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Performance of the Cepheid Methicillin-Resistant Staphylococcus aureus/S. aureus Skin and Soft Tissue Infection PCR Assay on Respiratory Samples from Mechanically Ventilated Patients for S. aureus Screening during the Phase 2 Double-Blind SAATELLITE Study. J Clin Microbiol 2022; 60:e0034722. [PMID: 35758652 PMCID: PMC9297837 DOI: 10.1128/jcm.00347-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
We investigated the performance of the Xpert methicillin-resistant Staphylococcus aureus (MRSA)/S. aureus skin and soft tissue (SSTI) quantitative PCR (qPCR) assay in SAATELLITE, a multicenter, double-blind, phase 2 study of suvratoxumab, a monoclonal antibody (MAb) targeting S. aureus alpha-toxin, for reducing the incidence of S. aureus pneumonia. The assay was used to detect methicillin-susceptible S. aureus (MSSA) and MRSA in lower respiratory tract (LRT) samples from mechanically ventilated patients. LRT culture results were compared with S. aureus protein A (spa) gene cycle threshold (CT) values. Receiver operating characteristic (ROC) and Youden index were used to determine the CT cutoff for best separation of culture-S. aureus-negative and S. aureus-positive patients. Of 720 screened subjects, 299 (41.5%) were S. aureus positive by qPCR, of whom 209 had culture data: 162 (77.5%) were S. aureus positive and 47 (22.5%) were S. aureus negative. Culture results were negatively affected by antibiotic use and cross-laboratory variability. An inverse linear correlation was observed between CT values and quantitative S. aureus culture results. A spa CT value of 29 (≈2 × 103 CFU/mL) served as the best cutoff for separation between culture-negative and culture-positive samples. The associated area under the ROC curve was 83.8% (95% confidence interval [CI], 78 to 90%). Suvratoxumab provided greater reduction in S. aureus pneumonia or death than placebo in subjects with low S. aureus load (CT ≥ 29; relative risk reduction [RRR], 50.0%; 90% CI, 2.7 to 74.4%) versus the total study population (RRR, 25.2%; 90% CI, -4.3 to 46.4%). The qPCR assay was easy to perform, sensitive, and standardized and provided better sensitivity than conventional culture for S. aureus detection. Quantitative PCR CT output correlated with suvratoxumab efficacy in reducing S. aureus pneumonia incidence or death in S. aureus-colonized, mechanically ventilated patients.
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Navarro-Torné A, Montuori EA, Kossyvaki V, Méndez C. Burden of pneumococcal disease among adults in Southern Europe (Spain, Portugal, Italy, and Greece): a systematic review and meta-analysis. Hum Vaccin Immunother 2021; 17:3670-3686. [PMID: 34106040 PMCID: PMC8437551 DOI: 10.1080/21645515.2021.1923348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/07/2021] [Accepted: 04/23/2021] [Indexed: 12/18/2022] Open
Abstract
The aim was to summarize pneumococcal disease burden data among adults in Southern Europe and the potential impact of vaccines on epidemiology. Of 4779 identified studies, 272 were selected. Invasive pneumococcal disease (IPD) incidence was 15.08 (95% CI 11.01-20.65) in Spain versus 2.56 (95% CI 1.54-4.24) per 100,000 population in Italy. Pneumococcal pneumonia incidence was 19.59 (95% CI 10.74-35.74) in Spain versus 2.19 (95% CI 1.36-3.54) per 100,000 population in Italy. Analysis of IPD incidence in Spain comparing pre-and post- PCV7 and PCV13 periods unveiled a declining trend in vaccine-type IPD incidence (larger and statistically significant for the elderly), suggesting indirect effects of childhood vaccination programme. Data from Portugal, Greece and, to a lesser extent, Italy were sparse, thus improved surveillance is needed. Pneumococcal vaccination uptake, particularly among the elderly and adults with chronic and immunosuppressing conditions, should be improved, including shift to a higher-valency pneumococcal conjugate vaccine when available.
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Risk factors for ventilator-associated pneumonia due to Staphylococcus aureus in patients with severe brain injury: A multicentre retrospective cohort study. Anaesth Crit Care Pain Med 2021; 40:100785. [DOI: 10.1016/j.accpm.2020.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/06/2020] [Accepted: 01/06/2020] [Indexed: 11/22/2022]
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Li Y, Liu C, Xiao W, Song T, Wang S. Incidence, Risk Factors, and Outcomes of Ventilator-Associated Pneumonia in Traumatic Brain Injury: A Meta-analysis. Neurocrit Care 2020; 32:272-285. [PMID: 31300956 PMCID: PMC7223912 DOI: 10.1007/s12028-019-00773-w] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ventilator-associated pneumonia (VAP) is one of the most severe complications in patients with traumatic brain injury (TBI) and is considered a risk factor for poor outcomes. However, the incidence of VAP among patients with TBI reported in studies varies widely. What is more, the risk factors and outcomes of VAP are controversial. This study estimates the incidence, risk factors, and outcomes of VAP in patients with TBI and provides evidence for prevention and treatment. PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched from the earliest records to May 2018. Data involving the incidence, risk factors, and outcomes were extracted for meta-analysis. The results showed that the incidence of VAP was 36% (95% confidence interval (CI) 31-41%); risk factors analyses showed that smoking [odds ratio (OR) 2.13; 95% CI 1.16-3.92], tracheostomy (OR 9.55; 95% CI 3.24-28.17), blood transfusion on admission (OR 2.54; 95% CI 1.24-5.18), barbiturate infusion (OR 3.52; 95% CI 1.68-7.40), injury severity score (OR 4.65; 95% CI 1.96-7.34), and head abbreviated injury scale (OR 2.99; 95% CI 1.66-5.37) were related to the occurrence of VAP. When patients developed VAP, mechanical ventilation time (OR 5.45; 95% CI 3.78-7.12), ICU length of stay (OR 6.85; 95% CI 4.90-8.79), and hospital length of stay (OR 10.92; 95% CI 9.12-12.72) were significantly increased. However, VAP was not associated with an increased risk of mortality (OR 1.28; 95% CI 0.74-2.21). VAP is common in patients with TBI. It is affected by a series of factors and has a poor prognosis.
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Affiliation(s)
- Yating Li
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Rm.212, No.107 Wenhua West Road, Jinan, 250012, Shandong Province, China
- School of Nursing, Shandong University, Jinan, Shandong Province, China
| | - Chenxia Liu
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Rm.212, No.107 Wenhua West Road, Jinan, 250012, Shandong Province, China
- School of Nursing, Shandong University, Jinan, Shandong Province, China
| | - Wei Xiao
- Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
| | - Tiantian Song
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Rm.212, No.107 Wenhua West Road, Jinan, 250012, Shandong Province, China
- School of Nursing, Shandong University, Jinan, Shandong Province, China
| | - Shuhui Wang
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Rm.212, No.107 Wenhua West Road, Jinan, 250012, Shandong Province, China.
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The utility of endotracheal aspirate bacteriology in identifying mechanically ventilated patients at risk for ventilator associated pneumonia: a single-center prospective observational study. BMC Infect Dis 2019; 19:756. [PMID: 31464593 PMCID: PMC6716855 DOI: 10.1186/s12879-019-4367-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 08/07/2019] [Indexed: 01/08/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is a well-known, life-threatening disease that persists despite preventative measures and approved antibiotic therapies. This prospective observational study investigated bacterial airway colonization, and whether its detection and quantification in the endotracheal aspirate (ETA) is useful for identifying mechanically ventilated ICU patients who are at risk of developing VAP. Methods 240 patients admitted to 3 ICUs at the Lahey Hospital and Medical Center (Burlington, MA) between June 2014 and June 2015 and mechanically ventilated for > 2 days were included. ETA samples and clinical data were collected. Airway colonization was assessed, and subsequently categorized into “heavy” and “light” by semi-quantitative microbiological analysis of ETAs. VAP was diagnosed retrospectively by the study sponsor according to a pre-specified pneumonia definition. Results Pathogenic bacteria were isolated from ETAs of 125 patients. The most common species isolated was S. aureus (56.8%), followed by K. pneumoniae, P. aeruginosa, and E. coli (35.2% combined). VAP was diagnosed in 85 patients, 44 (51.7%) with no bacterial pathogen, 18 associated with S. aureus and 18 Gram-negative-only cases, and 5 associated with other Gram-positive or mixed species. A higher proportion of patients who were heavily colonized with S. aureus developed VAP (32.4%) associated with S. aureus compared to those lightly colonized (17.6%). The same tendency was seen for patients heavily and lightly colonized with Gram-negative pathogens (30.0 and 0.0%, respectively). Detection of S. aureus in the ETA preceded S. aureus VAP by approximately 4 days, while Gram-negative organisms were first detected 2.5 days prior to Gram-negative VAP. VAP was associated with significantly longer duration of mechanical ventilation and hospitalization regardless of microbiologic cause when compared to patients who did not develop VAP. Conclusions The overall VAP rate was 35%. Heavy tracheal colonization supported identification of patients at higher risk of developing a corresponding S. aureus or Gram-negative VAP. Detection of bacterial ETA-positivity tended to precede VAP. Electronic supplementary material The online version of this article (10.1186/s12879-019-4367-7) contains supplementary material, which is available to authorized users.
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Roquilly A, Torres A, Villadangos JA, Netea MG, Dickson R, Becher B, Asehnoune K. Pathophysiological role of respiratory dysbiosis in hospital-acquired pneumonia. THE LANCET RESPIRATORY MEDICINE 2019; 7:710-720. [PMID: 31182406 DOI: 10.1016/s2213-2600(19)30140-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/06/2019] [Accepted: 03/08/2019] [Indexed: 12/19/2022]
Abstract
Hospital-acquired pneumonia is a major cause of morbidity and mortality. The incidence of hospital-acquired pneumonia remains high globally and treatment can often be ineffective. Here, we review the available data and unanswered questions surrounding hospital-acquired pneumonia, discuss alterations of the respiratory microbiome and of the mucosal immunity in patients admitted to hospital, and explore potential approaches to stratify patients for tailored treatments. The lungs have been considered a sterile organ for decades because microbiological culture techniques had shown negative results. Culture-independent techniques have shown that healthy lungs harbour a diverse and dynamic ecosystem of bacteria, changing our comprehension of respiratory physiopathology. Understanding dysbiosis of the respiratory microbiome and altered mucosal immunity in patients with critical illness holds great promise to develop targeted host-directed immunotherapy to reduce ineffective treatment, to improve patient outcomes, and to tackle the global threat of resistant bacteria that cause these infections.
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Affiliation(s)
- A Roquilly
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes, France; Department of Microbiology and Immunology, Faculty of Medicine, University of Nantes, Nantes, France
| | - A Torres
- Servei de Pneumologia, Hospital Clinic, Universitat de Barcelona Institut d'investigació Biomédica August Pi i Sunyer, Centro de Investigación Biomédica en Red.Enfermedades Respiratorias, Barcelona, Spain
| | - J A Villadangos
- Department of Microbiology and Immunology, Doherty Institute of Infection and Immunity and Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Parkville, VIC, Australia
| | - M G Netea
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - R Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA
| | - B Becher
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - K Asehnoune
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes, France; Department of Microbiology and Immunology, Faculty of Medicine, University of Nantes, Nantes, France.
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Effects of antibiotic prophylaxis on ventilator-associated pneumonia in severe traumatic brain injury. A post hoc analysis of two trials. J Crit Care 2019; 50:221-226. [DOI: 10.1016/j.jcrc.2018.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/11/2018] [Accepted: 12/16/2018] [Indexed: 11/21/2022]
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Dray S, Coiffard B, Persico N, Papazian L, Hraiech S. Are tracheal surveillance cultures useful in the intensive care unit? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:421. [PMID: 30581829 DOI: 10.21037/atm.2018.08.39] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endotracheal aspirate (ETA) surveillance cultures have been used to predict the microorganisms responsible for ventilator associated pneumonia (VAP) in intensive care unit (ICU) patients for 3 decades. However, although more than a dozen studies have been performed, the usefulness and the safety of this strategy are still debated. Tracheobronchial bacterial colonization often precedes the occurrence of VAP, and it has been postulated that the microbes present in the tracheal secretions a few days before VAP might be the same as those retrieved in the lower respiratory tract. A large number of studies, with heterogeneous designs and variable results, have questioned the possibility of predicting, by regular ETA cultures after the 48th hour of mechanical ventilation (MV), the microbiology of VAP and therefore of determining the adequate antibiotic therapy to limit the over-prescription of broad spectrum molecules when following guidelines. Although it has shown some promising results, the strategy has not achieved unanimity because of some discordant data. The aim of this review is to provide an updated overview of the literature available in the field and to attempt to determine the strengths and weaknesses of antibiotic stewardship based on ETA surveillance cultures in VAP, particularly in the global context of drug resistant microorganism emergence and the crucial necessity of broad spectrum molecule preservation.
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Affiliation(s)
- Sandrine Dray
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Benjamin Coiffard
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Nicolas Persico
- Service d'Accueil des Urgences Adultes, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France.,Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - Laurent Papazian
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Sami Hraiech
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
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Dahyot-Fizelier C, Frasca D, Lasocki S, Asehnoune K, Balayn D, Guerin AL, Perrigault PF, Geeraerts T, Seguin P, Rozec B, Elaroussi D, Cottenceau V, Guyonnaud C, Mimoz O. Prevention of early ventilation-acquired pneumonia (VAP) in comatose brain-injured patients by a single dose of ceftriaxone: PROPHY-VAP study protocol, a multicentre, randomised, double-blind, placebo-controlled trial. BMJ Open 2018; 8:e021488. [PMID: 30341115 PMCID: PMC6196869 DOI: 10.1136/bmjopen-2018-021488] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is the first cause of healthcare-associated infections in intensive care units (ICUs) and brain injury is one of the main risk factors for early-onset VAP. Antibiotic prophylaxis has been reported to decrease their occurrence in brain-injured patients, but a lack of controlled randomised trials and the risk of induction of bacterial resistance explain the low level of recommendations. The goal of this study is to determine whether a single dose of ceftriaxone within the 12 hours postintubation after severe brain injury can decrease the risk of early-onset VAP. METHODS AND ANALYSIS The PROPHY-VAP is a French multicentre, randomised, double-blind, placebo-controlled, clinical trial. Adult brain-injured patients (n=320) with a Glasgow Coma Scale ≤12, requiring mechanical ventilation for more than 48 hours, are randomised to receive either a single dose of ceftriaxone 2 g or a placebo within the 12 hours after tracheal intubation. The primary endpoint is the proportion of patients developing VAP from the 2nd to the 7th day after mechanical ventilation. Secondary endpoints include the proportion of patients developing late VAP (>7 days after tracheal intubation), the number of ventilator-free days, VAP-free days and antibiotic-free days, length of stay in the ICU, proportion of patients with ventilator-associated events and mortality during their ICU stay. ETHICS AND DISSEMINATION The initial research project was approved by the Institutional Review Board of OUEST III (France) on 20 October 2014 (registration No 2014-001668-36) and carried out according to the principles of the Declaration of Helsinki and the Clinical Trials Directive 2001/20/EC of the European Parliament relating to the Good Clinical Practice guidelines. The results of this study will be presented in national and international meetings and published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02265406; Pre-results.
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Affiliation(s)
- Claire Dahyot-Fizelier
- Anesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
- INSERM UMR1070 – Pharmacology of Anti-infective Agents, University of Poitiers, Poitiers, France
| | - Denis Frasca
- Anesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
- INSERM UMR1246 – Methods in Patient-Centered Outcomes and Health Research, Nantes, France
| | - Sigismond Lasocki
- Anesthesia and Intensive Care, University Hospital of Angers, Angers, France
| | - Karim Asehnoune
- Anesthesia and Intensive Care Unit, University Hospital of Nantes, Nantes, France
| | - Dorothée Balayn
- Anesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
| | - Anne-Laure Guerin
- Anesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
| | | | - Thomas Geeraerts
- Anesthesia and Intensive Care Unit, University Hospital of Toulouse, Toulouse, France
| | - Philippe Seguin
- Anesthesia and Intensive Care Unit, University Hospital of Rennes, Rennes, France
| | - Bertrand Rozec
- Anesthesia and Intensive Care Unit, University Hospital of Nantes, Nantes, France
| | - Djilali Elaroussi
- Anesthesia and Intensive Care Unit, University Hospital of Tours, Tours, France
| | - Vincent Cottenceau
- Anesthesia and Intensive Care Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Clément Guyonnaud
- Anesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
| | - Olivier Mimoz
- INSERM UMR1070 – Pharmacology of Anti-infective Agents, University of Poitiers, Poitiers, France
- Emergency Department and Pre-Hospital Care, University Hospital of Poitiers, Poitiers, France
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Hahn A, Warnken S, Pérez-Losada M, Freishtat RJ, Crandall KA. Microbial diversity within the airway microbiome in chronic pediatric lung diseases. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2018; 63:316-325. [PMID: 29225146 PMCID: PMC5992000 DOI: 10.1016/j.meegid.2017.12.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/22/2017] [Accepted: 12/07/2017] [Indexed: 12/31/2022]
Abstract
The study of the airway microbiome in children is an area of emerging research, especially in relation to the role microbial diversity may play in acute and chronic inflammation. Three such pediatric airway diseases include cystic fibrosis, asthma, and chronic lung disease of prematurity. In cystic fibrosis, the presence of Pseudomonas spp. is associated with decreased microbial diversity. Decreasing microbial diversity is also associated with poor lung function. In asthma, early viral infections appear to drive changes in bacterial diversity which may be associated with asthma risk. Premature infants with Ureaplasma spp. are at higher risk for chronic lung disease due to inflammation. Microbiome changes due to prematurity also appear to affect the inflammatory response to viral infections post-natally. Importantly, microbial diversity can be measured using metataxonomic (e.g., 16S rRNA sequencing) and metagenomic (e.g., shotgun sequencing) approaches. A metagenomics approach may be preferable as it can provide further granularity of the sample composition, identifying the bacterial species or strain, information on additional microbial components, including fungal and viral components, information about functional genomics of the microbiome, and information about antimicrobial resistance mutations. Future studies of pediatric airway diseases incorporating these techniques may provide evidence for new treatment approaches for these vulnerable patient populations.
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Affiliation(s)
- Andrea Hahn
- Division of Infectious Diseases, Children's National Health System (CNHS), Washington, D.C. 20010, USA; Department of Pediatrics, George Washington University (GWU) School of Medicine and Health Sciences (SMHS), Washington, D.C. 20052, USA.
| | - Stephanie Warnken
- Computational Biology Institute, Milken Institute School of Public Health, GWU, Washington, D.C. 20052, USA
| | - Marcos Pérez-Losada
- Computational Biology Institute, Milken Institute School of Public Health, GWU, Washington, D.C. 20052, USA; CIBIO-InBIO, Universidade do Porto, Campus Agrário de Vairão, Vairão 4485-661, Portugal
| | - Robert J Freishtat
- Department of Pediatrics, George Washington University (GWU) School of Medicine and Health Sciences (SMHS), Washington, D.C. 20052, USA; Division of Emergency Medicine, CNHS, Washington, D.C. 20010, USA
| | - Keith A Crandall
- Computational Biology Institute, Milken Institute School of Public Health, GWU, Washington, D.C. 20052, USA
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Karakuzu Z, Iscimen R, Akalin H, Kelebek Girgin N, Kahveci F, Sinirtas M. Prognostic Risk Factors in Ventilator-Associated Pneumonia. Med Sci Monit 2018; 24:1321-1328. [PMID: 29503436 PMCID: PMC5848715 DOI: 10.12659/msm.905919] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a nosocomial infection commonly seen in patients in intensive care units (ICU). This study aimed to analyze factors affecting prognosis of patients diagnosed with VAP. MATERIAL AND METHODS Critically ill patients with VAP were retrospectively evaluated between June 2002 and June 2011 in the ICU. VAP diagnosis was made according to 2005 ATS/IDSA (Infectious Diseases Society of America/American Thoracic Society) criteria. First pneumonia attacks of patients were analyzed. RESULTS When early- and late-onset pneumonia causes were compared according to ICU and hospital admittance, resistant bacteria were found to be more common in pneumonias classified as early-onset according to ICU admittance. APACHE II score of >21 (p=0.016), SOFA score of >6 (p<0.001) on admission to ICU and SOFA score of >6 (p<0.001) on day of diagnosis are risk factors affecting mortality. Additionally, low PaO2/FIO2 ratio at onset of VAP had a negative effect on prognosis (p<0.001). SOFA score of >6 on the day of VAP diagnosis was an independent risk factor for mortality [(p<0.001; OR (95%CI): 1.4 (1.2-1.6)]. CONCLUSIONS Resistant bacteria might be present in early-onset VAP. Especially, taking LOS into consideration may better estimate the presence of resistant bacteria. Acinetobacter baumannii, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus (MRSA) were the most frequent causative microorganisms for VAP. SOFA score might be more valuable than APACHE II score. Frequently surveilling SOFA scores may improve predictive performance over time.
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Affiliation(s)
- Ziyaattin Karakuzu
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Remzi Iscimen
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Halis Akalin
- Department of Microbiology and Infectious Disease, Uludag University, School of Medicine, Bursa, Turkey
| | - Nermin Kelebek Girgin
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Ferda Kahveci
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Melda Sinirtas
- Department of Microbiology and Infectious Disease, Uludag University, School of Medicine, Bursa, Turkey
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12
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Parker CM, Heyland DK. Aspiration and the Risk of Ventilator-Associated Pneumonia. Nutr Clin Pract 2017; 19:597-609. [PMID: 16215159 DOI: 10.1177/0115426504019006597] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is a major concern in the intensive care unit. It is estimated that the risk of developing VAP may be as high as 1% per ventilated day, and the attributable mortality approaches 50% in some series. A growing body of evidence implicates the role of microaspiration of contaminated oropharyngeal and perhaps gastroesophageal secretions into the airways as an integral step in the pathogenesis of VAP. In patients who have been intubated and mechanically ventilated for >72 hours, the majority of VAP is caused by enteric gram-negative organisms, presumably of gastrointestinal origin. As a result, strategies designed to minimize the risk of these contaminated secretions into the normally sterile airways are of paramount importance in terms of VAP prevention. This review highlights the important etiological role of the gut in the development of VAP and also discusses the evidence behind interventions that may modulate the risk of both aspiration and subsequent VAP.
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Affiliation(s)
- Chris M Parker
- Division of Respiratory and Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
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Kelly BJ, Imai I, Bittinger K, Laughlin A, Fuchs BD, Bushman FD, Collman RG. Composition and dynamics of the respiratory tract microbiome in intubated patients. MICROBIOME 2016; 4:7. [PMID: 26865050 PMCID: PMC4750361 DOI: 10.1186/s40168-016-0151-8] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 01/26/2016] [Indexed: 05/11/2023]
Abstract
BACKGROUND Lower respiratory tract infection (LRTI) is a major contributor to respiratory failure requiring intubation and mechanical ventilation. LRTI also occurs during mechanical ventilation, increasing the morbidity and mortality of intubated patients. We sought to understand the dynamics of respiratory tract microbiota following intubation and the relationship between microbial community structure and infection. RESULTS We enrolled a cohort of 15 subjects with respiratory failure requiring intubation and mechanical ventilation from the medical intensive care unit at an academic medical center. Oropharyngeal (OP) and deep endotracheal (ET) secretions were sampled within 24 h of intubation and every 48-72 h thereafter. Bacterial community profiling was carried out by purifying DNA, PCR amplification of 16S ribosomal RNA (rRNA) gene sequences, deep sequencing, and bioinformatic community analysis. We compared enrolled subjects to a cohort of healthy subjects who had lower respiratory tract sampling by bronchoscopy. In contrast to the diverse upper respiratory tract and lower respiratory tract microbiota found in healthy controls, critically ill subjects had lower initial diversity at both sites. Diversity further diminished over time on the ventilator. In several subjects, the bacterial community was dominated by a single taxon over multiple time points. The clinical diagnosis of LRTI ascertained by chart review correlated with low community diversity and dominance of a single taxon. Dominant taxa matched clinical bacterial cultures where cultures were obtained and positive. In several cases, dominant taxa included bacteria not detected by culture, including Ureaplasma parvum and Enterococcus faecalis. CONCLUSIONS Longitudinal analysis of respiratory tract microbiota in critically ill patients provides insight into the pathogenesis and diagnosis of LRTI. 16S rRNA gene sequencing of endotracheal aspirate samples holds promise for expanded pathogen identification.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Bronchoscopy
- Case-Control Studies
- Critical Illness
- DNA, Bacterial/genetics
- Female
- Genetic Variation
- Humans
- Intensive Care Units
- Intubation, Intratracheal
- Longitudinal Studies
- Male
- Microbiota/genetics
- Middle Aged
- Oropharynx/microbiology
- Pneumonia, Ventilator-Associated/diagnosis
- Pneumonia, Ventilator-Associated/microbiology
- Pneumonia, Ventilator-Associated/pathology
- RNA, Ribosomal, 16S/genetics
- Respiration, Artificial
- Respiratory Tract Infections/diagnosis
- Respiratory Tract Infections/microbiology
- Respiratory Tract Infections/pathology
- Sequence Analysis, RNA
- Trachea/microbiology
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Affiliation(s)
- Brendan J Kelly
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Ize Imai
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Kyle Bittinger
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Alice Laughlin
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Barry D Fuchs
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Frederic D Bushman
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Ronald G Collman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Wanke-Jellinek L, Keegan JW, Dolan JW, Guo F, Chen J, Lederer JA. Beneficial Effects of CpG-Oligodeoxynucleotide Treatment on Trauma and Secondary Lung Infection. THE JOURNAL OF IMMUNOLOGY 2015; 196:767-77. [PMID: 26673136 DOI: 10.4049/jimmunol.1500597] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 11/09/2015] [Indexed: 12/26/2022]
Abstract
Although Streptococcus pneumoniae is usually found as a commensal in healthy individuals, it can act as a pathogen in trauma patients, causing such complications as early-onset pneumonia and sepsis. We discovered that treating mice with an A-class CpG-oligodeoxynucleotide (ODN) at 2 h after traumatic injury significantly improved mouse survival following early-onset secondary lung infection with S. pneumoniae. This study used mass cytometry (cytometry by time-of-flight) and Luminex technologies to characterize the cellular immune response to secondary S. pneumoniae lung infection at 1 and 3 d postinfection. We found increased expression of CD14, CD64, and PD-L1 on F4-80(+) and F4-80(+)CD11c(+) macrophages, CD11c(+) dendritic cells, and CD14(+)CD172a(+) cells after burn-injury and infection, supporting previous reports of innate immune cell activation in sepsis. CpG-ODN treatment at 2 h after burn-injury reversed these effects; improved pathogen clearance; and led to an increased expression of CD25, CD27, MHCII, and IL-17 on or in TCRγδ cells at 1 d postinfection. At 3 d postinfection, CpG-ODN treatment increased the expression of PD-L1 on innate cell subsets. Furthermore, we analyzed cytokine levels in lung-washout samples of TCRγδ cell-depleted (TCRγδ(-)) mice to demonstrate that the effects of CpG-ODN on cytokine expression after burn-injury and S. pneumoniae infection rely on functional TCRγδ cells. In summary, we demonstrate that cytometry by time-of-flight provides an effective strategy to systematically identify specific cellular phenotypic responses to trauma and bacterial pneumonia and to discover changes in immune system phenotypes associated with beneficial immunotherapy.
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Affiliation(s)
- Lorenz Wanke-Jellinek
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115; Department of Trauma Surgery, Technical University of Munich, 81675 Munich, Germany
| | - Joshua W Keegan
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115
| | - James W Dolan
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115
| | - Fei Guo
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115; Burns Institute, The First Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China; and
| | - Jianfei Chen
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115; Department of Cardiology, Xinquiao Hospital, The Third Military Medical University, Chongqing 400037, People's Republic of China
| | - James A Lederer
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115;
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15
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Systemic antibiotics and respiratory tract colonization in critically ill patients: an unfinished story. Crit Care Med 2015; 43:911-2. [PMID: 25768354 DOI: 10.1097/ccm.0000000000000847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Ho VP, Madbak F, Horng H, Sifri ZC, Mohr AM. Analysis of Hypoxemia in Early Ventilator-Associated Pneumonia Secondary to Haemophilus in Trauma Patients. Surg Infect (Larchmt) 2015; 16:293-7. [PMID: 25894664 DOI: 10.1089/sur.2013.156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Haemophilus species bacteria (HSB) are known pathogens responsible for early pneumonia in intubated trauma patients. The primary goal of this study was to examine the incidence and extent of hypoxemia in intubated trauma patients who develop early ventilator-associated pneumonia (VAP) secondary to HSB. On the basis of our clinical experiences, we hypothesized that patients with Haemophilus species bacteria pneumonia (HSBP) would have a high rate of hypoxemia but that the effect would be transient. METHODS Retrospective review of intubated trauma patients from an urban level I trauma center with HSBP diagnosed by deep tracheal aspirate or bronchoalveolar lavage from April 2007 to November 2012. Collected variables included day of HSBP diagnosis; PaO2 to FIO2 ratio (P:F) at HSBP diagnosis as well as HSBP day three and HSBP day seven; injury severity score (ISS) and its component parts; admission Glasgow Coma Scale (GCS) score; and mortality. Hypoxemia was defined as P:F <200. χ(2) Tests were utilized to assess factors that differed between hypoxemic and non-hypoxemic patients; data are presented as median (interquartile range, IQR). RESULTS Sixty-nine patients were identified (80% male; age, 35 y [range, 24-49]; ISS 27 [9-59]). Diagnosis of HSBP occurred early (hospital day 4 [range, 3-5]). Forty-three percent of patients had acute respiratory distress syndrome (ARDS) on HSBP day 1; this decreased to 26% on day three and to 30% on day seven. Forty patients (77%) had a tracheostomy performed. Patients with hypoxemia were significantly less likely to have a severe head injury (GCS<9), p<0.05. Patients with hypoxemia had similar hospital length of stay and mortality to patients who did not develop hypoxemia. CONCLUSION Haemophilus species bacteria pneumonia in trauma patients is associated with high rates of transient hypoxemia and a high tracheostomy rate, although subsequent outcomes are not affected. Patients with head injuries had a lower incidence of hypoxemia from pneumonia.
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Affiliation(s)
- Vanessa P Ho
- 1Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York
| | - Firas Madbak
- 2Department of Surgery, University of Pennsylvania Reading Health System, Reading, Pennsylvania
| | - Helen Horng
- 3Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Ziad C Sifri
- 3Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Alicia M Mohr
- 4Department of Surgery, University of Florida, Gainesville, Florida
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Launey Y, Nesseler N, Le Cousin A, Feuillet F, Garlantezec R, Mallédant Y, Seguin P. Effect of a fever control protocol-based strategy on ventilator-associated pneumonia in severely brain-injured patients. Crit Care 2014; 18:689. [PMID: 25498970 PMCID: PMC4279880 DOI: 10.1186/s13054-014-0689-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 11/25/2014] [Indexed: 12/02/2022] Open
Abstract
Introduction Fever is associated with a poor outcome in severely brain-injured patients, and its control is one of the therapies used in this condition. But, fever suppression may promote infection, and severely brain-injured patients are frequently exposed to infectious diseases, particularly ventilator-associated pneumonia (VAP). Therefore, we designed a study to explore the role of a fever control protocol in VAP development during neuro-intensive care. Methods An observational study was performed on severely brain-injured patients hospitalized in a university ICU. The primary goal was to assess whether fever control was a risk factor for VAP in a prospective cohort in which a fever control protocol was applied and in a historical control group. Moreover, the density of VAP incidence was compared between the two groups. The statistical analysis was based on a competing risk model multivariate analysis. Results The study included 189 brain-injured patients (intervention group, n = 98, and historical control group, n = 91). The use of a fever control protocol was an independent risk factor for VAP (hazard ratio 2.73, 95% confidence interval (1.38, 5.38; P = 0.005)). There was a significant increase in the incidence of VAP in patients treated with a fever control protocol (26.1 versus 12.5 VAP cases per 1000 days of mechanical ventilation). In cases in which a fever control protocol was applied for >3 days, we observed a higher rate of VAP in comparison with the rate among patients treated for ≤3 days. Conclusions Fever control in brain-injured patients was a major risk factor for VAP occurrence, particularly when applied for >3 days.
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Affiliation(s)
- Yoann Launey
- CHU de Rennes. Hôpital Pontchaillou. Pôle Anesthésie-SAMU-Urgences-Réanimations. 2, rue Henri Le Guilloux, 35033, Rennes, Cedex, France. .,Inserm UMR991, équipe 2: "Stress, Defense and Regeneration". 2, rue Henri Le Guilloux, 35000, Rennes, France. .,Université Rennes 1, 35033, Rennes, Cedex, France.
| | - Nicolas Nesseler
- CHU de Rennes. Hôpital Pontchaillou. Pôle Anesthésie-SAMU-Urgences-Réanimations. 2, rue Henri Le Guilloux, 35033, Rennes, Cedex, France. .,Inserm UMR991, équipe 2: "Stress, Defense and Regeneration". 2, rue Henri Le Guilloux, 35000, Rennes, France. .,Université Rennes 1, 35033, Rennes, Cedex, France.
| | - Audren Le Cousin
- CHU de Rennes. Hôpital Pontchaillou. Pôle Anesthésie-SAMU-Urgences-Réanimations. 2, rue Henri Le Guilloux, 35033, Rennes, Cedex, France. .,Université Rennes 1, 35033, Rennes, Cedex, France.
| | - Fanny Feuillet
- Plateforme de Biométrie - Cellule de promotion à la recherche clinique, CHU Nantes, EA 4275 SPHERE "Biostatistics, Pharmacoepidemiology & Human Sciences Research", UFR de Pharmacie, Université de Nantes. 1, rue Gaston Veil, 44000, Nantes, France.
| | - Ronan Garlantezec
- Ecole Nationale Hautes Etudes de Santé Publique. 2, Avenue du Professeur Léon Bernard, 35033, Rennes, Cedex, France.
| | - Yannick Mallédant
- CHU de Rennes. Hôpital Pontchaillou. Pôle Anesthésie-SAMU-Urgences-Réanimations. 2, rue Henri Le Guilloux, 35033, Rennes, Cedex, France. .,Inserm UMR991, équipe 2: "Stress, Defense and Regeneration". 2, rue Henri Le Guilloux, 35000, Rennes, France. .,Université Rennes 1, 35033, Rennes, Cedex, France.
| | - Philippe Seguin
- CHU de Rennes. Hôpital Pontchaillou. Pôle Anesthésie-SAMU-Urgences-Réanimations. 2, rue Henri Le Guilloux, 35033, Rennes, Cedex, France. .,Inserm UMR991, équipe 2: "Stress, Defense and Regeneration". 2, rue Henri Le Guilloux, 35000, Rennes, France. .,Université Rennes 1, 35033, Rennes, Cedex, France.
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18
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Pascual JL, Blank NW, Holena DN, Robertson MP, Diop M, Allen SR, Martin ND, Kohl BA, Sims CA, Schwab CW, Reilly PM. There's no place like home: boarding surgical ICU patients in other ICUs and the effect of distances from the home unit. J Trauma Acute Care Surg 2014; 76:1096-102. [PMID: 24662877 PMCID: PMC4156017 DOI: 10.1097/ta.0000000000000180] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Intensive care units (ICUs) function frequently at capacity, requiring incoming critically ill patients to be placed in alternate geographically distinct ICUs. In some medical ICU populations, "boarding" in an overflow ICU has been associated with increased mortality. We hypothesized that surgical ICU patients experience more complications when boarding in an overflow ICU and that the frequency of these complications are greatest in boarders farthest from the home unit (HU). METHODS A 5-year (June 2005 to June 2010) retrospective review of a prospectively maintained ICU database was performed, and demographics, severity of illness, length of stay, and incidence of ICU complications were extracted. Distances between boarding patients' rooms and the HU were measured. Complications occurring in patients located in the same floor (BUSF) and different floor (BUDF) boarding units were compared and stratified by distance from HU to the patient room. Logistic regression was used to develop control for known confounders. RESULTS A total of 7,793 patients were admitted to the HU and 833 to a boarding unit (BUSF, n = 712; BUDF, n = 121). Boarders were younger, had a lower length of stay, and Acute Physiology and Chronic Health Evaluation II and were more often trauma/emergency surgery patients. Compared with in-HU patients, the incidence of aspiration pneumonia (2.2% vs. 3.6%, p < 0.01) was greater in BUSF patients and highest in those farthest from the HU (odds ratio [OR], 2.39; p = 0.01). Delirium occurred less often in HU than in BUDF patients (3.3% vs. 8.3 %, p < 0.01), and both delirium (OR, 6.09, p < 0.01) and ventilator-associated pneumonia (OR, 4.49, p < 0.05) were more frequent in patients farther from the HU. CONCLUSION Certain ICU complications occur more frequently in boarding patients particularly if they are located on a different floor or far from the HU. When surgical ICU bed availability forces overflow admissions to non-home ICUs, greater interdisciplinary awareness, education, and training may be needed to ensure equivalent care and outcomes. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.
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Affiliation(s)
- Jose L Pascual
- From the Division of Traumatology, Surgical Critical Care & Emergency Surgery (J.L.P., N.W.B., D.N.H., M.D., S.R.A., N.D.M., C.S., C.W.S., P.M.R.), and Department of Anesthesia and Critical Care (B.A.K.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; and University of Virginia Medical Center (M.R.), Charlottesville, Virginia
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Value of lower respiratory tract surveillance cultures to predict bacterial pathogens in ventilator-associated pneumonia: systematic review and diagnostic test accuracy meta-analysis. Intensive Care Med 2012. [PMID: 23188467 DOI: 10.1007/s00134-012-2759-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE In ventilator-associated pneumonia (VAP), early appropriate antimicrobial therapy may be hampered by involvement of multidrug-resistant (MDR) pathogens. METHODS A systematic review and diagnostic test accuracy meta-analysis were performed to analyse whether lower respiratory tract surveillance cultures accurately predict the causative pathogens of subsequent VAP in adult patients. Selection and assessment of eligibility were performed by three investigators by mutual consideration. Of the 525 studies retrieved, 14 were eligible for inclusion (all in English; published since 1994), accounting for 791 VAP episodes. The following data were collected: study and population characteristics; in- and exclusion criteria; diagnostic criteria for VAP; microbiological workup of surveillance and diagnostic VAP cultures. Sub-analyses were conducted for VAP caused by Staphylococcus aureus, Pseudomonas spp., and Acinetobacter spp., MDR microorganisms, frequency of sampling, and consideration of all versus the most recent surveillance cultures. RESULTS The meta-analysis showed a high accuracy of surveillance cultures, with pooled sensitivities up to 0.75 and specificities up to 0.92 in culture-positive VAP. The area under the curve (AUC) of the hierarchical summary receiver-operating characteristic curve demonstrates moderate accuracy (AUC: 0.90) in predicting multidrug resistance. A sampling frequency of >2/week (sensitivity 0.79; specificity 0.96) and consideration of only the most recent surveillance culture (sensitivity 0.78; specificity 0.96) are associated with a higher accuracy of prediction. CONCLUSIONS This study provides evidence for the benefit of surveillance cultures in predicting MDR bacterial pathogens in VAP. However, clinical and statistical heterogeneity, limited samples sizes, and bias remain important limitations of this meta-analysis.
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20
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Staphylococcus aureus throat carriage is associated with ABO-/secretor status. J Infect 2012; 65:310-7. [PMID: 22664149 DOI: 10.1016/j.jinf.2012.05.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 05/06/2012] [Accepted: 05/28/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVES In 30% of carriers, Staphylococcus aureus colonization affects exclusively the pharynx and occurs independently from its presence in the nares. This additional reservoir has implications for S. aureus transmission, infection, and decolonization. Host factors promoting colonization of the throat, however, are unknown. METHODS We determined pharyngeal and persistent nasal carriage of S. aureus, ABO histo-blood group and ABH secretor status phenotypes in 227 individuals. RESULTS Compared to group A/non-secretors, group O/non-secretor individuals were at increased risk of carrying S. aureus in their throat (OR 6.50, 95% confidence interval 1.28-33.03, P = 0.02) and group O/secretor individuals were protected (OR 0.24, 0.07-0.77, P = 0.02). Both associations became moderately stronger after adjusting for persistent S. aureus nasal carriage, which was found to be a risk factor for pharyngeal colonization in the univariable analysis (OR 2.41, 1.35-4.33, p = 0.003). Most simultaneous carriers (72%) had identical S. aureus genotypes in their nose and throat. CONCLUSIONS These findings are consistent with in vitro studies that proposed a role of histo-blood group antigens as ligands for S. aureus and support their contribution to the observed population variation in nasopharyngeal S. aureus colonization. Based on their tissue specific expression histo-blood group antigens appear to modulate individual S. aureus colonization patterns.
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Gil-Perotin S, Ramirez P, Marti V, Sahuquillo JM, Gonzalez E, Calleja I, Menendez R, Bonastre J. Implications of endotracheal tube biofilm in ventilator-associated pneumonia response: a state of concept. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R93. [PMID: 22621676 PMCID: PMC3580639 DOI: 10.1186/cc11357] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 05/23/2012] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Biofilm in endotracheal tubes (ETT) of ventilated patients has been suggested to play a role in the development of ventilator-associated pneumonia (VAP). Our purpose was to analyze the formation of ETT biofilm and its implication in the response and relapse of VAP. METHODS We performed a prospective, observational study in a medical intensive care unit. Patients mechanically ventilated for more than 24 hours were consecutively included. We obtained surveillance endotracheal aspirates (ETA) twice weekly and, at extubation, ETTs were processed for microbiological assessment and scanning electron microscopy. RESULTS Eighty-seven percent of the patients were colonized based on ETA cultures. Biofilm was found in 95% of the ETTs. In 56% of the cases, the same microorganism grew in ETA and biofilm. In both samples the most frequent bacteria isolated were Acinetobacter baumannii and Pseudomonas aeruginosa. Nineteen percent of the patients developed VAP (N = 14), and etiology was predicted by ETA in 100% of the cases. Despite appropriate antibiotic treatment, bacteria involved in VAP were found in biofilm (50%). In this situation, microbial persistence and impaired response to treatment (treatment failure and relapse) were more frequent (100% vs 29%, P = 0.021; 57% vs 14%, P = 0.133). CONCLUSIONS Airway bacterial colonization and biofilm formation on ETTs are early and frequent events in ventilated patients. There is microbiological continuity between airway colonization, biofilm formation and VAP development. Biofilm stands as a pathogenic mechanism for microbial persistence, and impaired response to treatment in VAP.
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Kim JH, Yoon SC, Lee YM, Son JW, Choi EG, Na MJ, Kwon SJ. Role of Microbiologic Culture Results of Specimens Prior to Onset of Ventilator-Associated Pneumonia in the Patients Admitted to Intensive Care Unit. Tuberc Respir Dis (Seoul) 2012. [DOI: 10.4046/trd.2012.72.1.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ji Hye Kim
- Department of Internal Medicine, Konyang University College of Medicine, Daejon, Korea
| | - Sung-Chul Yoon
- Department of Internal Medicine, Konyang University College of Medicine, Daejon, Korea
| | - Yu-Mi Lee
- Department of Internal Medicine, Konyang University College of Medicine, Daejon, Korea
| | - Ji-Woong Son
- Department of Internal Medicine, Konyang University College of Medicine, Daejon, Korea
| | - Eu-Gene Choi
- Department of Internal Medicine, Konyang University College of Medicine, Daejon, Korea
| | - Moon-Jun Na
- Department of Internal Medicine, Konyang University College of Medicine, Daejon, Korea
| | - Sun-Jung Kwon
- Department of Internal Medicine, Konyang University College of Medicine, Daejon, Korea
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Pneumonia in the surgical intensive care unit: Is every one preventable? Surgery 2011; 150:665-72. [DOI: 10.1016/j.surg.2011.08.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 08/25/2011] [Indexed: 11/21/2022]
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Vanhems P, Bénet T, Voirin N, Januel JM, Lepape A, Allaouchiche B, Argaud L, Chassard D, Guérin C, Lehot JJ, Robert MO, Fournier G, Jacques D, Artru F, Gueugniaud PY, Chassard D, Girard R, Cêtre JC, Nicolle MC, Metzger MH, Grando J. Early-onset ventilator-associated pneumonia incidence in intensive care units: a surveillance-based study. BMC Infect Dis 2011; 11:236. [PMID: 21896188 PMCID: PMC3190374 DOI: 10.1186/1471-2334-11-236] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 09/06/2011] [Indexed: 01/15/2023] Open
Abstract
Background The incidence of ventilator-associated pneumonia (VAP) within the first 48 hours of intensive care unit (ICU) stay has been poorly investigated. The objective was to estimate early-onset VAP occurrence in ICUs within 48 hours after admission. Methods We analyzed data from prospective surveillance between 01/01/2001 and 31/12/2009 in 11 ICUs of Lyon hospitals (France). The inclusion criteria were: first ICU admission, not hospitalized before admission, invasive mechanical ventilation during first ICU day, free of antibiotics at admission, and ICU stay ≥ 48 hours. VAP was defined according to a national protocol. Its incidence was the number of events per 1,000 invasive mechanical ventilation-days. The Poisson regression model was fitted from day 2 (D2) to D8 to incident VAP to estimate the expected VAP incidence from D0 to D1 of ICU stay. Results Totally, 367 (10.8%) of 3,387 patients in 45,760 patient-days developed VAP within the first 9 days. The predicted cumulative VAP incidence at D0 and D1 was 5.3 (2.6-9.8) and 8.3 (6.1-11.1), respectively. The predicted cumulative VAP incidence was 23.0 (20.8-25.3) at D8. The proportion of missed VAP within 48 hours from admission was 11% (9%-17%). Conclusions Our study indicates underestimation of early-onset VAP incidence in ICUs, if only VAP occurring ≥ 48 hours are considered to be hospital-acquired. Clinicians should be encouraged to develop a strategy for early detection after ICU admission.
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Affiliation(s)
- Philippe Vanhems
- Hospices Civils de Lyon, Infection Control Unit, Edouard Herriot Hospital, Lyon, France.
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Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2011; 19:19-53. [PMID: 19145262 DOI: 10.1155/2008/593289] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 12/19/2007] [Indexed: 02/07/2023]
Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are important causes of morbidity and mortality, with mortality rates approaching 62%. HAP and VAP are the second most common cause of nosocomial infection overall, but are the most common cause documented in the intensive care unit setting. In addition, HAP and VAP produce the highest mortality associated with nosocomial infection. As a result, evidence-based guidelines were prepared detailing the epidemiology, microbial etiology, risk factors and clinical manifestations of HAP and VAP. Furthermore, an approach based on the available data, expert opinion and current practice for the provision of care within the Canadian health care system was used to determine risk stratification schemas to enable appropriate diagnosis, antimicrobial management and nonantimicrobial management of HAP and VAP. Finally, prevention and risk-reduction strategies to reduce the risk of acquiring these infections were collated. Future initiatives to enhance more rapid diagnosis and to effect better treatment for resistant pathogens are necessary to reduce morbidity and improve survival.
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Seil JT, Rubien NM, Webster TJ, Tarquinio KM. Comparison of quantification methods illustrates reduced Pseudomonas aeruginosa activity on nanorough polyvinyl chloride. J Biomed Mater Res B Appl Biomater 2011; 98:1-7. [PMID: 21634005 DOI: 10.1002/jbm.b.31821] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 01/10/2011] [Indexed: 11/11/2022]
Abstract
Patients on mechanical ventilators for extended periods of time are faced with a high probability of developing ventilator associated pneumonia. Although this has been mostly addressed through the re-engineering of endotracheal tubes (ETTs) with antimicrobial materials, such material coatings may easily delaminate during use. However, the potential exists to apply nanotechnology to the ETT to avoid delamination but implement antibacterial properties. Selecting a protocol to evaluate in vitro material for anti-infection is difficult, partially due to the existence of conflicting reported methods of analysis. In this study, the susceptibility of conventional and nanorough polymeric materials to bacterial biofilm growth were evaluated. After creating nanorough polyvinyl chloride (PVC) ETTs, Pseudomonas aeruginosa biofilms were then grown on sample surfaces during a 24-h culture. Biofilms were then removed and assayed from sample surfaces using a variety of techniques. Comparisons between the different techniques used for biofilm removal indicated that vortexing provided adequate removal of the biofilm from sample surfaces. Most importantly, a protocol following the vortexing method of biofilm and bacteria removal provided an ∼40% lower yield of colony forming units from nanorough PVC compared to conventional PVC. This suggests that Pseudomonas aeruginosa are less adherent on nanorough PVC than conventional PVC.
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Affiliation(s)
- Justin T Seil
- Laboratory for Nanomedicine Research, Division of Engineering, Brown University, Providence, Rhode Island, USA
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Abstract
The prevention of ventilator-associated pneumonia (VAP) has been a challenge within many healthcare organizations. The initial efforts for VAP prevention focused on compliance with "ventilator bundles." VAP rates initially improved with implementation of the bundles but then reached a plateau. The trauma surgical intensive care unit (ICU) was interested in investigating measures to further improve the prevention of VAP after bundle implementation. A multidisciplinary team was formed to investigate innovative strategies to prevent VAP. The group identified their initial focus as head of bed (HOB) elevation intervention within and outside of the ICU through HOB audits and a transport checklist. Through these efforts, the VAP rate within the trauma surgical ICU dropped to the lowest level in 4 years.
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Neumonía asociada a la ventilación mecánica. Med Intensiva 2010; 34:318-24. [DOI: 10.1016/j.medin.2010.03.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 03/12/2010] [Indexed: 01/15/2023]
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Retrospective analysis of the risk factors and pathogens associated with early-onset ventilator-associated pneumonia in surgical-ICU head-trauma patients. J Neurosurg Anesthesiol 2010; 22:32-7. [PMID: 20027012 DOI: 10.1097/ana.0b013e3181bdf52f] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Early-onset ventilator associated pneumonia (EOVAP) are frequent in head-trauma patients, but specific risk factors are poorly studied in this population. METHODS We conducted a retrospective cohort study in a surgical intensive care unit. Consecutive severe head-trauma patients admitted from January 2000 to December 2002 were studied. Microorganisms, and risks factors for EOVAP were analyzed. RESULTS During the 3-year period, 161 patients were studied; 21.1% of them developed an EOVAP. On univariate analysis 6 variables were associated with EOVAP: early enteral feeding, barbiturate use, immunosuppression, mean Simplified Acute Physiology Score 2, acute respiratory distress syndrome, and initial neurosurgery procedures. On multivariate analysis, enteral feeding >2000 Kcal before day 5 [odds ratio (OR): 0.33, 95% confidence interval (CI): 0.21-0.85] and initial neurosurgical procedure (OR: 0.36, 95% CI: 0.15-0.89) remained protective factors for EOVAP, whereas immunosuppression (OR: 7.15, 95% CI: 1.66-30.73) and barbiturate use (OR: 2.68, 95% CI: 1.06-6.80) remained risk factors for EOVAP. EOVAP was also significantly associated with a longer duration of mechanical ventilation (14.0 vs. 11.0 d, P=0.024), and a longer sedation duration (8.3 vs. 5.8 d P=0.005). Methicillin-susceptible Staphylococcus aureus was the most common pathogen involved in EOVAP (46%). CONCLUSIONS We demonstrate for the first time that early enteral feeding is a protective factor for EOVAP, and this result could have clinical implications for the prevention of EOVAP after traumatic brain injury. This study also confirms that barbiturate use is an important risk factor of EOVAP whereas Methicillin-susceptible S. aureus was found to be the main pathogen involved in EOVAP.
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Sánchez García M. [Debates in intensive medicine: Pro: selective decontamination]. Med Intensiva 2010; 34:325-33. [PMID: 20219269 DOI: 10.1016/j.medin.2010.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 12/20/2009] [Accepted: 01/04/2010] [Indexed: 11/25/2022]
Abstract
Selective decontamination of the digestive tract (SDD) has been proven to prevent infections of endogenous development and reduce mortality in critically ill patients under prolonged mechanical ventilation. Historical arguments against its use, like the development of bacterial resistance or the selection of resistant microorganisms and the absence of influence on mortality have not been confirmed. Moreover, recent clinical trials designed to evaluate these variables, show remarkable reductions in the incidence of resistant bacteria and a significant beneficial effect on mortality. Furthermore, no increases in workload or costs have been documented. A few studies with post-trial and intermediate range follow-up periods didn't find increases in resistance. Implementation of SDD requires motivation and leadership in order to achieve cooperation of other related hospital specialists, training of several categories of healthcare professionals, and continuous monitoring of results. In order to facilitate the use of SDD in the critically ill, this preventive measure should be incorporated in guidelines of national and international scientific societies and working groups involved in the care of the critically ill patient. The general implementation of SDD in our intensive care units must be accompanied by a registry in order to be able to monitor the effect on the incidence of infection and bacterial resistance. For this purpose, the Spanish national ICU infection and resistance surveillance programme ENVIN-HELICS, active over the last 15 years, constitutes both a more than adequate tool, and the convenient reference data base.
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Affiliation(s)
- M Sánchez García
- Servicio de Medicina Intensiva, Hospital Clínico San Carlos, Madrid, Spain.
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31
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Non-Neurological Complications of Brain Injury. Neurocrit Care 2010. [DOI: 10.1007/978-1-84882-070-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Durairaj L, Mohamad Z, Launspach JL, Ashare A, Choi JY, Rajagopal S, Doern GV, Zabner J. Patterns and density of early tracheal colonization in intensive care unit patients. J Crit Care 2009; 24:114-21. [PMID: 19272547 DOI: 10.1016/j.jcrc.2008.10.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Revised: 07/14/2008] [Accepted: 10/21/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The study aimed to describe the patterns and density of early tracheal colonization among intubated patients and to correlate colonization status with levels of antimicrobial peptides and inflammatory cytokines. DESIGN The was a prospective cohort study. SETTING The study was conducted in medical and cardiovascular intensive care units of a tertiary referral hospital. PATIENTS Seventy-four adult patients admitted between March 2003 and May 2006 were recruited for the study. INTERVENTIONS Tracheal aspirates were collected daily for the first 4 days of intubation using standardized, sterile technique and sent for quantitative culture and cytokines, lactoferrin and lysozyme measurements. MEASUREMENTS AND MAIN RESULTS The mean acute physiology and chronic health evaluation (APACHE II) score in this cohort was 24 +/- 7. Proportion of subjects colonized by any microorganism increased over the first 4 days of intubation (47%, 60%, 70%, 70%, P = .08), but density of colonization for bacteria or yeast did not change significantly. No known risk factors predicted tracheal colonization on day 1 of intubation. Several patterns of colonization were observed (persistent, transient, new colonization, and clearance of initial colonization).The most common organisms cultured were Candida albicans and coagulase-negative Staphylococcus. Levels of cytokines, lactoferrin, or lysozyme did not change over time and were not correlated with tracheal colonization status. Four subjects (6%) had ventilator-associated pneumonia. CONCLUSIONS The density of tracheal colonization did not change significantly over the first 4 days of intubation in medical intensive care unit patients. There was no correlation between tracheal colonization and the levels of antimicrobial peptides or cytokines. Several different patterns of colonization may have to be considered while planning interventions to reduce airway colonization.
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Affiliation(s)
- Lakshmi Durairaj
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.
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Díaz E, Planas K, Rello J. [Infection associated with the use of assisted-ventilation devices]. Enferm Infecc Microbiol Clin 2009; 26:465-70. [PMID: 18842241 DOI: 10.1157/13125643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The second most important infectious complication in hospitalised patients is pneumonia, and it hits first place in the Intensive Care Unit (ICU). Almost 80% of the episodes of health-care pneumonia happens when patient is under mechanical ventilation, causing ventilator-associated pneumonia (VAP). VAP is associated with the highest rates of mortality in ICU infections, mainly if due to Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). It also increases days under mechanical ventilation and the length of stay in ICU and hospital. Although all the diagnostic procedures, the diagnosis of VAP is based basically in the clinics: X-ray infiltrates and purulent endotracheal secretions are the cornerstone of the diagnosis. We should evaluate and screen any risk factor for multiresistant pathogens. If we have an early VAP and no risk factors, the majority of empiric antibiotic strategies are useful, but if we have a patient with more than one week under mechanical ventilation, previous antibiotic use, and risk factors for multiresistant pathogens, we should then individualize empiric antibiotic treatment.
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Affiliation(s)
- Emili Díaz
- Servicio Medicina Intensiva, Hospital Universitari Joan XXIII, Tarragona, Spain.
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Physiotherapy does not prevent, or hasten recovery from, ventilator-associated pneumonia in patients with acquired brain injury. Intensive Care Med 2008; 35:258-65. [DOI: 10.1007/s00134-008-1278-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2007] [Accepted: 08/11/2008] [Indexed: 01/15/2023]
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Parker CM, Kutsogiannis J, Muscedere J, Cook D, Dodek P, Day AG, Heyland DK. Ventilator-associated pneumonia caused by multidrug-resistant organisms or Pseudomonas aeruginosa: prevalence, incidence, risk factors, and outcomes. J Crit Care 2008; 23:18-26. [PMID: 18359417 DOI: 10.1016/j.jcrc.2008.02.001] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Revised: 01/24/2008] [Accepted: 02/01/2008] [Indexed: 01/15/2023]
Abstract
PURPOSE The aim of this study was to clarify the prevalence and incidence of, risk factors for, and outcomes from suspected ventilator-associated pneumonia (VAP) associated with the isolation of either Pseudomonas or multidrug-resistant (MDR) bacteria ("high risk" pathogens) from respiratory secretions. MATERIALS AND METHODS Data were collected as part of a large, multicentered trial of diagnostic and therapeutic strategies for patients (n = 739) with suspected VAP. RESULTS At enrollment, 6.4% of patients had Pseudomonas species, and 5.1% of patients had at least 1 MDR organism isolated from respiratory secretions. Over the study period, the incidence of Pseudomonas and MDR organisms was 13.4% and 9.2%, respectively. Independent risk factors for the presence of these pathogens at enrollment were duration of hospital stay >or=48 hours before intensive care unit (ICU) admission (odds ratio, 2.37 [95% CI, 1.40-4.02]; P = .001] and prolonged duration of ICU stay before enrollment (odds ratio, 1.50 [95% CI, 1.17-1.93]; P = .002] per week. Fewer patients whose specimens grew either Pseudomonas or MDR organisms received appropriate empirical antibiotic therapy compared to those without these pathogens (68.5% vs 93.9%, P < .001). The isolation of high risk pathogens from respiratory secretions was associated with higher 28-day (relative risk, 1.59 [95% CI, 1.07-2.37]; P = .04] and hospital mortality (relative risk, 1.48 [95% CI, 1.05-2.07]; P = .05), and longer median duration of mechanical ventilation (12.6 vs 8.7 days, P = .05), ICU length of stay (16.2 vs 12.0 days, P = .05), and hospital length of stay (55.0 vs 41.8 days, P = .05). CONCLUSIONS In this patient population, the incidence of high-risk organisms newly acquired during an ICU stay is low. However, the presence of high risk pathogens is associated with worse clinical outcomes.
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Affiliation(s)
- Chris M Parker
- Department of Medicine, Queen's University, Kingston, Ontario, Canada K7L 2V7
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Jung B, Sebbane M, Chanques G, Courouble P, Verzilli D, Perrigault PF, Jean-Pierre H, Eledjam JJ, Jaber S. Previous endotracheal aspirate allows guiding the initial treatment of ventilator-associated pneumonia. Intensive Care Med 2008; 35:101-7. [PMID: 18712348 DOI: 10.1007/s00134-008-1248-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2007] [Accepted: 07/13/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Any delay in adequate antibiotic treatment compromises the outcome of ventilator-associated pneumonia (VAP). However, the diagnosis and optimal treatment of VAP remain a challenge for intensivists. We assessed the potential impact of using results of routine weekly endotracheal aspirate (EA) cultures to guide initial antibiotic treatment for VAP. DESIGN AND SETTING Retrospective analysis of prospectively collected data in a medical-surgical intensive care unit (ICU) of a university hospital. PATIENTS AND METHODS We studied 113 VAP episodes and evaluated the concordance between the latest EA and the broncho-alveolar lavage (BAL). We stratified patients into three groups: concordant EA-BAL (concordant group), discordant EA-BAL (discordant group) and EA not performed group. We then compared the adequacy of the antibiotic prescribed initially and outcomes between the three groups. MEASUREMENTS AND MAIN RESULTS Ninety assessable EA-BAL samples were evaluated. When guided by EA, the initial antibiotic regimen was adequate in 85% of situations, a proportion significantly superior (P < 0.05) to that resulting from application of the ATS guidelines (73%). When clinicians did not have a pre-VAP EA to guide their treatment (EA not performed group), only 61% of treatments were adequate. No significant difference was observed between the three groups for length of mechanical ventilation, length of ICU stay, nonpulmonary nosocomial infections and mortality. CONCLUSION Once-a-week routine quantitative EA cultures may help to improve the adequacy of empiric antibiotic therapy for VAP.
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Affiliation(s)
- Boris Jung
- Intensive Care Unit, Department of Critical Care and Anesthesiology, DAR B CHU de Montpellier, Hôpital Saint Eloi, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France
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Impact of the implementation of a therapeutic guideline on the treatment of nosocomial pneumonia acquired in the intensive care unit of a university hospital. J Bras Pneumol 2008; 33:175-84. [PMID: 17724537 DOI: 10.1590/s1806-37132007000200012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Accepted: 07/02/2006] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the impact that the implementation of therapeutic guidelines has on the empirical treatment of nosocomial pneumonia. METHODS A clinical trial, using historical controls and involving current ICU patients who had acquired nosocomial pneumonia, was carried out from June of 2002 to June of 2003. All were treated according to therapeutic guidelines developed by the Commission for Nosocomial Infection Control of the institution (group with intervention). As controls, the medical charts of the patients who acquired nosocomial pneumonia between June of 2000 and June of 2001 (group without intervention) were analyzed. Mortality and mean treatment period, as well as the length of hospital and ICU stays, were determined for the patients who acquired nosocomial pneumonia. RESULTS Mortality associated with pneumonia was lower in the group treated according to the therapeutic guidelines (26 vs. 53.6%; p = 0.00). As for overall mortality, there was no statistically significant difference between the two periods (51 vs. 57.9%; p = 0.37). There was also no difference in the type of microorganisms isolated, treatment period, length of hospital stay or length of ICU stay. CONCLUSION The implementation of therapeutic guidelines for the treatment of nosocomial pneumonia acquired in the ICU can be efficacious in decreasing mortality rates.
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Rammaert B, Ader F, Nseir S. Pneumonies acquises sous ventilation mécanique invasive et bronchopneumopathie chronique obstructive. Rev Mal Respir 2007; 24:1285-98. [DOI: 10.1016/s0761-8425(07)78507-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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40
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Cardoso TC, Lopes LM, Carneiro AH. A case-control study on risk factors for early-onset respiratory tract infection in patients admitted in ICU. BMC Pulm Med 2007; 7:12. [PMID: 17888157 PMCID: PMC2104533 DOI: 10.1186/1471-2466-7-12] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2006] [Accepted: 09/21/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Respiratory tract infections are common in intensive care units (ICU), with incidences reported from 10 to 65%, and case fatality rates over 20% in pneumonia. This study was designed to identify risk factors for the development of an early onset respiratory tract infection (ERI) and to review the microbiological profile and the effectiveness of first intention antibiotic therapy. METHODS Case-control, retrospective clinical study of the patients admitted to the Intensive Care Unit (ICU) of our hospital, a teaching and tertiary care facility, from January to September 2000 who had a respiratory tract infection diagnosed in the first 5 days of hospital stay. RESULTS Of the 385 patients admitted to our unit: 129 (33,5%) had a diagnosis of ERI and 86 patients were admitted to the control group. Documented aspiration (adjusted OR = 5,265; 95% CI = 1,155 - 24,007) and fractured ribs (adjusted OR = 12,150; 95% CI = 1,571 - 93,941) were found to be independent risk factors for the development of ERI (multiple logistic regression model performed with the diagnostic group as dependent variable and adjusted for age, sex, SAPS II, documented aspiration, non-elective oro-tracheal intubation (OTI), fractured ribs, pneumothorax and pleural effusion).A total of 78 organisms were isolated in 61 patients (47%). The normal flora of the upper airway (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenza and Moraxella catharralis) accounted for 72% of all isolations achieved, polimicrobian infections were responsible for 25% of all microbiological documented infections. First intention treatment was, in 62% of the patients, the association amoxacillin+clavulanate, being effective in 75% of the patients to whom it was administered. The patients with ERI needed more days of OTI (6 vs 2, p < 0,001) and mechanical ventilation (6 vs 2, p < 0,001) and had a longer ICU (7 vs 2, p < 0,001) and hospital length of stay (17 vs 11, p = 0,018), when compared with controls. CONCLUSION In this study documented tracheobronchial aspiration and fractured ribs were identified as independent risk factors for ERI. Microbiological profile was dominated by sensitive micro-organisms. The choice amoxacilin+clavulanate revealed to be a good option with an effectiveness rate of 77% in the patients in whom it was used.
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Affiliation(s)
- Teresa C Cardoso
- Intensive Care Unit, Hospital Geral de Santo António, Porto, Portugal, Unidade de Cuidados Intensivos Polivalente, Hospital Geral de Santo António, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Luís M Lopes
- Intensive Care Unit, Hospital Geral de Santo António, Porto, Portugal, Emergency Department, Hospital de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - António H Carneiro
- Intensive Care Unit, Hospital Geral de Santo António, Porto, Portugal, Unidade de Cuidados Intensivos Polivalente, Hospital Geral de Santo António, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal
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Abstract
Anaesthetic care of neurosurgical patients increasingly involves management issues that apply not only to 'asleep patients', but also to 'awake and waking-up patients' during and after intracranial operations. On one hand, awake brain surgery poses unique anaesthetic challenges for the provision of awake brain mapping, which requires that a part of the procedure is performed under conscious patient sedation. Recent case reports suggest that local infiltration anaesthesia combined with sedative regimens using short-acting drugs and improved monitoring devices have assumed increasing importance. These techniques may optimize rapid adjustments of the narcotic depth, providing analgesia and patient immobility yet permitting a swift return to cooperative patient alertness for functional brain tests. Regional anaesthesia and peripheral nerve blocks were used to prevent uncontrolled movements in special cases of intractable seizures. However, few of these strategies have been evaluated in controlled trials. Awake craniotomy for tumour removal is performed as early discharge surgery. Meticulous consideration of postoperative patient safety is therefore strongly advised. On the other hand, waking-up patients or the emergence from general anaesthesia after brain surgery is still an area with considerable variation in clinical practice. Developments indicate that fast-acting anaesthetic agents and prophylactic strategies to prevent postoperative complications minimize the adverse effects of anaesthesia on the recovery process. Recent data do not advocate a delay in extubating patients when neurological impairment is the only reason for prolonged intubation. An appropriate choice of sedatives and analgesics during mechanical ventilation of neurosurgical patients allows for a narrower range of wake-up time, and weaning protocols incorporating respiratory and neurological measures may improve outcome. In conclusion, despite a lack of key evidence to request 'fast-tracking pathways' for neurosurgical patients, innovative approaches to accelerate recovery after brain surgery are needed.
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Affiliation(s)
- S Himmelseher
- Department of Anaesthesiology, Technische Universität München, Klinikum Rechts der Isar, Munich, Germany.
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Agbaht K, Lisboa T, Pobo A, Rodriguez A, Sandiumenge A, Diaz E, Rello J. Management of ventilator-associated pneumonia in a multidisciplinary intensive care unit: does trauma make a difference? Intensive Care Med 2007; 33:1387-95. [PMID: 17563873 DOI: 10.1007/s00134-007-0729-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Accepted: 05/08/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Antibiotic exposure and timing of pneumonia onset influence ventilator-associated pneumonia (VAP) isolates. The first goal of this investigation was to evaluate whether trauma also influences prevalence of microorganisms. DESIGN A retrospective, single-center, observational cohort study. SETTING Multidisciplinary teaching ICU. PATIENTS Adult patients requiring mechanical ventilation identified as having VAP. INTERVENTIONS Retrospective evaluation of a prospective manual database. MEASUREMENTS AND MAIN RESULTS VAP isolates in a multidisciplinary ICU documented by quantitative respiratory cultures and recorded in a 42-month database were compared, based on the presence or absence of trauma. Causative microorganisms were classified in four groups, based on mechanical ventilation duration (> 5 days), and previous antibiotic exposure. One hundred eighty-three patients developed 196 episodes of VAP (98 trauma). Methicillin-sensitive Staphylococcus aureus (MSSA) was more frequent (34.5% vs. 11.5%, p < 0.01) in trauma, whereas methicillin-resistant Staphylococcus aureus (MRSA) was more frequent (2% vs. 11.5%, p < 0.01) in non-trauma. No significant differences were found between trauma and non-trauma patients regarding prevalence of other microorganisms. In trauma patients, MSSA episodes were equally distributed between early- and late-onset VAP (51% vs. 49%), but no MRSA episode occurred in the early-onset group. CONCLUSIONS Trauma influences the microbiology of pneumonia and it should be considered in the initial antibiotic regimen choice. Our data demonstrate that patients with trauma had a higher prevalence of MSSA, but the overall prevalence was sufficiently high to warrant S. aureus coverage for both groups. On the other hand, since no MRSA was isolated during the first 10 days of mechanical ventilation on trauma patients, MRSA coverage in these patients becomes necessary only 10 days after admission.
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Affiliation(s)
- Kemal Agbaht
- CIBER - Enfermedades Respiratorias, University of Rovira & Virgili, Critical Care Department, Joan XXIII University Hospital, Institut Pere Virgili, Carrer Dr. Mallafre Guasch 4, 43007 Tarragona, Spain
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Zygun DA, Zuege DJ, Boiteau PJE, Laupland KB, Henderson EA, Kortbeek JB, Doig CJ. Ventilator-associated pneumonia in severe traumatic brain injury. Neurocrit Care 2007; 5:108-14. [PMID: 17099256 DOI: 10.1385/ncc:5:2:108] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Pneumonia is an important cause of morbidity following severe traumatic brain injury (TBI). However, previous studies have been limited by inclusion of specific patient subgroups or by selection bias. The primary objective of this study was to describe the incidence, risk factors for, and outcome of ventilator-associated pneumonia in an unselected population-based cohort of patients with severe TBI. An additional goal was to define the relationship of ventilator-associated pneumonia (VAP) with nonneurological organ dysfunction. METHODS A prospective, observational cohort study was performed at Foothills Medical Centre, the sole adult tertiary-care trauma center servicing southern Alberta. All patients with severe TBI requiring ventilation for more than 48 hours between May 1, 2000 and December 30, 2002 were included. RESULTS A total of 60 patients (45%) acquired VAP for an incidence density of 42.7/1000 ventilator days. Patients with polytrauma were at higher risk (risk ratio 1.7, 95% confidence interval, 0.9-3.1) for development of VAP than those with isolated head injury. Development of VAP was associated with a significantly greater degree of nonneurological organ system dysfunction. Although VAP was not associated with increased hospital mortality, patients who developed VAP had a longer duration of mechanical ventilation (15 versus 8 days, p < 0.0001), longer intensive care unit (17 versus 9 days, p < 0.0001) and hospital (60 versus 28 days, p = 0.003) lengths of stay, and more often required tracheostomy (35 versus 18%, p = 0.003). CONCLUSIONS VAP occurs frequently and is associated with significant morbidity in patients with severe TBI.
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Affiliation(s)
- David A Zygun
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada.
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Rincón-Ferrari MD, Flores-Cordero JM, Leal-Noval SR, Murillo-Cabezas F, Cayuelas A, Muñoz-Sánchez MA, Sánchez-Olmedo JI. Impact of ventilator-associated pneumonia in patients with severe head injury. ACTA ACUST UNITED AC 2006; 57:1234-40. [PMID: 15625455 DOI: 10.1097/01.ta.0000119200.70853.23] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The impact of ventilator-associated pneumonia (VAP) on outcome seems to vary depending on the critically ill patients we analyze. Our objective, therefore, has been to evaluate the influence of VAP on the mortality and morbidity in patients with severe head injury (Glasgow Coma Scale score </= 8). METHODS A prospective, matched, case-control study was conducted in our intensive care unit (ICU) for a 3-year period (1998-2000). Seventy-two patients with severe head injury (HI) who developed VAP were matched with 72 patients with severe HI without VAP. The matching criteria were as follows: age (+/- 5 years); category of HI based on computed tomographic scanning; Acute Physiology and Chronic Health Evaluation II (+/- 4 points) score; Injury Severity Score (+/- 4 points); and duration of mechanical ventilation. VAP was diagnosed on the basis of quantitative microbiologic criteria. RESULTS Mortality did not differ significantly between cases and matched control subjects (15 [20.8%] vs. 11 [15.3%], p = 0.54). However, patients with VAP had a significantly longer duration of mechanical ventilation (median, 14 vs. 10 days; p = 0.015) and ICU stay (median, 21 vs. 15.5 days; p = 0.008). The occurrence of multiple organ failure was also significantly more frequent among the case group (33.3% vs. 12.5%, p = 0.004) during the overall ICU stay. CONCLUSION VAP does not seem to be associated with a significantly increased risk of death in patients with severe HI, but it may be associated with greater morbidity during the ICU stay.
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Seguin P, Tanguy M, Laviolle B, Tirel O, Mallédant Y. Effect of oropharyngeal decontamination by povidone-iodine on ventilator-associated pneumonia in patients with head trauma*. Crit Care Med 2006; 34:1514-9. [PMID: 16540962 DOI: 10.1097/01.ccm.0000214516.73076.82] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effect of a regular oropharyngeal application of povidone-iodine on the prevalence of ventilator-associated pneumonia in patients with severe head trauma. DESIGN Prospective randomized study. SETTING A surgical intensive care unit of a university hospital. INTERVENTIONS Patients with severe head trauma (Glasgow Coma Score of < or =8) expected to need ventilation for > or =2 days were prospectively randomized into three groups: those receiving nasopharynx and oropharynx rinsing with 20 mL of a 10% povidone-iodine aqueous solution, reconstituted in a 60-mL solution with sterile water (povidone-iodine group); those receiving nasopharynx and oropharynx rinsing with 60 mL of saline solution (saline group); or those undergoing a standard regimen without any instillation but with aspiration of oropharyngeal secretions (control group). MEASUREMENTS AND MAIN RESULTS The prevalence of ventilator-associated pneumonia was compared among the three groups. A total of 98 patients were analyzed (povidone-iodine group, n = 36; saline group, n = 31; and control group, n = 31). A total of 28 cases of ventilator-associated pneumonia were diagnosed. There was a significant decrease in the rate of ventilator-associated pneumonia in the povidone-iodine group when compared with the saline and control groups (3 of 36 patients [8%] vs. 12 of 31 patients [39%] and 13 of 31 patients [42%], respectively; p = .003 and .001, respectively). The length of stay and mortality in the surgical intensive care unit were not statistically different between the three groups. CONCLUSIONS The regular administration of povidone-iodine may be an effective strategy for decreasing the prevalence of ventilator-associated pneumonia in patients with severe head trauma.
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Affiliation(s)
- Philippe Seguin
- Surgical Intensive Care Unit, INSERM U620, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033 Rennes cedex, France
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Cavalcanti M, Ferrer M, Ferrer R, Morforte R, Garnacho A, Torres A. Risk and prognostic factors of ventilator-associated pneumonia in trauma patients. Crit Care Med 2006; 34:1067-72. [PMID: 16484918 DOI: 10.1097/01.ccm.0000206471.44161.a0] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the risk and prognostic factors of ventilator-associated pneumonia in trauma patients, with an emphasis on the inflammatory response. DESIGN Case-control study. SETTING Trauma intensive care unit. PATIENTS Of 190 consecutive mechanically ventilated patients, those with microbiologically confirmed pneumonia (n = 62) were matched with 62 controls without pneumonia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical, microbiological, and outcome variables were recorded. Cytokines were measured in serum and blind bronchoalveolar lavage specimens at onset of pneumonia. Multivariate analyses of risk and prognostic factors for ventilator-associated pneumonia were done. Increased severity of head and neck injury (odds ratio, 11.9; p < .001) was the only independent predictor of pneumonia. Among patients with pneumonia, serum levels of interleukin-6 (p = .019) and interleukin-8 (p = .036) at onset of pneumonia were higher in nonresponders to treatment. Moreover, serum levels of tumor necrosis factor-alpha (p = .028) and interleukin-6 (p = .007) at onset of pneumonia were higher in nonsurvivors. Mortality in the intensive care unit was 23% in cases and controls. Nonresponse to antimicrobial treatment (odds ratio, 22.2; p = .001) and the use of hyperventilation (p = .021) were independent predictors of mortality in the intensive care unit for patients with pneumonia. CONCLUSIONS Severe head and neck trauma is strongly associated with ventilator-associated pneumonia. A higher inflammatory response is associated with nonresponse to treatment and mortality among patients with pneumonia. Although pneumonia did not influence mortality, nonresponse to treatment independently predicted mortality among these patients.
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Affiliation(s)
- Manuela Cavalcanti
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Spain
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Vadeboncoeur TF, Davis DP, Ochs M, Poste JC, Hoyt DB, Vilke GM. The ability of paramedics to predict aspiration in patients undergoing prehospital rapid sequence intubation. J Emerg Med 2006; 30:131-6. [PMID: 16567245 DOI: 10.1016/j.jemermed.2005.04.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2004] [Revised: 02/19/2005] [Accepted: 04/29/2005] [Indexed: 10/24/2022]
Abstract
One of the purported benefits to invasive prehospital airway management is the prevention of aspiration; however, aspiration events may occur before the arrival of prehospital personnel. We explore the timing of aspiration in patients with severe traumatic brain injury (TBI) undergoing paramedic rapid sequence intubation (RSI). Severely head-injured (Glasgow Coma Scale [GCS] score 3-8) adults were prospectively enrolled into the San Diego Paramedic RSI Trial. As part of the prehospital data collection tool, paramedics prospectively assessed for clinical evidence of aspiration before RSI (pre-intubation), aspiration events occurring during RSI (peri-RSI), and regurgitation of vomitus or blood after intubation (post-intubation). Data were abstracted from work sheets used during the RSI procedure, a telephone debriefing by one of the principal investigators immediately after delivery of the patient, and San Diego County prehospital and trauma databases. The incidence of pre-intubation aspiration, peri-RSI aspiration, and post-intubation regurgitation of vomitus or blood were determined. Patients with and without pre-intubation aspiration were compared with regard to pre- and post-intubation hypoxia and the rate of aspiration pneumonia. Logistic regression was used to explore the association between pre-intubation aspiration and various demographic and clinical factors. The results showed that pre-intubation aspiration was noted by paramedics in 72/269 patients in whom complete data were available. Peri-RSI aspiration was reported in one patient; there were no reported cases of post-intubation regurgitation of vomitus or blood. Patients in the pre-intubation aspiration group required more intubation attempts, had a higher incidence of desaturations and lower pre- and post-intubation SaO(2) values, and were more frequently diagnosed with aspiration pneumonia. Pre-intubation aspiration was associated with severe TBI, GCS score of 3, younger age, and the absence of alcohol intoxication despite controlling for age, gender, GCS, Head AIS (Abbreviated Injury Score), and serum ethanol. It is concluded that paramedics seem to be able to accurately assess for aspiration in patients undergoing prehospital RSI. The vast majority of aspiration events seem to occur before the arrival of prehospital personnel. Alteration in consciousness from TBI may carry a higher risk of aspiration than with other causes, such as alcohol intoxication.
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Affiliation(s)
- Tyler F Vadeboncoeur
- Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California 92103-8676, USA
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Garcia R. A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions. Am J Infect Control 2005; 33:527-41. [PMID: 16260328 DOI: 10.1016/j.ajic.2005.02.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2004] [Accepted: 02/21/2005] [Indexed: 01/15/2023]
Affiliation(s)
- Robert Garcia
- The Brookdale Hospital Medical Center, Brooklyn, NY 11212, USA.
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Zygun D. Non-neurological organ dysfunction in neurocritical care: impact on outcome and etiological considerations. Curr Opin Crit Care 2005; 11:139-43. [PMID: 15758594 DOI: 10.1097/01.ccx.0000155356.86241.c0] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Organ dysfunction is an important determinant of outcome in critical care medicine. Patients with life threatening neurologic injury represent a distinct subset of critically ill patients in whom non-neurologic organ dysfunction may develop. In this paper the incidence and impact of non-neurologic organ dysfunction in patients with major neurologic injury will be reviewed. Further, potential etiological considerations will be addressed and management strategies discussed. RECENT FINDINGS Non-neurologic organ dysfunction is extremely common in patients with brain injury occurring in 80-90% of patients admitted to intensive-care units. Several studies have now identified this dysfunction as an independent predictor of poor outcome in neurocritical care. This dysfunction may arise as a result of the neurologic injury or secondary to treatment. Massive catecholamine release continues to be the primary etiological theory of non-neurologic organ dysfunction due to brain injury. Currently employed therapies directed at intracranial hypertension such as maintenance of cerebral perfusion pressure and the use of hypothermia or barbiturates predispose non-neurologic organ dysfunction. SUMMARY Non-neurologic organ dysfunction is common. This dysfunction independently predicts poor outcome following brain injury and represents a potentially modifiable risk factor. Further study is required to develop optimal management strategies.
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Affiliation(s)
- David Zygun
- Department of Critical Care Medicine, University of Calgary Intensivist, Calgary Health Region, Alberta, Canada.
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Pelosi P, Severgnini P, Chiaranda M. An integrated approach to prevent and treat respiratory failure in brain-injured patients. Curr Opin Crit Care 2005; 11:37-42. [PMID: 15659943 DOI: 10.1097/00075198-200502000-00006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Brain-injured patients are at increased risk of extracerebral organ dysfunction, in particular ventilator-associated pneumonia. The purpose of this review is to discuss functional abnormalities, clinical treatment, and possible prevention of respiratory function abnormalities in brain-injured patients. RECENT FINDINGS Ventilator-associated pneumonia worsens the neurologic outcome and increases the intensive care unit and hospital stay, costs, and risk of death. The respiratory dysfunction can be due to several causes, but atelectasis and/or consolidation of the lower lobes predominates in the most severe cases. Strategies should be implemented to prevent lung infections and accelerate weaning from mechanical ventilation to reduce the incidence of respiratory dysfunction and ventilator-associated pneumonia. SUMMARY An integrated approach including appropriate ventilatory, antibiotic, and fluid management could be extremely useful, not only to prevent and more rapidly treat respiratory failure but also to improve neurologic outcome and reduce hospital stay. Further studies are warranted to better elucidate the pathophysiology and clinical treatment of respiratory dysfunction in brain-injured patients.
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Affiliation(s)
- Paolo Pelosi
- Dipartimento Ambiente, Salute e Sicurezza, Universita' degli Studi dell'Insubria, Servizio di Anestesia e Rianimazione B, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.
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