A comparison of APACHE II and CPIS scores for the prediction of 30-day mortality in patients with ventilator-associated pneumonia. Int J Infect Dis. 2015;30:144-147. [PMID: 25461659 DOI: 10.1016/j.ijid.2014.11.005]

Chinese herbal compound for multidrug-resistant or extensively drug-resistant bacterial pneumonia: a meta-analysis and trial sequential analysis with association rule mining to identify core herb combinations

Purpose: Antibiotic-resistant bacterial pneumonia poses a significant therapeutic challenge. In China, Chinese herbal compound (CHC) is commonly used to treat bacterial pneumonia. We aimed to evaluate the efficacy and safety of CHC and identify core herb combinations for the treatment of multidrug-resistant or extensively drug-resistant bacterial pneumonia. Methods: Stata 16 and TSA 0.9.5.10 beta software were used for meta-analysis and trial sequential analysis (TSA), respectively. Exploring the sources of heterogeneity through meta-regression and subgroup analysis. Results: Thirty-eight studies involving 2890 patients were included in the analyses. Meta-analysis indicated that CHC combined with antibiotics improved the response rate (RR = 1.24; 95% CI: 1.19-1.28; p < 0.0001) and microbiological eradication (RR = 1.41; 95% CI: 1.27-1.57; p < 0.0001), lowered the white blood cell count (MD = -2.09; 95% CI: -2.65 to -1.53; p < 0.0001), procalcitonin levels (MD = -0.49; 95% CI: -0.59 to -0.40; p < 0.0001), C-reactive protein levels (MD = -11.80; 95% CI: -15.22 to -8.39; p < 0.0001), Clinical Pulmonary Infection Scores (CPIS) (MD = -1.97; 95% CI: -2.68 to -1.26; p < 0.0001), and Acute Physiology and Chronic Health Evaluation (APACHE)-II score (MD = -4.08; 95% CI: -5.16 to -3.00; p < 0.0001), shortened the length of hospitalization (MD = -4.79; 95% CI: -6.18 to -3.40; p < 0.0001), and reduced the number of adverse events. TSA indicated that the response rate and microbiological eradication results were robust. Moreover, Scutellaria baicalensis Georgi, Fritillaria thunbergii Miq, Lonicera japonica Thunb, and Glycyrrhiza uralensis Fisch were identified as core CHC prescription herbs. Conclusion: Compared with antibiotic treatment, CHC + antibiotic treatment was superior in improving response rate, microbiological eradication, inflammatory response, CPIS, and APACHE-II score and shortening the length of hospitalization. Association rule analysis identified four core herbs as promising candidates for treating antibiotic-resistant bacterial pneumonia. However, large-scale clinical studies are still required. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023410587.

Machine learning-based prediction of in-ICU mortality in pneumonia patients

Conventional severity-of-illness scoring systems have shown suboptimal performance for predicting in-intensive care unit (ICU) mortality in patients with severe pneumonia. This study aimed to develop and validate machine learning (ML) models for mortality prediction in patients with severe pneumonia. This retrospective study evaluated patients admitted to the ICU for severe pneumonia between January 2016 and December 2021. The predictive performance was analyzed by comparing the area under the receiver operating characteristic curve (AU-ROC) of ML models to that of conventional severity-of-illness scoring systems. Three ML models were evaluated: (1) logistic regression with L2 regularization, (2) gradient-boosted decision tree (LightGBM), and (3) multilayer perceptron (MLP). Among the 816 pneumonia patients included, 223 (27.3%) patients died. All ML models significantly outperformed the Simplified Acute Physiology Score II (AU-ROC: 0.650 [0.584-0.716] vs 0.820 [0.771-0.869] for logistic regression vs 0.827 [0.777-0.876] for LightGBM 0.838 [0.791-0.884] for MLP; P < 0.001). In the analysis for NRI, the LightGBM and MLP models showed superior reclassification compared with the logistic regression model in predicting in-ICU mortality in all length of stay in the ICU subgroups; all age subgroups; all subgroups with any APACHE II score, PaO₂/FiO₂ ratio < 200; all subgroups with or without history of respiratory disease; with or without history of CVA or dementia; treatment with mechanical ventilation, and use of inotropic agents. In conclusion, the ML models have excellent performance in predicting in-ICU mortality in patients with severe pneumonia. Moreover, this study highlights the potential advantages of selecting individual ML models for predicting in-ICU mortality in different subgroups.

Participant- and Disease-Related Factors as Independent Predictors of Treatment Outcomes in the RESTORE-IMI 2 Clinical Trial: A Multivariable Regression Analysis

Background

In the RESTORE-IMI 2 trial, imipenem/cilastatin/relebactam (IMI/REL) was noninferior to piperacillin/tazobactam in treating hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia. This post hoc analysis was conducted to determine independent predictors of efficacy outcomes in the RESTORE-IMI 2 trial, to assist in treatment decision making.

Methods

A stepwise multivariable regression analysis was conducted to identify variables that were independently associated with day 28 all-cause mortality (ACM), favorable clinical response at early follow-up (EFU), and favorable microbiologic response at end of treatment (EOT). The analysis accounted for the number of baseline infecting pathogens and in vitro susceptibility to randomized treatment.

Results

Vasopressor use, renal impairment, bacteremia at baseline, and Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores ≥15 were associated with a greater risk of day 28 ACM. A favorable clinical response at EFU was associated with normal renal function, an APACHE II score <15, no vasopressor use, and no bacteremia at baseline. At EOT, a favorable microbiologic response was associated with IMI/REL treatment, normal renal function, no vasopressor use, nonventilated pneumonia at baseline, intensive care unit admission at randomization, monomicrobial infections at baseline, and absence of Acinetobacter calcoaceticus-baumannii complex at baseline. These factors remained significant after accounting for polymicrobial infection and in vitro susceptibility to assigned treatment.

Conclusions

This analysis, which accounted for baseline pathogen susceptibility, validated well-recognized patient- and disease-related factors as independent predictors of clinical outcomes. These results lend further support to the noninferiority of IMI/REL to piperacillin/tazobactam and suggests that pathogen eradication may be more likely with IMI/REL.

Clinical Trials Registration

NCT02493764.

Prediction of survival time after terminal extubation: the balance between critical care unit utilization and hospice medicine in the COVID-19 pandemic era

BACKGROUND

We established 1-h and 1-day survival models after terminal extubation to optimize ventilator use and achieve a balance between critical care for COVID-19 and hospice medicine.

METHODS

Data were obtained from patients with end-of-life status at terminal extubation from 2015 to 2020. The associations between APACHE II scores and parameters with survival time were analyzed. Parameters with a p-value ≤ 0.2 in univariate analysis were included in multivariate models. Cox proportional hazards regression analysis was used for the multivariate analysis of survival time at 1 h and 1 day.

RESULTS

Of the 140 enrolled patients, 76 (54.3%) died within 1 h and 35 (25%) survived beyond 24 h. No spontaneous breathing trial (SBT) within the past 24 h, minute ventilation (MV) ≥ 12 L/min, and APACHE II score ≥ 25 were associated with shorter survival in the 1 h regression model. Lower MV, SpO2 ≥ 96% and SBT were related to longer survival in the 1-day model. Hospice medications did not influence survival time.

CONCLUSION

An APACHE II score of ≥ 25 at 1 h and SpO2 ≥ 96% at 1 day were strong predictors of disposition of patients to intensivists. These factors can help to objectively tailor pathways for post-extubation transition and rapidly allocate intensive care unit resources without sacrificing the quality of palliative care in the era of COVID-19. Trial registration They study was retrospectively registered. IRB No.: 202101929B0.

Prognostic Role of Serum Adrenomedullin in Patients with Ventilator Associated Pneumonia

Objective: Ventilator associated pneumonia is a common type of sepsis that occurs to about 9–27% of all mechanically ventilated patients and 20–50% of them develop septic shock. Several clinical, laboratory, and radiological methods have been used for diagnosing VAP. Adrenomedullin (ADM) has been found to be elevated in the plasma of septic patients. The study aim was to explore the prognostic role of ADM in the VAP patients. Design: A prospective observational study. Setting: Intensive Care Department of Alexandria University Hospitals. Patients: A total of 140 patients with proven VAP after medical ICU admission were consecutively enrolled. Methods: APACHE II score, SOFA score, CRP, lactate, and serum ADM were measured at day 0 of VAP diagnosis and 5 days later. The results were correlated with the outcomes of patients. Results: APACHE II, lactate, and serum ADM on day 0 could predict an unfavorable outcome. ADM prediction power was significantly higher than APACHE II and lactate. Day 5 readings of all tested parameters could predict occurrence of the unfavorable outcome. ADM on day 0 showed the highest sensitivity (96.25%). Conclusions: Serum adrenomedullin when measured at days 0 and 5 of VAP diagnosis may serve as an early predictor of unfavorable outcome.

Probiotic Supplementation Prevents the Development of Ventilator-Associated Pneumonia for Mechanically Ventilated ICU Patients: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Background

Ventilator-associated pneumonia (VAP) is one of the common critical complications of nosocomial infection (NI) in invasive mechanically ventilated intensive care unit (ICU) patients. The efficacy of total parenteral nutrition (TPN), enteral nutrition and/or adjuvant peripheral parenteral nutrition (EPN) supplemented with or without probiotic, prebiotic, and synbiotic therapies in preventing VAP among these patients has been questioned. We aimed to systematically and comprehensively summarize all available studies to generate the best evidence of VAP prevention for invasive mechanically ventilated ICU patients.

Methods

Randomized controlled trials (RCTs) for the administration of TPN, EPN, probiotics-supplemented EPN, prebiotics-supplemented EPN, and synbiotics-supplemented EPN for VAP prevention in invasive mechanically ventilated ICU patients were systematically retrieved from four electronic databases. The incidence of VAP was the primary outcome and was determined by the random-effects model of a Bayesian framework. The secondary outcomes were NI, ICU and hospital mortality, ICU and hospital length of stay, and mechanical ventilation duration. The registration number of Prospero is CRD42020195773.

Results

A total of 8339 patients from 31 RCTs were finally included in network meta-analysis. The primary outcome showed that probiotic-supplemented EPN had a higher correlation with the alleviation of VAP than EPN in critically invasive mechanically ventilated patients (odds ratio [OR] 0.75; 95% credible intervals [CrI] 0.58–0.95). Subgroup analyses showed that probiotic-supplemented EPN prevented VAP in trauma patients (OR 0.30; 95% CrI 0.13–0.83), mixed probiotic strain therapy was more effective in preventing VAP than EPN therapy (OR 0.55; 95% CrI 0.31–0.97), and low-dose probiotic therapy (less than 10¹⁰ CFU per day) was more associated with lowered incidence of VAP than EPN therapy (OR 0.16; 95% CrI 0.04–0.64). Secondary outcomes indicated that synbiotic-supplemented EPN therapy was more significantly related to decreased incidence of NI than EPN therapy (OR 0.34; 95% CrI 0.11–0.85). Prebiotic-supplemented EPN administration was the most effective in preventing diarrhea (OR 0.05; 95% CrI 0.00–0.71).

Conclusion

Probiotic supplementation shows promise in reducing the incidence of VAP in critically invasive mechanically ventilated patients. Currently, low quality of evidence reduces strong clinical recommendations. Further high-quality RCTs are needed to conclusively prove these findings.

Systamatic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020195773], identifier [CRD42020195773].

Early prediction of ventilator-associated pneumonia in critical care patients: a machine learning model

Background

This study was performed to develop and validate machine learning models for early detection of ventilator-associated pneumonia (VAP) 24 h before diagnosis, so that VAP patients can receive early intervention and reduce the occurrence of complications.

Patients and methods

This study was based on the MIMIC-III dataset, which was a retrospective cohort. The random forest algorithm was applied to construct a base classifier, and the area under the receiver operating characteristic curve (AUC), sensitivity and specificity of the prediction model were evaluated. Furthermore, We also compare the performance of Clinical Pulmonary Infection Score (CPIS)-based model (threshold value ≥ 3) using the same training and test data sets.

Results

In total, 38,515 ventilation sessions occurred in 61,532 ICU admissions. VAP occurred in 212 of these sessions. We incorporated 42 VAP risk factors at admission and routinely measured the vital characteristics and laboratory results. Five-fold cross-validation was performed to evaluate the model performance, and the model achieved an AUC of 84% in the validation, 74% sensitivity and 71% specificity 24 h after intubation. The AUC of our VAP machine learning model is nearly 25% higher than the CPIS model, and the sensitivity and specificity were also improved by almost 14% and 15%, respectively.

Conclusions

We developed and internally validated an automated model for VAP prediction using the MIMIC-III cohort. The VAP prediction model achieved high performance based on its AUC, sensitivity and specificity, and its performance was superior to that of the CPIS model. External validation and prospective interventional or outcome studies using this prediction model are envisioned as future work.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02031-w.

A functional polymorphism at the miR‑491‑5p binding site in the 3'‑untranslated region of the MMP‑9 gene increases the risk of developing ventilator‑associated pneumonia

Matrix metalloproteinase (MMP)‑9 is associated with the severity of ventilator‑associated pneumonia (VAP), while an rs1056629 SNP located in the 3'‑untranslated region (UTR) of MMP‑9 affects the microRNA (miRNA/miR)‑491‑mediated regulation of MMP‑9 expression. In the present study, the effect of rs1056629 on the development of VAP in patients with chronic obstructive pulmonary disease (COPD) was investigated. Patients with COPD were enrolled in the study and their genotypes of rs1056629 (CC, CA or AA) were determined. ELISA was used to analyze the levels of TNF‑α and IL‑6 in the monocytes of patients with COPD carrying differential genotypes of rs1056629. Reverse transcription‑quantitative PCR was carried out to evaluate the expression of miR‑491 and MMP‑9 mRNA in the different groups of patients with COPD. Luciferase assay was used to confirm the inhibitory role of miR‑491 in MMP‑9 expression. Western blot analysis was carried out to assess the expression of MMP‑9 protein in A549 and H1299 cells transfected with miR‑491 mimics. The risk and severity of VAP were significantly elevated in patients with COPD carrying the CC and AC genotypes of rs1056629. Although there was no difference in the expression of miR‑491 in patients carrying different genotypes of rs1056629, the expression levels of TNF‑α, IL‑6 and MMP‑9 were increased in patients with COPD carrying the CC and AC genotypes of rs1056629. The results of luciferase assay revealed that miR‑491 inhibited the expression of MMP‑9 through direct binding to the 3'UTR of MMP‑9. Transfection of miR‑491 mimics into A549 and H1299 cells markedly suppressed the expression of MMP‑9 in a concentration‑dependent manner. On the whole, the findings of the present study confirm that the CC and AC genotypes of rs1056629 increase the risk of developing VAP in patients with COPD by increasing the expression of MMP‑9.

Derivation and Validation of a Novel Severity Scoring System for Pneumonia at Intensive Care Unit Admission

BACKGROUND

Severity stratification scores developed in intensive care units (ICUs) are used in interventional studies to identify the most critically ill. Studies that evaluate accuracy of these scores in ICU patients admitted with pneumonia are lacking. This study aims to determine performance of severity scores as predictors of mortality in critically ill patients admitted with pneumonia.

METHODS

Prospective cohort study in a general ICU in Brazil. ICU severity scores (Simplified Acute Physiology Score 3 [SAPS 3] and Sepsis-Related Organ Failure Assessment [qSOFA]), prognostic scores of pneumonia (CURB-65 [confusion, urea, respiratory rate, blood pressure, age] and CRB-65 [confusion, respiratory rate, blood pressure, age]), and clinical and epidemiological variables in the first 6 hours of hospitalization were analyzed.

RESULTS

Two hundred patients were included between 2015 and 2018, with a median age of 81 years (interquartile range, 67-90 years) and female predominance (52%), primarily admitted from the emergency department (65%) with community-acquired pneumonia (CAP, 80.5%). SAPS 3, CURB-65, CRB-65,and qSOFA all exhibited poor performance in predicting mortality. Multivariate regression identified variables independently associated with mortality that were used to develop a novel pneumonia-specific ICU severity score (Pneumonia Shock score) that outperformed SAPS 3, CURB-65, and CRB-65. The Shock score was validated in an external multicenter cohort of critically ill patients admitted with CAP.

CONCLUSIONS

We created a parsimonious score that accurately identifies patients with pneumonia at highest risk of ICU death. These findings are critical to accurately stratify patients with severe pneumonia in therapeutic trials that aim to reduce mortality.

Pneumonia scoring systems for severe COVID-19: which one is better

PURPOSE

To investigate the predictive significance of different pneumonia scoring systems in clinical severity and mortality risk of patients with severe novel coronavirus pneumonia.

MATERIALS AND METHODS

A total of 53 cases of severe novel coronavirus pneumonia were confirmed. The APACHE II, MuLBSTA and CURB-65 scores of different treatment methods were calculated, and the predictive power of each score on clinical respiratory support treatment and mortality risk was compared.

RESULTS

The APACHE II score showed the largest area under ROC curve in both noninvasive and invasive respiratory support treatment assessments, which is significantly different from that of CURB-65. Further, the MuLBSTA score had the largest area under ROC curve in terms of death risk assessment, which is also significantly different from that of CURB-65; however, no difference was noted with the APACHE II score.

CONCLUSION

For patients with COVID, the APACHE II score is an effective predictor of the disease severity and mortality risk. Further, the MuLBSTA score is a good predictor only in terms of mortality risk.

Identification of Factors Affecting Mortality in Late-Onset Ventilator-Associated Pneumonia

Objective

Pneumonia that develops 48 hours after intubation has been defined as ventilator-associated pneumonia (VAP) in patients hospitalized in the intensive care unit (ICU). Late-onset VAP (LO-VAP) is described as pneumonia that occurs within or after the 5th day of mechanical ventilation. We aimed to determine the factors that affect the mortality and survival in patients with LO-VAP.

Materials and Methods

We retrospectively reviewed the hospital records of adult patients (>18 years) who developed LO-VAP in the training and research hospital between January 2014 and June 2018. We compared the demographic findings and laboratory characteristics of the survivors and deaths on the 28-day mortality.

Results

The mean age of 231 (90 female and 141 male) patients with LO-VAP was 73.43±14.06 years. As a result of multivariate logistic regression analysis, we determined that advanced age (p=0.023; 95% confidence interval [CI]: 1.003-1.047) and unconsciousness (p=0.001; 95% CI: 1.674-6.547) were the independent factors affecting mortality. However, parenteral nutrition (PN) (p=0.027; 95% CI: 0.263-0.923) and tracheostomy (p=0.001; 95% CI: 0.112-0.545) were the independent factors supporting survival. We found that acute physiology and chronic health evaluation II score, presence of bacteremia, and enteral nutrition did not have a significant effect on mortality.

Conclusion

Use of tracheostomy and PN in patients with LO-VAP has a positive effect on survival. Our study also points out that mortality can be high in patients with advanced age and unconsciousness.

Clinical and microbiological characteristics of adults with hospital-acquired pneumonia: a 10-year prospective observational study in China

Hospital-acquired pneumonia (HAP) is a significant nosocomial infection; data on the distribution and antimicrobial resistance profiles of HAP in China are limited. We included 2827 adult patients with HAP from the Chinese Antimicrobial Resistance Surveillance of Nosocomial Infections network admitted in 15 Chinese teaching hospitals between 2007 and 2016. Clinical data and antimicrobial susceptibility of isolated pathogens were obtained from the medical records and central laboratory, respectively. Multivariable logistic regression was performed to determine the risk factors for mortality and multidrug resistance (MDR). A total of 386 (13.7%) patients died in the hospital, while 1181 (41.8%) developed ventilator-associated pneumonia (VAP). Active immunosuppressant therapy (OR 1.915 (95% CI 1.475-2.487)), solid tumor (OR 1.860 (95% CI 1.410-2.452)), coma (OR 1.783 (95% CI 1.364-2.333)), clinical pulmonary infection score ≥7 (OR 1.743 (95% CI 1.373-2.212)), intensive care unit stay (OR 1.652 (95% CI 1.292-2.111)), age ≥65 years (OR 1.621 (95% CI 1.282-2.049)), and tracheal cannula insertion (OR 1.613 (95% CI 1.169-2.224)) were independent risk factors for in-hospital mortality. Liver cirrhosis (OR 3.120 (95% CI 1.436-6.780)) and six other variables were independent predictors of MDR. Acinetobacter baumannii (25.6%), Pseudomonas aeruginosa (20.1%), Klebsiella pneumoniae (15.4%), and Staphylococcus aureus (12.6%) were the most common pathogens (MDR prevalence 64.9%). Isolates from VAP patients showed more A. baumannii and less K. pneumoniae and E. coli strains (p < 0.001, respectively) than those from patients without VAP. The proportion of methicillin-resistant S. aureus strains decreased; that of carbapenem-resistant A. baumannii and Enterobacterales strains increased. There had been changes in the antibiotic resistance profiles of HAP pathogens in China. Risk factors for mortality and MDR are important for the selection of antimicrobials for HAP in China.

Assessment of the Clinical Pulmonary Infection Scores for prediction of ventilator associated pneumonia in patients with out of hospital cardiac arrest

BACKGROUND

Patients suffering out-of-hospital cardiac arrest (OHCA) are at an increased risk of aspiration pneumonitis and development of subsequent aspiration pneumonia. The diagnostic uncertainty in this context can lead to a large proportion receiving broad spectrum antibiotics.

METHODS

This was a three-year, retrospective cohort study of consecutive patients admitted with OHCA. Data were collected in an Australian tertiary centre intensive care unit (ICU) between December 2016-December 2019. We assessed the incidence of Ventilator associated pneumonia (VAP), admission Clinical Pulmonary Infection Scores (CPIS) in patients with OHCA and its' association with VAP at day 3 [1]. We also assessed antibiotics prescribing (timing of initiation and drug choice) and intensive care mortality relative to the day 1 CPIS.

RESULTS

Over the three years, 100 patients were admitted with OHCA. The incidence of VAP was 6%. The CPIS on admission was not associated with development of VAP at day 3 (p = 0.75) and no significant association was found between choice of antibiotic regimens and VAP incidence. Timing of initiation of antibiotics was associated with VAP (12hrs vs 48hrs, p = 0.035) but not the choice of antibiotic (penicillin and cephalosporins vs antipseudomonal antibiotics). CPIS score at day 1 was not associated with ICU mortality in a multivariate analysis.

CONCLUSION

We demonstrated a very low incidence of VAP in OHCA patients in comparison to published studies. In this context, there was no evidence for an association between CPIS score and VAP at day 3. The CPIS may have utility as a decision support tool for targeted antibiotic prescribing in this cohort.

Clinical Characteristics and Factors Associated With Long-Term Viral Excretion in Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection: a Single-Center 28-Day Study

Background

Despite the ongoing spread of coronavirus disease 2019 (COVID-19), knowledge about factors affecting prolonged viral excretion is limited.

Methods

In this study, we retrospectively collected data from 99 hospitalized patients with coronavirus disease 2019 (COVID-19) between 19 January and 17 February 2020 in Zhejiang Province, China. We classified them into 2 groups based on whether the virus test results eventually became negative. Cox proportional hazards regression was used to evaluate factors associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) shedding.

Results

Among 99 patients, 61 patients had SARS-CoV-2 clearance (virus-negative group), but 38 patients had sustained positive results (virus-positive group). The median duration of SARS-CoV-2 excretion was 15 (interquartile range, 12–19) days among the virus-negative patients. The shedding time was significantly increased if the fecal SARS-CoV-2 RNA test result was positive. Male sex (hazard ratio [HR], 0.58 [95% confidence interval {CI}, .35–.98]), immunoglobulin use (HR, 0.42 [95% CI, .24–.76]), APACHE II score (HR, 0.89 [95% CI, .84–.96]), and lymphocyte count (HR, 1.81 [95% CI, 1.05–3.1]) were independent factors associated with a prolonged duration of SARS-CoV-2 shedding. Antiviral therapy and corticosteroid treatment were not independent factors.

Conclusions

SARS-CoV-2 RNA clearance time was associated with sex, disease severity, and lymphocyte function. The current antiviral protocol and low-to-moderate dosage of corticosteroid had little effect on the duration of viral excretion.

Active surveillance of ventilator-associated pneumonia in the intensive care unit and establishment of the risk grading system and effect evaluation

BACKGROUND

To discuss ventilator-associated pneumonia (VAP) patient's clinical characteristic and related factors in the intensive care unit (ICU), and to establish a risk grading system for VAP patients in the ICU in order to provide a reference for VAP prevention.

METHODS

A total of 1,513 patients in eight ICUs who received mechanical ventilation between June 2015 and June 2018 were randomized and into two groups, with 908 patients in the model group and 605 patients in the verification group. The model group was used to analyze the influencing factors of VAP and establish a risk grading system, while the verification group was used to verify the risk grading system. A receiver operating characteristic (ROC) curve was used to evaluate the predictive effect of the grading system.

RESULTS

During the 3-year study period, of the 1,513 total patients, 188 patients were infected with VAP, leading to an incidence rate of 12.43% (188/1,513) and an infection rate of 15.23‰ (188/12,347). ICU length of stay, mechanical ventilation days, frequency of oral care, unused subglottic secretion drainage, tracheotomy, APACHE II score, and combined antibiotics use were risk factors of VAP infection for patients who received mechanical ventilation in the modeling group (P<0.05). In a VAP risk-grading system established based on risk factors, the high, medium and low-grade patients had a statistically significantly different VAP infection rate in the model group, and patients with a high grade had a higher risk of VAP infection. Patients' data in the model and verification groups were used to draw a ROC curve which showed a good predictive effect.

CONCLUSIONS

This study establishes and verifies the VAP risk grading system for patients who receive mechanical ventilation. It is helpful in high-risk patient surveillance and in reducing and preventing VAP infection.

Application of pulse index continuous cardiac output system in elderly patients with acute myocardial infarction complicated by cardiogenic shock: A prospective randomized study

BACKGROUND

Cardiogenic shock (CS) secondary to acute myocardial infarction (AMI) complicates management of the condition, and often leads to poor prognosis. Prompt and accurate monitoring of cardiovascular and accompanying hemodynamic changes is crucial in achieving adequate management of the condition. Advances in technology has availed procedures such as pulse index continuous cardiac output (PiCCO), which can offer precise monitoring of cardiovascular functions and hemodynamic parameters. In this study, PiCCO is evaluated for its potential utility in improving management and clinical outcomes among elderly patients with AMI complicated by CS.

AIM

To assess whether use of the PiCCO system can improve clinical outcomes in elderly patients with AMI complicated by CS.

METHODS

Patients from emergency intensive care units (EICU) or coronary care units (CCU) were randomized to receive PiCCO monitoring or not. The APACHE II score, SOFA score, hs-TnI, NT-proBNP, PaO₂/FiO₂ ratio and lactate levels on day 1, 3 and 7 after treatment were compared. The infusion and urine volume at 0-24 h, 24-48 h and 48-72 h were recorded, as were the cardiac index (CI), extravascular lung water index (EVLWI), intrathoracic blood volume index (ITBVI) and global end diastolic volume index (GEDVI) at similar time intervals.

RESULTS

Sixty patients with AMI complicated by CS were included in the study. The PiCCO group had a significantly lower APACHE II score, SOFA score, hs-TnI and NT-proBNP levels on day 1, 3 and 7 after treatment. The infusion and urine volume during 0-24 h in the PiCCO group were significantly greater, and this group also showed significantly higher ADL scores. Furthermore, the PiCCO group spent lesser days on vasoactive agents, mechanical ventilation, and had a reduced length of stay in EICU/CCU. Additionally, the CI was significantly higher at 48 h and 72 h in the PiCCO group compared with that at 24 h, and the EVLWI, ITBVI and GEDVI were significantly decreased at 48 h and 72 h.

CONCLUSION

Applying the PiCCO system could improve the clinical outcomes of elderly patients with AMI complicated by CS.

Relationship between disease severity and thyroid function in Chinese patients with euthyroid sick syndrome

Euthyroid sick syndrome (ESS) is commonly observed in various acute and chronic illness as risk factor for mortality in patients with severe diseases, with lower triiodothyronine (T3) and free triiodothyronine (fT3).To explore the relationship between disease severity and thyroid function in critically ill Chinese patients with ESS.A total of 51 patients admitted to intensive care unit were examined to determine acute physiology and chronic health assessment II (APACHE II) scores within 24 hours of admission; thyroid function tests (TSH, fT3, fT4, tT3, tT4) and rT3 levels were determined on the second day. Based on the test results, patients were divided into euthyroid (n = 13), decreased fT3 or fT4 (n = 17), and decreased TSH (n = 21) groups. APACHE II scores and thyroid function were compared between the 3 groups. Furthermore, the relationship between the severity of disease and euthyroid sick syndrome was assessed.Out of 51 patients, 38 were men and 13 were women [mean age (± SD): 60.39 (± 19.32) years; range, 15-88 years]. APACHE II scores and rT3 levels were increased in all the 3 groups (P > .05). APACHE II scores showed a positive correlation with rT3 (P = .004, r = 0.379).Critically ill Chinese patients with ESS have a poor health state. Higher rT3 values are associated with severe disease.

Diagnostic Efficacy of Serum Amyloid A Protein and Soluble Intercellular Adhesion Molecule 1 in Pediatric Ventilator-Associated Pneumonia

Objectives:

Study of inflammatory biomarkers which may aid in early detection of ventilator-associated pneumonia (VAP) in children and predicting their outcome.

Patients:

Thirty-five children, aged 2 months to 13 years, needed mechanical ventilation (MV) for more than 48 hours due to causes other than pneumonia.

Methods:

Measurement of serum amyloid A (SAA) protein, soluble intercellular adhesion molecule 1 (sICAM-1), and C-reactive protein (CRP), modified clinical pulmonary infection score (CPIS) and performing culture of endotracheal aspirate at the start and on the third day of MV.

Results:

Ventilator-associated pneumonia was diagnosed by CPIS in 6 (17.1%) of 35 patients. On the third day of MV, there was a significant increase in serum mean levels of SAA, sICAM-1, and CRP in comparison to the start of MV ( P = .005, .004, and .01, respectively). Three (50%) of 6 patients with VAP died, while 4 (14.28%) of 28 patients without VAP died. The sensitivity of serum SAA, sICAM-1, and CPIS were 100% for predicting VAP, while specificity was highest for CPIS (96.55%) followed by SAA (93.1%). Combination of CPIS and SAA increased the specificity to 100%. For predicting nonsurvival, serum SAA and sICAM-1 had a sensitivity of 100% and a specificity of 92.86% and 89.29%, respectively.

Conclusion:

Serum amyloid A and sICAM-1 may be considered as reliable markers for detection of VAP. Combination of serum SAA with CPIS increased the specificity to 100%. Measurement of SAA in patients with VAP also had a good predictive value for nonsurvival in such patients.

Risk prediction models for mortality in patients with ventilator-associated pneumonia: A systematic review and meta-analysis

PURPOSE

Ventilator-associated pneumonia (VAP) is a common and serious complication in patients requiring mechanical ventilation in the intensive care unit. The aims of this study were to identify models used to predict mortality in VAP patients and to assess their prognostic accuracy.

METHODS

The PubMed and EMBASE were searched in February 2016. We included studies in English that evaluated models' ability to predict the risk of mortality in patients with VAP. The reported mortality with the longest follow-up was used in the meta-analysis. Prognostic accuracy was measured with the area under the receiver operator characteristic curve (AUC).

RESULTS

We identified 19 articles studying 7 different models' ability to predict mortality in VAP patients. The models were Acute Physiology and Chronic Health Evaluation (APACHE) II (9 studies, n = 1398); Clinical Pulmonary Infection Score (4 studies, n = 303); "Immunodeficiency, Blood pressure, Multilobular infiltrates on chest radiograph, Platelets and hospitalization 10 days before onset of VAP" (3 studies, n = 406); "VAP Predisposition, Insult Response and Organ dysfunction" (2 studies, n = 589); Sequential Organ Failure Assessment (7 studies, n = 1019); Simplified Acute Physiology Score II (6 studies, n = 1043); and APACHE III (1 study, n = 198). APACHE II had the highest pooled AUC (95% confidence intervals), 0.72 (0.64-0.80), and CPIS had the lowest pooled AUC, 0.64 (0.55-0.72).

CONCLUSION

We identified 7 models that have been evaluated for their ability to predict mortality in patients with VAP. The models had nearly equal predictive accuracies, although some models are more complex and time consuming.

Role of APACHE II scoring system in the prediction of severity and outcome of acute intracerebral hemorrhage

PURPOSE

Acute intracerebral hemorrhage (ICH) is prone to multiple organ dysfunction and has high disability and mortality. This study was to determine the role of acute physiology and chronic health evaluation II (APACHE II) scoring system in the prediction of severity and outcome of acute ICH.

METHODS

A total of 546 ICH patients were prospectively recruited between 1 January 2013 and 31 December 2014. Patients were divided into three groups according to the APACHE II scores: low score group (5-16), moderate score group (17-28) and high score group (≥29). The ICH volume and location, National Institutes of Health Stroke Scale (NIHSS) scores, Glasgow Coma Score and modified Rankin Scale (mRS) scores were used to assess the severity of acute ICH. Global outcome at three months was evaluated with the mRS.

RESULTS

Of 479 patients, the average age was 56.4 ± 3.4 years, 287 (59.9%) survived and 192 (40.1%) died. Results showed that the higher the APACHE II score, the higher the mortality was; the average hospital stay, ICH volume, NIHSS scores, mRS scores and survival rate were significantly different among three APACHE II groups (p < 0.05). APACHE II scores were able to predict the mortality and correlated positively with actual mortality (r = 0.84, p < 0.01).

CONCLUSIONS

APACHE II scoring system can be used to predict the severity and outcome of acute ICH.

APACHE III Outcome Prediction in Patients Admitted to the Intensive Care Unit with Sepsis Associated Acute Lung Injury

BACKGROUND AND OBJECTIVE

Acute Physiology and Chronic Health Evaluation (APACHE) III score has been widely used for prediction of clinical outcomes in mixed critically ill patients. However, it has not been validated in patients with sepsis-associated acute lung injury (ALI). The aim of the study was to explore the calibration and predictive value of APACHE III in patients with sepsis-associated ALI.

METHOD

The study was a secondary analysis of a prospective randomized controlled trial investigating the efficacy of rosuvastatin in sepsis-associated ALI (Statins for Acutely Injured Lungs from Sepsis, SAILS). The study population was sepsis-related ALI patients. The primary outcome of the current study was the same as in the original trial, 60-day in-hospital mortality, defined as death before hospital discharge, censored 60 days after enrollment. Discrimination of APACHE III was assessed by calculating the area under the receiver operating characteristic (ROC) curve (AUC) with its 95% CI. Hosmer-Lemeshow goodness-of-fit statistic was used to assess the calibration of APACHE III. The Brier score was reported to represent the overall performance of APACHE III in predicting outcome.

MAIN RESULTS

A total of 745 patients were included in the study, including 540 survivors and 205 non-survivors. Non-survivors were significantly older than survivors (59.71 ± 16.17 vs 52.00 ± 15.92 years, p < 0.001). The primary causes of ALI were also different between survivors and non-survivors (p = 0.017). Survivors were more likely to have the cause of sepsis than non-survivors (21.2% vs. 15.1%). APACHE III score was higher in non-survivors than in survivors (106.72 ± 27.30 vs. 88.42 ± 26.86; p < 0.001). Discrimination of APACHE III to predict mortality in ALI patients was moderate with an AUC of 0.68 (95% confidence interval: 0.64-0.73).

CONCLUSION

this study for the first time validated the discrimination of APACHE III in sepsis associated ALI patients. The result shows that APACHE III score has moderate predictive value for in-hospital mortality among adults with sepsis-associated acute lung injury.