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Quarton S, Livesey A, Pittaway H, Adiga A, Grudzinska F, McNally A, Dosanjh D, Sapey E, Parekh D. Clinical challenge of diagnosing non-ventilator hospital-acquired pneumonia and identifying causative pathogens: a narrative review. J Hosp Infect 2024; 149:189-200. [PMID: 38621512 DOI: 10.1016/j.jhin.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024]
Abstract
Non-ventilated hospital-acquired pneumonia (NV-HAP) is associated with a significant healthcare burden, arising from high incidence and associated morbidity and mortality. However, accurate identification of cases remains challenging. At present, there is no gold-standard test for the diagnosis of NV-HAP, requiring instead the blending of non-specific signs and investigations. Causative organisms are only identified in a minority of cases. This has significant implications for surveillance, patient outcomes and antimicrobial stewardship. Much of the existing research in HAP has been conducted among ventilated patients. The paucity of dedicated NV-HAP research means that conclusions regarding diagnostic methods, pathology and interventions must largely be extrapolated from work in other settings. Progress is also limited by the lack of a widely agreed definition for NV-HAP. The diagnosis of NV-HAP has large scope for improvement. Consensus regarding a case definition will allow meaningful research to improve understanding of its aetiology and the heterogeneity of outcomes experienced by patients. There is potential to optimize the role of imaging and to incorporate novel techniques to identify likely causative pathogens. This would facilitate both antimicrobial stewardship and surveillance of an important healthcare-associated infection. This narrative review considers the utility of existing methods to diagnose NV-HAP, with a focus on the significance and challenge of identifying pathogens. It discusses the limitations in current techniques, and explores the potential of emergent molecular techniques to improve microbiological diagnosis and outcomes for patients.
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Affiliation(s)
- S Quarton
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK.
| | - A Livesey
- National Institute for Health Research/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham, Birmingham, UK
| | - H Pittaway
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - A Adiga
- Warwick Hospital, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - F Grudzinska
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - A McNally
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - D Dosanjh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - E Sapey
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK; National Institute for Health Research Midlands Patient Safety Research Collaboration, University of Birmingham, Birmingham, UK; National Institute for Health Research Midlands Applied Research Collaborative, University of Birmingham, Birmingham, UK
| | - D Parekh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Feet JA, Müller KE, Grewal HMS, Ulvestad E, Heggelund L. A retrospective study of non-ventilator hospital-acquired pneumonia in a Norwegian hospital: a serious medical condition in need of better and timelier microbiological diagnostics. Infect Dis (Lond) 2024:1-9. [PMID: 38922311 DOI: 10.1080/23744235.2024.2369909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 06/15/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Hospital-acquired pneumonia (HAP) is the most common hospital-acquired infection (HAI). HAP is associated with a high burden of morbidity and mortality, but the diagnosis is difficult to establish and the incidence uncertain. METHODS Patients aged ≥ 18 years hospitalised with radiologically verified non-ventilator hospital acquired pneumonia (NV-HAP) during 2018 were retrospectively identified at Drammen Hospital, a Norwegian general hospital. Infectious Diseases Society of America and the American Thoracic Society's definition of HAP was used. RESULTS In total 119 cases of NV-HAP were identified among 27,701 admissions. The incidence was 4.3 per 1000 admissions and 1.2 per 1000 patient-days. The median age was 74 years, 63% were male and median Charlson comorbidity index was 5. Coronary heart disease (42%) was the most common comorbidity. Median length of stay was 17.2 days. A blood culture was obtained in 53.8% of patients, while samples from lower airways were seldom obtained (10.9%). In-hospital mortality was 21%, accumulated 30-day mortality was 27.7% and accumulated 1-year mortality was 39.5%. Thirty-day readmission rate among survivors was 39.4%. CONCLUSION NV-HAP was present in approximately 1 in 250 hospitalisations, most had multiple comorbidities, and 1 in 5 died in hospital. Although thorough microbiological sampling is recommended when NV-HAP is suspected, our data indicate that airway sampling is infrequent in clinical practice. Our findings underscore the need to develop microbiological diagnostic strategies to achieve targeted antimicrobial treatment that may improve patient outcomes and reduce broad-spectrum antibiotic usage.
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Affiliation(s)
- Jon Anders Feet
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Vestre Viken Hospital Trust, Drammen, Norway
| | - Karl Erik Müller
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Vestre Viken Hospital Trust, Drammen, Norway
| | - Harleen M S Grewal
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Elling Ulvestad
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Lars Heggelund
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Vestre Viken Hospital Trust, Drammen, Norway
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Cilloniz C, Dy-Agra G, Pagcatipunan RS, Torres A. Viral Pneumonia: From Influenza to COVID-19. Semin Respir Crit Care Med 2024; 45:207-224. [PMID: 38228165 DOI: 10.1055/s-0043-1777796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
Respiratory viruses are increasingly recognized as a cause of community-acquired pneumonia (CAP). The implementation of new diagnostic technologies has facilitated their identification, especially in vulnerable population such as immunocompromised and elderly patients and those with severe cases of pneumonia. In terms of severity and outcomes, viral pneumonia caused by influenza viruses appears similar to that caused by non-influenza viruses. Although several respiratory viruses may cause CAP, antiviral therapy is available only in cases of CAP caused by influenza virus or respiratory syncytial virus. Currently, evidence-based supportive care is key to managing severe viral pneumonia. We discuss the evidence surrounding epidemiology, diagnosis, management, treatment, and prevention of viral pneumonia.
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Affiliation(s)
- Catia Cilloniz
- Hospital Clinic of Barcelona, IDIBAPS, CIBERESA, Barcelona, Spain
- Faculty of Health Sciences, Continental University, Huancayo, Peru
| | - Guinevere Dy-Agra
- Institute of Pulmonary Medicine, St Luke's Medical Center-Global City, Taguig, Metro Manila, Philippines
| | - Rodolfo S Pagcatipunan
- Institute of Pulmonary Medicine, St Luke's Medical Center-Global City, Taguig, Metro Manila, Philippines
| | - Antoni Torres
- Hospital Clinic of Barcelona, IDIBAPS, CIBERESA, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
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Amodio E, Schreiber PW, Faes Hesse M, Wolfensberger A. Adverse Outcomes of Patients with Non-Ventilator-Associated Hospital-Acquired Pneumonia (nvHAP)-A Single Centre Cohort Study. Infect Dis Rep 2024; 16:228-238. [PMID: 38525765 PMCID: PMC10961785 DOI: 10.3390/idr16020018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 03/01/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024] Open
Abstract
Non-ventilator associated hospital-acquired pneumonia (nvHAP) is a common nosocomial infection, but little is known about the outcomes of patients with nvHAP and the risk factors for adverse outcomes. In this retrospective study conducted in a Swiss tertiary care centre, adverse outcomes like in-hospital mortality, intensive care unit (ICU) admission, and mechanical ventilation, both all-cause and nvHAP-associated, were investigated. Of 244 patients with nvHAP, 72 (30%) died, 35 (14%) deaths were attributed to nvHAP. While 36 (15%) patients acquired nvHAP on the ICU, another 173 patients were eligible for ICU-transferral, and 76 (43.9%) needed ICU-admission. Of all patients hospitalized on the ICU 58 (51.8%) needed intubation due to nvHAP. Multivariable logistic regression analysis identified lower body mass index (OR per unit increase: 0.90, 95%CI: 0.82-0.98) and lower haemoglobin on admission (OR per unit in g/l increase: 0.98, 95%CI: 0.97-1.00) as patient specific factors independently associated with nvHAP-associated mortality. Given the frequency of nvHAP adverse outcomes, hospitals should evaluate increasing nvHAP prevention efforts, especially for patients at high risk for nvHAP mortality. To what extent pneumonia prevention interventions do lower nvHAP mortality in these patients is still to be evaluated.
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Affiliation(s)
| | | | | | - Aline Wolfensberger
- Department for Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
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Baker DL, Giuliano KK, Desmarais M, Worzala C, Cloke A, Zawistowich L. Impact of hospital-acquired pneumonia on the Medicare program. Infect Control Hosp Epidemiol 2024; 45:316-321. [PMID: 37877198 PMCID: PMC10933505 DOI: 10.1017/ice.2023.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/26/2023] [Accepted: 09/06/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Patient safety organizations and researchers describe hospital-acquired pneumonia (HAP) as a largely preventable hospital-acquired infection that affects patient safety and quality of care. We provide evidence regarding the consequences of HAP among 2019 Medicare beneficiaries. DESIGN Retrospective case-control study. PATIENTS Calendar year 2019 Medicare beneficiaries with HAP during an initial hospitalization, defined by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding on inpatient claims (n = 2,457). Beneficiaries with HAP were matched using diagnosis-related group (DRG) codes with beneficiaries who did not experience HAP (n = 2,457). METHODS The 2019 calendar year Medicare 5% Standard Analytic Files (SAF), for inpatient, outpatient, physician, and all postacute hospital settings. The case group (HAP) and control group (non-HAP) were matched on disease severity, age, sex, and race and were compared for hospital length of stay, costs, and mortality during the initial hospitalization and across settings for 30, 60, and 90 days after discharge. The 2019 fiscal year MedPAR Claims data were used to determine Medicare costs. RESULTS Medicare beneficiaries with HAP were 2.8 times more likely to die within 90 days compared with matched beneficiaries who did not develop HAP. Among those who survived, beneficiaries with HAP spent 6.6 more days in the hospital (69%) and cost the Medicare program an average of $14,487 (24%) more per episode of care across initial inpatient and postdischarge services. CONCLUSIONS The findings of higher mortality and cost among Medicare beneficiaries who develop HAP suggest that HAP prevention should be prioritized as a patient safety and quality initiative for the Medicare program.
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Affiliation(s)
- Dian L. Baker
- School of Nursing, California State University, Sacramento, California
| | - Karen K. Giuliano
- Elaine Marieb Center for Nursing and Engineering Innovation, Amherst, Massachusetts
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Rhee C, Klompas M, Pak TR, Köhler JR. In Support of Universal Admission Testing for SARS-CoV-2 During Significant Community Transmission. Clin Infect Dis 2024; 78:439-444. [PMID: 37463411 DOI: 10.1093/cid/ciad424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/27/2023] [Accepted: 07/13/2023] [Indexed: 07/20/2023] Open
Abstract
Many hospitals have stopped or are considering stopping universal admission testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We discuss reasons why admission testing should still be part of a layered system to prevent hospital-acquired SARS-CoV-2 infections during times of significant community transmission. These include the morbidity of SARS-CoV-2 in vulnerable patients, the predominant contribution of presymptomatic and asymptomatic people to transmission, the high rate of transmission between patients in shared rooms, and data suggesting surveillance testing is associated with fewer nosocomial infections. Preferences of diverse patient populations, particularly the hardest-hit communities, should be surveyed and used to inform prevention measures. Hospitals' ethical responsibility to protect patients from serious infections should predominate over concerns about costs, labor, and inconvenience. We call for more rigorous data on the incidence and morbidity of nosocomial SARS-CoV-2 infections and more research to help determine when to start, stop, and restart universal admission testing and other prevention measures.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Theodore R Pak
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julia R Köhler
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Sopena N, Isernia V, Casas I, Díez B, Guasch I, Sabrià M, Pedro-Botet ML. Intervention to reduce the incidence of non-ventilator-associated hospital-acquired pneumonia: A pilot study. Am J Infect Control 2023; 51:1324-1328. [PMID: 37295678 DOI: 10.1016/j.ajic.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/31/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Our aim was to evaluate the effectiveness of an intervention to reduce the incidence of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) and determine compliance with preventive measures. METHODS This was a quasi-experimental before-after study involving patients in the 53-bed Internal Medicine ward in a university hospital in Spain. The preventive measures included hand hygiene, dysphagia detection, head-of-bed elevation, withdrawal of sedatives in the event of confusion, oral care, and sterile or bottled water use. A prospective post-intervention study of the incidence of NV-HAP was carried out from February 2017 to January 2018 and compared with baseline incidence (May 2014 to April 2015). Compliance with preventive measures was analyzed with 3-point-prevalence studies (December 2015, October 2016, and June 2017). RESULTS The rate of NV-HAP decreased from 0.45 cases (95% confidence interval 0.24-0.77) in the pre-intervention period to 0.18 cases per 1,000 patient-days (95% confidence interval 0.07-0.39) in the post-intervention period (P = .07). Compliance with most preventive measures improved after intervention and remained stable over time. CONCLUSIONS The strategy improved the adherence to most of the preventive measures, with a decrease in the incidence of NV-HAP. Efforts to enhance adherence to such fundamental preventive measures are critical to lowering the incidence of NV-HAP.
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Affiliation(s)
- Nieves Sopena
- Department of Infectious Diseases, Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain; Autonomous University of Barcelona, Bellaterra, Barcelona, Spain.
| | - Valentina Isernia
- Department of Infectious Diseases, Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
| | - Irma Casas
- Autonomous University of Barcelona, Bellaterra, Barcelona, Spain; Department of Preventive Medicine, Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
| | - Beatriz Díez
- Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
| | - Ignasi Guasch
- Autonomous University of Barcelona, Bellaterra, Barcelona, Spain; Radiology Department, Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
| | - Miquel Sabrià
- Department of Infectious Diseases, Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain; Autonomous University of Barcelona, Bellaterra, Barcelona, Spain
| | - María Luisa Pedro-Botet
- Department of Infectious Diseases, Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain; Autonomous University of Barcelona, Bellaterra, Barcelona, Spain
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Lee K, Kummerfeld E, Robinson E, Anderson L, Rantz M. Data-Driven Analytics to Discover APRN's Impact on Nursing Home Hospitalization: Causal Discovery Analysis. J Am Med Dir Assoc 2023; 24:1746-1754. [PMID: 37302798 DOI: 10.1016/j.jamda.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Research shows advanced practice registered nurses (APRNs) embedded in nursing homes (NHs) reduce resident hospitalizations. However, the specific APRN activities that reduce hospitalizations have not been adequately investigated. This study aims to identify the causal links between APRN activities and NHs resident hospitalization. The study also examined relationships among other variables, including advanced directives, clinical diagnosis, and length of hospitalization. DESIGN Secondary data analysis. SETTING AND PARTICIPANTS Residents of NHs participating in the Missouri Quality Initiative for Nursing Homes, 2016-2019. METHODS We performed a secondary analysis of data from the Missouri Quality Initiative for Nursing Homes Intervention using causal discovery analysis, a machine learning, data-driven technique to determine causal relationships across data. The resident roster and INTERACT resident hospitalization datasets were combined to create the final dataset. Variables in the analysis model were divided into before and after hospitalization. Expert consensus was used to validate and interpret the outcomes. RESULTS The research team analyzed 1161 hospitalization events and their associated NH activities. APRNs evaluated NH residents before a transfer, expedited follow-up nursing assessments, and authorized hospitalization when necessary. No significant causal relationships were found between APRN activities and the clinical diagnosis of a resident. The analysis also showed multifaceted relationships related to having advanced directives and duration of hospitalization. CONCLUSIONS AND IMPLICATIONS This study demonstrated the importance of APRNs embedded in NHs to improve resident outcomes. APRNs in NHs can facilitate communication and collaboration among the nursing team, leading to early identification and treatment for resident status changes. APRNs can also initiate more timely transfers by reducing the need for physician authorization. These findings emphasize the crucial role of APRNs in NHs and suggest that budgeting for APRN services may be an effective strategy to reduce hospitalizations. Additional findings regarding advance directives are discussed.
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Affiliation(s)
- Knoo Lee
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.
| | - Erich Kummerfeld
- Institute of Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - Erin Robinson
- School of Health Professions, University of Missouri, Columbia, MO, USA
| | - Linda Anderson
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
| | - Marilyn Rantz
- Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
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Roberts G, Chang L, Park JM, Thynne T. The occurrence of Hospital-Acquired Pneumonia is independently associated with elevated Stress Hyperglycaemia Ratio at admission but not elevated blood glucose. Diabetes Res Clin Pract 2023; 205:110955. [PMID: 37839754 DOI: 10.1016/j.diabres.2023.110955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/02/2023] [Accepted: 10/13/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The association between stress-induced hyperglycaemia (SIH) and increased infection rates in hospitalised subjects is well-known. It is less clear if SIH at admission independently drives new-onset infections. We assessed the relationship between early exposure at admission to both the Stress Hyperglycaemia Ratio (SHR) and Blood Glucose (BG) with Hospital-Acquired Pneumonia (HAP). METHODS This observational retrospective study included those with length-of-stay > 1 day, BG within 24 h of admission and recent haemoglobin A1c. SIH was defined as BG ≥ 10 mmol/L, or SHR ≥ 1.1, measured at both admission and as a 24-hour maximum. Multivariable analyses were adjusted for length-of-stay, age, mechanical ventilation, and chronic respiratory disease. RESULTS Of 5,339 eligible subjects, 110 (2.1%) experienced HAP. Admission SHR ≥ 1.1 was independently associated with HAP (OR 3.04, 95% CI 1.98-4.68, p < 0.0001) but not BG ≥ 10 mmol/L (OR 0.65, 95% CI 0.41-1.03, p = 0.0675). The association with SHR strengthened using maximum 24-hour values (OR 3.37, 95% CI 2.05-5.52, p < 0.0001) while BG ≥ 10 mmol/L remained insignificant (OR 0.96, 95% CI 0.63-1.46, p = 0.86). Of those experiencing HAP 40 (36.4%) occurred in subjects with no recorded BG ≥ 10 mmol/L but SHR ≥ 1.1. CONCLUSION SIH at admission defined as SHR ≥ 1.1, but not the conventional marker of BG ≥ 10 mmol/L, was independently associated with the subsequent onset of HAP, commonly at BG < 10 mmol/L.
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Affiliation(s)
- Gregory Roberts
- SA Pharmacy, Flinders Medical Centre, Bedford Park SA 5042, Australia; College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia.
| | - Leonard Chang
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia.
| | - Joong-Min Park
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia.
| | - Tilenka Thynne
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia; Department of Clinical Pharmacology, Flinders Medical Centre, Bedford Park SA 5042, Australia.
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Candel FJ, Salavert M, Estella A, Ferrer M, Ferrer R, Gamazo JJ, García-Vidal C, del Castillo JG, González-Ramallo VJ, Gordo F, Mirón-Rubio M, Pérez-Pallarés J, Pitart C, del Pozo JL, Ramírez P, Rascado P, Reyes S, Ruiz-Garbajosa P, Suberviola B, Vidal P, Zaragoza R. Ten Issues to Update in Nosocomial or Hospital-Acquired Pneumonia: An Expert Review. J Clin Med 2023; 12:6526. [PMID: 37892664 PMCID: PMC10607368 DOI: 10.3390/jcm12206526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Nosocomial pneumonia, or hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) are important health problems worldwide, with both being associated with substantial morbidity and mortality. HAP is currently the main cause of death from nosocomial infection in critically ill patients. Although guidelines for the approach to this infection model are widely implemented in international health systems and clinical teams, information continually emerges that generates debate or requires updating in its management. This scientific manuscript, written by a multidisciplinary team of specialists, reviews the most important issues in the approach to this important infectious respiratory syndrome, and it updates various topics, such as a renewed etiological perspective for updating the use of new molecular platforms or imaging techniques, including the microbiological diagnostic stewardship in different clinical settings and using appropriate rapid techniques on invasive respiratory specimens. It also reviews both Intensive Care Unit admission criteria and those of clinical stability to discharge, as well as those of therapeutic failure and rescue treatment options. An update on antibiotic therapy in the context of bacterial multiresistance, in aerosol inhaled treatment options, oxygen therapy, or ventilatory support, is presented. It also analyzes the out-of-hospital management of nosocomial pneumonia requiring complete antibiotic therapy externally on an outpatient basis, as well as the main factors for readmission and an approach to management in the emergency department. Finally, the main strategies for prevention and prophylactic measures, many of them still controversial, on fragile and vulnerable hosts are reviewed.
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Affiliation(s)
- Francisco Javier Candel
- Clinical Microbiology and Infectious Diseases, Transplant Coordination, IdISSC & IML Health Research Institutes, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain
| | - Miguel Salavert
- Infectious Diseases Unit, La Fe (IIS) Health Research Institute, Hospital Universitario y Politécnico La Fe, 46026 València, Spain
| | - Angel Estella
- Intensive Medicine Service, Hospital Universitario de Jerez, 11407 Jerez, Spain
- Departamento de Medicina, INIBICA, Universidad de Cádiz, 11003 Cádiz, Spain
| | - Miquel Ferrer
- UVIR, Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic de Barcelona, IDIBAPS, CibeRes (CB06/06/0028), Universitat de Barcelona, 08007 Barcelona, Spain;
| | - Ricard Ferrer
- Intensive Medicine Service, Hospital Universitario Valle de Hebrón, 08035 Barcelona, Spain;
| | - Julio Javier Gamazo
- Servicio de Urgencias, Hospital Universitario de Galdakao, 48960 Bilbao, Spain;
| | | | | | | | - Federico Gordo
- Intensive Medicine Service, Hospital Universitario del Henares, 28822 Coslada, Spain;
| | - Manuel Mirón-Rubio
- Servicio de Hospitalización a Domicilio, Hospital Universitario de Torrejón, 28850 Torrejón de Ardoz, Spain;
| | - Javier Pérez-Pallarés
- Division of Respiratory Medicine, Hospital Universitario Santa Lucía, 30202 Cartagena, Spain;
| | - Cristina Pitart
- Department of Clinical Microbiology, ISGlobal, Hospital Clínic-University of Barcelona, CIBERINF, 08036 Barcelona, Spain;
| | - José Luís del Pozo
- Servicio de Enfermedades Infecciosas, Servicio de Microbiología, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Paula Ramírez
- Intensive Medicine Service, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | - Pedro Rascado
- Intensive Care Unit, Complejo Hospitalario Universitario Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | - Soledad Reyes
- Neumology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Borja Suberviola
- Intensive Medicine Service, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Sanitaria IDIVAL, 39011 Santander, Spain;
| | - Pablo Vidal
- Intensive Medicine Service, Complexo Hospitalario Universitario de Ourense, 32005 Ourense, Spain;
| | - Rafael Zaragoza
- Intensive Care Unit, Hospital Dr. Peset, 46017 Valencia, Spain;
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11
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Galerneau LM, Bailly S, Terzi N, Ruckly S, Garrouste-Orgeas M, Oziel J, Hong Tuan Ha V, Gainnier M, Siami S, Dupuis C, Forel JM, Dartevel A, Dessajan J, Adrie C, Goldgran-Toledano D, Laurent V, Argaud L, Reignier J, Pepin JL, Darmon M, Timsit JF. Non-ventilator-associated ICU-acquired pneumonia (NV-ICU-AP) in patients with acute exacerbation of COPD: From the French OUTCOMEREA cohort. Crit Care 2023; 27:359. [PMID: 37726796 PMCID: PMC10508006 DOI: 10.1186/s13054-023-04631-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Non-ventilator-associated ICU-acquired pneumonia (NV-ICU-AP), a nosocomial pneumonia that is not related to invasive mechanical ventilation (IMV), has been less studied than ventilator-associated pneumonia, and never in the context of patients in an ICU for severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD), a common cause of ICU admission. This study aimed to determine the factors associated with NV-ICU-AP occurrence and assess the association between NV-ICU-AP and the outcomes of these patients. METHODS Data were extracted from the French ICU database, OutcomeRea™. Using survival analyses with competing risk management, we sought the factors associated with the occurrence of NV-ICU-AP. Then we assessed the association between NV-ICU-AP and mortality, intubation rates, and length of stay in the ICU. RESULTS Of the 844 COPD exacerbations managed in ICUs without immediate IMV, NV-ICU-AP occurred in 42 patients (5%) with an incidence density of 10.8 per 1,000 patient-days. In multivariate analysis, prescription of antibiotics at ICU admission (sHR, 0.45 [0.23; 0.86], p = 0.02) and no decrease in consciousness (sHR, 0.35 [0.16; 0.76]; p < 0.01) were associated with a lower risk of NV-ICU-AP. After adjusting for confounders, NV-ICU-AP was associated with increased 28-day mortality (HR = 3.03 [1.36; 6.73]; p < 0.01), an increased risk of intubation (csHR, 5.00 [2.54; 9.85]; p < 0.01) and with a 10-day increase in ICU length of stay (p < 0.01). CONCLUSION We found that NV-ICU-AP incidence reached 10.8/1000 patient-days and was associated with increased risks of intubation, 28-day mortality, and longer stay for patients admitted with AECOPD.
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Affiliation(s)
- Louis-Marie Galerneau
- Medical Intensive Care Unit, University Hospital of Grenoble Alpes, 10217 38043, Grenoble, CS, France.
- Grenoble Alpes University, INSERM 1300, HP2, Grenoble, France.
| | | | - Nicolas Terzi
- Medical Intensive Care Unit, University Hospital of Grenoble Alpes, 10217 38043, Grenoble, CS, France
- Grenoble Alpes University, INSERM 1300, HP2, Grenoble, France
| | | | - Maité Garrouste-Orgeas
- Medical Unit, French and British Hospital Cognacq-Jay Fondation, Levallois-Perret, France
| | - Johanna Oziel
- Intensive Care Unit, Avicenne Hospital, AP-HP, Paris, France
| | | | - Marc Gainnier
- Medical Intensive Care Unit, La Timone Hospital, Marseille, France
| | - Shidasp Siami
- Critical Care Medicine Unit, Etampes-Dourdan Hospital, Etampes, France
| | - Claire Dupuis
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Jean-Marie Forel
- Medical Intensive Care Unit, Nord University Hospital, Marseille, France
| | - Anaïs Dartevel
- Medical Intensive Care Unit, University Hospital of Grenoble Alpes, 10217 38043, Grenoble, CS, France
| | - Julien Dessajan
- Medical and Infectious Diseases Intensive Care Unit (MI2), Bichat Hospital, AP-HP, Paris, France
| | - Christophe Adrie
- Polyvalent Intensive Care Unit, Delafontaine Hospital, Saint-Denis, France
| | | | | | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Hospital, Lyon Civil Hospices, Lyon, France
| | - Jean Reignier
- Medical Intensive Care Unit, Nantes University Hospital, Nantes, France
| | | | - Michael Darmon
- Intensive Care Unit, Saint-Louis Hospital, AP-HP, Paris, France
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit (MI2), Bichat Hospital, AP-HP, Paris, France
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Bălan AM, Bodolea C, Trancă SD, Hagău N. Trends in Molecular Diagnosis of Nosocomial Pneumonia Classic PCR vs. Point-of-Care PCR: A Narrative Review. Healthcare (Basel) 2023; 11:healthcare11091345. [PMID: 37174887 PMCID: PMC10177880 DOI: 10.3390/healthcare11091345] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/23/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Nosocomial pneumonia is one of the most frequent hospital-acquired infections. One of the types of nosocomial pneumonia is ventilator-associated pneumonia, which occurs in endotracheally intubated patients in intensive care units (ICU). Ventilator-associated pneumonia may be caused by multidrug-resistant pathogens, which increase the risk of complications due to the difficulty in treating them. Pneumonia is a respiratory disease that requires targeted antimicrobial treatment initiated as early as possible to have a good outcome. For the therapy to be as specific and started sooner, diagnostic methods have evolved rapidly, becoming quicker and simpler to perform. Polymerase chain reaction (PCR) is a rapid diagnostic technique with numerous advantages compared to classic plate culture-based techniques. Researchers continue to improve diagnostic methods; thus, the newest types of PCR can be performed at the bedside, in the ICU, so-called point of care testing-PCR (POC-PCR). The purpose of this review is to highlight the benefits and drawbacks of PCR-based techniques in managing nosocomial pneumonia.
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Affiliation(s)
- Andrei-Mihai Bălan
- Department of Anaesthesia and Intensive Care 2, "Iuliu Hatieganu", University of Medicine and Pharmacy Cluj-Napoca, 400012 Cluj-Napoca, Romania
- Department of Anaesthesia and Intensive Care, Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Constantin Bodolea
- Department of Anaesthesia and Intensive Care 2, "Iuliu Hatieganu", University of Medicine and Pharmacy Cluj-Napoca, 400012 Cluj-Napoca, Romania
- Department of Anaesthesia and Intensive Care, Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Sebastian Daniel Trancă
- Department of Anaesthesia and Intensive Care 2, "Iuliu Hatieganu", University of Medicine and Pharmacy Cluj-Napoca, 400012 Cluj-Napoca, Romania
- Emergency Department, The Emergency County Hospital Cluj, 400347 Cluj-Napoca, Romania
| | - Natalia Hagău
- Department of Anaesthesia and Intensive Care 2, "Iuliu Hatieganu", University of Medicine and Pharmacy Cluj-Napoca, 400012 Cluj-Napoca, Romania
- Department of Anaesthesia and Intensive Care, "Regina Maria" Hospital, 400221 Cluj-Napoca, Romania
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13
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Qi W, Murphy TE, Doyle MM, Ferrante LE. Association Between Daily Average of Mobility Achieved During Physical Therapy Sessions and Hospital-Acquired or Ventilator-Associated Pneumonia among Critically Ill Patients. J Intensive Care Med 2023; 38:418-424. [PMID: 36278257 PMCID: PMC10065937 DOI: 10.1177/08850666221133318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Hospital-acquired and ventilator-associated pneumonias (HAP and VAP) are associated with increased morbidity and mortality. Immobility is a risk factor for developing ICU-acquired weakness (ICUAW). Early mobilization is associated with improved physical function, but its association with hospital-acquired (HAP) and ventilator-associated pneumonias (VAP) is unknown. The purpose of this study is to evaluate the association between daily average of highest level of mobility achieved during physical therapy (PT) and incidence of HAP or VAP among critically ill patients. MATERIALS AND METHODS In a retrospective cohort study of progressive mobility program participants in the medical ICU, we used a validated method to abstract new diagnoses of HAP and VAP. We captured scores on a mobility scale achieved during each inpatient physical therapy session and used a Bayesian, discrete time-to-event model to evaluate the association between daily average of highest level of mobility achieved and occurrence of HAP or VAP. RESULTS The primary outcome of HAP/VAP occurred in 55 (26.8%) of the 205 participants. Each increase in the daily average of highest level of mobility achieved during PT (0-6 mobility scale) exhibited a protective association with occurrence of HAP or VAP (adjusted hazard ratio [HR] 0.61; 95% CI 0.44, 0.85). Age, baseline ambulatory status, Acute Physiology and Chronic Health Evaluation (APACHE) II, and previous day's mechanical ventilation (MV) status were not significantly associated with the occurrence of HAP/VAP. CONCLUSIONS Among critically ill patients in a progressive mobility program, a higher daily average of highest level of mobility achieved during PT was associated with a decreased risk of HAP or VAP.
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Affiliation(s)
- Wei Qi
- Brigham and Women’s Hospital Department of Medicine, Division of Pulmonary and Critical Care Medicine, Boston, MA, USA
| | - Terrence E. Murphy
- Yale University, Internal Medicine, Geriatrics Section, New Haven, CT, USA
| | - Margaret M. Doyle
- Yale University, Internal Medicine, Geriatrics Section, New Haven, CT, USA
| | - Lauren E. Ferrante
- Yale School of Medicine, Internal Medicine; Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA
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14
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Elmassry MM, Colmer-Hamood JA, Kopel J, San Francisco MJ, Hamood AN. Anti- Pseudomonas aeruginosa Vaccines and Therapies: An Assessment of Clinical Trials. Microorganisms 2023; 11:916. [PMID: 37110338 PMCID: PMC10144840 DOI: 10.3390/microorganisms11040916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Pseudomonas aeruginosa is a Gram-negative opportunistic pathogen that causes high morbidity and mortality in cystic fibrosis (CF) and immunocompromised patients, including patients with ventilator-associated pneumonia (VAP), severely burned patients, and patients with surgical wounds. Due to the intrinsic and extrinsic antibiotic resistance mechanisms, the ability to produce several cell-associated and extracellular virulence factors, and the capacity to adapt to several environmental conditions, eradicating P. aeruginosa within infected patients is difficult. Pseudomonas aeruginosa is one of the six multi-drug-resistant pathogens (ESKAPE) considered by the World Health Organization (WHO) as an entire group for which the development of novel antibiotics is urgently needed. In the United States (US) and within the last several years, P. aeruginosa caused 27% of deaths and approximately USD 767 million annually in health-care costs. Several P. aeruginosa therapies, including new antimicrobial agents, derivatives of existing antibiotics, novel antimicrobial agents such as bacteriophages and their chelators, potential vaccines targeting specific virulence factors, and immunotherapies have been developed. Within the last 2-3 decades, the efficacy of these different treatments was tested in clinical and preclinical trials. Despite these trials, no P. aeruginosa treatment is currently approved or available. In this review, we examined several of these clinicals, specifically those designed to combat P. aeruginosa infections in CF patients, patients with P. aeruginosa VAP, and P. aeruginosa-infected burn patients.
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Affiliation(s)
- Moamen M. Elmassry
- Department of Biological Sciences, Texas Tech University, Lubbock, TX 79409, USA
| | - Jane A. Colmer-Hamood
- Department of Medical Education, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Department of Immunology and Molecular Microbiology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Jonathan Kopel
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Michael J. San Francisco
- Department of Biological Sciences, Texas Tech University, Lubbock, TX 79409, USA
- Honors College, Texas Tech University, Lubbock, TX 79409, USA
| | - Abdul N. Hamood
- Department of Immunology and Molecular Microbiology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
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15
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Yadollahi M, Shams AH, Norouzi M, Feizi M. Evaluation of the Risk Factors of Nosocomial Pneumonia and the Prevalence of Antibiotic Resistance in Trauma Patients in Need of Immediate Intervention. Surg Infect (Larchmt) 2023; 24:358-365. [PMID: 36946788 DOI: 10.1089/sur.2022.277] [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: 03/23/2023] Open
Abstract
Background: Pneumonia is the most common nosocomial infection reported worldwide in intensive care units. This study aimed to evaluate the risk factors of nosocomial pneumonia and the frequency of antibiotic resistance in trauma patients who need immediate intervention. Patients and Methods: This prospective cohort study was conducted in Shahid Rajaei Trauma Hospital in Shiraz between 2020 and 2021. All the trauma patients who needed immediate intervention (levels 1 and 2 based on the Canadian Emergency Department Triage and Acuity Scale) and had no symptoms of infection were included. Patients who were discharged or died before 48 hours were excluded. Results: The results demonstrated that major trauma (Injury Severity Score [ISS] ≥16), intubation, and use of invasive mechanical ventilation increase nosocomial pneumonia and death rate. The most common causes of nosocomial infections were Acinetobacter baumannii (23%) and coagulase-negative staphylococcus (18.5%). The highest levels of antibiotic resistance were related to cefoxitin, erythromycin, ciprofloxacin, and trimethoprim-sulfamethoxazole. Conclusions: Major trauma, intubation, and invasive mechanical ventilation were the effective factors in the development of nosocomial pneumonia. Continuous monitoring for mentioned risk factors and strict surveillance of antibiotic prescription can decrease the prevalence of nosocomial infections and subsequent deaths.
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Affiliation(s)
- Mahnaz Yadollahi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Hossein Shams
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojtaba Norouzi
- Department of Epidemiology and Biostatistics, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Monireh Feizi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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16
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Electronic surveillance criteria for non-ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity. Infect Control Hosp Epidemiol 2023:1-7. [PMID: 36920040 DOI: 10.1017/ice.2022.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
OBJECTIVE Surveillance of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses. METHODS We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans' Affairs (VA) hospitals from January 1, 2015, to November 30, 2020. We randomly selected 250 hospitalizations meeting NV-HAP surveillance criteria for independent review by 2 clinicians and calculated the percent of hospitalizations with (1) clinical deterioration, (2) CDC National Healthcare Safety Network (CDC-NHSN) criteria, (3) NV-HAP according to a reviewer, (4) NV-HAP according to a treating clinician, (5) pneumonia diagnosis in discharge summary; and (6) discharge diagnosis codes for HAP. We assessed interrater reliability by calculating simple agreement and the Cohen κ (kappa). RESULTS Among 3.1 million hospitalizations, 14,023 met NV-HAP electronic surveillance criteria. Among reviewed cases, 98% had a confirmed clinical deterioration; 67% met CDC-NHSN criteria; 71% had NV-HAP according to a reviewer; 60% had NV-HAP according to a treating clinician; 49% had a discharge summary diagnosis of pneumonia; and 82% had NV-HAP according to any definition according to at least 1 reviewer. Only 8% had diagnosis codes for HAP. Interrater agreement was 75% (κ = 0.50) for CDC-NHSN criteria and 78% (κ = 0.55) for reviewer diagnosis of NV-HAP. CONCLUSIONS Electronic NV-HAP surveillance criteria correlated moderately with existing manual surveillance criteria. Reviewer variability for all manual assessments was high. Electronic surveillance using clinical data may therefore allow for more consistent and efficient surveillance with similar accuracy compared to manual assessments or diagnosis codes.
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Wolfensberger A, Clack L, von Felten S, Faes Hesse M, Saleschus D, Meier MT, Kusejko K, Kouyos R, Held L, Sax H. Prevention of non-ventilator-associated hospital-acquired pneumonia in Switzerland: a type 2 hybrid effectiveness-implementation trial. THE LANCET. INFECTIOUS DISEASES 2023:S1473-3099(22)00812-X. [PMID: 36893785 DOI: 10.1016/s1473-3099(22)00812-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND Non-ventilator-associated hospital-acquired pneumonia (nvHAP) is a frequent, but under-researched infection. We aimed to simultaneously test an nvHAP prevention intervention and a multifaceted implementation strategy. METHODS In this single-centre, type 2 hybrid effectiveness-implementation study, all patients of nine surgical and medical departments at the University Hospital Zurich, Switzerland, were included and surveyed over three study periods: baseline (14-33 months, depending on department), implementation (2 months), and intervention (3-22 months, depending on department). The five-measure nvHAP prevention bundle consisted of oral care, dysphagia screening and management, mobilisation, discontinuation of non-indicated proton-pump inhibitors, and respiratory therapy. The implementation strategy comprised department-level implementation teams who conducted and locally adapted the core strategies of education, training, and changing infrastructure. Intervention effectiveness on the primary outcome measure of nvHAP incidence rate was quantified using a generalised estimating equation method in a Poisson regression model, with hospital departments as clusters. Implementation success scores and determinants were derived longitudinally through semistructured interviews with health-care workers. This trial is registered with ClinicalTrials.gov (NCT03361085). FINDINGS Between Jan 1, 2017, and Feb 29, 2020, 451 nvHAP cases occurred during 361 947 patient-days. nvHAP incidence rate was 1·42 (95% CI 1·27-1·58) per 1000 patient-days in the baseline period and 0·90 (95% CI 0·73-1·10) cases per 1000 patient-days in the intervention period. The intervention-to-baseline nvHAP incidence rate ratio, adjusted for department and seasonality, was 0·69 (95% CI 0·52-0·91; p=0·0084). Implementation success scores correlated with lower nvHAP rate ratios (Pearson correlation -0·71, p=0·034). Determinants of implementation success were positive core business alignment, high perceived nvHAP risk, architectural characteristics promoting physical proximity of health-care staff, and favourable key individual traits. INTERPRETATION The prevention bundle led to a reduction of nvHAP. Knowledge of the determinants of implementation success might help in upscaling nvHAP prevention. FUNDING Swiss Federal Office of Public Health.
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Affiliation(s)
- Aline Wolfensberger
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Lauren Clack
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
| | - Stefanie von Felten
- Department of Biostatistics, Institute of Epidemiology, Biostatistics, and Prevention, University of Zurich, Zurich, Switzerland
| | - Mirjam Faes Hesse
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Dirk Saleschus
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marie-Theres Meier
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Katharina Kusejko
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Roger Kouyos
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Leonhard Held
- Department of Biostatistics, Institute of Epidemiology, Biostatistics, and Prevention, University of Zurich, Zurich, Switzerland
| | - Hugo Sax
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
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Determinants of Mortality for Ventilated Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia. Crit Care Explor 2023; 5:e0867. [PMID: 36861046 PMCID: PMC9970264 DOI: 10.1097/cce.0000000000000867] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
Hospital-acquired pneumonia (HAP) is the most common hospital-acquired infection, accounting for 22% of all nosocomial infections. The available studies to date have not attempted to assess whether confounding factors may account for the observed difference in mortality for the two forms of nosocomial pneumonia associated with mechanical ventilation, namely ventilated HAP (vHAP) and ventilator-associated pneumonia (VAP). OBJECTIVES To determine if vHAP is an independent predictor of mortality among patients with nosocomial pneumonia. DESIGN SETTING AND PARTICIPANTS Single-center retrospective cohort study conducted at Barnes-Jewish Hospital, St. Louis, MO, between 2016 and 2019. Adult patients with a pneumonia discharge diagnosis were screened and patients diagnosed with vHAP and VAP were included. All patient data was extracted from the electronic health record. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day all-cause mortality (ACM). RESULTS One thousand one-hundred twenty unique patient admissions were included (410 vHAP, 710 VAP). Thirty-day ACM was greater for patients with vHAP compared with VAP (37.1% vs 28.5%; p = 0.003). Logistic regression analysis identified vHAP (adjusted odds ratio [AOR], 1.77; 95% CI, 1.51-2.07), vasopressor use (AOR, 2.34; 95% CI, 1.94-2.82), Charlson Comorbidity Index (1-point increments) (AOR, 1.21; 95% CI, 1.18-1.24), total antibiotic treatment days (1-d increments) (AOR, 1.13; 95% CI, 1.11-1.14), and Acute Physiology and Chronic Health Evaluation II score (1-point increments) (AOR, 1.04; 95% CI, 1.03-1.06) as independent predictors of 30-day ACM. The most common bacterial pathogens identified as causes of vHAP and VAP were Staphylococcus aureus, Enterobacterales species, and Pseudomonas aeruginosa. CONCLUSIONS AND RELEVANCE In this single-center cohort study with low rates of initial inappropriate antibiotic therapy, vHAP had greater 30-day ACM compared with VAP after adjusting for potential confounding variables including disease severity and comorbidities. This finding suggests that clinical trials enrolling patients with vHAP need to account for this outcome difference in their trial design and data interpretation.
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Gardiner W, Brown K, Richardson H, Pretorius N, Heales L. The incidence, characteristics and in-hospital mortality of non-ventilator-associated hospital-acquired pneumonia in regional Queensland: A retrospective descriptive study. Aust J Rural Health 2023; 31:138-143. [PMID: 36106699 DOI: 10.1111/ajr.12923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 08/08/2022] [Accepted: 08/21/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the incidence, characteristics and in-hospital mortality of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) in a regional (Modified Monash Model 2) Australian hospital. METHODS All cases with NV-HAP were obtained from the Business Analysis and Decision Support (BADS) Unit between 1st January 2013 and 31st December 2018. Medical records were reviewed, and data pertaining to incidence, characteristics (age and gender), length of stay, co-morbidities (measured using the Charlson Comorbidity Index) and in-hospital mortality were extracted. Incidence rate was calculated as a proportion of NV-HAP cases per 1000 bed-days. DESIGN A retrospective study design was used to review all cases of NV-HAP between 1 January 2013 and 31 December 2018 at a single regional Australian hospital. Using the Modified Monash Model (MMM), our regional setting is classified as a regional centre (MMM-2). SETTING Rockhampton Hospital, Australia. PARTICIPANTS Patient cases. MAIN OUTCOME MEASURES Incidence rate, Incidence proportion, mortality. RESULTS A total of 501 cases were identified with an incidence rate of 0.98 cases per 1000 bed-days over the study period 2013-2018. Cases with NV-HAP had a median age of 78.2 years (interquartile range 18.8), a median length of stay of 13.0 days (interquartile range 12.0) and a median Charlson Comorbidity Index score of 3.0 out of 39 (interquartile range 3.0), and a greater proportion was male (n = 297, 57%). The in-hospital mortality rate for NV-HAP cases was 18.9%. CONCLUSION This study revealed an overall incidence rate of 0.98 cases per 1000 bed-days from 2013 to 2018 in a regional Australian hospital. In addition, this study provided the descriptive characteristics for patients with NV-HAP at our regional hospital.
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Affiliation(s)
- Wenonah Gardiner
- Department of Speech Pathology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Kassandra Brown
- Department of Speech Pathology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Heather Richardson
- Aged Care, Clinical and Rehabilitation Services, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Nellie Pretorius
- Oral Health Department, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia.,School of Health, Medical and Applied Sciences, College of Health Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | - Luke Heales
- School of Health, Medical and Applied Sciences, College of Health Sciences, Central Queensland University, Rockhampton, Queensland, Australia
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Multisite Evaluation of Toothbrushes and Microbial Growth in the Hospital Setting. CLIN NURSE SPEC 2023; 37:83-89. [PMID: 36799704 PMCID: PMC9969552 DOI: 10.1097/nur.0000000000000733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
DESIGN This observational, descriptive study was conducted to determine the prevalence of microbial growth on toothbrushes found in hospital patient rooms. METHODS Toothbrush sampling was conducted in 136 acute care hospitals and medical centers from November 2018 through February 2022. Inclusion criteria for the units and patient rooms sampled were as follows: general adult medical-surgical units or critical care units; rooms occupied by adults 18 years or older who were capable of (1) mobilizing to the bathroom; (2) using a standard manual, bristled toothbrush; and (3) room did not have signage indicating isolation procedures. RESULTS A total of 5340 patient rooms were surveyed. Of the rooms included, 46% (2455) of patients did not have a toothbrush available or had not used a toothbrush (still in package and/or toothpaste not opened). Of the used toothbrushes collected (n = 1817): 48% (872/1817) had at least 1 organism; 14% (251/1817) of the toothbrushes were positive for 3 or more organisms. CONCLUSIONS These results identify the lack of availability of toothbrushes for patients and support the need for hospitals to incorporate a rigorous, consistent, and comprehensive oral care program to address the evident risk of microbe exposure in the oral cavity.
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Cilloniz C, Luna CM, Hurtado JC, Marcos MÁ, Torres A. Respiratory viruses: their importance and lessons learned from COVID-19. Eur Respir Rev 2022; 31:31/166/220051. [PMID: 36261158 DOI: 10.1183/16000617.0051-2022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/30/2022] [Indexed: 01/08/2023] Open
Abstract
Respiratory virus infection can cause severe illnesses capable of inducing acute respiratory failure that can progress rapidly to acute respiratory distress syndrome (ARDS). ARDS is related to poor outcomes, especially in individuals with a higher risk of infection, such as the elderly and those with comorbidities, i.e. obesity, asthma, diabetes mellitus and chronic respiratory or cardiovascular disease. Despite this, effective antiviral treatments available for severe viral lung infections are scarce. The coronavirus disease 2019 (COVID-19) pandemic demonstrated that there is also a need to understand the role of airborne transmission of respiratory viruses. Robust evidence supporting this exists, but better comprehension could help implement adequate measures to mitigate respiratory viral infections. In severe viral lung infections, early diagnosis, risk stratification and prognosis are essential in managing patients. Biomarkers can provide reliable, timely and accessible information possibly helpful for clinicians in managing severe lung viral infections. Although respiratory viruses highly impact global health, more research is needed to improve care and prognosis of severe lung viral infections. In this review, we discuss the epidemiology, diagnosis, clinical characteristics, management and prognosis of patients with severe infections due to respiratory viruses.
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Affiliation(s)
- Catia Cilloniz
- Pneumology Dept, Respiratory Institute, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain .,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (Ciberes), Barcelona, Spain.,Faculty of Health Sciences, Continental University, Huancayo, Peru
| | - Carlos M Luna
- Pneumology Division, Hospital of Clínicas, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Juan Carlos Hurtado
- Dept of Microbiology, Hospital Clinic, Universitat de Barcelona, ISGlobal, Barcelona, Spain
| | - María Ángeles Marcos
- Dept of Microbiology, Hospital Clinic, Universitat de Barcelona, ISGlobal, Barcelona, Spain
| | - Antoni Torres
- Pneumology Dept, Respiratory Institute, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
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Birrer M, Perrig M, Hobi F, Gfeller C, Atkinson A, Egger M, Bartholdi C, Aujesky D, Marschall J, Sommerstein R. Droplet precautions on-site (DroPS) during the influenza season 2018/2019: a possible alternative to single room isolation for respiratory viral infections. Antimicrob Resist Infect Control 2022; 11:2. [PMID: 35000584 PMCID: PMC8743058 DOI: 10.1186/s13756-021-01038-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 11/12/2022] Open
Abstract
Background The guideline-driven and widely implemented single room isolation strategy for respiratory viral infections (RVI) such as influenza or respiratory syncytial virus (RSV) can lead to a shortage of available hospital beds. We discuss our experience with the introduction of droplet precautions on-site (DroPS) as a possible alternative. Methods During the 2018/19 influenza season we introduced DroPS on several wards of a single tertiary care center, while other wards maintained the traditional single room isolation strategy. On a daily basis, we evaluated patients for the development of respiratory symptoms and screened those with a clinical diagnosis of hospital-acquired respiratory viral infection (HARVI) for influenza/RSV by molecular rapid test. If negative, it was followed by a multiplex respiratory virus PCR. We report the concept of DroPS, the feasibility of the strategy and the rate of microbiologically confirmed HARVI with influenza or RSV infection on the DroPS wards compared to wards using the traditional single room isolation strategy. Results We evaluated all hospitalised patients at risk for a HARVI, 741 (72%) on the DroPS wards and 293 (28%) on the regular wards. The hospital-acquired infection rate with influenza or RSV was 2/741 (0.3%; 1× influenza A, 1× RSV) on the DroPS wards and 2/293 (0.7%; 2× influenza A) on the regular wards. Conclusions Droplet precautions on-site (DroPS) may be a simple and potentially resource-saving alternative to the standard single room isolation strategy for respiratory viral infections. Further studies in a larger clinical context are needed to document its safety. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-01038-y.
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Carey E, Chen HYP, Baker D, Blankenhorn R, Vega RJ, Ho M, Munro S. The association between non-ventilator associated hospital acquired pneumonia and patient outcomes among U.S. Veterans. Am J Infect Control 2022; 50:1339-1345. [PMID: 35231564 DOI: 10.1016/j.ajic.2022.02.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/14/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Non-ventilator associated hospital acquired pneumonia (NV-HAP) affects approximately 1 in 100 hospitalized patients yet risk-adjusted outcomes associated with developing NV-HAP are unknown. METHODS Retrospective cohort study with propensity score matched populations (NV-HAP vs no NV-HAP), using ICD-10 codes for bacterial pneumonia not present on admission. Outcomes included the patient level probability of NV-HAP developing among acute care non-transfer admissions in 133 Veterans Affairs hospitals and subsequent mortality, length of stay, inpatient sepsis, and 12-month costs. RESULTS NV-HAP occurred in 0.6% of Veteran admissions. Among admissions that developed NV-HAP, the mean length of stay of 26.3 days (6.72 days among non-NV-HAP), 30-day mortality was 18.4% (4.5% among non-NV-HAP), 1-year mortality was 47.8% (21.4% among non-NV-HAP), and total median 12-month direct medical costs were $138,136.32 ($64,357.21 among non-NV-HAP). Inpatient sepsis occurred in approximately 20% of NV-HAP admissions (0.7% among non-NV-HAP). Data available at admission was insufficient to identify high and low risk patient groups. CONCLUSIONS NV-HAP is associated with severely worse patient outcomes and increased costs of care up to 12 months post-episode. Since population risk stratification is not feasible, prevention efforts should be directed at the full population of hospitalized Veterans.
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Affiliation(s)
- Evan Carey
- Research and Development, Rocky Mountain Regional VA Medical Center, Aurora, CO; The VA Collaborative Evaluation Center (VACE), A virtual center based at the Rocky Mountain Regional, Seattle, and Louis Stokes Cleveland VA Medical Centers; Aurora, CO, Seattle, WA, Cleveland, OH; Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Auora, CO.
| | - Hung-Yuan P Chen
- Research and Development, Rocky Mountain Regional VA Medical Center, Aurora, CO; The VA Collaborative Evaluation Center (VACE), A virtual center based at the Rocky Mountain Regional, Seattle, and Louis Stokes Cleveland VA Medical Centers; Aurora, CO, Seattle, WA, Cleveland, OH
| | - Dian Baker
- School of Nursing, California State University, Sacramento, CA
| | - Richard Blankenhorn
- Research and Development, Rocky Mountain Regional VA Medical Center, Aurora, CO; The VA Collaborative Evaluation Center (VACE), A virtual center based at the Rocky Mountain Regional, Seattle, and Louis Stokes Cleveland VA Medical Centers; Aurora, CO, Seattle, WA, Cleveland, OH
| | - Ryan J Vega
- Office of Healthcare Innovation and Learning, Veterans Health Administration, Washington, DC; Department of Internal Medicine, George Washington School of Medicine and Health Sciences, Washington DC
| | - Michael Ho
- Research and Development, Rocky Mountain Regional VA Medical Center, Aurora, CO; The VA Collaborative Evaluation Center (VACE), A virtual center based at the Rocky Mountain Regional, Seattle, and Louis Stokes Cleveland VA Medical Centers; Aurora, CO, Seattle, WA, Cleveland, OH; Department of Medicine, Division of Cardiology, University of Colorado Denver - Anschutz Medical Campus, Denver, CO
| | - Shannon Munro
- Research and Development, Salem VA Medical Center, Salem, VA
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Hu L, Zhang Y, Wang J, Xuan J, Yang J, Wang J, Wei B. A Prognostic Model for In-Hospital Mortality in Critically Ill Patients with Pneumonia. Infect Drug Resist 2022; 15:6441-6450. [PMID: 36349215 PMCID: PMC9637337 DOI: 10.2147/idr.s377411] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose To determine the utility of a novel serum biomarker for the outcome prediction of critically ill patients with pneumonia. Patients and Methods A retrospective analysis of critically ill patients was performed at an emergency department. The expression and prediction value of parameters were assessed. Binary logistic regression analysis was utilized to determine the indicators associated with in-hospital mortality of pneumonia patients. The Last Absolute Shrinkage and Selection Operator was used to further determine the independent predictors, which were validated by multiple logistic regression. The receiver operator characteristic curve was performed to assess their prediction values. A prognostic nomogram model was finally established for the outcome prediction for critically ill patients with pneumonia. Results Retinol-binding protein (RBP) was significantly reduced in non-survived and pneumonia patients. CURB-65 score, levels of RBP, and blood urea nitrogen (BUN) were associated with in-hospital mortality of critically ill patients with pneumonia. Their combination was determined to be an ideal prognostic predictor (area under the curve of 0.762) and further developed into a nomogram prediction model (c-index 0.764). Conclusion RBP is a novel in-hospital mortality predictor, which well supplements the CURB-65 score for critical pneumonia patients.
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Affiliation(s)
- Le Hu
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Clinical Center for Medicine in Acute Infection, Capital Medical University, Beijing, People’s Republic of China
| | - Ying Zhang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Clinical Center for Medicine in Acute Infection, Capital Medical University, Beijing, People’s Republic of China
| | - Jia Wang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Clinical Center for Medicine in Acute Infection, Capital Medical University, Beijing, People’s Republic of China
| | - Jingchao Xuan
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Clinical Center for Medicine in Acute Infection, Capital Medical University, Beijing, People’s Republic of China
| | - Jun Yang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Clinical Center for Medicine in Acute Infection, Capital Medical University, Beijing, People’s Republic of China
| | - Junyu Wang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Clinical Center for Medicine in Acute Infection, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Junyu Wang; Bing Wei, Department of Emergency Medicine, Beijing Chao-Yang Hospital Jingxi Branch, Capital Medical University, No. 5 Jingyuan Road, Shijingshan, Beijing, 100043, People’s Republic of China, Email ;
| | - Bing Wei
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Clinical Center for Medicine in Acute Infection, Capital Medical University, Beijing, People’s Republic of China
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Analysis of Microbiological and Clinical Characteristics of Bacterial Infection in Patients with Pulmonary Infection. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:5607358. [PMID: 35755768 PMCID: PMC9225854 DOI: 10.1155/2022/5607358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 04/24/2022] [Accepted: 05/06/2022] [Indexed: 01/06/2023]
Abstract
Objective Using data investigation, the microbiology of bacterial infection in patients with pulmonary infection was discussed, and its clinical characteristics were analyzed. Methods The clinical data of 160 patients with pulmonary infection in our hospital from March 2019 to March 2021 were collected and analyzed. Blood samples were collected and cultured, and the pathogens were identified. The distribution, constituent ratio, and drug resistance of pathogens in elderly patients with pulmonary infection were analyzed. Logistics regression analysis was adopted to analyze the risk factors of pulmonary infection. Results Of the 160 patients with pulmonary infection, 107 were males (66.88%) and 53 were females (33.13%). The age ranged from 12 to 97 years old, with an average of 63.82 ± 12.64 years old. Sevent-six patients (47.50%) were over 65 years old. Urban patients accounted for 71.88%, and rural patients accounted for 28.13%, of which workers accounted for 46.25%, and farmers and cadres each accounted for about 4%. 85.62% of smokers have smoked for more than 4 years. Eighty-five patients had chronic diseases such as coronary heart disease, hypertension, diabetes, and cerebrovascular disease. Heart failure occurred in 10.00%, old tuberculosis in 11.25%, and new tuberculosis in 5.63%. The average hospital stay of the patients was 14.93 days, and the improvement rate was 91.25%. Eleven patients died. Among the 160 patients with pulmonary infection, COPD, pneumonia, and lung cancer accounted for the highest proportions, and idiopathic pulmonary fibrosis, bronchitis dilatation, tuberculosis, and bronchial asthma also played an important role. Pathogenic bacteria were detected in 104 of the 160 elderly patients with pulmonary infection, and the detection rate was 65.00%. A total of 444 strains of pathogenic bacteria were detected, including 328 strains of Gram-negative bacteria (73.87%, mainly Klebsiella pneumoniae, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and Serratia marcescens), 28 strains of Gram-positive bacteria (6.30%, mainly Staphylococcus aureus), and 88 strains of fungi (20.00%, mainly Candida albicans). Regarding Klebsiella pneumoniae in elderly patients with pulmonary infection, the drug resistance rates were 59.72% for amoxicillin-clavulanate potassium, 52.78% for ampicillin sodium-sulbactam sodium, and 51.39% for cefazolin sodium. Regarding Pseudomonas aeruginosa, the drug resistance rates were 29.31% for ticarcillin sodium-potassium clavulanate, 27.59% for piperacillin sodium, and 24.14% for gentamicin. Regarding Stenotrophomonas maltophilia, the drug resistance rates were 79.55% for ceftazidime, 38.64% for chloramphenicol, and 31.82% for levofloxacin. Regarding Serratia marcescens, the drug resistance rates from high to low were 74.42% for cefotaxime, 72.09% for moxifloxacin, and 69.77% for gentamicin. Regarding Staphylococcus aureus in elderly patients with pulmonary infection, the drug resistance rates were 100.00% for penicillin, 61.54% for erythromycin, 61.54% for clarithromycin, and 61.54% for azithromycin. Regarding Candida albicans, the drug resistance rates from high to low were 22.41% for caspofungin, 15.52% for itraconazole, and 9.09% for fluconazole. The results of univariate analysis of pulmonary bacterial infection indicated that there were no significant differences in sex and body mass index between nonbacterial infection group and bacterial infection group (P > 0.05). There were significant differences in terms of dust or harmful gas exposure, family member smoking, chronic lung disease history, age, smoking, family cooking, hospital stay, and indwelling catheter (P < 0.05). Exposure to dust or harmful gases, family cooking, age, history of chronic lung disease, indwelling catheter, and length of hospital stay were risk factors for pulmonary bacterial infection (P < 0.05). Conclusion Gram-negative bacteria are the main pathogens in elderly patients with pulmonary infection. Antibiotics should be administered reasonably according to the results of the drug sensitivity test. Older age, history of chronic lung disease, catheter indwelling, and length of stay are the risk factors for pulmonary bacterial infection.
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Kim JY, Yang KS, Chung Y, Lee KB, Suh JW, Kim SB, Sohn JW, Yoon YK. Epidemiologic Characteristics and Clinical Significance of Respiratory Viral Infections Among Adult Patients Admitted to the Intensive Care Unit. Front Med (Lausanne) 2022; 9:829624. [PMID: 35685411 PMCID: PMC9171106 DOI: 10.3389/fmed.2022.829624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background The diagnosis of respiratory viral infections (RVIs) in critically ill patients is important for determining treatment options and adhering to infection-control protocols. However, data on the incidence and occurrence patterns of RVIs are scarce. We investigated the epidemiology and clinical impact of RVIs in critically ill patients. Methods This retrospective observational study was conducted in a tertiary hospital in South Korea between November 2014 and September 2020. Adult patients (≥ 18 years of age) who tested positive for an RVI by multiplex polymerase chain reaction (mPCR) and were admitted to the intensive care unit (ICU) were included in the study. Clinical characteristics and outcomes were obtained by reviewing electronic medical records. Pearson's χ2 test and Fisher's exact test, Mann-Whitney U test was used to compare between groups of patients. Trend analysis and the χ2-based Q test was used to analyze test behavior of physicians performing mPCR test. Results Among 22,517 patients admitted to the ICU during the study period, 2,222 (9.9%) underwent mPCR testing for an RVI. The median timing of mPCR testing after ICU admission was 1 day (IQR, 0-2). A total of 335 (15.1%) non-duplicative RVI-positive cases were included in the analysis. The incidence rate of RVIs in ICU patients was 30.45 per 10,000 patient-days. The most frequently detected RVI was influenza A (27.8%), followed by rhinovirus (25.4%). Thirty-two (9.6%) RVI-positive patients were diagnosed with upper respiratory infections, 193 (64.1%) with community-acquired, and 108 (35.9%) with hospital-acquired pneumonia. All-cause mortality and mortality related to respiratory tract infection (RTI) were 30.7% and 22.1%, respectively. The initial presentation of septic shock, requirement for mechanical ventilation, and lymphocytopenia were significant predictors of RTI-related mortality. Of the RVI-positive patients, 151 (45.1%) had nonviral coinfections and presented with higher clinical severity and longer hospital stays than patients infected solely with viral pathogens. Conclusion The incidence of RVIs in ICU patients is common. ICU patients with RVIs had high mortality and frequently presented with coinfections with nonviral pathogens, which were associated with a higher clinical severity than sole RVI. Increased testing for RVIs will enhance infection-control efforts and improve patient care.
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Affiliation(s)
- Jeong Yeon Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Kyung Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Seoul, South Korea
| | - Youseung Chung
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Ki-Byung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jin Woong Suh
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Sun Bean Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jang Wook Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
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M. Patil S. Hospital-Acquired Pneumonia. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Pneumonia acquired during hospitalization is called nosocomial pneumonia (NP). Nosocomial pneumonia is divided into two types. Hospital-acquired pneumonia (HAP) refers to hospital-acquired pneumonia, whereas ventilator-associated pneumonia (VAP) refers to ventilator-associated pneumonia. Most clinical literature stresses VAP’s importance and associated mortality and morbidity, whereas HAP is not given enough attention even while being the most common cause of NP. HAP, like VAP, carries a high mortality and morbidity. HAP is the commonest cause of mortality from hospital-acquired infections. HAP is a common determinant for intensive care unit (ICU) admits with respiratory failure. Recent research has identified definite risk factors responsible for HAP. If these are prevented or modified, the HAP incidence can be significantly decreased with improved clinical outcomes and lesser utilization of the health care resources. The prevention approach will need multiple strategies to address the issues. Precise epidemiological data on HAP is deficient due to limitations of the commonly used diagnostic measures. The diagnostic modalities available in HAP are less invasive than VAP. Recent infectious disease society guidelines have stressed the importance of HAP by removing healthcare-associated pneumonia as a diagnosis. Specific differences exist between HAP and VAP, which are gleaned over in this chapter.
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Moeinafshar A, Rezaei N. Introductory Chapter: Pneumonia. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.103675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Chen Z, Xu Z, Wu H, Gao S, Wang H, Jiang J, Li X, Chen L. Derivation and validation of a nomogram for predicting nonventilator hospital-acquired pneumonia among older hospitalized patients. BMC Pulm Med 2022; 22:144. [PMID: 35428276 PMCID: PMC9011946 DOI: 10.1186/s12890-022-01941-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background Currently, there is no effective tool for predicting the risk of nonventilator hospital-acquired pneumonia (NV-HAP) in older hospitalized patients. The current study aimed to develop and validate a simple nomogram and a dynamic web-based calculator for predicting the risk of NV-HAP among older hospitalized patients. Methods A retrospective evaluation was conducted on 15,420 consecutive older hospitalized patients admitted to a tertiary hospital in China between September 2017 and June 2020. The patients were randomly divided into training (n = 10,796) and validation (n = 4624) cohorts at a ratio of 7:3. Predictors of NV-HAP were screened using the least absolute shrinkage and selection operator method and multivariate logistic regression. The identified predictors were integrated to construct a nomogram using R software. Furthermore, the optimum cut-off value for the clinical application of the model was calculated using the Youden index. The concordance index (C-index), GiViTI calibration belts, and decision curve were analysed to validate the discrimination, calibration, and clinical utility of the model, respectively. Finally, a dynamic web-based calculator was developed to facilitate utilization of the nomogram. Results Predictors included in the nomogram were the Charlson comorbidity index, NRS-2002, enteral tube feeding, Barthel Index, use of sedatives, use of NSAIDs, use of inhaled steroids, and "time at risk". The C-index of the nomogram for the training and validation cohorts was 0.813 and 0.821, respectively. The 95% CI region of the GiViTI calibration belt in the training (P = 0.694) and validation (P = 0.614) cohorts did not cross the diagonal bisector line, suggesting that the prediction model had good discrimination and calibration. Furthermore, the optimal cut-off values for the training and validation cohorts were 1.58 and 1.74%, respectively. Analysis of the decision curve showed that the nomogram had good clinical value when the threshold likelihood was between 0 and 49%. Conclusion The developed nomogram can be used to predict the risk of NV-HAP among older hospitalized patients. It can, therefore, help healthcare providers initiate targeted medical interventions in a timely manner for high-risk groups. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01941-z.
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Scannapieco FA, Giuliano KK, Baker D. Oral health status and the etiology and prevention of nonventilator hospital-associated pneumonia. Periodontol 2000 2022; 89:51-58. [PMID: 35244952 DOI: 10.1111/prd.12423] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Nonventilator hospital-associated pneumonia has recently emerged as an important preventable hospital-associated infection, and is a leading cause of healthcare-associated infection. Substantial accumulated evidence links poor oral health with an increased risk of pneumonia, which can be caused by bacterial, viral, or fungal pathogens, each with their own distinct mechanisms of transmission and host susceptibility. These infections are frequently polymicrobial, and often include microbes from biofilms in the oral cavity. Evidence documenting the importance of oral care to prevent nonventilator hospital-associated pneumonia is continuing to emerge. Reduction of oral biofilm in these populations will reduce the numbers of potential respiratory pathogens in the oral secretions that can be aspirated, which in turn can reduce the risk for pneumonia. This review summarizes up-to-date information on the role of oral care in the prevention of nonventilator hospital-associated pneumonia.
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Affiliation(s)
- Frank A Scannapieco
- Department of Oral Biology, School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Karen K Giuliano
- Elaine Marieb Center for Nursing and Engineering Innovation, Institute for Applied Life Sciences and College of Nursing, Nursing and Engineering Center for Innovation, University of Massachusetts, Amherst, Massachusetts, USA
| | - Dian Baker
- School of Nursing, California State University, Sacramento, California, USA
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Gao J, Guo J, Chen J, Ding C, Wang J, Huang Q, Jian Y, Zhao X, Li M, Gao Y, Yang C, Wang W. d-Amino Acid-Based Metabolic Labeling Enables a Fast Antibiotic Susceptibility Test of Both Isolated Bacteria and Bronchoalveolar Lavage Fluid. Adv Healthc Mater 2022; 11:e2101736. [PMID: 34898025 DOI: 10.1002/adhm.202101736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/18/2021] [Indexed: 11/07/2022]
Abstract
The threat of multidrug-resistant bacteria has escalated rapidly, increasing the demand for accurate antibiotic susceptibility tests (ASTs). Traditional bacterial growth yield-based ASTs often take overnight to report, delaying the timely guidance of antibiotic use. Here, a fluorescent d-amino acid (FDAA) labeling-based AST (FaAST) is reported, which can quickly provide accurate minimum inhibitory concentrations (MICs). The FDAA-labeling signals that reflect the bacterial metabolic status underlie the flow cytometry-based strategy for MIC determination. Resistant bacteria show a reluctant decline in FDAA-labeling (inhibited metabolism) after treatment with the corresponding antibiotics, whereas susceptible bacteria demonstrate quick responses to low doses of drugs. The MICs are determined based on the changing trends in labeling. After testing 23 clinical isolates and laboratory strains of the most critical drug-resistant bacteria against a panel of representative antibiotics, FaAST shows a high susceptibility category with an accuracy of 98.13%. Moreover, FaAST can also make quick and accurate diagnosis against bronchoalveolar lavage fluids collected from hospital-acquired pneumonia patients, saving 2-4 days in guiding antibiotic use for this life-threatening infection. Thus, the speed, accuracy, and broad applicability of FaAST will be valuable in informing antibiotic decisions when treating critical infections caused by drug-resistant bacteria.
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Affiliation(s)
- Juan Gao
- Institute of Molecular Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Junnan Guo
- Institute of Molecular Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Jianxiao Chen
- Department of Critical Care Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Chenling Ding
- Department of Critical Care Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Jiemin Wang
- Department of Critical Care Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Qian Huang
- Department of Laboratory Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Ying Jian
- Department of Laboratory Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Xianyuan Zhao
- Department of Critical Care Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Min Li
- Department of Laboratory Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Yuan Gao
- Department of Critical Care Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
| | - Chaoyong Yang
- Institute of Molecular Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
- The MOE Key Laboratory of Spectrochemical Analysis and Instrumentation Key Laboratory for Chemical Biology of Fujian Province State Key Laboratory of Physical Chemistry of Solid Surfaces Department of Chemical Biology College of Chemistry and Chemical Engineering Xiamen University Xiamen 361005 China
| | - Wei Wang
- Institute of Molecular Medicine Renji Hospital Shanghai Jiao Tong University School of Medicine Shanghai 200127 China
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Finding the balance between overtreatment versus undertreatment for hospital-acquired pneumonia. Infect Control Hosp Epidemiol 2022; 43:376-378. [PMID: 34847978 DOI: 10.1017/ice.2021.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Cillóniz C, Pericàs JM, Rojas JR, Torres A. Severe Infections Due to Respiratory Viruses. Semin Respir Crit Care Med 2022; 43:60-74. [PMID: 35172359 DOI: 10.1055/s-0041-1740982] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Severe viral infections may result in severe illnesses capable of causing acute respiratory failure that could progress rapidly to acute respiratory distress syndrome (ARDS), related to worse outcomes, especially in individuals with a higher risk of infection, including the elderly and those with comorbidities such as asthma, diabetes mellitus and chronic respiratory or cardiovascular disease. In addition, in cases of severe viral pneumonia, co-infection with bacteria such as Streptococcus pneumoniae and Staphylococcus aureus is related to worse outcomes. Respiratory viruses like influenza, rhinovirus, parainfluenza, adenovirus, metapneumovirus, respiratory syncytial virus, and coronavirus have increasingly been detected. This trend has become more prevalent, especially in critically ill patients, due to the availability and implementation of molecular assays in clinical practice. Respiratory viruses have been diagnosed as a frequent cause of severe pneumonia, including cases of community-acquired pneumonia, hospital-acquired pneumonia, and ventilator-associated pneumonia. In this review, we will discuss the epidemiology, diagnosis, clinical characteristics, management, and prognosis of patients with severe infections due to respiratory viruses, with a focus on influenza viruses, non-influenza viruses, and coronaviruses.
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Affiliation(s)
- Catia Cillóniz
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Juan M Pericàs
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain.,Internal Medicine Department, Vall d'Hebron Institute for Research, Barcelona, Spain
| | - Jorge R Rojas
- Department of Pneumology, Hospital Regional Docente Clínico Quirúrgico Daniel Alcides Carrión, Huancayo, Perú
| | - Antoni Torres
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
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Nimer NA. Nosocomial Infection and Antibiotic-Resistant Threat in the Middle East. Infect Drug Resist 2022; 15:631-639. [PMID: 35241915 PMCID: PMC8887909 DOI: 10.2147/idr.s351755] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/08/2022] [Indexed: 12/13/2022] Open
Abstract
The prevalence of nosocomial infections (NIs) is associated with different bacteria found in hospitals. These infections in their extreme conditions result in morbidity and mortality. This study aims to provide a detailed review of literary studies to identify the prevalence of nosocomial infections and antibiotic-resistance specifically in Middle Eastern countries. A literature review approach is followed in this study. It further identifies different causes and effects associated with nosocomial infections in the given regions. Relevant studies were used to extract important information, specifically related to the Middle Eastern countries. The findings indicated that nosocomial infections following antibiotic resistance are an emerging problem in Middle Eastern countries, leading to significant morbidity and mortality. Most frequently reported NIs in Middle East in our review are bloodstream infections (BSIs) (50%) and surgical site infections (SSIs) (50%) followed by urinary tract infections (UTIs). Escherichia coli and Klebsiella species among gram-negative bacteria, Staphylococcus aureus among gram-positive bacterial and fungal pathogens such as Candida species are most reported pathogens involved in nosocomial infections and resistance to penicillins, cephalosporins, carbapenems and fluoroquinolones antibiotics were significantly reported. However, most studies showed minimum resistance of pathogens against drug colistin. To control the growth rate of the given condition, government officials are suggested to ensure that hospitals follow adequate healthcare mechanisms. Also, sufficient education must be provided to the hospital staff about the causes and effects of the given disease.
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Affiliation(s)
- Nabil A Nimer
- Faculty of Pharmacy, Philadelphia University, Amman, Jordan
- Correspondence: Nabil A Nimer, Email
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Wicky PH, Martin-Loeches I, Timsit JF. "HAP and VAP after Guidelines". Semin Respir Crit Care Med 2022; 43:248-254. [PMID: 35042265 DOI: 10.1055/s-0041-1740246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Nosocomial pneumonia is associated with worsened prognosis when diagnosed in intensive care unit (ICU), ranging from 12 to 48% mortality. The incidence rate of ventilation-acquired pneumonia tends to decrease below 15/1,000 intubation-day. Still, international guidelines are heterogeneous about diagnostic criteria because of inaccuracy of available methods. New entities have thus emerged concerning lower respiratory tract infection, namely ventilation-acquired tracheobronchitis (VAT), or ICU-acquired pneumonia (ICUAP), eventually requiring invasive ventilation (v-ICUAP), according to the type of ventilation support. The potential discrepancy with non-invasive methods could finally lead to underdiagnosis in almost two-thirds of non-intubated patients. Delayed diagnostic could explain in part the 2-fold increase in mortality of penumonia when invasive ventilation is initiated. Here we discuss the rationale underlying this new classification.Many situations can lead to misdiagnosis, even more when the invasive mechanical ventilation is initiated. The chest radiography lacks sntivity and specificity for diagnosing pneumonia. The place of chest computed tomography and lung ultrasonography for routine diagnostic of new plumonary infiltrate remain to be evaluated.Microbiological methods used to confirm the diagnostic can be heterogeneous. The development of molecular diagnostic tools may improve the adequacy of antimicrobial therapies of ventilated patients with pneumonia, but we need to further assess its impact in non-ventilated pneumonia.In this review we introduce distinction between hospital-acquired pneumonia according to the localization in the hospital and the oxygenation/ventilation mode. A clarification of definition is the first step to develop more accurate diagnostic strategies and to improve the patients' prognosis.
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Affiliation(s)
- Paul-Henri Wicky
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France
| | - Ignacio Martin-Loeches
- Department of Anaesthesia and Critical Care Medicine, St. James's Hospital, Dublin, Ireland.,Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France.,UMR 1137, IAME, Université Paris Diderot, Paris, France
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Renaud C, Kollef MH. Classical and Molecular Techniques to Diagnose HAP/VAP. Semin Respir Crit Care Med 2022; 43:219-228. [PMID: 35042263 DOI: 10.1055/s-0041-1739359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Nosocomial pneumonia, including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), are the most common nosocomial infections occurring in critically ill patients requiring intensive care. However, challenges exist in making a timely and accurate diagnosis of HAP and VAP. Under diagnosis of HAP and VAP can result in greater mortality risk, especially if accompanied by delays in the administration of appropriate antimicrobial treatment. Over diagnosis of HAP and VAP results in the unnecessary administration of broad spectrum antibiotics that can lead to further escalation of antibiotic resistance. Optimal diagnosis and management of HAP and VAP require a systematic approach that combines clinical and radiographic assessments along with proper microbiologic techniques. The use of more invasive sampling methods (bronchoalveolar lavage and protected specimen brush) may enhance specimen collection resulting in more specific diagnoses to limit unnecessary antibiotic exposure. Molecular techniques, currently in use and investigational technique, may improve the diagnosis of HAP and VAP by allowing more rapid identification of offending pathogens, if present, thus increasing both appropriate antibiotic treatment and avoiding unnecessary drug exposure.
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Affiliation(s)
- Cherie Renaud
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
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Klompas M. New Insights into the Prevention of Hospital-Acquired Pneumonia/Ventilator-Associated Pneumonia Caused by Viruses. Semin Respir Crit Care Med 2022; 43:295-303. [PMID: 35042261 DOI: 10.1055/s-0041-1740582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A fifth or more of hospital-acquired pneumonias may be attributable to respiratory viruses. The SARS-CoV-2 pandemic has clearly demonstrated the potential morbidity and mortality of respiratory viruses and the constant threat of nosocomial transmission and hospital-based clusters. Data from before the pandemic suggest the same can be true of influenza, respiratory syncytial virus, and other respiratory viruses. The pandemic has also helped clarify the primary mechanisms and risk factors for viral transmission. Respiratory viruses are primarily transmitted by respiratory aerosols that are routinely emitted when people exhale, talk, and cough. Labored breathing and coughing increase aerosol generation to a much greater extent than intubation, extubation, positive pressure ventilation, and other so-called aerosol-generating procedures. Transmission risk is proportional to the amount of viral exposure. Most transmissions take place over short distances because respiratory emissions are densest immediately adjacent to the source but then rapidly dilute and diffuse with distance leading to less viral exposure. The primary risk factors for transmission then are high viral loads, proximity, sustained exposure, and poor ventilation as these all increase net viral exposure. Poor ventilation increases the risk of long-distance transmission by allowing aerosol-borne viruses to accumulate over time leading to higher levels of exposure throughout an enclosed space. Surgical and procedural masks reduce viral exposure but do not eradicate it and thus lower but do not eliminate transmission risk. Most hospital-based clusters have been attributed to delayed diagnoses, transmission between roommates, and staff-to-patient infections. Strategies to prevent nosocomial respiratory viral infections include testing all patients upon admission, preventing healthcare providers from working while sick, assuring adequate ventilation, universal masking, and vaccinating both patients and healthcare workers.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.
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Affiliation(s)
- Catia Cillóniz
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Michael S Niederman
- Weill Cornell Medical College, Department of Pulmonary Critical Care Medicine, New York, NY, USA
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Klompas M, Milton DK, Rhee C, Baker MA, Leekha S. Current Insights Into Respiratory Virus Transmission and Potential Implications for Infection Control Programs : A Narrative Review. Ann Intern Med 2021; 174:1710-1718. [PMID: 34748374 DOI: 10.7326/m21-2780] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Policies to prevent respiratory virus transmission in health care settings have traditionally divided organisms into Droplet versus Airborne categories. Droplet organisms (for example, influenza) are said to be transmitted via large respiratory secretions that rapidly fall to the ground within 1 to 2 meters and are adequately blocked by surgical masks. Airborne pathogens (for example, measles), by contrast, are transmitted by aerosols that are small enough and light enough to carry beyond 2 meters and to penetrate the gaps between masks and faces; health care workers are advised to wear N95 respirators and to place these patients in negative-pressure rooms. Respirators and negative-pressure rooms are also recommended when caring for patients with influenza or SARS-CoV-2 who are undergoing "aerosol-generating procedures," such as intubation. An increasing body of evidence, however, questions this framework. People routinely emit respiratory particles in a range of sizes, but most are aerosols, and most procedures do not generate meaningfully more aerosols than ordinary breathing, and far fewer than coughing, exercise, or labored breathing. Most transmission nonetheless occurs at close range because virus-laden aerosols are most concentrated at the source; they then diffuse and dilute with distance, making long-distance transmission rare in well-ventilated spaces. The primary risk factors for nosocomial transmission are community incidence rates, viral load, symptoms, proximity, duration of exposure, and poor ventilation. Failure to appreciate these factors may lead to underappreciation of some risks (for example, overestimation of the protection provided by medical masks, insufficient attention to ventilation) or misallocation of limited resources (for example, reserving N95 respirators and negative-pressure rooms only for aerosol-generating procedures or requiring negative-pressure rooms for all patients with SARS-CoV-2 infection regardless of stage of illness). Enhanced understanding of the factors governing respiratory pathogen transmission may inform the development of more effective policies to prevent nosocomial transmission of respiratory pathogens.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (M.K., C.R., M.A.B.)
| | - Donald K Milton
- Maryland Institute for Applied Environmental Health, School of Public Health, University of Maryland, College Park, Maryland (D.K.M.)
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (M.K., C.R., M.A.B.)
| | - Meghan A Baker
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (M.K., C.R., M.A.B.)
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland (S.L.)
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40
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Assessing the Impact of Gender and COPD on the Incidence and Mortality of Hospital-Acquired Pneumonia. A Retrospective Cohort Study Using the Spanish National Discharge Database (2016-2019). J Clin Med 2021; 10:jcm10225453. [PMID: 34830733 PMCID: PMC8625205 DOI: 10.3390/jcm10225453] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND We aim to analyze incidence and outcomes of patients hospitalized with hospital-acquired pneumonia (HAP) according to chronic obstructive pulmonary disease (COPD) status and sex in Spain (2016-2019). METHODS We conducted a retrospective cohort study using national hospital discharge data of patients ≥40 years with a primary diagnosis of HAP, using the specific diagnostics of non-ventilator (NV)-HAP and ventilator-associated pneumonia (VAP). RESULTS We identified 37,029 patients with HAP ((NV)-HAP 87.28%, VAP 12.72%), 13.40% with COPD. HAP incidence increased over time, but only in subjects without COPD (p < 0.001). In women, incidence of HAP and (NV)-HAP was similar regardless of COPD status, but VAP incidence was lower in COPD women (p = 0.007). In men, the incidence of (NV)-HAP was significantly higher in those with COPD, while VAP incidence was lower in COPD men (p < 0.001). The in-hospital mortality (IHM) was similar in men and women with and without COPD. The risk of dying in hospital increased with age, congestive heart failure, cancer, and dialysis among men and women with COPD. Men that underwent surgery had a lower risk of IHM. VAP increased 2.58-times the probability of dying in men and women. Finally, sex was not associated with IHM among COPD patients. CONCLUSIONS Incidence of HAP was significantly higher in COPD patients than in those without COPD, at the expense of (NV)-HAP but not of VAP. When stratifying by sex, we found that the difference was caused by men. IHM was similar in COPD and non-COPD patients, with no significant change overtime. In addition, sex was not associated with IHM.
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Ilges D, Ritchie DJ, Krekel T, Neuner EA, Hampton N, Kollef MH, Micek S. Assessment of Antibiotic De-escalation by Spectrum Score in Patients With Nosocomial Pneumonia: A Single-Center, Retrospective Cohort Study. Open Forum Infect Dis 2021; 8:ofab508. [PMID: 34805436 PMCID: PMC8600177 DOI: 10.1093/ofid/ofab508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hospital-acquired and ventilator-associated pneumonia (HAP/VAP) cause significant mortality. Guidelines recommend empiric broad-spectrum antibiotics followed by de-escalation (DE). This study sought to assess the impact of DE on treatment failure. METHODS This single-center retrospective cohort study screened all adult patients with a discharge diagnosis code for pneumonia from 2016 to 2019. Patients were enrolled if they met predefined criteria for HAP/VAP ≥48 hours after admission. Date of pneumonia diagnosis was defined as day 0. Spectrum scores were calculated, and DE was defined as a score reduction on day 3 versus day 1. Patients with DE were compared to patients with no de-escalation (NDE). The primary outcome was composite treatment failure, defined as all-cause mortality or readmission for pneumonia within 30 days of diagnosis. RESULTS Of 11860 admissions screened, 1812 unique patient-admissions were included (1102 HAP, 710 VAP). Fewer patients received DE (876 DE vs 1026 NDE). Groups were well matched at baseline, although more patients receiving DE had respiratory cultures ordered (56.6% vs 50.6%, P = .011). There was no difference in composite treatment failure (35.0% DE vs 33.8% NDE, P = .604). De-escalation was not associated with treatment failure on multivariable Cox regression analysis (hazard ratio, 1.13; 95% confidence interval, 0.96-1.33). Patients receiving DE had fewer antibiotic days (median 9 vs 11, P < .0001), episodes of Clostridioides difficile infection (2.2% vs 3.8%, P = .046), and hospital days (median 20 vs 22 days, P = .006). CONCLUSIONS De-escalation and NDE resulted in similar rates of 30-day treatment failure; however, DE was associated with fewer antibiotic days, episodes of C difficile infection, and days of hospitalization.
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Affiliation(s)
- Dan Ilges
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - David J Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Elizabeth A Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Nicholas Hampton
- Center for Clinical Excellence, BJC HealthCare, St. Louis, Missouri, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott Micek
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
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42
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Lukasewicz Ferreira SA, Hubner Dalmora C, Anziliero F, de Souza Kuchenbecker R, Klarmann Ziegelmann P. Factors predicting non-ventilated hospital-acquired pneumonia: systematic review and meta-analysis. J Hosp Infect 2021; 119:64-76. [PMID: 34666117 DOI: 10.1016/j.jhin.2021.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/29/2021] [Accepted: 09/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hospital-acquired pneumonia (HAP) results in approximately 15-20% of all infections in hospitals, with more than two-thirds being in patients not using mechanical ventilation. The incidence of non-ventilated hospital-acquired pneumonia (NVHAP) is increasing, and it is associated with a longer length of stay, the need for intensive care unit hospitalization and mechanical ventilation use, and higher mortality. AIM To identify, quantify, and summarize predictive factors for NVHAP in adult patients admitted to non-intensive care units as determined by previous observational studies. METHODS PubMed, Embase, Scopus, and LILACS were systematically searched. Case-control and cohort studies were included, and a meta-analysis was performed for all factors studied more than once. National Institute of Health assessment tools were applied to assess the quality of the studies. FINDINGS Thirty-eight articles showing 204 predictive factors were included. A meta-analysis was performed for 58 factors, 32 of which were significantly associated with NVHAP. When the sensitivity analysis was performed without poor-quality studies, 24 factors remained associated with NVHAP. CONCLUSION Although there is a lack of good-quality studies to establish predictive factors for NVHAP, the results of this study showed 24 factors associated with the development of this infectious complication. Knowledge of the significant predictive factors for NVHAP will enable the identification of patients most likely to develop it.
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Affiliation(s)
- S A Lukasewicz Ferreira
- Hospital Infection Control Service, Hospital de Clínicas de Porto Alegre and Qualis, Porto Alegre, Brazil.
| | - C Hubner Dalmora
- Hospital Infection Control Service, Hospital de Clínicas de Porto Alegre and Qualis, Porto Alegre, Brazil
| | - F Anziliero
- Military Police of Rio Grande do Sul, Brazil
| | - R de Souza Kuchenbecker
- Health Technology Assessment Institute (IATS/CNPq), Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - P Klarmann Ziegelmann
- Health Technology Assessment Institute (IATS/CNPq), Department of Statistics, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Campos CGP, Pacheco A, Gaspar MDDR, Arcaro G, Reche PM, Nadal JM, Farago PV. Analysis of diagnostic criteria for ventilator-associated pneumonia: a cohort study. Rev Bras Enferm 2021; 74:e20190653. [PMID: 34406231 DOI: 10.1590/0034-7167-2019-0653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/09/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to analyze the diagnostic criteria for ventilator-associated pneumonia recommended by the Brazilian Health Regulatory Agency and the National Healthcare Safety Network/Centers for Disease Control and Prevention, as well as its risk factors. METHODS retrospective cohort study carried out in an intensive care unit throughout 12 months, in 2017. Analyses included chi-square, simple linear regression, and Kappa statistical tests and were conducted using Stata 12 software. RESULTS the sample was 543 patients who were in the intensive care unit and under mechanical ventilation, of whom 330 (60.9%) were men and 213 (39.1%) were women. Variables such as gender, age, time under mechanical ventilation, and oral hygiene proved to be significant risk factors for the development of ventilator-associated pneumonia. CONCLUSIONS patients submitted to mechanical ventilation need to be constantly evaluated so the used diagnostic methods can be accurate and applied in an objective and standardized way in Brazilian hospitals.
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Affiliation(s)
| | - Aline Pacheco
- Universidade Estadual de Ponta Grossa. Ponta Grossa, Paraná, Brazil
| | | | - Guilherme Arcaro
- Universidade Estadual de Ponta Grossa. Ponta Grossa, Paraná, Brazil
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Meng N, Ye Z, Liu Y, Qin C, Su Y. Impact of the 'weekend effect' on hospital-acquired pneumonia after aneurysmal subarachnoid hemorrhage. Postgrad Med 2021; 133:974-978. [PMID: 34323649 DOI: 10.1080/00325481.2021.1959936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Weekend admission has been reported to be associated with poor clinical outcomes of various diseases. This study aimed to determine whether weekend admission increases the incidence of hospital-acquired pneumonia (HAP) in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively analyzed aSAH patients admitted to our hospital between 2014 and 2020. These patients were divided into weekend and weekday groups. We compared the incidence of HAP and other clinical outcomes between the two groups. Risk factors for HAP were identified by logistic regression analysis. RESULTS Of 653 included aSAH patients, 145 (22%) were admitted on weekends and 508 (78%) were admitted on weekdays. The incidence of HAP in the weekend group was significantly higher than that in the weekday group (25% vs 16%, P = 0.01). The weekend group showed worse clinical outcomes, including worse neurological outcome (74% vs 65%, P = 0.03), higher risk of intensive care unit (ICU) admission (21% vs 13%, P = 0.01) and longer length of stay (21.3 vs 16.4 days, P < 0.01). Age ≥ 60 years (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3-3.0, P < 0.01), modified Fisher score (MFS) ≥ 3 (OR = 1.7, 95% CI = 1.1-2.6, P = 0.02), weekend admission (OR = 1.8, 95% CI = 1.1-2.8, P = 0.02) and operative treatment (OR = 2.3, 95% CI = 1.2-4.5, P = 0.02) were risk factors for HAP following aSAH. CONCLUSION Weekend admission was associated with a higher incidence of HAP in aSAH patients. This study suggested that medical administrators may need to optimize healthcare services on weekends.
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Affiliation(s)
- Ningqin Meng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ziming Ye
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ying Liu
- Department of Rehabilitation, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Chao Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ying Su
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Munro SC, Baker D, Giuliano KK, Sullivan SC, Haber J, Jones BE, Crist MB, Nelson RE, Carey E, Lounsbury O, Lucatorto M, Miller R, Pauley B, Klompas M. Nonventilator hospital-acquired pneumonia: A call to action. Infect Control Hosp Epidemiol 2021; 42:991-996. [PMID: 34103108 PMCID: PMC10947501 DOI: 10.1017/ice.2021.239] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In 2020 a group of U.S. healthcare leaders formed the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) to issue a call to action to address non-ventilator-associated hospital-acquired pneumonia (NVHAP). NVHAP is one of the most common and morbid healthcare-associated infections, but it is not tracked, reported, or actively prevented by most hospitals. This national call to action includes (1) launching a national healthcare conversation about NVHAP prevention; (2) adding NVHAP prevention measures to education for patients, healthcare professionals, and students; (3) challenging healthcare systems and insurers to implement and support NVHAP prevention; and (4) encouraging researchers to develop new strategies for NVHAP surveillance and prevention. The purpose of this document is to outline research needs to support the NVHAP call to action. Primary needs include the development of better models to estimate the economic cost of NVHAP, to elucidate the pathophysiology of NVHAP and identify the most promising pathways for prevention, to develop objective and efficient surveillance methods to track NVHAP, to rigorously test the impact of prevention strategies proposed to prevent NVHAP, and to identify the policy levers that will best engage hospitals in NVHAP surveillance and prevention. A joint task force developed this document including stakeholders from the Veterans' Health Administration (VHA), the U.S. Centers for Disease Control and Prevention (CDC), The Joint Commission, the American Dental Association, the Patient Safety Movement Foundation, Oral Health Nursing Education and Practice (OHNEP), Teaching Oral-Systemic Health (TOSH), industry partners and academia.
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Affiliation(s)
- Shannon C. Munro
- Research and Development, Salem Veterans’ Affairs Medical Center, Salem
| | - Dian Baker
- School of Nursing, California State University, Sacramento, California
| | - Karen K. Giuliano
- College of Nursing & Institute for Applied Life Sciences, University of Massachusetts–Amherst, Amherst, Massachusetts
| | - Sheila C. Sullivan
- Research, Evidence Based Practice and Analytics, Office of Nursing Services, Department of Veterans’ Affairs, Washington, DC
| | - Judith Haber
- Oral Health Nursing Education and Practice, Rory Meyers College of Nursing, New York University, New York, New York
| | - Barbara E. Jones
- Pulmonary & Critical Care Medicine, University of Utah, Salt Lake City, Utah
- Salt Lake City Veterans’ Affairs Healthcare System, Salt Lake City, Utah
| | - Matthew B. Crist
- Division of Health Care Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Richard E. Nelson
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
- George E. Wahlen Department of Veterans’ Affairs Medical Center, Salt Lake City, Utah
| | - Evan Carey
- Research and Development, Rocky Mountain Regional Veterans’ Affairs Medical Center, Aurora, Colorado
| | | | - Michelle Lucatorto
- Office of Nursing Services, Department of Veterans’ Affairs, Washington, DC
| | - Ryan Miller
- Office of Nursing Services, Department of Veterans’ Affairs, Washington, DC
| | - Brian Pauley
- Geriatrics & Extended Care, Veterans’ Affairs Pacific Islands Healthcare System, Honolulu, Hawaii
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston
- Department of Medicine, Brigham and Women’s Hospital, Boston
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Ko RE, Min KH, Hong SB, Baek AR, Lee HK, Cho WH, Kim C, Chang Y, Lee SS, Oh JY, Lee HB, Bae S, Moon JY, Yoo KH, Jeon K. Characteristics, management, and clinical outcomes of patients with hospital-acquired and ventilator-associated pneumonia: a multicenter cohort study in Korea. Tuberc Respir Dis (Seoul) 2021; 84:317-325. [PMID: 34134465 PMCID: PMC8497766 DOI: 10.4046/trd.2021.0018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/02/2021] [Indexed: 11/24/2022] Open
Abstract
Background Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are significant public health issues in the world, but the epidemiological data pertaining to HAP/VAP is limited in Korea. The objective of this study was to investigate the characteristics, management, and clinical outcomes of HAP/VAP in Korea. Methods This study is a multicenter retrospective cohort study. In total, 206,372 adult patients, who were hospitalized at one of the 13 participating tertiary hospitals in Korea, were screened for eligibility during the six-month study period. Among them, we included patients who were diagnosed with HAP/VAP based on the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) definition for HAP/VAP. Results Using the IDSA/ATS diagnostic criteria, 526 patients were identified as HAP/VAP patients. Among them, 27.9% were diagnosed at the intensive care unit (ICU). The cohort of patients had a median age of 71.0 (range from 62.0 to 79.0) years. Most of the patients had a high risk of aspiration (63.3%). The pathogen involved was identified in 211 patients (40.1%). Furthermore, multidrug resistant (MDR) pathogens were isolated in 138 patients; the most common MDR pathogen was Acinetobacter baumannii. During hospitalization, 107 patients with HAP (28.2%) had to be admitted to the ICU for additional care. The hospital mortality rate was 28.1% in the cohort of this study. Among the 378 patients who survived, 54.2% were discharged and sent back home, while 45.8% were transferred to other hospitals or facilities. Conclusion This study found that the prevalence of HAP/VAP in adult hospitalized patients in Korea was 2.54/1,000 patients. In tertiary hospitals in Korea, patients with HAP/VAP were elderly and had a risk of aspiration, so they were often referred to step-down centers.
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Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Hoon Min
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ae-Rin Baek
- Devision of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchun hyang University Bucheon Hospital, Bucheon, Korea
| | - Hyun-Kyung Lee
- Department of Internal Medicinn, Division of pulmonology, allergy and critical care medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Woo Hyun Cho
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Changhwan Kim
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Sung-Soon Lee
- Division of Pulmonary and Critical Care Medicine, Departmen of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Ilsan, Korea
| | - Jee Youn Oh
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Heung Bum Lee
- Department of Internal Medicine, Research Center for Pulmonary Disorders, Jeonbuk National University Medical School, Jeonju, Korea
| | - Soohyun Bae
- Deppartmen of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Jae Young Moon
- Department of Pulmonary and Critical Care Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Kwang Ha Yoo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Giuliano KK, Penoyer D, Middleton A, Baker D. Original Research: Oral Care as Prevention for Nonventilator Hospital-Acquired Pneumonia: A Four-Unit Cluster Randomized Study. Am J Nurs 2021; 121:24-33. [PMID: 33993136 DOI: 10.1097/01.naj.0000753468.99321.93] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Nonventilator hospital-acquired pneumonia (NV-HAP) presents a serious and largely preventable threat to patient safety in U.S. hospitals. There is an emerging body of evidence on the effectiveness of oral care in preventing NV-HAP. PURPOSE The primary aim of this study was to determine the effectiveness of a universal, standardized oral care protocol in preventing NV-HAP in the acute care setting. The primary outcome measure was NV-HAP incidence per 1,000 patient-days. METHODS This 12-month study was conducted on four units at an 800-bed tertiary medical center. Patients on one medical and one surgical unit were randomly assigned to receive enhanced oral care (intervention units); patients on another medical and another surgical unit received usual oral care (control units). RESULTS Total enrollment was 8,709. For the medical control versus intervention units, oral care frequency increased from a mean of 0.95 to 2.25 times per day, and there was a significant 85% reduction in the NV-HAP incidence rate. The odds of developing NV-HAP were 7.1 times higher on the medical control versus intervention units, a significant finding. For the surgical control versus intervention units, oral care frequency increased from a mean of 1.18 to 2.02 times per day, with a 56% reduction in the NV-HAP incidence rate. The odds of developing NV-HAP were 1.6 times higher on the surgical control versus intervention units, although this result did not reach significance. CONCLUSIONS These findings add to the growing body of evidence that daily oral care as a means of primary source control may have a role in NV-HAP prevention. The implementation of effective strategies to ensure that such care is consistently provided warrants further study. It's not yet known what degree and frequency of oral care are required to effect favorable changes in the oral microbiome during acute care hospitalization.
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Affiliation(s)
- Karen K Giuliano
- Karen K. Giuliano is an associate professor at the College of Nursing and the Institute for Applied Life Sciences, University of Massachusetts Amherst. Daleen Penoyer is the director of the Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL. Aurea Middleton is the research coordinator for Orlando Health's Center for Nursing Research. Dian Baker is a professor at the School of Nursing, California State University, Sacramento. Financial support for this study was provided by Medline Industries (which supplied the kits used) and Orlando Health. Baker and Giuliano have also created a CE program on NV-HAP sponsored by Medline. An intervention toolkit is available from the authors. The authors acknowledge Joohyun Chung for her guidance and review of the statistical approach and analyses. Contact author: Karen K. Giuliano, . The authors have disclosed no other potential conflicts of interest, financial or otherwise
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Meade E, Slattery MA, Garvey M. Biocidal Resistance in Clinically Relevant Microbial Species: A Major Public Health Risk. Pathogens 2021; 10:598. [PMID: 34068912 PMCID: PMC8156472 DOI: 10.3390/pathogens10050598] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 11/16/2022] Open
Abstract
Antimicrobial resistance is one of the greatest dangers to public health of the 21st century, threatening the treatment and prevention of infectious diseases globally. Disinfection, the elimination of microbial species via the application of biocidal chemicals, is essential to control infectious diseases and safeguard animal and human health. In an era of antimicrobial resistance and emerging disease, the effective application of biocidal control measures is vital to protect public health. The COVID-19 pandemic is an example of the increasing demand for effective biocidal solutions to reduce and eliminate disease transmission. However, there is increasing recognition into the relationship between biocide use and the proliferation of Antimicrobial Resistance species, particularly multidrug-resistant pathogens. The One Health approach and WHO action plan to combat AMR require active surveillance and monitoring of AMR species; however, biocidal resistance is often overlooked. ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) pathogens and numerous fungal species have demonstrated drug and biocidal resistance where increased patient mortality is a risk. Currently, there is a lack of information on the impact of biocide application on environmental habitats and ecosystems. Undoubtedly, the excessive application of disinfectants and AMR will merge to result in secondary disasters relating to soil infertility, loss of biodiversity and destruction of ecosystems.
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Affiliation(s)
- Elaine Meade
- Department of Life Science, Sligo Institute of Technology, Sligo, Ireland;
| | | | - Mary Garvey
- Department of Life Science, Sligo Institute of Technology, Sligo, Ireland;
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Welte T, Scheeren TW, Overcash JS, Saulay M, Engelhardt M, Hamed K. Efficacy and safety of ceftobiprole in patients aged 65 years or older: a post hoc analysis of three Phase III studies. Future Microbiol 2021; 16:543-555. [PMID: 33960817 DOI: 10.2217/fmb-2021-0042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Aim: To evaluate the efficacy and safety of ceftobiprole in patients aged ≥65 years. Materials & methods: We conducted a post hoc analysis of three randomized, double-blind, Phase III studies in patients with acute bacterial skin and skin structure infections, community-acquired pneumonia and hospital-acquired pneumonia. Results: Findings for patients aged ≥65 years (n = 633) were consistent with those for the overall study populations, although a trend toward improved outcomes was reported in some subgroups, for example, patients aged ≥75 years with community-acquired pneumonia were more likely to achieve an early clinical response with ceftobiprole than comparator (treatment difference 16.3% [95% CI:1.8-30.8]). The safety profile was similar between treatment groups in all studies. Conclusion: This analysis further supports the efficacy and safety of ceftobiprole in older patients with acute bacterial skin and skin structure infections or pneumonia. Clinicaltrials.gov trial identifiers: NCT03137173, NCT00326287, NCT00210964, NCT00229008.
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Affiliation(s)
- Tobias Welte
- Department of Respiratory Medicine & Member of the German Centre for Lung Research, Medizinische Hochschule Hannover, Hannover, Germany
| | - Thomas Wl Scheeren
- Department of Anesthesiology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Mikael Saulay
- Basilea Pharmaceutica International Ltd., Basel, Switzerland
| | - Marc Engelhardt
- Basilea Pharmaceutica International Ltd., Basel, Switzerland
| | - Kamal Hamed
- Basilea Pharmaceutica International Ltd., Basel, Switzerland
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Zhong X, Wang DL, Xiao LH. Research on the economic loss of hospital-acquired pneumonia caused by Klebsiella pneumonia base on propensity score matching. Medicine (Baltimore) 2021; 100:e25440. [PMID: 33847646 PMCID: PMC8052027 DOI: 10.1097/md.0000000000025440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/27/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Hospital-acquired pneumonia (HAP) caused by Klebsiella pneumonia (KP) is a common nosocomial infection (NI). However, the reports on the economic burden of hospital-acquired pneumonia caused by Klebsiella pneumonia (KP-HAP) were scarce. The study aims to study the direct economic loss caused by KP-HAP with the method of propensity score matching (PSM) to provide a basis for the cost accounting of NI and provide references for the formulation of infection control measures. METHODS A retrospective investigation was conducted on the hospitalization information of all patients discharged from a tertiary group hospital in Shenzhen, Guangdong province, China, from June 2016 to August 2019. According to the inclusion and exclusion criteria, patients were divided into the HAP group and noninfection group, the extended-spectrum beta-lactamases (ESBLs) positive KP infection group, and the ESBLs-negative KP infection group. After the baselines of each group were balanced with the PSM, length of stay (LOS) and hospital cost of each group were compared. RESULTS After the PSM, there were no differences in the baselines of each group. Compared with the noninfection group, the median LOS in the KP-HAP group increased by 15 days (2.14 times), and the median hospital costs increased by 7329 yuan (0.89 times). Compared with the ESBLs-negative KP-HAP group, the median LOS in the ESBLs-positive KP-HAP group increased by 7.5 days (0.39 times), and the median hospital costs increased by 22,424 yuan (1.90 times). CONCLUSION KP-HAP prolonged LOS and increased hospital costs, and HAP caused by ESBLs-positive KP had more economic losses than ESBLs-negative, which deserves our attention and should be controlled by practical measures.
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Affiliation(s)
- Xiao Zhong
- Department of Nosocomial Infection, University of Chinese Academy of Sciences, Shenzhen Hospital
| | - Dong-Li Wang
- Inspection Center, Guangming District Center for Disease Control and Prevention, Shenzhen, Guangdong, China
| | - Li-Hua Xiao
- Department of Nosocomial Infection, University of Chinese Academy of Sciences, Shenzhen Hospital
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