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Wu Z, Liu Y, Xu J, Xie J, Zhang S, Huang L, Huang Y, Yang Y, Qiu H. A Ventilator-associated Pneumonia Prediction Model in Patients With Acute Respiratory Distress Syndrome. Clin Infect Dis 2021; 71:S400-S408. [PMID: 33367575 DOI: 10.1093/cid/ciaa1518] [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] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mechanical ventilation is crucial for acute respiratory distress syndrome (ARDS) patients and diagnosis of ventilator-associated pneumonia (VAP) in ARDS patients is challenging. Hence, an effective model to predict VAP in ARDS is urgently needed. METHODS We performed a secondary analysis of patient-level data from the Early versus Delayed Enteral Nutrition (EDEN) of ARDSNet randomized controlled trials. Multivariate binary logistic regression analysis established a predictive model, incorporating characteristics selected by systematic review and univariate analyses. The model's discrimination, calibration, and clinical usefulness were assessed using the C-index, calibration plot, and decision curve analysis (DCA). RESULTS Of the 1000 unique patients enrolled in the EDEN trials, 70 (7%) had ARDS complicated with VAP. Mechanical ventilation duration and intensive care unit (ICU) stay were significantly longer in the VAP group than non-VAP group (P < .001 for both) but the 60-day mortality was comparable. Use of neuromuscular blocking agents, severe ARDS, admission for unscheduled surgery, and trauma as primary ARDS causes were independent risk factors for VAP. The area under the curve of the model was .744, and model fit was acceptable (Hosmer-Lemeshow P = .185). The calibration curve indicated that the model had proper discrimination and good calibration. DCA showed that the VAP prediction nomogram was clinically useful when an intervention was decided at a VAP probability threshold between 1% and 61%. CONCLUSIONS The prediction nomogram for VAP development in ARDS patients can be applied after ICU admission, using available variables. Potential clinical benefits of using this model deserve further assessment.
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Affiliation(s)
- Zongsheng Wu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yao Liu
- Department of Emergency, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Jingyuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Shi Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Lili Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yingzi Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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Alrabiah A, Alhussinan K, Alyousef M, Alsayed A, Aljasser A, Alduraywish S, Alammar A. Microbiological profiles of tracheostomy patients: a single-center experience. Multidiscip Respir Med 2021; 16:811. [PMID: 35070294 PMCID: PMC8743611 DOI: 10.4081/mrm.2021.811] [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: 09/27/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022] Open
Abstract
Background This study compared the prevalence of common microorganisms in obstructed and non-obstructed cases across the four quarters on the first post-tracheostomy year. Methods A retrospective chart review of the microbiological profiles of all adult patients who underwent a tracheostomy was conducted between June 2015 and September 2019 at our hospital. Based on the tracheostomy indications, patients were allocated to obstructed or non-obstructed group. Any patient with at least one positive sample was followed up quarterly for a year. The first culture result obtained was recorded at least one month following the last antibiotic dose in each quarter. Results Out of the 65 tracheal aspirate results obtained from 58 patients (mean age, 57.5±16.48 years), the most common procedure and indications were surgical tracheostomy (72.4%) and non-obstructed causes (74.1%), respectively. Moreover, 47.7% of the culture results indicated Pseudomonas aeruginosa, which showed significantly different proportions across the quarters (p=0.006). Among obstructed patients, P. aeruginosa was the most common (35%), followed by methicillin-resistant Staphylococcus aureus (MRSA; 23.5%). Conclusions The most common post-tracheostomy microorganism was P. aeruginosa. MRSA showed a strong association with tracheostomy for obstructive indications.
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Affiliation(s)
- Abdulaziz Alrabiah
- Department of Otolaryngology-Head & Neck Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh.,Department of Otolaryngology-Head & Neck Surgery, Prince Sultan Military Medical City, Riyadh
| | - Khaled Alhussinan
- King Saud University, College of Medicine, King Saud University Medical City, Riyadh
| | - Mohammed Alyousef
- King Saud University, College of Medicine, King Saud University Medical City, Riyadh
| | - Ahmed Alsayed
- Department of Otolaryngology-Head & Neck Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh
| | - Abdullah Aljasser
- Department of Otolaryngology-Head & Neck Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh
| | - Shatha Alduraywish
- Department of Family and Community Medicine, Prince Sattam bin Abdulaziz Research Chair for Epidemiology and Public Health, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed Alammar
- Department of Otolaryngology-Head & Neck Surgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh
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Decreased duration of intravenous cephalosporins in intensive care unit patients with selective digestive decontamination: a retrospective before-and-after study. Eur J Clin Microbiol Infect Dis 2020; 39:2115-2120. [PMID: 32617694 PMCID: PMC7330883 DOI: 10.1007/s10096-020-03966-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/25/2020] [Indexed: 12/18/2022]
Abstract
Selective digestive decontamination (SDD) reduces the rate of infection and improves the outcomes of patients admitted to an intensive care unit (ICU). A risk associated with its use is the development of multi-drug-resistant organisms. We hypothesized that a 1-day reduction in systemic antimicrobial exposure in the SDD regimen would not affect the outcomes of our patients. In this before-and-after study design, 199 patients and 248 patients were included in a 3-day SDD group and a 2-day SDD group, respectively. The rates of hospital-acquired pneumonia and ICU infections were similar in both groups. The rates of bloodstream infection and bacteriuria were significantly lower in the 2-day SDD group than in the 3-day SDD group. Compared with the patients in the 3-day group, the patients in the 2-day SDD group received fewer antibiotics and less exposure to mechanical ventilation, and they used fewer ICU resources. The rates of ICU mortality and 28-day mortality were similar in both groups. The incidence of multi-drug-resistant organisms was similar in both groups. Within the limitations inherent to our study design, reducing the exposure of prophylactic systemic antibiotics in the SDD setting from 3 days to 2 days was not associated with impaired outcomes. Future randomized controlled trials should be conducted to test this hypothesis and investigate the effects on the development of multi-drug resistant organisms.
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Lee DH, Lee BK, Jeung KW, Jung YH, Cho YS, Youn CS, Min YI. Neuromuscular blockade requirement is associated with good neurologic outcome in cardiac arrest survivors treated with targeted temperature management. J Crit Care 2017; 40:218-224. [PMID: 28448951 DOI: 10.1016/j.jcrc.2017.04.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/07/2017] [Accepted: 04/15/2017] [Indexed: 01/31/2023]
Abstract
PURPOSE We examined the association between neuromuscular blockade (NMB) requirements and outcomes and lactate clearance in cardiac arrest survivors treated with targeted temperature management (TTM). METHODS We included consecutive adult cardiac arrest survivors treated with TTM between 2012 and 2015. NMB use was categorized into 3 groups: no NMB, bolus NMB (intermittent bolus use), and continuous NMB (continuous infusion). Serum lactate levels were measured on admission and at 12h, 24h, and 48h after admission. The primary outcome was neurologic outcome at discharge. The secondary outcomes were in-hospital mortality and lactate clearance. RESULTS In total, 309 patients were included. Of these, 206 (66.7%) and 73 (23.6%) were discharged with poor neurologic outcome and death, respectively. Multivariate analysis revealed that continuous NMB, as opposed to no NMB use, was associated with decreased poor neurologic outcomes (odds ratio [OR], 0.317; 95% confidence interval [CI], 0.124-0.815) and decreased in-hospital mortality (OR, 0.414; 95% CI, 0.183-0.941). There were no differences in lactate clearance between the NMB groups. CONCLUSION Continuous NMB requirement was associated with improved neurologic outcome and decreased in-hospital mortality in cardiac arrest survivors treated with TTM. The NMB requirement was not associated with lactate clearance.
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Affiliation(s)
- Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea.
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea
| | - Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, Republic of Korea
| | - Yong Il Min
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, Republic of Korea
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Habib SF, Mukhtar AM, Abdelreheem HM, Khorshied MM, El Sayed R, Hafez MH, Gouda HM, Ghaith DM, Hasanin AM, Eladawy AS, Ali MA, Fouad AZ. Diagnostic values of CD64, C-reactive protein and procalcitonin in ventilator-associated pneumonia in adult trauma patients: a pilot study. Clin Chem Lab Med 2017; 54:889-95. [PMID: 26501164 DOI: 10.1515/cclm-2015-0656] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 09/25/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections; however, its diagnosis remains difficult to establish in the critical care setting. We investigated the potential role of neutrophil CD64 (nCD64) expression as an early marker for the diagnosis of VAP. METHODS Forty-nine consecutive patients with clinically suspected VAP were prospectively included in a single-center study. The levels of nCD64, C-reactive protein (CRP), and serum procalcitonin (PCT) were analyzed for diagnostic evaluation at the time of intubation (baseline), at day 0 (time of diagnosis), and at day 3. The receiver operating characteristic curves were analyzed to identify the ideal cutoff values. RESULTS VAP was confirmed in 36 of 49 cases. In patients with and without VAP, the median levels (interquartile range, IQR) of nCD64 did not differ either at baseline [2.4 (IQR, 1.8-3.1) and 2.6 (IQR, 2.3-3.2), respectively; p=0.3] or at day 0 [2 (IQR, 2.5-3.0) and 2.6 (IQR, 2.4-2.9), respectively; p=0.8]. CRP showed the largest area under the curve (AUC) at day 3. The optimum cutoff value for CRP according to the maximum Youden index was 133 mg/dL. This cutoff value had 69% sensitivity and 76% specificity for predicting VAP; the AUC was 0.73 (95% CI, 0.59-0.85). The nCD64 and PCT values could not discriminate between the VAP and non-VAP groups either at day 0 or day 3. CONCLUSIONS The results of this pilot study suggest that neutrophil CD64 measurement has a poor role in facilitating the diagnosis of VAP and thus may not be practically recommended to guide the administration of antibiotics when VAP is suspected.
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Rapid diagnostic test and use of antibiotic against methicillin-resistant Staphylococcus aureus in adult intensive care unit. Eur J Clin Microbiol Infect Dis 2016; 36:267-272. [DOI: 10.1007/s10096-016-2795-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
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Does low-dose hydrocortisone therapy prevent ventilator-associated pneumonia in trauma patients? Am J Ther 2015; 22:22-8. [PMID: 23698187 DOI: 10.1097/mjt.0b013e3182691af0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The incidence of ventilator-associated pneumonia (VAP) is particularly high in trauma patients. Immediate acute inflammation response is one of the hallmarks of multiple trauma. This phenomenon is associated with an immunosuppression state and may increase the risk of VAP. In our study, we aimed to evaluate whether low-dose steroids prevent VAP onset in multiple trauma patients. All adult patients admitted in our intensive care unit (ICU) for multiple trauma with predicted duration of mechanical ventilation over 48 hours were included. We compared 2 different periods: a retrospective cohort of patients who did not receive low-dose steroids for VAP prevention and a prospective cohort of patients who received hydrocortisone with a dose of 100 mg/8 hours for a scheduled period of 7 days. We included 175 patients: 92 in the steroids (-) group and 83 in the steroids (+) group. The incidence of VAP was not different between the 2 studied groups (29.3% and 26.5%; P = 0.676). When predictive factors of VAP onset were studied in multivariate analysis, steroids had no preventive effect on VAP [OR = 1.6; 95% confidence interval, 0.73-3.6; P = 0.234]. We did not find any difference between the 2 groups, neither in terms of ICU length of stay (respectively, 11 ± 9.7 days vs. 12.3 ± 10.7 days; P = 0.372) nor in terms of ICU mortality (29.3% vs 24.1%; P = 0.434).
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Does selective digestive decontamination prevent ventilator-associated pneumonia in trauma patients? Am J Ther 2015; 21:470-6. [PMID: 23567785 DOI: 10.1097/mjt.0b013e31825e7a8f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The incidence of ventilator-associated pneumonia (VAP) is particularly high in patients with trauma. The efficacy and safety of selective digestive decontamination (SDD) was not studied extensively. We aimed in our randomized double-blind, placebo-controlled study to evaluate whether SDD prevents VAP onset in multiple trauma patients. All adult patients admitted in our intensive care unit for multiple trauma with a predicted duration of mechanical ventilation (MV) over 48 hours were included. We included 44 patients who were divided into 4 groups: group A receiving subglottic and gastric treatment suspension (polymyxin E 100 mg, vancomycin 1 g, and amphotericin B 500 mg), group B receiving placebo, group C receiving subglottic placebo and gastric treatment suspension, and group D receiving subglottic treatment suspension and gastric placebo. The suspension was given 4 times a day during 7 consecutive days. To this topical treatment, we associated an intravenous administration of cefotaxime (1 g 3 times a day during 4 consecutive days). The incidence of VAP in the 4 groups was, respectively, 45.5%, 46.2%, 22.2%, and 27.3% (P=0.236). In multivariate analysis, none of the 3 tested regimens was identified as a protective factor against VAP. However, prolonged duration of MV was the only independent factor predicting VAP onset (odds ratio=1.1; 95% confidence interval [1.1-1.4]; P=0.049).
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Lascarrou JB, Le Gouge A, Dimet J, Lacherade JC, Martin-Lefèvre L, Fiancette M, Vinatier I, Lebert C, Bachoumas K, Yehia A, Lagarrigue MH, Colin G, Reignier J. Neuromuscular blockade during therapeutic hypothermia after cardiac arrest: Observational study of neurological and infectious outcomes. Resuscitation 2014; 85:1257-62. [DOI: 10.1016/j.resuscitation.2014.05.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 05/21/2014] [Accepted: 05/22/2014] [Indexed: 01/15/2023]
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Ghanbarpour R, Saghafinia M, Ramezani Binabaj M, Madani SJ, Tadressi D, Forozanmehr MJ. Pulmonary infections in ICU patients without underlying disease on ventilators. Trauma Mon 2014; 19:e15958. [PMID: 25337514 PMCID: PMC4199291 DOI: 10.5812/traumamon.15958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 12/06/2013] [Accepted: 04/28/2014] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND At present, the use of ventilator support is an important part of treatment in ICU patients. However, aside from its well-known advantages, the use of these devices is also associated with complications, the most important of which is pulmonary infection (PI). PI has a high rate of morbidity and mortality. OBJECTIVES This study aimed to evaluate the prevalence of PI in mechanically-ventilated patients and the role that factors, such as age, sex, and duration of intubation, play in this regard. MATERIALS AND METHODS This descriptive cross-sectional study evaluated the prevalence of PI in mechanically ventilated patients, with no underlying condition which could compromise their immune system. Age, sex, and duration of intubation were assessed. Data were analyzed using SPSS (version 16) software. RESULTS A total of 37 ICU patients on ventilators were evaluated, including 21 males (56.8%) and 16 females (43.2%). The mean age of the patients was 54 ± 19 years (range 19 to 86 years), with a mean age of 52 ± 20 years in men, and 56 ± 18 years in women (P = 0.52). The mean duration of ventilation was 6 ± 4 days (range 2 to 20 days). The mean duration of ventilation was 5 ± 2 days in men, and 6 ± 5 days in women (P = 0.42). A total of 16 patients (43.2%) developed ventilator-associated pneumonia (VAP); of whom, 50% were male and 50% female (P = 0.46). Patients who developed a pulmonary infection had a significantly longer duration of ventilation. The mean duration of ventilation was 8 ± 4 days in patients who had developed VAP, while this duration was 4 ± 2 days in the non-affected patients (P = 0.005). Overall, 17 patients died, and 7 of these deaths were attributed to VAP. CONCLUSIONS The prevalence of VAP in this study was approximately 43%, which is relatively high. In total, the percentage of deaths due to VAP among the patients was 18.91%. Duration of ventilator support was significantly correlated with the prevalence of PI.
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Affiliation(s)
- Reza Ghanbarpour
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Masoud Saghafinia
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Masoud Saghafinia, Trauma Research Center, Baqiyatallah University of Medical Sciences, P.O.Box: 19945/581, Mollasadra St., Tehran, IR Iran. Tel./Fax: +98-2188053766, E-mail:
| | - Mahdi Ramezani Binabaj
- Students’ Research Committee, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Seyed Jallal Madani
- Anesthesia Group, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Davood Tadressi
- Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
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Chaari A, Kssibi H, Zribi W, Medhioub F, Chelly H, Algia NB, Hamida CB, Bahloul M, Bouaziz M. Ventilator-associated pneumonia in trauma patients with open tracheotomy: Predictive factors and prognosis impact. J Emerg Trauma Shock 2013; 6:246-51. [PMID: 24339656 PMCID: PMC3841530 DOI: 10.4103/0974-2700.120364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 09/16/2012] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To assess the predictive factors of ventilator associated pneumonia (VAP) occurrence following open tracheotomy in trauma patients. MATERIALS AND METHODS We conducted an observational, prospective study over 15 months, between 01/08/2010 and 30/11/2011. All trauma patients (except those with cervical spine trauma), older than 15 years, undergoing open tracheotomy during their ICU stay were included. All episode of VAP following tracheotomy were recorded. Predictive factor of VAP onset were studied. RESULTS We included 106 patients. Mean age was 37.9 ± 15.5 years. Mean Glasgow coma Scale (GCS) was 8.5 ± 3.7 and mean Injury Severity Score (ISS) was 53.1 ± 23.8. Tracheotomy was performed for 53 patients (50%) because of prolonged ventilation whereas 83 patients (78.3%) had tracheotomy because of projected long mechanical ventilation. Tracheotomy was performed within 8.6 ± 5.3 days. Immediate complications were bleeding events (22.6%) and barotrauma (0.9%). Late complications were stomal infection (28.3%) and VAP (52.8%). In multivariate analysis, independent factors predicting VAP onset were delayed tracheotomy (OR = 0.041; CI95% [1.02-7.87]; P = 0.041) and stomal infection (OR = 3.04; CI95% [1.02-9.93]; P = 0.045). Thirty three patients died in ICU (31.1%) without significant impact of VAP on mortality. CONCLUSION Late tracheotomy and stomal infection are independent factors predicting VAP onset after open tracheotomy in trauma patients. The occurrence of VAP prolongers mechanical ventilation duration and intensive care unit (ICU) length of stay (LOS) but doesn't increase mortality.
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Affiliation(s)
- Anis Chaari
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia
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Daneman N, Sarwar S, Fowler RA, Cuthbertson BH. Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2013; 13:328-41. [PMID: 23352693 DOI: 10.1016/s1473-3099(12)70322-5] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many meta-analyses have shown reductions in infection rates and mortality associated with the use of selective digestive decontamination (SDD) or selective oropharyngeal decontamination (SOD) in intensive care units (ICUs). These interventions have not been widely implemented because of concerns that their use could lead to the development of antimicrobial resistance in pathogens. We aimed to assess the effect of SDD and SOD on antimicrobial resistance rates in patients in ICUs. METHODS We did a systematic review of the effect of SDD and SOD on the rates of colonisation or infection with antimicrobial-resistant pathogens in patients who were critically ill. We searched for studies using Medline, Embase, and Cochrane databases, with no limits by language, date of publication, study design, or study quality. We included all studies of selective decontamination that involved prophylactic application of topical non-absorbable antimicrobials to the stomach or oropharynx of patients in ICUs, with or without additional systemic antimicrobials. We excluded studies of interventions that used only antiseptic or biocide agents such as chlorhexidine, unless antimicrobials were also included in the regimen. We used the Mantel-Haenszel model with random effects to calculate pooled odds ratios. FINDINGS We analysed 64 unique studies of SDD and SOD in ICUs, of which 47 were randomised controlled trials and 35 included data for the detection of antimicrobial resistance. When comparing data for patients in intervention groups (those who received SDD or SOD) versus data for those in control groups (who received no intervention), we identified no difference in the prevalence of colonisation or infection with Gram-positive antimicrobial-resistant pathogens of interest, including meticillin-resistant Staphylococcus aureus (odds ratio 1·46, 95% CI 0·90-2·37) and vancomycin-resistant enterococci (0·63, 0·39-1·02). Among Gram-negative bacilli, we detected no difference in aminoglycoside-resistance (0·73, 0·51-1·05) or fluoroquinolone-resistance (0·52, 0·16-1·68), but we did detect a reduction in polymyxin-resistant Gram-negative bacilli (0·58, 0·46-0·72) and third-generation cephalosporin-resistant Gram-negative bacilli (0·33, 0·20-0·52) in recipients of selective decontamination compared with those who received no intervention. INTERPRETATION We detected no relation between the use of SDD or SOD and the development of antimicrobial-resistance in pathogens in patients in the ICU, suggesting that the perceived risk of long-term harm related to selective decontamination cannot be justified by available data. However, our study indicates that the effect of decontamination on ICU-level antimicrobial resistance rates is understudied. We recommend that future research includes a non-crossover, cluster randomised controlled trial to assess long-term ICU-level changes in resistance rates. FUNDING None.
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Affiliation(s)
- Nick Daneman
- Trauma, Emergency, and Critical Care Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada.
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Forel JM, Voillet F, Pulina D, Gacouin A, Perrin G, Barrau K, Jaber S, Arnal JM, Fathallah M, Auquier P, Roch A, Azoulay E, Papazian L. Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R65. [PMID: 22524447 PMCID: PMC3681394 DOI: 10.1186/cc11312] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Revised: 02/02/2012] [Accepted: 04/18/2012] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) may contribute to the mortality associated with acute respiratory distress syndrome (ARDS). We aimed to determine the incidence, outcome, and risk factors of bacterial VAP complicating severe ARDS in patients ventilated by using a strictly standardized lung-protective strategy. METHODS This prospective epidemiologic study was done in all the 339 patients with severe ARDS included in a multicenter randomized, placebo-controlled double-blind trial of cisatracurium besylate in severe ARDS patients. Patients with suspected VAP underwent bronchoalveolar lavage to confirm the diagnosis. RESULTS Ninety-eight (28.9%) patients had at least one episode of microbiologically documented bacterial VAP, including 41 (41.8%) who died in the ICU, compared with 74 (30.7%) of the 241 patients without VAP (P = 0.05). After adjustment, age and severity at baseline, but not VAP, were associated with ICU death. Cisatracurium besylate therapy within 2 days of ARDS onset decreased the risk of ICU death. Factors independently associated with an increased risk to develop a VAP were male sex and worse admission Glasgow Coma Scale score. Tracheostomy, enteral nutrition, and the use of a subglottic secretion-drainage device were protective. CONCLUSIONS In patients with severe ARDS receiving lung-protective ventilation, VAP was associated with an increased crude ICU mortality which did not remain significant after adjustment.
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Affiliation(s)
- Jean-Marie Forel
- Service de Réanimation des Détresses Respiratoires et Infections Sévères, Assistance Publique Hôpitaux de Marseille, URMITE CNRS-UMR 6236, Aix-Marseille Univ, Marseille 13015, France
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Al-Dorzi HM, El-Saed A, Rishu AH, Balkhy HH, Memish ZA, Arabi YM. The results of a 6-year epidemiologic surveillance for ventilator-associated pneumonia at a tertiary care intensive care unit in Saudi Arabia. Am J Infect Control 2012; 40:794-9. [PMID: 22317860 DOI: 10.1016/j.ajic.2011.10.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Revised: 10/01/2011] [Accepted: 10/03/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) prevention is an important patient safety initiative. We describe the impact of a multidisciplinary surveillance program on VAP rates in a tertiary medical-surgical-trauma intensive care unit (ICU). METHODS An epidemiologic surveillance program was established in 2003 as a joint project between ICU and Infection Prevention and Control Department to regularly report VAP rates to guide evidence-based VAP preventive strategies. VAP cases were diagnosed according to predefined criteria and prospectively recorded by a research physician. VAP microbiology, risk factors, and outcomes were noted. RESULTS Of 2,812 ventilated patients, 433 (15.4%) developed VAP corresponding to 15.9 episodes per 1,000 ventilator-days. The rate decreased from 19.1 in 2003 to 6.3 per 1,000 ventilator-days in 2009. On multivariate analysis, VAP was associated with accidental extubation (hazard ratio [HR], 4.11; 95% confidence interval [CI]: 1.93-8.73), trauma versus medical diagnosis (HR, 2.59; 95% CI: 2.07-3.23), chronic obstructive pulmonary disease (HR, 1.55; 95% CI: 1.08-2.22), and neuromuscular blockade (HR, 1.39; 95% CI: 1.07-1.81). The most common isolated pathogens were Gram-negative organisms. VAP patients had longer mechanical ventilation duration, ICU and hospital length of stay, but similar ICU and hospital mortality compared with non-VAP patients. CONCLUSION The study showed a reduction in VAP rates with active surveillance, reporting and evidence-based preventive strategies and identified several modifiable risk factors, which should be the focus of additional interventions.
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Sacristán B, Blanco MT, Galán-Ladero MA, Blanco J, Pérez-Giraldo C, Gómez-García AC. Aspartyl proteinase, phospholipase, hemolytic activities and biofilm production of Candida albicans isolated from bronchial aspirates of ICU patients. Med Mycol 2010; 49:94-7. [PMID: 20465518 DOI: 10.3109/13693786.2010.482947] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
A correlation between mucosal colonization by Candida albicans and the subsequent development of invasive respiratory infection has been previously described. The aim of this study was to evaluate different enzymatic activities in vitro and to determine the capacity to form biofilms by 17 C. albicans isolates from bronchial aspirates of mechanically ventilated patients hospitalized in intensive care units. All the C. albicans clinical isolates tested were biofilm producers and displayed detectable levels of proteinase and hemolytic activities, although phospholipase activity was not detected in one strain. The correlation noted among the virulence factors studied suggests that the presence of more than one concurrent factor could facilitate the spread of infection.
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Affiliation(s)
- B Sacristán
- Area of Microbiology, Department of Biomedical Sciences, Faculty of Medicine, University of Extremadura, Badajoz, Spain
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Gacouin A, Barbarot N, Camus C, Salomon S, Isslame S, Marque S, Lavoué S, Donnio PY, Thomas R, Le Tulzo Y. Late-onset ventilator-associated pneumonia in nontrauma intensive care unit patients. Anesth Analg 2009; 109:1584-90. [PMID: 19713267 DOI: 10.1213/ane.0b013e3181b6e9b6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Most studies designed to determine the factors associated with the acquisition of late-onset ventilator-associated pneumonia (VAP) were performed in critically ill trauma patients. The impact of enteral nutrition (EN) on the risk of acquiring VAP has been discussed. In this study, we assessed factors associated with late-onset VAP in nontrauma patients and determined whether nutrition provided early was associated with development of late-onset VAP in this population. METHODS We performed a prospective observational cohort study in a 21-bed polyvalent intensive care unit in a university hospital. RESULTS Three hundred sixty-one intubated adult patients with a duration of mechanical ventilation (MV) of 6 days or more were admitted over a 28-mo period. Late-onset VAP was confirmed in 76 patients (21%) by the presence of at least one microorganism at a concentration >or=10(4) colony-forming units/mL on the bronchoalveolar lavage. Gram-negative bacilli represented 75% and Staphylococcus aureus 21% of recovered organisms. Factors independently associated with late-onset VAP by multivariate analysis included a high simplified acute physiology score II score (odds ratio: 1.021; 95% confidence interval [CI]: 1.005-1.038; P = 0.01), development of acute respiratory distress syndrome during the first 5 days of MV (odds ratio: 1.98; 95% CI: 1.05-3.67; P = 0.04), and size of the endotracheal tube >or=7.5 (odds ratio: 2.06; 95% CI: 1.88-3.90; P = 0.03). EN started within 48 h of MV onset was not associated with a higher risk for late-onset VAP. CONCLUSION In our nontrauma patient population, early EN was not associated with development of late-onset VAP. In this population, severity of the disease during the first 5 days of MV seemed to be associated with late-onset VAP. In addition, our results suggest that the risk of late-onset VAP is higher in patients with a tube size >or=7.5 than in patients with a tube size <7.5.
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Affiliation(s)
- Arnaud Gacouin
- Service des Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, 35033 Rennes Cedex 9, France.
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Durairaj L, Mohamad Z, Launspach JL, Ashare A, Choi JY, Rajagopal S, Doern GV, Zabner J. Patterns and density of early tracheal colonization in intensive care unit patients. J Crit Care 2009; 24:114-21. [PMID: 19272547 DOI: 10.1016/j.jcrc.2008.10.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Revised: 07/14/2008] [Accepted: 10/21/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The study aimed to describe the patterns and density of early tracheal colonization among intubated patients and to correlate colonization status with levels of antimicrobial peptides and inflammatory cytokines. DESIGN The was a prospective cohort study. SETTING The study was conducted in medical and cardiovascular intensive care units of a tertiary referral hospital. PATIENTS Seventy-four adult patients admitted between March 2003 and May 2006 were recruited for the study. INTERVENTIONS Tracheal aspirates were collected daily for the first 4 days of intubation using standardized, sterile technique and sent for quantitative culture and cytokines, lactoferrin and lysozyme measurements. MEASUREMENTS AND MAIN RESULTS The mean acute physiology and chronic health evaluation (APACHE II) score in this cohort was 24 +/- 7. Proportion of subjects colonized by any microorganism increased over the first 4 days of intubation (47%, 60%, 70%, 70%, P = .08), but density of colonization for bacteria or yeast did not change significantly. No known risk factors predicted tracheal colonization on day 1 of intubation. Several patterns of colonization were observed (persistent, transient, new colonization, and clearance of initial colonization).The most common organisms cultured were Candida albicans and coagulase-negative Staphylococcus. Levels of cytokines, lactoferrin, or lysozyme did not change over time and were not correlated with tracheal colonization status. Four subjects (6%) had ventilator-associated pneumonia. CONCLUSIONS The density of tracheal colonization did not change significantly over the first 4 days of intubation in medical intensive care unit patients. There was no correlation between tracheal colonization and the levels of antimicrobial peptides or cytokines. Several different patterns of colonization may have to be considered while planning interventions to reduce airway colonization.
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Affiliation(s)
- Lakshmi Durairaj
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.
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Yilmazlar A, Ozyurt G, Kahveci F, Goral G. Selective Digestive Decontamination can be an Infection-Prevention Regimen for the Intoxicated Patients. ACTA ACUST UNITED AC 2008. [DOI: 10.3923/jpt.2009.36.40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
PURPOSE OF REVIEW This review describes the most recent advances in the management and prevention of nosocomial pneumonia. The new ATS guidelines in particular are most likely to affect clinical practice outside the USA. RECENT FINDINGS The problem of multidrug-resistant bacteria causing nosocomial pneumonia seems to be increasing. This is particularly true for methicillin-resistant Staphylococcus aureus. While the diagnosis of ventilator associated pneumonia remains a conflictive issue, serial tracheobronchial aspirates may improve the selection of adequate antimicrobial treatment. Combined beta-lactam and aminoglycoside therapy is inferior to beta-lactam monotherapy, both in terms of clinical outcome and in the prevention of resistance during treatment; in addition, it carries an increased risk of nephrotoxicity. SUMMARY The updated ATS guidelines will considerably impact clinical approaches to nosocomial and healthcare-related pneumonia. Serial tracheobronchial aspirates can be used to guide selection of antimicrobial treatment in ventilator associated pneumonia. The combination of beta-lactams and aminoglycosides is likely to be abandoned in the future. New potent treatment options for pneumonia due to nonfermenters are urgently needed.
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Affiliation(s)
- Uwe Ostendorf
- Thoraxzentrum Ruhrgebiet, Evangelisches Krankenhaus Herne und Augusta-Kranken-Anstalt Bochum, Bochum, Germany
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Déchelotte P, Hasselmann M, Cynober L, Allaouchiche B, Coëffier M, Hecketsweiler B, Merle V, Mazerolles M, Samba D, Guillou YM, Petit J, Mansoor O, Colas G, Cohendy R, Barnoud D, Czernichow P, Bleichner G. L-alanyl-L-glutamine dipeptide-supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients: the French controlled, randomized, double-blind, multicenter study. Crit Care Med 2006; 34:598-604. [PMID: 16505644 DOI: 10.1097/01.ccm.0000201004.30750.d1] [Citation(s) in RCA: 250] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Glutamine (Gln)-supplemented total parenteral nutrition (TPN) improves clinical outcome after planned surgery, but the benefits of Gln-TPN for critically ill (intensive care unit; ICU) patients are still debated. DESIGN Prospective, double-blind, controlled, randomized trial. SETTING ICUs in 16 hospitals in France. PATIENTS One-hundred fourteen ICU patients admitted for multiple trauma (38), complicated surgery (65), or pancreatitis (11). INTERVENTIONS Patients were randomized to receive isocaloric isonitrogenous TPN via a central venous catheter providing 37.5 kcal and 1.5 g amino acids.kg-1.day-1 supplemented with either L-alanyl-L-glutamine dipeptide (0.5 g.kg-1.day-1; Ala-Gln group, n=58) or L-alanine+L-proline (control group, n=56) over at least 5 days. MEASUREMENTS AND MAIN RESULTS Complicated clinical outcome was defined a priori by the occurrence of infectious complications (according to the criteria of the Centers for Disease Control and Prevention), wound complication, or death. The two groups were compared by chi-square test on an intention-to-treat basis. The two groups did not differ at inclusion for type and severity of injury (mean simplified acute physiology score II, 30 vs. 30.5; mean injury severity score, 44.9 vs. 42.3). Similar volumes of TPN were administered in both groups. Ala-Gln-supplemented TPN was associated with a lower incidence of complicated outcome (41% vs. 61%; p<.05), which was mainly due to a reduced infection rate per patient (mean, 0.45 vs. 0.71; p<.05) and incidence of pneumonia (10 vs. 19; p<.05). Early death rate during treatment and 6-month survival were not different. Hyperglycemia was less frequent (20 vs. 30 patients; p<.05) and there were fewer insulin-requiring patients (14 vs. 22; p<.05) in the Ala-Gln group. CONCLUSIONS TPN supplemented with Ala-Gln dipeptide in ICU patients is associated with a reduced rate of infectious complications and better metabolic tolerance.
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Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C, Tasker R. Year in review in intensive care medicine,
2005. II. Infection and sepsis, ventilator-associated pneumonia, ethics, haematology and haemostasis, ICU organisation and scoring, brain injury. Intensive Care Med 2006; 32:380-90. [PMID: 16485094 DOI: 10.1007/s00134-005-0060-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2005] [Accepted: 12/26/2005] [Indexed: 11/28/2022]
Affiliation(s)
- Peter Andrews
- Western General Hospital, Intensive Care Unit, Edinburgh, UK
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Reply to the comment by Fox et al. on “Risk factors for late-onset ventilator associated pneumonia in trauma patients receiving selective digestive decontamination”. Intensive Care Med 2005. [DOI: 10.1007/s00134-005-2637-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Fox MA, Sarginson RE, Zandstra DF, Meynaar I, van Saene HK. Comment on “Risk factors for late-onset ventilator-associated pneumonia in trauma patients receiving selective digestive decontamination” by Leone et al. Intensive Care Med 2005; 31:999; author reply 1000. [PMID: 15838677 DOI: 10.1007/s00134-005-2636-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2005] [Indexed: 11/30/2022]
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