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Soubirou JF, Gault N, Alfaiate T, Lolom I, Tubach F, Andremont A, Lucet JC, Wolff M, Barbier F. Ventilator-associated pneumonia due to carbapenem-resistant Gram-negative bacilli in an intensive care unit without carbapenemase-producing Enterobacteriaceae or epidemic Acinetobacter baumannii. ACTA ACUST UNITED AC 2014; 46:215-20. [PMID: 24447250 DOI: 10.3109/00365548.2013.871644] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Risk factors for ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Gram-negative bacilli (CR-GNB) have rarely been evaluated in intensive care units (ICU) without epidemic carbapenemase-producing Acinetobacter baumannii or Enterobacteriaceae. We addressed this issue in a cohort of 141 patients (previous antimicrobial exposure, n = 131) with a first episode of VAP in a medico-surgical ICU. Twenty-six VAP (18.4%) involved a CR-GNB (Pseudomonas aeruginosa, n = 14, Stenotrophomonas maltophilia, n = 11, and A. baumannii, n = 1), without previous carbapenem exposure in 12 (46.1%) cases. GNB resistant to all β-lactams except carbapenems were equally isolated in CR-GNB VAP (co-infections, 23%) and other episodes (30%). Previous exposure to aminoglycosides (odds ratio (OR) 1.14 per day, 95% confidence interval (CI) 1.02-1.30, p = 0.02) and the number of antimicrobial classes used before VAP (OR 1.38 per class, 95% CI 1.10-1.73, p = 0.006) were the only independent predictors of CR-GNB. These results suggest that the empirical use of a carbapenem-colistin combination should be evaluated in late-onset VAP following broad-spectrum antimicrobial exposure.
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Cataldi M, Sblendorio V, Leo A, Piazza O. Biofilm-dependent airway infections: a role for ambroxol? Pulm Pharmacol Ther 2013; 28:98-108. [PMID: 24252805 DOI: 10.1016/j.pupt.2013.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/31/2013] [Accepted: 11/11/2013] [Indexed: 11/16/2022]
Abstract
Biofilms are a key factor in the development of both acute and chronic airway infections. Their relevance is well established in ventilator associated pneumonia, one of the most severe complications in critically ill patients, and in cystic fibrosis, the most common lethal genetic disease in Caucasians. Accumulating evidence suggests that biofilms could have also a role in chronic obstructive pulmonary disease and their involvement in bronchiectasis has been proposed as well. When they grow in biofilms, microorganisms become multidrug-resistant. Therefore the treatment of biofilm-dependent airway infections is problematic. Indeed, it still largely based on measures aiming to prevent the formation of biofilms or remove them once that they are formed. Here we review recent evidence suggesting that the mucokinetic drug ambroxol has specific anti-biofilm properties. We also discuss how additional pharmacological properties of this drug could be beneficial in biofilm-dependent airway infections. Specifically, we review the evidence showing that: 1-ambroxol exerts anti-inflammatory effects by inhibiting at multiple levels the activity of neutrophils, and 2-it improves mucociliary clearance by interfering with the activity of airway epithelium ion channels and transporters including sodium/bicarbonate and sodium/potassium/chloride cotransporters, cystic fibrosis transmembrane conductance regulator and aquaporins. As a whole, the data that we review here suggest that ambroxol could be helpful in biofilm-dependent airway infections. However, considering the limited clinical evidence available up to date, further clinical studies are required to support the use of ambroxol in these diseases.
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Affiliation(s)
- M Cataldi
- Division of Pharmacology, Department of Neuroscience, Reproductive and Odontostomatologic Sciences, Federico II University of Naples, Via Pansini 5, 80131 Napoli, Italy.
| | - V Sblendorio
- Division of Pharmacology, Department of Neuroscience, Reproductive and Odontostomatologic Sciences, Federico II University of Naples, Via Pansini 5, 80131 Napoli, Italy
| | - A Leo
- Department of Health Sciences, University Magna Græcia of Catanzaro, University Campus "Salvatore Venuta", Viale Europa, I-88100 Catanzaro, Italy
| | - O Piazza
- University of Salerno, Via Allende, 84081 Baronissi, Italy
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Cobos-Trigueros N, Rinaudo M, Solé M, Castro P, Pumarol J, Hernández C, Fernández S, Nicolás JM, Mallolas J, Vila J, Morata L, Gatell JM, Soriano A, Mensa J, Martínez JA. Acquisition of resistant microorganisms and infections in HIV-infected patients admitted to the ICU. Eur J Clin Microbiol Infect Dis 2013; 33:611-20. [DOI: 10.1007/s10096-013-1995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 10/07/2013] [Indexed: 11/29/2022]
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Kollef MH. Ventilator-associated tracheobronchitis and ventilator-associated pneumonia: truth vs myth. Chest 2013; 144:3-5. [PMID: 23880669 DOI: 10.1378/chest.12-3015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Marin H Kollef
- From the Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.
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The author replies. Crit Care Med 2013; 41:e97. [DOI: 10.1097/ccm.0b013e318291b89e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Impact de la position du patient sur le risque de pneumonie acquise sous ventilation mécanique. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0681-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gandra S, Ellison RT. Modern trends in infection control practices in intensive care units. J Intensive Care Med 2013; 29:311-26. [PMID: 23753240 DOI: 10.1177/0885066613485215] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hospital-acquired infections (HAIs) are common in intensive care unit (ICU) patients and are associated with increased morbidity and mortality. There has been an increasing effort to prevent HAIs, and infection control practices are paramount in avoiding these complications. In the last several years, numerous developments have been seen in the infection prevention strategies in various health care settings. This article reviews the modern trends in infection control practices to prevent HAIs in ICUs with a focus on methods for monitoring hand hygiene, updates in isolation precautions, new methods for environmental cleaning, antimicrobial bathing, prevention of ventilator-associated pneumonia, central line-associated bloodstream infections, catheter-associated urinary tract infections, and Clostridium difficile infection.
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Affiliation(s)
- Sumanth Gandra
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Richard T Ellison
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA, USA
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Cotte J, Prunet B, Esnault P, Lacroix G, D'aranda E, Cungi PJ, Goutorbe P, Dantzer E, Meaudre E. Early onset pneumonia in patients with severely burned face and neck: a 5-year retrospective study. Burns 2013; 39:892-6. [PMID: 23332161 DOI: 10.1016/j.burns.2012.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 12/01/2012] [Accepted: 12/04/2012] [Indexed: 11/18/2022]
Abstract
Patients with face and neck burns (FNBs) often undergo prehospital intubation, or sustain inhalation injury which are risk factors for pneumonia in specific populations. Early onset pneumonia (EOP) might be caused by initial management. The primary goal of this study was to find risk factors for EOP in FNB patients. This is a retrospective, single-center trial. We screened all FNB patients for EOP with the Clinical Pulmonary Infection Score. Pneumonia diagnosis was with culture from a mini broncho-alveolar lavage. Potential risk factors for EOP were recorded. We included 152 patients, EOP was diagnosed in 58 (38.2%). EOP patients had a greater burned surface area median (20±17% vs. 10±17%; p<0.001), were more frequently intubated during prehospital care (65.5% vs. 21.3%; p<0.001), had more abnormal fiberoptic bronchoscopy at admission (58.6% vs. 19.1%; p=0.002) and a lower initial PaO2/FiO2 ratio (median 314±118.6 vs. 365±105.7; p=0.01). Multivariate analysis showed that only prehospital intubation was independently associated with EOP (odds ratio 3.6; 95% confidence interval, 1.34-10). Prehospital intubation appears to be an independent risk factor for EOP in severe burn patients. Assessments of the risk-benefit ratios of intubating and of not intubating those patients are indicated.
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Affiliation(s)
- Jean Cotte
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France.
| | - Bertrand Prunet
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre Esnault
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Guillaume Lacroix
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Erwan D'aranda
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre Julien Cungi
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Philippe Goutorbe
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Eric Dantzer
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Eric Meaudre
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
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Value of lower respiratory tract surveillance cultures to predict bacterial pathogens in ventilator-associated pneumonia: systematic review and diagnostic test accuracy meta-analysis. Intensive Care Med 2012. [PMID: 23188467 DOI: 10.1007/s00134-012-2759-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE In ventilator-associated pneumonia (VAP), early appropriate antimicrobial therapy may be hampered by involvement of multidrug-resistant (MDR) pathogens. METHODS A systematic review and diagnostic test accuracy meta-analysis were performed to analyse whether lower respiratory tract surveillance cultures accurately predict the causative pathogens of subsequent VAP in adult patients. Selection and assessment of eligibility were performed by three investigators by mutual consideration. Of the 525 studies retrieved, 14 were eligible for inclusion (all in English; published since 1994), accounting for 791 VAP episodes. The following data were collected: study and population characteristics; in- and exclusion criteria; diagnostic criteria for VAP; microbiological workup of surveillance and diagnostic VAP cultures. Sub-analyses were conducted for VAP caused by Staphylococcus aureus, Pseudomonas spp., and Acinetobacter spp., MDR microorganisms, frequency of sampling, and consideration of all versus the most recent surveillance cultures. RESULTS The meta-analysis showed a high accuracy of surveillance cultures, with pooled sensitivities up to 0.75 and specificities up to 0.92 in culture-positive VAP. The area under the curve (AUC) of the hierarchical summary receiver-operating characteristic curve demonstrates moderate accuracy (AUC: 0.90) in predicting multidrug resistance. A sampling frequency of >2/week (sensitivity 0.79; specificity 0.96) and consideration of only the most recent surveillance culture (sensitivity 0.78; specificity 0.96) are associated with a higher accuracy of prediction. CONCLUSIONS This study provides evidence for the benefit of surveillance cultures in predicting MDR bacterial pathogens in VAP. However, clinical and statistical heterogeneity, limited samples sizes, and bias remain important limitations of this meta-analysis.
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Zahar JR, Schwebel C, Adrie C, Garrouste-Orgeas M, Français A, Vesin A, Nguile-Makao M, Tabah A, Laupland K, Le-Monnier A, Timsit JF. Outcome of ICU patients with Clostridium difficile infection. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R215. [PMID: 23127327 PMCID: PMC3672590 DOI: 10.1186/cc11852] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 10/25/2012] [Indexed: 12/18/2022]
Abstract
INTRODUCTION As data from Clostridium difficile infection (CDI) in intensive care unit (ICU) are still scarce, our objectives were to assess the morbidity and mortality of ICU-acquired CDI. METHODS We compared patients with ICU-acquired CDI (watery or unformed stools occurring ≥ 72 hours after ICU admission with a stool sample positive for C. difficile toxin A or B) with two groups of controls hospitalized at the same time in the same unit. The first control group comprised patients with ICU-acquired diarrhea occurring ≥ 72 hours after ICU admission with a stool sample negative for C. difficile and for toxin A or B. The second group comprised patients without any diarrhea. RESULTS Among 5,260 patients, 512 patients developed one episode of diarrhea. Among them, 69 (13.5%) had a CDI; 10 (14.5%) of them were community-acquired, contrasting with 12 (17.4%) that were hospital-acquired and 47 (68%) that were ICU-acquired. A pseudomembranous colitis was associated in 24/47 (51%) ICU patients. The median delay between diagnosis and metronidazole administration was one day (25th Quartile; 75th Quartile (0; 2) days). The case-fatality rate for patients with ICU-acquired CDI was 10/47 (21.5%), as compared to 112/443 (25.3%) for patients with negative tests. Neither the crude mortality (cause specific hazard ratio; CSHR = 0.70, 95% confidence interval; CI 0.36 to 1.35, P = 0.3) nor the adjusted mortality to confounding variables (CSHR = 0.81, 95% CI 0.4 to 1.64, P = 0.6) were significantly different between CDI patients and diarrheic patients without CDI. Compared to the general ICU population, neither the crude mortality (SHR = 0.64, 95% CI 0.34 to 1.21, P = 0.17), nor the mortality adjusted to confounding variables (CSHR = 0.71, 95% confidence interval (CI) 0.38 to 1.35, P = 0.3), were significantly different between the two groups. The estimated increase in the duration of stay due to CDI was 8.0 days ± 9.3 days, (P = 0.4) in comparison to the diarrheic population, and 6.3 days ± 4.3 (P = 0.14) in comparison to the general ICU population. CONCLUSIONS If treated early, ICU-acquired CDI is not independently associated with an increased mortality and impacts marginally the ICU length of stay.
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Rapid detection of Staphylococcus aureus in lower respiratory tract secretions from patients with suspected ventilator-associated pneumonia: evaluation of the Cepheid Xpert MRSA/SA SSTI assay. J Clin Microbiol 2012; 50:4095-7. [PMID: 22993185 DOI: 10.1128/jcm.02409-12] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A preclinical evaluation was conducted to evaluate the performance of the Cepheid Xpert assay on 135 lower respiratory tract secretions for detection of methicillin-resistant Staphylococcus aureus and S. aureus. Compared with the quantitative culture, the sensitivity, specificity, and positive and negative predictive values were 99.0%, 72.2%, 90.7%, and 96.3%, respectively.
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Coeurjolly JF, Nguile-Makao M, Timsit JF, Liquet B. Attributable risk estimation for adjusted disability multistate models: Application to nosocomial infections. Biom J 2012; 54:600-16. [DOI: 10.1002/bimj.201100222] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 05/09/2012] [Accepted: 05/10/2012] [Indexed: 11/06/2022]
Affiliation(s)
- Jean-François Coeurjolly
- Laboratory Jean Kuntzmann; Department of Statistics; Grenoble University; 38041 Grenoble Cedex 9; France
| | | | | | - Benoit Liquet
- University Bordeaux Segalen; INSERM U897; 146 rue Leo Saignat; 33076; Bordeaux Cedex; France
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Liquet B, Timsit JF, Rondeau V. Investigating hospital heterogeneity with a multi-state frailty model: application to nosocomial pneumonia disease in intensive care units. BMC Med Res Methodol 2012; 12:79. [PMID: 22702430 PMCID: PMC3537543 DOI: 10.1186/1471-2288-12-79] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 05/10/2012] [Indexed: 12/05/2022] Open
Abstract
Background Multistate models have become increasingly useful to study the evolution of a patient’s state over time in intensive care units ICU (e.g. admission, infections, alive discharge or death in ICU). In addition, in critically-ill patients, data come from different ICUs, and because observations are clustered into groups (or units), the observed outcomes cannot be considered as independent. Thus a flexible multi-state model with random effects is needed to obtain valid outcome estimates. Methods We show how a simple multi-state frailty model can be used to study semi-competing risks while fully taking into account the clustering (in ICU) of the data and the longitudinal aspects of the data, including left truncation and right censoring. We suggest the use of independent frailty models or joint frailty models for the analysis of transition intensities. Two distinct models which differ in the definition of time t in the transition functions have been studied: semi-Markov models where the transitions depend on the waiting times and nonhomogenous Markov models where the transitions depend on the time since inclusion in the study. The parameters in the proposed multi-state model may conveniently be computed using a semi-parametric or parametric approach with an existing R package FrailtyPack for frailty models. The likelihood cross-validation criterion is proposed to guide the choice of a better fitting model. Results We illustrate the use of our approach though the analysis of nosocomial infections (ventilator-associated pneumonia infections: VAP) in ICU, with “alive discharge” and “death” in ICU as other endpoints. We show that the analysis of dependent survival data using a multi-state model without frailty terms may underestimate the variance of regression coefficients specific to each group, leading to incorrect inferences. Some factors are wrongly significantly associated based on the model without frailty terms. This result is confirmed by a short simulation study. We also present individual predictions of VAP underlining the usefulness of dynamic prognostic tools that can take into account the clustering of observations. Conclusions The use of multistate frailty models allows the analysis of very complex data. Such models could help improve the estimation of the impact of proposed prognostic features on each transition in a multi-centre study. We suggest a method and software that give accurate estimates and enables inference for any parameter or predictive quantity of interest.
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Affiliation(s)
- Benoit Liquet
- Univ. Bordeaux, ISPED, centre INSERM U-897-Epidémiologie-Biostatistique, Bordeaux, F-33000, France.
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Kwak HJ, Kim SH, Kim TH, Yoon HJ, Shin DH, Park SS, Sohn JW. Exhaled Nitric Oxide in Patients with Ventilator Associated Pneumonia. Korean J Crit Care Med 2012. [DOI: 10.4266/kjccm.2012.27.2.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Hyun Jung Kwak
- Department of Pulmonary and Critical Care Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sang-Heon Kim
- Department of Pulmonary and Critical Care Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Tae Hyung Kim
- Department of Pulmonary and Critical Care Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Ho Joo Yoon
- Department of Pulmonary and Critical Care Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dong Ho Shin
- Department of Pulmonary and Critical Care Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sung Soo Park
- Department of Pulmonary and Critical Care Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jang Won Sohn
- Department of Pulmonary and Critical Care Medicine, Hanyang University College of Medicine, Seoul, Korea
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