluid support significantly diminished pulmonary edema and improved pulmonary mechanics by 1hr in advanced age HVT subjects. In 4hr ventilations, conservative fluid support significantly diminished pulmonary edema, improved lung mechanics, and resulted in

Pneumonia: challenges in the definition, diagnosis, and management of disease.

PubMed

Ottosen, Julie; Evans, Heather

2014-12-01

Defining health care-associated pneumonia, which includes both hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), is problematic and controversial. Aspiration pneumonia is often included as a subtype of HAP but may be related to community-acquired aspiration events. Scoring systems exist and new surveillance guidelines have been implemented to make early recognition of pneumonia more precise and objective. Management and prevention should follow recommendations, including early empirical therapy, targeted therapy, and limited duration of treatment. Patients with trauma present a challenge to the diagnosis and management of pneumonia, because of increased risk for aspiration and underlying chest and pulmonary injury. Copyright © 2014 Elsevier Inc. All rights reserved.

Ventilators in ICU: A boon or burden

PubMed Central

Mehndiratta, Man Mohan; Nayak, Rajeev; Ali, Sana; Sharma, Ajay; Gulati, Natasha Singh

2016-01-01

Background and Aims: Ventilator-associated pneumonia (VAP) is a major challenge in intensive care units (ICUs). This challenge is even more discernible in a neurological setting owing to the predispositions of patients. Data on VAP in the neurology and neurosurgery ICUs (NNICUs) are scanty in developing countries. This study was conducted to find out the occurrence of VAP, its risk factors, microbiological profile, and antibiotic resistance in patients admitted to the NNICU of a tertiary care institute in India. Materials and Methods: Endotracheal aspirate and blood samples were collected from 100 patients admitted to the NNICU. Complete blood count, microscopic examination, culture and sensitivity testing of aspirate were done. Chest x-ray was also performed to aid in the diagnosis of VAP. Results: Incidence rate of VAP was found to be 24%. Acinetobacter baumannii was the most common pathogen (24.3%) isolated from patients with VAP, and all of these isolates were sensitive to meropenem. Duration of mechanical ventilation (P < 0.0001) and associated comorbid illness (P = 0.005) were found to be significantly associated with VAP, and the duration of mechanical ventilation was found to be the only independent risk factor (P < 0.0001). Conclusions: This study highlights the risks and microbiological perspective of ventilator use among neurology patients so that adequate preventive strategies can be adopted on time. PMID:27011632

Incidence of ventilator-associated pneumonia in Australasian intensive care units: use of a consensus-developed clinical surveillance checklist in a multisite prospective audit

PubMed Central

Elliott, Doug; Elliott, Rosalind; Burrell, Anthony; Harrigan, Peter; Murgo, Margherita; Rolls, Kaye; Sibbritt, David

2015-01-01

Objectives With disagreements on diagnostic criteria for ventilator-associated pneumonia (VAP) hampering efforts to monitor incidence and implement preventative strategies, the study objectives were to develop a checklist for clinical surveillance of VAP, and conduct an audit in Australian/New Zealand intensive care units (ICUs) using the checklist. Setting Online survey software was used for checklist development. The prospective audit using the checklist was conducted in 10 ICUs in Australia and New Zealand. Participants Checklist development was conducted with members of a bi-national professional society for critical care physicians using a modified Delphi technique and survey. A 30-day audit of adult patients mechanically ventilated for >72 h. Primary and secondary outcome measures Presence of items on the screening checklist; physician diagnosis of VAP, clinical characteristics, investigations, treatments and patient outcome. Results A VAP checklist was developed with five items: decreasing gas exchange, sputum changes, chest X-ray infiltrates, inflammatory response, microbial growth. Of the 169 participants, 17% (n=29) demonstrated characteristics of VAP using the checklist. A similar proportion had an independent physician diagnosis (n=30), but in a different patient subset (only 17% of cases were identified by both methods). The VAP rate per 1000 mechanical ventilator days for the checklist and clinician diagnosis was 25.9 and 26.7, respectively. The item ‘inflammatory response’ was most associated with the first episode of physician-diagnosed VAP. Conclusions VAP rates using the checklist and physician diagnosis were similar to ranges reported internationally and in Australia. Of note, different patients were identified with VAP by the checklist and physicians. While the checklist items may assist in identifying patients at risk of developing VAP, and demonstrates synergy with the recently developed Centers for Disease Control (CDC) guidelines

Analysis of ventilator-associated pneumonia infection route by genome macrorestriction-pulsed-field gel electrophoresis and its prevention with combined nursing strategies.

PubMed

Wang, Xiaodong; Wang, Junping; Li, Jing; Wang, Jing

2014-12-01

The aim of the present study was to explore the infection route of ventilator-associated pneumonia (VAP) and assess the effectiveness of a combined nursing strategy to prevent VAP in intensive care units. Bacteria from the gastric juice and drainage from the hypolarynx and lower respiratory tracts of patients with VAP were analyzed using genome macrorestriction-pulsed-field gel electrophoresis (GM-PFGE). A total of 124 patients with tracheal intubation were placed in the intervention group and were treated with a combined nursing strategy, comprising mosapride (gastric motility stimulant) administration and semi-reclining positioning. A total of 112 intubated patients were placed in the control group and received routine nursing care. The incidence rate of VAP, days of ventilation and mortality rate of patients were compared between the two groups. The GM-PFGE fingerprinting results of three strains of Pseudomonas aeruginosa from the gastric juice, subglottic secretion drainage and drainage of the lower respiratory tract in patients with VAP were similar across groups. The number of days spent on a ventilator by patients in the intervention group (7.37±5.32 days) was lower compared with that by patients in the control group (12.34±4.98 days) (P<0.05). The incidence rate of VAP was reduced from 40.81 to 21.25% following intervention with the combined nursing strategy (P<0.05); furthermore, the mortality rate of intubated patients in the intervention group was 29.46%, a significant reduction compared with the 41.94% mortality rate observed in the control group (P<0.05). Gastroesophageal reflux (GER) was confirmed as one of the infection routes for VAP. The combined nursing strategy of gastric motility stimulant administration and the adoption of a semi-reclining position was effective in preventing VAP by reducing the occurrence of GER.

Methicillin-resistant Staphylococcus aureus prolongs intensive care unit stay in ventilator-associated pneumonia, despite initially appropriate antibiotic therapy.

PubMed

Shorr, Andrew F; Combes, Alain; Kollef, Marin H; Chastre, Jean

2006-03-01

To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) on length of stay in the intensive care unit (ICU) for patients with ventilator-associated pneumonia (VAP) and to control for the effect of initially inappropriate antibiotic treatment on outcomes by focusing only on persons who were given appropriate antibiotic therapy for their infection. Retrospective analysis of pooled, patient-level data from multiple clinical trials in VAP. Multiple ICUs in France. Persons with bronchoscopically confirmed VAP due to either MRSA or methicillin-susceptible S. aureus (MSSA) and who received initially appropriate antibiotic treatment. All persons with MRSA VAP received vancomycin (15 mg/kg intravenously, twice daily). None. We compared patients with MRSA VAP to persons with MSSA VAP. ICU length of stay represented the primary end point and ICU-free days served as a secondary end point. We recorded information regarding multiple confounders, including demographics, reasons for ICU admission and mechanical ventilation (MV), severity of illness at both ICU admission and time of diagnosis of VAP, and duration of mechanical ventilation before and following the onset of VAP. The final cohort included 107 patients, and one third of cases were due to MRSA. Despite receiving initially appropriate antibiotic treatment, median ICU length of stay was significantly longer for persons with MRSA infection (33 days vs. 22 days; p=.047). The median number of ICU-free days was concomitantly lower in MRSA VAP (0 days vs. 5 days; p=.011). Survival analysis employing a Cox proportional hazards model identified several predictors of remaining in the ICU: Pao2/Fio2 ratio at diagnosis of VAP, duration of MV before VAP, duration of MV after diagnosis of VAP, and reason for MV. Additionally, infection with MRSA as opposed MSSA doubled the probability of needing continued ICU care (hazard ratio, 2.08; 95% confidence interval, 1.09-3.95; p=.025). MRSA VAP independently prolongs

The incidence and microbial spectrum of ventilator-associated pneumonia after tracheotomy in a selective decontamination of the digestive tract-setting.

PubMed

Veelo, Denise P; Bulut, Tomas; Dongelmans, Dave A; Korevaar, Johanna C; Spronk, Peter E; Schultz, Marcus J

2008-01-01

Tracheotomy is considered to be an independent risk factor for ventilator-associated pneumonia (VAP). Antimicrobial prophylaxis, in particular with coverage of Pseudomonas aeruginosa, is presently advocated. Selective decontamination of the digestive tract (SDD) aims to prevent VAP in critically ill patients, including those after tracheotomy. We determined the incidence and microbial spectrum of VAP after tracheotomy in a SDD-setting. Retrospective analysis of 231 tracheotomized patients during a 2-year period. Thirteen patients (5.6%) developed VAP. The median [IQR] day of onset was 8.0 [3.0-10.5] days after tracheotomy. The most predominant causative pathogen was Methicillin-sensitive Staphylococcus aureus (MSSA). Timing of tracheotomy was not different between patients developing VAP and those who did not. The type of tracheotomy (percutaneous or surgical, 84.6% versus 15.4%) had no significant influence on the incidence of VAP. The incidence of VAP after tracheotomy in a SDD-setting is low, with MSSA as the predominant causative pathogen. Accordingly, if antimicrobial prophylaxis is considered, it may be advisable to cover MSSA in an SDD-setting.

Accuracy of tracheal aspirate gram stain in predicting Staphylococcus aureus infection in ventilator-associated pneumonia.

PubMed

Seligman, Renato; Seligman, Beatriz Graeff Santos; Konkewicz, Loriane; Dos Santos, Rodrigo Pires

2015-01-01

The Gram stain can be used to direct initial empiric antimicrobial therapy when complete culture is not available. This rapid test could prevent the initiation of inappropriate therapy and adverse outcomes. However, several studies have attempted to determine the value of the Gram stain in the diagnosis and therapy of bacterial infection in different populations of patients with ventilator-associated pneumonia (VAP) with conflicting results. The objective of this study is to evaluate the accuracy of the Gram stain in predicting the existence of Staphylococcus aureus infections from cultures of patients suspected of having VAP. This prospective single-center open cohort study enrolled 399 patients from December 2005 to December 2010. Patients suspected of having VAP by ATS IDSA criteria were included. Respiratory secretion samples were collected by tracheal aspirate (TA) for standard bacterioscopic analysis by Gram stain and culture. Respiratory secretion samples collected by tracheal aspirates of 392 patients were analyzed by Gram stain and culture. When Gram-positive cocci were arranged in clusters, the sensitivity was 68.4%, specificity 97.8%, positive predictive value 88.1% and negative predictive value 92.8% for predicting the presence of Staphylococcus aureus in culture (p < 0.001). A tracheal aspirate Gram stain can be used to rule out the presence of Staphylococcus aureus in patients with a clinical diagnosis of VAP with a 92.8% Negative Predictive Value. Therefore, 7.2% of patients with Staphylococcus aureus would not be protected by an empiric treatment that limits antimicrobial coverage to Staphylococcus aureus only when Gram positive cocci in clusters are identified.

The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention.

PubMed

Safdar, Nasia; Crnich, Christopher J; Maki, Dennis G

2005-06-01

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with major morbidity and attributable mortality. Strategies to prevent VAP are likely to be successful only if based upon a sound understanding of pathogenesis and epidemiology. The major route for acquiring endemic VAP is oropharyngeal colonization by the endogenous flora or by pathogens acquired exogenously from the intensive care unit environment, especially the hands or apparel of health-care workers, contaminated respiratory equipment, hospital water, or air. The stomach represents a potential site of secondary colonization and reservoir of nosocomial Gram-negative bacilli. Endotracheal-tube biofilm formation may play a contributory role in sustaining tracheal colonization and also have an important role in late-onset VAP caused by resistant organisms. Aspiration of microbe-laden oropharyngeal, gastric, or tracheal secretions around the cuffed endotracheal tube into the normally sterile lower respiratory tract results in most cases of endemic VAP. In contrast, epidemic VAP is most often caused by contamination of respiratory therapy equipment, bronchoscopes, medical aerosols, water (eg, Legionella) or air (eg, Aspergillus or the severe acute respiratory syndrome virus). Strategies to eradicate oropharyngeal and/or intestinal microbial colonization, such as with chlorhexidine oral care, prophylactic aerosolization of antimicrobials, selective aerodigestive mucosal antimicrobial decontamination, or the use of sucralfate rather than H(2) antagonists for stress ulcer prophylaxis, and measures to prevent aspiration, such as semirecumbent positioning or continuous subglottic suctioning, have all been shown to reduce the risk of VAP. Measures to prevent epidemic VAP include rigorous disinfection of respiratory equipment and bronchoscopes, and infection-control measures to prevent contamination of medical aerosols. Hospital water should be

Gram staining of protected pulmonary specimens in the early diagnosis of ventilator-associated pneumonia.

PubMed

Mimoz, O; Karim, A; Mazoit, J X; Edouard, A; Leprince, S; Nordmann, P

2000-11-01

We evaluated prospectively the use of Gram staining of protected pulmonary specimens to allow the early diagnosis of ventilator-associated pneumonia (VAP), compared with the use of 60 bronchoscopic protected specimen brushes (PSB) and 126 blinded plugged telescopic catheters (PTC) obtained from 134 patients. Gram stains were from Cytospin slides; they were studied for the presence of microorganisms in 10 and 50 fields by two independent observers and classified according to their Gram stain morphology. Quantitative cultures were performed after serial dilution and plating on appropriate culture medium. A final diagnosis of VAP, based on a culture of > or = 10(3) c.f.u. ml-1, was established after 81 (44%) samplings. When 10 fields were analysed, a strong relationship was found between the presence of bacteria on Gram staining and the final diagnosis of VAP (for PSB and PTC respectively: sensitivity 74 and 81%, specificity 94 and 100%, positive predictive value 91 and 100%, negative predictive value 82 and 88%). The correlation was less when we compared the morphology of microorganisms observed on Gram staining with those of bacteria obtained from quantitative cultures (for PSB and PTC respectively: sensitivity 54 and 69%, specificity 86 and 89%, positive predictive value 72 and 78%, negative predictive value 74 and 84%). Increasing the number of fields read to 50 was associated with a slight decrease in specificity and positive predictive value of Gram staining, but with a small increase in its sensitivity and negative predictive value. The results obtained by the two observers were similar to each other for both numbers of fields analysed. Gram staining of protected pulmonary specimens performed on 10 fields predicted the presence of VAP and partially identified (using Gram stain morphology) the microorganisms growing at significant concentrations, and could help in the early choice of the treatment of VAP. Increasing the number of fields read or having the Gram

Incidence, characteristic and outcomes of ventilator-associated pneumonia among type 2 diabetes patients: An observational population-based study in Spain.

PubMed

Jiménez-Trujillo, Isabel; Jiménez-García, Rodrigo; de Miguel-Díez, Javier; de Miguel-Yanes, José M; Hernández-Barrera, Valentín; Méndez-Bailón, Manuel; Pérez-Farinós, Napoleón; Salinero-Fort, Miguel-Ángel; López-de-Andrés, Ana

2017-05-01

To describe incidence, characteristics and outcomes of ventilator-associated pneumonia (VAP) during hospitalization among patients with or without type 2 diabetes (T2DM). We used the Spanish national hospital discharge database to select all hospitalization with VAP in subjects aged 40years or more from 2010 to 2014. We analyzed incidence, patient comorbidities, procedures, pneumonia pathogens and in-hospital outcomes according to diabetes status (T2DM and no-diabetes). We used propensity score analysis to estimate the effect of T2DM on in-hospital mortality RESULTS: In 7952 admissions, the patient developed a VAP (13.6% with T2DM). Adjusted incidence rate of VAP was slightly, but significantly, higher in T2DM than in non-diabetic patients (36.46[95% CI 34.41-38.51] vs. 32.57[95% CI 31.40-33.74] cases per 100,000/inhabitants). T2DM people were older and had higher Charlson comorbidity index than non-diabetic people. T2DM patients had a lower mean number of failing organs than non-diabetic patients (1.20 SD 1.17 vs. 1.45 SD 1.44, p<0.001). Pseudomonas was the most frequently isolated agent in both groups. IHM was 41.92% for T2DM patients and 37.91% for non-diabetic patients (p<0.05). Factors associated with a higher mortality in both groups included: older age, more comorbidities and primary diagnoses of vein or artery occlusion, pulmonary disease and cancer. T2DM was not associated with a higher in-hospital mortality after adjustment using a propensity score (OR 0.88; 95% CI 0.76-1.35). VAP incidence rates were higher among T2DM patients. In-hospital mortality was higher among the older patients and those with more co-morbid conditions. T2DM does not predict higher mortality in VAP during hospitalization. Copyright © 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients.

PubMed

Philippart, François; Gaudry, Stéphane; Quinquis, Laurent; Lau, Nicolas; Ouanes, Islem; Touati, Samia; Nguyen, Jean Claude; Branger, Catherine; Faibis, Frédéric; Mastouri, Maha; Forceville, Xavier; Abroug, Fekri; Ricard, Jean Damien; Grabar, Sophie; Misset, Benoît

2015-03-15

The occurrence of ventilator-associated pneumonia (VAP) is linked to the aspiration of contaminated pharyngeal secretions around the endotracheal tube. Tubes with cuffs made of polyurethane rather than polyvinyl chloride or with a conical rather than a cylindrical shape increase tracheal sealing. To test whether using polyurethane and/or conical cuffs reduces tracheal colonization and VAP in patients with acute respiratory failure. We conducted a multicenter, prospective, open-label, randomized study in four parallel groups in four intensive care units between 2010 and 2012. A cohort of 621 patients with expected ventilation longer than 2 days was included at intubation with a cuff composed of cylindrical polyvinyl chloride (n = 148), cylindrical polyurethane (n = 143), conical polyvinyl chloride (n = 150), or conical polyurethane (n = 162). We used Kaplan-Meier estimates and log-rank tests to compare times to events. After excluding 17 patients who secondarily refused participation or had met an exclusion criterion, 604 were included in the intention-to-treat analysis. Cumulative tracheal colonization greater than 10(3) cfu/ml at Day 2 was as follows (median [interquartile range]): cylindrical polyvinyl chloride, 0.66 (0.58-0.74); cylindrical polyurethane, 0.61 (0.53-0.70); conical polyvinyl chloride, 0.67 (0.60-0.76); and conical polyurethane, 0.62 (0.55-0.70) (P = 0.55). VAP developed in 77 patients (14.4%), and postextubational stridor developed in 28 patients (6.4%) (P = 0.20 and 0.28 between groups, respectively). Among patients requiring mechanical ventilation, polyurethane and/or conically shaped cuffs were not superior to conventional cuffs in preventing tracheal colonization and VAP. Clinical trial registered with clinicaltrials.gov (NCT01114022).

Repertoire of Intensive Care Unit Pneumonia Microbiota

PubMed Central

Bousbia, Sabri; Papazian, Laurent; Saux, Pierre; Forel, Jean Marie; Auffray, Jean-Pierre; Martin, Claude; Raoult, Didier; La Scola, Bernard

2012-01-01

Despite the considerable number of studies reported to date, the causative agents of pneumonia are not completely identified. We comprehensively applied modern and traditional laboratory diagnostic techniques to identify microbiota in patients who were admitted to or developed pneumonia in intensive care units (ICUs). During a three-year period, we tested the bronchoalveolar lavage (BAL) of patients with ventilator-associated pneumonia, community-acquired pneumonia, non-ventilator ICU pneumonia and aspiration pneumonia, and compared the results with those from patients without pneumonia (controls). Samples were tested by amplification of 16S rDNA, 18S rDNA genes followed by cloning and sequencing and by PCR to target specific pathogens. We also included culture, amoeba co-culture, detection of antibodies to selected agents and urinary antigen tests. Based on molecular testing, we identified a wide repertoire of 160 bacterial species of which 73 have not been previously reported in pneumonia. Moreover, we found 37 putative new bacterial phylotypes with a 16S rDNA gene divergence ≥98% from known phylotypes. We also identified 24 fungal species of which 6 have not been previously reported in pneumonia and 7 viruses. Patients can present up to 16 different microorganisms in a single BAL (mean ± SD; 3.77±2.93). Some pathogens considered to be typical for ICU pneumonia such as Pseudomonas aeruginosa and Streptococcus species can be detected as commonly in controls as in pneumonia patients which strikingly highlights the existence of a core pulmonary microbiota. Differences in the microbiota of different forms of pneumonia were documented. PMID:22389704

Dental hygiene intervention to prevent nosocomial pneumonias.

PubMed

Barnes, Caren M

2014-06-01

Nosocomial and ventilator associated pneumonias that plague critically ill, elderly and long-term care residents could be reduced with effective oral hygiene practices facilitated collaboratively between nurses and dental hygienists. Nosocomial pneumonias, specifically aspiration pneumonias and ventilator-associated pneumonias in the elderly and infirm have become a major health care issue, The provision of oral care in hospital and hospital-like facilities presents challenges that can prevent patients from receiving optimal oral care One sequela can be aspiration pneumonia which ranks first in mortality and second in morbidity among all nosocomial infections. Since aspiration pneumonia is linked to the colonization of oral bacteria in dental plaque and biofilm, it is time to look for creative solutions to integrating the expertise of dental hygienists into health care teams in these institutional settings. A comprehensive review of the literature was conducted regarding the etiology and prevalence of health care related pneumonias. Evidence describing the challenges and barriers that the nurses, nursing staff, and dental hygienists face in the provision of oral care in hospitals and long-term care facilities is provided. Intercollaborative solutions to providing optimal oral care in hospitals and long-term care facilities are suggested. Dental hygienists have the expertise and practice experience to provide oral care in hospitals, long-term care and residential facilities. They can contribute to solving oral care challenges through intercollaboration with other health care team members. Yet, there are long-standing systemic barriers that must be addressed in order to provide this optimal care. Dental hygienists becoming better assimilated within the total health care team in hospital and residential facilities can positively impact the suffering, morbidity and mortality associated with aspiration pneumonias. Copyright © 2014 Elsevier Inc. All rights reserved.

Novel pharmacotherapy for the treatment of hospital-acquired and ventilator-associated pneumonia caused by resistant gram-negative bacteria.

PubMed

Kidd, James M; Kuti, Joseph L; Nicolau, David P

2018-03-01

Hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) are among the most prevalent infections in hospitalized patients, particularly those in the intensive care unit. Importantly, the frequency of multidrug resistant (MDR) Gram-negative (GN) bacteria as the bacteriologic cause of HABP/VABP is increasing. These include MDR Pseudomonas aeruginosa, Acinetobacter baumannii, and carbapenem resistant Enterobacteriaceae (CRE). Few antibiotics are currently available when such MDR Gram-negatives are encountered and older agents such as polymyxin B, colistin (polymyxin E), and tigecycline have typically performed poorly in HABP/VABP. Areas covered: In this review, the authors summarize novel antibiotics which have reached phase 3 clinical trials including patients with HABP/VABP. For each agent, the spectrum of activity, pertinent pharmacological characteristics, clinical trial data, and potential utility in the treatment of MDR-GN HABP/VABP is discussed. Expert opinion: Novel antibiotics currently available, and those soon to be, will expand opportunities to treat HABP/VABP caused by MDR-GN organisms and minimize the use of more toxic, less effective drugs. However, with sparse clinical data available, defining the appropriate role for each of the new agents is challenging. In order to maximize the utility of these antibiotics, combination therapy and the role of therapeutic drug monitoring should be investigated.

Randomized controlled trial of toothbrushing to reduce ventilator-associated pneumonia pathogens and dental plaque in a critical care unit.

PubMed

Needleman, Ian G; Hirsch, Nicholas P; Leemans, Michele; Moles, David R; Wilson, Michael; Ready, Derren R; Ismail, Salim; Ciric, Lena; Shaw, Michael J; Smith, Martin; Garner, Anne; Wilson, Sally

2011-03-01

To investigate the effect of a powered toothbrush on colonization of dental plaque by ventilator-associated pneumonia (VAP)-associated organisms and dental plaque removal. Parallel-arm, single-centre, examiner- and analyst-masked randomized controlled trial. Forty-six adults were recruited within 48 h of admission. Test intervention: powered toothbrush, control intervention: sponge toothette, both used four times per day for 2 min. Groups received 20 ml, 0.2% chlorhexidine mouthwash at each time point. The results showed a low prevalence of respiratory pathogens throughout with no statistically significant differences between groups. A highly statistically significantly greater reduction in dental plaque was produced by the powered toothbrush compared with the control treatment; mean plaque index at day 5, powered toothbrush 0.75 [95% confidence interval (CI) 0.53, 1.00], sponge toothette 1.35 (95% CI 0.95, 1.74), p=0.006. Total bacterial viable count was also highly statistically significantly lower in the test group at day 5; Log(10) mean total bacterial counts: powered toothbrush 5.12 (95% CI 4.60, 5.63), sponge toothette 6.61 (95% CI 5.93, 7.28), p=0.002. Powered toothbrushes are highly effective for plaque removal in intubated patients in a critical unit and should be tested for their potential to reduce VAP incidence and health complications. © 2011 John Wiley & Sons A/S.

Viruses are prevalent in non-ventilated hospital-acquired pneumonia.

PubMed

Shorr, Andrew F; Zilberberg, Marya D; Micek, Scott T; Kollef, Marin H

2017-01-01

Hospital-acquired pneumonia arising in non-ventilated patients (NVHAP) is traditionally thought to be caused by bacteria, and little is known about viral etiologies in this syndrome. We sought to describe the prevalence of viruses causing NVHAP and to determine factors independently associated with the isolation of a virus. We identified patients with NVHAP over one year and reviewed their cultures to determine etiologies. Patients with a viral process were compared to those with either negative cultures or a bacterial infection to determine variables independently associated with the recovery of a virus. Among 174 cases, cultures were positive in 46.0%, with viruses identified in 22.4%. Bacterial pathogens arose 23.6% of subjects. The most common viruses included rhinovirus, influenza, and parainfluenza. We noted no seasonality in the isolation of viral organisms, and most cases of viral NVHAP developed after more than a week length of stay (LOS). Outcomes in viral NVHAP were similar to those with bacterial NVHAP. Patients with viral and bacterial NVHAP were generally similar. Two variables were independently associated with isolation of a virus: a history of coronary artery disease (adjusted odds ratio: 5.16, 95% CI: 1.14-22.44) and a LOS of greater than 10 days prior to NVHAP diagnosis (adjusted odds ratio: 2.97, 95% CI: 1.35-6.51). As a screening test for a virus, neither had a good sensitivity or specificity. Viruses represent a common cause of NVHAP. Clinicians should consider viral diagnostic testing in NVHAP, as this may represent a means to enhance antimicrobial stewardship. Copyright © 2016 Elsevier Ltd. All rights reserved.

Nosocomial pneumonia in the ICU: a prospective cohort study.

PubMed

Hyllienmark, Petra; Gårdlund, Bengt; Persson, Jan-Olov; Ekdahl, Karl

2007-01-01

Ventilator-associated pneumonia (VAP) is the most common intensive care unit (ICU)-acquired infection among patients requiring mechanical ventilation. A prospective surveillance programme of all patients has been implemented at the ICU, Karolinska University Hospital, Sweden since 2001. Within this programme, incidence and risk factors for ICU-acquired pneumonia and associated death over a 2-y period have been studied. Of 329 patients enrolled in the study, 221 required mechanical ventilation. 33 of 221 patients (15%) developed VAP, corresponding to a rate of 29 VAP/1000 ventilator d. Risk factors for VAP were aspiration (hazard ratio 3.79; 95% CI 1.48-9.68), recent surgery (HR 3.58; 95% CI 1.15-11.10) and trauma (HR 3.00; 95% CI 1.03-8.71). 11 patients of 33 (33%) with VAP died within 28 d compared to 46 of 288 (16%) without ICU-acquired pneumonia (odds ratio 2.73; 95% CI 0.97-7.63). We conclude that: 1) incidence of VAP was 15% and the most important risk factor was aspiration; 2) APACHE II score > or = 20 is a stronger predictor for poor outcome than VAP; 3) a minority of patients with APACHE II score > or = 20 develop VAP; and 4) continuous surveillance programmes are feasible and provide valuable data for improvement of quality of care.

The Challenging Diagnosis of Non-Community-Acquired Pneumonia in Non-Mechanically Ventilated Subjects: Value of Microbiological Investigation.

PubMed

Messika, Jonathan; Stoclin, Annabelle; Bouvard, Eric; Fulgencio, Jean-Pierre; Ridel, Christophe; Muresan, Ioan-Paul; Boffa, Jean-Jacques; Bachmeyer, Claude; Denis, Michel; Gounant, Valérie; Esteso, Adoracion; Loi, Valeria; Verdet, Charlotte; Prigent, Hélène; Parrot, Antoine; Fartoukh, Muriel

2016-02-01

Early recognition and an attempt at obtaining microbiological documentation are recommended in patients with non-community-acquired pneumonia (NCAP), whether hospital-acquired (HAP) or health care-associated (HCAP). We aimed to characterize the clinical features and microbial etiologies of NCAP to assess the impact of microbiological investigation on their management. This was a prospective 1-y study in a university hospital with 141 non-mechanically ventilated subjects suspected of having HAP (n = 110) or HCAP (n = 31). Clinical criteria alone poorly identified pneumonia (misdiagnosis in 50% of cases). Microbiological confirmation was achievable in 80 subjects (57%). Among 79 microorganisms isolated, 28 were multidrug-resistant aerobic Gram-negative bacilli and group III Enterobacteriaceae and 6 were methicillin-resistant Staphylococcus aureus. Multidrug-resistant aerobic Gram-negative bacilli accounted for one third of the microorganisms in early-onset HAP and for 50% in late-onset HAP. Methicillin-resistant S. aureus was most often recovered from subjects with HCAP. Inappropriate empirical antibiotics were administered to 36% of subjects with confirmed pneumonia. Forty subjects were admitted to the ICU, 13 (33%) of whom died. Overall, 39 subjects (28%) died in the hospital. Integrating the microbiological investigation in the complex clinical diagnostic workup of patients suspected of having NCAP is mandatory. Respiratory tract specimens should be obtained whenever possible for appropriate management. Copyright © 2016 by Daedalus Enterprises.

A Randomized Trial of the Amikacin Fosfomycin Inhalation System for the Adjunctive Therapy of Gram-Negative Ventilator-Associated Pneumonia: IASIS Trial.

PubMed

Kollef, Marin H; Ricard, Jean-Damien; Roux, Damien; Francois, Bruno; Ischaki, Eleni; Rozgonyi, Zsolt; Boulain, Thierry; Ivanyi, Zsolt; János, Gál; Garot, Denis; Koura, Firas; Zakynthinos, Epaminondas; Dimopoulos, George; Torres, Antonio; Danker, Wayne; Montgomery, A Bruce

2017-06-01

Clinical failures in ventilator-associated pneumonia (VAP) caused by gram-negative bacteria are common and associated with substantial morbidity, mortality, and resource utilization. We assessed the safety and efficacy of the amikacin fosfomycin inhalation system (AFIS) for the treatment of gram-negative bacterial VAP in a randomized double-blind, placebo-controlled, parallel group, phase 2 study between May 2013 and March 2016. We compared standard of care in each arm plus 300 mg amikacin/120 mg fosfomycin or placebo (saline), delivered by aerosol twice daily for 10 days (or to extubation if < 10 days) via the investigational eFlow Inline System (PARI GmbH). The primary efficacy end point was change from baseline in the Clinical Pulmonary Infection Score (CPIS) during the randomized course of AFIS/placebo, using the subset of patients with microbiologically proven baseline infections with gram-negative bacteria. There were 143 patients randomized: 71 to the AFIS group, and 72 to the placebo group. Comparison of CPIS change from baseline between treatment groups was not different (P = .70). The secondary hierarchical end point of no mortality and clinical cure at day 14 or earlier was also not significant (P = .68) nor was the hierarchical end point of no mortality and ventilator-free days (P = .06). The number of deaths in the AFIS group was 17 (24%) and 12 (17%) in the placebo group (P = .32). The AFIS group had significantly fewer positive tracheal cultures on days 3 and 7 than placebo. In this trial of adjunctive aerosol therapy compared with standard of care IV antibiotics in patients with gram-negative VAP, the AFIS was ineffective in improving clinical outcomes despite reducing bacterial burden. ClinicalTrials.gov; No.: NCT01969799; URL: www.clinicaltrials.gov. Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

The IRIDICA PCR/Electrospray Ionization-Mass Spectrometry Assay on Bronchoalveolar Lavage for Bacterial Etiology in Mechanically Ventilated Patients with Suspected Pneumonia.

PubMed

Strålin, Kristoffer; Ehn, Fredrik; Giske, Christian G; Ullberg, Måns; Hedlund, Jonas; Petersson, Johan; Spindler, Carl; Özenci, Volkan

2016-01-01

We studied the diagnostic performance of the IRIDICA PCR/electrospray ionization-mass spectrometry (PCR/ESI-MS) assay applied on bronchoalveolar lavage (BAL) samples, from 51 mechanically ventilated patients with suspected pneumonia, in a prospective study. In 32 patients with X-ray verified pneumonia, PCR/ESI-MS was positive in 66% and BAL culture was positive in 38% (p = 0.045), and either of the methods was positive in 69%. The following BAL result combinations were noted: PCR/ESI-MS+/culture+, 34%; PCR/ESI-MS+/culture-, 31%; PCR/ESI-MS-/culture+, 3.1%; PCR/ESI-MS-/culture-, 31%; kappa 0.36 (95% confidence interval (CI), 0.10-0.63). In pneumonia patients without prior antibiotic treatment, optimal agreement was noted with 88% PCR/ESI-MS+/culture+ and 12% PCR/ESI-MS-/culture- (kappa 1.0). However, in patients with prior antibiotic treatment, the test agreement was poor (kappa 0.16; 95% CI, -0.10-0.44), as 10 patients were PCR/ESI-MS+/culture-. In 8/10 patients the pathogens detected by PCR/ESI-MS could be detected by other conventional tests or PCR tests on BAL. Compared with BAL culture, PCR/ESI-MS showed specificities and negative predictive values of ≥87% for all individual pathogens, an overall sensitivity of 77% and positive predictive value (PPV) of 42%. When other conventional tests and PCR tests were added to the reference standard, the overall PPV increased to 87%. The PCR/ESI-MS semi-quantitative level tended to be higher for PCR/ESI-MS positive cases with pneumonia compared with cases without pneumonia (p = 0.074). In conclusion, PCR/ESI-MS applied on BAL showed a promising performance and has potential to be clinically useful in mechanically ventilated patients with suspected pneumonia. The usefulness of the method for establishment of pneumonia etiology and selection of antibiotic therapy should be further studied.

Clinical cure and survival in Gram-positive ventilator-associated pneumonia: retrospective analysis of two double-blind studies comparing linezolid with vancomycin.

PubMed

Kollef, Marin H; Rello, Jordi; Cammarata, Sue K; Croos-Dabrera, Rodney V; Wunderink, Richard G

2004-03-01

To assess the effect of baseline variables, including treatment, on clinical cure and survival rates in patients with Gram-positive, ventilator-associated pneumonia (VAP). Retrospective analysis of two randomized, double-blind studies. Multinational study with 134 sites. 544 patients with suspected Gram-positive VAP, including 264 with documented Gram-positive VAP and 91 with methicillin-resistant S. aureus (MRSA) VAP. Linezolid 600 mg or vancomycin 1 g every 12 h for 7-21 days, each with aztreonam. Clinical cure rates assessed 12-28 days after the end of therapy and excluding indeterminate or missing outcomes significantly favored linezolid in the Gram-positive and MRSA subsets. Logistic regression showed that linezolid was an independent predictor of clinical cure with odds ratios of 1.8 for all patients, 2.4 for Gram-positive VAP, and 20.0 for MRSA VAP. Kaplan-Meier survival rates favored linezolid in the MRSA subset. Logistic regression showed that linezolid was an independent predictor of survival with odds ratios of 1.6 for all patients, 2.6 for Gram-positive VAP, and 4.6 for MRSA VAP. Initial linezolid therapy was associated with significantly better clinical cure and survival rates than was initial vancomycin therapy in patients with MRSA VAP.

Rearrangement of a large novel Pseudomonas aeruginosa gene island in strains isolated from a patient developing ventilator-associated pneumonia.

PubMed

Singh, G; Srinivasan, R; Cheng, J; Peng, Z; Fujimura, K; Baek, M S; Panzer, A R; Tringe, S G; Chen, F; Sorek, R; Weng, L; Bristow, J; Wiener-Kronish, J P; Lynch, S V

2014-07-01

Bacterial gene islands add to the genetic repertoire of opportunistic pathogens. Here, we perform comparative analyses of three Pseudomonas aeruginosa strains isolated sequentially over a 3-week period from a patient with ventilator-associated pneumonia (VAP) who received clindamycin and piperacillin-tazobactam as part of their treatment regime. While all three strains appeared to be clonal by standard pulsed-field gel electrophoresis, whole-genome sequencing revealed subtle alterations in the chromosomal organization of the last two strains; specifically, an inversion event within a novel 124-kb gene island (PAGI 12) composed of 137 open reading frames [ORFs]. Predicted ORFs in the island included metabolism and virulence genes. Overexpression of a gene island-borne putative β-lactamase gene was observed following piperacillin-tazobactam exposure and only in those strains that had undergone the inversion event, indicating altered gene regulation following genomic remodeling. Examination of a separate cohort of 76 patients with VAP for integration at this tRNA(lys) recombination site demonstrated that patients exhibiting evidence of integration at this site had significantly higher 28-day mortality. These findings provide evidence that P. aeruginosa can integrate, rapidly remodel, and express exogenous genes, which likely contributes to its fitness in a clinical setting. Copyright © 2014, American Society for Microbiology. All Rights Reserved.

Rearrangement of a Large Novel Pseudomonas aeruginosa Gene Island in Strains Isolated from a Patient Developing Ventilator-Associated Pneumonia

PubMed Central

Singh, G.; Srinivasan, R.; Cheng, J.; Peng, Z.; Fujimura, K.; Baek, M. S.; Panzer, A. R.; Tringe, S. G.; Chen, F.; Sorek, R.; Weng, L.; Bristow, J.; Wiener-Kronish, J. P.

2014-01-01

Bacterial gene islands add to the genetic repertoire of opportunistic pathogens. Here, we perform comparative analyses of three Pseudomonas aeruginosa strains isolated sequentially over a 3-week period from a patient with ventilator-associated pneumonia (VAP) who received clindamycin and piperacillin-tazobactam as part of their treatment regime. While all three strains appeared to be clonal by standard pulsed-field gel electrophoresis, whole-genome sequencing revealed subtle alterations in the chromosomal organization of the last two strains; specifically, an inversion event within a novel 124-kb gene island (PAGI 12) composed of 137 open reading frames [ORFs]. Predicted ORFs in the island included metabolism and virulence genes. Overexpression of a gene island-borne putative β-lactamase gene was observed following piperacillin-tazobactam exposure and only in those strains that had undergone the inversion event, indicating altered gene regulation following genomic remodeling. Examination of a separate cohort of 76 patients with VAP for integration at this tRNAlys recombination site demonstrated that patients exhibiting evidence of integration at this site had significantly higher 28-day mortality. These findings provide evidence that P. aeruginosa can integrate, rapidly remodel, and express exogenous genes, which likely contributes to its fitness in a clinical setting. PMID:24789195

Device-related infections in critically ill patients. Part II: Prevention of ventilator-associated pneumonia and urinary tract infections.

PubMed

Di Filippo, A; De Gaudio, A R

2003-12-01

Device utilization in critically ill patients is responsible for a high risk of complications such as catheter-related bloodstream infections (CRBSI), ventilator-associated pneumonia (VAP) and urinary tract infections (UTI). In this article we will review the current status of data regarding the prevention of VAP and UTI. The results of the more recent (5 years) randomized controlled trials are reviewed and discussed. General recommendations include staff education and use of a surveillance program with a restrictive antibiotic policy. Adequate time must be allowed for hand washing and barrier precautions must always be used during device manipulation. Specific measures for VAP prevention are: 1) use of multi-use, closed-system suction catheters; 2) no routine change of the breathing circuit; 3) lubrication of the cuff of the endotracheal tube (ET) with a water-soluble gel; 4) maintenance of patient in semi-recumbent position to improve chest physiotherapy in intubated patients. Specific measures for UTI prevention include: 1) use of a catheter-valve instead of a standard drainage system; 2) use of a silver-alloy, hydro gel-coated latex urinary catheter instead of uncoated catheters. Biofilm represents a new variable: the capacity of bacteria to organize a biofilm on a device surface can explain the difficulty in preventing and eradicating an infection in a critically ill patient. More clinical trials are needed to verify the efficacy of prevention measures of ICU infections.

[Nosocomial pneumonia].

PubMed

Díaz, Emili; Martín-Loeches, Ignacio; Vallés, Jordi

2013-12-01

The hospital acquired pneumonia (HAP) is one of the most common infections acquired among hospitalised patients. Within the HAP, the ventilator-associated pneumonia (VAP) is the most common nosocomial infection complication among patients with acute respiratory failure. The VAP and HAP are associated with increased mortality and increased hospital costs. The rise in HAP due to antibiotic-resistant bacteria also causes an increase in the incidence of inappropriate empirical antibiotic therapy, with an associated increased risk of hospital mortality. It is very important to know the most common organisms responsible for these infections in each hospital and each Intensive Care Unit, as well as their antimicrobial susceptibility patterns, in order to reduce the incidence of inappropriate antibiotic therapy and improve the prognosis of patients. Additionally, clinical strategies aimed at the prevention of HAP and VAP should be employed in hospital settings caring for patients at risk for these infections. Copyright © 2013 Elsevier España, S.L. All rights reserved.

A survey on microorganisms and their sensitivity by E-test in ventilator-associated pneumonia at Toxicological-Intensive Care Unit of Loghman-Hakim Hospital.

PubMed

Talaie, Haleh; Sabeti, Shahram; Mahdavinejad, Arezou; Barari, Behjat; Kamalbeik, Sepideh

2010-12-01

Ventilator associated pneumonia (VAP) is the most common nosocomial infection at ICUs, with high mortality and morbidity. The diagnostic method for VAP is based on the combination of clinical, radiological, and microbiological criteria. Lower respiratory tract culture results are useful to confirm the etiology of VAP and adjusted antibiotics. Endotracheal aspiration (EA) is the simplest noninvasive technique for performing lower respiratory tract culture, with high sensitivity and moderately high specificity. The aim of this survey was to evaluate the quantitative cultures of endotracheal aspirates in VAP patients and the sensitivity patterns of microorganisms through E-test. Among 582 ICU admitted patients who were under mechanical ventilation for more than 48 hours, 72 suspected patients of VAP were prospectively evaluated during a 10 month period. Evaluation of our ICU standards by APACHE III scoring, and GCS were carried out on the first day of admission in all patients. Quantitative cultures of EA were performed on all 72 patients. Antibiotic resistance pattern of isolated pathogens was defined by E-test. VAP was confirmed in 46 out of 72 cases (50, 69.4% males and 22, 30.6% females - mean age was 33 +/- 12 years) through quantitative cultures of EA samples. The probable incidence of VAP was 7.9% (per ventilated patients > or = 48 hours). The mean APACHE III score was 31.28 +/- 16. GCS in most of the patients was between 8 and 12. Staphylococcus aureus was the most frequently isolated organism (58.7%), with high sensitivity to Amikacin, Ciprofloxacin, and Teicoplanin (>92%); Pseudomonas aeruginosa was the second most frequent organism (17.4 percent); Acinetobacter isolates were potentially drug resistant, and only Amikacin was effective. Tracheal aspirates in combination with clinical findings show important roles in the management of VAP and decrease inappropriate antimicrobial therapy. S. aureus is the main agent leading to VAP in the TICU of the Loghman

Increased Nasopharyngeal Density and Concurrent Carriage of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis Are Associated with Pneumonia in Febrile Children

PubMed Central

2016-01-01

Background We assessed nasopharyngeal (NP) carriage of five pathogens in febrile children with and without acute respiratory infection (ARI) of the upper (URTI) or lower tract, attending health facilities in Tanzania. Methods NP swabs collected from children (N = 960) aged 2 months to 10 years, and with a temperature ≥38°C, were utilized to quantify bacterial density of S. pneumoniae (Sp), H. influenzae (Hi), M. catarrhalis (Mc), S. aureus (Sa), and N. meningitidis (Nm). We determined associations between presence of individual species, densities, or concurrent carriage of all species combination with respiratory diseases including clinical pneumonia, pneumonia with normal chest radiography (CXR) and endpoint pneumonia. Results Individual carriage, and NP density, of Sp, Hi, or Mc, but not Sa, or Nm, was significantly associated with febrile ARI and clinical pneumonia when compared to febrile non-ARI episodes. Density was also significantly increased in severe pneumonia when compared to mild URTI (Sp, p<0.002; Hi p<0.001; Mc, p = 0.014). Accordingly, concurrent carriage of Sp+, Hi+, and Mc+, in the absence of Sa- and Nm-, was significantly more prevalent in children with ARI (p = 0.03), or clinical pneumonia (p<0.001) than non-ARI, and in children with clinical pneumonia (p = 0.0007) than URTI. Furthermore, Sp+, Hi+, and Mc+ differentiated children with pneumonia with normal CXR, or endpoint pneumonia, from those with URTI, and non-ARI cases. Conclusions Concurrent NP carriage of Sp, Hi, and Mc was a predictor of clinical pneumonia and identified children with pneumonia with normal CXR and endpoint pneumonia from those with febrile URTI, or non-ARI episodes. PMID:27907156

Emergence of carbapenem-resistant Acinetobacter baumannii as the major cause of ventilator-associated pneumonia in intensive care unit patients at an infectious disease hospital in southern Vietnam

PubMed Central

Nhu, Nguyen Thi Khanh; Lan, Nguyen Phu Huong; Campbell, James I.; Parry, Christopher M.; Thompson, Corinne; Tuyen, Ha Thanh; Hoang, Nguyen Van Minh; Tam, Pham Thi Thanh; Le, Vien Minh; Nga, Tran Vu Thieu; Nhu, Tran Do Hoang; Van Minh, Pham; Nga, Nguyen Thi Thu; Thuy, Cao Thu; Dung, Le Thi; Yen, Nguyen Thi Thu; Van Hao, Nguyen; Loan, Huynh Thi; Yen, Lam Minh; Nghia, Ho Dang Trung; Hien, Tran Tinh; Thwaites, Louise; Thwaites, Guy; Chau, Nguyen Van Vinh

2014-01-01

Ventilator-associated pneumonia (VAP) is a serious healthcare-associated infection that affects up to 30 % of intubated and mechanically ventilated patients in intensive care units (ICUs) worldwide. The bacterial aetiology and corresponding antimicrobial susceptibility of VAP is highly variable, and can differ between countries, national provinces and even between different wards in the same hospital. We aimed to understand and document changes in the causative agents of VAP and their antimicrobial susceptibility profiles retrospectively over an 11 year period in a major infectious disease hospital in southern Vietnam. Our analysis outlined a significant shift from Pseudomonas aeruginosa to Acinetobacter spp. as the most prevalent bacteria isolated from quantitative tracheal aspirates in patients with VAP in this setting. Antimicrobial resistance was common across all bacterial species and we found a marked proportional annual increase in carbapenem-resistant Acinetobacter spp. over a 3 year period from 2008 (annual trend; odds ratio 1.656, P = 0.010). We further investigated the possible emergence of a carbapenem-resistant Acinetobacter baumannii clone by multiple-locus variable number tandem repeat analysis, finding a blaOXA-23-positive strain that was associated with an upsurge in the isolation of this pathogen. We additionally identified a single blaNDM-1-positive A. baumannii isolate. This work highlights the emergence of a carbapenem-resistant clone of A. baumannii and a worrying trend of antimicrobial resistance in the ICU of the Hospital for Tropical Diseases in Ho Chi Minh City, Vietnam. PMID:25038137

Ventilator-associated respiratory infection in a resource-restricted setting: impact and etiology.

PubMed

Phu, Vu Dinh; Nadjm, Behzad; Duy, Nguyen Hoang Anh; Co, Dao Xuan; Mai, Nguyen Thi Hoang; Trinh, Dao Tuyet; Campbell, James; Khiem, Dong Phu; Quang, Tran Ngoc; Loan, Huynh Thi; Binh, Ha Son; Dinh, Quynh-Dao; Thuy, Duong Bich; Lan, Huong Nguyen Phu; Ha, Nguyen Hong; Bonell, Ana; Larsson, Mattias; Hoan, Hoang Minh; Tuan, Đang Quoc; Hanberger, Hakan; Minh, Hoang Nguyen Van; Yen, Lam Minh; Van Hao, Nguyen; Binh, Nguyen Gia; Chau, Nguyen Van Vinh; Van Kinh, Nguyen; Thwaites, Guy E; Wertheim, Heiman F; van Doorn, H Rogier; Thwaites, C Louise

2017-01-01

Ventilator-associated respiratory infection (VARI) is a significant problem in resource-restricted intensive care units (ICUs), but differences in casemix and etiology means VARI in resource-restricted ICUs may be different from that found in resource-rich units. Data from these settings are vital to plan preventative interventions and assess their cost-effectiveness, but few are available. We conducted a prospective observational study in four Vietnamese ICUs to assess the incidence and impact of VARI. Patients ≥ 16 years old and expected to be mechanically ventilated > 48 h were enrolled in the study and followed daily for 28 days following ICU admission. Four hundred fifty eligible patients were enrolled over 24 months, and after exclusions, 374 patients' data were analyzed. A total of 92/374 cases of VARI (21.7/1000 ventilator days) were diagnosed; 37 (9.9%) of these met ventilator-associated pneumonia (VAP) criteria (8.7/1000 ventilator days). Patients with any VARI, VAP, or VARI without VAP experienced increased hospital and ICU stay, ICU cost, and antibiotic use ( p  < 0.01 for all). This was also true for all VARI ( p  < 0.01 for all) with/without tetanus. There was no increased risk of in-hospital death in patients with VARI compared to those without (VAP HR 1.58, 95% CI 0.75-3.33, p  = 0.23; VARI without VAP HR 0.40, 95% CI 0.14-1.17, p  = 0.09). In patients with positive endotracheal aspirate cultures, most VARI was caused by Gram-negative organisms; the most frequent were Acinetobacter baumannii (32/73, 43.8%) Klebsiella pneumoniae (26/73, 35.6%), and Pseudomonas aeruginosa (24/73, 32.9%). 40/68 (58.8%) patients with positive cultures for these had carbapenem-resistant isolates. Patients with carbapenem-resistant VARI had significantly greater ICU costs than patients with carbapenem-susceptible isolates (6053 USD (IQR 3806-7824) vs 3131 USD (IQR 2108-7551), p  = 0.04) and after correction for adequacy of initial antibiotics

Variation in the Diagnosis of Aspiration Pneumonia and Association with Hospital Pneumonia Outcomes.

PubMed

Lindenauer, Peter K; Strait, Kelly M; Grady, Jacqueline N; Ngo, Chi K; Parisi, Madeline L; Metersky, Mark; Ross, Joseph S; Bernheim, Susannah M; Dorsey, Karen

2018-05-01

National efforts to compare hospital outcomes for patients with pneumonia may be biased by hospital differences in diagnosis and coding of aspiration pneumonia, a condition that has traditionally been excluded from pneumonia outcome measures. To evaluate the rationale and impact of including patients with aspiration pneumonia in hospital mortality and readmission measures. Using Medicare fee-for-service claims for patients 65 years and older from July 2012 to June 2015, we characterized the proportion of hospitals' patients with pneumonia diagnosed with aspiration pneumonia, calculated hospital-specific risk-standardized rates of 30-day mortality and readmission for patients with pneumonia, analyzed the association between aspiration pneumonia coding frequency and these rates, and recalculated these rates including patients with aspiration pneumonia. A total of 1,101,892 patients from 4,263 hospitals were included in the mortality measure analysis, including 192,814 with aspiration pneumonia. The median proportion of hospitals' patients with pneumonia diagnosed with aspiration pneumonia was 13.6% (10th-90th percentile, 4.2-26%). Hospitals with a higher proportion of patients with aspiration pneumonia had lower risk-standardized mortality rates in the traditional pneumonia measure (12.0% in the lowest coding and 11.0% in the highest coding quintiles) and were far more likely to be categorized as performing better than the national mortality rate; expanding the measure to include patients with aspiration pneumonia attenuated the association between aspiration pneumonia coding rate and hospital mortality. These findings were less pronounced for hospital readmission rates. Expanding the pneumonia cohorts to include patients with a principal diagnosis of aspiration pneumonia can overcome bias related to variation in hospital coding.

The IRIDICA PCR/Electrospray Ionization–Mass Spectrometry Assay on Bronchoalveolar Lavage for Bacterial Etiology in Mechanically Ventilated Patients with Suspected Pneumonia

PubMed Central

Ehn, Fredrik; Giske, Christian G.; Ullberg, Måns; Hedlund, Jonas; Petersson, Johan; Spindler, Carl; Özenci, Volkan

2016-01-01

We studied the diagnostic performance of the IRIDICA PCR/electrospray ionization–mass spectrometry (PCR/ESI-MS) assay applied on bronchoalveolar lavage (BAL) samples, from 51 mechanically ventilated patients with suspected pneumonia, in a prospective study. In 32 patients with X-ray verified pneumonia, PCR/ESI-MS was positive in 66% and BAL culture was positive in 38% (p = 0.045), and either of the methods was positive in 69%. The following BAL result combinations were noted: PCR/ESI-MS+/culture+, 34%; PCR/ESI-MS+/culture-, 31%; PCR/ESI-MS-/culture+, 3.1%; PCR/ESI-MS-/culture-, 31%; kappa 0.36 (95% confidence interval (CI), 0.10–0.63). In pneumonia patients without prior antibiotic treatment, optimal agreement was noted with 88% PCR/ESI-MS+/culture+ and 12% PCR/ESI-MS-/culture- (kappa 1.0). However, in patients with prior antibiotic treatment, the test agreement was poor (kappa 0.16; 95% CI, -0.10–0.44), as 10 patients were PCR/ESI-MS+/culture-. In 8/10 patients the pathogens detected by PCR/ESI-MS could be detected by other conventional tests or PCR tests on BAL. Compared with BAL culture, PCR/ESI-MS showed specificities and negative predictive values of ≥87% for all individual pathogens, an overall sensitivity of 77% and positive predictive value (PPV) of 42%. When other conventional tests and PCR tests were added to the reference standard, the overall PPV increased to 87%. The PCR/ESI-MS semi-quantitative level tended to be higher for PCR/ESI-MS positive cases with pneumonia compared with cases without pneumonia (p = 0.074). In conclusion, PCR/ESI-MS applied on BAL showed a promising performance and has potential to be clinically useful in mechanically ventilated patients with suspected pneumonia. The usefulness of the method for establishment of pneumonia etiology and selection of antibiotic therapy should be further studied. PMID:27463099

Variable ventilation improves pulmonary function and reduces lung damage without increasing bacterial translocation in a rat model of experimental pneumonia.

PubMed

de Magalhães, Raquel F; Samary, Cynthia S; Santos, Raquel S; de Oliveira, Milena V; Rocha, Nazareth N; Santos, Cintia L; Kitoko, Jamil; Silva, Carlos A M; Hildebrandt, Caroline L; Goncalves-de-Albuquerque, Cassiano F; Silva, Adriana R; Faria-Neto, Hugo C; Martins, Vanessa; Capelozzi, Vera L; Huhle, Robert; Morales, Marcelo M; Olsen, Priscilla; Pelosi, Paolo; de Abreu, Marcelo Gama; Rocco, Patricia R M; Silva, Pedro L

2016-11-25

Variable ventilation has been shown to improve pulmonary function and reduce lung damage in different models of acute respiratory distress syndrome. Nevertheless, variable ventilation has not been tested during pneumonia. Theoretically, periodic increases in tidal volume (V T ) and airway pressures might worsen the impairment of alveolar barrier function usually seen in pneumonia and could increase bacterial translocation into the bloodstream. We investigated the impact of variable ventilation on lung function and histologic damage, as well as markers of lung inflammation, epithelial and endothelial cell damage, and alveolar stress, and bacterial translocation in experimental pneumonia. Thirty-two Wistar rats were randomly assigned to receive intratracheal of Pseudomonas aeruginosa (PA) or saline (SAL) (n = 16/group). After 24-h, animals were anesthetized and ventilated for 2 h with either conventional volume-controlled (VCV) or variable volume-controlled ventilation (VV), with mean V T  = 6 mL/kg, PEEP = 5cmH 2 O, and FiO 2  = 0.4. During VV, tidal volume varied randomly with a coefficient of variation of 30% and a Gaussian distribution. Additional animals assigned to receive either PA or SAL (n = 8/group) were not ventilated (NV) to serve as controls. In both SAL and PA, VV improved oxygenation and lung elastance compared to VCV. In SAL, VV decreased interleukin (IL)-6 expression compared to VCV (median [interquartile range]: 1.3 [0.3-2.3] vs. 5.3 [3.6-7.0]; p = 0.02) and increased surfactant protein-D expression compared to NV (2.5 [1.9-3.5] vs. 1.2 [0.8-1.2]; p = 0.0005). In PA, compared to VCV, VV reduced perivascular edema (2.5 [2.0-3.75] vs. 6.0 [4.5-6.0]; p < 0.0001), septum neutrophils (2.0 [1.0-4.0] vs. 5.0 [3.3-6.0]; p = 0.0008), necrotizing vasculitis (3.0 [2.0-5.5] vs. 6.0 [6.0-6.0]; p = 0.0003), and ultrastructural lung damage scores (16 [14-17] vs. 24 [14-27], p < 0.0001). Blood colony-forming-unit (CFU

Streptococcus pneumoniae-associated pneumonia complicated by purulent pericarditis: case series *

PubMed Central

Cillóniz, Catia; Rangel, Ernesto; Barlascini, Cornelius; Piroddi, Ines Maria Grazia; Torres, Antoni; Nicolini, Antonello

2015-01-01

Abstract Objective: In the antibiotic era, purulent pericarditis is a rare entity. However, there are still reports of cases of the disease, which is associated with high mortality, and most such cases are attributed to delayed diagnosis. Approximately 40-50% of all cases of purulent pericarditis are caused by Gram-positive bacteria, Streptococcus pneumoniae in particular. Methods: We report four cases of pneumococcal pneumonia complicated by pericarditis, with different clinical features and levels of severity. Results: In three of the four cases, the main complication was cardiac tamponade. Microbiological screening (urinary antigen testing and pleural fluid culture) confirmed the diagnosis of severe pneumococcal pneumonia complicated by purulent pericarditis. Conclusions: In cases of pneumococcal pneumonia complicated by pericarditis, early diagnosis is of paramount importance to avoid severe hemodynamic compromise. The complications of acute pericarditis appear early in the clinical course of the infection. The most serious complications are cardiac tamponade and its consequences. Antibiotic therapy combined with pericardiocentesis drastically reduces the mortality associated with purulent pericarditis. PMID:26398760

Diagnostic accuracy of pulmonary host inflammatory mediators in the exclusion of ventilator-acquired pneumonia

PubMed Central

Hellyer, Thomas P; Conway Morris, Andrew; McAuley, Daniel F; Walsh, Timothy S; Anderson, Niall H; Singh, Suveer; Dark, Paul; Roy, Alistair I; Baudouin, Simon V; Wright, Stephen E; Perkins, Gavin D; Kefala, Kallirroi; Jeffels, Melinda; McMullan, Ronan; O'Kane, Cecilia M; Spencer, Craig; Laha, Shondipon; Robin, Nicole; Gossain, Savita; Gould, Kate; Ruchaud-Sparagano, Marie-Hélène; Scott, Jonathan; Browne, Emma M; MacFarlane, James G; Wiscombe, Sarah; Widdrington, John D; Dimmick, Ian; Laurenson, Ian F; Nauwelaers, Frans; Simpson, A John

2015-01-01

Background Excessive use of empirical antibiotics is common in critically ill patients. Rapid biomarker-based exclusion of infection may improve antibiotic stewardship in ventilator-acquired pneumonia (VAP). However, successful validation of the usefulness of potential markers in this setting is exceptionally rare. Objectives We sought to validate the capacity for specific host inflammatory mediators to exclude pneumonia in patients with suspected VAP. Methods A prospective, multicentre, validation study of patients with suspected VAP was conducted in 12 intensive care units. VAP was confirmed following bronchoscopy by culture of a potential pathogen in bronchoalveolar lavage fluid (BALF) at >104 colony forming units per millilitre (cfu/mL). Interleukin-1 beta (IL-1β), IL-8, matrix metalloproteinase-8 (MMP-8), MMP-9 and human neutrophil elastase (HNE) were quantified in BALF. Diagnostic utility was determined for biomarkers individually and in combination. Results Paired BALF culture and biomarker results were available for 150 patients. 53 patients (35%) had VAP and 97 (65%) patients formed the non-VAP group. All biomarkers were significantly higher in the VAP group (p<0.001). The area under the receiver operator characteristic curve for IL-1β was 0.81; IL-8, 0.74; MMP-8, 0.76; MMP-9, 0.79 and HNE, 0.78. A combination of IL-1β and IL-8, at the optimal cut-point, excluded VAP with a sensitivity of 100%, a specificity of 44.3% and a post-test probability of 0% (95% CI 0% to 9.2%). Conclusions Low BALF IL-1β in combination with IL-8 confidently excludes VAP and could form a rapid biomarker-based rule-out test, with the potential to improve antibiotic stewardship. PMID:25298325

Nosocomial methicillin resistant Staphylococcus aureus pneumonia - epidemiology and trends based on data of a network of 586 German ICUs (2005-2009)

PubMed Central

2010-01-01

The epidemiology of MRSA pneumonia varies across countries. One of the most import risk factors for the development of nosocomial MRSA pneumonia is mechanical ventilation. Methicillin resistance in S. aureus ventilator associated pneumonia (VAP) ranged between 37% in German, 54% in the US American and 78% in Asian and Latin American ICUs. In 2009, the incidence density of nosocomial VAP caused by MRSA was 0.28 per 1000 ventilation days in a network of 586 German ICUs. Incidences peaked in neurological and neurosurgical ICUs. Crude hospital mortality in studies performed after 2005 lay between 27% and 59% and attributable MRSA pneumonia mortality at 40%. Since 2005, US American and German data indicate decreasing trends for MRSA pneumonia. Measures to reduce MRSA pneumonia or to control the spread of MRSA include hand hygiene, standard and contact precautions, oral contamination with chlor hexidine, skin decontamination with antiseptics, screening, and (possibly) patient isolation in a single room. PMID:21163726

[Using TRM to Enhance the Accuracy of Ventilator-Associated Pneumonia Preventive Measures Implemented by Neonatal Intensive Care Unit Medical Staffs].

PubMed

Huang, Yu-Ting; Huang, Chao-Ya; Su, Hsiu-Ya; Ma, Chen-Te

2018-06-01

Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection in the neonatal intensive care unit (NICU). The average VAP infection density was 4.7‰ in our unit between June and August 2015. The results of a status survey indicated that in-service education lacked specialization, leading to inadequate awareness among staffs regarding the proper care of newborns with VAP and a lack of related care guides. This, in turn, resulted in inconsistencies in care measures for newborns with VAP. To improve the accuracy of implementation of preventive measures for VAP among medical staffs and reduce the density of VAP infections in the NICU. Conduct a literature search and adopt medical team resources management methods; establish effective team communication; establish monitoring mechanisms and incentives; establish mandatory in-service specialization education contents and a VAP preventive care guide exclusively for newborns as a reference for medical staffs during care execution; install additional equipment and aids and set reminders to ensure the implementation of VAP preventive measures. The accuracy rate of preventive measure execution by medical staffs improved from 70.1% to 97.9% and the VAP infection density in the NICU decreased from 4.7‰ to 0.52‰. Team integration effectively improved the accuracy of implementation of VAP-prevention measures, reduced the density of VAP infections, enhanced quality of care, and ensured that newborns received care that was more in line with specialization needs.

Surveillance versus clinical adjudication: differences persist with new ventilator-associated event definition.

PubMed

McMullen, Kathleen M; Boyer, Anthony F; Schoenberg, Noah; Babcock, Hilary M; Micek, Scott T; Kollef, Marin H

2015-06-01

The National Healthcare Safety Network (NHSN) has recently supported efforts to shift surveillance away from ventilator-associated pneumonia to ventilator-associated events (VAEs) to decrease subjectivity in surveillance and minimize concerns over clinical correlation. The goals of this study were to compare the results of an automated surveillance strategy using the new VAE definition with a prospectively performed clinical application of the definition. All patients ventilated for ≥2 days in a medical and surgical intensive care unit were evaluated by 2 methods: retrospective surveillance using an automated algorithm combined with manual chart review after the NHSN's VAE methodology and prospective surveillance by pulmonary physicians in collaboration with the clinical team administering care to the patient at the bedside. Overall, a similar number of events were called by each method (69 vs 67). Of the 1,209 patients, 56 were determined to have VAEs by both methods (κ = .81, P = .04). There were 24 patients considered to be a VAE by only 1 of the methods. Most discrepancies were the result of clinical disagreement with the NHSN's VAE methodology. There was good agreement between the study teams. Awareness of the limitations of the surveillance definition for VAE can help infection prevention personnel in discussions with critical care partners about optimal use of these data. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Hydrocarbon pneumonia

MedlinePlus

... pneumonia is caused by drinking or breathing in gasoline , kerosene , furniture polish , paint thinner, or other oily ... Arterial blood gas monitoring Breathing support, including oxygen, inhalation treatment, breathing tube and ventilator (machine), in severe ...

Congestive heart failure in children with pneumonia and respiratory failure.

PubMed

Nimdet, Kachaporn; Techakehakij, Win

2017-03-01

Congestive heart failure (CHF) is one of the most common cardiac complications of pneumonia in adulthood leading to increased risk of morbidity and mortality. Little is known, however, of CHF and pneumonia in children. The aim of this study was therefore to investigate the characteristics and factors associated with CHF in under-5 children with pneumonia and respiratory failure. A retrospective cohort was conducted in hospitalized patients aged 2-59 months with community-acquired pneumonia and respiratory failure from June 2011 to June 2014 at Suratthani Hospital, Thailand. The characteristics, therapeutic strategy, and clinical outcomes of CHF were reviewed. Baseline characteristics and basic laboratory investigations on admission were compared between the CHF and non-CHF groups. Of 135 patients, 14 (10%) had CHF. Compared with patients without CHF, the CHF group had prolonged intubation and hospital stay and high rates of associated complications such as ventilator-associated pneumonia, sepsis, shock, and 30 day mortality. CHF was significantly associated with certain characteristics, including male sex and bacterial pneumonia. Pneumonia with respiratory failure is associated with CHF even in healthy children without cardiac risks. The awareness and early recognition of CHF, particularly in male, and bacterial pneumonia, is important in order to provide immediate treatment to reduce complications. © 2016 Japan Pediatric Society.

Effect of nebulized eucalyptus on contamination of microbial plaque of endotracheal tube in ventilated patients

PubMed Central

Amini, Nazanin; Rezaei, Korosh; Yazdannik, Ahmadreza

2016-01-01

Background: Formation of biofilm and bacterial colonization within the endotracheal tube (ETT) are significant sources of airway contamination and play a role in the development of ventilator-associated pneumonia (VAP). This study was conducted to examine the effect of nebulized eucalyptus (NE) on bacterial colonization of ETT biofilm. Materials and Methods: We performed a randomized clinical trial in three intensive care units (ICUs) of an educational hospital. Seventy intubated patients were selected and randomly divided into intervention (n = 35) and control (n = 35) groups. The intervention group received 4 ml (5%) of eucalyptus in 6 ml normal saline every 8 h. The placebo group received only 10 ml of normal saline in the same way. On extubation, the interior of the tube was immediately sampled using a sterile swab for standard microbiological analysis. Chi-square and Fisher's exact tests were used for statistical analysis in SPSS. P values less than 0.05 were considered statistically significant. Results: In both samples, Klebsiella pneumoniae and Acinetobacter baumannii were the most frequently isolated bacteria. In the control group, heavy colonization was greater than in the intervention group (P = 0.002). The frequency of isolation of K. pneumoniae in the intervention group was lower than in the control group (P < 0.001). However, there was no difference between the two groups in other isolated bacteria. Conclusions: NE can reduce microbial contamination of the endotracheal tube biofilm in ventilated patients. Moreover, K. pneumoniae was the most sensitive to NE. PMID:27095990

Coal Use, Stove Improvement, and Adult Pneumonia Mortality in Xuanwei, China: A Retrospective Cohort Study

PubMed Central

Shen, Min; Chapman, Robert S.; Vermeulen, Roel; Tian, Linwei; Zheng, Tongzhang; Chen, Bingshu E.; Engels, Eric A.; He, Xingzhou; Blair, Aaron; Lan, Qing

2009-01-01

Background In Xuanwei County, China, unvented indoor coal burning is strongly associated with increased risk of lung cancer and chronic obstructive pulmonary disease. However, the impact of coal burning and stove improvement on risk of pneumonia is not clear. Methods We conducted a retrospective cohort study among all farmers born 1917 through 1951 and living in Xuanwei as of 1 January 1976. The analysis included a total of 42,422 cohort members. Follow-up identified all deaths in the cohort from 1976 through 1996. Ages at entry into and at exit from follow-up ranged from 24 to 59 years and from 25 to 80 years, respectively. The record search detected 225 deaths from pneumonia, and 32,332 (76%) were alive as of 31 December 1996. We constructed multivariable Cox models (time variable = age) to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Results Use of coal, especially smokeless coal, was positively associated with pneumonia mortality. Annual tonnage and lifetime duration of smoky and smokeless coal use were positively associated with pneumonia mortality. Stove improvement was associated with a 50% reduction in pneumonia deaths (smoky coal users: HR, 0.521; 95% CI, 0.340–0.798; smokeless coal users: HR, 0.449; 95% CI, 0.215–0.937). Conclusions Our analysis is the first to suggest that indoor air pollution from unvented coal burning is an important risk factor for pneumonia death in adults and that improving ventilation by installing a chimney is an effective measure to decrease it. PMID:19270797

Oral decontamination is cost-saving in the prevention of ventilator-associated pneumonia in intensive care units.

PubMed

van Nieuwenhoven, Christianne A; Buskens, Erik; Bergmans, Dennis C; van Tiel, Frank H; Ramsay, Graham; Bonten, Marc J M

2004-01-01

Although the development of ventilator-associated pneumonia (VAP) is assumed to increase costs of intensive care unit stay, it is unknown whether prevention of VAP by means of oropharyngeal decontamination is cost-effective. Because of wide ranges of individual patient costs, crude cost comparisons did not show significant cost reductions. Based on actual cost data of 181 individual patients included in a former randomized clinical trial, cost-effectiveness of prevention of VAP was determined using a decision model and univariate sensitivity analyses, and bootstrapping was used to assess the impact of variability in the various outcomes. Published data on prevention of VAP by oropharyngeal decontamination, which resulted in a relative risk for VAP of 0.45, with a baseline rate of VAP of 29% among control patients. The mean costs of the intervention were 351 dollars per patient (32 dollars per patient per day). All other costs were derived from the hospital administrative database for all individual patients. Prevention of VAP led to mean total costs of 16,119 dollars and 18,268 dollars for patients without preventive measures administered. Thus, costs were saved and instances of VAP were prevented. Similar results were observed in terms of overall survival. Prevention of VAP remains cost-saving if the relative risk for VAP because of intervention is <0.923, the costs of the intervention are less than 2,500 dollars, and the prevalence of VAP without intervention is >4%. Bootstrapping confirmed that, with about 80% certainty, oropharyngeal decontamination results in prevention of VAP and simultaneously saves costs. In terms of a survival benefit, the results are less evident; the results indicate that with only about 60% certainty can we confirm that oropharyngeal decontamination would result in a survival benefit and simultaneously save costs. This study provides strong evidence that prevention of VAP by means of oropharyngeal decontamination is cost-effective.

Nebulized antibiotics in mechanically ventilated patients: roadmap and challenges.

PubMed

Poulakou, G; Siakallis, G; Tsiodras, S; Arfaras-Melainis, A; Dimopoulos, G

2017-03-01

Nebulized antibiotics use has become common practice in the therapeutics of pneumonia in cystic fibrosis patients. There is an increasing interest in their use for respiratory infections in mechanically ventilated (MV) patients in order to a) overcome pharmacokinetic issues in the lung compartment with traditional systemic antibiotic use and b) prevent the emergence of multi-drug-resistant (MDR) pathogens. Areas covered: The beneficial effects of antibiotic nebulization in MV patients e.g. increasing efficacy, reduced toxicity and prevention of resistance are described. Physicochemical parameters of optimal lung deposition, characteristics of currently available nebulizers, practical aspects of the procedure, including drug preparation and adjustments of ventilator and circuit parameter are presented. Antibiotics used in nebulized route, along with efficacy in various clinical indications and safety issues are reviewed. Expert commentary: The safety of nebulization of antibiotics has been proven in numerous studies; efficacy as adjunctive treatment to intravenous regimens or as monotherapy has been demonstrated in ventilator-associated pneumonia or ventilator-associated tracheobronchitis due to MDR or susceptible pathogens. However, due to the heterogeneity of studies, multiple meta-analyses fail to demonstrate a clear effect. Clarification of indications, standardization of technique and implementation of clinical practice guidelines, based on new large-scale trials will lead to the optimal use of nebulized antibiotics.

Pneumonia in the surgical intensive care unit: is every one preventable?

PubMed

Wahl, Wendy L; Zalewski, Christy; Hemmila, Mark R

2011-10-01

Pneumonia is a major complication for hospitalized patients and has come under the scrutiny of health care regulating bodies, which propose that hospital-acquired pneumonia should not be reimbursed and potentially be a "never event." We hypothesized that many of our acutely injured patients develop pneumonia at the time of their initial traumatic event despite aggressive measures to prevent pneumonia during hospitalization. This retrospective review included all mechanically ventilated patients admitted to a mixed surgical intensive care units (ICU; trauma, general surgery, and burns) who developed pneumonia from 2006 to 2008. All pneumonia diagnosed by culture were obtained from bronchoalveolar lavage (BAL) specimens with ≥ 10(4) colony forming united (CFU)/mL considered a positive result. Criteria for ventilator-associated pneumonia (VAP) applied only to those patients ventilated mechanically for >48 hours at the time of a positive BAL culture. Aspiration organisms included Streptococcus species, methicillin-sensitive Staphylococcus aureus, Haemophilus influenzae, and oral flora. This was an institutional review board-approved study. There were 208 mechanically ventilated who patients underwent BAL, half of which were performed in the first 48 hours after admission for fever, infiltrate on chest radiograph, or increasing white blood cell count (early BAL group). Of these patients, 58% had positive BAL cultures (pneumonia) but did not have VAP. Only 10% of patients studied with early BAL had no growth on culture. Although the predominant organisms in the early BAL group were aspiration-type organisms, 17% had resistant pathogens, and 16% had other Gram-negative rods (GNR). This percentage was compared with the VAP group in whom 33% of patients had resistant organisms (P = .04) and 8% other GNR (P = NS). Twenty-five patients with ≤ 10(4) CFU/mL on early BAL underwent repeat BAL, and 16 (64%) were later diagnosed with VAP. Many intubated patients in the surgical

Comparison of the clinical efficacy between tigecycline plus extended-infusion imipenem and sulbactam plus imipenem against ventilator-associated pneumonia with pneumonic extensively drug-resistant Acinetobacter baumannii bacteremia, and correlation of clinical efficacy with in vitro synergy tests.

PubMed

Jean, Shio-Shin; Hsieh, Tai-Chin; Hsu, Chin-Wan; Lee, Wen-Sen; Bai, Kuan-Jen; Lam, Carlos

2016-12-01

To compare the clinical efficacy between salvage antimicrobial regimen consisting of tigecycline plus extended-infusion imipenem/cilastatin (TIC) and regimen of sulbactam plus imipenem/cilastatin (SIC) for patients with ventilator-associated pneumonia and pneumonic bacteremia due to extensively drug-resistant (XDR) Acinetobacter baumannii (Ab) isolates, and determine the correlation of results of in vitro tigecycline-imipenem synergy test with clinical efficacy. The comparative survey was conducted at a medical center in Taiwan in 2013. Patients comprising the TIC group (n = 28) received tigecycline plus extended-infusion imipenem/cilastatin following unresponsiveness to 3-day sulbactam-imipenem/cilastatin therapy, and those in the SIC group (n = 56) received sulbactam-imipenem/cilastatin throughout the course. Univariate and multivariate analyses were applied to explore 30-day case-fatality independent predictors. Additionally, the checkerboard test and time-kill analysis were performed for the bloodstream XDR-Ab isolates from patients in the TIC group, and molecular characterization was done for the bloodstream XDR-Ab strains of all patients. We found that the TIC scheme has a significant benefit on improving patients' survival status (the mortality rate of TIC and SIC group patients was 14.3% and 64.3%, respectively), corresponding well with in vitro synergy or additivity results by the checkerboard test. Twenty TIC group cases had monomicrobial XDR-Ab cultured from tracheal aspirates after 10 days of tigecycline-imipenem/cilastatin therapy, but none developed subsequent pneumonia. However, breakthrough primary Burkholderia cepacia (n = 3) and Pseudomonas aeruginosa (n = 1) bacteremias were attributed to four TIC case fatalities. Shock, SIC regimen usage, and development of breakthrough bacteremia were independent predictors of 30-day in-hospital mortality. Although the TIC regimen showed good efficacy, its value regarding managing XDR-Ab ventilator-associated

Impact of imipenem and amikacin pharmacokinetic/pharmacodynamic parameters on microbiological outcome of Gram-negative bacilli ventilator-associated pneumonia.

PubMed

Pajot, O; Burdet, C; Couffignal, C; Massias, L; Armand-Lefevre, L; Foucrier, A; Da Silva, D; Lasocki, S; Laouénan, C; Mentec, H; Mentré, F; Wolff, M

2015-05-01

Despite recent advances, antibiotic therapy of ventilator-associated pneumonia (VAP) in ICU patients is still challenging. We assessed the impact of imipenem and amikacin pharmacokinetic and pharmacodynamic parameters on microbiological outcome in these patients. Patients with Gram-negative bacilli (GNB) VAP were prospectively included. Blood samples for pharmacokinetic analysis were collected after empirical administration of a combination of imipenem three times daily and one single dose of amikacin. MICs were estimated for each GNB obtained from respiratory samples. Microbiological success was defined as a ≥10(3) cfu/mL decrease in bacterial count in quantitative cultures between baseline and the third day of treatment. Thirty-nine patients [median (min-max) age = 60 years (28-84) and median SAPS2 at inclusion = 40 (19-73)] were included. Median MICs of imipenem and amikacin were 0.25 mg/L (0.094-16) and 2 mg/L (1-32), respectively. Median times over MIC and over 5× MIC for imipenem were 100% (8-100) and 74% (3-100), respectively. The median C1/MIC ratio for amikacin was 23 (1-76); 34 patients (87%) achieved a C1/MIC ≥10. Microbiological success occurred in 29 patients (74%). No imipenem pharmacodynamic parameter was significantly associated with the microbiological success. For amikacin, C1/MIC was significantly higher in the microbiological success group: 26 (1-76) versus 11 (3-26) (P = 0.004). In ICU patients with VAP, classic imipenem pharmacodynamic targets are easily reached with usual dosing regimens. In this context, for amikacin, a higher C1/MIC ratio than previously described might be necessary. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Comparison of invasive and noninvasive positive pressure ventilation delivered by means of a helmet for weaning of patients from mechanical ventilation.

PubMed

Carron, Michele; Rossi, Sandra; Carollo, Cristiana; Ori, Carlo

2014-08-01

The effectiveness of noninvasive positive pressure ventilation delivered by helmet (H-NPPV) as a weaning approach in patients with acute respiratory failure is unclear. We randomly and evenly assigned 64 patients intubated for acute respiratory failure to conventional weaning with invasive mechanical ventilation (IMV) or H-NPPV. The primary end point was a reduction in IMV duration by 6 days between the 2 groups. Secondary end points were the occurrence of ventilator-associated pneumonia and major complications, duration of mechanical ventilation and weaning, intensive care unit and hospital length of stay, and survival. The mean duration of IMV was significantly reduced in the H-NPPV group compared with the IMV group (P<.0001), without significant difference in duration of weaning (P=.26) and total ventilatory support (P=.45). In the H-NPPV group, the incidence of major complications was less than the IMV group (P=.032). Compared with the H-NPPV group, the IMV group was associated with a greater incidence of VAP (P=.018) and an increased risk of nosocomial pneumonia (P=.049). The mortality rate was similar between the groups, with no significant difference in overall intensive care unit (P=.47) or hospital length of stay (P=.37). H-NPPV was well tolerated and effective in patients who were difficult to wean. Copyright © 2014 Elsevier Inc. All rights reserved.

Candida Pneumonia in Intensive Care Unit?

PubMed Central

Schnabel, Ronny M.; Linssen, Catharina F.; Guion, Nele; van Mook, Walther N.; Bergmans, Dennis C.

2014-01-01

It has been questioned if Candida pneumonia exists as a clinical entity. Only histopathology can establish the definite diagnosis. Less invasive diagnostic strategies lack specificity and have been insufficiently validated. Scarcity of this pathomechanism and nonspecific clinical presentation make validation and the development of a clinical algorithm difficult. In the present study, we analyze whether Candida pneumonia exists in our critical care population. We used a bronchoalveolar lavage (BAL) specimen database that we have built in a structural diagnostic approach to ventilator-associated pneumonia for more than a decade consisting of 832 samples. Microbiological data were linked to clinical information and available autopsy data. We searched for critically ill patients with respiratory failure with no other microbiological or clinical explanation than exclusive presence of Candida species in BAL fluid. Five cases could be identified with Candida as the likely cause of pneumonia. PMID:25734099

Microfloral diversity in the lower respiratory tracts of neonates with bacterial infectious pneumonia combined with ventilator‑associated pneumonia.

PubMed

Lu, Wei; Yu, Jia-Lin; Li, Lu-Quan; Lu, Qi; Wang, Zheng-Li; Pan, Yun

2016-12-01

Bacterial infectious pneumonia is one of the major causes of mortality in neonates, particularly when the neonates suffer from ventilator‑associated pneumonia (VAP). However, the causes of pneumonia are difficult to define. Thus, the present study focused on understanding the diversity of microflora in the lower respiratory tract to elucidate the causes. The experimental groups comprised newborns who suffered from infectious pneumonia with or without VAP (IVAP and IP groups, respectively), whereas the control group comprised newborns who suffered from respiratory distress syndrome (RDS) without VAP (RDS group). Following 1, 3 and 5 days of ventilation, sputum samples were collected and the DNA was extracted. The DNA was amplified and separated, and the 16S rDNA was then sequenced and analyzed for diversity. The results of the diversity and Shannon‑Wiener indices were ordered as follows: IVAP group < IP group < RDS group. The percentages of Streptococcus sp., Serratia sp. and Achromobacter sp. in the IP and IVAP groups were higher, compared with those in the RDS group, whereas the percentages of Klebsiella sp. and Acinetobacter sp. were lower on day 1. The percentages of Klebsiella sp. and Streptococcus sp. on days 1 and 3 were ordered as follows: IVAP group > IP group > RDS group, and the percentages of Serratia sp., Acinetobacter sp. and Achromobacter sp. were ordered as follows: IVAP group < IP group < RDS group. After 3‑5 days, the percentages of Klebsiella sp., Acinetobacter sp., Streptococcus sp., Serratia sp. and Achromobacter sp. in the IVAP group were lower, compared with those in the RDS and IP groups. It was concluded that the decreased microfloral diversity, increased constituent ratios of Klebsiella sp. and Streptococcus sp., and decreased ratios of Serratia sp. and Acinetobacter sp. in the lower respiratory tract of neonates suffering from pneumonia may be indicators of VAP.

Outcome of ventilator-associated pneumonia due to multidrug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa treated with aerosolized colistin in neonates: a retrospective chart review.

PubMed

Celik, Istemi Han; Oguz, Serife Suna; Demirel, Gamze; Erdeve, Omer; Dilmen, Ugur

2012-02-01

Multidrug-resistant (MDR) gram-negative bacteria-related nosocomial infections and ventilator-associated pneumonia (VAP) presents an emerging challenge to clinicians. Older antimicrobial agents such as colistin have become life-saving drugs because of the susceptibility of these pathogens. We report our experience with aerosolized colistin in two preterm and one term neonate with Acinetobacter baumannii and Pseudomonas aeruginosa-related VAP who were unresponsiveness to previous antimicrobial treatment. All pathogens were isolated from tracheal aspirate. We used 5 mg/kg (base activity) aerosolized colistin methanesulfonate sodium in every 12 h as an adjunctive therapy for VAP. VAP was treated by 14, 14, and 16-day courses of aerosolized colistin in these patients, respectively. No adverse effect such as nephrotoxicity or neurotoxicity was observed. We found that aerosolized colistin was tolerable and safe, and it may be an adjunctive treatment option for MDR gram-negative bacterial VAP in neonates. Further studies are needed to determine appropriate doses for aerosolized colistin and its eligibility as an alternative treatment choice in newborns.

Paradoxical Acinetobacter-associated ventilator-associated pneumonia incidence rates within prevention studies using respiratory tract applications of topical polymyxin: benchmarking the evidence base.

PubMed

Hurley, J C

2018-04-10

Regimens containing topical polymyxin appear to be more effective in preventing ventilator-associated pneumonia (VAP) than other methods. To benchmark the incidence rates of Acinetobacter-associated VAP (AAVAP) within component (control and intervention) groups from concurrent controlled studies of polymyxin compared with studies of various VAP prevention methods other than polymyxin (non-polymyxin studies). An AAVAP benchmark was derived using data from 77 observational groups without any VAP prevention method under study. Data from 41 non-polymyxin studies provided additional points of reference. The benchmarking was undertaken by meta-regression using generalized estimating equation methods. Within 20 studies of topical polymyxin, the mean AAVAP was 4.6% [95% confidence interval (CI) 3.0-6.9] and 3.7% (95% CI 2.0-5.3) for control and intervention groups, respectively. In contrast, the AAVAP benchmark was 1.5% (95% CI 1.2-2.0). In the AAVAP meta-regression model, group origin from a trauma intensive care unit (+0.55; +0.16 to +0.94, P = 0.006) or membership of a polymyxin control group (+0.64; +0.21 to +1.31, P = 0.023), but not membership of a polymyxin intervention group (+0.24; -0.37 to +0.84, P = 0.45), were significant positive correlates. The mean incidence of AAVAP within the control groups of studies of topical polymyxin is more than double the benchmark, whereas the incidence rates within the groups of non-polymyxin studies and, paradoxically, polymyxin intervention groups are more similar to the benchmark. These incidence rates, which are paradoxical in the context of an apparent effect against VAP within controlled trials of topical polymyxin-based interventions, force a re-appraisal. Copyright © 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Association of C-Reactive Protein With Bacterial and Respiratory Syncytial Virus–Associated Pneumonia Among Children Aged <5 Years in the PERCH Study

PubMed Central

Le, Tham; O’Brien, Katherine L.; Murdoch, David R.; Prosperi, Christine; Baggett, Henry C.; Brooks, W. Abdullah; Feikin, Daniel R.; Hammitt, Laura L.; Howie, Stephen R. C.; Kotloff, Karen L.; Levine, Orin S.; Scott, J. Anthony G.; Thea, Donald M.; Awori, Juliet O.; Baillie, Vicky L.; Cascio, Stephanie; Chuananon, Somchai; DeLuca, Andrea N.; Driscoll, Amanda J.; Ebruke, Bernard E.; Endtz, Hubert P.; Kaewpan, Anek; Kahn, Geoff; Karani, Angela; Karron, Ruth A.; Moore, David P.; Park, Daniel E.; Rahman, Mohammed Ziaur; Salaudeen, Rasheed; Seidenberg, Phil; Somwe, Somwe Wa; Sylla, Mamadou; Tapia, Milagritos D.; Zeger, Scott L.; Deloria Knoll, Maria; Madhi, Shabir A.; O’Brien, Katherine L.; Levine, Orin S.; Knoll, Maria Deloria; Feikin, Daniel R.; DeLuca, Andrea N.; Driscoll, Amanda J.; Fancourt, Nicholas; Fu, Wei; Hammitt, Laura L.; Higdon, Melissa M.; Kagucia, E. Wangeci; Karron, Ruth A.; Li, Mengying; Park, Daniel E.; Prosperi, Christine; Wu, Zhenke; Zeger, Scott L.; Watson, Nora L.; Crawley, Jane; Murdoch, David R.; Brooks, W. Abdullah; Endtz, Hubert P.; Zaman, Khalequ; Goswami, Doli; Hossain, Lokman; Jahan, Yasmin; Ashraf, Hasan; Howie, Stephen R. C.; Ebruke, Bernard E.; Antonio, Martin; McLellan, Jessica; Machuka, Eunice; Shamsul, Arifin; Zaman, Syed M.A.; Mackenzie, Grant; Scott, J. Anthony G.; Awori, Juliet O.; Morpeth, Susan C.; Kamau, Alice; Kazungu, Sidi; Ominde, Micah Silaba; Kotloff, Karen L.; Tapia, Milagritos D.; Sow, Samba O.; Sylla, Mamadou; Tamboura, Boubou; Onwuchekwa, Uma; Kourouma, Nana; Toure, Aliou; Madhi, Shabir A.; Moore, David P.; Adrian, Peter V.; Baillie, Vicky L.; Kuwanda, Locadiah; Mudau, Azwifarwi; Groome, Michelle J.; Mahomed, Nasreen; Baggett, Henry C.; Thamthitiwat, Somsak; Maloney, Susan A.; Bunthi, Charatdao; Rhodes, Julia; Sawatwong, Pongpun; Akarasewi, Pasakorn; Thea, Donald M.; Mwananyanda, Lawrence; Chipeta, James; Seidenberg, Phil; Mwansa, James; Wa Somwe, Somwe; Kwenda, Geoffrey; Anderson, Trevor P.; Mitchell, Joanne

2017-01-01

Abstract Background. Lack of a gold standard for identifying bacterial and viral etiologies of pneumonia has limited evaluation of C-reactive protein (CRP) for identifying bacterial pneumonia. We evaluated the sensitivity and specificity of CRP for identifying bacterial vs respiratory syncytial virus (RSV) pneumonia in the Pneumonia Etiology Research for Child Health (PERCH) multicenter case-control study. Methods. We measured serum CRP levels in cases with World Health Organization–defined severe or very severe pneumonia and a subset of community controls. We evaluated the sensitivity and specificity of elevated CRP for “confirmed” bacterial pneumonia (positive blood culture or positive lung aspirate or pleural fluid culture or polymerase chain reaction [PCR]) compared to “RSV pneumonia” (nasopharyngeal/oropharyngeal or induced sputum PCR-positive without confirmed/suspected bacterial pneumonia). Receiver operating characteristic (ROC) curves were constructed to assess the performance of elevated CRP in distinguishing these cases. Results. Among 601 human immunodeficiency virus (HIV)–negative tested controls, 3% had CRP ≥40 mg/L. Among 119 HIV-negative cases with confirmed bacterial pneumonia, 77% had CRP ≥40 mg/L compared with 17% of 556 RSV pneumonia cases. The ROC analysis produced an area under the curve of 0.87, indicating very good discrimination; a cut-point of 37.1 mg/L best discriminated confirmed bacterial pneumonia (sensitivity 77%) from RSV pneumonia (specificity 82%). CRP ≥100 mg/L substantially improved specificity over CRP ≥40 mg/L, though at a loss to sensitivity. Conclusions. Elevated CRP was positively associated with confirmed bacterial pneumonia and negatively associated with RSV pneumonia in PERCH. CRP may be useful for distinguishing bacterial from RSV-associated pneumonia, although its role in discriminating against other respiratory viral-associated pneumonia needs further study. PMID:28575375

Reduced Mortality of Cytomegalovirus Pneumonia After Hematopoietic Cell Transplantation Due to Antiviral Therapy and Changes in Transplantation Practices

PubMed Central

Erard, Veronique; Guthrie, Katherine A.; Seo, Sachiko; Smith, Jeremy; Huang, MeeiLi; Chien, Jason; Flowers, Mary E. D.; Corey, Lawrence; Boeckh, Michael

2015-01-01

Background. Despite major advances in the prevention of cytomegalovirus (CMV) disease, the treatment of CMV pneumonia in recipients of hematopoietic cell transplant remains a significant challenge. Methods. We examined recipient, donor, transplant, viral, and treatment factors associated with overall and attributable mortality using Cox regression models. Results. Four hundred twenty-one cases were identified between 1986 and 2011. Overall survival at 6 months was 30% (95% confidence interval [CI], 25%–34%). Outcome improved after the year 2000 (all-cause mortality: adjusted hazard ratio [aHR], 0.7 [95% CI, .5–1.0]; P = .06; attributable mortality: aHR, 0.6 [95% CI, .4–.9]; P = .01). Factors independently associated with an increased risk of all-cause and attributable mortality included female sex, elevated bilirubin, lymphopenia, and mechanical ventilation; grade 3/4 acute graft-vs-host disease was associated with all-cause mortality only. An analysis of patients who received transplants in the current preemptive therapy era (n = 233) showed only lymphopenia and mechanical ventilation as significant risk factors for overall and attributable mortality. Antiviral treatment with ganciclovir or foscarnet was associated with improved outcome compared with no antiviral treatment. However, the addition of intravenous pooled or CMV-specific immunoglobulin to antiviral treatment did not seem to improve overall or attributable mortality. Conclusions. Outcome of CMV pneumonia showed a modest improvement over the past 25 years. However, advances seem to be due to antiviral treatment and changes in transplant practices rather than immunoglobulin-based treatments. Novel treatment strategies for CMV pneumonia are needed. PMID:25778751

Discontinuous ventilator weaning of patients with acute SCI.

PubMed

Füssenich, Wout; Hirschfeld Araujo, Sven; Kowald, Birgitt; Hosman, Allard; Auerswald, Marc; Thietje, Roland

2018-05-01

Retrospective, single centre cohort study. To determine factors associated with ventilator weaning success and failure in patients with acute spinal cord injury (SCI); determine length of time and attempts required to wean from the ventilator successfully and determine the incidence of pneumonia. BG Klinikum Hamburg, Level 1 trauma centre, SCI Department, Germany. From 2010 until 2017, 165 consecutive patients with cervical SCI, initially dependent on a ventilator, were included and weaned discontinuously via tracheal cannula. Data related to anthropometric details, neurological injury, respiratory outcomes, and weaning parameters were prospectively recorded in a database and retrospectively analysed. Seventy-nine percent of all patients were successfully weaned from ventilation. Average duration of the complete weaning process was 37 days. Ninety-one percent of the successfully weaned patients completed this on first attempt. Age (>56 years), level of injury (C4 and/or above), vital capacity (<1500 ml), obesity (>25 kg/m 2 ), and chronic obstructive pulmonary disease (COPD) significantly decreased the chance of successful weaning. These factors also correlated with a higher number of weaning attempts. High level of injury, older age, and reduced vital capacity also increased the duration of the weaning process. Patients with low vital capacity and concurrent therapy with Baclofen and Dantrolene showed higher rates of pneumonia. We conclude that mentioned factors are associated with weaning outcome and useful for clinical recommendations and patient counselling. These data further support the complexity of ventilator weaning in the SCI population due to associated complications, therefore we recommend conducting weaning of patients with SCI on intensive or intermediate care units (ICU/IMCU) in specialised centres.

Ventilator-associated pneumonia rates at major trauma centers compared with a national benchmark: a multi-institutional study of the AAST.

PubMed

Michetti, Christopher P; Fakhry, Samir M; Ferguson, Pamela L; Cook, Alan; Moore, Forrest O; Gross, Ronald

2012-05-01

Ventilator-associated pneumonia (VAP) rates reported by the National Healthcare Safety Network (NHSN) are used as a benchmark and quality measure, yet different rates are reported from many trauma centers. This multi-institutional study was undertaken to elucidate VAP rates at major trauma centers. VAP rate/1,000 ventilator days, diagnostic methods, institutional, and aggregate patient data were collected retrospectively from a convenience sample of trauma centers for 2008 and 2009 and analyzed with descriptive statistics. At 47 participating Level I and II centers, the pooled mean VAP rate was 17.2 versus 8.1 for NHSN (2006-2008). Hospitals' rates were highly variable (range, 1.8-57.6), with 72.3% being above NHSN's mean. Rates differed based on who determined the rate (trauma service, 27.5; infection control or quality or epidemiology, 11.9; or collaborative effort, 19.9) and the frequency with which VAP was excluded based on aspiration or diagnosis before hospital day 5. In 2008 and 2009, blunt trauma patients had higher VAP rates (17.3 and 17.6, respectively) than penetrating patients (11.0 and 10.9, respectively). More centers used a clinical diagnostic strategy (57%) than a bacteriologic strategy (43%). Patients with VAP had a mean Injury Severity Score of 28.7, mean Intensive Care Unit length of stay of 20.8 days, and a 12.2% mortality rate. 50.5% of VAP patients had a traumatic brain injury. VAP rates at major trauma centers are markedly higher than those reported by NHSN and vary significantly among centers. Available data are insufficient to set benchmarks, because it is questionable whether any one data set is truly representative of most trauma centers. Application of a single benchmark to all centers may be inappropriate, and reliable diagnostic and reporting standards are needed. Prospective analysis of a larger data set is warranted, with attention to injury severity, risk factors specific to trauma patients, diagnostic method used, VAP definitions

Streamlining Safety Data Collection in Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia Trials: Recommendations of the Clinical Trials Transformation Initiative Antibacterial Drug Development Project Team.

PubMed

Donnelly, Helen; Alemayehu, Demissie; Botgros, Radu; Comic-Savic, Sabrina; Eisenstein, Barry; Lorenz, Benjamin; Merchant, Kunal; Pelfrene, Eric; Reith, Christina; Santiago, Jonas; Tiernan, Rosemary; Wunderink, Richard; Tenaerts, Pamela; Knirsch, Charles

2016-08-15

Resistant bacteria are one of the leading causes of hospital-acquired/ventilator-associated bacterial pneumonia (HABP/VABP). HABP/VABP trials are complex and difficult to conduct due to the large number of medical procedures, adverse events, and concomitant medications involved. Differences in the legislative frameworks between different regions of the world may also lead to excessive data collection. The Clinical Trials Transformation Initiative (CTTI) seeks to advance antibacterial drug development (ABDD) by streamlining clinical trials to improve efficiency and feasibility while maintaining ethical rigor, patient safety, information value, and scientific validity. In 2013, CTTI engaged a multidisciplinary group of experts to discuss challenges impeding the conduct of HABP/VABP trials. Separate workstreams identified challenges associated with current data collection processes. Experts defined "data collection" as the act of capturing and reporting certain data on the case report form as opposed to recording of data as part of routine clinical care. The ABDD Project Team developed strategies for streamlining safety data collection in HABP/VABP trials using a Quality by Design approach. Current safety data collection processes in HABP/VABP trials often include extraneous information. More targeted strategies for safety data collection in HABP/VABP trials will rely on optimal protocol design and prespecification of which safety data are essential to satisfy regulatory reporting requirements. A consensus and a cultural change in clinical trial design and conduct, which involve recognition of the need for more efficient data collection, are urgently needed to advance ABDD and to improve HABP/VABP trials in particular. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

The impact of initial antibiotic treatment failure: Real-world insights in healthcare-associated or nosocomial pneumonia.

PubMed

Ryan, Kellie; Karve, Sudeep; Peeters, Pascale; Baelen, Elisa; Potter, Danielle; Rojas-Farreras, Sonia; Pascual, Esther; Rodríguez-Baño, Jesús

2018-05-06

To assess real-world treatment patterns and clinical outcomes associated with initial antibiotic therapy (IAT, antibiotics received ≤ 48 h post-initiation of antibiotic therapy), including level of IAT failure, and potential risk factors for IAT failure in healthcare-associated infections. Data were obtained from medical records of adult patients hospitalized with healthcare-associated pneumonia (HCAP) and nosocomial pneumonia (NP), including ventilator-associated pneumonia, from 1 July 2013 to 30 June 2014 in Brazil, France, Italy, Russia and Spain during the retrospective, observational study, RECOMMEND (NCT02364284; D4280R00005). Potential risk factors for IAT failure were explored using logistic regression analyses. Mean (standard deviation) age and Deyo-Charlson Comorbidity Score were 66.0 (16.2) years and 2.4 (2.4), respectively (N = 451). Most patients (62.5%) received monotherapy. Mean (standard deviation) duration of IAT was 8.8 (7.2) days. Multidrug-resistant (MDR) pathogens were identified in 52.4% of patients with ≥ 1 pathogen isolated (154/294). IAT failure was recorded in 72.5% of patients and was significantly associated with isolation of a MDR pathogen and country using multivariate analyses. Real-world data demonstrate the burden of HCAP/NP, with high rates of IAT failure. The association of IAT failure with MDR pathogens highlights the urgent need to understand and account for local prevalence of MDR pathogens when selecting IAT for the management of HCAP/NP. Copyright © 2018. Published by Elsevier Ltd.

Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization.

PubMed

Akdogan, Ozlem; Ersoy, Yasemin; Kuzucu, Ciğdem; Gedik, Ender; Togal, Turkan; Yetkin, Funda

The effectiveness of prevention bundles on the occurrence and mortality of ventilator associated pneumonia (VAP) was evaluated in many studies. However, the effectiveness of endotracheal tube with subglottic secretion drainage (ETT-SD) and cuff pressure monitorization in VAP bundles have not been adequately assessed. In this study, we aimed to evaluate the effectiveness of VAP bundle containing ETT-SD and cuff pressure monitorization. This was a prospective, controlled study that was carried out between March 2011 and April 2012 including intubated patients. The study was conducted at the Anesthesiology Intensive Care Unit 1 and 2 (10 beds each) in a 898-bed university hospital. Occurrence of VAP and compliance with the parameters of the VAP prevention bundles were assessed daily. Patients intubated with the standard endotracheal tube were recruited as controls, mainly in the first six months of the study as ETT-SD and cuff pressure monometer had not yet been implemented. In the second term, patients intubated with ETT-SD were included as cases. Occurrence of VAP, mortality, and compliance with VAP prevention bundles were monitored. A total of 133 patients, 37 cases and 96 controls were recruited. VAP incidence declined from 40.82 to 22.16 per 1000 ventilator days among controls and cases, respectively (p<005). On average, VAP occurred 17.33±21.09 days in the case group and 10.43±7.83 days in the control group (p=0.04). However, mortality of cases and controls at the 14th and 30th days was not different. VAP prevention bundles including the utilization of ETT-SD, monitoring cuff pressure, and oral care with chlorhexidine were efficient in reducing the rate of VAP. Copyright © 2017 Sociedade Brasileira de Infectologia. Published by Elsevier Editora Ltda. All rights reserved.

Particle size concentration distribution and influences on exhaled breath particles in mechanically ventilated patients.

PubMed

Wan, Gwo-Hwa; Wu, Chieh-Liang; Chen, Yi-Fang; Huang, Sheng-Hsiu; Wang, Yu-Ling; Chen, Chun-Wan

2014-01-01

Humans produce exhaled breath particles (EBPs) during various breath activities, such as normal breathing, coughing, talking, and sneezing. Airborne transmission risk exists when EBPs have attached pathogens. Until recently, few investigations had evaluated the size and concentration distributions of EBPs from mechanically ventilated patients with different ventilation mode settings. This study thus broke new ground by not only evaluating the size concentration distributions of EBPs in mechanically ventilated patients, but also investigating the relationship between EBP level and positive expiratory end airway pressure (PEEP), tidal volume, and pneumonia. This investigation recruited mechanically ventilated patients, with and without pneumonia, aged 20 years old and above, from the respiratory intensive care unit of a medical center. Concentration distributions of EBPs from mechanically ventilated patients were analyzed with an optical particle analyzer. This study finds that EBP concentrations from mechanically ventilated patients during normal breathing were in the range 0.47-2,554.04 particles/breath (0.001-4.644 particles/mL). EBP concentrations did not differ significantly between the volume control and pressure control modes of the ventilation settings in the mechanically ventilated patients. The patient EBPs were sized below 5 µm, and 80% of them ranged from 0.3 to 1.0 µm. The EBPs concentrations in patients with high PEEP (> 5 cmH₂O) clearly exceeded those in patients with low PEEP (≤ 5 cmH₂O). Additionally, a significant negative association existed between pneumonia duration and EBPs concentration. However, tidal volume was not related to EBPs concentration.

Length of stay and hospital costs associated with a pharmacodynamic-based clinical pathway for empiric antibiotic choice for ventilator-associated pneumonia.

PubMed

Nicasio, Anthony M; Eagye, Kathryn J; Kuti, Effie L; Nicolau, David P; Kuti, Joseph L

2010-05-01

To determine hospital costs associated with the use of a clinical pathway implemented in our intensive care units (ICUs) to optimize antibiotic regimen selection for patients with ventilator-associated pneumonia (VAP) compared with costs in a historical control group treated according to prescriber preference. Retrospective cost analysis from the hospital perspective. Single, tertiary-care medical center. One hundred sixty-six adults with VAP from the medical, surgical, and neurotrauma ICUs (73 historical control patients [2004-2005] and 93 patients given an empiric antibiotic clinical pathway for VAP [2006-2007]). The VAP clinical pathway consisted of an ICU-specific three-drug regimen that considered local minimum inhibitory concentration distributions and a pharmacodynamically optimized dosing strategy. Hospital cost data were collected and inflated to 2007 according to the consumer price index. The VAP-related length of treatment, hospitalization costs, and antibiotic costs were compared between groups. The median VAP length of treatment was 24 days (interquartile range [IQR] 13-35 days] and 11 days (IQR 7-17 days) for historical and clinical pathway groups, respectively (p<0.001). Daily hospital costs were similar for both cohorts over the first 7 days, after which costs declined significantly for patients treated with the clinical pathway (p<0.001). When controlling for baseline differences between groups and length of stay before development of VAP, patients treated with the clinical pathway had shorter lengths of ICU stay after VAP, shorter total hospital lengths of stay after VAP, and lower hospital costs after the treatment of VAP. Median total antibiotic costs for individual patients were similar between groups ($535 [IQR $261-998] vs $482 [IQR $222-985] clinical pathway vs control, p=0.45), and the proportion of VAP hospital resources consumed by antibiotics for both groups was low. Although aggressive dosing of more costly antibiotics was empirically

Impact of pathogen-directed antimicrobial therapy for ventilator-associated pneumonia in trauma patients on charges and recurrence.

PubMed

Sharpe, John P; Magnotti, Louis J; Weinberg, Jordan A; Swanson, Joseph M; Wood, G Christopher; Fabian, Timothy C; Croce, Martin A

2015-04-01

Ventilator-associated pneumonia (VAP) represents one of the driving forces behind antibiotic use in the ICU. In a previous study, we established a defined algorithm for treatment of hospital-acquired VAP dictated by the causative pathogen. The purpose of the current study was to evaluate the impact of this algorithm for hospital-acquired VAP on recurrence and charges in trauma patients. Patients with VAP secondary to MRSA, Acinetobacter baumannii, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, or Enterobacteriaceae during 5 years subsequent to the previous study were evaluated. All VAP were diagnosed using quantitative cultures of the bronchoalveolar lavage effluent. Duration of antimicrobial therapy was dictated by the causative pathogen. If microbiologic resolution, defined as <10(3) colony-forming units/mL, was achieved, therapy was stopped by day 10. The remainder received 14 days of therapy. Recurrence was defined as >10(5) colony-forming units/mL on subsequent bronchoalveolar lavage performed within 2 weeks after completion of appropriate therapy. Five hundred and twenty-nine VAP episodes were identified in 381 patients. Overall recurrence was unchanged compared with the previous study (1.5% vs 2%; p = 0.3). There was a decrease in the number of bronchoalveolar lavages performed per patient compared with the previous study (1.6 vs 2.3; p = 0.24) and a reduction of 4.8 antibiotic days per VAP episode compared with the previous study. Both changes resulted in a cumulative reduction of $3,535.04 per patient, for a savings of $1.35 million during the study period. Hospital-acquired VAP can be managed effectively by a defined course of therapy dictated by the causative pathogen. Adherence to an established algorithm simplified the management of VAP and contributed to a cumulative reduction in patient charges without impacting recurrence. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Clinical Characteristics of Influenza-Associated Pneumonia of Adults: Clinical Features and Factors Contributing to Severity and Mortality.

PubMed

Ishiguro, Takashi; Kagiyama, Naho; Uozumi, Ryuji; Odashima, Kyuto; Takaku, Yotaro; Kurashima, Kazuyoshi; Morita, Satoshi; Takayanagi, Noboru

2017-06-01

Background : Pneumonia is a major complication of influenza that contributes to mortality. Clinical characteristics and factors of influenza virus contributing to the severity and mortality of pneumonia have not been fully elucidated. Objective : The objective was to clarify clinical characteristics and factors contributing to the severity and mortality of influenza-associated pneumonia ( flu-p ). Methods : We retrospectively analyzed patients with flu-p . Results : From December 1999 to March 2016, 210 patients with a median age of 69 (range, 17 to 92) years with flu-p based on positive rapid antigen tests, increased antibody titers of paired sera, or positive results of reverse transcription polymerase chain reaction were admitted to our institution. A multivariate analysis found that advanced age (≥ 65 years), pneumonia subtypes (unclassified), diabetes mellitus, and acute kidney injury complicated with flu-p were independent factors associated with disease severity, whereas pneumonia subtypes (mixed viral and bacterial pneumonia and unclassified), healthcare-associated pneumonia, acute kidney injury complicated with flu-p , and severity on admission (severe) were independent factors associated with non-survival. Conclusion : The clinical characteristics of flu-p are varied, and the contribution of several factors to the severity and mortality of flu-p suggest their importance in either preventing flu-p or managing flu-p after it develops.

Clinical Characteristics of Influenza-Associated Pneumonia of Adults: Clinical Features and Factors Contributing to Severity and Mortality

PubMed Central

Ishiguro, Takashi; Kagiyama, Naho; Uozumi, Ryuji; Odashima, Kyuto; Takaku, Yotaro; Kurashima, Kazuyoshi; Morita, Satoshi; Takayanagi, Noboru

2017-01-01

Background: Pneumonia is a major complication of influenza that contributes to mortality. Clinical characteristics and factors of influenza virus contributing to the severity and mortality of pneumonia have not been fully elucidated. Objective: The objective was to clarify clinical characteristics and factors contributing to the severity and mortality of influenza-associated pneumonia (flu-p). Methods: We retrospectively analyzed patients with flu-p. Results: From December 1999 to March 2016, 210 patients with a median age of 69 (range, 17 to 92) years with flu-p based on positive rapid antigen tests, increased antibody titers of paired sera, or positive results of reverse transcription polymerase chain reaction were admitted to our institution. A multivariate analysis found that advanced age (≥ 65 years), pneumonia subtypes (unclassified), diabetes mellitus, and acute kidney injury complicated with flu-p were independent factors associated with disease severity, whereas pneumonia subtypes (mixed viral and bacterial pneumonia and unclassified), healthcare-associated pneumonia, acute kidney injury complicated with flu-p, and severity on admission (severe) were independent factors associated with non-survival. Conclusion: The clinical characteristics of flu-p are varied, and the contribution of several factors to the severity and mortality of flu-p suggest their importance in either preventing flu-p or managing flu-p after it develops. PMID:28656006

Risk of pneumonia associated with incident benzodiazepine use among community-dwelling adults with Alzheimer disease

PubMed Central

Taipale, Heidi; Tolppanen, Anna-Maija; Koponen, Marjaana; Tanskanen, Antti; Lavikainen, Piia; Sund, Reijo; Tiihonen, Jari; Hartikainen, Sirpa

2017-01-01

BACKGROUND: Knowledge regarding whether benzodiazepines and similarly acting non-benzodiazepines (Z-drugs) are associated with an increased risk of pneumonia among older adults is lacking. We sought to investigate this association among community-dwelling adults with Alzheimer disease, a condition in which both sedative/hypnotic use and pneumonia are common. METHODS: We obtained data on all community-dwelling adults with a recent diagnosis of Alzheimer disease in Finland (2005–2011) from the Medication use and Alzheimer disease (MEDALZ) cohort, which incorporates national registry data on prescriptions, reimbursement, hospital discharges and causes of death. Incident users of benzodiazepines and Z-drugs were identified using a 1-year washout period and matched with nonusers using propensity scores. The association with hospital admission or death due to pneumonia was analyzed with the Cox proportional hazards model and adjusted for use of other psychotropic drugs in a time-dependent manner. RESULTS: Among 49 484 eligible participants with Alzheimer disease, 5232 taking benzodiazepines and 3269 taking Z-drugs were matched 1:1 with those not taking these drugs. Collectively, use of benzodiazepines and Z-drugs was associated with an increased risk of pneumonia (adjusted hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.05–1.42). When analyzed separately, benzodiazepine use was significantly associated with an increased risk of pneumonia (adjusted HR 1.28, 95% CI 1.07–1.54), whereas Z-drug use was not (adjusted HR 1.10, 95% CI 0.84–1.44). The risk of pneumonia was greatest within the first 30 days of benzodiazepine use (HR 2.09, 95% CI 1.26–3.48). INTERPRETATION: Benzodiazepine use was associated with an increased risk of pneumonia among patients with Alzheimer disease. Risk of pneumonia should be considered when weighing the benefits and risks of benzodiazepines in this population. PMID:28396328

Clinical Correlates of Surveillance Events Detected by National Healthcare Safety Network Pneumonia and Lower Respiratory Infection Definitions—Pennsylvania, 2011–2012

PubMed Central

See, Isaac; Chang, Julia; Gualandi, Nicole; Buser, Genevieve L.; Rohrbach, Pamela; Smeltz, Debra A.; Bellush, Mary Jo; Coffin, Susan E.; Gould, Jane M.; Hess, Debra; Hennessey, Patricia; Hubbard, Sydney; Kiernan, Andrea; O’Donnell, Judith; Pegues, David A.; Miller, Jeffrey R.; Magill, Shelley S.

2017-01-01

Objective To determine the clinical diagnoses associated with National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance events. Design Retrospective chart review. Setting Eight acute care hospitals in Pennsylvania. Patients All patients hospitalized during 2011–2012. Methods Medical records were reviewed from a random sample of patients reported to NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU/LRI events were recorded. Results We reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to NHSN; 29 (12%) of reported events fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassification. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia, of which 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or non-infectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator-associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI, 84% were in mechanically-ventilated patients, and 21% had no corresponding clinical diagnosis documented. Conclusions In adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded to compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015. PMID:27072043

Cost assessment of a new oral care program in the intensive care unit to prevent ventilator-associated pneumonia.

PubMed

Ory, Jérôme; Mourgues, Charline; Raybaud, Evelyne; Chabanne, Russell; Jourdy, Jean Christophe; Belard, Fabien; Guérin, Renaud; Cosserant, Bernard; Faure, Jean Sébastien; Calvet, Laure; Pereira, Bruno; Guelon, Dominique; Traore, Ousmane; Gerbaud, Laurent

2018-06-01

Ventilator-associated pneumonia (VAP) is the most frequent hospital-acquired infections in intensive care units (ICU). In the bundle of care to prevent the VAP, the oral care is very important strategies, to decrease the oropharyngeal bacterial colonization and presence of causative bacteria of VAP. In view of the paucity of medical economics studies, our objective was to determine the cost of implementing this oral care program for preventing VAP. In five ICUs, during period 1, caregivers used a foam stick for oral care and, during period 2, a stick and tooth brushing with aspiration. Budgetary effect of the new program from the hospital's point of view was analyzed for both periods. The costs avoided were calculated from the incidence density of VAP (cases per 1000 days of intubation). The cost study included device cost, benefit lost, and ICU cost (medication, employer and employee contributions, blood sample analysis…). A total of 2030 intubated patients admitted to the ICUs benefited from oral care. The cost of implementing the study protocol was estimated to be €11,500 per year. VAP rates decreased significantly between the two periods (p1 = 12.8% and p2 = 8.5%, p = 0.002). The VAP revenue was ranged from €28,000 to €45,000 and the average cost from €39,906 to €42,332. The total cost assessment calculated was thus around €1.9 million in favor of the new oral care program. Our study showed that the implementation of a simple strategy improved the quality of patient care is economically viable. NCT02400294.

Randomized Pilot Trial of Two Modified Endotracheal Tubes To Prevent Ventilator-associated Pneumonia.

PubMed

Deem, Steven; Yanez, David; Sissons-Ross, Laura; Broeckel, Jo Ann Elrod; Daniel, Stephen; Treggiari, Miriam

2016-01-01

Ventilator-associated pneumonia (VAP) is a prevalent and costly nosocomial infection related to instrumentation of the airway with an endotracheal tube (ETT), enabling microaspiration of contaminated secretions. Modification of the ETT design to reduce microaspiration and/or biofilm formation may play an important role in VAP prevention. However, there is insufficient evidence to provide strong recommendations regarding the use of modified ETT and unaddressed safety concerns. We performed a pilot randomized controlled trial comparing two modified ETTs designed specifically to prevent VAP, with the standard ETT, to test the feasibility of and inform planning for a large, pivotal, randomized trial. This study was conducted with institutional review board approval under exception from informed consent. We randomized in a blinded fashion patients undergoing emergency endotracheal intubation both out of and in hospital to receive one of three different ETT types: (1) a polyurethane-cuffed tube (PUC-ETT), (2) a polyurethane-cuffed tube equipped with a port for continuous aspiration of subglottic secretions (PUC-CASS-ETT), or a (3) standard polyvinylchloride-cuffed tube (PVC-ETT). In addition to investigating feasibility and safety, the study coprimary end points were tracheal bacterial colonization reaching a cfu count >10(6) cfu per milliliter and the incidence of invasively diagnosed VAP. A total of 102 subjects were randomized and met the eligibility criteria. Randomization procedures performed well and integrity of blinding at randomization was maintained. The majority of intubations occurred in the hospital setting (n = 77), and the remainder occurred out of hospital (n = 25). Compared with the PVC-ETT, there were no significant differences in tracheal colonization for PUC-ETT (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.31-3.09) or for PUC-CASS-ETT (OR, 1.26; 95% CI, 0.42-3.76). There were no differences in the risk of invasively diagnosed VAP

Randomized Pilot Trial of Two Modified Endotracheal Tubes To Prevent Ventilator-associated Pneumonia

PubMed Central

Yanez, David; Sissons-Ross, Laura; Elrod Broeckel, Jo Ann; Daniel, Stephen; Treggiari, Miriam

2016-01-01

Rationale: Ventilator-associated pneumonia (VAP) is a prevalent and costly nosocomial infection related to instrumentation of the airway with an endotracheal tube (ETT), enabling microaspiration of contaminated secretions. Modification of the ETT design to reduce microaspiration and/or biofilm formation may play an important role in VAP prevention. However, there is insufficient evidence to provide strong recommendations regarding the use of modified ETT and unaddressed safety concerns. Objectives: We performed a pilot randomized controlled trial comparing two modified ETTs designed specifically to prevent VAP, with the standard ETT, to test the feasibility of and inform planning for a large, pivotal, randomized trial. Methods: This study was conducted with institutional review board approval under exception from informed consent. We randomized in a blinded fashion patients undergoing emergency endotracheal intubation both out of and in hospital to receive one of three different ETT types: (1) a polyurethane-cuffed tube (PUC-ETT), (2) a polyurethane-cuffed tube equipped with a port for continuous aspiration of subglottic secretions (PUC-CASS-ETT), or a (3) standard polyvinylchloride-cuffed tube (PVC-ETT). In addition to investigating feasibility and safety, the study coprimary end points were tracheal bacterial colonization reaching a cfu count >106 cfu per milliliter and the incidence of invasively diagnosed VAP. Measurements and Main Results: A total of 102 subjects were randomized and met the eligibility criteria. Randomization procedures performed well and integrity of blinding at randomization was maintained. The majority of intubations occurred in the hospital setting (n = 77), and the remainder occurred out of hospital (n = 25). Compared with the PVC-ETT, there were no significant differences in tracheal colonization for PUC-ETT (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.31–3.09) or for PUC-CASS-ETT (OR, 1.26; 95% CI, 0.42–3

[Pneumonia associated with health care versus community acquired pneumonia: different entities, distinct approaches].

PubMed

Guimarães, C; Lares Santos, C; Costa, F; Barata, F

2011-01-01

Healthcare-associated pneumonia (HCAP) is now identified as a unique entity that differs from community-acquired pneumonia (CAP), and in many ways is similar to nosocomial pneumonia (NP). Patients with the diagnosis of CAP and HCAP admitted to our Pneumology Unit during one year were retrospectively analysed. The objective was to compare the characteristics and the approach of these two entities. 197 patients were included, 144 with CAP and 53 with HCAP. Sex, age, comorbilities, Pneumonia Severity Index (PSI) score, radiological involvement, bacteriology, treatment and outcomes were analysed in the 2 groups. Compared to CAP, HCAP was associated with more severe disease, a higher mortality rate and greater length of hospitalization. HCAP differed from CAP mainly in bacteriology and outcomes. Copyright © 2010 Sociedade Portuguesa de Pneumologia. Published by Elsevier España. All rights reserved.

[Value of optimization of bedside Gram staining of sputum smear in the early diagnosis and treatment of ventilator-associated pneumonia].

PubMed

Liao, Xinyan; Ran, Yu; Bian, Shichang; Wang, Chao; Xu, Lei

2014-12-01

To investigate the significance of optimization of bedside Gram staining of sputum smear in the early diagnosis and antimicrobial treatment for ventilator-associated pneumonia (VAP) patients. The data of patients with VAP undergoing mechanical ventilation over 48 hours in the Department of Critical Care Medicine of Tianjin Fourth Central Hospital from June 2009 to June 2014 were analyzed. The patients were divided into two groups according to whether or not bedside Gram staining of sputum smear was used or not. The sputum samples from lower respiratory tract of all VAP patients were collected daily with tracheal catheter. In empirical examination group (from June 2009 to December 2011, n=43), the patients received antibiotics at the time of onset of VAP, selection of antibiotics depended on the information of bacterial epidemiology of the intensive care unit (ICU), and also existence of high risk factors of multi-drug resistant bacteria. In target treatment group (from January 2012 to June 2014, n=43), the patients received antibiotics according to the results of bedside instant sputum smear examination and empirical antibiotic regime. The correlation between the results of sputum smear examination and culture result was analyzed. The levels of body temperature, white blood cell (WBC) count, procalcitonin (PCT) level,and high sensitivity C- reactive protein (hs-CRP) were measured on the 1st day and 3rd day. The length of antibiotics treatment, duration of mechanical ventilation, and the time of ICU stay were recorded for both groups. There were 512 qualified sputum specimens for culture, from which 336 pathogens were found, and 358 strains of pathogenic bacteria were found from microscopic examination of 512 qualified sputum smear. The coincidence rate of results of bedside examination of sputum smear and that of sputum culture was 78.32%(401/512). The diagnostic acumen of the former was 85.42% (287/336), specificity was 64.77% (114/176), positive predictive value

Diagnostic Performance of Soluble Triggering Receptor Expressed on Myeloid Cells-1 in Ventilator-Associated Pneumonia of Patients with Ischemic Stroke.

PubMed

Yu, Yuetian; Zhu, Cheng; Liu, Chunyan; Gao, Yuan; Yin, Rong; Cao, Jianguo

2017-01-01

Objective . To investigate the effect of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in serum, bronchoalveolar lavage fluid (BALF), endotracheal aspiration (ETA), and exhaled breath condensate (EBC) samples as early biomarkers for the diagnosis of ventilator-associated pneumonia (VAP) in patients with ischemic stroke. Methods . One hundred and thirty-two patients with clinically suspected VAP were enrolled in this study. Bronchoscopy was performed on the day of clinically suspected VAP. sTREM-1 levels in serum, BALF, ETA, and EBC were measured. VAP was diagnosed by quantitative cultures of BALF (≥10 4  cfu/mL). Results . VAP was confirmed in 76 (57.58%) cases. Patients with VAP showed significantly higher sTREM-1 in BALF [32.35 (IQR, 30.08-41.72) versus 18.92 (11.89-31.72)] pg/mL and in EBC [1.57 (IQR, 1.02-2.61) versus 0.41 (0.19-1.61)] pg/mL than patients without VAP. The area under the curve was 0.813 ( p < 0.001). The optimum cut-off value for sTREM-1 in BALF was 23.61 pg/mL, yielding sensitivity and specificity of 85.5% and 73.1%. sTREM-1 in BALF had excellent correlation with that in EBC ( R 2 = 0.78, p < 0.05). Conclusions . sTREM-1 in EBC and BALF had good diagnostic performance in differentiating patients with and without VAP.

Diagnostic Performance of Soluble Triggering Receptor Expressed on Myeloid Cells-1 in Ventilator-Associated Pneumonia of Patients with Ischemic Stroke

PubMed Central

Yu, Yuetian; Liu, Chunyan

2017-01-01

Objective. To investigate the effect of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in serum, bronchoalveolar lavage fluid (BALF), endotracheal aspiration (ETA), and exhaled breath condensate (EBC) samples as early biomarkers for the diagnosis of ventilator-associated pneumonia (VAP) in patients with ischemic stroke. Methods. One hundred and thirty-two patients with clinically suspected VAP were enrolled in this study. Bronchoscopy was performed on the day of clinically suspected VAP. sTREM-1 levels in serum, BALF, ETA, and EBC were measured. VAP was diagnosed by quantitative cultures of BALF (≥104 cfu/mL). Results. VAP was confirmed in 76 (57.58%) cases. Patients with VAP showed significantly higher sTREM-1 in BALF [32.35 (IQR, 30.08–41.72) versus 18.92 (11.89–31.72)] pg/mL and in EBC [1.57 (IQR, 1.02–2.61) versus 0.41 (0.19–1.61)] pg/mL than patients without VAP. The area under the curve was 0.813 (p < 0.001). The optimum cut-off value for sTREM-1 in BALF was 23.61 pg/mL, yielding sensitivity and specificity of 85.5% and 73.1%. sTREM-1 in BALF had excellent correlation with that in EBC (R2 = 0.78, p < 0.05). Conclusions. sTREM-1 in EBC and BALF had good diagnostic performance in differentiating patients with and without VAP. PMID:28321261

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review.

PubMed

Guilhermino, Michelle C; Inder, Kerry J; Sundin, Deborah

2018-03-26

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes. The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes. Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity. Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay. Limited evidence of the effectiveness of

A randomized trial of 7-day doripenem versus 10-day imipenem-cilastatin for ventilator-associated pneumonia.

PubMed

Kollef, Marin H; Chastre, Jean; Clavel, Marc; Restrepo, Marcos I; Michiels, Bart; Kaniga, Koné; Cirillo, Iolanda; Kimko, Holly; Redman, Rebecca

2012-11-13

The aim of this study was to compare a 7-day course of doripenem to a 10-day course of imipenem-cilastatin for ventilator-associated pneumonia (VAP) due to Gram-negative bacteria. This was a prospective, double-blinded, randomized trial comparing a fixed 7-day course of doripenem one gram as a four-hour infusion every eight hours with a fixed 10-day course of imipenem-cilastatin one gram as a one-hour infusion every eight hours (April 2008 through June 2011). The study was stopped prematurely at the recommendation of the Independent Data Monitoring Committee that was blinded to treatment arm assignment and performed a scheduled review of data which showed signals that were close to the pre-specified stopping limits. The final analyses included 274 randomized patients. The clinical cure rate at the end of therapy (EOT) in the microbiological intent-to-treat (MITT) population was numerically lower for patients in the doripenem arm compared to the imipenem-cilastatin arm (45.6% versus 56.8%; 95% CI, -26.3% to 3.8%). Similarly, the clinical cure rate at EOT was numerically lower for patients with Pseudomonas aeruginosa VAP, the most common Gram-negative pathogen, in the doripenem arm compared to the imipenem-cilastatin arm (41.2% versus 60.0%; 95% CI, -57.2 to 19.5). All cause 28-day mortality in the MITT group was numerically greater for patients in the doripenem arm compared to the imipenem-cilastatin arm (21.5% versus 14.8%; 95% CI, -5.0 to 18.5) and for patients with P. aeruginosa VAP (35.3% versus 0.0%; 95% CI, 12.6 to 58.0). Among patients with microbiologically confirmed late-onset VAP, a fixed 7-day course of doripenem was found to have non-significant higher rates of clinical failure and mortality compared to a fixed 10-day course of imipenem-cilastatin. Consideration should be given to treating patients with VAP for more than seven days to optimize clinical outcome. ClinicalTrials.gov: NCT00589693.

A randomized trial of 7-day doripenem versus 10-day imipenem-cilastatin for ventilator-associated pneumonia

PubMed Central

2012-01-01

Introduction The aim of this study was to compare a 7-day course of doripenem to a 10-day course of imipenem-cilastatin for ventilator-associated pneumonia (VAP) due to Gram-negative bacteria. Methods This was a prospective, double-blinded, randomized trial comparing a fixed 7-day course of doripenem one gram as a four-hour infusion every eight hours with a fixed 10-day course of imipenem-cilastatin one gram as a one-hour infusion every eight hours (April 2008 through June 2011). Results The study was stopped prematurely at the recommendation of the Independent Data Monitoring Committee that was blinded to treatment arm assignment and performed a scheduled review of data which showed signals that were close to the pre-specified stopping limits. The final analyses included 274 randomized patients. The clinical cure rate at the end of therapy (EOT) in the microbiological intent-to-treat (MITT) population was numerically lower for patients in the doripenem arm compared to the imipenem-cilastatin arm (45.6% versus 56.8%; 95% CI, -26.3% to 3.8%). Similarly, the clinical cure rate at EOT was numerically lower for patients with Pseudomonas aeruginosa VAP, the most common Gram-negative pathogen, in the doripenem arm compared to the imipenem-cilastatin arm (41.2% versus 60.0%; 95% CI, -57.2 to 19.5). All cause 28-day mortality in the MITT group was numerically greater for patients in the doripenem arm compared to the imipenem-cilastatin arm (21.5% versus 14.8%; 95% CI, -5.0 to 18.5) and for patients with P. aeruginosa VAP (35.3% versus 0.0%; 95% CI, 12.6 to 58.0). Conclusions Among patients with microbiologically confirmed late-onset VAP, a fixed 7-day course of doripenem was found to have non-significant higher rates of clinical failure and mortality compared to a fixed 10-day course of imipenem-cilastatin. Consideration should be given to treating patients with VAP for more than seven days to optimize clinical outcome. Trial Registration ClinicalTrials.gov: NCT00589693

The pulmonary physician in critical care * 4: Nosocomial pneumonia.

PubMed

Ewig, S; Bauer, T; Torres, A

2002-04-01

Much progress has been made in the understanding of nosocomial pneumonia but important issues in diagnosis and treatment remain unresolved. The controversy over diagnostic tools should be closed. Instead, every effort should be made to increase our ability to make valid clinical predictions about the presence of ventilator associated pneumonia and to establish criteria to guide restricting empirical antimicrobial treatment without causing patient harm. More emphasis must be put on local infection control measures such as routine surveillance of pathogens, definition of controlled policies of antimicrobial treatment, and effective implementation of strategies of prevention.

A randomized clinical trial comparing an extended-use hygroscopic condenser humidifier with heated-water humidification in mechanically ventilated patients.

PubMed

Kollef, M H; Shapiro, S D; Boyd, V; Silver, P; Von Harz, B; Trovillion, E; Prentice, D

1998-03-01

To determine the safety and cost-effectiveness of mechanical ventilation with an extended-use hygroscopic condenser humidifier (Duration; Nellcor Puritan-Bennett; Eden Prairie, Minn) compared with mechanical ventilation with heated-water humidification. Prospective randomized clinical trial. Medical and surgical ICUs of Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. Three hundred ten consecutive qualified patients undergoing mechanical ventilation. Patients requiring mechanical ventilation were randomly assigned to receive humidification with either an extended-use hygroscopic condenser humidifier (for up to the first 7 days of mechanical ventilation) or heated-water humidification. Occurrence of ventilator-associated pneumonia, endotracheal tube occlusion, duration of mechanical ventilation, lengths of intensive care and hospitalization, acquired multiorgan dysfunction, and hospital mortality. One hundred sixty-three patients were randomly assigned to receive humidification with an extended-use hygroscopic condenser humidifier, and 147 patients were randomly assigned to receive heated-water humidification. The two groups were similar at the time of randomization with regard to demographic characteristics, ICU admission diagnoses, and severity of illness. Risk factors for the development of ventilator-associated pneumonia were also similar during the study period for both treatment groups. Ventilator-associated pneumonia was seen in 15 (9.2%) patients receiving humidification with an extended-use hygroscopic condenser humidifier and in 15 (10.2%) patients receiving heated-water humidification (relative risk, 0.90; 95% confidence interval=0.46 to 1.78; p=0.766). No statistically significant differences for hospital mortality, duration of mechanical ventilation, lengths of stay in the hospital ICU, or acquired organ system derangements were found between the two treatment groups. No episode of endotracheal tube occlusion occurred during

Outcome of Concurrent Occult Hemothorax and Pneumothorax in Trauma Patients Who Required Assisted Ventilation

PubMed Central

Mahmood, Ismail; Tawfeek, Zainab; El-Menyar, Ayman; Zarour, Ahmad; Afifi, Ibrahim; Kumar, Suresh; Latifi, Rifat; Al-Thani, Hassan

2015-01-01

Background. The management and outcomes of occult hemopneumothorax in blunt trauma patients who required mechanical ventilation are not well studied. We aimed to study patients with occult hemopneumothorax on mechanical ventilation who could be carefully managed without tube thoracostomy. Methods. Chest trauma patients with occult hemopneumothorax who were on mechanical ventilation were prospectively evaluated. The presence of hemopneumothorax was confirmed by CT scanning. Hospital length of stay, complications, and outcome were recorded. Results. A total of 56 chest trauma patients with occult hemopneumothorax who were on ventilatory support were included with a mean age of 36 ± 13 years. Hemopneumothorax was managed conservatively in 72% cases and 28% underwent tube thoracostomy as indicated. 29% of patients developed pneumonia, 16% had Acute Respiratory Distress Syndrome (ARDS), and 7% died. Thickness of hemothorax, duration of mechanical ventilation, and development of ARDS were significantly associated with tube thoracostomy in comparison to no-chest tube group. Conclusions. The majority of occult hemopneumothorax can be carefully managed without tube thoracostomy in patients who required positive pressure ventilation. Tube thoracotomy could be restricted to those who had evidence of increase in the size of the hemothorax or pneumothorax on follow-up chest radiographs or developed respiratory compromise. PMID:25785199

What is the best therapeutic approach to methicillin-resistant Staphylococcus aureus pneumonia?

PubMed

Peyrani, Paula; Ramirez, Julio

2015-04-01

The purpose of this review is to define what the best therapeutic approach is for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Although two meta-analyses reported conflicting findings, recent retrospective studies reported higher success rates in patients with MRSA pneumonia treated with linezolid when compared to vancomycin. Only registration trials are available for some anti-MRSA antibiotics, such as telavancin, ceftaroline, and ceftobiprole. Scarce information is available regarding the best therapeutic approach for MRSA community-acquired pneumonia. Linezolid seems to be a better choice than vancomycin for the treatment of MRSA ventilator-associated pneumonia. It is still unclear whether this affirmation holds for other forms of MRSA pneumonia. Further research is needed to define whether newer antibiotics are better alternatives than currently recommended agents.

Clinical Correlates of Surveillance Events Detected by National Healthcare Safety Network Pneumonia and Lower Respiratory Infection Definitions-Pennsylvania, 2011-2012.

PubMed

See, Isaac; Chang, Julia; Gualandi, Nicole; Buser, Genevieve L; Rohrbach, Pamela; Smeltz, Debra A; Bellush, Mary Jo; Coffin, Susan E; Gould, Jane M; Hess, Debra; Hennessey, Patricia; Hubbard, Sydney; Kiernan, Andrea; O'Donnell, Judith; Pegues, David A; Miller, Jeffrey R; Magill, Shelley S

2016-07-01

OBJECTIVE To determine the clinical diagnoses associated with the National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance events DESIGN Retrospective chart review SETTING A convenience sample of 8 acute-care hospitals in Pennsylvania PATIENTS All patients hospitalized during 2011-2012 METHODS Medical records were reviewed from a random sample of patients reported to the NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU and LRI events were recorded. RESULTS We reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to the NHSN; 29 reported events (12%) fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassifications. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia; of these, 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or noninfectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI patients, 84% were mechanically ventilated and 21% had no corresponding clinical diagnosis documented. CONCLUSIONS In adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded with compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015. Infect Control Hosp Epidemiol 2016;37:818-824.

Krypton-81m ventilation scanning: acute respiratory disease

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lavender, J.P.; Irving, H.; Armstrong, J.D. II

1981-02-01

From experience with 700 patients undergoing ventilation and perfusion lung scanning with krypton-81m/technetium-99m technique, 34 patients suffering from nonembolic acute respiratory disease were selected for review. In 16 patients with pneumonia, all had defects of ventilation corresponding to, or larger than, the radiologic consolidation. In 13 patients there was some preservation of perfusion in the consolidated region. In two of the three patients with matched defects, the pneumonia was of long standing. In seven patients with collapse or atelectasis and in 11 patients with acute reversible bronchial obstruction and normal volume lungs, a similar pattern or ventillation and perfusion wasmore » observed.« less

Sanosil, a more effective agent for preventing the hospital-acquired ventilator associated pneumonia.

PubMed

Yousefshahi, Fardin; Khajavi, Mohammad Reza; Anbarafshan, Mohammad; Khashayar, Patricia; Najafi, Atabak

2010-01-01

The aim of this study is to compare the effects of Sanosil and glutaraldehyde 2 percent in disinfecting ventilator connecting tubes in an intensive care unit (ICU) environment. The 12-week open-labelled clinical trial was conducted in the surgical ICU of a teaching hospital from March to May 2005. In the first phase of the study, high level disinfection was performed using glutaraldehyde 2 percent, whereas Sanosil was used as the disinfectant agent of the second phase. Samples for microbial culture were obtained from the Y piece, the expiratory limb proximal to the ventilator and the humidifier in different stages; the results were then compared. Positive culture was more frequently reported in Y pieces, humidifiers and expiratory end of ventilators. Comparing the two groups, there were more positive cultures in the glutaraldehyde group (p value = 0.005); multiple organism growths, gram negative, gram positive and fungi were also more frequent in this group (p value = 0.01; 0. 007; 0. 062; 0.144, respectively). The paper shows that Sanosil is an effective agent in reducing the contamination risk in the tubes used in ICUs.

Microbial profiling of dental plaque from mechanically ventilated patients

PubMed Central

Twigg, Joshua A.; Lewis, Michael A. O.; Wise, Matt P.; Marchesi, Julian R.; Smith, Ann; Wilson, Melanie J.; Williams, David W.

2016-01-01

Micro-organisms isolated from the oral cavity may translocate to the lower airways during mechanical ventilation (MV) leading to ventilator-associated pneumonia (VAP). Changes within the dental plaque microbiome during MV have been documented previously, primarily using culture-based techniques. The aim of this study was to use community profiling by high throughput sequencing to comprehensively analyse suggested microbial changes within dental plaque during MV. Bacterial 16S rDNA gene sequences were obtained from 38 samples of dental plaque sampled from 13 mechanically ventilated patients and sequenced using the Illumina platform. Sequences were processed using Mothur, applying a 97 % gene similarity cut-off for bacterial species level identifications. A significant ‘microbial shift’ occurred in the microbial community of dental plaque during MV for nine out of 13 patients. Following extubation, or removal of the endotracheal tube that facilitates ventilation, sampling revealed a decrease in the relative abundance of potential respiratory pathogens and a compositional change towards a more predominantly (in terms of abundance) oral microbiota including Prevotella spp., and streptococci. The results highlight the need to better understand microbial shifts in the oral microbiome in the development of strategies to reduce VAP, and may have implications for the development of other forms of pneumonia such as community-acquired infection. PMID:26690690

Microbial profiling of dental plaque from mechanically ventilated patients.

PubMed

Sands, Kirsty M; Twigg, Joshua A; Lewis, Michael A O; Wise, Matt P; Marchesi, Julian R; Smith, Ann; Wilson, Melanie J; Williams, David W

2016-02-01

Micro-organisms isolated from the oral cavity may translocate to the lower airways during mechanical ventilation (MV) leading to ventilator-associated pneumonia (VAP). Changes within the dental plaque microbiome during MV have been documented previously, primarily using culture-based techniques. The aim of this study was to use community profiling by high throughput sequencing to comprehensively analyse suggested microbial changes within dental plaque during MV. Bacterial 16S rDNA gene sequences were obtained from 38 samples of dental plaque sampled from 13 mechanically ventilated patients and sequenced using the Illumina platform. Sequences were processed using Mothur, applying a 97% gene similarity cut-off for bacterial species level identifications. A significant 'microbial shift' occurred in the microbial community of dental plaque during MV for nine out of 13 patients. Following extubation, or removal of the endotracheal tube that facilitates ventilation, sampling revealed a decrease in the relative abundance of potential respiratory pathogens and a compositional change towards a more predominantly (in terms of abundance) oral microbiota including Prevotella spp., and streptococci. The results highlight the need to better understand microbial shifts in the oral microbiome in the development of strategies to reduce VAP, and may have implications for the development of other forms of pneumonia such as community-acquired infection.

In vitro activity of ceftazidime/avibactam against Gram-negative pathogens isolated from pneumonia in hospitalised patients, including ventilated patients.

PubMed

Flamm, Robert K; Nichols, Wright W; Sader, Helio S; Farrell, David J; Jones, Ronald N

2016-03-01

The activities of the novel β-lactam/non-β-lactam β-lactamase inhibitor combination ceftazidime/avibactam and comparators were evaluated against isolates from pneumonia in hospitalised patients including ventilated patients (PHP, pneumonia not designated as VABP; VABP, pneumonia in ventilated patients). Isolates were from the European-Mediterranean region (EuM), China and the USA collected in the SENTRY Antimicrobial Surveillance Program between 2009 and 2011 inclusive. A total of 2393 organisms from PHP were from the EuM, 888 from China and 3213 from the USA; from VABP patients there were 918, 97 and 692 organisms collected, respectively. Among Enterobacteriaceae from PHP, ceftazidime/avibactam MIC90 values against Escherichia coli ranged from 0.25-0.5mg/L and Klebsiella spp. MIC90 values were 0.5mg/L in each region. Among VABP isolates, MIC90 values for ceftazidime/avibactam against E. coli were 0.25mg/L; for Klebsiella spp. from VABP patients, MIC90 values were similar to those obtained against PHP isolates. The MIC of ceftazidime/avibactam was ≤8mg/L against 92-96% of Pseudomonas aeruginosa isolated from PHP patients. Isolates of P. aeruginosa from VABP patients were of lower susceptibility to all antibacterial agents (e.g. depending on region, meropenem susceptibilities were 51.2-69.4% in contrast to 68.3-76.7% among PHP patients). However, ceftazidime/avibactam inhibited 79.2-95.4% of VABP isolates at an MIC of ≤8mg/L. Acinetobacter spp. were resistant to many agents and only rates of susceptibility to colistin were >90% across all regions both for PHP and VABP isolates. Ceftazidime/avibactam was generally active against a high proportion of isolates resistant to ceftazidime from PHP and VAPB patients. Copyright © 2016 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.

Association between substandard classroom ventilation rates and students' academic achievement.

PubMed

Haverinen-Shaughnessy, U; Moschandreas, D J; Shaughnessy, R J

2011-04-01

This study focuses on the relationship between classroom ventilation rates and academic achievement. One hundred elementary schools of two school districts in the southwest United States were included in the study. Ventilation rates were estimated from fifth-grade classrooms (one per school) using CO(2) concentrations measured during occupied school days. In addition, standardized test scores and background data related to students in the classrooms studied were obtained from the districts. Of 100 classrooms, 87 had ventilation rates below recommended guidelines based on ASHRAE Standard 62 as of 2004. There is a linear association between classroom ventilation rates and students' academic achievement within the range of 0.9-7.1 l/s per person. For every unit (1 l/s per person) increase in the ventilation rate within that range, the proportion of students passing standardized test (i.e., scoring satisfactory or above) is expected to increase by 2.9% (95%CI 0.9-4.8%) for math and 2.7% (0.5-4.9%) for reading. The linear relationship observed may level off or change direction with higher ventilation rates, but given the limited number of observations, we were unable to test this hypothesis. A larger sample size is needed for estimating the effect of classroom ventilation rates higher than 7.1 l/s per person on academic achievement. The results of this study suggest that increasing the ventilation rates toward recommended guideline ventilation rates in classrooms should translate into improved academic achievement of students. More studies are needed to fully understand the relationships between ventilation rate, other indoor environmental quality parameters, and their effects on students' health and achievement. Achieving the recommended guidelines and pursuing better understanding of the underlying relationships would ultimately support both sustainable and productive school environments for students and personnel. © 2010 John Wiley & Sons A/S.

Severe Varicella Pneumonia in Adults: Seven Years' Single-center Experience from India.

PubMed

Singh, Akashdeep; Parkash, Siddharth; Gupta, Sunil K; Soni, R K

2018-03-01

Varicella pneumonia is a rare but a serious complication of chickenpox in adults. There is paucity of data on varicella pneumonia from India. The aim of this study is to describe the clinical manifestations, hospital course, treatment, and outcome of adult patients with severe varicella pneumonia. This was a retrospective, observational study of patients with severe varicella pneumonia attending a tertiary care teaching hospital. The cases of varicella were identified by a computerized search of the medical record for the period between January 2010 and December 2016. During this period, 137 patients got admitted with varicella of which 22 had severe varicella pneumonia. Mean and standard deviation were computed. Fisher's Z-test of proportions and analysis of variance were applied. There were 17 (77.3%) men and 5 (22.7%) women. The mean age of the patients was 33.4 ± 10.8 years. History of contact with an infected person followed by high-grade fever and typical rash was present in all patients. Forty-five percent (10/22) of patients were immunosuppressed. All the patients received intravenous acyclovir. Forty-five percent (10/22) of patients received invasive mechanical ventilation. The various factors associated with the need for mechanical ventilation were partial pressure of oxygen:fraction of inspired oxygen ratio <150, quick sequential (sepsis-related) organ failure assessment (qSOFA) >2, and early bacterial coinfection. The mean Intensive Care Unit and hospital stay were 7 days (range; 1-16) and 9 days (range; 4-21), respectively. The overall mortality was 22.7% and reached 50% in those requiring invasive ventilation. The mortality was higher among patients with qSOFA >3, mean arterial blood pressure <60 mmHg, and severe acute respiratory distress syndrome at presentation. Patients with severe varicella pneumonia are at an increased risk of respiratory failure and death.

Risk factors and outcomes of carbapenem-resistant Acinetobacter baumannii ventilator-associated pneumonia in the neonate: A case-case-control study.

PubMed

Thatrimontrichai, Anucha; Techato, Chirabat; Dissaneevate, Supaporn; Janjindamai, Waricha; Maneenil, Gunlawadee; Kritsaneepaiboon, Supika; Tanaanantarak, Pattama

2016-07-01

Carbapenem-resistant and susceptible Acinetobacter baumannii (CRAB and CSAB) have emerged as serious threats among critically ill neonates. We aimed to identify the risks and outcomes for CRAB and CSAB ventilator-associated pneumonia (VAP) compared with a control group. We performed a retrospective and case-case-control study in a neonatal intensive care unit between 2009 and 2014. The numbers of patients in the CRAB VAP, CSAB VAP, and control groups were 63, 13, and 25, respectively. The mean gestational ages and median birthweights of CRAB VAP, CSAB VAP, and control groups were 33.2, 35.0, and 32.6 weeks and 1800, 2230, and 2245 g, respectively. By multivariate analysis, infants who had a birthweight of 1000-1499 g (P = 0.04), cesarean section (P = 0.01), history of cephalosporin use (P = 0.02), and surfactant replacement (P = 0.01) in CRAB VAP were significantly higher than in the control group. Inborn infant (P = 0.01), reintubation (P = 0.04), and umbilical artery catheterization (P = 0.04) in the CRAB VAP group were significantly more than in the CSAB VAP group. The crude mortality rates (CMRs) of CRAB VAP and CSAB VAP were 15.9% and 7.7%, respectively. By univariate analysis, the CMR, septic shock, and bronchopulmonary dysplasia in CRAB VAP were higher than in the control group. There are very high mortality and short-term morbidity rates in CRAB VAP. Surfactant replacement therapy, fewer cesarean sections, and the reduced use of cephalosporin in very preterm infants may reduce CRAB VAP. Copyright © 2016 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Endogenous lipoid pneumonia associated with Legionella pneumophila serogroup 1.

PubMed

Hui, Chee-Kin

2013-03-01

Endogenous lipoid pneumonia is an uncommon condition. This is a report of a 29-year-old woman diagnosed with endogenous lipoid pneumonia associated with Legionella pneumophila serogroup 1 infection. The patient's endogenous lipoid pneumonia resolved completely after treatment for Legionella pneumophila infection. This suggests that early diagnosis and aggressive treatment of the underlying infection may prevent any long-term sequelae of lipoid pneumonia.

Frequency and Intensive Care Related Risk Factors of Pneumothorax in Ventilated Neonates

PubMed Central

Bhat Yellanthoor, Ramesh; Ramdas, Vidya

2014-01-01

Objectives. Relationships of mechanical ventilation to pneumothorax in neonates and care procedures in particular are rarely studied. We aimed to evaluate the relationship of selected ventilator variables and risk events to pneumothorax. Methods. Pneumothorax was defined as accumulation of air in pleural cavity as confirmed by chest radiograph. Relationship of ventilator mode, selected settings, and risk procedures prior to detection of pneumothorax was studied using matched controls. Results. Of 540 neonates receiving mechanical ventilation, 10 (1.85%) were found to have pneumothorax. Respiratory distress syndrome, meconium aspiration syndrome, and pneumonia were the underlying lung pathology. Pneumothorax mostly (80%) occurred within 48 hours of life. Among ventilated neonates, significantly higher percentage with pneumothorax received mandatory ventilation than controls (70% versus 20%; P < 0.01). Peak inspiratory pressure >20 cm H2O and overventilation were not significantly associated with pneumothorax. More cases than controls underwent care procedures in the preceding 3 hours of pneumothorax event. Mean airway pressure change (P = 0.052) and endotracheal suctioning (P = 0.05) were not significantly associated with pneumothorax. Reintubation (P = 0.003), and bagging (P = 0.015) were significantly associated with pneumothorax. Conclusion. Pneumothorax among ventilated neonates occurred at low frequency. Mandatory ventilation and selected care procedures in the preceding 3 hours had significant association. PMID:24876958

Increased Lymphatic Vessel Length Is Associated With the Fibroblast Reticulum and Disease Severity in Usual Interstitial Pneumonia and Nonspecific Interstitial Pneumonia

PubMed Central

Cosgrove, Gregory P.; Janssen, William J.; Huie, Tristan J.; Burnham, Ellen L.; Heinz, David E.; Curran-Everett, Douglas; Sahin, Hakan; Schwarz, Marvin I.; Cool, Carlyne D.; Groshong, Steve D.; Geraci, Mark W.; Tuder, Rubin M.; Hyde, Dallas M.; Henson, Peter M.

2012-01-01

Background: Lymphangiogenesis responds to tissue injury as a key component of normal wound healing. The development of fibrosis in the idiopathic interstitial pneumonias may result from abnormal wound healing in response to injury. We hypothesize that increased lymphatic vessel (LV) length, a marker of lymphangiogenesis, is associated with parenchymal components of the fibroblast reticulum (organizing collagen, fibrotic collagen, and fibroblast foci), and its extent correlates with disease severity. Methods: We assessed stereologically the parenchymal structure of fibrotic lungs and its associated lymphatic network, which was highlighted immunohistochemically in age-matched samples of usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP) with FVC < 80%, COPD with a Global Initiative for Obstructive Lung Disease stage 0, and normal control lungs. Results: LV length density, as opposed to vessel volume density, was found to be associated with organizing and fibrotic collagen density (P < .0001). Length density of LVs and the volume density of organizing and fibrotic collagen were significantly associated with severity of both % FVC (P < .001) and diffusing capacity of the lung for carbon monoxide (P < .001). Conclusions: Severity of disease in UIP and NSIP is associated with increased LV length and is strongly associated with components of the fibroblast reticulum, namely organizing and fibrotic collagen, which supports a pathogenic role of LVs in these two diseases. Furthermore, the absence of definable differences between UIP and NSIP suggests that LVs are a unifying mechanism for the development of fibrosis in these fibrotic lung diseases. PMID:22797508

Stroke-induced immunodepression and dysphagia independently predict stroke-associated pneumonia - The PREDICT study.

PubMed

Hoffmann, Sarah; Harms, Hendrik; Ulm, Lena; Nabavi, Darius G; Mackert, Bruno-Marcel; Schmehl, Ingo; Jungehulsing, Gerhard J; Montaner, Joan; Bustamante, Alejandro; Hermans, Marcella; Hamilton, Frank; Göhler, Jos; Malzahn, Uwe; Malsch, Carolin; Heuschmann, Peter U; Meisel, Christian; Meisel, Andreas

2017-12-01

Stroke-associated pneumonia is a frequent complication after stroke associated with poor outcome. Dysphagia is a known risk factor for stroke-associated pneumonia but accumulating evidence suggests that stroke induces an immunodepressive state increasing susceptibility for stroke-associated pneumonia. We aimed to confirm that stroke-induced immunodepression syndrome is associated with stroke-associated pneumonia independently from dysphagia by investigating the predictive properties of monocytic HLA-DR expression as a marker of immunodepression as well as biomarkers for inflammation (interleukin-6) and infection (lipopolysaccharide-binding protein). This was a prospective, multicenter study with 11 study sites in Germany and Spain, including 486 patients with acute ischemic stroke. Daily screening for stroke-associated pneumonia, dysphagia and biomarkers was performed. Frequency of stroke-associated pneumonia was 5.2%. Dysphagia and decreased monocytic HLA-DR were independent predictors for stroke-associated pneumonia in multivariable regression analysis. Proportion of pneumonia ranged between 0.9% in the higher monocytic HLA-DR quartile (≥21,876 mAb/cell) and 8.5% in the lower quartile (≤12,369 mAb/cell). In the presence of dysphagia, proportion of pneumonia increased to 5.9% and 18.8%, respectively. Patients without dysphagia and normal monocytic HLA-DR expression had no stroke-associated pneumonia risk. We demonstrate that dysphagia and stroke-induced immunodepression syndrome are independent risk factors for stroke-associated pneumonia. Screening for immunodepression and dysphagia might be useful for identifying patients at high risk for stroke-associated pneumonia.

Early Cardiac Arrest in Patients Hospitalized With Pneumonia

PubMed Central

Yuen, Trevor C.; McConville, John F.; Kress, John P.; VandenHoek, Terry L.; Hall, Jesse B.; Edelson, Dana P.

2012-01-01

Background: Pneumonia is the leading infectious cause of death. Early deterioration and death commonly result from progressive sepsis, shock, respiratory failure, and cardiac complications. Recent data suggest that cardiac arrest may also be common, yet few previous studies have addressed this. Accordingly, we sought to characterize early cardiac arrest in patients who are hospitalized with coexisting pneumonia. Methods: We performed a retrospective analysis of a multicenter cardiac arrest database, with data from > 500 North American hospitals. We included in-hospital cardiac arrest events that occurred in community-dwelling adults with pneumonia within the first 72 h after hospital admission. We compared patient and event characteristics for patients with and without pneumonia. For patients with pneumonia, we also compared events according to event location. Results: We identified 4,453 episodes of early cardiac arrest in patients who were hospitalized with pneumonia. Among patients with preexisting pneumonia, only 36.5% were receiving mechanical ventilation and only 33.3% were receiving infusions of vasoactive drugs prior to cardiac arrest. Only 52.3% of patients on the ward were receiving ECG monitoring prior to cardiac arrest. Shockable rhythms were uncommon in all patients with pneumonia (ventricular tachycardia or fibrillation, 14.8%). Patients on the ward were significantly older than patients in the ICU. Conclusions: In patients with preexisting pneumonia, cardiac arrest may occur in the absence of preceding shock or respiratory failure. Physicians should be alert to the possibility of abrupt cardiopulmonary collapse, and future studies should address this possibility. The mechanism may involve myocardial ischemia, a maladaptive response to hypoxia, sepsis-related cardiomyopathy, or other phenomena. PMID:22194592

Conservative fluid management prevents age-associated ventilator induced mortality.

PubMed

Herbert, Joseph A; Valentine, Michael S; Saravanan, Nivi; Schneck, Matthew B; Pidaparti, Ramana; Fowler, Alpha A; Reynolds, Angela M; Heise, Rebecca L

2016-08-01

Approximately 800 thousand patients require mechanical ventilation in the United States annually with an in-hospital mortality rate of over 30%. The majority of patients requiring mechanical ventilation are over the age of 65 and advanced age is known to increase the severity of ventilator-induced lung injury (VILI) and in-hospital mortality rates. However, the mechanisms which predispose aging ventilator patients to increased mortality rates are not fully understood. Ventilation with conservative fluid management decreases mortality rates in acute respiratory distress patients, but to date there has been no investigation of the effect of conservative fluid management on VILI and ventilator associated mortality rates. We hypothesized that age-associated increases in susceptibility and incidence of pulmonary edema strongly promote age-related increases in ventilator associated mortality. 2month old and 20month old male C57BL6 mice were mechanically ventilated with either high tidal volume (HVT) or low tidal volume (LVT) for up to 4h with either liberal or conservative fluid support. During ventilation, lung compliance, total lung capacity, and hysteresis curves were quantified. Following ventilation, bronchoalveolar lavage fluid was analyzed for total protein content and inflammatory cell infiltration. Wet to dry ratios were used to directly measure edema in excised lungs. Lung histology was performed to quantify alveolar barrier damage/destruction. Age matched non-ventilated mice were used as controls. At 4h, both advanced age and HVT ventilation significantly increased markers of inflammation and injury, degraded pulmonary mechanics, and decreased survival rates. Conservative fluid support significantly diminished pulmonary edema and improved pulmonary mechanics by 1h in advanced age HVT subjects. In 4h ventilations, conservative fluid support significantly diminished pulmonary edema, improved lung mechanics, and resulted in significantly lower mortality rates in