1
|
Farrington N, Dubey V, Johnson A, Horner I, Stevenson A, Unsworth J, Jimenez-Valverde A, Schwartz J, Das S, Hope W, Darlow CA. Molecular pharmacodynamics of meropenem for nosocomial pneumonia caused by Pseudomonas aeruginosa. mBio 2024; 15:e0316523. [PMID: 38236031 PMCID: PMC10865990 DOI: 10.1128/mbio.03165-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/11/2023] [Indexed: 01/19/2024] Open
Abstract
Hospital-acquired pneumonia (HAP) is a leading cause of morbidity and mortality, commonly caused by Pseudomonas aeruginosa. Meropenem is a commonly used therapeutic agent, although emergent resistance occurs during treatment. We used a rabbit HAP infection model to assess the bacterial kill and resistance pharmacodynamics of meropenem. Meropenem 5 mg/kg administered subcutaneously (s.c.) q8h (±amikacin 3.33-5 mg/kg q8h administered intravenously[i.v.]) or meropenem 30 mg/kg s.c. q8h regimens were assessed in a rabbit lung infection model infected with P. aeruginosa, with bacterial quantification and phenotypic/genotypic characterization of emergent resistant isolates. The pharmacokinetic/pharmacodynamic output was fitted to a mathematical model, and human-like regimens were simulated to predict outcomes in a clinical context. Increasing meropenem monotherapy demonstrated a dose-response effect to bacterial kill and an inverted U relationship with emergent resistance. The addition of amikacin to meropenem suppressed the emergence of resistance. A network of porin loss, efflux upregulation, and increased expression of AmpC was identified as the mechanism of this emergent resistance. A bridging simulation using human pharmacokinetics identified meropenem 2 g i.v. q8h as the licensed clinical regimen most likely to suppress resistance. We demonstrate an innovative experimental platform to phenotypically and genotypically characterize bacterial emergent resistance pharmacodynamics in HAP. For meropenem, we have demonstrated the risk of resistance emergence during therapy and identified two mitigating strategies: (i) regimen intensification and (ii) use of combination therapy. This platform will allow pre-clinical assessment of emergent resistance risk during treatment of HAP for other antimicrobials, to allow construction of clinical regimens that mitigate this risk.IMPORTANCEThe emergence of antimicrobial resistance (AMR) during antimicrobial treatment for hospital-acquired pneumonia (HAP) is a well-documented problem (particularly in pneumonia caused by Pseudomonas aeruginosa) that contributes to the wider global antimicrobial resistance crisis. During drug development, regimens are typically determined by their sufficiency to achieve bactericidal effect. Prevention of the emergence of resistance pharmacodynamics is usually not characterized or used to determine the regimen. The innovative experimental platform described here allows characterization of the emergence of AMR during the treatment of HAP and the development of strategies to mitigate this. We have demonstrated this specifically for meropenem-a broad-spectrum antibiotic commonly used to treat HAP. We have characterized the antimicrobial resistance pharmacodynamics of meropenem when used to treat HAP, caused by initially meropenem-susceptible P. aeruginosa, phenotypically and genotypically. We have also shown that intensifying the regimen and using combination therapy are both strategies that can both treat HAP and suppress the emergence of resistance.
Collapse
Affiliation(s)
- Nicola Farrington
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Vineet Dubey
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Adam Johnson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Iona Horner
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Adam Stevenson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Jennifer Unsworth
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Ana Jimenez-Valverde
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | | | - Shampa Das
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Christopher A. Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| |
Collapse
|
2
|
Semet C. The ongoing challenge of ventilator-associated pneumonia: epidemiology, prevention, and risk factors for mortality in a secondary care hospital intensive care unit. Infect Prev Pract 2023; 5:100320. [PMID: 38028359 PMCID: PMC10663678 DOI: 10.1016/j.infpip.2023.100320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality among intensive care unit infections. Despite various preventive measures, the incidence of VAP remains high. Aims This study aimed to explore the epidemiology and risk factors for VAP associated mortality in a secondary care hospital, comparing outcomes before and after implementing a VAP prevention bundle. Methods This retrospective study was conducted from July 1, 2021, to June 30, 2023, at a secondary care hospital. Patients over 18 years old who underwent mechanical ventilation for more than 48 hours were included. The study compared the incidence, microbiological etiology, and outcomes of VAP before and after implementing the VAP prevention bundle and analyzed risk factors for mortality from VAP. Results A total of 83 patients diagnosed with VAP were included. Despite concerted efforts to implement the VAP prevention bundle, there was no significant decrease in the VAP rate per 1000 ventilator days, early-onset VAP, secondary bloodstream infections, acute respiratory distress syndrome, and 30-day mortality. The microbiological etiology of VAP remained consistent between the two periods. A decrease in lymphocyte count and albumin level were identified as independent risk factors for 30-day mortality. Conclusions Concerted efforts to implement a VAP prevention bundle did not significantly reduce the incidence or improve outcomes of VAP in this secondary care hospital setting. The microbiological etiology remained unchanged. Monitoring lymphocyte count and albumin level may help identify patients at high mortality risk. Further research is needed to develop more effective VAP prevention and management strategies.
Collapse
Affiliation(s)
- Cihan Semet
- İnegöl State Hospital, Department of Infectious Diseases and Clinical Microbiology, Burhaniye, Mimar Sinan Cd. No:54, İnegöl, 16400, Bursa, Turkey
| |
Collapse
|
3
|
Alshammari MK, Alotaibi MA, AlOtaibi AS, Alosaime HT, Aljuaid MA, Alshehri BM, AlOtaibi YB, Alasmari AA, Alasmari GA, Mohammed MH, Althobaiti SM, Almuhaya RA, Alkhoshi TA, Alosaimi AS, Alotaibi AA. Prevalence and Etiology of Community- and Hospital-Acquired Pneumonia in Saudi Arabia and Their Antimicrobial Susceptibility Patterns: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040760. [PMID: 37109718 PMCID: PMC10143967 DOI: 10.3390/medicina59040760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 03/30/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
(1) Background and Objectives: Pneumonia is a major cause of morbidity and mortality worldwide, including in Saudi Arabia, and the prevalence and etiology of the disease varies depending on the setting. The development of effective strategies can help reduce the adverse impact of this disease. Therefore, this systematic review was conducted to explore the prevalence and etiology of community-acquired and hospital-acquired pneumonia in Saudi Arabia, as well as their antimicrobial susceptibility. (2) Materials and Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations were followed for this systematic review. Several databases were used to perform a thorough literature search, and papers were then assessed for eligibility by two independent reviewers. The Newcastle-Ottawa Scale (NOS) was used to extract the data from the relevant research and evaluate its quality. (3) Results: This systematic review included 28 studies that highlighted the fact that gram-negative bacteria, particularly Acinetobacter spp. and Pseudomonas aeruginosa, were the common cause of hospital-acquired pneumonia, while Staphylococcus aureus and Streptococcus spp. were responsible for community-acquired pneumonia in children. The study also found that bacterial isolates responsible for pneumonia showed high resistance rates against several antibiotics, including cephalosporins and carbapenems. (4) Conclusions: In conclusion, the study found that different bacteria are responsible for community- and hospital-acquired pneumonia in Saudi Arabia. Antibiotic resistance rates were high for several commonly used antibiotics, highlighting the need for rational antibiotic use to prevent further resistance. Moreover, there is a need to conduct more regular multicenter studies to assess etiology, resistance, and susceptibility patterns of pneumonia-causing pathogens in Saudi Arabia.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Asma Ali Alasmari
- Clinical Pharmacy & Pharmacology Department, Ibn Sina National College for Medical Studies, Jeddah 22421, Saudi Arabia
| | - Ghadi Ali Alasmari
- Department of Ambulatory Care Pharmacy, International Medical Center, Jeddah 23214, Saudi Arabia
| | | | | | | | | | | | | |
Collapse
|
4
|
Effect of an educational intervention on compliance with care bundle items to prevent ventilator-associated pneumonia. Intensive Crit Care Nurs 2023; 75:103342. [PMID: 36464606 DOI: 10.1016/j.iccn.2022.103342] [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: 07/06/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES We aimed to evaluate the effectiveness of our ventilator-associated pneumonia prevention bundle implemented by education of the nursing staff, and to describe the tendency of knowledge retention. RESEARCH METHODOLOGY A prospective, before-and-after study was performed. The ventilator-associated pneumonia prevention bundle was implemented through a single educational intervention of the nursing staff. The risk of ventilator-associated pneumonia over time was estimated using a Cox proportional cause-specific hazard model. Compliance to preventive measures was assessed at three time-points: before education, at three months and 12 months after education. SETTING A 29-bed mixed medical-surgical intensive care unit. MAIN OUTCOME MEASURES Ventilator-associate pneumonia incidence densities, the risk of ventilator-associated pneumonia, and compliance to preventive measures in the pre-implementation and post-implementation periods. RESULTS We analyzed the data of 251 patients. The incidence density of pneumonia decreased from 29.3/1000 to 15.3/1000 ventilator-days after the implementation of the prevention program. Patients in the post-implementation period had significantly lower risk to develop pneumonia (hazard ratio 0.34, 95 % confidence interval 0.19-0.61, p = 0.001). At 3 months of implementation, a significant improvement was detected to all the individual bundle components. Complete compliance increased from 16.2 % to 62.2 % (p < 0.001). Compliance with bundle components decreased to baseline levels after 12 months of implementation apart from head-of-bed elevation. CONCLUSION This study supports existing evidence that educational interventions improve compliance. The gained knowledge was well translated into clinical practice reflected by the decreasing ventilator-associated pneumonia rate. It may be assumed that a refresher educational session within 12 months after implementation is needed.
Collapse
|
5
|
Echocardiographic Probability of Pulmonary Hypertension in Cardiac Surgery Patients—Occurrence and Association with Respiratory Adverse Events—An Observational Prospective Single-Center Study. J Clin Med 2022; 11:jcm11195749. [PMID: 36233617 PMCID: PMC9573503 DOI: 10.3390/jcm11195749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Pulmonary hypertension (PH) is an independent risk factor of increased morbidity and mortality in cardiac surgery patients (CS). The most common cause underlying PH is left ventricular (LV) diastolic dysfunction. This study aimed to evaluate the echocardiographic probability of PH in patients undergoing CS and its correlation with postoperative respiratory adverse events (RAE). Methods: The echocardiographic probability of PH and its correlation with LV diastolic dysfunction was assessed in 56 consecutive adult patients who were qualified for coronary artery bypass grafting (CABG). Later, the postoperative RAE (such as pneumonia, pulmonary congestion, or hypoxemia), the length of intensive care unit (ICU) treatment and mortality in groups with moderate or high (PH-m/h) and low (PH-l) probability of pulmonary hypertension were examined. Results: PH-m/h was observed in 29 patients, of whom 65.5 % had LV diastolic dysfunction stage II or III. A significantly higher occurrence of RAE was observed in the PH-m/h group as compared to the PH-l group. There were no differences between the PH-m/h and PH-l patient groups regarding the in-hospital length of stay or mortality. Conclusions: High or intermediate probability of PH is common in cardiac surgical patients with left ventricular diastolic dysfunction and correlates with respiratory adverse events.
Collapse
|
6
|
Gi A, Gouveia RH, Corte Real F, Carvalho L. Mortality due to respiratory infections: an alert study before COVID-19 pandemic. Pathologica 2022; 114:146-151. [PMID: 35481565 PMCID: PMC9248254 DOI: 10.32074/1591-951x-306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022] Open
Abstract
Objective Respiratory tract infections remain a common problem in clinical practice with high morbidity and mortality worldwide. In Portugal, pneumonia was the third leading death cause in 2018. Due to COVID-19 pandemic, there is a growing concern about the burden of respiratory diseases and preventable risk factors. The present study started before the pandemic and its aim was to determine the occurrence of pneumonia/bronchopneumonia in a postmortem series and to characterize its circumstantial context. Methods A retrospective anatomopathological study was performed on cases with acute pneumonia/bronchopneumonia at the Medicolegal Portuguese Institute (2011-2017). Results In an autopsy series of 737 patients, 521 were male and 675 presented comorbidities. The mean age was 63.87 ± 19.8 years. The most common acquisition site was community (65.1%), as natural death (65.5%). Concerning the manner of death, most cases (48.0%) were sudden deaths, followed by accidents (29.2%). A statistically significant association was observed between the medicolegal etiology and the place of infection acquisition, with higher prevalence of natural obitus (91.0%) in community-acquired pneumonia/bronchopneumonia versus higher prevalence of violent obitus in hospital-acquired pneumonia/bronchopneumonia (82.1%) (p < 0.001). Conclusions Forensic anatomopathological postmortem data may contribute to better understand community and hospital pulmonary infections.
Collapse
Affiliation(s)
- Andreia Gi
- Institute of Anatomical and Molecular Pathology (IAP-PM), Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal.,ULSNE - Unidade Local de Saúde do Nordeste, E.P.E., Portugal
| | - Rosa H Gouveia
- Institute of Anatomical and Molecular Pathology (IAP-PM), Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal.,Forensic Pathology, Instituto Nacional de Medicina Legal e Ciências Forenses (INMLCF), Coimbra, Portugal.,Pathology, Lana, Lda, Funchal, Madeira, Portugal
| | - Francisco Corte Real
- Forensic Pathology, Instituto Nacional de Medicina Legal e Ciências Forenses (INMLCF), Coimbra, Portugal
| | - Lina Carvalho
- Institute of Anatomical and Molecular Pathology (IAP-PM), Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal.,CHUC, Coimbra University Hospital, Coimbra, Portugal
| |
Collapse
|
7
|
Hasslacher J, Steinkohl F, Ulmer H, Lehner G, Klein S, Mayerhoefer T, Joannidis M. Increased risk of ventilator-associated pneumonia in patients after cardiac arrest treated with mild therapeutic hypothermia. Acta Anaesthesiol Scand 2022; 66:704-712. [PMID: 35338658 PMCID: PMC9321159 DOI: 10.1111/aas.14063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
Background We aimed at investigating the incidence, characteristics and outcome of ventilator‐associated pneumonia (VAP) in patients after cardiac arrest (CA) and its potential association with mild therapeutic hypothermia (MTH). We hypothesized, that MTH might increase the risk of VAP. Methods Prospective observational study including comatose adult patients after successful resuscitation from out‐of‐hospital or in‐hospital CA with presumed cardiac cause admitted to ICU and treated with MTH at 33°C for 24 h or normothermia (NT) with treatment of fever ≥38°C by pharmacological means. The primary outcome measure was the development of VAP. VAP diagnosis included mechanical ventilation >48 h combined with clinical and radiologic criteria. For a microbiologically confirmed VAP (mcVAP), a positive respiratory culture was required. Results About 23% of 171 patients developed VAP, 6% presented with mcVAP. VAP was associated with increased ICU‐LOS (9 (IQR 5–14) vs. 6 (IQR 3–9) days; p < .01), ventilator‐dependent days (6 (IQR 4–9) vs. 4 (IQR 2–7) days; p < .01) and duration of antibiotic treatment (9 (IQR 5–13) vs. 5 (IQR 2–9) days; p < .01), but not with mortality (OR 0.88 (95% CI: 0.43–1.81); p = .74). Patients treated with MTH (47%) presented higher VAP (30% vs. 17%; p = .04) and mcVAP rates (11% vs. 2%; p = .03). MTH was associated with VAP in multivariable logistic regression analysis with an OR of 2.67 (95% CI: 1.22–5.86); p = .01. Conclusions VAP appears to be a common complication in patients after CA, accompanied by more ventilator‐dependent days, prolonged antibiotic treatment, and ICU‐LOS. Treatment with MTH is significantly associated with development of VAP.
Collapse
Affiliation(s)
- Julia Hasslacher
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
| | - Fabian Steinkohl
- Department of Radiology Medical University Innsbruck Innsbruck Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics Medical University Innsbruck Innsbruck Austria
| | - Georg Lehner
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
| | - Sebastian Klein
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
| | - Timo Mayerhoefer
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine Department of Internal Medicine Medical University Innsbruck Innsbruck Austria
| |
Collapse
|
8
|
Lee TY, Oh JW, Lee MK, Kim JS, Sohn JE, Wi JH. Clinical Implications of the Newly Defined Concept of Ventilator-Associated Events in Trauma Patients. JOURNAL OF TRAUMA AND INJURY 2021. [DOI: 10.20408/jti.2021.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
9
|
Abdelaleem NA, Makhlouf HA, Nagiub EM, Bayoumi HA. Prognostic biomarkers in predicting mortality in respiratory patients with ventilator-associated pneumonia. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2021. [PMCID: PMC7971396 DOI: 10.1186/s43168-021-00062-1] [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] [Indexed: 12/16/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is the most common nosocomial infection. Red cell distribution width (RDW) and neutrophil-lymphocyte ratio (NLR) are prognostic factors to mortality in different diseases. The aim of this study is to evaluate prognostic efficiency RDW, NLR, and the Sequential Organ Failure Assessment (SOFA) score for mortality prediction in respiratory patients with VAP. Results One hundred thirty-six patients mechanically ventilated and developed VAP were included. Clinical characteristics and SOFA score on the day of admission and at diagnosis of VAP, RDW, and NLR were assessed and correlated to mortality. The average age of patients was 58.80 ± 10.53. These variables had a good diagnostic performance for mortality prediction AUC 0.811 for SOFA at diagnosis of VAP, 0.777 for RDW, 0.728 for NLR, and 0.840 for combined of NLR and RDW. The combination of the three parameters demonstrated excellent diagnostic performance (AUC 0.889). A positive correlation was found between SOFA at diagnosis of VAP and RDW (r = 0.446, P < 0.000) and with NLR (r = 0.220, P < 0.010). Conclusions NLR and RDW are non-specific inflammatory markers that could be calculated quickly and easily via routine hemogram examination. These markers have comparable prognostic accuracy to severity scores. Consequently, RDW and NLR are simple, yet promising markers for ICU physicians in monitoring the clinical course, assessment of organ dysfunction, and predicting mortality in mechanically ventilated patients. Therefore, this study recommends the use of blood biomarkers with the one of the simplest ICU score (SOFA score) in the rapid diagnosis of critical patients as a daily works in ICU.
Collapse
|
10
|
Rosario BH, Shafi H, Yii ACA, Tee LY, Ang ASH, Png GK, Ang WST, Lee YQ, Tan PT, Sahu A, Zhou LF, Zheng YL, Slamat RB, Taha AAM. Evaluation of multi-component interventions for prevention of nosocomial pneumonia in older adults: a randomized, controlled trial. Eur Geriatr Med 2021; 12:1045-1055. [PMID: 34081314 PMCID: PMC8173511 DOI: 10.1007/s41999-021-00506-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/28/2021] [Indexed: 11/26/2022]
Abstract
AIMS To evaluate the efficacy of multi-component interventions for prevention of hospital-acquired pneumonia in older patients hospitalized in geriatric wards. METHODS A randomized, parallel-group, controlled trial was undertaken in patients aged 65 and above who were admitted to a tertiary hospital geriatric unit from January 1, 2016 to June 30, 2018 for an acute non-respiratory illness. Participants were randomized by to receive either a multi-component intervention (consisting of reverse Trendelenburg position, dysphagia screening, oral care and vaccinations), or usual care. The outcome measures were the proportion of patients who developed hospital-acquired pneumonia during hospitalisation, and mean time from randomization to the next hospitalisation due to respiratory infections in 1 year. RESULTS A total of 123 participants (median age, 85; 43.1% male) were randomized, (n = 59) to intervention group and (n = 64) to control group. The multi-component interventions did not significantly reduce the incidence of hospital-acquired pneumonia but did increase the mean time to next hospitalisation due to respiratory infection (11.5 months vs. 9.5 months; P = 0.049), and reduced the risk of hospitalisation in 1 year (18.6% vs. 34.4%; P = 0.049). Implementation of multi-component interventions increased diagnoses of oropharyngeal dysphagia (35.6% vs. 20.3%; P < 0.001) and improved the influenza (54.5% vs 17.2%; P < 0.001) and pneumococcal vaccination rates (52.5% vs. 20.3%; P < 0.001). CONCLUSIONS The nosocomial pneumonia multi-component intervention did not significantly reduce the incidence of hospital-acquired pneumonia during hospitalisation but reduce subsequent hospitalisations for respiratory infections. CLINICAL TRIAL REGISTRATION ClinicalTrial.gov, NCT04347395.
Collapse
Affiliation(s)
- Barbara H Rosario
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore.
| | - Humaira Shafi
- Department of Infectious Diseases, Changi General Hospital, Singapore, Singapore
| | - Anthony C A Yii
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Louis Y Tee
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Arron S H Ang
- Department of Accident and Emergency, Changi General Hospital, Singapore, Singapore
| | - Gek Kheng Png
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Wendy S T Ang
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Yan Qing Lee
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Pei Ting Tan
- Clinical Trials and Research Unit, Changi General Hospital, Singapore, Singapore
| | - Aniruddha Sahu
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Lin Fang Zhou
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Yi Ling Zheng
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Roslinda Binte Slamat
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Aza A M Taha
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| |
Collapse
|
11
|
Latorre MC, Pérez-Granda MJ, Savage PB, Alonso B, Martín-Rabadán P, Samaniego R, Bouza E, Muñoz P, Guembe M. Endotracheal tubes coated with a broad-spectrum antibacterial ceragenin reduce bacterial biofilm in an in vitro bench top model. J Antimicrob Chemother 2021; 76:1168-1173. [PMID: 33544817 DOI: 10.1093/jac/dkab019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/08/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia is one of the most common nosocomial infections, caused mainly by bacterial/fungal biofilm. Therefore, it is necessary to develop preventive strategies to avoid biofilm formation based on new compounds. OBJECTIVES We performed an in vitro study to compare the efficacy of endotracheal tubes (ETTs) coated with the ceragenin CSA-131 and that of uncoated ETTs against the biofilm of clinical strains of Pseudomonas aeruginosa (PA), Escherichia coli (EC) and Staphylococcus aureus (SA). METHODS We applied an in vitro bench top model using coated and uncoated ETTs that were treated with three different clinical strains of PA, EC and SA for 5 days. After exposure to biofilm, ETTs were analysed for cfu count by culture of sonicate and total number of cells by confocal laser scanning microscopy. RESULTS The median (IQR) cfu/mL counts of PA, EC and SA in coated and uncoated ETTs were, respectively, as follows: 1.00 × 101 (0.0-3.3 × 102) versus 3.32 × 109 (6.6 × 108-3.8 × 109), P < 0.001; 0.0 (0.0-5.4 × 103) versus 1.32 × 106 (2.3 × 103-5.0 × 107), P < 0.001; and 8.1 × 105 (8.5 × 101-1.4 × 109) versus 2.7 × 108 (8.6 × 106-1.6 × 1011), P = 0.058. The median (IQR) total number of cells of PA, EC and SA in coated and non-coated ETTs were, respectively, as follows: 11.0 [5.5-not applicable (NA)] versus 87.9 (60.5-NA), P = 0.05; 9.1 (6.7-NA) versus 62.6 (42.0-NA), P = 0.05; and 97.7 (94.6-NA) versus 187.3 (43.9-NA), P = 0.827. CONCLUSIONS We demonstrated significantly reduced biofilm formation in coated ETTs. However, the difference for SA was not statistically significant. Future clinical studies are needed to support our findings.
Collapse
Affiliation(s)
- María Consuelo Latorre
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - María Jesús Pérez-Granda
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Paul B Savage
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, USA
| | - Beatriz Alonso
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Pablo Martín-Rabadán
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES, (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Rafael Samaniego
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Confocal Laser Scanning Microscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emilio Bouza
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES, (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES, (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| |
Collapse
|
12
|
Park GE, Ko JH, Ki HK. Clinical Benefits of Piperacillin/Tazobactam versus a Combination of Ceftriaxone and Clindamycin in the Treatment of Early, Non-Ventilator, Hospital-Acquired Pneumonia in a Community-Based Hospital. Int J Gen Med 2020; 13:705-712. [PMID: 33061539 PMCID: PMC7522409 DOI: 10.2147/ijgm.s271301] [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: 07/14/2020] [Accepted: 09/07/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose There is an increasing prevalence of multidrug-resistant (MDR) organisms worldwide. Therefore, broad-spectrum antibiotics are recommended in the treatment of hospital-acquired pneumonia (HAP). However, it remains controversial whether patients with early onset, non-ventilator HAP (NV-HAP) should also be empirically treated with broad-spectrum antibiotics. We compared the clinical benefit of ceftriaxone plus clindamycin vs piperacillin/tazobactam as the initial empirical treatment of adults with early NV-HAP. Patients and Methods Retrospective cohort study was conducted in adult patients who were diagnosed with early, NV-HAP between January 2013 and June 2017 at a community-based tertiary care hospital. Patients were eligible for inclusion if they had received empiric treatment with either ceftriaxone and clindamycin or piperacillin/tazobactam for at least 3 days. Patients with increased risk of MDR pathogens were excluded. Results A total of 89 patients were treated with ceftriaxone and clindamycin, while 124 received piperacillin/tazobactam. There were no significant differences between the two antibiotic groups with regard to median age, sex, or risk of pneumonia. The 30-day all-cause mortality did not differ significantly between the ceftriaxone plus clindamycin and piperacillin/tazobactam groups (4.5% vs 1.6%, P=0.202, respectively). However, in multivariate analysis, clinical failure was more frequent in the ceftriaxone plus clindamycin group than in the piperacillin/tazobactam group (HR 3.316; 95% CI, 1.589–6918, P=0.001). Conclusion Treatment with piperacillin/tazobactam was more effective than that with ceftriaxone plus clindamycin in patients with early NV-HAP. This study supports the recent treatment recommendations that patients with early NV-HAP should be treated empirically with broad-spectrum antibiotics.
Collapse
Affiliation(s)
- Ga Eun Park
- Division of Infectious Disease, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jae-Hoon Ko
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Seoul, Korea
| | - Hyun Kyun Ki
- Division of Infectious Disease, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| |
Collapse
|
13
|
Lupia T, Corcione S, Mornese Pinna S, De Rosa FG. New cephalosporins for the treatment of pneumonia in internal medicine wards. J Thorac Dis 2020; 12:3747-3763. [PMID: 32802454 PMCID: PMC7399401 DOI: 10.21037/jtd-20-417] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The burden of hospital admission for pneumonia in internal medicine wards may not be underestimated; otherwise, cases of pneumonia are a frequent indication for antimicrobial prescriptions. Community- and hospital-acquired pneumonia are characterized by high healthcare costs, morbidity and non-negligible rates of fatality. The overcoming prevalence of resistant gram-negative and positive bacteria (e.g., methicillin-resistant Staphylococcus aureus, penicillin and ceftriaxone-resistant Streptococcus pneumoniae, extended-spectrum β-lactamases and carbapenemases producing Enterobacteriaceae) has made the most of the first-line agents ineffective for treating lower respiratory tract infections. A broad-spectrum of activity, favourable pulmonary penetration, harmlessness and avoiding in some cases a combination therapy, characterise new cephalosporins such as ceftolozane/tazobactam, ceftobiprole, ceftazidime/avibactam and ceftaroline. We aimed to summarise the role and place in therapy of new cephalosporins in community- and hospital-acquired pneumonia within the setting of internal medicine wards. The “universal pneumonia antibiotic strategy” is no longer acceptable for treating lung infections. Antimicrobial therapy should be individualized considering local antimicrobial resistance and epidemiology, the stage of the illness and potential host factors predisposing to a high risk for specific pathogens.
Collapse
Affiliation(s)
- Tommaso Lupia
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy.,School of Medicine, Tufts University, Boston, MA, USA
| | - Simone Mornese Pinna
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | | |
Collapse
|
14
|
Ott SR, Bodmann KF, Grabein B, Höffken G, Kolditz M, Lode H, Pletz MW, Thalhammer F. Calculated parenteral initial treatment of bacterial infections: Respiratory infections. GMS INFECTIOUS DISEASES 2020; 8:Doc15. [PMID: 32373440 PMCID: PMC7186806 DOI: 10.3205/id000059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This is the fifth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. It provides recommendations for the empirical and targeted antimicrobial treatment of lower respiratory tract infections, with a special emphasis on the treatment of acute exacerbation of COPD, community-acquired pneumonia and hospital-acquired pneumonia.
Collapse
Affiliation(s)
| | - Klaus-Friedrich Bodmann
- Klinik für Internistische Intensiv- und Notfallmedizin und Klinische Infektiologie, Klinikum Barnim GmbH, Werner Forßmann Krankenhaus, Eberswalde, Germany
| | - Béatrice Grabein
- Stabsstelle Klinische Mikrobiologie und Krankenhaushygiene, Klinikum der Universität München, Munich, Germany
| | | | - Martin Kolditz
- Pneumologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | | | - Mathias W. Pletz
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Germany
| | - Florian Thalhammer
- Klinische Abteilung für Infektiologie und Tropenmedizin, Medizinische Universität Wien, Vienna, Austria
| |
Collapse
|
15
|
Campogiani L, Tejada S, Ferreira-Coimbra J, Restrepo MI, Rello J. Evidence supporting recommendations from international guidelines on treatment, diagnosis, and prevention of HAP and VAP in adults. Eur J Clin Microbiol Infect Dis 2019; 39:483-491. [PMID: 31823149 PMCID: PMC7223521 DOI: 10.1007/s10096-019-03748-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/24/2019] [Indexed: 12/25/2022]
Abstract
Clinical practice guidelines (CPGs) are intended to support clinical decisions and should be based on high-quality evidence. The objective of the study was to evaluate the quality of evidence supporting the recommendations issued in CPGs for therapy, diagnosis, and prevention of hospital-acquired and ventilator-associated pneumonia (HAP/VAP). CPGs released by international scientific societies after year 2000, using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology, were analyzed. Number and strength of recommendations and quality of evidence (high, moderate, low, and very low) were extracted and indexed in the aforementioned sections. High-quality evidence was based on randomized control trials (RCT) without important limitations and exceptionally on rigorous observational studies. Eighty recommendations were assessed, with 7 (8.7%), 24 (30.0%), 29 (36.3%), and 20 (25.0%) being supported by high, moderate, low, and very low-quality evidence, respectively. Highest evidence degree was reported for 26 prevention recommendations, with 7 (26.9%) supported by high-quality evidence and no recommendation based on very low-quality evidence. In contrast, among 9 recommendations for diagnosis and 45 for therapy, none was supported by high-quality evidence, in spite of being recommended as strong in 33.3% and 46.7%, respectively. Among HAP/VAP diagnosis recommendations, the majority of evidence was rated as low or very low-quality (55.6% and 22.2%, respectively) whereas among HAP/VAP therapy recommendations, 4/5 were rated as low and very low-quality (40% each). In conclusion, among HAP/VAP international guidelines, most recommendations, particularly in therapy, remain supported by observational studies, case reports, and expert opinion. Well-designed RCTs are urgently needed.
Collapse
Affiliation(s)
- Laura Campogiani
- Clinical Infectious Disease, Department of System Medicine, Tor Vergata University, Rome, Italy.
| | - Sofia Tejada
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Barcelona, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - João Ferreira-Coimbra
- Internal Medicine Department, Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - Marcos I Restrepo
- South Texas Veterans Healthcare System and University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Jordi Rello
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Barcelona, Spain.,Clinical Research/Epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| |
Collapse
|
16
|
Staub LJ, Biscaro RRM, Maurici R. Emergence of Alveolar Consolidations in Serial Lung Ultrasound and Diagnosis of Ventilator-Associated Pneumonia. J Intensive Care Med 2019; 36:304-312. [PMID: 31818178 DOI: 10.1177/0885066619894279] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Lung ultrasound (LUS) has been reported as a promising diagnostic tool for ventilator-associated pneumonia (VAP), but patients with previous lung parenchyma commitment have been not studied. PURPOSE To evaluate whether the emergence of sonographic consolidations, rather than their presence, can improve the VAP diagnosis in a sample including patients with previous lung parenchyma diseases. METHODS Patients who completed 48 hours of mechanical ventilation were prospectively studied with daily LUS examinations. We checked the emergence of different consolidation types on the eve and on the day of a clinical suspicion of VAP. We elaborated an algorithm considering, sequentially, the emergence of (1) subpleural consolidations in anterior lung regions on the eve of suspicion; (2) lobar/sublobar consolidation in anterior lung regions on the day of suspicion; (3) lobar/sublobar consolidation with dynamic air bronchograms on the day of suspicion; and (4) any other lobar/sublobar consolidation on the day of suspicion in association with a positive Gram smear of endotracheal aspirate. RESULTS Of the 188 included patients, 60 were suspected and 33 confirmed VAP. The presence of sonographic consolidations at the clinical suspicion had no diagnostic value for VAP. The emergence of subpleural consolidations in anterior lung regions on the eve of suspicion had specificity of 95% (95% confidence interval [CI], 79%-99%). The emergence of lobar/sublobar consolidations in anterior lung regions on the day of suspicion had specificity of 100% (95% CI, 87%-100%). The emergence of lobar/sublobar consolidations with dynamic air bronchograms on the day of suspicion had specificity of 96% (95% CI, 81%-99%). Finally, the proposed algorithm had sensitivity of 63% (95% CI, 46%-77%) and specificity of 85% (95% CI, 67%-94%) for VAP. CONCLUSIONS The presence of sonographic consolidations was not accurate for VAP when patients with previous lung parenchyma commitment were included. However, serial LUS examinations detected the emergence of specific signs of VAP.
Collapse
Affiliation(s)
- Leonardo Jönck Staub
- Department of Clinical Medicine, 28117Federal University of Santa Catarina, Florianópolis, Brazil.,Division of Clinical Medicine, University Hospital of 28117Federal University of Santa Catarina, Florianópolis, Brazil
| | | | - Rosemeri Maurici
- Department of Clinical Medicine, 28117Federal University of Santa Catarina, Florianópolis, Brazil.,Graduate Program in Clinical Sciences, 28117Federal University of Santa Catarina, Florianópolis, Brazil
| |
Collapse
|
17
|
Asempa TE, Motos A, Abdelraouf K, Bissantz C, Zampaloni C, Nicolau DP. Meropenem-nacubactam activity against AmpC-overproducing and KPC-expressing Pseudomonas aeruginosa in a neutropenic murine lung infection model. Int J Antimicrob Agents 2019; 55:105838. [PMID: 31705960 DOI: 10.1016/j.ijantimicag.2019.10.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 10/22/2019] [Accepted: 10/27/2019] [Indexed: 10/25/2022]
Abstract
Nacubactam is a novel non-β-lactam diazabicyclooctane β-lactamase inhibitor under development for the treatment of serious Gram-negative infections. This study assessed the efficacy of human-simulated epithelial lining fluid (ELF) exposure of nacubactam in combination with meropenem against AmpC-overproducing (n=4) and Klebsiella pneumoniae carbapenemase (KPC)-expressing (n=3) Pseudomonas aeruginosa isolates in the neutropenic murine lung infection model. Meropenem, nacubactam and meropenem-nacubactam (1:1 concentration ratio) minimum inhibitory concentrations (MICs) were determined in triplicate using broth microdilution. Regimens that provided ELF profiles mimicking those observed in humans given nacubactam 2 g q8h (1.5-h infusion) alone and in combination with a subtherapeutic ELF exposure of meropenem were administered 2 h after inoculation. Efficacy was assessed as the change in log10 colony-forming units (CFU)/lung at 24 h compared with 24-h meropenem monotherapy. Meropenem, nacubactam and meropenem-nacubactam MICs were 8->64, 128->256 and 2-16 mg/L, respectively. Meropenem and nacubactam monotherapy groups demonstrated bacterial growth over 24 h for each isolate. Against AmpC-overproducing and KPC-expressing P. aeruginosa isolates, meropenem-nacubactam resulted in -2.73±0.93 and -4.35±1.90 log10CFU/lung reduction, respectively, relative to meropenem monotherapy. Meropenem-nacubactam showed promising in-vivo activity against meropenem-resistant P. aeruginosa, indicative of a potential role for the treatment of infections caused by these challenging pathogens.
Collapse
Affiliation(s)
- Tomefa E Asempa
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Ana Motos
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Kamilia Abdelraouf
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Caterina Bissantz
- Roche Pharma Research and Early Development Pharmaceutical Science, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Claudia Zampaloni
- Roche Pharma Research and Early Development, Immunology, Inflammation and Infectious Diseases, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA; Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA.
| |
Collapse
|
18
|
Powell J, Garnett JP, Mather MW, Cooles FAH, Nelson A, Verdon B, Scott J, Jiwa K, Ruchaud-Sparagano MH, Cummings SP, Perry JD, Wright SE, Wilson JA, Pearson J, Ward C, Simpson AJ. Excess Mucin Impairs Subglottic Epithelial Host Defense in Mechanically Ventilated Patients. Am J Respir Crit Care Med 2019; 198:340-349. [PMID: 29425465 DOI: 10.1164/rccm.201709-1819oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Aspiration of infective subglottic secretions causes ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Mechanisms underlying subglottic colonization in critical illness have not been defined, limiting strategies for targeted prevention of VAP. OBJECTIVES To characterize subglottic host defense dysfunction in mechanically ventilated patients in the ICU; to determine whether subglottic mucin contributes to neutrophil phagocytic impairment and bacterial growth. METHODS Prospective subglottic sampling in mechanically ventilated patients (intubated for four or more days), and newly intubated control patients (intubated for less than 30 min); isolation and culture of primary subglottic epithelial cells from control patients; laboratory analysis of host innate immune defenses. MEASUREMENTS AND MAIN RESULTS Twenty-four patients in the ICU and 27 newly intubated control patients were studied. Subglottic ICU samples had significantly reduced microbiological diversity and contained potential respiratory pathogens. The subglottic microenvironment in the ICU was characterized by neutrophilic inflammation, significantly increased proinflammatory cytokines and neutrophil proteases, and altered physical properties of subglottic secretions, including accumulation of mucins. Subglottic mucin from ICU patients impaired the capacity of neutrophils to phagocytose and kill bacteria. Phagocytic impairment was reversible on treatment with a mucolytic agent. Subglottic mucus promoted growth and invasion of bacterial pathogens in a novel air-liquid interface model of primary human subglottic epithelium. CONCLUSIONS Mechanical ventilation in the ICU is characterized by substantial mucin secretion and neutrophilic inflammation. Mucin impairs neutrophil function and promotes bacterial growth. Mucolytic agents reverse mucin-mediated neutrophil dysfunction. Enhanced mucus disruption and removal has potential to augment preventive benefits of subglottic drainage.
Collapse
Affiliation(s)
| | | | | | | | | | - Bernard Verdon
- 3 Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, United Kingdom
| | | | | | | | - Stephen P Cummings
- 4 School of Science, Engineering and Design, Teesside University, Middlesbrough, United Kingdom; and
| | | | | | - Janet A Wilson
- 7 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom.,8 Department of Otolaryngology-Head and Neck Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals National Health Service (NHS) Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | | | | |
Collapse
|
19
|
Esposito S, Pennoni G, Mencarini V, Palladino N, Peccini L, Principi N. Antimicrobial Treatment of Staphylococcus aureus in Patients With Cystic Fibrosis. Front Pharmacol 2019; 10:849. [PMID: 31447669 PMCID: PMC6692479 DOI: 10.3389/fphar.2019.00849] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/03/2019] [Indexed: 11/13/2022] Open
Abstract
Staphylococcus aureus is a ubiquitous human commensal pathogen. It is commonly isolated in cystic fibrosis (CF) patients and is considered one of the main causes of the recurrent acute pulmonary infections and progressive decline in lung function that characterize this inherited life-threatening multisystem disorder. However, the true role of S. aureus in CF patients is not completely understood. The main aim of this narrative review is to discuss the present knowledge of the role of S. aureus in CF patients. Literature review showed that despite the fact that the availability and use of drugs effective against S. aureus have coincided with a significant improvement in the prognosis of lung disease in CF patients, clearly evidencing the importance of S. aureus therapy, how to use old and new drugs to obtain the maximal effectiveness has not been precisely defined. The most important problem remains that the high frequency with which S. aureus is carried in healthy subjects prevents the differentiation of simple colonization from infection. Moreover, although experts recommend antibiotic administration in CF patients with symptoms and in those with persistent detection of S. aureus, the best antibiotic approach has not been defined. All these problems are complicated by the evidence that the most effective antibiotic against methicillin-resistant S. aureus (MRSA) cannot be used in patients with CF with the same schedules used in patients without CF. Further studies are needed to solve these problems and to assure CF patients the highest level of care.
Collapse
Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Cystic Fibrosis Center of Umbria Region, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Guido Pennoni
- Pediatric Unit, Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Valeria Mencarini
- Pediatric Unit, Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Nicola Palladino
- Pediatric Unit, Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Laura Peccini
- Pediatric Clinic, Cystic Fibrosis Center of Umbria Region, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | | |
Collapse
|
20
|
Abstract
Ventilator-associated tracheobronchitis (VAT) might represent an intermediate process between lower respiratory tract colonization and ventilator-associated pneumonia (VAP), or even a less severe spectrum of VAP. There is an urgent need for new concepts in the arena of ventilator-associated lower respiratory tract infections. Ideally, the gold standard of care is based on prevention rather than treatment of respiratory infection. However, despite numerous and sometimes imaginative efforts to validate the benefit of these measures, most clinicians now accept that currently available measures have failed to eradicate VAP. Stopping the progression from VAT to VAP could improve patient outcomes.
Collapse
|
21
|
Ge W, Wei W, Shuang P, Yan-Xia Z, Ling L. Nasointestinal Tube in Mechanical Ventilation Patients is More Advantageous. Open Med (Wars) 2019; 14:426-430. [PMID: 31198856 PMCID: PMC6555240 DOI: 10.1515/med-2019-0045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/13/2019] [Indexed: 11/28/2022] Open
Abstract
Objective To assess the effects of two different nutritional mode on the occurrence of ventilator-associated pneumonia (VAP) in patients on mechanical ventilation. Methods 70 patients admitted to the ICU and under mechanical ventilation, were randomly divided into the nasointestinal tube group and nasogastric tube group. Patients from both groups received enteral nutrition, using the same nutritional agent, through intubation. The duration of stay in the ICU, duration of mechanical ventilation, incidence of VAP, nutritional state, and survival of the intestinal tract were compared between the two groups. Results The duration of stay in the ICU, duration of mechanical ventilation and incidence of VAP in the nasointestinal tube group was lower than that in the nasogastric tube group (P<0.05). There was an increase in the levels of prealbumin and transferrin in the nasointestinal tube group (P<0.05). However, there were no obvious difference in the nasogastric tube group (P<0.05). The incidence of abdominal distension, diarrhea, regurgitation, aspiration, and hyperglycemia in the nasointestinal tube group was much lower than that in the nasogastric tube group (P < 0.05). Conclusion This study showed that enteral nutrition delivery using a nasointestinal way can effectively reduce the incidence of VAP and improve the nutritional status of patients under mechanical ventilation.
Collapse
Affiliation(s)
- Wu Ge
- Department of General Practice, school of General Practice Xi'an Medical University, Shaanxi Province, China
| | - Wu Wei
- Department of Respiratory and Critical Care Medicine, The second Affiliated Hospital of Xi'an Medical University, Shaanxi Province, China
| | - Pan Shuang
- Department of General Practice, school of General Practice Xi'an Medical University, Shaanxi Province, China
| | - Zheng Yan-Xia
- Department of General Practice, school of General Practice Xi'an Medical University, Shaanxi Province, China
| | - Lv Ling
- Department of Respiratory and Critical Care Medicine, Weinan Central Hospital, Shaanxi Province, China
| |
Collapse
|
22
|
Factors influencing mortality in hospital-acquired pneumonia caused by Gram-negative bacteria in China. J Infect Public Health 2019; 12:630-633. [PMID: 30824328 DOI: 10.1016/j.jiph.2019.02.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/17/2019] [Accepted: 02/06/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hospital-acquired pneumonia (HAP) remains an important cause of morbidity and mortality despite advances in antimicrobial therapy. The emergence of Gram-negative bacteria (GNB) is of major concern. The objective of this study was to describe the epidemiology, microbiology, and predictors of infection-related 30-day mortality in HAP with GNB. METHODS We performed a retrospective, single-center analysis of HAP patients with GNB occurring from January 2014 and December 2017. Univariate and multivariate analyses were performed to identify the risk factors for mortality. RESULTS During the observational period, there were 1472 cases of HAP; 314 cases were bacterial culture-positive, 269 cases were caused by GNB, with a predominance of Acinetobacter baumannii and Pseudomonas aeruginosa. The mortality related to GNB was 14.5% (39 deaths).In the multivariate logistic regression analysis, the risk factors for mortality were age >70 years, intensive care unit (ICU) admission, blood lymphocyte count < 0.8 × 109/L, multidrug-resistant Gram-negative bacteria(MDR-GNB) infection, and elevation of blood urea nitrogen(BUN) level. We identified these factors as significant predictors of GNB related mortality; the area under the receiver operating characteristic (ROC) curves was 0.836. CONCLUSION The results provided can help clinicians in identifying individuals who are at risk of infection-related 30-day mortality in HAP with GNB.
Collapse
|
23
|
Wen Z, Wei L, Chen J, Xie A, Li M, Bian L. Is continuous better than intermittent control of tracheal cuff pressure? A meta-analysis. Nurs Crit Care 2018; 24:76-82. [PMID: 30537009 DOI: 10.1111/nicc.12393] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/23/2018] [Accepted: 09/13/2018] [Indexed: 11/28/2022]
Abstract
AIM To compare and evaluate the efficacy and safety of continuous and intermittent control of cuff pressure. METHODS We performed a comprehensive and systematic meta-analysis of randomized controlled trials (RCTs) assessing the continuous and intermittent control of Pcuff by searching PUBMED, EMBASE and other such databases (from inception to 31 March 2018). Summary odds ratios or mean differences with 95% confidence intervals were calculated using a fixed- or random-effects model. MEASUREMENTS AND MAIN RESULTS Seven randomised controlled trials with 970 mechanically ventilated patients were included in this study. The continuous control of cuff pressure significantly reduced the incidence of cuff pressure < 20 cm H2 O (0.03 (OR) (95% CI: 0.01-0.07)), Pcuff > 30 cm H2 O (0.06 (95% CI: 0.03-0.15)) and VAP (0.39 (95% CI: 0.28-0.55)) when compared with intermittent control of cuff pressure. No significant differences in duration of MV (-1.94 (95% CI: -4.06 to -0.17)), length of ICU stay (-3.88 (95% CI: -9.00 to -1.23)) and mortality (0.99 (95% CI: 0.73-1.35)) were found between the two groups. CONCLUSIONS Continuous control of cuff pressure offers more benefits in stabilizing the cuff pressure and reducing the incidence of VAP, and more studies are warranted to further evaluate the role of continuous control of cuff pressure. RELEVANCE TO PRACTICE The continuous control of cuff pressure should be conducted whenever possible as it is the most ideal for the prognosis of MV patients.
Collapse
Affiliation(s)
- Zunjia Wen
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Li Wei
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Junyu Chen
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ailing Xie
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Mei Li
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lanzheng Bian
- Children's Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
24
|
Akil N, Muhlebach MS. Biology and management of methicillin resistant Staphylococcus aureus in cystic fibrosis. Pediatr Pulmonol 2018; 53:S64-S74. [PMID: 30073802 DOI: 10.1002/ppul.24139] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/20/2018] [Indexed: 02/06/2023]
Abstract
Staphylococcus aureus is one of the earliest bacteria isolated from the respiratory tract in people with cystic fibrosis (CF). Its methicillin resistant form, MRSA, has gained attention due to the rapid increase in the last decades and worse outcomes with chronic infection. In the United States, prevalence of MRSA in CF is around 27%, but is much lower (3-18%) in most other countries. Methicillin is typically genetically encoded by the mecA gene, which encodes for an alternative penicillin binding protein (PRBa). This PRBa has low affinity to β-lactams, thereby enabling growth of S. aureus in the presence of penicillinase resistant penicillins and most other β-lactams. Non-mecA positive strains of MRSA, so-called borderline resistant (BORSA) have also been described. In addition to production of toxins, the virulence of S. aureus is conferred by its adaptability allowing persistence in face of antibiotic therapies and host defense. These adaptive growth mechanisms include small colony variants, biofilms, and growth under anaerobic conditions. Several reports have described successful eradication of MRSA, yet only two randomized trials of eradication during early infection have been conducted. A list of MRSA specific antibiotics with dosing relevant to CF patients is presented here. Many of these require special dosing in people with CF. Novel antibiotics are in trials for skin and soft tissue infections and it is unclear if and when those might be available for lung infections. Thus the best strategies for MRSA would be primary prevention.
Collapse
Affiliation(s)
- Nour Akil
- Division of Pulmonology, Department of Pediatrics, University of NC at Chapel Hill, Chapel Hill, North Carolina
| | - Marianne S Muhlebach
- Division of Pulmonology, Department of Pediatrics, University of NC at Chapel Hill, Chapel Hill, North Carolina.,Marisco Lung Institute, University of NC at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
25
|
Alves AE, Pereira JM. Antibiotic therapy in ventilator-associated tracheobronchitis: a literature review. Rev Bras Ter Intensiva 2018; 30:80-85. [PMID: 29742211 PMCID: PMC5885235 DOI: 10.5935/0103-507x.20180014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 06/02/2017] [Indexed: 12/16/2022] Open
Abstract
The concept of ventilator-associated tracheobronchitis is controversial; its
definition is not unanimously accepted and often overlaps with
ventilator-associated pneumonia. Ventilator-associated tracheobronchitis has an
incidence similar to that of ventilator-associated pneumonia, with a high
prevalence of isolated multiresistant agents, resulting in an increase in the
time of mechanical ventilation and hospitalization but without an impact on
mortality. The performance of quantitative cultures may allow better diagnostic
definition of tracheobronchitis associated with mechanical ventilation, possibly
avoiding the overdiagnosis of this condition. One of the major difficulties in
differentiating between ventilator-associated tracheobronchitis and
ventilator-associated pneumonia is the exclusion of a pulmonary infiltrate by
chest radiography; thoracic computed tomography, thoracic ultrasonography, or
invasive specimen collection may also be required. The institution of systemic
antibiotic therapy does not improve the clinical impact of ventilator-associated
tracheobronchitis, particularly in reducing time of mechanical ventilation,
hospitalization or mortality, despite the possible reduced progression to
ventilator-associated pneumonia. However, there are doubts regarding the
methodology used. Thus, considering the high prevalence of tracheobronchitis
associated with mechanical ventilation, routine treatment of this condition
would result in high antibiotic usage without clear benefits. However, we
suggest the institution of antibiotic therapy in patients with tracheobronchitis
associated with mechanical ventilation and septic shock and/or worsening of
oxygenation, and other auxiliary diagnostic tests should be simultaneously
performed to exclude ventilator-associated pneumonia. This review provides a
better understanding of the differentiation between tracheobronchitis associated
with mechanical ventilation and pneumonia associated with mechanical
ventilation, which can significantly decrease the use of antibiotics in
critically ventilated patients.
Collapse
Affiliation(s)
- Abel Eduardo Alves
- Serviço de Medicina Intensiva, Hospital do Divino Espírito Santo, Ponta Delgada, Portugal
| | - José Manuel Pereira
- Serviço de Medicina Intensiva e Emergência, Centro Hospitalar de São João, Porto, Portugal
| |
Collapse
|
26
|
Bactericidal activity of ceftobiprole combined with different antibiotics against selected Gram-positive isolates. Diagn Microbiol Infect Dis 2018; 93:77-81. [PMID: 30291042 DOI: 10.1016/j.diagmicrobio.2018.07.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/16/2018] [Accepted: 07/25/2018] [Indexed: 11/24/2022]
Abstract
This study investigated the in vitro susceptibility of ceftobiprole and its potential synergistic activity in combination with other antimicrobials against 46 selected Gram-positive pathogens displaying resistance or decrease susceptibility to several drugs. The gradient-cross method was used to assess synergism between ceftobiprole and daptomycin, levofloxacin, linezolid, rifampicin and piperacillin/tazobactam. Time-kill curves were performed for seven representative isolates. Ceftobiprole MICs ranged from 0.25-6 mg/L for staphylococci; 4-≥32 mg/L for Enterococcus faecalis, and 0.38-≥32 mg/L for E. faecium. Ceftobiprole plus daptomycin was synergistic against all isolates. Ceftobiprole plus linezolid was synergistic against 4 isolates belonging to different species. Ceftobiprole plus levofloxacin was synergistic only against enterococci. In conclusion, ceftobiprole exhibited a potent in vitro antibacterial activity and exhibited synergy with daptomycin against all Gram-positive isolates, despite their antibiotic resistance phenotypes. The use of ceftobiprole in combination may provide a promising alternative therapy for the treatment of resistant Gram-positive infections.
Collapse
|
27
|
Corrêa RDA, Costa AN, Lundgren F, Michelin L, Figueiredo MR, Holanda M, Gomes M, Teixeira PJZ, Martins R, Silva R, Athanazio RA, da Silva RM, Pereira MC. 2018 recommendations for the management of community acquired pneumonia. J Bras Pneumol 2018; 44:405-423. [PMID: 30517341 PMCID: PMC6467584 DOI: 10.1590/s1806-37562018000000130] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 09/11/2018] [Indexed: 12/17/2022] Open
Abstract
Community-acquired pneumonia (CAP) is the leading cause of death worldwide. Despite the vast diversity of respiratory microbiota, Streptococcus pneumoniae remains the most prevalent pathogen among etiologic agents. Despite the significant decrease in the mortality rates for lower respiratory tract infections in recent decades, CAP ranks third as a cause of death in Brazil. Since the latest Guidelines on CAP from the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association) were published (2009), there have been major advances in the application of imaging tests, in etiologic investigation, in risk stratification at admission and prognostic score stratification, in the use of biomarkers, and in the recommendations for antibiotic therapy (and its duration) and prevention through vaccination. To review these topics, the SBPT Committee on Respiratory Infections summoned 13 members with recognized experience in CAP in Brazil who identified issues relevant to clinical practice that require updates given the publication of new epidemiological and scientific evidence. Twelve topics concerning diagnostic, prognostic, therapeutic, and preventive issues were developed. The topics were divided among the authors, who conducted a nonsystematic review of the literature, but giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. All authors had the opportunity to review and comment on all questions, producing a single final document that was approved by consensus.
Collapse
Affiliation(s)
- Ricardo de Amorim Corrêa
- . Faculdade de Medicina, Universidade Federal de Minas Gerais - UFMG - Belo Horizonte (MG) Brasil
| | - Andre Nathan Costa
- . Faculdade de Medicina, Universidade de São Paulo - USP - São Paulo (SP) Brasil
| | | | - Lessandra Michelin
- . Faculdade de Medicina, Universidade de Caxias do Sul, Caxias do Sul (RS) Brasil
| | | | - Marcelo Holanda
- . Faculdade de Medicina, Universidade Federal do Ceará - UFC - Fortaleza (CE) Brasil
| | - Mauro Gomes
- . Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo (SP) Brasil
| | | | - Ricardo Martins
- . Faculdade de Medicina, Universidade de Brasília - UnB - Brasília (DF) Brasil
| | - Rodney Silva
- . Faculdade de Medicina, Universidade Federal do Paraná - UFPR - Curitiba (PR) Brasil
| | | | | | - Mônica Corso Pereira
- . Faculdade de Medicina, Universidade Estadual de Campinas - Unicamp - Campinas (SP) Brasil
| |
Collapse
|
28
|
Santerre Henriksen A, Smart JI, Hamed K. Susceptibility to ceftobiprole of respiratory-tract pathogens collected in the United Kingdom and Ireland during 2014-2015. Infect Drug Resist 2018; 11:1309-1320. [PMID: 30214251 PMCID: PMC6118268 DOI: 10.2147/idr.s176369] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Lower respiratory tract infections (LRTIs) can cause significant morbidity and mortality and are becoming increasingly difficult to treat because of the growing prevalence of resistance to conventional antimicrobial agents. This study aimed to assess the current in vitro susceptibility of respiratory tract pathogens collected from the UK and Ireland to ceftobiprole, an advanced-generation cephalosporin, as compared with other antibiotics. Methods Pathogens isolated from patients with LRTIs were analyzed as part of the British Society for Antimicrobial Chemotherapy Antimicrobial Resistance Surveillance Programme during 2014–2015. Antibiotic susceptibility was evaluated using European Committee on Antimicrobial Susceptibility Testing breakpoints, including the ceftobiprole pharmacokinetic/pharmacodynamic non-species-specific breakpoint when species-specific breakpoints were not available. Results One thousand one hundred and sixty-eight isolates from community-onset LRTIs and 1,264 isolates from hospital-onset LRTIs were analyzed. The ceftobiprole susceptibility rate was 99.8% (428/429) for Streptococcus pneumoniae, 100% (502/502) for Haemophilus influenzae, and 99.6% (236/237) for Moraxella catarrhalis. All Staphylococcus aureus isolates, including methicillin-susceptible S. aureus (MSSA; N=181) and methicillin-resistant S. aureus (MRSA; N=35), were susceptible to ceftobiprole. Overall, ceftobiprole susceptibility was observed in 88.1% (215/244) of Escherichia coli isolates, 83.4% (156/187) of Klebsiella pneumoniae isolates and 86.7% (98/113) of Enterobacter spp. isolates. Conclusion Ceftobiprole had in vitro activity against all S. aureus (both MSSA and MRSA) isolates, and almost all S. pneumoniae isolates, as well as against Gram-negative bacteria associated with community-onset or hospital-onset LRTIs. Based on this analysis, ceftobiprole is a good treatment option when broad-spectrum antibiotic coverage is needed for LRTIs.
Collapse
Affiliation(s)
| | - Jennifer I Smart
- Basilea Pharmaceutica International Ltd., Basel 4005, Switzerland,
| | - Kamal Hamed
- Basilea Pharmaceutica International Ltd., Basel 4005, Switzerland,
| |
Collapse
|
29
|
Accidental dual humidification in intensive care units: Repeated alerts and system changes are not enough. J Crit Care 2018; 47:159-163. [PMID: 30005301 DOI: 10.1016/j.jcrc.2018.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/07/2018] [Accepted: 06/28/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE The inadvertent, simultaneous use of heat and moisture exchangers (HMEs) and heated humidifiers (HHs) can result in waterlogging of the filter and sudden ventilation tube occlusion, with potentially fatal consequences. Following an NHS England Safety Alert, a near miss and educational reminders in our institution, we introduced new guidelines to solely use HHs in the intensive care unit and HMEs only for patient transfers. No further incidents have occurred, however this solution is potentially fallible. Two years later, we sought to assess staff knowledge and likelihood of recognising this error should it occur. MATERIALS AND METHODS In a simulation study, a tracheally intubated and ventilated mannequin had a breathing circuit containing both a HME and a HH. Participants were asked to assess the circuit, identify errors and undertake corrective measures. RESULTS Only 30% (6/20) recognised and undertook corrective measures. CONCLUSIONS Despite educational efforts and system changes, recognition of this error remained poor. System changes may reduce the likelihood of the error occurring, but when it does, recognition may not occur. Substantial reductions or elimination of this error may be achieved through a safety-engineered fail-safe within the equipment, which alerts staff to improve recognition and prevent the mistake.
Collapse
|
30
|
Ambaras Khan R, Aziz Z. The methodological quality of guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia: A systematic review. J Clin Pharm Ther 2018; 43:450-459. [PMID: 29722052 DOI: 10.1111/jcpt.12696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/27/2018] [Indexed: 12/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Clinical practice guidelines serve as a framework for physicians to make decisions and to support best practice for optimizing patient care. However, if the guidelines do not address all the important components of optimal care sufficiently, the quality and validity of the guidelines can be reduced. The objectives of this study were to systematically review current guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), evaluate their methodological quality and highlight the similarities and differences in their recommendations for empirical antibiotic and antibiotic de-escalation strategies. METHODS This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Electronic databases including MEDLINE, CINAHL, PubMed and EMBASE were searched up to September 2017 for relevant guidelines. Other databases such as NICE, Scottish Intercollegiate Guidelines Network (SIGN) and the websites of professional societies were also searched for relevant guidelines. The quality and reporting of included guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument. RESULTS AND DISCUSSION Six guidelines were eligible for inclusion in our review. Among 6 domains of AGREE-II, "clarity of presentation" scored the highest (80.6%), whereas "applicability" scored the lowest (11.8%). All the guidelines supported the antibiotic de-escalation strategy, whereas the majority of the guidelines (5 of 6) recommended that empirical antibiotic therapy should be implemented in accordance with local microbiological data. All the guidelines suggested that for early-onset HAP/VAP, therapy should start with a narrow spectrum empirical antibiotic such as penicillin or cephalosporins, whereas for late-onset HAP/VAP, the guidelines recommended the use of a broader spectrum empirical antibiotic such as the penicillin extended spectrum carbapenems and glycopeptides. WHAT IS NEW AND CONCLUSIONS Expert guidelines promote the judicious use of antibiotics and prevent antibiotic overuse. The quality and validity of available HAP/VAP guidelines would be enhanced by improving their adherence to accepted best practice for the management of HAP and VAP.
Collapse
Affiliation(s)
- R Ambaras Khan
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Z Aziz
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
31
|
Dat VQ, Geskus RB, Wolbers M, Loan HT, Yen LM, Binh NT, Chien LT, Mai NTH, Phu NH, Lan NPH, Hao NV, Long HB, Thuy TP, Kinh NV, Trung NV, Phu VD, Cap NT, Trinh DT, Campbell J, Kestelyn E, Wertheim HFL, Wyncoll D, Thwaites GE, van Doorn HR, Thwaites CL, Nadjm B. Continuous versus intermittent endotracheal cuff pressure control for the prevention of ventilator-associated respiratory infections in Vietnam: study protocol for a randomised controlled trial. Trials 2018; 19:217. [PMID: 29615093 PMCID: PMC5883270 DOI: 10.1186/s13063-018-2587-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 03/12/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Ventilator-associated respiratory infection (VARI) comprises ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). Although their diagnostic criteria vary, together these are the most common hospital-acquired infections in intensive care units (ICUs) worldwide, responsible for a large proportion of antibiotic use within ICUs. Evidence-based strategies for the prevention of VARI in resource-limited settings are lacking. Preventing the leakage of oropharyngeal secretions into the lung using continuous endotracheal cuff pressure control is a promising strategy. The aim of this study is to investigate the efficacy of automated, continuous endotracheal cuff pressure control in preventing the development of VARI and reducing antibiotic use in ICUs in Vietnam. METHODS/DESIGN This is an open-label randomised controlled multicentre trial. We will enrol 600 adult patients intubated for ≤ 24 h at the time of enrolment. Eligible patients will be stratified according to admission diagnosis (180 tetanus, 420 non-tetanus) and site and will be randomised in a 1:1 ratio to receive either (1) automated, continuous control of endotracheal cuff pressure or (2) intermittent measurement and control of endotracheal cuff pressure using a manual cuff pressure meter. The primary outcome is the occurrence of VARI, defined as either VAP or VAT during the ICU admission up to a maximum of 90 days after randomisation. Patients in both groups who are at risk for VARI will receive a standardised battery of investigations if their treating physician feels a new infection has occurred, the results of which will be used by an endpoint review committee, blinded to the allocated arm and independent of patient care, to determine the primary outcome. All enrolled patients will be followed for mortality and endotracheal tube cuff-related complications at 28 days and 90 days after randomisation. Other secondary outcomes include antibiotic use; days ventilated, in ICU and in hospital; inpatient mortality; costs of antibiotics in ICU; duration of ICU stay; and duration of hospital stay. DISCUSSION This study will provide high-quality evidence concerning the use of continuous endotracheal cuff pressure control as a method to reduce VARI, antibiotic use and hospitalisation costs and to shorten stay. TRIAL REGISTRATION ClinicalTrials.gov, NCT02966392 . Registered on November 9, 2016. Protocol version: 2.0; issue date March 3, 2017.
Collapse
Affiliation(s)
- Vu Quoc Dat
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.,Department of Infectious Diseases, Hanoi Medical University, Hanoi, Vietnam
| | - Ronald B Geskus
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Marcel Wolbers
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Huynh Thi Loan
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Lam Minh Yen
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Nguyen Thi Hoang Mai
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Nguyen Van Hao
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Hoang Bao Long
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Tran Phuong Thuy
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Vu Dinh Phu
- National Hospital for Tropical Diseases, Hanoi, Vietnam
| | | | | | - James Campbell
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Evelyne Kestelyn
- Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Heiman F L Wertheim
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Duncan Wyncoll
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Guy Edward Thwaites
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - H Rogier van Doorn
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - C Louise Thwaites
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Wellcome Asia Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Behzad Nadjm
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| |
Collapse
|
32
|
Mansour MGE, Albendary S. Multiplex polymerase chain reaction: Could change diagnosis of Ventilator-associated pneumonia in pediatric critical care units to the fast track? EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2018. [DOI: 10.1016/j.ejmhg.2017.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
33
|
Nicolás MF, Ramos PIP, Marques de Carvalho F, Camargo DRA, de Fátima Morais Alves C, Loss de Morais G, Almeida LGP, Souza RC, Ciapina LP, Vicente ACP, Coimbra RS, Ribeiro de Vasconcelos AT. Comparative Genomic Analysis of a Clinical Isolate of Klebsiella quasipneumoniae subsp. similipneumoniae, a KPC-2 and OKP-B-6 Beta-Lactamases Producer Harboring Two Drug-Resistance Plasmids from Southeast Brazil. Front Microbiol 2018; 9:220. [PMID: 29503635 PMCID: PMC5820359 DOI: 10.3389/fmicb.2018.00220] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/30/2018] [Indexed: 12/19/2022] Open
Abstract
The aim of this study was to unravel the genetic determinants responsible for multidrug (including carbapenems) resistance and virulence in a clinical isolate of Klebsiella quasipneumoniae subsp. similipneumoniae by whole-genome sequencing and comparative analyses. Eighty-three clinical isolates initially identified as carbapenem-resistant K. pneumoniae were collected from nosocomial infections in southeast Brazil. After RAPD screening, the KPC-142 isolate, showing the most divergent DNA pattern, was selected for complete genome sequencing in an Illumina HiSeq 2500 instrument. Reads were assembled into scaffolds, gaps between scaffolds were resolved by in silico gap filling and extensive bioinformatics analyses were performed, using multiple comparative analysis tools and databases. Genome sequencing allowed to correct the classification of the KPC-142 isolate as K. quasipneumoniae subsp. similipneumoniae. To the best of our knowledge this is the first complete genome reported to date of a clinical isolate of this subspecies harboring both class A beta-lactamases KPC-2 and OKP-B-6 from South America. KPC-142 has one 5.2 Mbp chromosome (57.8% G+C) and two plasmids: 190 Kbp pKQPS142a (50.7% G+C) and 11 Kbp pKQPS142b (57.3% G+C). The 3 Kbp region in pKQPS142b containing the blaKPC−2 was found highly similar to that of pKp13d of K. pneumoniae Kp13 isolated in Southern Brazil in 2009, suggesting the horizontal transfer of this resistance gene between different species of Klebsiella. KPC-142 additionally harbors an integrative conjugative element ICEPm1 that could be involved in the mobilization of pKQPS142b and determinants of resistance to other classes of antimicrobials, including aminoglycoside and silver. We present the completely assembled genome sequence of a clinical isolate of K. quasipneumoniae subsp. similipneumoniae, a KPC-2 and OKP-B-6 beta-lactamases producer and discuss the most relevant genomic features of this important resistant pathogen in comparison to several strains belonging to K. quasipneumoniae subsp. similipneumoniae (phylogroup II-B), K. quasipneumoniae subsp. quasipneumoniae (phylogroup II-A), K. pneumoniae (phylogroup I), and K. variicola (phylogroup III). Our study contributes to the description of the characteristics of a novel K. quasipneumoniae subsp. similipneumoniae strain circulating in South America that currently represent a serious potential risk for nosocomial settings.
Collapse
Affiliation(s)
- Marisa F Nicolás
- Laboratório Nacional de Computação Científica, Petrópolis, Brazil
| | | | | | | | | | | | - Luiz G P Almeida
- Laboratório Nacional de Computação Científica, Petrópolis, Brazil
| | - Rangel C Souza
- Laboratório Nacional de Computação Científica, Petrópolis, Brazil
| | | | - Ana C P Vicente
- Laboratório de Genética Molecular de Microrganismos, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Roney S Coimbra
- Neurogenômica, Fiocruz Institute Renê Rachou, Belo Horizonte, Brazil
| | | |
Collapse
|
34
|
Klompas M. Vive la difference! France's new guidelines on hospital-acquired pneumonia. Anaesth Crit Care Pain Med 2018; 37:13-15. [PMID: 29362160 DOI: 10.1016/j.accpm.2017.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, United States; Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States.
| |
Collapse
|
35
|
Álvarez-Lerma F, Palomar-Martínez M, Sánchez-García M, Martínez-Alonso M, Álvarez-Rodríguez J, Lorente L, Arias-Rivera S, García R, Gordo F, Añón JM, Jam-Gatell R, Vázquez-Calatayud M, Agra Y. Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU "Pneumonia Zero" Program. Crit Care Med 2018; 46:181-188. [PMID: 29023261 PMCID: PMC5770104 DOI: 10.1097/ccm.0000000000002736] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The "Pneumonia Zero" project is a nationwide multimodal intervention based on the simultaneous implementation of a comprehensive evidence-based bundle measures to prevent ventilator-associated pneumonia in critically ill patients admitted to the ICU. DESIGN Prospective, interventional, and multicenter study. SETTING A total of 181 ICUs throughout Spain. PATIENTS All patients admitted for more than 24 hours to the participating ICUs between April 1, 2011, and December 31, 2012. INTERVENTION Ten ventilator-associated pneumonia prevention measures were implemented (seven were mandatory and three highly recommended). The database of the National ICU-Acquired Infections Surveillance Study (Estudio Nacional de Vigilancia de Infecciones Nosocomiales [ENVIN]) was used for data collection. Ventilator-associated pneumonia rate was expressed as incidence density per 1,000 ventilator days. Ventilator-associated pneumonia rates from the incorporation of the ICUs to the project, every 3 months, were compared with data of the ENVIN registry (April-June 2010) as the baseline period. Ventilator-associated pneumonia rates were adjusted by characteristics of the hospital, including size, type (public or private), and teaching (postgraduate) or university-affiliated (undergraduate) status. MEASUREMENTS AND MAIN RESULTS The 181 participating ICUs accounted for 75% of all ICUs in Spain. In a total of 171,237 ICU admissions, an artificial airway was present on 505,802 days (50.0% of days of stay in the ICU). A total of 3,474 ventilator-associated pneumonia episodes were diagnosed in 3,186 patients. The adjusted ventilator-associated pneumonia incidence density rate decreased from 9.83 (95% CI, 8.42-11.48) per 1,000 ventilator days in the baseline period to 4.34 (95% CI, 3.22-5.84) after 19-21 months of participation. CONCLUSIONS Implementation of the bundle measures included in the "Pneumonia Zero" project resulted in a significant reduction of more than 50% of the incidence of ventilator-associated pneumonia in Spanish ICUs. This reduction was sustained 21 months after implementation.
Collapse
Affiliation(s)
- Francisco Álvarez-Lerma
- Service of Intensive Care Medicine, Spanish Society of Intensive and Critical Care Medicine and Research Group in Critical Disorders (GREPAC), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Coronary Units (SEMICYUC) Working Group on Infectious Diseases, Hospital del Mar, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mercedes Palomar-Martínez
- Service of Intensive Care Medicine, Spanish Society of Intensive and Critical Care Medicine and Research Group in Critical Disorders (GREPAC), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Coronary Units (SEMICYUC) Working Group on Infectious Diseases, Hospital del Mar, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miguel Sánchez-García
- Working Group on Infectious Diseases, SEMICYUC, Department of Critical Care, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Joaquín Álvarez-Rodríguez
- Service of Intensive Care Medicine, SEMICYUC Working Group on Safety, Quality and Management, Hospital de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - Leonardo Lorente
- Service of Intensive Care Medicine, SEMICYUC Working Group on Infectious Diseases, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Susana Arias-Rivera
- Service of Intensive Care Medicine, Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC), Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Rosa García
- Service of Anesthesiology and Resuscitation, SEEIUC, Hospital Universitario de Basurto, Bilbao, Bizkaia, Spain
| | - Federico Gordo
- Service of Intensive Care Medicine, SEMICYUC Working Group on Acute Respiratory Insufficiency, Hospital Universitario del Henares, Colsada, Madrid, Spain
| | - José M. Añón
- Service of Intensive Care Medicine, SEMICYUC Working Group on Acute Respiratory Insufficiency, CIBER of Respiratory Diseases, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - Rosa Jam-Gatell
- Critical Care Center, SEEIUC, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Tauli I3P3, Sabadell, Barcelona, Spain
| | - Mónica Vázquez-Calatayud
- Area of Nursing Research Training and Development, SEEIUC, Clínica Universidad de Navarra, Pamplona, Spain
| | - Yolanda Agra
- Patient Safety Unit, Spanish Ministry of Health, Social Policy and Equality, Madrid, Spain
| |
Collapse
|
36
|
Pneumonia. FOUNDATIONS OF RESPIRATORY MEDICINE 2018. [PMCID: PMC7120251 DOI: 10.1007/978-3-319-94127-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The chapter will begin with an overview of pathological-clinical correlates in pneumonia, and of the principles of diagnosis and treatment that can be broadly applied to all pneumonias. Thereafter, community-acquired pneumonia, hospital-acquired and ventilator-associated pneumonia, and aspiration pneumonia will be considered separately, considering aspects of management specifically relevant to each. The chapter will end by discussing preventive strategies, and with a brief outline of future challenges for the management of pneumonia.
Collapse
|
37
|
De Pascale G, Ranzani OT, Nseir S, Chastre J, Welte T, Antonelli M, Navalesi P, Garofalo E, Bruni A, Coelho LM, Skoczynski S, Longhini F, Taccone FS, Grimaldi D, Salzer HJF, Lange C, Froes F, Artigas A, Díaz E, Vallés J, Rodríguez A, Panigada M, Comellini V, Fasano L, Soave PM, Spinazzola G, Luyt CE, Alvarez-Lerma F, Marin J, Masclans JR, Chiumello D, Pezzi A, Schultz M, Mohamed H, Van Der Eerden M, Hoek RAS, Gommers DAMPJ, Pasquale MD, Civljak R, Kutleša M, Bassetti M, Dimopoulos G, Nava S, Rios F, Zampieri FG, Povoa P, Bos LD, Aliberti S, Torres A, Martín-Loeches I. Intensive care unit patients with lower respiratory tract nosocomial infections: the ENIRRIs project. ERJ Open Res 2017; 3:00092-2017. [PMID: 29164144 PMCID: PMC5691166 DOI: 10.1183/23120541.00092-2017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/17/2017] [Indexed: 11/21/2022] Open
Abstract
The clinical course of intensive care unit (ICU) patients may be complicated by a large spectrum of lower respiratory tract infections (LRTI), defined by specific epidemiological, clinical and microbiological aspects. A European network for ICU-related respiratory infections (ENIRRIs), supported by the European Respiratory Society, has been recently established, with the aim at studying all respiratory tract infective episodes except community-acquired ones. A multicentre, observational study is in progress, enrolling more than 1000 patients fulfilling the clinical, biochemical and radiological findings consistent with a LRTI. This article describes the methodology of this study. A specific interest is the clinical impact of non-ICU-acquired nosocomial pneumonia requiring ICU admission, non-ventilator-associated LRTIs occurring in the ICU, and ventilator-associated tracheobronchitis. The clinical meaning of microbiologically negative infectious episodes and specific details on antibiotic administration modalities, dosages and duration are also highlighted. Recently released guidelines address many unresolved questions which might be answered by such large-scale observational investigations. In light of the paucity of data regarding such topics, new interesting information is expected to be obtained from our network research activities, contributing to optimisation of care for critically ill patients in the ICU. Methodology for the first European network for ICU-related respiratory infections (ENIRRIs) projecthttp://ow.ly/sud930fU1e7
Collapse
Affiliation(s)
- Gennaro De Pascale
- Dept of Anesthesiology and Intensive Care, Università Cattolica del Sacro Cuore, Fondazione Policlinico Agostino Gemelli, Rome, Italy
| | - Otavio T Ranzani
- Institut del Torax, Hospital Clinic, Dept of Pulmonology, University of Barcelona, Institut D'investigacions August Pi I Sunyer (IDIBAPS); Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Barcelona, Spain
| | - Saad Nseir
- Dept of Intensive Care Medicine, Critical Care Center, CHU Lille, Lille, France
| | - Jean Chastre
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Tobias Welte
- Dept of Respiratory Medicine, Member of the German Center of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Massimo Antonelli
- Dept of Anesthesiology and Intensive Care, Università Cattolica del Sacro Cuore, Fondazione Policlinico Agostino Gemelli, Rome, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Dipartimento Scienze Mediche e Chirurgiche, Università della Magna Graecia, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care, Dipartimento Scienze Mediche e Chirurgiche, Università della Magna Graecia, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Dipartimento Scienze Mediche e Chirurgiche, Università della Magna Graecia, Catanzaro, Italy
| | - Luis Miguel Coelho
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CEDOC, New University of Lisbon, Lisbon, Portugal
| | - Szymon Skoczynski
- Dept of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Federico Longhini
- Anesthesia and Intensive Care Medicine, Sant'Andrea Hospital, Vercelli, Italy
| | - Fabio Silvio Taccone
- Dept of Intensive Care, CUB - Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - David Grimaldi
- Dept of Intensive Care, CUB - Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Helmut J F Salzer
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center of Infection Research, Borstel, Germany.,International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - Christoph Lange
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany.,German Center of Infection Research, Borstel, Germany.,International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - Filipe Froes
- Intensive Care Unit, Chest Dept, Hospital Pulido Valente, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Antoni Artigas
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, CIBER de Enfermedades Respiratorias (CIBERES), Sabadell, Spain
| | - Emili Díaz
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, CIBER de Enfermedades Respiratorias (CIBERES), Sabadell, Spain
| | - Jordi Vallés
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, CIBER de Enfermedades Respiratorias (CIBERES), Sabadell, Spain
| | - Alejandro Rodríguez
- Critical Care Dept, Hospital Universitari Joan XXIII, IISPV-URV, Tarragona, Spain
| | - Mauro Panigada
- Dept of Anesthesiology, Intensive Care and Emergency, U.O.C. Rianimazione e Terapia Intensiva, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Vittoria Comellini
- Alma Mater University, Dept of Clinical, Integrated and Experimental Medicine (DIMES), S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Luca Fasano
- Alma Mater University, Dept of Clinical, Integrated and Experimental Medicine (DIMES), S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Paolo M Soave
- Dept of Anesthesiology and Intensive Care, Università Cattolica del Sacro Cuore, Fondazione Policlinico Agostino Gemelli, Rome, Italy
| | - Giorgia Spinazzola
- Dept of Anesthesiology and Intensive Care, Università Cattolica del Sacro Cuore, Fondazione Policlinico Agostino Gemelli, Rome, Italy
| | - Charles-Edouard Luyt
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Francisco Alvarez-Lerma
- Critical Care Dept, Hospital del Mar, Critical Illness Research Group (GREPAC), Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Judith Marin
- Critical Care Dept, Hospital del Mar, Critical Illness Research Group (GREPAC), Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Joan Ramon Masclans
- Critical Care Dept, Hospital del Mar, Critical Illness Research Group (GREPAC), Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Davide Chiumello
- Dipartimento di Emergenza - Urgenza, ASST Santi Paolo e Carlo, Milan, Italy.,Dipartimento di Scienze della salute, Università degli Studi di Milano, Milan, Italy
| | - Angelo Pezzi
- Dipartimento di Emergenza - Urgenza, ASST Santi Paolo e Carlo, Milan, Italy.,Dipartimento di Scienze della salute, Università degli Studi di Milano, Milan, Italy
| | - Marcus Schultz
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Hafiz Mohamed
- Dept of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | | | | | | | - Marta Di Pasquale
- Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rok Civljak
- 'Dr. Fran Mihaljevic' University Hospital for Infectious Diseases, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Marko Kutleša
- 'Dr. Fran Mihaljevic' University Hospital for Infectious Diseases, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Dept of Medicine University of Udine and Santa Maria Misericordia Hospital, Udine, Italy
| | - George Dimopoulos
- Dept of Critical Care, University Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Stefano Nava
- Alma Mater University, Dept of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Fernando Rios
- Hospital Nacional Profesor A Posadas, Buenos Aires, Argentina
| | | | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CEDOC, New University of Lisbon, Lisbon, Portugal
| | - Lieuwe D Bos
- Academic Medical Center, Amsterdam, The Netherlands
| | - Stefano Aliberti
- Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antoni Torres
- Institut del Torax, Hospital Clinic, Dept of Pulmonology, University of Barcelona, Institut D'investigacions August Pi I Sunyer (IDIBAPS); Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Barcelona, Spain
| | - Ignacio Martín-Loeches
- Dept of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| |
Collapse
|
38
|
|
39
|
Pharmacokinetics and Dosing of Ceftobiprole Medocaril for the Treatment of Hospital- and Community-Acquired Pneumonia in Different Patient Populations. Clin Pharmacokinet 2017; 55:1507-1520. [PMID: 27272266 PMCID: PMC5107198 DOI: 10.1007/s40262-016-0418-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hospital-acquired pneumonia (HAP) and community-acquired pneumonia (CAP) are among the most common infections treated in the hospital setting, and together they place a significant burden on healthcare systems. Successful management of HAP and CAP depends on rapid initiation of empirical antibiotic therapy with broad-spectrum antibiotics. Ceftobiprole is a new-generation, broad-spectrum cephalosporin antibiotic for the treatment of HAP (excluding ventilator-associated pneumonia) and CAP. It displays potent in vitro activity against a broad range of pathogens important in pneumonia. This review summarizes the pharmacokinetic profile of ceftobiprole, and considers the pharmacokinetic parameters and pharmacodynamics underlying the choice of dosing regimen. Ceftobiprole shows linear pharmacokinetics after single and multiple doses and is eliminated predominantly through the kidneys. Ceftobiprole is administered as a 500 mg intravenous infusion over 2 h every 8 h, and steady-state concentrations are reached on the first day of dosing. Dose adjustment is recommended for patients with moderate or severe renal impairment and for those with end-stage renal disease. Extending the infusion time of ceftobiprole to 4 h is recommended to optimize drug exposure in critically ill patients with augmented renal clearance. However, there is no need for dose adjustments based on age, sex or ethnicity, or for patients with severe obesity. Population pharmacokinetic modelling and Monte Carlo simulations were used to determine the optimal dosing regimen for ceftobiprole in special patient populations, including paediatric patients. Future studies of ceftobiprole in patients with HAP and CAP would be of interest.
Collapse
|
40
|
Garnacho-Montero J, Gutiérrez-Pizarraya A, Lopez-García I, Miranda JC, González-Galán V, Corcia-Palomo Y, Alonso-Araujo I, Martín-Villén L, Aznar-Martín J, Amaya-Villar R. Pneumonia in mechanically ventilated patients: no diagnostic and prognostic value of different quantitative tracheal aspirates thresholds. Infect Dis (Lond) 2017; 50:44-51. [PMID: 28776434 DOI: 10.1080/23744235.2017.1362110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Diagnosis of pneumonia in ventilated patients is challenging due to the lack of specific and definitive clinical symptoms, laboratory data or radiological abnormalities. METHODS Based on quantitative tracheal aspirate (QTA) results, three groups of patients were compared: <105 cfu/ml, ≥105 cfu/ml and <106 cfu/ml, and ≥106 cfu/ml. We recorded demographic variables, underlying diseases and severity of illness at ICU admission. On the day of pneumonia diagnosis, we registered temperature, leukocyte count, C-reactive protein, Sequential Organ Failure Assessment (SOFA) score, clinical pulmonary infection score (CPIS) and adequacy of empirical antimicrobial therapy. RESULTS In 231 episodes, clinical presentation, laboratory data, severity of illness, CPIS, the presence of bacteremia and radiological score did not differ among the three groups. ICU and hospital mortalities were also similar in the three groups. Factors independently associated with in-hospital mortality were age, SOFA score and inappropriate antimicrobial therapy. The bacterial burden in the QTA was not included in the model. CONCLUSIONS Quantification of tracheal aspirate samples may not be necessary in ventilated patients clinically suspected of having nosocomial pneumonia.
Collapse
Affiliation(s)
- J Garnacho-Montero
- a Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen Macarena , Sevilla , Spain.,b Instituto de Biomedicina de Sevilla (IBIS) , Seville , Spain
| | - A Gutiérrez-Pizarraya
- b Instituto de Biomedicina de Sevilla (IBIS) , Seville , Spain.,c Infectious Disease, Microbiology and Preventive medicine Clinical Unit , Virgen Macarena University Hospital , Seville , Spain
| | - I Lopez-García
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - J C Miranda
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - V González-Galán
- e Infectious Disease, Microbiology and Preventive medicine Clinical Unit , Virgen del Rocío University Hospital , Seville , Spain
| | - Y Corcia-Palomo
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - I Alonso-Araujo
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - L Martín-Villén
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - J Aznar-Martín
- e Infectious Disease, Microbiology and Preventive medicine Clinical Unit , Virgen del Rocío University Hospital , Seville , Spain
| | - R Amaya-Villar
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| |
Collapse
|
41
|
High frequency of silver resistance genes in invasive isolates of Enterobacter and Klebsiella species. J Hosp Infect 2017; 96:256-261. [DOI: 10.1016/j.jhin.2017.04.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/02/2017] [Indexed: 11/19/2022]
|
42
|
Sommerstein R, Atkinson A, Lo Priore EF, Kronenberg A, Marschall J. Characterizing non-linear effects of hospitalisation duration on antimicrobial resistance in respiratory isolates: an analysis of a prospective nationwide surveillance system. Clin Microbiol Infect 2017; 24:45-52. [PMID: 28559001 DOI: 10.1016/j.cmi.2017.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 05/16/2017] [Accepted: 05/17/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Our objective was to systematically study the influence of length of hospital stay on bacterial resistance in relevant respiratory tract isolates. METHODS Using prospective epidemiological data from the National Swiss Antibiotic Resistance Surveillance System, susceptibility testing results for respiratory isolates retrospectively retrieved from patients hospitalised between 2008 and 2014 were compiled. Generalized additive models were used to illustrate resistance rates relative to hospitalisation duration and to adjust for co-variables. RESULTS In all, 19 622 isolates of six relevant and predominant species were included. Resistance patterns for the predominant species showed a species-specific and antibiotic-resistance-specific profile in function of hospitalisation duration. The oxacillin resistance profile in Staphylococcus aureus isolates was constantly increasing (monophasic). The pattern of resistance to cefepime in Pseudomonas aeruginosa was biphasic with a decreasing resistance rate for the first 5 days of hospitalisation and an increase for days 6-30. A different biphasic pattern occurred in Escherichia coli regarding amoxicillin-clavulanic acid resistance: odds/day increased for the first 7 days of hospitalisation and then remained stable for days 8-30. In the adjusted models epidemiological characteristics such as age, ward type, hospital type and linguistic region were identified as relevant co-variables for the resistance rates. The contribution of these confounders was specific to the individual species/antibiotic resistance models. CONCLUSIONS Resistance rates do not follow a dichotomic pattern (early versus late nosocomial) as suggested by current hospital-acquired pneumonia treatment guidelines. Duration of hospitalisation rather appears to have a more complex and non-linear relationship with bacterial resistance in hospital-acquired pneumonia, also depending on host and environmental factors.
Collapse
Affiliation(s)
- R Sommerstein
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland.
| | - A Atkinson
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland
| | - E F Lo Priore
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland
| | - A Kronenberg
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland; Institute for Infectious Diseases, University of Bern, Switzerland
| | - J Marschall
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland
| | | |
Collapse
|
43
|
Antibiotic prophylaxis against ventilator-associated pneumonia in patients with coma: Where are we now? Med Intensiva 2017; 41:248-251. [DOI: 10.1016/j.medin.2016.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/06/2016] [Accepted: 09/11/2016] [Indexed: 11/22/2022]
|
44
|
Effect of Prior Atorvastatin Treatment on the Frequency of Hospital Acquired Pneumonia and Evolution of Biomarkers in Patients with Acute Ischemic Stroke: A Multicenter Prospective Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5642704. [PMID: 28357403 PMCID: PMC5357518 DOI: 10.1155/2017/5642704] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 12/23/2016] [Accepted: 01/04/2017] [Indexed: 02/05/2023]
Abstract
Objective. To investigate whether prior treatment of atorvastatin reduces the frequency of hospital acquired pneumonia (HAP). Methods. Totally, 492 patients with acute ischemic stroke and Glasgow Coma Scale ≤ 8 were enrolled in this study. Subjects were assigned to prior atorvastatin treatment group (n = 268, PG) and no prior treatment group (n = 224, NG). All the patients were given 20 mg atorvastatin every night during their hospital stay. HAP frequency and 28-day mortality were measured. Levels of inflammatory biomarkers [white blood cell (WBC), procalcitonin (PCT), tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6)] were tested. Results. There was no significant difference in the incidence of HAP between PG and NG (25.74% versus. 24.55%, p > 0.05) and 28-day mortality (50.72% versus 58.18%, p > 0.05). However, prior statin treatment did modify the mortality of ventilator associated pneumonia (VAP) (36.54% versus 58.14%, p = 0.041) and proved to be a protective factor (HR, 0.564; 95% CI, 0.310~0.825, p = 0.038). Concentrations of TNF-α and IL-6 in PG VAP cases were lower than those in NG VAP cases (p < 0.01). Conclusions. Prior atorvastatin treatment in patients with ischemic stroke was associated with a lower concentration of IL-6 and TNF-α and improved the outcome of VAP. This clinical study has been registered with ChiCTR-ROC-17010633 in Chinese Clinical Trial Registry.
Collapse
|
45
|
Carbonne H, Le Dorze M, Bourrel AS, Poupet H, Poyart C, Cambau E, Mira JP, Charpentier J, Amarsy R. Relation between presence of extended-spectrum β-lactamase-producing Enterobacteriaceae in systematic rectal swabs and respiratory tract specimens in ICU patients. Ann Intensive Care 2017; 7:13. [PMID: 28155050 PMCID: PMC5289933 DOI: 10.1186/s13613-017-0237-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 01/20/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The choice of empirical antimicrobial therapy for pneumonia in intensive care unit (ICU) is a challenge, since pneumonia is often related to multidrug-resistant pathogens, particularly extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E). To prevent the overuse of broad-spectrum antimicrobial therapy, the main objective of this study was to test the performance of digestive colonization surveillance as a predictor of ESBL-E presence or absence in respiratory samples performed in ICU and to evaluate the impact of time sampling (≤5 days or >5 days) on such prediction. DESIGN Multicentric retrospective observational study, including every patient with a respiratory tract specimen positive culture and a previous rectal ESBL-E screening performed within 7 days before the respiratory sample, between January 2012 and December 2014. Results were analyzed in two groups: respiratory samples obtained during the first 5 days of ICU stay (early group) and respiratory samples obtained after 5 days (late group). INTERVENTIONS none. RESULTS Among 2498 respiratory tract samples analyzed corresponding to 1503 patients, 1557 (62.3%) were performed early (≤5 days) and 941 (37.7%) later (>5 days). Positivity rates for ESBL-E were 15.0 and 36.8% for rectal swabs in the early and late groups, respectively. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratios were calculated for ESBL-E digestive colonization as a predictor of ESBL-E presence in respiratory samples. PPVs of ESBL-E digestive colonization were 14.5% (95% CI [12.8; 16.3]) and 34.4% (95% CI [31.4; 37.4]), for the early and late groups, respectively, whereas NPVs were 99.2% (95% CI [98.7; 99.6]) and 93.4% (95% CI [91.9; 95.0]), respectively. CONCLUSIONS Systematic surveillance of ESBL-E digestive colonization may be useful to limit the use of carbapenems when pneumonia is suspected in ICU. When rectal swabs are negative, the risk of having ESBL-E in respiratory samples is very low even after 5 days of ICU stay.
Collapse
Affiliation(s)
- Hélène Carbonne
- Service de Réanimation Chirurgicale Polyvalente, Département d'Anesthésie Réanimation SMUR, Hôpital Lariboisière, AP-HP 2, Rue Ambroise Paré, 75475, Paris Cedex 10, France. .,Service de Réanimation Médicale, Hôpital Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Matthieu Le Dorze
- Service de Réanimation Chirurgicale Polyvalente, Département d'Anesthésie Réanimation SMUR, Hôpital Lariboisière, AP-HP 2, Rue Ambroise Paré, 75475, Paris Cedex 10, France.
| | - Anne-Sophie Bourrel
- Laboratoire de Microbiologie, Hôpital Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Hélène Poupet
- Laboratoire de Microbiologie, Hôpital Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Claire Poyart
- Laboratoire de Microbiologie, Hôpital Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Emmanuelle Cambau
- Laboratoire de Bactériologie-Virologie, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75475, Paris Cedex 10, France
| | - Jean-Paul Mira
- Service de Réanimation Médicale, Hôpital Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Julien Charpentier
- Service de Réanimation Médicale, Hôpital Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Rishma Amarsy
- Laboratoire de Bactériologie-Virologie, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75475, Paris Cedex 10, France.,Equipe Opérationnelle d'Hygiène, Hôpital Lariboisière, AP-HP, 2 Rue Ambroise Paré, 75475, Paris Cedex 10, France
| |
Collapse
|
46
|
Rodrigues ME, Lopes SP, Pereira CR, Azevedo NF, Lourenço A, Henriques M, Pereira MO. Polymicrobial Ventilator-Associated Pneumonia: Fighting In Vitro Candida albicans-Pseudomonas aeruginosa Biofilms with Antifungal-Antibacterial Combination Therapy. PLoS One 2017; 12:e0170433. [PMID: 28114348 PMCID: PMC5256963 DOI: 10.1371/journal.pone.0170433] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/04/2017] [Indexed: 11/17/2022] Open
Abstract
The polymicrobial nature of ventilator-associated pneumonia (VAP) is now evident, with mixed bacterial-fungal biofilms colonizing the VAP endotracheal tube (ETT) surface. The microbial interplay within this infection may contribute for enhanced pathogenesis and exert impact towards antimicrobial therapy. Consequently, the high mortality/morbidity rates associated to VAP and the worldwide increase in antibiotic resistance has promoted the search for novel therapeutic strategies to fight VAP polymicrobial infections. Under this scope, this work aimed to assess the activity of mono- vs combinational antimicrobial therapy using one antibiotic (Polymyxin B; PolyB) and one antifungal (Amphotericin B; AmB) agent against polymicrobial biofilms of Pseudomonas aeruginosa and Candida albicans. The action of isolated antimicrobials was firstly evaluated in single- and polymicrobial cultures, with AmB being more effective against C. albicans and PolyB against P. aeruginosa. Mixed planktonic cultures required equal or higher antimicrobial concentrations. In biofilms, only PolyB at relatively high concentrations could reduce P. aeruginosa in both monospecies and polymicrobial populations, with C. albicans displaying only punctual disturbances. PolyB and AmB exhibited a synergistic effect against P. aeruginosa and C. albicans mixed planktonic cultures, but only high doses (256 mg L-1) of PolyB were able to eradicate polymicrobial biofilms, with P. aeruginosa showing loss of cultivability (but not viability) at 2 h post-treatment, whilst C. albicans only started to be inhibited after 14 h. In conclusion, combination therapy involving an antibiotic and an antifungal agent holds an attractive therapeutic option to treat severe bacterial-fungal polymicrobial infections. Nevertheless, optimization of antimicrobial doses and further clinical pharmacokinetics/pharmacodynamics and toxicodynamics studies underpinning the optimal use of these drugs are urgently required to improve therapy effectiveness and avoid reinfection.
Collapse
Affiliation(s)
- Maria E Rodrigues
- Centre of Biological Engineering, LIBRO-Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, Campus de Gualtar, Braga, Portugal
| | - Susana P Lopes
- Centre of Biological Engineering, LIBRO-Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, Campus de Gualtar, Braga, Portugal
| | - Cláudia R Pereira
- Centre of Biological Engineering, LIBRO-Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, Campus de Gualtar, Braga, Portugal
| | - Nuno F Azevedo
- LEPABE-Dep. of Chemical Engineering, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, Porto, Portugal
| | - Anália Lourenço
- Departamento de Informática-Universidade de Vigo, ESEI-Escuela Superior de Ingeniería Informática, Edificio politécnico, Campus Universitario As Lagoas, Ourense, Spain.,Centre of Biological Engineering, University of Minho, Campus de Gualtar, Braga, Portugal
| | - Mariana Henriques
- Centre of Biological Engineering, LIBRO-Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, Campus de Gualtar, Braga, Portugal
| | - Maria O Pereira
- Centre of Biological Engineering, LIBRO-Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, Campus de Gualtar, Braga, Portugal
| |
Collapse
|
47
|
Broad-Range Detection of Microorganisms Directly from Bronchoalveolar Lavage Specimens by PCR/Electrospray Ionization-Mass Spectrometry. PLoS One 2017; 12:e0170033. [PMID: 28085931 PMCID: PMC5235381 DOI: 10.1371/journal.pone.0170033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/27/2016] [Indexed: 11/28/2022] Open
Abstract
The clinical demand on rapid microbiological diagnostic is constantly increasing. PCR coupled to electrospray ionization-mass spectrometry, PCR/ESI-MS, offers detection and identification of over 750 bacteria and Candida species directly from clinical specimens within 6 hours. In this study, we investigated the clinical performance of the IRIDICA BAC LRT Assay for detection of bacterial pathogens in 121 bronchoalveolar lavage (BAL) samples that were received consecutively at our bacterial laboratory for BAL culture. Commensal or pathogenic microorganisms were detected in 118/121 (98%) BAL samples by PCR/ESI-MS, while in 104/121 (86%) samples by routine culture (P<0.01). Detection of potentially pathogenic microorganisms by PCR/ESI-MS was evaluated in comparison with conventional culture-based or molecular methods. The agreement between positive findings was overall good. Most Staphylococcus aureus-positive PCR/ESI-MS results were confirmed by culture or species-specific PCR (27/33, 82%). The identity of Streptococcus pneumoniae could however be confirmed for only 6/17 (35%) PCR/ESI-MS-positive samples. Non-cultivable and fastidious pathogens, which were not covered by standard culture procedures were readily detected by PCR/ESI-MS, including Legionella pneumophila, Bordetella pertussis, Norcadia species and Mycoplasma pneumoniae. In conclusion, PCR/ESI-MS detected a broad range of potential pathogens with equal or superior sensitivity compared to conventional methods within few hours directly from BAL samples. This novel method might thus provide a relevant tool for diagnostics in critically ill patients.
Collapse
|
48
|
Pássaro L, Harbarth S, Landelle C. Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review. Antimicrob Resist Infect Control 2016; 5:43. [PMID: 27895901 PMCID: PMC5109660 DOI: 10.1186/s13756-016-0150-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 11/09/2016] [Indexed: 01/28/2023] Open
Abstract
Background Pneumonia is one of the leading hospital-acquired infections worldwide and has an important impact. Although preventive measures for ventilator-associated pneumonia (VAP) are well known, less is known about appropriate measures for prevention of hospital-acquired pneumonia (HAP). Aim The purpose of this narrative review is to provide an overview of the current standards for preventing HAP in non-ventilated adult patients. Methods A search of the literature up to May 2015 was conducted using Medline for guidelines published by national professional societies or professional medical associations. In addition, a comprehensive search for the following preventive measures was performed: hand hygiene, oral care, bed position, mobilization, diagnosis and treatment of dysphagia, aspiration prevention, viral infections and stress bleeding prophylaxis. Findings Regarding international guidelines, several measures were recommended for VAP, whilst no specific recommendations for HAP prevention in non-ventilated patients are available. There is reasonable evidence available that oral care is associated with a reduction in HAP. Early mobilization interventions, swift diagnosis and treatment of dysphagia, and multimodal programmes for the prevention of nosocomial influenza cross-infection, have a positive impact on HAP reduction. The impact of bed position and stress bleeding prophylaxis remains uncertain. Systematic antibiotic prophylaxis for HAP prevention should be avoided. Conclusion Scant literature and little guidance is available for the prevention of HAP among non-ventilated adult patients. In addition, the criteria used for the diagnosis of HAP and the populations targeted in the studies selected are heterogeneous. Oral care was the most studied measure and was commonly associated with a decrease in HAP rate, although a broad range of interventions are proposed. No robust evidence is available for other measures. Further high-quality studies are required to evaluate the impact of specific measures on HAP prevention in non-ventilated adult patients.
Collapse
Affiliation(s)
- Leonor Pássaro
- Infection Control Programme, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Caroline Landelle
- Infection Control Programme, Geneva University Hospitals and Medical School, Geneva, Switzerland ; Infection Control Unit, Centre Hospitalier Universitaire (CHU) Grenoble Alpes, CS 10217, 38043 Grenoble Cedex 9, France ; ThEMAS TIM-C UMR 5525, University Grenoble Alpes/CNRS, Grenoble, France
| |
Collapse
|
49
|
Bouza E, Martínez-Alarcón J, Maseda E, Palomar M, Zaragoza R, Pérez-Granda MJ, Muñoz P, Burillo A. Quality of the aetiological diagnosis of ventilator-associated pneumonia in Spain in the opinion of intensive care specialists and microbiologists. Enferm Infecc Microbiol Clin 2016; 35:153-164. [PMID: 27743679 DOI: 10.1016/j.eimc.2016.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Current guidelines for the microbiological diagnosis of ventilator-associated pneumonia (VAP) are imprecise. Based on data provided by intensive care specialists (ICS) and microbiologists, this study defines the clinical practices and microbiological techniques currently used for an aetiological diagnosis of VAP and pinpoints deficiencies. METHODS Eighty hospitals in the national health network with intensive care and microbiology departments were sent two questionnaires, one for each department, in order to collect data on VAP diagnosis for the previous year. RESULTS Out of the 80 hospitals, 35 (43.8%) hospitals participated. These included 673 ICU beds, 32,020 ICU admissions, 173,820 ICU days stay, and generated 27,048 lower respiratory tract specimens in the year. A third of the hospitals (35%) had a microbiology department available 24/7. Most samples (83%) were tracheal aspirates. Gram stain results were immediately reported in around half (47%) of the hospitals. Quantification was made in 75% of hospitals. Molecular techniques and direct susceptibility testing were performed in 12% and one institution, respectively. Mean turnaround time for a microbiological report was 1.7 (SD; 0.7), and 2.2 (SD; 0.6) days for a negative and positive result, respectively. Telephone/in-person information was offered by 65% of the hospitals. Most (89%) ICS considered microbiological information as very useful. No written procedures were available in half the ICUs. CONCLUSIONS Both ICS and microbiologists agreed that present guidelines for the diagnosis of VAP could be much improved, and that a new set of consensus guidelines is urgently required. A need for guidelines to be more effectively implemented was also identified in order to improve outcomes in patients with VAP.
Collapse
Affiliation(s)
- Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain
| | - José Martínez-Alarcón
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; The present affiliation of José Martínez-Alarcón is Department of Microbiology, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
| | - Emilio Maseda
- Department of Anesthesia, Hospital General Universitario La Paz, Madrid, Spain
| | - Mercedes Palomar
- Intensive Care Dept., Hospital Universitari Arnau de Vilanova, Lérida, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0036), Spain
| | - Rafael Zaragoza
- Intensive Care Dept., Hospital Universitario Doctor Peset, Valencia, Spain
| | - María Jesús Pérez-Granda
- Department of Anesthesia, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain
| | - Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
| |
Collapse
|
50
|
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]
|