151
|
Lakbar I, Medam S, Ronflé R, Cassir N, Delamarre L, Hammad E, Lopez A, Lepape A, Machut A, Boucekine M, Zieleskiewicz L, Baumstarck K, Savey A, Leone M. Association between mortality and highly antimicrobial-resistant bacteria in intensive care unit-acquired pneumonia. Sci Rep 2021; 11:16497. [PMID: 34389761 PMCID: PMC8363636 DOI: 10.1038/s41598-021-95852-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/26/2021] [Indexed: 12/21/2022] Open
Abstract
Data on the relationship between antimicrobial resistance and mortality remain scarce, and this relationship needs to be investigated in intensive care units (ICUs). The aim of this study was to compare the ICU mortality rates between patients with ICU-acquired pneumonia due to highly antimicrobial-resistant (HAMR) bacteria and those with ICU-acquired pneumonia due to non-HAMR bacteria. We conducted a multicenter, retrospective cohort study using the French National Surveillance Network for Healthcare Associated Infection in ICUs ("REA-Raisin") database, gathering data from 200 ICUs from January 2007 to December 2016. We assessed all adult patients who were hospitalized for at least 48 h and presented with ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii. The association between pneumonia caused by HAMR bacteria and ICU mortality was analyzed using the whole sample and using a 1:2 matched sample. Among the 18,497 patients with at least one documented case of ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii, 3081 (16.4%) had HAMR bacteria. The HAMR group was associated with increased ICU mortality (40.3% vs. 30%, odds ratio (OR) 95%, CI 1.57 [1.45-1.70], P < 0.001). This association was confirmed in the matched sample (3006 HAMR and 5640 non-HAMR, OR 95%, CI 1.39 [1.27-1.52], P < 0.001) and after adjusting for confounding factors (OR ranged from 1.34 to 1.39, all P < 0.001). Our findings suggest that ICU-acquired pneumonia due to HAMR bacteria is associated with an increased ICU mortality rate, ICU length of stay, and mechanical ventilation duration.
Collapse
Affiliation(s)
- Ines Lakbar
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France.,Department of Anesthesiology and Intensive Care Unit, University hospital of Toulouse, Toulouse, France
| | - Sophie Medam
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Romain Ronflé
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Nadim Cassir
- MEPHI, IHU Méditerranée Infection, Aix Marseille Université, Marseille, France
| | - Louis Delamarre
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France.,Department of Anesthesiology and Intensive Care Unit, University hospital of Toulouse, Toulouse, France
| | - Emmanuelle Hammad
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Alexandre Lopez
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France.,MEPHI, IHU Méditerranée Infection, Aix Marseille Université, Marseille, France
| | - Alain Lepape
- Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre Bénite, Hospices Civils de Lyon, France.,Rea-Raisin study group (National network for Healthcare-Associated Infection surveillance in ICU, Marseille, France.,PHE3ID, Centre International de Recherche en Infectiologie, INSERM U1111, CNRS Unité Mixte de Recherche 5308, ENS de Lyon, Université Claude Bernard Lyon 1, Saint Genis Laval, France
| | - Anaïs Machut
- Rea-Raisin study group (National network for Healthcare-Associated Infection surveillance in ICU, Marseille, France.,Infection Control & Prevention, Hôpital Henry Gabrielle, Hospices Civils de Lyon, Saint Genis Laval, France
| | - Mohamed Boucekine
- APHM, EA 3279 CEReSS, School of Medicine, La Timone Medical Campus, Health Service Research and Quality of Life Center, Aix Marseille Université, Marseille, France
| | - Laurent Zieleskiewicz
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Karine Baumstarck
- APHM, EA 3279 CEReSS, School of Medicine, La Timone Medical Campus, Health Service Research and Quality of Life Center, Aix Marseille Université, Marseille, France
| | - Anne Savey
- Rea-Raisin study group (National network for Healthcare-Associated Infection surveillance in ICU, Marseille, France.,Infection Control & Prevention, Hôpital Henry Gabrielle, Hospices Civils de Lyon, Saint Genis Laval, France.,PHE3ID, Centre International de Recherche en Infectiologie, INSERM U1111, CNRS Unité Mixte de Recherche 5308, ENS de Lyon, Université Claude Bernard Lyon 1, Saint Genis Laval, France
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France. .,MEPHI, IHU Méditerranée Infection, Aix Marseille Université, Marseille, France. .,Service d'anesthésie et de réanimation, Chemin des Bourrely, Hôpital Nord, 13015, Marseille, France.
| | | |
Collapse
|
152
|
Wunderink RG, Roquilly A, Croce M, Rodriguez Gonzalez D, Fujimi S, Butterton JR, Broyde N, Popejoy MW, Kim JY, De Anda C. A Phase 3, Randomized, Double-Blind Study Comparing Tedizolid Phosphate and Linezolid for Treatment of Ventilated Gram-Positive Hospital-Acquired or Ventilator-Associated Bacterial Pneumonia. Clin Infect Dis 2021; 73:e710-e718. [PMID: 33720350 PMCID: PMC8326538 DOI: 10.1093/cid/ciab032] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) are associated with high mortality rates. We evaluated the efficacy and safety of tedizolid (administered as tedizolid phosphate) for treatment of gram-positive ventilated HABP/VABP. METHODS In this randomized, noninferiority, double-blind, double-dummy, global phase 3 trial, patients were randomized 1:1 to receive intravenous tedizolid phosphate 200 mg once daily for 7 days or intravenous linezolid 600 mg every 12 hours for 10 days. Treatment was 14 days in patients with concurrent gram-positive bacteremia. The primary efficacy end points were day 28 all-cause mortality (ACM; noninferiority margin, 10%) and investigator-assessed clinical response at test of cure (TOC; noninferiority margin, 12.5%) in the intention-to-treat population. RESULTS Overall, 726 patients were randomized (tedizolid, n = 366; linezolid, n = 360). Baseline characteristics, including incidence of methicillin-resistant Staphylococcus aureus (31.3% overall), were well balanced. Tedizolid was noninferior to linezolid for day 28 ACM rate: 28.1% and 26.4%, respectively (difference, -1.8%; 95% confidence interval [CI]: -8.2 to 4.7). Noninferiority of tedizolid was not demonstrated for investigator-assessed clinical cure at TOC (tedizolid, 56.3% vs linezolid, 63.9%; difference, -7.6%; 97.5% CI: -15.7 to 0.5). In post hoc analyses, no single factor accounted for the difference in clinical response between treatment groups. Drug-related adverse events occurred in 8.1% and 11.9% of patients who received tedizolid and linezolid, respectively. CONCLUSIONS Tedizolid was noninferior to linezolid for day 28 ACM in the treatment of gram-positive ventilated HABP/VABP. Noninferiority of tedizolid for investigator-assessed clinical response at TOC was not demonstrated. Both drugs were well tolerated. CLINICAL TRIALS REGISTRATION NCT02019420.
Collapse
Affiliation(s)
- Richard G Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Antoine Roquilly
- Université de Nantes, Centre Hospitalier Universitaire de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Service d’Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, F-44000
| | | | | | - Satoshi Fujimi
- Department of Trauma, Critical Care, and Emergency Medicine, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Joan R Butterton
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Natasha Broyde
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Myra W Popejoy
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Jason Y Kim
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
| | - Carisa De Anda
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey, USA
- Correspondence: Carisa De Anda, Merck & Co, Inc, 2000 Galloping Hill Rd, Kenilworth, NJ 07033, USA ()
| |
Collapse
|
153
|
Abujaber A, Fadlalla A, Gammoh D, Al-Thani H, El-Menyar A. Machine Learning Model to Predict Ventilator Associated Pneumonia in patients with Traumatic Brain Injury: The C.5 Decision Tree Approach. Brain Inj 2021; 35:1095-1102. [PMID: 34357830 DOI: 10.1080/02699052.2021.1959060] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is paucity in the literature to predict the occurrence of Ventilator Associated Pneumonia (VAP) in patients with Traumatic Brain Injury (TBI). We aimed to build a C.5. Decision Tree (C.5 DT) machine learning model to predict VAP in patients with moderate to severe TBI. METHODS This was a retrospective study including all adult patients who were hospitalized with TBI plus head abbreviated injury scale (AIS) ≥ 3 and were mechanically ventilated in a level 1 trauma center between 2014 and 2019. RESULTS A total of 772 eligible patients were enrolled, of them 169 had VAP (22%). The C.5 DT model achieved moderate performance with 83.5% accuracy, 80.5% area under the curve, 71% precision, 86% negative predictive value, 43% sensitivity, 95% specificity and 54% F-score. Out of 24 predictors, C.5 DT identified 5 variables predicting occurrence of VAP post-moderate to severe TBI (Time from injury to emergency department arrival, blood transfusion during resuscitation, comorbidities, Injury Severity Score and pneumothorax). CONCLUSIONS This study could serve as baseline for the quest of predicting VAP in patients with TBI through the utilization of C.5. DT machine learning approach. This model helps provide timely decision support to caregivers to improve patient's outcomes.
Collapse
Affiliation(s)
- Ahmad Abujaber
- Assistant Executive Director of Nursing, Hamad Medical Corporation, Doha, Qatar
| | - Adam Fadlalla
- Management Information Systems, Business, and Economics Faculty, Qatar University, Doha, Qatar
| | - Diala Gammoh
- Industrial Engineering, University of Central Florida- USA
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar.,Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| |
Collapse
|
154
|
Nseir S, Gaudet A. Continuous Control of Tracheal Cuff Pressure and Ventilator-Associated Pneumonia: Beyond Agate and Feng Shui. Chest 2021; 160:393-395. [PMID: 34366021 DOI: 10.1016/j.chest.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Saad Nseir
- Médecine Intensive-Réanimation, CHU de Lille, Lille, France; Unité de Glycobiologie Structurale et Fonctionnelle, Inserm U1285, Univ. Lille, Lille, France.
| | - Alexandre Gaudet
- Médecine Intensive-Réanimation, CHU de Lille, Lille, France; Centre d'Infection et d'Immunité de Lille, Univ. Lille, CHU de Lille, Institut Pasteur de Lille, Lille, France
| |
Collapse
|
155
|
Luo W, Xing R, Wang C. The effect of ventilator-associated pneumonia on the prognosis of intensive care unit patients within 90 days and 180 days. BMC Infect Dis 2021; 21:684. [PMID: 34266399 PMCID: PMC8280627 DOI: 10.1186/s12879-021-06383-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/17/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is often applied in critically ill patients in intensive care unit (ICU) to protect the airway from aspiration, and supplement more oxygen. MV may result in ventilator-associated pneumonia (VAP) in ICU patients. This study was to estimate the 90-day and 180-day mortalities of ICU patients with VAP, and to explore the influence of VAP on the outcomes of ICU patients. METHODS Totally, 8182 patients who aged ≥18 years and received mechanical ventilation (MV) in ICU from Medical Information Mart for Intensive Care III (MIMIC III) database were involved in this study. All subjects were divided into the VAP group (n = 537) and the non-VAP group (n = 7626) based on the occurrence of VAP. Clinical data of all participants were collected. The effect of VAP on the prognosis of ICU patients was explored by binary logistic regression analysis. RESULTS The results delineated that the 90-day mortality of VAP patients in ICU was 33.33% and 180-day mortality was 37.62%. The 90-day and 180-day mortality rates were higher in the VAP group than in the non-VAP group. After adjusting the confounders including age, ethnicity, heart failure, septicemia, simplified acute physiology score II (SAPSII) score, sequential organ failure assessment (SOFA) score, serum lactate, white blood cell (WBC), length of ICU stay, length of hospital stay, length of ventilation, antibiotic treatment, Pseudomonas aeruginosa (P.aeruginosa), methicillin-resistant Staphylococcus aureus (MRSA), other pathogens, the risk of 90-day and 180-day mortalities in VAP patients were 1.465 times (OR = 1.465, 95%CI: 1.188-1.807, P < 0.001) and 1.635 times (OR = 1.635, 95%CI: 1.333-2.005, P < 0.001) higher than those in non-VAP patients, respectively. CONCLUSIONS Our study revealed that ICU patients with VAP had poorer prognosis than those without VAP. The results of this study might offer a deeper insight into preventing the occurrence of VAP.
Collapse
Affiliation(s)
- Wenjuan Luo
- Department of Critical Care Medicine, Guangdong Second Provincial General Hospital, No.466 Xingang Middle Road, Guangzhou, 510000, Guangdong, China.
| | - Rui Xing
- Department of Critical Care Medicine, Guangdong Second Provincial General Hospital, No.466 Xingang Middle Road, Guangzhou, 510000, Guangdong, China
| | - Canmin Wang
- Department of Critical Care Medicine, Guangdong Second Provincial General Hospital, No.466 Xingang Middle Road, Guangzhou, 510000, Guangdong, China
| |
Collapse
|
156
|
Seitz A, Baker JE, Levinsky NC, Morris MC, Edwards MJ, Gulbins E, Blakeman TC, Rodriquez D, Branson RD, Goodman M. Antimicrobial coating prevents ventilator-associated pneumonia in a 72 hour large animal model. J Surg Res 2021; 267:424-431. [PMID: 34229130 DOI: 10.1016/j.jss.2021.05.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 04/22/2021] [Accepted: 05/27/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The primary goal of this study was to demonstrate that endotracheal tubes coated with antimicrobial lipids plus mucolytic or antimicrobial lipids with antibiotics plus mucolytic would significantly reduce pneumonia in the lungs of pigs after 72 hours of continuous mechanical ventilation compared to uncoated controls. MATERIALS AND METHODS Eighteen female pigs were mechanically ventilated for up to 72 hours through uncoated endotracheal tubes, endotracheal tubes coated with the antimicrobial lipid, octadecylamine, and the mucolytic, N-acetylcysteine, or tubes coated with octadecylamine, N-acetylcysteine, doxycycline, and levofloxacin (6 pigs per group). No exogenous bacteria were inoculated into the pigs, pneumonia resulted from the pigs' endogenous oral flora. Vital signs were recorded every 15 minutes and arterial blood gas measurements were obtained for the duration of the experiment. Pigs were sacrificed either after completion of 72 hours of mechanical ventilation or just prior to hypoxic arrest. Lungs, trachea, and endotracheal tubes were harvested for analysis to include bacterial counts of lung, trachea, and endotracheal tubes, lung wet and dry weights, and lung tissue for histology. RESULTS Pigs ventilated with coated endotracheal tubes were less hypoxic, had less bacterial colonization of the lungs, and survived significantly longer than pigs ventilated with uncoated tubes. Octadecylamine-N-acetylcysteine-doxycycline-levofloxacin coated endotracheal tubes had less bacterial colonization than uncoated or octadecylamine-N-acetylcysteine coated tubes. CONCLUSION Endotracheal tubes coated with antimicrobial lipids plus mucolytic and antimicrobial lipids with antibiotics plus mucolytic reduced bacterial colonization of pig lungs after prolonged mechanical ventilation and may be an effective strategy to reduce ventilator-associated pneumonia.
Collapse
Affiliation(s)
- Aaron Seitz
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
| | - Jennifer E Baker
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Nick C Levinsky
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mackenzie C Morris
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael J Edwards
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Erich Gulbins
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio; Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thomas C Blakeman
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Dario Rodriquez
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Richard D Branson
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael Goodman
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| |
Collapse
|
157
|
Impact of Cardiovascular Failure in Intensive CareUnit-Acquired Pneumonia: A Single-Center, Prospective Study. Antibiotics (Basel) 2021; 10:antibiotics10070798. [PMID: 34209181 PMCID: PMC8300830 DOI: 10.3390/antibiotics10070798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 01/20/2023] Open
Abstract
Background: Cardiovascular failure (CVF) may complicate intensive care unit-acquired pneumonia (ICUAP) and radically alters the empirical treatment of this condition. The aim of this study was to determine the impact of CVF on outcome in patients with ICUAP. Methods: A prospective, single-center, observational study was conducted in six medical and surgical ICUs at a University Hospital. CVS was defined as a score of 3 or more on the cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score. At the onset of ICUAP, CVF was reported as absent, transient (if lasting ≤ 3 days) or persistent (>3 days). The primary outcome was 90-day mortality modelled through a Cox regression analysis. Secondary outcomes were 28-day mortality, hospital mortality, ICU length of stay (LOS) and hospital LOS. Results: 358 patients were enrolled: 203 (57%) without CVF, 82 (23%) with transient CVF, and 73 (20%) with persistent CVF. Patients with transient and persistent CVF were more severely ill and presented higher inflammatory response than those without CVF. Despite having similar severity and aetiology, the persistent CVF group more frequently received inadequate initial antibiotic treatment and presented more treatment failures than the transient CVF group. In the persistent CVF group, at day 3, a bacterial superinfection was more frequently detected. The 90-day mortality was significantly higher in the persistent CVF group (62%). The 28-day mortality rates for patients without CVF, with transient and with persistent CVF were 19, 35 and 41% respectively and ICU mortality was 60, 38 and 19% respectively. In the multivariate analysis chronic pulmonary conditions, lack of Pa02/FiO2 improvement at day 3, pulmonary superinfection at day 3 and persistent CVF were independently associated with 90-day mortality in ICUAP patients. Conclusions: Persistent CVF has a significant impact on the outcome of patients with ICUAP. Patients at risk from persistent CVF should be promptly recognized to optimize treatment and outcomes.
Collapse
|
158
|
Li Y, Yuan X, Sun B, Li HC, Chu HW, Wang L, Zhao Y, Tang X, Wang R, Li XY, Tong ZH, Wang C. Rapid-flow expulsion maneuver in subglottic secretion clearance to prevent ventilator-associated pneumonia: a randomized controlled study. Ann Intensive Care 2021; 11:98. [PMID: 34165661 PMCID: PMC8222955 DOI: 10.1186/s13613-021-00887-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/14/2021] [Indexed: 11/25/2022] Open
Abstract
Background Following endotracheal intubation, clearing secretions above the endotracheal tube cuff decreases the incidence of ventilator-associated pneumonia (VAP); therefore, subglottic secretion drainage (SSD) is widely advocated. Our group developed a novel technique to remove the subglottic secretions, the rapid-flow expulsion maneuver (RFEM). The objective of this study was to explore the effectiveness and safety of RFEM compared with SSD. Methods This study was a single-center, prospective, randomized and controlled trial, conducted at Respiratory Intensive Care Unit (ICU) of Beijing Chao-Yang Hospital, a university-affiliated tertiary hospital. The primary outcome was the incidence of VAP, assessed for non-inferiority. Results Patients with an endotracheal tube allowing drainage of subglottic secretions (n = 241) were randomly assigned to either the RFEM group (n = 120) or SSD group (n = 121). Eleven patients (9.17%) in the RFEM group and 13 (10.74%) in the SSD group developed VAP (difference, − 1.59; 95% confidence interval [CI] [− 9.20 6.03]), as the upper limit of 95% CI was not greater than the pre-defined non-inferiority limit (10%), RFEM was declared non-inferior to SSD. There were no statistically significant differences in the duration of mechanical ventilation, ICU mortality, or ICU length of stay and costs between groups. In terms of safety, no accidental extubation or maneuver-related barotrauma occurred in the RFEM group. The incidence of post-extubation laryngeal edema and reintubation was similar in both groups. Conclusions RFEM is effective and safe, with non-inferiority compared to SSD in terms of the incidence of VAP. RFEM could be an alternative method in first-line treatment of respiratory ICU patients. Trial registration This study has been registered on ClinicalTrials.gov (Registration Number: NCT02032849, https://clinicaltrials.gov/ct2/show/NCT02032849); registered on January 2014 Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00887-5.
Collapse
Affiliation(s)
- Ying Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Xue Yuan
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Bing Sun
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China. .,Beijing Institute of Respiratory Medicine, Beijing, China. .,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China. .,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China.
| | - Hai-Chao Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Hui-Wen Chu
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Li Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Yu Zhao
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Xiao Tang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Rui Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Xu-Yan Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Zhao-Hui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gongtinan Road, Beijing, 100020, China.,Beijing Institute of Respiratory Medicine, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,Beijing Engineering Research Centre for Diagnosis and Treatment of Respiratory and Critical Care Medicine (Beijing Chao-Yang Hospital), Beijing, China
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Respiratory Medicine, Capital Medical University, Beijing, China
| |
Collapse
|
159
|
Núñez SA, Roveda G, Zárate MS, Emmerich M, Verón MT. Ventilator-associated pneumonia in patients on prolonged mechanical ventilation: description, risk factors for mortality, and performance of the SOFA score. ACTA ACUST UNITED AC 2021; 47:e20200569. [PMID: 34190861 PMCID: PMC8332725 DOI: 10.36416/1806-3756/e20200569] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/22/2021] [Indexed: 12/30/2022]
Abstract
Objective: Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation (MV). However, data on VAP in patients on prolonged MV (PMV) are scarce. We aimed to describe the characteristics of VAP patients on PMV and to identify factors associated with mortality. Methods: This was a retrospective cohort study including VAP patients on PMV. We recorded baseline characteristics, as well as 30-day and 90-day mortality rates. Variables associated with mortality were determined by Kaplan-Meier survival analysis and Cox regression model. Results: We identified 80 episodes of VAP in 62 subjects on PMV. The medians for age, Charlson Comorbidity Index, SOFA score, and days on MV were, respectively, 69.5 years, 5, 4, and 56 days. Episodes of VAP occurred between days 21 and 50 of MV in 28 patients (45.2%) and, by day 90 of MV, in 48 patients (77.4%). The 30-day and 90-day mortality rates were 30.0% and 63.7%, respectively. There were associations of 30-day mortality with the SOFA score (hazard ratio [HR] = 1.30; 95% CI: 1.12-1.52; p < 0.001) and use of vasoactive agents (HR = 4.0; 95% CI: 1.2-12.9; p = 0.02), whereas 90-day mortality was associated with age (HR = 1.03; 95% CI: 1.00-1.05; p = 0.003), SOFA score (HR = 1.20; 95% CI: 1.07-1.34; p = 0.001), use of vasoactive agents (HR = 4.07; 95% CI: 1.93-8.55; p < 0.001), and COPD (HR = 3.35; 95% CI: 1.71-6.60; p < 0.001). Conclusions: Mortality rates in VAP patients on PMV are considerably high. The onset of VAP can occur various days after MV initiation. The SOFA score is useful for predicting fatal outcomes. The factors associated with mortality could help guide therapeutic decisions and determine prognosis.
Collapse
Affiliation(s)
| | | | | | - Mónica Emmerich
- . Unidad de Paciente Critico Crónico, Sanatorio Güemes, Buenos Aires, Argentina
| | | |
Collapse
|
160
|
Tang R, Luo R, Wu B, Wang F, Song H, Chen X. Effectiveness and safety of adjunctive inhaled antibiotics for ventilator-associated pneumonia: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2021; 65:133-139. [PMID: 34144265 DOI: 10.1016/j.jcrc.2021.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The efficacy and safety of adjunctive inhaled antibiotic therapy for ventilator-associated pneumonia (VAP) was systematically reviewed based on updated studies. METHODS We searched four databases and four clinical trial registration platforms to identify relevant studies published prior to May 19, 2020. Randomized controlled trials (RCTs) assessing adjunctive antibiotic inhalation treatment for VAP patients were eligible for this review. Two reviewers independently screened the articles and extracted the data. Information on inhaled therapy and clinical outcomes was collected. Study quality was assessed with the Cochrane risk of bias tool. The meta-analysis was conducted with Review Manager and R software. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines were used to evaluate the quality of evidence for each pooled outcome. RESULTS Eleven RCTs and 1210 patients were included in this analysis after the application of the inclusion and exclusion criteria. Compared with the use of intravenous injection alone, the use of adjunctive inhaled antibiotic therapy improved the rates of clinical cure (relative risk (RR) 1.13, 95% CI [1.02,1.26]) and microbiological eradication (RR 1.45, 95% CI [1.19,1.76]) in VAP patients. However, despite these improvements, mortality was not reduced (RR 1.00, 95% CI [0.82,1.21]). Adjunctive antibiotics delivered through the respiratory tract were not associated with a higher risk of renal impairment but were associated with an increased risk of bronchospasm (RR 2.74, 95% CI [1.31,5.73] during treatment. CONCLUSIONS Adjunctive inhaled antibiotics improved the clinical outcomes in VAP patients, but the increased rates clinical cure and microbiological eradication were not associated with reduced mortality. The use of nebulized antibiotics is not supported by the currently available evidence as a routine therapeutic strategy for VAP. PROSPERO REGISTRATION NUMBER CRD42020186970.
Collapse
Affiliation(s)
- Rui Tang
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China.
| | - Rui Luo
- Department of Pain Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bin Wu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Fusheng Wang
- Department of Critical Care, The Sixth Affiliated Hospital of Kunming Medical University, Kunming Medical University, Yuxi, China
| | - Haoxin Song
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiujuan Chen
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
161
|
Watson K, Reoch J, Heales LJ, Fernando J, Tan E, Smith K, Austin D, Divanoglou A. The incidence and characteristics of ventilator-associated pneumonia in a regional nontertiary Australian intensive care unit: A retrospective clinical audit study. Aust Crit Care 2021; 35:294-301. [PMID: 34144862 DOI: 10.1016/j.aucc.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation in the intensive care unit. The incidence, patient characteristics, and outcomes have not been described in a regional Australian setting. OBJECTIVES Τhe primary objective was to establish the incidence of VAP in a regional intensive care unit using predetermined diagnostic criteria. The secondary objective was to compare the agreement between criteria-based and physician-based diagnostic processes. The tertiary objectives were to compare patient characteristics and clinical outcomes of cases with and without VAP. METHODS A retrospective clinical audit was performed of adult patients admitted to Rockhampton Intensive Care Unit, Australia, between 2013 and 2016. We included all patients ventilated for ≥72 h and not diagnosed with a pneumonia before or during the first 72 h of ventilation. RESULTS A total of 170 cases met the inclusion criteria. The incidence of VAP as per the criteria-based diagnosis was 27.3 cases per 1000 ventilator days (95% confidence interval [CI]: 18.4-36.2) and as per the physician-based diagnosis was 25.8 cases per 1000 ventilator days (95% CI: 17.1-34.4). There was a moderate chance-corrected agreement between the criteria- and physician-based diagnosis. Very obese cases (body mass index [BMI] ≥40) were nearly four times more likely to develop VAP than cases with normal BMI (BMI <30) (odds ratio: 3.664; 95% CI: 1.394-9.634; p = 0.008). After controlling for sex, BMI category, comorbidities, and Acute Physiology and Chronic Health Evaluation II scores, there was a trend (p = 0.283) for higher adjusted mortality rate for cases with VAP (10.1%, 95% CI: 4.8-21.5) than for those without VAP (6.1%, 95% CI: 3.0-12.4). Cases with VAP had a higher total hospital cost ($123,223 AUD vs $66,425 AUD, p < 0.001), than cases without VAP. CONCLUSIONS This is the first study reporting incidence of VAP in an Australian regional intensive care unit setting. An increased length of stay and significantly higher hospital costs warrant research investigating reliable and valid clinical prediction rules to forecast those at risk of VAP.
Collapse
Affiliation(s)
- Kirsty Watson
- Intensive Care Unit, Rockhampton Hospital, Rockhampton, QLD, Australia; Allied Health, Rockhampton Hospital, Rockhampton, QLD, Australia.
| | - Josephine Reoch
- Intensive Care Unit, Rockhampton Hospital, Rockhampton, QLD, Australia.
| | - Luke J Heales
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, QLD, Australia.
| | - Jeremy Fernando
- Rural Clinical School, Rockhampton, University of Queensland, Australia.
| | - Elise Tan
- Intensive Care Unit, Rockhampton Hospital, Rockhampton, QLD, Australia.
| | - Karen Smith
- Intensive Care Unit, Rockhampton Hospital, Rockhampton, QLD, Australia.
| | - David Austin
- Intensive Care Unit, Rockhampton Hospital, Rockhampton, QLD, Australia.
| | - Anestis Divanoglou
- Department of Rehabilitation Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| |
Collapse
|
162
|
Papajk J, Mezerová K, Uvízl R, Štosová T, Kolář M. Clonal Diversity of Klebsiella spp. and Escherichia spp. Strains Isolated from Patients with Ventilator-Associated Pneumonia. Antibiotics (Basel) 2021; 10:antibiotics10060674. [PMID: 34198723 PMCID: PMC8228920 DOI: 10.3390/antibiotics10060674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 11/21/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is one of the most severe complications affecting mechanically ventilated patients. The condition is caused by microaspiration of potentially pathogenic bacteria from the upper respiratory tract into the lower respiratory tract or by bacterial pathogens from exogenous sources such as healthcare personnel, devices, aids, fluids and air. The aim of our prospective, observational study was to confirm the hypothesis that in the etiology of VAP, an important role is played by etiological agents from the upper airway bacterial microflora. At the same time, we studied the hypothesis that the vertical spread of bacterial pathogens is more frequent than their horizontal spread among patients. A total of 697 patients required mechanical ventilation for more than 48 h. The criteria for VAP were met by 47 patients. Clonality of bacterial isolates from 20 patients was determined by comparing their macrorestriction profiles obtained by pulsed-field gel electrophoresis (PFGE). Among these 20 patients, a total of 29 PFGE pulsotypes of Klebsiella spp. and Escherichia spp. strains were observed. The high variability of clones proves that there was no circulation of bacterial pathogens among hospitalized patients. Our finding confirms the development of VAP as a result of bacterial microaspiration and therefore the endogenous origin of VAP.
Collapse
Affiliation(s)
- Jan Papajk
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Olomouc, 77900 Olomouc, Czech Republic; (J.P.); (R.U.)
| | - Kristýna Mezerová
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacký University Olomouc, 77515 Olomouc, Czech Republic
- Correspondence:
| | - Radovan Uvízl
- Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Olomouc, 77900 Olomouc, Czech Republic; (J.P.); (R.U.)
| | - Taťána Štosová
- Department of Microbiology, University Hospital Olomouc, 77515 Olomouc, Czech Republic; (T.Š.); (M.K.)
| | - Milan Kolář
- Department of Microbiology, University Hospital Olomouc, 77515 Olomouc, Czech Republic; (T.Š.); (M.K.)
| |
Collapse
|
163
|
Influence of microbiological culture results on antibiotic choices for veterans with hospital-acquired pneumonia and ventilator-associated pneumonia. Infect Control Hosp Epidemiol 2021; 43:589-596. [PMID: 34085618 DOI: 10.1017/ice.2021.186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE We examined the impact of microbiological results from respiratory samples on choice of antibiotic therapy in patients treated for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP). DESIGN Four-year retrospective study. SETTING Veterans' Health Administration (VHA). PATIENTS VHA patients hospitalized with HAP or VAP and with respiratory cultures between October 1, 2014, and September 30, 2018. INTERVENTIONS We compared patients with positive and negative respiratory culture results, assessing changes in antibiotic class and Antibiotic Spectrum Index (ASI) from the day of sample collection (day 0) through day 7. RESULTS Between October 1, 2014, and September 30, 2018, we identified 5,086 patients with HAP/VAP: 2,952 with positive culture results and 2,134 with negative culture results. All-cause 30-day mortality was 21% for both groups. The mean time from respiratory sample receipt in the laboratory to final respiratory culture result was longer for those with positive (2.9 ± 1.3 days) compared to negative results (2.5 ± 1.3 days; P < .001). The most common pathogens were Staphylococcus aureus and Pseudomonas aeruginosa. Vancomycin and β-lactam/β-lactamase inhibitors were the most commonly prescribed agents. The decrease in the median ASI from 13 to 8 between days 0 and 6 was similar among patients with positive and negative respiratory cultures. Patients with negative cultures were more likely to be off antibiotics from day 3 onward. CONCLUSIONS The results of respiratory cultures had only a small influence on antibiotics used during the treatment of HAP/VAP. The decrease in ASI for both groups suggests the integration of antibiotic stewardship principles, including de-escalation, into the care of patients with HAP/VAP.
Collapse
|
164
|
Aretha D, Kiekkas P. Obesity and the Incidence of Ventilator-Associated Pneumonia in Critically Ill Patients With Shock: The Paradox Persists. Chest 2021; 159:2135-2136. [PMID: 34099118 DOI: 10.1016/j.chest.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/06/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Diamanto Aretha
- Anesthesiology and Intensive Care Medicine, University General Hospital of Patras, Patras, Greece.
| | | |
Collapse
|
165
|
Nseir S, Martin-Loeches I, Povoa P, Metzelard M, Du Cheyron D, Lambiotte F, Tamion F, Labruyere M, Makris D, Boulle Geronimi C, Pinetonde Chambrun M, Nyunga M, Pouly O, Mégarbane B, Saade A, Gomà G, Magira E, Llitjos JF, Torres A, Ioannidou I, Pierre A, Coelho L, Reignier J, Garot D, Kreitmann L, Baudel JL, Voiriot G, Contou D, Beurton A, Asfar P, Boyer A, Thille AW, Mekontso-Dessap A, Tsolaki V, Vinsonneau C, Floch PE, Le Guennec L, Ceccato A, Artigas A, Bouchereau M, Labreuche J, Duhamel A, Rouzé A. Relationship between ventilator-associated pneumonia and mortality in COVID-19 patients: a planned ancillary analysis of the coVAPid cohort. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:177. [PMID: 34034777 PMCID: PMC8146175 DOI: 10.1186/s13054-021-03588-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/27/2021] [Indexed: 11/10/2022]
Abstract
Background Patients with SARS-CoV-2 infection are at higher risk for ventilator-associated pneumonia (VAP). No study has evaluated the relationship between VAP and mortality in this population, or compared this relationship between SARS-CoV-2 patients and other populations. The main objective of our study was to determine the relationship between VAP and mortality in SARS-CoV-2 patients. Methods Planned ancillary analysis of a multicenter retrospective European cohort. VAP was diagnosed using clinical, radiological and quantitative microbiological criteria. Univariable and multivariable marginal Cox’s regression models, with cause-specific hazard for duration of mechanical ventilation and ICU stay, were used to compare outcomes between study groups. Extubation, and ICU discharge alive were considered as events of interest, and mortality as competing event.
Findings Of 1576 included patients, 568 were SARS-CoV-2 pneumonia, 482 influenza pneumonia, and 526 no evidence of viral infection at ICU admission. VAP was associated with significantly higher risk for 28-day mortality in SARS-CoV-2 group (adjusted HR 1.65 (95% CI 1.11–2.46), p = 0.013), but not in influenza (1.74 (0.99–3.06), p = 0.052), or no viral infection groups (1.13 (0.68–1.86), p = 0.63). VAP was associated with significantly longer duration of mechanical ventilation in the SARS-CoV-2 group, but not in the influenza or no viral infection groups. VAP was associated with significantly longer duration of ICU stay in the 3 study groups. No significant difference was found in heterogeneity of outcomes related to VAP between the 3 groups, suggesting that the impact of VAP on mortality was not different between study groups. Interpretation VAP was associated with significantly increased 28-day mortality rate in SARS-CoV-2 patients. However, SARS-CoV-2 pneumonia, as compared to influenza pneumonia or no viral infection, did not significantly modify the relationship between VAP and 28-day mortality.
Clinical trial registration The study was registered at ClinicalTrials.gov, number NCT04359693. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03588-4.
Collapse
Affiliation(s)
- Saad Nseir
- Médecine Intensive-Réanimation, CHU de Lille, F-59000, Lille, France. .,Inserm U1285, CNRS, UMR 8576-UGSF-Unité de Glycobiologie Structurale et Fonctionnelle, Univ. Lille, Lille, France.
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St. James Street, Dublin 8, Dublin, Eire, Ireland.,Hospital Clinic, IDIBAPS, Universided de Barcelona, CIBERes, Barcelona, Spain
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, and NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | | | - Damien Du Cheyron
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France
| | - Fabien Lambiotte
- Service de Réanimation Polyvalente, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Fabienne Tamion
- Medical Intensive Care Unit, Rouen University Hospital, Normandie Université, UNIROUEN, Inserm U1096, FHU-REMOD-VHF, 76000, Rouen, France
| | - Marie Labruyere
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Demosthenes Makris
- Intensive Care Unit, University Hospital of Larissa, University of Thessaly, 41110, Biopolis Larissa, Greece
| | - Claire Boulle Geronimi
- Service de Réanimation Et de Soins Intensifs, Centre Hospitalier de Douai, Route de Cambrai, Douai, France
| | - Marc Pinetonde Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | | | - Olivier Pouly
- Médecine Intensive Réanimation, Hôpital Saint Philibert GHICL, Université Catholique, Lille, France
| | - Bruno Mégarbane
- Réanimation Médicale Et Toxicologique, Hôpital Lariboisière, Université de Paris, INSERM UMRS-1144, Paris, France
| | - Anastasia Saade
- Service de Médecine Intensive Et Réanimation, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Gemma Gomà
- Critical Care Department, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - Eleni Magira
- 1St Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos Hospital, Athens, Greece
| | - Jean-François Llitjos
- Medical Intensive Care Unit, Cochin Hospital, AP-HP. Centre, Université de Paris, Paris, France
| | - Antoni Torres
- Department of Pulmonology, Hospital Clinic Barcelona, University of Barcelona, IDIBAPS, CIBERES, ICREA, Barcelona, Spain
| | - Iliana Ioannidou
- 1St Department of Pulmonary Medicine and Intensive Care Unit, National and Kapodistrian University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | | | - Luis Coelho
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, and NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France
| | - Denis Garot
- Service de Médecine Intensive Réanimation, CHU de Tours, Hôpital Bretonneau, 2 Bd Tonnellé, 37000, Tours, France
| | - Louis Kreitmann
- Service de Médecine Intensive - Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 5, place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Jean-Luc Baudel
- Service de Médecine Intensive Réanimation, AP-HP, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Guillaume Voiriot
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, Paris, France
| | - Damien Contou
- Réanimation Polyvalente, CH Victor Dupouy, Argenteuil, France
| | - Alexandra Beurton
- Service de Pneumologie, Médecine Intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale Et Clinique, Paris, France
| | - Pierre Asfar
- Département de Médecine Intensive-Réanimation, CHU D'Angers, Université D'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Alexandre Boyer
- Intensive Care Unit, Pellegrin-Tripode Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Arnaud W Thille
- CHU de Poitiers, Médecine Intensive Réanimation, CIC 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Armand Mekontso-Dessap
- APHP, CHU Henri Mondor, Service de Médecine Intensive RéanimationUniversité Paris Est-Créteil, Faculté de Santé, Groupe de Recherche Clinique CARMASINSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Vassiliki Tsolaki
- Intensive Care Unit, University Hospital of Larissa, University of Thessaly, 41110, Biopolis Larissa, Greece
| | - Christophe Vinsonneau
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Béthune, Réseau de Recherche Boréal, 62408, Béthune, France
| | - Pierre-Edouard Floch
- Service de Réanimation, Hôpital Duchenne, Rue Monod, 62200, Boulogne-sur-Mer, France
| | - Loïc Le Guennec
- Sorbonne Université, AP-HP, Hôpital de La Pitié-Salpêtrière, Département de Neurologie, Unité de Médecine Intensive Réanimation Neurologique, Paris, France
| | - Adrian Ceccato
- Intensive Care Unit, Hospital Universitari Sagrat Cor, and Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028)-Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Antonio Artigas
- Critical Care Center, Corporacion Sanitaria Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Parc Tauli 1, 08028, Sabadell, Spain
| | | | - Julien Labreuche
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation Des Technologies de Santé Et Des Pratiques Médicales, 59000, Lille, France
| | - Alain Duhamel
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation Des Technologies de Santé Et Des Pratiques Médicales, 59000, Lille, France
| | - Anahita Rouzé
- Médecine Intensive-Réanimation, CHU de Lille, F-59000, Lille, France.,Inserm U1285, CNRS, UMR 8576-UGSF-Unité de Glycobiologie Structurale et Fonctionnelle, Univ. Lille, Lille, France
| | | |
Collapse
|
166
|
Mancini CM, Wimmer M, Schulz LT, Zhang Y, Fu X, Postelnick M, Bhowmick T, Lee F, Blumenthal KG. Association of Penicillin or Cephalosporin Allergy Documentation and Antibiotic Use in Hospitalized Patients with Pneumonia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3060-3068.e1. [PMID: 34029776 DOI: 10.1016/j.jaip.2021.04.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/31/2021] [Accepted: 04/29/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Treatment guidelines for pneumonia recommend beta-lactam antibiotic-based therapy. Although reported penicillin allergy is common, more than 90% of patients with reported penicillin allergy are not allergic. OBJECTIVE We evaluated the association of a documented penicillin and/or cephalosporin (P/C) allergy to antibiotic use for the treatment of inpatient pneumonia. METHODS This was a national cross-sectional study conducted among Vizient, Inc., network hospitals that voluntarily contributed data. Among hospitalized patients with pneumonia, we examined the relation of a documented P/C allergy in the electronic health record to prevalence of first-line beta-lactam antibiotic administration and alternative antibiotics using multivariable log-binomial regression with generalized estimating equations. RESULTS Of 2,276 inpatients receiving antibiotics for pneumonia at 95 U.S. hospitals, 450 (20%) had a documented P/C allergy. Compared with pneumonia patients without a documented P/C allergy, patients with a documented P/C allergy had reduced prevalence of first-line beta-lactam antibiotic use (adjusted prevalence ratio [aPR] 0.79; 95% confidence interval [95% CI] 0.69-0.89]). Patients with high-risk P/C reactions (n = 91) had even lower prevalence of first-line beta-lactam antibiotic use (aPR 0.47; 95% CI 0.35-0.64). Alternative antibiotics associated with a higher use in pneumonia patients with a documented P/C allergy included carbapenems (aPR 1.61; 95% CI 1.22-2.13) and fluoroquinolones (aPR 1.52; 95% CI 1.21-1.91). CONCLUSIONS Inpatients with documented P/C allergy and pneumonia were less likely to receive recommended beta-lactams and more likely to receive carbapenems and fluoroquinolones. Inpatient allergy assessment may improve optimal antibiotic therapy for the 20% of inpatients with pneumonia and a documented P/C allergy.
Collapse
Affiliation(s)
- Christian M Mancini
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, The Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | - Megan Wimmer
- Department of Pharmacy, University of Wisconsin Health, Madison, Wis
| | - Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Health, Madison, Wis
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, The Mongan Institute, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Clinical Epidemiology Research and Training, Boston University School of Medicine, Boston, Mass
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, The Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | | | - Tanaya Bhowmick
- Division of Allergy, Immunology, and Infectious Diseases, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Francesca Lee
- Department of Pathology and Internal Medicine, Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, The Mongan Institute, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| |
Collapse
|
167
|
Shaqour B, Aizawa J, Guarch-Pérez C, Górecka Ż, Christophersen L, Martinet W, Choińska E, Riool M, Verleije B, Beyers K, Moser C, Święszkowski W, Zaat SAJ, Cos P. Coupling Additive Manufacturing with Hot Melt Extrusion Technologies to Validate a Ventilator-Associated Pneumonia Mouse Model. Pharmaceutics 2021; 13:pharmaceutics13060772. [PMID: 34064276 PMCID: PMC8224298 DOI: 10.3390/pharmaceutics13060772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/08/2021] [Accepted: 05/18/2021] [Indexed: 12/02/2022] Open
Abstract
Additive manufacturing is widely used to produce highly complex structures. Moreover, this technology has proven its superiority in producing tools which can be used in different applications. We designed and produced an extrusion nozzle that allowed us to hot melt extrude drug-loaded tubes. The tubes were an essential part of a new mouse ventilator-associated pneumonia (VAP) model. Ciprofloxacin (CPX) was selected for its expected activity against the pathogen Staphylococcus aureus and ease of incorporation into thermoplastic polyurethane (TPU). TPU was selected as the carrier polymer for its biocompatibility and use in a variety of medical devices such as tubing and catheters. The effect of loading CPX within the TPU polymeric matrix and the physicochemical properties of the produced tubes were investigated. CPX showed good thermal stability and in vitro activity in preventing S. aureus biofilm formation after loading within the tube’s polymeric matrix. Moreover, the produced tubes showed anti-infective efficacy in vivo. The produced tubes, which were extruded via our novel nozzle, were vital for the validation of our mouse VAP model. This model can be adopted to investigate other antibacterial and antibiofilm compounds incorporated in polymeric tubes using hot melt extrusion.
Collapse
Affiliation(s)
- Bahaa Shaqour
- Laboratory for Microbiology, Parasitology and Hygiene (LMPH), Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Universiteitsplein 1 S.7, 2610 Wilrijk, Belgium; (J.A.); (P.C.)
- Mechanical and Mechatronics Engineering Department, Faculty of Engineering & Information Technology, An-Najah National University, Nablus P.O. Box 7, Palestine
- Correspondence:
| | - Juliana Aizawa
- Laboratory for Microbiology, Parasitology and Hygiene (LMPH), Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Universiteitsplein 1 S.7, 2610 Wilrijk, Belgium; (J.A.); (P.C.)
| | - Clara Guarch-Pérez
- Department of Medical Microbiology and Infection Prevention, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (C.G.-P.); (M.R.); (S.A.J.Z.)
| | - Żaneta Górecka
- Faculty of Materials Sciences and Engineering, Warsaw University of Technology, Woloska 141, 02-507 Warsaw, Poland; (Ż.G.); (E.C.); (W.Ś.)
- Centre for Advanced Materials and Technologies CEZAMAT, Warsaw University of Technology, Poleczki 19, 02-822 Warsaw, Poland
| | - Lars Christophersen
- Department for Clinical Microbiology, Rigshospitalet, Henrik Harpestrengsvej 4A, Afsnit 93.01, 2100 Copenhagen, Denmark; (L.C.); (C.M.)
| | - Wim Martinet
- Laboratory of Physiopharmacology, University of Antwerp, Universiteitsplein 1 T.2, 2610 Wilrijk, Belgium;
| | - Emilia Choińska
- Faculty of Materials Sciences and Engineering, Warsaw University of Technology, Woloska 141, 02-507 Warsaw, Poland; (Ż.G.); (E.C.); (W.Ś.)
| | - Martijn Riool
- Department of Medical Microbiology and Infection Prevention, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (C.G.-P.); (M.R.); (S.A.J.Z.)
| | - Bart Verleije
- Voxdale bv, Bijkhoevelaan 32, 2110 Wijnegem, Belgium; (B.V.); (K.B.)
| | - Koen Beyers
- Voxdale bv, Bijkhoevelaan 32, 2110 Wijnegem, Belgium; (B.V.); (K.B.)
| | - Claus Moser
- Department for Clinical Microbiology, Rigshospitalet, Henrik Harpestrengsvej 4A, Afsnit 93.01, 2100 Copenhagen, Denmark; (L.C.); (C.M.)
| | - Wojciech Święszkowski
- Faculty of Materials Sciences and Engineering, Warsaw University of Technology, Woloska 141, 02-507 Warsaw, Poland; (Ż.G.); (E.C.); (W.Ś.)
| | - Sebastian A. J. Zaat
- Department of Medical Microbiology and Infection Prevention, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (C.G.-P.); (M.R.); (S.A.J.Z.)
| | - Paul Cos
- Laboratory for Microbiology, Parasitology and Hygiene (LMPH), Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Universiteitsplein 1 S.7, 2610 Wilrijk, Belgium; (J.A.); (P.C.)
| |
Collapse
|
168
|
Rahimibashar F, Miller AC, Yaghoobi MH, Vahedian-Azimi A. A comparison of diagnostic algorithms and clinical parameters to diagnose ventilator-associated pneumonia: a prospective observational study. BMC Pulm Med 2021; 21:161. [PMID: 33985474 PMCID: PMC8118372 DOI: 10.1186/s12890-021-01527-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 05/06/2021] [Indexed: 12/15/2022] Open
Abstract
Background Suspicion and clinical criteria continue to serve as the foundation for ventilator-associated pneumonia (VAP) diagnosis, however the criteria used to diagnose VAP vary widely. Data from head-to-head comparisons of clinical diagnostic algorithms is lacking, thus a prospective observational study was performed to determine the performance characteristics of the Johanson criteria, Clinical Pulmonary Infection Score (CPIS), and Centers for Disease Control and Prevention’s National Healthcare Safety Network (CDC/NHSN) criteria as compared to Hospital in Europe Link for Infection Control through Surveillance (HELICS) reference standard. Methods A prospective observational cohort study was performed in three mixed medical-surgical ICUs from one academic medical center from 1 October 2016 to 30 April 2018. VAP diagnostic criteria were applied to each patient including CDC/NHSN, CPIS, HELICS and Johanson criteria. Tracheal aspirate cultures (TAC) and serum procalcitonin values were obtained for each patient. Results Eighty-five patients were enrolled (VAP 45, controls 40). Using HELICS as the reference standard, the sensitivity and specificity for each of the assessed diagnostic algorithms were: CDC/NHSN (Sensitivity 54.2%; Specificity 100%), CPIS (Sensitivity 68.75%; Specificity 95.23%), Johanson (Sensitivity 67.69%; Specificity 95%). The positive TAC rate was 81.2%. The sensitivity for positive TAC with the serum procalcitonin level > 0.5 ng/ml was 51.8%. Conclusion VAP remains a considerable source of morbidity and mortality in modern intensive care units. The optimal diagnostic method remains unclear. Using HELICS criteria as the reference standard, CPIS had the greatest comparative diagnostic accuracy, whereas the sensitivity of the CDC/NHSN was only marginally better than a positive TAC plus serum procalcitonin > 0.5 ng/ml. Algorithm accuracy was improved by adding serum procalcitonin > 0.5 ng/ml, but not positive quantitative TAC. Trial Registration: Not indicated for this study type.
Collapse
Affiliation(s)
- Farshid Rahimibashar
- Anesthesia and Critical Care Department, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Andrew C Miller
- Department of Emergency Medicine, Nazareth Hospital, Philadelphia, PA, USA
| | - Mojtaba H Yaghoobi
- Department of Infectious and Tropical Diseases, Alborz University of Medical Sciences, Alborz, Iran
| | - Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
169
|
Accurately Measuring Preventable Ventilator-associated Pneumonia Deaths Using Observational Data: It's about Time. Ann Am Thorac Soc 2021; 18:777-779. [PMID: 33929311 PMCID: PMC8086539 DOI: 10.1513/annalsats.202102-126ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
|
170
|
Nakane S, Tsuda K, Kinoshita M, Kato S, Iwata S, Lin YC, Mizuno M, Saitoh S, Iwata O. Airway gas temperature within endotracheal tube can be monitored using rapid response thermometer. Sci Rep 2021; 11:9537. [PMID: 33953212 PMCID: PMC8100119 DOI: 10.1038/s41598-021-88787-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 04/15/2021] [Indexed: 11/09/2022] Open
Abstract
Inappropriate preparation of respiratory gases is associated with serious complications during mechanical ventilation. To develop a temperature monitoring system of respiratory gases within the endotracheal tube, four newborn piglets were studied using an ultra-rapid-response thermometer attached to the closed endotracheal tube suction system. Respiratory gas temperatures were monitored at the mouth-corner level of the endotracheal tube using three thermocouples (Tairway, inserted into the endotracheal tube via the closed suction system; Ttube_centre and Ttube_wall, embedded within the endotracheal tube 0.5 mm and 1.6 mm from the tube wall, respectively). Univariate analysis showed that inspiratory Ttube_centre and inspiratory Ttube_wall were positively correlated with inspiratory Tairway (both p < 0.001). Multivariate analysis showed the dependence of inspiratory Tairway on inspiratory Ttube_centre and Ttube_wall and deflation of endotracheal tube cuff (p < 0.001, p = 0.001 and p = 0.046, respectively). Inspiratory gas temperature within the endotracheal tube can be monitored using a thermometer attached to the closed endotracheal tube suction system. Our system, with further validation, might help optimise respiratory gas humidification during mechanical ventilation.
Collapse
Affiliation(s)
- Shigeharu Nakane
- Department of Paediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Japan.,Department of Paediatrics, Daido Hospital, Nagoya, Japan
| | - Kennosuke Tsuda
- Department of Paediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Japan
| | - Masahiro Kinoshita
- Department of Paediatrics and Child Health, Kurume University School of Medicine, Fukuoka, Japan
| | - Shin Kato
- Department of Paediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Japan
| | - Sachiko Iwata
- Department of Paediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Japan
| | - Yung-Chieh Lin
- Department of Paediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Japan.,Department of Paediatrics, National Cheng Kung University Hospital, Tainan, Taiwan, ROC
| | - Mihoko Mizuno
- Department of Paediatrics, Daido Hospital, Nagoya, Japan
| | - Shinji Saitoh
- Department of Paediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Japan
| | - Osuke Iwata
- Department of Paediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, Japan.
| |
Collapse
|
171
|
Ben Lakhal H, M’Rad A, Naas T, Brahmi N. Antimicrobial Susceptibility among Pathogens Isolated in Early- versus Late-Onset Ventilator-Associated Pneumonia. Infect Dis Rep 2021; 13:401-410. [PMID: 33925385 PMCID: PMC8167786 DOI: 10.3390/idr13020038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/20/2021] [Accepted: 04/23/2021] [Indexed: 11/16/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is associated with increased hospital stay and high morbidity and mortality in critically ill patients. The aims of this study were to (i) determine the incidence of multidrug-resistant (MDR) pathogens in the first episodes of VAP and to assess potential differences in bacterial profiles of subjects with early- versus late-onset VAP. This was a retrospective cohort study over a period of 18 months including all patients who had a first episode of VAP confirmed by positive bacterial culture. Subjects were distributed into two groups according to the number of intubation days: early-onset VAP (<5 days) or late-onset VAP (≥5 days). The primary endpoint was the nature of causative pathogens and their resistance profiles. Sixty patients were included, 29 men and 31 women, with an average age of 38 ± 16 years. The IGS 2 at admission was 40.5 [32–44] and APACHE was 19 [15–22]. Monomicrobial infections were diagnosed in 77% of patients (n = 46). The most frequently isolated bacteria were A. baumannii, 53% (n = 32); P. aeruginosa in 37% (n = 22); Enterobacterales in 28% (n = 17) and S. aureus in 5% (n = 3). Ninety-seven percent of the bacteria were MDR. The VAP group comprised 36 (60%) episodes of early-onset VAP and 24 (40%) episodes of late-onset VAP. There was no significant difference in the distribution of the bacterial isolates, nor in terms of antibacterial resistances between early- and late-onset VAPs. Our data support recent observations that there is no microbiological difference in the prevalence of potential MDR pathogens or in their resistance profiles associated with early- versus late-onset VAPs, especially in countries with high rates of MDR bacteria.
Collapse
Affiliation(s)
- Hend Ben Lakhal
- Service de Reanimation, Centre Hospitalier de Chartres, 4, Rue Claude-Bernard, 28630 Le Coudray, France
- Service de Reanimation, Centre d’Assistance Médicale Urgente (CAMU) de Tunis, 50 Rue Abou Kacem Chebbi, Tunis 1089, Tunisia; (A.M.); (N.B.)
- Correspondence:
| | - Aymen M’Rad
- Service de Reanimation, Centre d’Assistance Médicale Urgente (CAMU) de Tunis, 50 Rue Abou Kacem Chebbi, Tunis 1089, Tunisia; (A.M.); (N.B.)
| | - Thierry Naas
- Bacteriology-Hygiene Unit, Assistance Publique/Hôpitaux de Paris, Bicêtre Hospital, 94270 Le Kremlin-Bicêtre, France;
- Team ReSIST, INSERM U1184, School of Medicine Université Paris-Saclay, LabEx LERMIT, 94270 Le Kremlin-Bicêtre, France
| | - Nozha Brahmi
- Service de Reanimation, Centre d’Assistance Médicale Urgente (CAMU) de Tunis, 50 Rue Abou Kacem Chebbi, Tunis 1089, Tunisia; (A.M.); (N.B.)
| |
Collapse
|
172
|
Abstract
Pneumonia is a common acute respiratory infection that affects the alveoli and distal airways; it is a major health problem and associated with high morbidity and short-term and long-term mortality in all age groups worldwide. Pneumonia is broadly divided into community-acquired pneumonia or hospital-acquired pneumonia. A large variety of microorganisms can cause pneumonia, including bacteria, respiratory viruses and fungi, and there are great geographical variations in their prevalence. Pneumonia occurs more commonly in susceptible individuals, including children of <5 years of age and older adults with prior chronic conditions. Development of the disease largely depends on the host immune response, with pathogen characteristics having a less prominent role. Individuals with pneumonia often present with respiratory and systemic symptoms, and diagnosis is based on both clinical presentation and radiological findings. It is crucial to identify the causative pathogens, as delayed and inadequate antimicrobial therapy can lead to poor outcomes. New antibiotic and non-antibiotic therapies, in addition to rapid and accurate diagnostic tests that can detect pathogens and antibiotic resistance will improve the management of pneumonia.
Collapse
|
173
|
Montero S, Huang F, Rivas-Lasarte M, Chommeloux J, Demondion P, Bréchot N, Hékimian G, Franchineau G, Persichini R, Luyt CÉ, Garcia-Garcia C, Bayes-Genis A, Lebreton G, Cinca J, Leprince P, Combes A, Alvarez-Garcia J, Schmidt M. Awake venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:585-594. [PMID: 33822901 DOI: 10.1093/ehjacc/zuab018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/08/2021] [Accepted: 03/11/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is currently one of the first-line therapies for refractory cardiogenic shock (CS), but its applicability is undermined by the high morbidity associated with its complications, especially those related to mechanical ventilation (MV). We aimed to assess the prognostic impact of keeping patients in refractory CS awake at cannulation and during the VA-ECMO run. METHODS A 7-year database of patients given peripheral VA-ECMO support was used to conduct a propensity-score (PS)-matched analysis to balance their clinical profiles. Patients were classified as 'awake ECMO' or 'non-awake ECMO', respectively, if invasive MV was used during ≤50% or >50% of the VA-ECMO run. Primary outcomes included ventilator-associated pneumonia and ECMO-related complication rates, and secondary outcomes were 60-day and 1-year mortality. A multivariate logistic-regression analysis was used to identify whether MV at cannulation was independently associated with 60-day mortality. RESULTS Among 231 patients included, 91 (39%) were 'awake' and 140 (61%) 'non-awake'. After PS-matching adjustment, the 'awake ECMO' group had significantly lower rates of pneumonia (35% vs. 59%, P = 0.017), tracheostomy, renal replacement therapy, and less antibiotic and sedative consumption. This strategy was also associated with reduced 60-day (20% vs. 41%, P = 0.018) and 1-year mortality rates (31% vs. 54%, P = 0.021) compared to the 'non-awake' group, respectively. Lastly, MV at ECMO cannulation was independently associated with 60-day mortality. CONCLUSION An 'awake ECMO' management in VA-ECMO-supported CS patients is feasible, safe, and associated with improved short- and long-term outcomes.
Collapse
Affiliation(s)
- Santiago Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Spain.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France
| | - Florent Huang
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France
| | - Mercedes Rivas-Lasarte
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juliette Chommeloux
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France
| | - Pierre Demondion
- Thoracic and Cardiovascular Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Nicolas Bréchot
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Guillaume Hékimian
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Guillaume Franchineau
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Romain Persichini
- Medical-Surgical Intensive Care Unit, CHU de La Réunion, Felix-Guyon Hospital, Saint Denis, La Réunion, France
| | - Charles-Édouard Luyt
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Cosme Garcia-Garcia
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Antoni Bayes-Genis
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Guillaume Lebreton
- Thoracic and Cardiovascular Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Juan Cinca
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pascal Leprince
- Thoracic and Cardiovascular Department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France
| | - Alain Combes
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France.,Sorbonne Université, GRC 30, RESPIRE, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| | - Jesus Alvarez-Garcia
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matthieu Schmidt
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris Cedex 13 75651, France.,Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13 75651, France.,Sorbonne Université, GRC 30, RESPIRE, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| |
Collapse
|
174
|
Heffernan AJ, Sime FB, Lim SMS, Naicker S, Andrews KT, Ellwood D, Lipman J, Grimwood K, Roberts JA. Impact of the Epithelial Lining Fluid Milieu on Amikacin Pharmacodynamics Against Pseudomonas aeruginosa. Drugs R D 2021; 21:203-215. [PMID: 33797739 PMCID: PMC8017437 DOI: 10.1007/s40268-021-00344-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 12/14/2022] Open
Abstract
Background Even though nebulised administration of amikacin can achieve high epithelial lining fluid concentrations, this has not translated into improved patient outcomes in clinical trials. One possible reason is that the cellular and chemical composition of the epithelial lining fluid may inhibit amikacin-mediated bacterial killing. Objective The objective of this study was to identify whether the epithelial lining fluid components inhibit amikacin-mediated bacterial killing. Methods Two amikacin-susceptible (minimum inhibitory concentrations of 2 and 8 mg/L) Pseudomonas aeruginosa isolates were exposed in vitro to amikacin concentrations up to 976 mg/L in the presence of an acidic pH, mucin and/or surfactant as a means of simulating the epithelial lining fluid, the site of bacterial infection in pneumonia. Pharmacodynamic modelling was used to describe associations between amikacin concentrations, bacterial killing and emergence of resistance. Results In the presence of broth alone, there was rapid and extensive (> 6 − log10) bacterial killing, with emergence of resistance identified in amikacin concentrations < 976 mg/L. In contrast, the rate and extent of bacterial killing was reduced (≤ 5 − log10) when exposed to an acidic pH and mucin. Surfactant did not appreciably impact the bacterial killing or resistance emergence when compared with broth alone for either isolate. The combination of mucin and an acidic pH further reduced the rate of bacterial killing, with the maximal bacterial killing occurring 24 h following initial exposure compared with approximately 4–8 h for either mucin or an acidic pH alone. Conclusions Our findings indicate that simulating the epithelial lining fluid antagonises amikacin-mediated killing of P. aeruginosa, even at the high concentrations achieved following nebulised administration. Supplementary Information The online version contains supplementary material available at 10.1007/s40268-021-00344-5.
Collapse
Affiliation(s)
- Aaron J Heffernan
- School of Medicine, Griffith University, Gold Coast, QLD, Australia. .,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Cornwall St, Woolloongabba, QLD, 4102, Australia.
| | - Fekade B Sime
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Cornwall St, Woolloongabba, QLD, 4102, Australia.,Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Sazlyna Mohd Sazlly Lim
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Cornwall St, Woolloongabba, QLD, 4102, Australia.,Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Saiyuri Naicker
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Cornwall St, Woolloongabba, QLD, 4102, Australia.,Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Katherine T Andrews
- Griffith Institute for Drug Discovery, Griffith University, Nathan, QLD, Australia
| | - David Ellwood
- School of Medicine, Griffith University, Gold Coast, QLD, Australia.,Gold Coast Health, Southport, QLD, Australia
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Keith Grimwood
- School of Medicine, Griffith University, Gold Coast, QLD, Australia.,Gold Coast Health, Southport, QLD, Australia
| | - Jason A Roberts
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Cornwall St, Woolloongabba, QLD, 4102, Australia.,Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| |
Collapse
|
175
|
Jiao J, Li Z, Wu X, Cao J, Liu G, Liu Y, Li F, Zhu C, Song B, Jin J, Liu Y, Wen X, Cheng S, Wan X. Risk factors for 3-month mortality in bedridden patients with hospital-acquired pneumonia: A multicentre prospective study. PLoS One 2021; 16:e0249198. [PMID: 33784317 PMCID: PMC8009424 DOI: 10.1371/journal.pone.0249198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 03/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Mortality among patients with hospital-acquired pneumonia (HAP) is quite high; however, information on risk factors for short-term mortality in this population remains limited. The aim of the current study was to identify the risk factors for mortality in bedridden patients with HAP during a 3-month observation period. METHODS A secondary data analysis was conducted. In total, 1141 HAP cases from 25 hospitals were included in the analysis. Univariate and multilevel regression analyses were performed to identify the risk factors for mortality. RESULTS During the 3-month observation period, there were 189 deaths among bedridden patients with HAP. The mortality rate in this study was 16.56%. Multilevel regression analysis showed that ventilator-associated pneumonia (OR = 2.034, 95%CI: 1.256, 3.296, p = 0.004), pressure injuries (OR = 2.202, 95%CI: 1.258, 3.852, p = 0.006), number of comorbidities (OR = 1.076, 95%CI: 1.016,1.140, p = 0.013) and adjusted Charlson Comorbidity Index score (OR = 1.210, 95%CI: 1.090, 1.343, p<0.001) were associated with an increased risk of mortality, while undergoing surgery with general anaesthesia (OR = 0.582, 95%CI: 0.368, 0.920, p = 0.021) was associated with a decreased risk of mortality. CONCLUSIONS The identification of risk factors associated with mortality is an important step towards individualizing care plans. Our findings may help healthcare workers select high-risk patients for specific interventions. Further study is needed to explore whether appropriate interventions against modifiable risk factors, such as reduced immobility complications or ventilator-associated pneumonia, could improve the prognoses.
Collapse
Affiliation(s)
- Jing Jiao
- Department of Nursing, Peking Union Medical College Hospital, Beijing, China
| | - Zhen Li
- Department of Nursing, Peking Union Medical College Hospital, Beijing, China
| | - Xinjuan Wu
- Department of Nursing, Peking Union Medical College Hospital, Beijing, China
| | - Jing Cao
- Department of Nursing, Peking Union Medical College Hospital, Beijing, China
| | - Ge Liu
- Department of Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Ying Liu
- Department of Nursing, Peking Union Medical College Hospital, Beijing, China
| | - Fangfang Li
- Department of Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Chen Zhu
- Department of Nursing, Peking Union Medical College Hospital, Beijing, China
| | - Baoyun Song
- Department of Nursing, Henan Provincial People’s Hospital, Zhengzhou, Henan Province, China
| | - Jingfen Jin
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yilan Liu
- Department of Nursing, Wuhan Union Hospital, Wuhan, Hubei Province, China
| | - Xianxiu Wen
- Department of Nursing, Sichuan Provincial People’s Hospital, Chengdu, Sichuan Province, China
| | - Shouzhen Cheng
- Department of Nursing, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xia Wan
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, Beijing, China
| |
Collapse
|
176
|
Burns KEA, Rizvi L, Cook DJ, Lebovic G, Dodek P, Villar J, Slutsky AS, Jones A, Kapadia FN, Gattas DJ, Epstein SK, Pelosi P, Kefala K, Meade MO. Ventilator Weaning and Discontinuation Practices for Critically Ill Patients. JAMA 2021; 325:1173-1184. [PMID: 33755077 PMCID: PMC7988370 DOI: 10.1001/jama.2021.2384] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 02/09/2021] [Indexed: 01/31/2023]
Abstract
Importance Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice. Objective To describe practice variation in IMV discontinuation internationally, associations between initial discontinuation events and outcomes, and factors associated with the use of select discontinuation strategies and failed initial spontaneous breathing trials (SBTs). Design, Setting, and Participants Prospective, multinational, observational study of critically ill adults who received IMV for at least 24 hours from 142 intensive care units (ICUs) in 19 countries within 6 regions (27 in Canada, 23 in India, 22 in the UK, 26 in Europe, 21 in Australia/New Zealand, and 23 in the US). Exposures Receiving IMV. Main Outcomes and Measures Primary analyses characterized types of initial IMV discontinuation events (extubation, SBT, or tracheostomy) and associations with clinical outcomes (including duration of ventilation, ICU and hospital mortality, and ICU and hospital length of stay). Secondary analyses examined the associations between SBT outcome and SBT timing and clinical outcomes. Results Among 1868 patients (median [interquartile range] age, 61.8 [48.9-73.1] years; 1173 [62.8%] men) 424 (22.7%) underwent direct extubation, 930 (49.8%) had an initial SBT (761 [81.8%] successful), 150 (8.0%) underwent direct tracheostomy, and 364 (19.5%) died before a weaning attempt. Across regions, there was variation in the use of written directives to guide care, daily screening, SBT techniques, ventilator modes, and the roles played by clinicians involved in weaning. Compared with initial direct extubation, patients who had an initial SBT had higher ICU mortality (20 [4.7%] vs 96 [10.3%]; absolute difference, 5.6% [95% CI, 2.6%-8.6%]), longer duration of ventilation (median of 2.9 vs 4.1 days; absolute difference, 1.2 days [95% CI, 0.7-1.6]), and longer ICU stay (median of 6.7 vs 8.1 days; absolute difference, 1.4 days [95% CI, 0.8-2.4]). Patients whose initial SBT failed (vs passed) had higher ICU mortality (29 [17.2%] vs 67 [8.8%]; absolute difference, 8.4% [95% CI, 2.0%-14.7%]), longer duration of ventilation (median of 6.1 vs 3.5 days; absolute difference, 2.6 days [95% CI, 1.6-3.6]), and longer ICU stay (median of 10.6 vs 7.7 days; absolute difference, 2.8 days [95% CI, 1.1-5.2]). Compared with patients who underwent early initial SBTs, patients who underwent late initial SBTs (>2.3 days after intubation) had longer duration of ventilation (median of 2.1 vs 6.1 days; absolute difference, 4.0 days [95% CI, 3.7-4.5]), longer ICU stay (median of 5.9 vs 10.8 days; absolute difference, 4.9 days [95% CI, 4.0-6.3]), and longer hospital stay (median of 14.3 vs 22.8 days; absolute difference, 8.5 days [95% CI, 6.0-11.0]). Conclusions and Relevance In this observational study of invasive mechanical ventilation discontinuation in 142 ICUs in Canada, India, the UK, Europe, Australia/New Zealand, and the US from 2013 to 2016, weaning practices varied internationally. Trial Registration ClinicalTrials.gov Identifier: NCT03955874.
Collapse
Affiliation(s)
- Karen E. A. Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Leena Rizvi
- Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | - Deborah J. Cook
- Division of Critical Care Medicine, St Joseph’s Hospital, Hamilton, Ontario, Canada
- Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gerald Lebovic
- Applied Health Research Centre, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Peter Dodek
- Centre for Health Evaluation and Outcome Sciences, Division of Critical Care Medicine, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr Negrin, Las Palmas de Gran Canaria, Spain
| | - Arthur S. Slutsky
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Andrew Jones
- Department of Critical Care Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Farhad N. Kapadia
- Department of Intensive Care, Hinduja National Hospital, Bombay, India
| | - David J. Gattas
- Intensive Care Unit, Royal Prince Alfred Hospital, University of Sydney, Camperdown, New South Wales, Australia
- The George Institute for Global Health, Sydney Australia
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Kallirroi Kefala
- Anaesthesia, Critical Care and Pain Medicine, Edinburgh Royal Infirmary, Edinburgh, Scotland, United Kingdom
| | - Maureen O. Meade
- Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
177
|
Photoinactivation of Staphylococci with 405 nm Light in a Trachea Model with Saliva Substitute at 37 °C. Healthcare (Basel) 2021; 9:healthcare9030310. [PMID: 33799642 PMCID: PMC7998829 DOI: 10.3390/healthcare9030310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 02/03/2023] Open
Abstract
The globally observed rise in bacterial resistance against antibiotics has increased the need for alternatives to antibiotic treatments. The most prominent and important pathogen bacteria are the ESKAPE pathogens, which include among others Staphylococcus aureus, Klebsiella pneumoniae and Acinetobacter baumannii. These species cause ventilator-associated pneumonia (VAP), which accounts for 24% of all nosocomial infections. In this study we tested the efficacy of photoinactivation with 405 nm violet light under conditions comparable to an intubated patient with artificial saliva for bacterial suspension at 37 °C. A technical trachea model was developed to investigate the visible light photoinactivation of Staphylococcus carnosus as a non-pathogen surrogate of the ESKAPE pathogen S. aureus (MRSA). The violet light was coupled into the tube with a fiber optic setup. The performed tests proved, that photoinactivation at 37 °C is more effective with a reduction of almost 3 log levels (99.8%) compared to 25 °C with a reduction of 1.2 log levels. The substitution of phosphate buffered saline (PBS) by artificial saliva solution slightly increased the efficiency during the experimental course. The increased efficiency might be caused by a less favorable environment for bacteria due to for example the ionic composition.
Collapse
|
178
|
Xu E, Pérez-Torres D, Fragkou PC, Zahar JR, Koulenti D. Nosocomial Pneumonia in the Era of Multidrug-Resistance: Updates in Diagnosis and Management. Microorganisms 2021; 9:534. [PMID: 33807623 PMCID: PMC8001201 DOI: 10.3390/microorganisms9030534] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/25/2021] [Accepted: 03/03/2021] [Indexed: 12/11/2022] Open
Abstract
Nosocomial pneumonia (NP), including hospital-acquired pneumonia in non-intubated patients and ventilator-associated pneumonia, is one of the most frequent hospital-acquired infections, especially in the intensive care unit. NP has a significant impact on morbidity, mortality and health care costs, especially when the implicated pathogens are multidrug-resistant ones. This narrative review aims to critically review what is new in the field of NP, specifically, diagnosis and antibiotic treatment. Regarding novel imaging modalities, the current role of lung ultrasound and low radiation computed tomography are discussed, while regarding etiological diagnosis, recent developments in rapid microbiological confirmation, such as syndromic rapid multiplex Polymerase Chain Reaction panels are presented and compared with conventional cultures. Additionally, the volatile compounds/electronic nose, a promising diagnostic tool for the future is briefly presented. With respect to NP management, antibiotics approved for the indication of NP during the last decade are discussed, namely, ceftobiprole medocaril, telavancin, ceftolozane/tazobactam, ceftazidime/avibactam, and meropenem/vaborbactam.
Collapse
Affiliation(s)
- Elena Xu
- Burns, Trauma and Critical Care Research Centre, University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD 4029, Australia;
| | - David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, 47012 Valladolid, Spain;
| | - Paraskevi C. Fragkou
- Fourth Department of Internal Medicine, Attikon University Hospital, 12462 Athens, Greece;
| | - Jean-Ralph Zahar
- Microbiology Department, Infection Control Unit, Hospital Avicenne, 93000 Bobigny, France;
| | - Despoina Koulenti
- Burns, Trauma and Critical Care Research Centre, University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD 4029, Australia;
- Second Critical Care Department, Attikon University Hospital, 12462 Athens, Greece
| |
Collapse
|
179
|
Kang SY, DiStefano MJ, Yehia F, Koszalka MV, Padula WV. Critical Care Beds With Continuous Lateral Rotation Therapy to Prevent Ventilator-Associated Pneumonia and Hospital-Acquired Pressure Injury: A Cost-effectiveness Analysis. J Patient Saf 2021; 17:149-155. [PMID: 30896557 DOI: 10.1097/pts.0000000000000582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Mechanical ventilation increases the risk of hospital-acquired conditions (HACs) such as ventilator-associated pneumonia (VAP) and pressure injury (PrI). Beds with continuous lateral rotation therapy (CLRT) are shown to reduce HAC incidence, but the value of switching to CLRT beds is presently unknown. We compared the cost-effectiveness of CLRT beds with standard care in intensive care units. METHODS A cost-effectiveness analysis from the healthcare sector and societal perspectives was conducted. A Markov model was constructed to predict health state transitions from time of ventilation through 28 days for the healthcare sector perspective and 1 year for the U.S. societal perspective. Value of information was calculated to determine whether parameter uncertainty warranted further research. RESULTS Our analysis suggested that CLRT beds dominate standard care from both perspectives. From the healthcare sector perspective, expected cost for CLRT was U.S. $47,165/patient compared with a higher cost of U.S. $49,258/patient for standard care. The expected effectiveness of CLRT is 0.0418 quality-adjusted life years/patient compared with 0.0416 quality-adjusted life years/patient for standard care. Continuous lateral rotation therapy dominated standard care in approximately 93% of Monte Carlo simulations from both perspectives. Value of information analysis suggests that additional research is potentially cost-effective. CONCLUSIONS Continuous lateral rotation therapy is highly cost-effective compared with standard care by preventing HACs that seriously harm patients in the intensive care unit.
Collapse
Affiliation(s)
- So-Yeon Kang
- From the Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael J DiStefano
- From the Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Farah Yehia
- From the Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | |
Collapse
|
180
|
Nanao T, Nishizawa H, Fujimoto J, Ogawa T. Additional medical costs associated with ventilator-associated pneumonia in an intensive care unit in Japan. Am J Infect Control 2021; 49:340-344. [PMID: 32721417 DOI: 10.1016/j.ajic.2020.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Additional health care costs associated with ventilator-associated pneumonia (VAP) vary widely per country; none of which have been explored in Japan. Thus, we aimed to examine the economic and clinical effects of VAP in Japan. METHODS This was a retrospective matched case-control study of 22 patients with VAP who were treated in the intensive care unit of Yokohama Rosai Hospital between January 2012 and December 2018. Twenty-two matched controls were selected based on 5 variables (ie, sex, age, diagnosis and surgical procedure, underlying disease with or without advanced malignant tumor, and best motor response). The additional health care costs incurred owing to VAP were calculated from the difference between the mean costs of VAP and control cases. RESULTS VAP incurred an additional cost of approximately United States Dollars (USD) 34,884 per case. The length of hospitalization itself was the major factor contributing to additional medical costs, generating a difference of 9,824 USD. DISCUSSION VAP not only worsens patient outcomes but also generates significant additional medical costs. Patients who had developed VAP required more medical resources such as the performance of a tracheostomy. CONCLUSIONS VAP incurs a higher mean total hospital medical cost. Thus, appropriate infection control strategies should be implemented.
Collapse
Affiliation(s)
- Taikan Nanao
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan; International University of Health and Welfare Graduate School of Public Health, Tokyo, Japan.
| | - Hideo Nishizawa
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Junichi Fujimoto
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Toshio Ogawa
- International University of Health and Welfare Graduate School of Public Health, Tokyo, Japan
| |
Collapse
|
181
|
Hurley JC. Is selective decontamination (SDD/SOD) safe in the ICU context? J Antimicrob Chemother 2021; 74:1167-1172. [PMID: 30753529 DOI: 10.1093/jac/dky573] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Multiple individual studies of selective digestive decontamination/selective oropharyngeal decontamination (SDD/SOD) among ICU patients appear to show potent infection prevention effects. Surprisingly, the event rates for multiple endpoints including ventilator-associated pneumonia, bacteraemia and candidaemia among concurrent control groups within SDD/SOD studies appear unusually high versus other rates in the literature. These paradoxical observations raise concern that the contextual effects of SDD/SOD, as postulated in the original SDD/SOD study, not only exist but also are strong. Until these effects are addressed within an optimally designed study, the safety of SDD/SOD within the 'whole of ICU' remains questionable.
Collapse
Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Division of Internal Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| |
Collapse
|
182
|
Blonz G, Kouatchet A, Chudeau N, Pontis E, Lorber J, Lemeur A, Planche L, Lascarrou JB, Colin G. Epidemiology and microbiology of ventilator-associated pneumonia in COVID-19 patients: a multicenter retrospective study in 188 patients in an un-inundated French region. Crit Care 2021; 25:72. [PMID: 33602296 PMCID: PMC7891465 DOI: 10.1186/s13054-021-03493-w] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/08/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic is responsible for many hospitalizations in intensive care units (ICU), with widespread use of invasive mechanical ventilation (IMV) which exposes patients to the risk of ventilator-associated pneumonia (VAP). The characteristics of VAP in COVID-19 patients remain unclear. METHODS We retrospectively collected data on all patients hospitalized for COVID-19 during the first phase of the epidemic in one of the seven ICUs of the Pays-de-Loire region (North-West France) and who were on invasive mechanical ventilation for more than 48 h. We studied the characteristics of VAP in these patients. VAP was diagnosed based on official recommendations, and we included only cases of VAP that were confirmed by a quantitative microbiological culture. FINDINGS We analyzed data from 188 patients. Of these patients, 48.9% had VAP and 19.7% experienced multiple episodes. Our study showed an incidence of 39.0 VAP per 1000 days of IMV (until the first VAP episode) and an incidence of 33.7 VAP per 1000 days of IMV (including all 141 episodes of VAP). Multi-microbial VAP accounted for 39.0% of all VAP, and 205 pathogens were identified. Enterobacteria accounted for 49.8% of all the isolated pathogens. Bacteremia was associated in 15 (10.6%) cases of VAP. Pneumonia was complicated by thoracic empyema in five cases (3.5%) and by pulmonary abscess in two cases (1.4%). Males were associated with a higher risk of VAP (sHR 2.24 CI95% [1.18; 4.26] p = 0.013). INTERPRETATION Our study showed an unusually high incidence of VAP in patients admitted to the ICU for severe COVID-19, even though our services were not inundated during the first wave of the epidemic. We also noted a significant proportion of enterobacteria. VAP-associated complications (abscess, empyema) were not exceptional. REGISTRATION As an observational study, this study has not been registered.
Collapse
Affiliation(s)
- Gauthier Blonz
- Médecine Intensive Réanimation, Centre Hospitalier Départemental de Vendee, Les Oudairies, 85000, La Roche-Sur-Yon, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, University Hospital of Angers, 4 rue Larrey 49933, Angers, France
| | - Nicolas Chudeau
- Médecine Intensive Réanimation, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037, Le Mans, France
| | - Emmanuel Pontis
- Médecine Intensive Réanimation, Centre Hospitalier de Laval, 33, rue du Haut Roche, Laval, 53015, Canada
| | - Julien Lorber
- Médecine Intensive Réanimation, Centre Hospitalier de Saint-Nazaire, 11 Boulevard Georges Charpak, 44600, Saint-Nazaire, France
| | - Anthony Lemeur
- Médecine Intensive Réanimation, Centre Hospitalier de Cholet, 1 Rue de Marengo, 49300, Cholet, France
| | - Lucie Planche
- Clinical Research Unit, Centre Hospitalier Départmental de Vendée, Les Oudairies, 85000, La Roche-Sur-Yon, France
| | - Jean-Baptiste Lascarrou
- Médecine Intensive Réanimation, University Hospital of Nantes, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Gwenhael Colin
- Médecine Intensive Réanimation, Centre Hospitalier Départemental de Vendee, Les Oudairies, 85000, La Roche-Sur-Yon, France.
| |
Collapse
|
183
|
Molecular Characterization of Baseline Enterobacterales and Pseudomonas aeruginosa Isolates from a Phase 3 Nosocomial Pneumonia (ASPECT-NP) Clinical Trial. Antimicrob Agents Chemother 2021; 65:AAC.02461-20. [PMID: 33318005 DOI: 10.1128/aac.02461-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/06/2020] [Indexed: 11/20/2022] Open
Abstract
We reviewed β-lactam-resistant baseline Enterobacterales species and Pseudomonas aeruginosa lower respiratory tract isolates collected during the ASPECT-NP phase 3 clinical trial that evaluated the safety and efficacy of ceftolozane-tazobactam compared with meropenem for the treatment of nosocomial pneumonia in ventilated adults. Isolates were subjected to whole-genome sequencing, real-time PCR for the quantification of the expression levels of β-lactamase and efflux pump genes, and Western blot analysis for the detection of OprD (P. aeruginosa only). Extended-spectrum β-lactamase (ESBL) genes were detected in 168 of 262 Enterobacterales isolates, and among these, bla CTX-M-15 was the most common, detected in 125 isolates. Sixty-one Enterobacterales isolates carried genes encoding carbapenemases, while 33 isolates did not carry ESBLs or carbapenemases. Carbapenemase-producing isolates carried mainly NDM and OXA-48 variants, with ceftolozane-tazobactam MIC values ranging from 4 to 128 µg/ml. Most ceftolozane-tazobactam-nonsusceptible Enterobacterales isolates that did not carry carbapenemases were Klebsiella pneumoniae isolates that exhibited disrupted OmpK35, specific mutations in OmpK36, and, in some isolates, elevated expression of bla CTX-M-15 Among 89 P. aeruginosa isolates, carbapenemases and ESBL-encoding genes were observed in 12 and 22 isolates, respectively. P. aeruginosa isolates without acquired β-lactamases displaying elevated expression of AmpC (14 isolates), elevated expression of efflux pumps (11 isolates), and/or a decrease or loss of OprD (22 isolates) were susceptible to ceftolozane-tazobactam. Ceftolozane-tazobactam was active against >75% of the Enterobacterales isolates from the ASPECT-NP trial that did not carry carbapenemases. K. pneumoniae strains resistant to ceftolozane-tazobactam might represent a challenge for treatment due to their multiple resistance mechanisms. Ceftolozane-tazobactam was among the agents that displayed the greatest activity against P. aeruginosa isolates. (This study has been registered at ClinicalTrials.gov under registration no. NCT02070757.).
Collapse
|
184
|
Nseir S, Le Gouge A, Pouly O, Lascarrou JB, Lacherade JC, Mira JP, Mercier E, Declercq PL, Sirodot M, Piton G, Tinturier F, Coupez E, Gaudry S, Djibré M, Thevenin D, Balduyck M, Reignier J. Relationship Between Obesity and Ventilator-Associated Pneumonia: A Post Hoc Analysis of the NUTRIREA2 Trial. Chest 2021; 159:2309-2317. [PMID: 33561455 DOI: 10.1016/j.chest.2021.01.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/05/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with obesity are at higher risk for community-acquired and nosocomial infections. However, no study has specifically evaluated the relationship between obesity and ventilator-associated pneumonia (VAP). RESEARCH QUESTION Is obesity associated with an increased incidence of VAP? STUDY DESIGN AND METHODS This study was a post hoc analysis of the Impact of Early Enteral vs Parenteral Nutrition on Mortality in Patients Requiring Mechanical Ventilation and Catecholamines (NUTRIREA2) open-label, randomized controlled trial performed in 44 French ICUs. Adults receiving invasive mechanical ventilation and vasopressor support for shock and parenteral nutrition or enteral nutrition were included. Obesity was defined as BMI ≥ 30 kg/m2 at ICU admission. VAP diagnosis was adjudicated by an independent blinded committee, based on all available clinical, radiologic, and microbiologic data. Only first VAP episodes were taken into account. Incidence of VAP was analyzed by using the Fine and Gray model, with extubation and death as competing risks. RESULTS A total of 699 (30%) of the 2,325 included patients had obesity; 224 first VAP episodes were diagnosed (60 and 164 in obese and nonobese groups, respectively). The incidence of VAP at day 28 was 8.6% vs 10.1% in the two groups (hazard ratio, 0.85; 95% CI 0.63-1.14; P = .26). After adjustment on sex, McCabe score, age, antiulcer treatment, and Sequential Organ Failure Assessment at randomization, the incidence of VAP remained nonsignificant between obese and nonobese patients (hazard ratio, 0.893; 95% CI, 0.66-1.2; P = .46). Although no significant difference was found in duration of mechanical ventilation and ICU length of stay, 90-day mortality was significantly lower in obese than in nonobese patients (272 of 692 [39.3%] patients vs 718 of 1,605 [44.7%]; P = .02). In a subgroup of patients (n = 123) with available pepsin and alpha-amylase measurements, no significant difference was found in rate of abundant microaspiration of gastric contents, or oropharyngeal secretions between obese and nonobese patients. INTERPRETATION Our results suggest that obesity has no significant impact on the incidence of VAP.
Collapse
Affiliation(s)
- Saad Nseir
- Médecine Intensive-Réanimation, CHU Lille, Lille, France; Inserm U1285, Univ. Lille, CNRS, UMR 8576-UGSF-Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France.
| | | | - Olivier Pouly
- Médecine Intensive-Réanimation, CHU Lille, Lille, France
| | - Jean-Baptiste Lascarrou
- Medecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jean-Claude Lacherade
- Médecine Intensive Réanimation, Centre Hospitalier Départemental de la Vendée, La Roche-sur-Yon, France
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Emmanuelle Mercier
- Médecine Intensive Réanimation, Hôpital Bretonneau, CHU Tours, Tours, France
| | | | - Michel Sirodot
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Annecy-Genevois, Metz-Tessy, Pringy, France
| | - Gaël Piton
- Medical Intensive Care Unit, CHRU Besançon, Besançon, France; EA3920, Université de Franche Comté, Besançon, France
| | | | - Elisabeth Coupez
- Intensive Care Unit, Hôpital Gabriel Montpied, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (AP-HP), Bobigny, France; INSERM, UMR_S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, Paris, Paris, France
| | - Michel Djibré
- Service de Médecine intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Didier Thevenin
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Docteur Schaffner, Lens, France
| | | | - Jean Reignier
- Medecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | | |
Collapse
|
185
|
Heffernan AJ, Sime FB, Naicker S, Andrews K, Ellwood D, Guerra-Valero Y, Wallis S, Lipman J, Grimwood K, Roberts JA. Pharmacodynamics of once- versus twice-daily dosing of nebulized amikacin in an in vitro Hollow-Fiber Infection Model against 3 clinical isolates of Pseudomonas aeruginosa. Diagn Microbiol Infect Dis 2021; 100:115329. [PMID: 33714790 DOI: 10.1016/j.diagmicrobio.2021.115329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 01/20/2021] [Accepted: 01/24/2021] [Indexed: 10/22/2022]
Abstract
This study aims to compare the bacterial killing of once- versus twice-daily nebulized amikacin against Pseudomonas aeruginosa and to determine the optimal duration of therapy. Three clinical P. aeruginosa isolates (amikacin MICs 2, 8, and 64 mg/L) were exposed to simulated epithelial lining fluid exposures of nebulized amikacin with dosing regimens of 400 mg and 800 mg once- or twice-daily up to 7-days using the in vitro hollow-fiber infection model. Quantitative cultures were performed. Simulated amikacin dosing regimens of 400 mg twice-daily and 800 mg once-daily achieved ≥2-log reduction in the bacterial burden within the first 24-hours of therapy for all isolates tested. No dosing regimen suppressed the emergence of amikacin resistance. No difference in bacterial killing or regrowth was observed between 3- and 7-days of amikacin. Amikacin doses of 800 mg once-daily for up to 3-days may be considered for future clinical trials.
Collapse
Affiliation(s)
- Aaron James Heffernan
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia; Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Fekade Bruck Sime
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia; University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Saiyuri Naicker
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia; University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Katherine Andrews
- Griffith Institute for Drug Discovery, Griffith University, Nathan, Queensland, Australia
| | - David Ellwood
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia; Gold Coast Health, Southport, Queensland, Australia
| | - Yarmarly Guerra-Valero
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Steven Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| | - Keith Grimwood
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia; Gold Coast Health, Southport, Queensland, Australia
| | - Jason Alexander Roberts
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia; University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France.
| |
Collapse
|
186
|
He Q, Wang W, Zhu S, Wang M, Kang Y, Zhang R, Zou K, Zong Z, Sun X. The epidemiology and clinical outcomes of ventilator-associated events among 20,769 mechanically ventilated patients at intensive care units: an observational study. Crit Care 2021; 25:44. [PMID: 33531078 PMCID: PMC7851639 DOI: 10.1186/s13054-021-03484-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection (HAI) in intensive care units (ICUs). Ventilator-associated event (VAE), a more objective definition, has replaced traditional VAP surveillance and is now widely used in the USA. However, the adoption outside the USA is limited. This study aims to describe the epidemiology and clinical outcomes of VAEs in China, based on a prospectively maintained registry. Methods An observational study was conducted using an ICU-HAI registry in west China. Patients that were admitted to ICUs and underwent mechanical ventilation (MV) between April 1, 2015, and December 31, 2018, were included. The characteristics and outcomes were compared between patients with and without VAEs. The rates of all VAEs dependent on different ICUs were calculated, and the pathogen distribution of patients with possible VAP (PVAP) was described. Results A total of 20,769 ICU patients received MV, accounting for 21,723 episodes of mechanical ventilators and 112,697 ventilator-days. In all, we identified 1882 episodes of ventilator-associated condition (VAC) events (16.7 per 1000 ventilator-days), 721 episodes of infection-related ventilator-associated complications (IVAC) events (6.4 per 1000 ventilator-days), and 185 episodes of PVAP events (1.64 per 1000 ventilator-days). The rates of VAC varied across ICUs with the highest incidence in surgical ICUs (23.72 per 1000 ventilator-days). The median time from the start of ventilation to the onset of the first VAC, IVAC, and PVAP was 5 (3–8), 5 (3–9), and 6 (4–13) days, respectively. The median length of hospital stays was 28.00 (17.00–43.00), 30.00 (19.00–44.00), and 30.00 (21.00–46.00) days for the three VAE tiers, which were all longer than that of patients without VAEs (16.00 [12.00–23.00]). The hospital mortality among patients with VAEs was more than three times of those with non-VAEs. Conclusions VAE was common in ICU patients with ≥ 4 ventilator days. All tiers of VAEs were highly correlated with poor clinical outcomes, including longer ICU and hospital stays and increased risk of mortality. These findings highlight the importance of VAE surveillance and the development of new strategies to prevent VAEs.
Collapse
Affiliation(s)
- Qiao He
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Wen Wang
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Shichao Zhu
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Mingqi Wang
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yan Kang
- Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Rui Zhang
- Information Center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Kang Zou
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Zhiyong Zong
- Department of Infection Control, West China Hospital of Sichuan University, Chengdu, 610041, China. .,Center of Infection Diseases, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Xin Sun
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital of Sichuan University, Chengdu, 610041, China.
| |
Collapse
|
187
|
Feng JY, Peng CK, Sheu CC, Lin YC, Chan MC, Wang SH, Chen CM, Shen YC, Zheng ZR, Lin YT, Yang KY. Efficacy of adjunctive nebulized colistin in critically ill patients with nosocomial carbapenem-resistant Gram-negative bacterial pneumonia: a multi-centre observational study. Clin Microbiol Infect 2021; 27:1465-1473. [PMID: 33540113 DOI: 10.1016/j.cmi.2021.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To investigate the association between adjunctive nebulized colistin and treatment outcomes in critically ill patients with nosocomial carbapenem-resistant Gram-negative bacterial (CR-GNB) pneumonia. METHODS This retrospective, multi-centre, cohort study included individuals admitted to the intensive care unit with nosocomial pneumonia caused by colistin-susceptible CR-GNB. Enrolled patients were divided into groups with/without nebulized colistin as adjunct to at least one effective intravenous antibiotic. Propensity score matching was performed in the original cohort (model 1) and a time-window bias-adjusted cohort (model 2). The association between adjunctive nebulized colistin and treatment outcomes was analysed. RESULTS In total, 181 and 326 patients treated with and without nebulized colistin, respectively, were enrolled for analysis. The day 14 clinical failure rate and mortality rate were 41.4% (75/181) versus 46% (150/326), and 14.9% (27/181) versus 21.8% (71/326), respectively. In the propensity score-matching analysis, patients with nebulized colistin had lower day 14 clinical failure rates (model 1: 41% (68/166) versus 54.2% (90/166), p 0.016; model 2: 35.3% (41/116) versus 56.9% (66/116), p 0.001). On multivariate analysis, nebulized colistin was an independent factor associated with fewer day 14 clinical failures (model 1: adjusted odds ratio (aOR) 0.59, 95% CI 0.37-0.92; model 2: aOR 0.37, 95% CI 0.21-0.65). Nebulized colistin was not associated independently with a lower 14-day mortality rate in the time-dependent analysis in both models 1 and 2. CONCLUSIONS Adjunctive nebulized colistin was associated with lower day 14 clinical failure rate, but not lower 14-day mortality rate, in critically ill patients with nosocomial pneumonia caused by colistin-susceptible CR-GNB.
Collapse
Affiliation(s)
- Jia-Yih Feng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defence Medical Centre, Taipei, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chao Lin
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Ming-Cheng Chan
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; College of Science, Tunghai University, Taichung, Taiwan
| | - Sheng-Huei Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defence Medical Centre, Taipei, Taiwan
| | - Chia-Min Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Cheng Shen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Zhe-Rong Zheng
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan; Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Tsung Lin
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Cancer Progression Research Center, National Yang-Ming University, Taipei, Taiwan.
| | | |
Collapse
|
188
|
Arayasukawat P, So-Ngern A, Reechaipichitkul W, Chumpangern W, Arunsurat I, Ratanawatkul P, Chuennok W. Microorganisms and clinical outcomes of early- and late-onset ventilator-associated pneumonia at Srinagarind Hospital, a tertiary center in Northeastern Thailand. BMC Pulm Med 2021; 21:47. [PMID: 33516213 PMCID: PMC7847239 DOI: 10.1186/s12890-021-01415-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 01/21/2021] [Indexed: 02/07/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is a common nocosomial infection in intensive care unit (ICU). Local microbiological surveillance of pathogens and resistance patterns for early-onset VAP (EOVAP) and late-onset VAP (LOVAP) will help to choose appropriate empiric antibiotics. Objective To compare the multi-drug resistant (MDR) pathogens, treatment outcomes, and factors associated with hospital mortality of VAP. Method A cross-sectional study between 1 January 2015 and 31 December 2017 at Srinagarind hospital, Khon Kaen University was conducted. The demographic data, causative pathogens, hospital length of stay (LOS), ICU LOS, mechanical ventilator (MV) days, and hospital mortality were retrospectively reviewed. Results One hundred and ninety patients were enrolled; 42 patients (22%) were EOVAP and 148 patients (78%) were LOVAP. Acinetobacter baumannii was the most common pathogen in both groups (50% EOVAP vs 52.7% LOVAP). MDR pathogens were significant greater in LOVAP (81.8%) than EOVAP (61.9%) (p = 0.007). The EOVAP had a significantly better ICU LOS [median (interquartile range, IQR) 20.0 (11.0, 30.0) vs. 26.5 (17.0, 43.0) days], hospital LOS [median (IQR) 26.5 (15.0, 44.0) vs. 35.5 (24.0, 56.0) days] shorter MV days [median (IQR) 14.0 (10.0, 29.0) vs. 23.0 (14.0, 35.5) days] and lower hospital mortality (16.7% vs 35.1%) than LOVAP (p < 0.05). The factor associated with hospital mortality was having simplified acute physiology (SAP) II score ≥ 40 with an adjusted odds ratio (aOR) of 2.22 [95% confidence interval (CI), 1.08–4.54, p = 0.02]. Conclusion LOVAP had significantly higher MDR pathogens, MV days, ICU LOS, hospital LOS and hospital mortality than EOVAP. A broad-spectrum antibiotic to cover MDR pathogens should be considered in LOVAP. The factor associated with hospital mortality of VAP was a SAPII score ≥ 40.
Collapse
Affiliation(s)
- Pavarit Arayasukawat
- Department of Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Apichart So-Ngern
- Division of Sleep Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
| | - Wipa Reechaipichitkul
- Division of Pulmonary and Critical Care Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Worawat Chumpangern
- Division of Pulmonary and Critical Care Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Itthiphat Arunsurat
- Division of Pulmonary and Critical Care Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pailin Ratanawatkul
- Division of Pulmonary and Critical Care Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Wanna Chuennok
- Infectious Control Unit, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| |
Collapse
|
189
|
Llitjos JF, Bredin S, Lascarrou JB, Soumagne T, Cojocaru M, Leclerc M, Lepetit A, Gouhier A, Charpentier J, Piton G, Faron M, Stoclin A, Pène F. Increased susceptibility to intensive care unit-acquired pneumonia in severe COVID-19 patients: a multicentre retrospective cohort study. Ann Intensive Care 2021; 11:20. [PMID: 33512602 PMCID: PMC7844782 DOI: 10.1186/s13613-021-00812-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 01/18/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The aim of this study is to determine whether severe COVID-19 patients harbour a higher risk of ICU-acquired pneumonia. METHODS This retrospective multicentre cohort study comprised all consecutive patients admitted to seven ICUs for severe COVID-19 pneumonia during the first COVID-19 surge in France. Inclusion criteria were laboratory-confirmed SARS-CoV-2 infection and requirement for invasive mechanical ventilation for 48 h or more. Control groups were two historical cohorts of mechanically ventilated patients admitted to the ICU for bacterial or non-SARS-CoV-2 viral pneumonia. The outcome of interest was the development of ICU-acquired pneumonia. The determinants of ICU-acquired pneumonia were investigated in a multivariate competing risk analysis. RESULT One hundred and seventy-six patients with severe SARS-CoV-2 pneumonia admitted to the ICU between March 1st and 30th June of 2020 were included into the study. Historical control groups comprised 435 patients with bacterial pneumonia and 48 ones with viral pneumonia. ICU-acquired pneumonia occurred in 52% of COVID-19 patients, whereas in 26% and 23% of patients with bacterial or viral pneumonia, respectively (p < 0.001). Times from initiation of mechanical ventilation to ICU-acquired pneumonia were similar across the three groups. In multivariate analysis, the risk of ICU-acquired pneumonia remained independently associated with underlying COVID-19 (SHR = 2.18; 95 CI 1.2-3.98, p = 0.011). CONCLUSION COVID-19 appears an independent risk factor of ICU-acquired pneumonia in mechanically ventilated patients with pneumonia. Whether this is driven by immunomodulatory properties by the SARS-CoV-2 or this is related to particular processes of care remains to be investigated.
Collapse
Affiliation(s)
- Jean-François Llitjos
- 3i Department, Team Pulmonary and Systemic Immune Responses During Acute and Chronic Bacterial Infections, Institut Cochin, INSERM U1016, CNRS UMR8104, Université de Paris, Paris, France.
- Intensive care unit, Gustave Roussy, Université Paris-Saclay, Villejuif, France.
| | - Swann Bredin
- Medical Intensive Care Unit, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, APHP, Centre, Paris, France
| | | | - Thibaud Soumagne
- Intensive Care Unit, Hôpital Jean Minjoz Hospital, Besançon, France
| | - Mariana Cojocaru
- Surgical Intensive Care Unit, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, APHP, Centre, Paris, France
| | - Maxime Leclerc
- Intensive Care Unit, Centre Hospitalier Mémorial France Etats-Unis, Saint-Lô, France
| | - Arnaud Lepetit
- Intensive Care Unit, Centre Hospitalier Mémorial France Etats-Unis, Saint-Lô, France
| | - Albin Gouhier
- Intensive Care Unit, Centre Hospitalier Intercommunal Alençon Mamers, Alençon, France
| | - Julien Charpentier
- Medical Intensive Care Unit, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, APHP, Centre, Paris, France
| | - Gaël Piton
- Intensive Care Unit, Hôpital Jean Minjoz Hospital, Besançon, France
| | - Matthieu Faron
- Department of Biostatistics and Epidemiology, Inserm UNIT 1018 CESP Oncostat Team, Gustave Roussy Cancer Campus, Villejuif, France
| | - Annabelle Stoclin
- Intensive care unit, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Frédéric Pène
- 3i Department, Team Pulmonary and Systemic Immune Responses During Acute and Chronic Bacterial Infections, Institut Cochin, INSERM U1016, CNRS UMR8104, Université de Paris, Paris, France
- Medical Intensive Care Unit, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, APHP, Centre, Paris, France
| |
Collapse
|
190
|
Minozzi S, Pifferi S, Brazzi L, Pecoraro V, Montrucchio G, D'Amico R. Topical antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving mechanical ventilation. Cochrane Database Syst Rev 2021; 1:CD000022. [PMID: 33481250 PMCID: PMC8094382 DOI: 10.1002/14651858.cd000022.pub4] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients treated with mechanical ventilation in intensive care units (ICUs) have a high risk of developing respiratory tract infections (RTIs). Ventilator-associated pneumonia (VAP) has been estimated to affect 5% to 40% of patients treated with mechanical ventilation for at least 48 hours. The attributable mortality rate of VAP has been estimated at about 9%. Selective digestive decontamination (SDD), which consists of the topical application of non-absorbable antimicrobial agents to the oropharynx and gastroenteric tract during the whole period of mechanical ventilation, is often used to reduce the risk of VAP. A related treatment is selective oropharyngeal decontamination (SOD), in which topical antibiotics are applied to the oropharynx only. This is an update of a review first published in 1997 and updated in 2002, 2004, and 2009. OBJECTIVES To assess the effect of topical antibiotic regimens (SDD and SOD), given alone or in combination with systemic antibiotics, to prevent mortality and respiratory infections in patients receiving mechanical ventilation for at least 48 hours in ICUs. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, PubMed, and Embase on 5 February 2020. We also searched the WHO ICTRP and ClinicalTrials.gov for ongoing and unpublished studies on 5 February 2020. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and cluster-RCTs assessing the efficacy and safety of topical prophylactic antibiotic regimens in adults receiving intensive care and mechanical ventilation. The included studies compared topical plus systemic antibiotics versus placebo or no treatment; topical antibiotics versus no treatment; and topical plus systemic antibiotics versus systemic antibiotics. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included a total of 41 trials involving 11,004 participants (five new studies were added in this update). The minimum duration of mechanical ventilation ranged from 2 (19 studies) to 6 days (one study). Thirteen studies reported the mean length of ICU stay, ranging from 11 to 33 days. The percentage of immunocompromised patients ranged from 0% (10 studies) to 22% (1 study). The reporting quality of the majority of included studies was very poor, so we judged more than 40% of the studies as at unclear risk of selection bias. We judged all studies to be at low risk of performance bias, though 47.6% were open-label, because hospitals usually have standardised infection control programmes, and possible subjective decisions on who should be tested for the presence or absence of RTIs are unlikely in an ICU setting. Regarding detection bias, we judged all included studies as at low risk for the outcome mortality. For the outcome RTIs, we judged all double-blind studies as at low risk of detection bias. We judged five open-label studies as at high risk of detection bias, as the diagnosis of RTI was not based on microbiological exams; we judged the remaining open-label studies as at low risk of detection bias, as a standardised set of diagnostic criteria, including results of microbiological exams, were used. Topical plus systemic antibiotic prophylaxis reduces overall mortality compared with placebo or no treatment (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.73 to 0.96; 18 studies; 5290 participants; high-certainty evidence). Based on an illustrative risk of 303 deaths in 1000 people this equates to 48 (95% CI 15 to 79) fewer deaths with topical plus systemic antibiotic prophylaxis. Topical plus systemic antibiotic prophylaxis probably reduces RTIs (RR 0.43, 95% CI 0.35 to 0.53; 17 studies; 2951 participants; moderate-certainty evidence). Based on an illustrative risk of 417 RTIs in 1000 people this equates to 238 (95% CI 196 to 271) fewer RTIs with topical plus systemic antibiotic prophylaxis. Topical antibiotic prophylaxis probably reduces overall mortality compared with no topical antibiotic prophylaxis (RR 0.96, 95% CI 0.87 to 1.05; 22 studies, 4213 participants; moderate-certainty evidence). Based on an illustrative risk of 290 deaths in 1000 people this equates to 19 (95% CI 37 fewer to 15 more) fewer deaths with topical antibiotic prophylaxis. Topical antibiotic prophylaxis may reduce RTIs (RR 0.57, 95% CI 0.44 to 0.74; 19 studies, 2698 participants; low-certainty evidence). Based on an illustrative risk of 318 RTIs in 1000 people this equates to 137 (95% CI 83 to 178) fewer RTIs with topical antibiotic prophylaxis. Sixteen studies reported adverse events and dropouts due to adverse events, which were poorly reported with sparse data. The certainty of the evidence ranged from low to very low. AUTHORS' CONCLUSIONS Treatments based on topical prophylaxis probably reduce respiratory infections, but not mortality, in adult patients receiving mechanical ventilation for at least 48 hours, whereas a combination of topical and systemic prophylactic antibiotics reduces both overall mortality and RTIs. However, we cannot rule out that the systemic component of the combined treatment provides a relevant contribution in the observed reduction of mortality. No conclusion can be drawn about adverse events as they were poorly reported with sparse data.
Collapse
Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Silvia Pifferi
- Department of Anesthesiology and Intensive Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anaesthesia, Intensive Care and Emergency, 'Città della salute e della Scienza' Hospital, Turin, Italy
| | - Valentina Pecoraro
- Department of Laboratory Medicine, Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Giorgia Montrucchio
- Department of Anaesthesia, Intensive Care and Emergency, 'Città della salute e della Scienza' Hospital, Turin, Italy
| | - Roberto D'Amico
- Italian Cochrane Centre, University of Modena and Reggio Emilia, Modena, Italy
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
- Unit of Methodological/Statistical Support to Clinical Research, Azienda-Ospedaliero Universitaria, Modena, Italy
| |
Collapse
|
191
|
Short-Term Effects of Appropriate Empirical Antimicrobial Treatment with Ceftolozane/Tazobactam in a Swine Model of Nosocomial Pneumonia. Antimicrob Agents Chemother 2021; 65:AAC.01899-20. [PMID: 33168605 DOI: 10.1128/aac.01899-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/30/2020] [Indexed: 11/20/2022] Open
Abstract
The rising frequency of multidrug-resistant and extensively drug-resistant (MDR/XDR) pathogens is making more frequent the inappropriate empirical antimicrobial therapy (IEAT) in nosocomial pneumonia, which is associated with increased mortality. We aim to determine the short-term benefits of appropriate empirical antimicrobial treatment (AEAT) with ceftolozane/tazobactam (C/T) compared with IEAT with piperacillin/tazobactam (TZP) in MDR Pseudomonas aeruginosa pneumonia. Twenty-one pigs with pneumonia caused by an XDR P. aeruginosa strain (susceptible to C/T but resistant to TZP) were ventilated for up to 72 h. Twenty-four hours after bacterial challenge, animals were randomized to receive 2-day treatment with either intravenous saline (untreated) or 25 to 50 mg of C/T per kg body weight (AEAT) or 200 to 225 mg of TZP per kg (IEAT) every 8 h. The primary outcome was the P. aeruginosa burden in lung tissue and the histopathology injury. P. aeruginosa burden in tracheal secretions and bronchoalveolar lavage (BAL) fluid, the development of antibiotic resistance, and inflammatory markers were secondary outcomes. Overall, P. aeruginosa lung burden was 5.30 (range, 4.00 to 6.30), 4.04 (3.64 to 4.51), and 4.04 (3.05 to 4.88) log10CFU/g in the untreated, AEAT, and IEAT groups, respectively (P = 0.299), without histopathological differences (P = 0.556). In contrast, in tracheal secretions (P < 0.001) and BAL fluid (P = 0.002), bactericidal efficacy was higher in the AEAT group. An increased MIC to TZP was found in 3 animals, while resistance to C/T did not develop. Interleukin-1β (IL-1β) was significantly downregulated by AEAT in comparison to other groups (P = 0.031). In a mechanically ventilated swine model of XDR P. aeruginosa pneumonia, appropriate initial treatment with C/T decreased respiratory secretions' bacterial burden, prevented development of resistance, achieved the pharmacodynamic target, and may have reduced systemic inflammation. However, after only 2 days of treatment, P. aeruginosa tissue concentrations were moderately affected.
Collapse
|
192
|
Bellomy ML, Engoren MC, Martin BJ, Shi Y, Shotwell MS, Hughes CG, Freundlich RE. The Attributable Mortality of Postoperative Bleeding Exceeds the Attributable Mortality of Postoperative Venous Thromboembolism. Anesth Analg 2021; 132:82-88. [PMID: 32675637 DOI: 10.1213/ane.0000000000004989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Bleeding and venous thromboembolic disease are considered important sources of postoperative morbidity and mortality. Clinically, treatment of these 2 disorders is often competing. We sought to better understand the relative contributions of bleeding and venous thromboembolic disease to postoperative attributable mortality in a national cohort. METHODS A retrospective analysis of the 2006-2017 American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database was performed to assess the adjusted odds ratio and attributable mortality for postoperative bleeding and venous thromboembolism, adjusted by year. RESULTS After adjustment for confounding variables, bleeding exhibited a high postoperative attributable mortality in every year studied. Venous thromboembolism appeared to contribute minimal attributable mortality. CONCLUSIONS Bleeding complications are a consistent source of attributable mortality in surgical patients, while the contribution of venous thromboembolic disease appears to be minimal in this analysis. Further studies are warranted to better understand the etiology of this disparity.
Collapse
Affiliation(s)
- Melissa L Bellomy
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | | | - Matthew S Shotwell
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.,Biostatistics
| | - Christopher G Hughes
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert E Freundlich
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.,Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
193
|
Degroote T, Jaillette E, Reignier J, Zerimech F, Girault C, Brunin G, Chiche A, Lacherade JC, Mira JP, Maboudou P, Balduyck M, Nseir S. Is COPD associated with increased risk for microaspiration in intubated critically ill patients? Ann Intensive Care 2021; 11:7. [PMID: 33428002 PMCID: PMC7798009 DOI: 10.1186/s13613-020-00794-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Although COPD patients are at higher risk for aspiration when breathing spontaneously, no information is available on the risk for microaspiration in invasively ventilated COPD patients. The aim of our study was to determine the relationship between COPD and abundant microaspiration in intubated critically ill patients. Methods This was a retrospective analysis of prospectively collected data, provided by 3 randomized controlled trials on microaspiration in critically ill patients receiving invasive mechanical ventilation for more than 48 h. Abundant microaspiration was defined as the presence of pepsin and or alpha-amylase at significant levels in tracheal aspirates. In all study patients, pepsin and alpha-amylase were quantitatively measured in all tracheal aspirates collected during a 48-h period. COPD was defined using spirometry criteria. Results Among the 515 included patients, 70 (14%) had proven COPD. Pepsin and alpha-amylase were quantitatively measured in 3873 and 3764 tracheal aspirates, respectively. No significant difference was found in abundant microaspiration rate between COPD and non-COPD patients (62 of 70 patients (89%) vs 366 of 445 (82%) patients, p = 0.25). Similarly, no significant difference was found in abundant microaspiration of gastric contents (53% vs 45%, p = 0.28), oropharyngeal secretions (71% vs 71%, p = 0.99), or VAP (19% vs 22%, p = 0.65) rates between the two groups. No significant difference was found between COPD and non-COPD patients in duration of mechanical ventilation, ICU length of stay, or ICU mortality. Conclusions Our results suggest that COPD is not associated with increased risk for abundant microaspiration in intubated critically ill patients.
Collapse
Affiliation(s)
- Thècle Degroote
- Service de Médecine Intensive et Réanimation, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | | | - Jean Reignier
- Medecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France.,Université de Nantes, Nantes, France
| | - Farid Zerimech
- Centre de Biologie Et de Pathologie, CHU Lille, 59000, Lille, France
| | - Christophe Girault
- Normandie Univ, UNIROUEN, EA 3830, Rouen University Hospital, Medical Intensive Care Unit, 76000, Rouen, France
| | - Guillaume Brunin
- Intensive Care Unit, Boulogne Sur Mer Hospital, Boulogne-sur-Mer, France
| | - Arnaud Chiche
- Intensive Care Unit, Tourcoing Hospital, Tourcoing, France
| | - Jean-Claude Lacherade
- Service de Médecine Intensive Réanimation, Centre Hospitalier Départemental de La Vendée, La Roche sur Yon, France
| | - Jean-Paul Mira
- Groupe Hospitalier Paris Centre-Université de Paris, Cochin University Hospital, Medical Intensive Care Unit, Paris, France
| | - Patrice Maboudou
- Centre de Biologie Et de Pathologie, CHU Lille, 59000, Lille, France
| | - Malika Balduyck
- Centre de Biologie Et de Pathologie, CHU Lille, 59000, Lille, France
| | - Saad Nseir
- Critical Care Center, CHU Lille, 59000, Lille, France. .,INSERM U995, Lille Inflammation Research International Center E2, Lille University, Lille, France.
| | | |
Collapse
|
194
|
Zhao J, Li LQ, Chen CY, Zhang GS, Cui W, Tian BP. Do probiotics help prevent ventilator-associated pneumonia in critically ill patients? A systematic review with meta-analysis. ERJ Open Res 2021; 7:00302-2020. [PMID: 33532460 PMCID: PMC7836470 DOI: 10.1183/23120541.00302-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/28/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Probiotic treatments might contribute to the prevention of ventilator-associated pneumonia (VAP). Due to its unclear clinical effects, here we intend to assess the preventive effect and safety of probiotics on intensive care unit (ICU) patients. METHODS Eligible randomised controlled trials were selected in databases until 30 September 2019. The characteristics of the studies were extracted, including study design, definition of VAP, probiotics intervention, category of included patients, incidence of VAP, mortality, duration of mechanical ventilation (MV) and ICU stay. Heterogeneity was evaluated by Chi-squared and I2 tests. RESULTS 15 studies involving 2039 patients were identified for analysis. The pooled analysis suggests significant reduction on VAP (risk ratio, 0.68; 95% Cl, 0.60 to 0.77; p<0.00001) in a fixed-effects model. Subgroup analyses performed on the category of clinical and microbiological criteria both support the above conclusion; however, there were no significant differences in duration of MV or length of ICU stay in a random-effects model. Also, no significant differences in total mortality, overall mortality, 28-day mortality or 90-day mortality were found in the fixed-effects model. CONCLUSIONS The probiotics helped to prevent VAP without impacting the duration of MV, length of ICU stay or mortality.
Collapse
Affiliation(s)
| | | | | | | | | | - Bao-ping Tian
- Dept of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 310009, China
| |
Collapse
|
195
|
Bhalala U, Samraj R. Serum procalcitonin: A promising biomarker for ventilator-associated pneumonia in children. JOURNAL OF PEDIATRIC CRITICAL CARE 2021. [DOI: 10.4103/jpcc.jpcc_78_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
196
|
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation. We sought to investigate factors associated with the development of VAP in critically ill trauma patients. METHODS We conducted a retrospective review of trauma patients admitted to our trauma intensive care unit between 2016 and 2018. Patients with ventilator-associated pneumonia were identified from the trauma database. Data collected from the trauma database included demographics (age, gender and race), mechanism of injury (blunt, penetrating), injury severity (injury severity score "ISS"), the presence of VAP, transfused blood products and presenting vital signs. RESULTS A total of 1403 patients were admitted to the trauma intensive care unit (TICU) during the study period; of these, 45 had ventilator-associated pneumonia. Patients with VAP were older (p = 0.030), and they had a higher incidence of massive transfusion (p = 0.015) and received more packed cells in the first 24 h of admission (p = 0.028). They had a higher incidence of face injury (p = 0.001), injury to sternum (p = 0.011) and injury to spine (p = 0.024). Patients with VAP also had a higher incidence of acute kidney injury (AKI) (p < 0.001) and had a longer ICU (p < 0.001) and hospital length of stay (p < 0.001). Multiple logistic regression models controlling for age and injury severity (ISS) showed massive transfusion (p = 0.017), AKI (p < 0.001), injury to face (p < 0.001), injury to sternum (p = 0.007), injury to spine (p = 0.047) and ICU length of stay (p < 0.001) to be independent predictors of VAP. CONCLUSIONS Among critically ill trauma patients, acute kidney injury, injury to the spine, face or sternum, massive transfusion and intensive care unit length of stay were associated with VAP.
Collapse
|
197
|
Zhao T, Wu X, Zhang Q, Li C, Worthington HV, Hua F. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev 2020; 12:CD008367. [PMID: 33368159 PMCID: PMC8111488 DOI: 10.1002/14651858.cd008367.pub4] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND 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, swab, toothbrush, or combination, together with suction of secretions, may reduce the risk of VAP in these patients. OBJECTIVES To assess the effects of oral hygiene care (OHC) on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs). SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 25 February 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 1), MEDLINE Ovid (1946 to 25 February 2020), Embase Ovid (1980 to 25 February 2020), LILACS BIREME Virtual Health Library (1982 to 25 February 2020) and CINAHL EBSCO (1937 to 25 February 2020). We also searched the VIP Database (January 2012 to 8 March 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, gel, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours. DATA COLLECTION AND ANALYSIS 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 reported risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, using the random-effects model of meta-analysis when data from four or more trials were combined. MAIN RESULTS We included 40 RCTs (5675 participants), which were conducted in various countries including China, USA, Brazil and Iran. We categorised these RCTs into five main comparisons: chlorhexidine (CHX) mouthrinse or gel versus placebo/usual care; CHX mouthrinse versus other oral care agents; toothbrushing (± antiseptics) versus no toothbrushing (± antiseptics); powered versus manual toothbrushing; and comparisons of other oral care agents used in OHC (other oral care agents versus placebo/usual care, or head-to-head comparisons between other oral care agents). We assessed the overall risk of bias as high in 31 trials and low in two, with the rest being unclear. Moderate-certainty evidence from 13 RCTs (1206 participants, 92% adults) shows that CHX mouthrinse or gel, as part of OHC, probably reduces the incidence of VAP compared to placebo or usual care from 26% to about 18% (RR 0.67, 95% confidence intervals (CI) 0.47 to 0.97; P = 0.03; I2 = 66%). This is equivalent to a number needed to treat for an additional beneficial outcome (NNTB) of 12 (95% CI 7 to 128), i.e. providing OHC including CHX for 12 ventilated patients in intensive care would prevent one patient developing VAP. There was no evidence of a difference between interventions for the outcomes of mortality (RR 1.03, 95% CI 0.80 to 1.33; P = 0.86, I2 = 0%; 9 RCTs, 944 participants; moderate-certainty evidence), duration of mechanical ventilation (MD -1.10 days, 95% CI -3.20 to 1.00 days; P = 0.30, I2 = 74%; 4 RCTs, 594 participants; very low-certainty evidence) or duration of intensive care unit (ICU) stay (MD -0.89 days, 95% CI -3.59 to 1.82 days; P = 0.52, I2 = 69%; 5 RCTs, 627 participants; low-certainty evidence). Most studies did not mention adverse effects. One study reported adverse effects, which were mild, with similar frequency in CHX and control groups and one study reported there were no adverse effects. Toothbrushing (± antiseptics) may reduce the incidence of VAP (RR 0.61, 95% CI 0.41 to 0.91; P = 0.01, I2 = 40%; 5 RCTs, 910 participants; low-certainty evidence) compared to OHC without toothbrushing (± antiseptics). There is also some evidence that toothbrushing may reduce the duration of ICU stay (MD -1.89 days, 95% CI -3.52 to -0.27 days; P = 0.02, I2 = 0%; 3 RCTs, 749 participants), but this is very low certainty. Low-certainty evidence did not show a reduction in mortality (RR 0.84, 95% CI 0.67 to 1.05; P = 0.12, I2 = 0%; 5 RCTs, 910 participants) or duration of mechanical ventilation (MD -0.43, 95% CI -1.17 to 0.30; P = 0.25, I2 = 46%; 4 RCTs, 810 participants). AUTHORS' CONCLUSIONS Chlorhexidine mouthwash or gel, as part of OHC, probably reduces the incidence of developing ventilator-associated pneumonia (VAP) in critically ill patients from 26% to about 18%, when compared to placebo or usual care. We did not find a difference in mortality, duration of mechanical ventilation or duration of stay in the intensive care unit, although the evidence was low certainty. OHC including both antiseptics and toothbrushing may be more effective than OHC with antiseptics alone to reduce the incidence of VAP and the length of ICU stay, but, again, the evidence is low certainty. There is insufficient evidence to determine whether any of the interventions evaluated in the studies are associated with adverse effects.
Collapse
Affiliation(s)
- Tingting Zhao
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Xinyu Wu
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Qi Zhang
- Department of Oral Implantology, The Affiliated Stomatology Hospital, Zhejiang University School of Medicine, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Hangzhou, China
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Helen V Worthington
- Cochrane Oral Health, Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Fang Hua
- Hubei-MOST KLOS & KLOBM, School and Hospital of Stomatology, Wuhan University, Wuhan, China
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Centre for Evidence-Based Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| |
Collapse
|
198
|
Karvouniaris M, Pontikis K, Nitsotolis T, Poulakou G. New perspectives in the antibiotic treatment of mechanically ventilated patients with infections from Gram-negatives. Expert Rev Anti Infect Ther 2020; 19:825-844. [PMID: 33270485 DOI: 10.1080/14787210.2021.1859369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Ventilator-associated pneumonia (VAP) is a common and potentially fatal complication of mechanical ventilation that is often caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB). Despite the repurposing of older treatments and the novel antimicrobials, many resistance mechanisms cannot be confronted, and novel therapies are needed.Areas covered: We searched the literature for keywords regarding the treatment of GNB infections in mechanically ventilated patients. This narrative review presents new data on antibiotics and non-antibiotic approaches focusing on Phase 3 trials against clinically significant GNB that cause VAP.Expert opinion: Ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-relebactam stand out as new options for infections by Klebsiella pneumoniae carbapenemase-producing bacteria, whereas ceftolozane-tazobactam adds therapeutic flexibility in Pseudomonas aeruginosa infections with multiple resistance mechanisms. Ceftazidime-avibactam and ceftolozane-tazobactam have relevant literature. Aztreonam-avibactam holds promise for the treatment of infections by metallo-β-lactamase (MBL)-producing organisms. Recently approved cefiderocol possesses an extended antibacterial spectrum, including KPC- and MBL-producers. However, recently published data have toned down optimism about treating VAP caused by carbapenem-resistant Acinetobacter baumannii. For the latter, eravacycline may provide additional hope, pending pertinent data. Non-antibiotic treatments currently being considered as adjunct therapeutic approaches are welcome. Nevertheless, they will hopefully substitute current antimicrobials in the future.
Collapse
Affiliation(s)
- Marios Karvouniaris
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Konstantinos Pontikis
- ICU First Department of Respiratory Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Thomas Nitsotolis
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Garyphallia Poulakou
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| |
Collapse
|
199
|
Albin OR, Henig O, Patel TS, Valley TS, Pogue JM, Petty LA, Mills JP, Brancaccio A, Martin ET, Kaye KS. Clinical Implications of Microbiologic Treatment Failure in the Setting of Clinical Cure of Bacterial Pneumonia. Clin Infect Dis 2020; 71:3033-3041. [PMID: 31832641 PMCID: PMC7819508 DOI: 10.1093/cid/ciz1187] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/11/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Microbiologic cure is a common outcome in pneumonia clinical trials, but its clinical significance is incompletely understood. METHODS We conducted a retrospective cohort study of adult patients hospitalized with bacterial pneumonia who achieved clinical cure. Rates of recurrent pneumonia and death were compared between patients with persistent growth of the index pathogen at the time of clinical cure (microbiologic failure) and those with pathogen eradication (microbiologic cure). RESULTS Among 441 patients, 237 experienced microbiologic cure and 204 experienced microbiologic failure. Prevalences of comorbidities, ventilator dependence, and severity of acute illness were similar between groups. Patients with microbiologic failure experienced significantly higher rates of recurrent pneumonia or death following clinical cure than patients with microbiologic cure, controlling for comorbid conditions, severity of acute illness, appropriateness of empiric antibiotics, intensive care unit placement, tracheostomy dependence, and immunocompromised status (90-day multivariable adjusted odds ratio [OR], 1.56; 95% confidence interval [CI], 1.04-2.35). This association was observed among patients with pneumonias caused by Staphylococcus aureus (90-day multivariable adjusted OR, 3.69; 95% CI, 1.73-7.90). A trend was observed among pneumonias caused by nonfermenting gram-negative bacilli, but not Enterobacteriaceae or other pathogens. CONCLUSIONS Microbiologic treatment failure was independently associated with recurrent pneumonia or death among patients with bacterial pneumonia following clinical cure. Microbiologic cure merits further study as a metric to guide therapeutic interventions for patients with bacterial pneumonia.
Collapse
Affiliation(s)
- Owen R Albin
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Oryan Henig
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Twisha S Patel
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan, USA
| | - Thomas S Valley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan, USA
| | - Lindsay A Petty
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - John P Mills
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Adamo Brancaccio
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan, USA
| | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| |
Collapse
|
200
|
Transesophageal echocardiography-associated tracheal microaspiration and ventilator-associated pneumonia in intubated critically ill patients: a multicenter prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:679. [PMID: 33287866 PMCID: PMC7719845 DOI: 10.1186/s13054-020-03380-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/09/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Microaspiration of gastric and oropharyngeal secretions is the main causative mechanism of ventilator-associated pneumonia (VAP). Transesophageal echocardiography (TEE) is a routine investigation tool in intensive care unit and could enhance microaspiration. This study aimed at evaluating the impact of TEE on microaspiration and VAP in intubated critically ill adult patients. METHODS It is a four-center prospective observational study. Microaspiration biomarkers (pepsin and salivary amylase) concentrations were quantitatively measured on tracheal aspirates drawn before and after TEE. The primary endpoint was the percentage of patients with TEE-associated microaspiration, defined as: (1) ≥ 50% increase in biomarker concentration between pre-TEE and post-TEE samples, and (2) a significant post-TEE biomarker concentration (> 200 μg/L for pepsin and/or > 1685 IU/L for salivary amylase). Secondary endpoints included the development of VAP within three days after TEE and the evolution of tracheal cuff pressure throughout TEE. RESULTS We enrolled 100 patients (35 females), with a median age of 64 (53-72) years. Of the 74 patients analyzed for biomarkers, 17 (23%) got TEE-associated microaspiration. However, overall, pepsin and salivary amylase levels were not significantly different between before and after TEE, with wide interindividual variability. VAP occurred in 19 patients (19%) within 3 days following TEE. VAP patients had a larger tracheal tube size and endured more attempts of TEE probe introduction than their counterparts but showed similar aspiration biomarker concentrations. TEE induced an increase in tracheal cuff pressure, especially during insertion and removal of the probe. CONCLUSIONS We could not find any association between TEE-associated microaspiration and the development of VAP during the three days following TEE in intubated critically ill patients. However, our study cannot formally rule out a role for TEE because of the high rate of VAP observed after TEE and the limitations of our methods.
Collapse
|