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Duchnowski P, Śmigielski W. Risk Factors of Postoperative Hospital-Acquired Pneumonia in Patients Undergoing Cardiac Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1993. [PMID: 38004042 PMCID: PMC10672909 DOI: 10.3390/medicina59111993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/24/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives. Hospital-acquired pneumonia is one of the complications that may occur in the postoperative period in patients undergoing heart valve surgery, which may result in prolonged hospitalization, development of respiratory failure requiring mechanical ventilation or even death. This study investigated the preoperative risk factors of postoperative pneumonia after heart valve surgery. Materials and Methods: This was a prospective study in a group of consecutive patients with hemodynamically significant valvular heart disease undergoing valve surgery. The primary endpoint at the in-hospital follow-up was hospital-acquired pneumonia after heart valve surgery. Logistic regression analysis was used to assess which variables were predictive of the primary endpoint, and odds ratios (ORdis) were calculated with a 95% confidence interval (CI). Multivariate analysis was based on the results of single-factor logistic regression, i.e., in further steps all statistically significant variables were taken into consideration. Results: The present study included 505 patients. Postoperative pneumonia occurred in 23 patients. The mean time to diagnosis of pneumonia was approximately 3 days after heart valve surgery (±2 days). In multivariate analysis, preoperative level of high-sensitivity Troponin T (hs-TnT) (OR 2.086; 95% CI 1.211-3.593; p = 0.008) and right ventricular systolic pressure (RVSP) (OR 1.043; 95% CI 1.018-1.067; p 0.004) remained independent predictors of the postoperative pneumonia. Of the patients with postoperative pneumonia, 3 patients died due to the development of multiple organ dysfunction syndrome (MODS). Conclusions: Preoperative determination of serum hs-TnT concentration and echocardiographic measurement of the RVSP parameter may be useful in predicting postoperative pneumonia in patients undergoing heart valve surgery.
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Affiliation(s)
- Piotr Duchnowski
- Ambulatory Care Unit, Cardinal Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
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2
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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3
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Choi MI, Han SY, Jeon HS, Choi ES, Won SE, Lee YJ, Yang JH, Baek CY, Shim H, Mun SJ. The influence of professional oral hygiene care on reducing ventilator-associated pneumonia in trauma intensive care unit patients. Br Dent J 2022; 232:253-259. [PMID: 35217746 DOI: 10.1038/s41415-022-3986-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/06/2021] [Indexed: 11/09/2022]
Abstract
Aim This study aimed to examine the effects of professional oral hygiene care for the prevention of ventilator-associated pneumonia (VAP) and the improvement of oral hygiene among patients in the trauma intensive care unit (TICU).Materials and methods TICU patients who underwent intubation were randomly assigned to either the experimental group (n = 29) or control group (n = 28). The developed professional oral hygiene care protocol was administered to patients in the experimental group every 24 hours. Additionally, data regarding general characteristics, medical history, oral hygiene status, Clinical Pulmonary Infection Score and quantitative polymerase chain reaction were assessed.Results The incidence of VAP differed between the control group (10.58) and experimental group (0) post intervention. Post-admission bedside oral exam scores with significant differences in oral hygiene were observed in the experimental group (in contrast to the control group) from 48 hours onwards (10.69 ± 3.43, p = 0.06). Staphylococcus aureus and Klebsiella pneumoniae exhibited significant differences in count as professional oral hygiene care continued.Conclusions This study suggests a model in which different health care professionals can cooperate to reduce the incidence of VAP and improve oral health conditions.
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Affiliation(s)
- Ma-I Choi
- Department of Dental Hygiene, College of Software and Digital Healthcare Convergence, Yonsei University, Republic Of Korea
| | - Sun-Young Han
- Department of Dental Hygiene, College of Software and Digital Healthcare Convergence, Yonsei University, Republic Of Korea
| | - Hyun-Sun Jeon
- Department of Dental Hygiene, Yeoju Institute of Technology, Republic Of Korea
| | - Eun-Sil Choi
- Department of Dental Hygiene, The Graduate School, Yonsei University, Republic Of Korea
| | - Seung-Eun Won
- Dental Life Science Research Institute, The Seoul National University Dental Hospital, Republic Of Korea
| | - Ye-Ji Lee
- Dental Hygiene, NYU College of Dentistry, New York, USA
| | - Ji-Hye Yang
- Department of Oral Pathology, Yonsei University College of Dentistry, Republic Of Korea
| | - Chi-Yun Baek
- Department of Nursing, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Republic Of Korea
| | - Hongjin Shim
- Regional Trauma Centre, Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Republic Of Korea
| | - So-Jung Mun
- Department of Dental Hygiene, Yeoju Institute of Technology, Republic Of Korea.
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Cagle LA, Hopper K, Epstein SE. Complications associated with long-term positive-pressure ventilation in dogs and cats: 67 cases. J Vet Emerg Crit Care (San Antonio) 2022; 32:376-385. [PMID: 35001482 DOI: 10.1111/vec.13177] [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: 08/12/2020] [Revised: 11/04/2020] [Accepted: 12/16/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the complications associated with positive-pressure ventilation (PPV) in dogs and cats. DESIGN Retrospective study from October 2009 to September 2013. SETTING University Teaching Hospital. ANIMALS Fifty-eight dogs and 9 cats. MEASUREMENTS AND MAIN RESULTS Medical records were retrospectively reviewed; signalment, complications associated with PPV, duration of PPV, and outcome were recorded. Complications most commonly recorded during PPV included hypothermia 41/67 (61%), hypotension 39/67 (58%), cardiac arrhythmias 33/67 (49%), a positive fluid balance 31/67 (46%), oral lesions 25/67 (37%), and corneal ulcerations 24/67 (36%). A definition of ventilator-associated events (VAE) extrapolated from the Center of Disease Control's criteria was applied to 21 cases that received PPV for at least 4 days in this study. Ventilator-associated conditions occurred in 5 of 21 (24%) of cases with infection-related ventilator-associated conditions and ventilator-associated pneumonia identified in 3 of 21 (14%) cases. CONCLUSIONS Complications are common and diverse in dogs and cats receiving long-term PPV and emphasizes the importance of intensive, continuous patient monitoring and appropriate nursing care protocols. Many of the complications identified could be serious without intervention and suggests that appropriate equipment alarms could improve patient safety. Development of veterinary specific surveillance tools such as the VAE criteria would aid future investigations and allow for effective multicenter studies.
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Affiliation(s)
- Laura A Cagle
- William R. Pritchard Veterinary Medical Teaching Hospital, University of California Davis, Davis, California, USA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California Davis, Davis, California, USA
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Weinberger J, Cocoros N, Klompas M. Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention. Infect Dis Clin North Am 2021; 35:871-899. [PMID: 34752224 DOI: 10.1016/j.idc.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events in 2013 to increase the objectivity and reproducibility of surveillance and to encourage quality improvement programs to focus on preventing a broader array of complications. Ventilator-associated events are associated with a doubling of the risk of dying. Prospective studies have found that minimizing sedation, increasing spontaneous awakening and breathing trials, and conservative fluid management can decrease event rates and the duration of ventilation. Multifaceted interventions to enhance these practices can decrease ventilator-associated event rates.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA
| | - Noelle Cocoros
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Peña-López Y, Ramirez-Estrada S, Eshwara VK, Rello J. Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes. Expert Rev Respir Med 2018; 12:1037-1050. [PMID: 30460868 DOI: 10.1080/17476348.2018.1549492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
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Affiliation(s)
- Yolanda Peña-López
- a Pediatric Critical Care Department , Vall d'Hebron Barcelona Hospital Campus , Barcelona , Spain
| | | | - Vandana Kalwaje Eshwara
- c Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education , Manipal University , Manipal , India
| | - Jordi Rello
- d Clinical Research/epidemiology In Pneumonia & Sepsis , Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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Meißner A, Hasenclever D, Brosteanu O, Chaberny IF. EFFECT of daily antiseptic body wash with octenidine on nosocomial primary bacteraemia and nosocomial multidrug-resistant organisms in intensive care units: design of a multicentre, cluster-randomised, double-blind, cross-over study. BMJ Open 2017; 7:e016251. [PMID: 29122787 PMCID: PMC5695441 DOI: 10.1136/bmjopen-2017-016251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Nosocomial infections are serious complications that increase morbidity, mortality and costs and could potentially be avoidable. Antiseptic body wash is an approach to reduce dermal micro-organisms as potential pathogens on the skin. Large-scale trials with chlorhexidine as the antiseptic agent suggest a reduction of nosocomial infection rates. Octenidine is a promising alternative agent which could be more effective against Gram-negative organisms. We hypothesise that daily antiseptic body wash with octenidine reduces the risk of intensive care unit (ICU)-acquired primary bacteraemia and ICU-acquired multidrug-resistant organisms (MDRO) in a standard care setting. METHODS AND ANALYSIS EFFECT is a controlled, cluster-randomised, double-blind study. The experimental intervention consists in using octenidine-impregnated wash mitts for the daily routine washing procedure of the patients. This will be compared with using placebo wash mitts. Replacing existing washing methods is the only interference into clinical routine.Participating ICUs are randomised in an AB/BA cross-over design. There are two 15-month periods, each consisting of a 3-month wash-out period followed by a 12-month intervention and observation period. Randomisation determines only the sequence in which octenidine-impregnated or placebo wash mitts are used. ICUs are left unaware of what mitts packages they are using.The two coprimary endpoints are ICU-acquired primary bacteraemia and ICU-acquired MDRO. Endpoints are defined based on individual ward-movement history and microbiological test results taken from the hospital information systems without need for extra documentation. Data on clinical symptoms of infection are not collected. EFFECT aims at recruiting about 45 ICUs with about 225 000 patient-days per year. ETHICS AND DISSEMINATION The study was approved by the ethics committee of the University of Leipzig (number 340/16-ek) in November 2016. Findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER DRKS-ID: DRKS00011282.
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Affiliation(s)
- Anne Meißner
- Institute of Hygiene/Hospital Epidemiology, Medical Faculty of the University of Leipzig, Leipzig, Saxony, Germany
| | - Dirk Hasenclever
- Institute for Medical Informatics, Statistics and Epidemiology, Medical Faculty of the University of Leipzig, Leipzig, Saxony, Germany
| | - Oana Brosteanu
- Clinical Trial Centre Leipzig, Medical Faculty of the University of Leipzig, Leipzig, SAxony, Germany
| | - Iris Freya Chaberny
- Institute of Hygiene/Hospital Epidemiology, Medical Faculty of the University of Leipzig, Leipzig, Saxony, Germany
- Institute of Hygiene/Hospital Epidemiology, Leipzig University Hospital, Leipzig, Saxony, Germany
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Walaszek M, Gniadek A, Kolpa M, Wolak Z, Kosiarska A. The effect of subglottic secretion drainage on the incidence of ventilator associated pneumonia. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2017; 161:374-380. [PMID: 29042707 DOI: 10.5507/bp.2017.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/12/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Ventilator-Associated Pneumonia (VAP) is an undesired side effect of mechanical ventilation in intensive care units (ICUs). AIM We evaluated whether endotracheal tubes with subglottic secretion drainage (SSD) would reduce the incidence of VAP among patients undergoing mechanical ventilation in an ICU. METHODS The analysis of medical records of patients undergoing mechanical ventilation exceeding 48 h who were hospitalised in ICUs between 2007 and 2014 led to separating two groups of patients: those in whom no subglottic drainage was applied (NSSD) (records dating from 2007-2010) and those whose treatment involved endotracheal tubes with subglottic secretion drainage (SSD) (records dating from 2011-2014). RESULTS Analysis of 1807 patients hospitalised in ICUs (804 NSSD patients and 1003 SSD patients). A difference was found in the frequency of VAP incidence between the groups (P<0.001). In the NSSD group as many as 84 cases were reported (incidence: 10.7%), and in the SSD group - 43 cases (incidence: 5.2%). The odds ratio (OR) and relative risk (RR) was 2.5. The probability of VAP was significantly higher in the NSSD group. The risk factors of VAP incidence (P<0.001) included the correlation between reintubation (R=0.271), tracheostomy (R=0.309) and bronchoscopy (R=0.316). CONCLUSION Use of endotracheal tubes with subglottic secretion drainage in patients in the ICU on mechanical ventilation significantly reduced the incidence of VAP.
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Affiliation(s)
- Marta Walaszek
- Sw. Lukasz Provincial Hospital in Tarnow, Poland.,Department of Nursing, Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland
| | - Agnieszka Gniadek
- Department of Nursing Management and Epidemiology Nursing, Faculty of Health Sciences, Jagiellonian University Medical College, Cracow, Poland
| | - Malgorzata Kolpa
- Department of Nursing, Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland
| | - Zdzislaw Wolak
- Department of Nursing, Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland
| | - Alicja Kosiarska
- Department of Nursing, Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland
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Abstract
The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events (VAEs) in 2013. The shift was designed to increase the objectivity and reproducibility of surveillance and to encourage quality-improvement programs to tackle a broader array of complications in mechanically ventilated patients. Prospective intervention studies have found that minimizing sedation, increasing the use of spontaneous awakening and breathing trials, and conservative fluid management can lower VAE rates and decrease duration of mechanical ventilation. Additional strategies to prevent VAEs include early mobility programs, low tidal volume ventilation, and restrictive transfusion thresholds.
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Affiliation(s)
- Noelle M Cocoros
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, 401 Park Street, Suite 401, Boston, MA 02215, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, 401 Park Street, Suite 401, Boston, MA 02215, USA; Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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The Comparison of the Effect of the Head of Bed Elevation to 30 and 45 Degreess on the Incidence of Ventilator Associated Pneumonia and the Risk for Pressure Ulcers: A Controlled Randomized Clinical Trial. IRANIAN RED CRESCENT MEDICAL JOURNAL 2017. [DOI: 10.5812/ircmj.14224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Propofol Sedation Exacerbates Kidney Pathology and Dissemination of Bacteria during Staphylococcus aureus Bloodstream Infections. Infect Immun 2017; 85:IAI.00097-17. [PMID: 28461390 DOI: 10.1128/iai.00097-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for large numbers of postsurgical nosocomial infections across the United States and worldwide. Propofol anesthesia is widely used in surgery and in intensive care units, and recent evidence indicates that even brief exposure to propofol can substantially increase host susceptibility to microbial infection. Here, we delineate the impact of propofol sedation on MRSA bloodstream infections in mice in the presence and absence of prophylactic antibiotic treatment. Consistent with previous reports, brief periods of anesthesia with propofol were sufficient to significantly increase bacterial burdens and kidney pathology in mice infected with MRSA. Propofol exposure increased neutrophilic infiltrates into the kidney and enhanced bacterial dissemination throughout kidney tissue. Propofol sedation reduced populations of effector phagocytes and mature dendritic cells within the kidney and led to the apparent expansion of myeloid-derived suppressor cell-like populations. When propofol was coadministered with vancomycin prophylaxis, it dramatically increased kidney abscess formation and bacterial dissemination throughout kidney tissue at early times post-S. aureus infection compared to antibiotic-treated but nonsedated animals. Taken together, our data indicate that short-term sedation with propofol significantly increases the severity of bloodstream MRSA infection, even when administered in conjunction with vancomycin prophylaxis.
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Nobre V, Borges I. Prognostic value of procalcitonin in hospitalized patients with lower respiratory tract infections. Rev Bras Ter Intensiva 2017; 28:179-89. [PMID: 27305038 PMCID: PMC4943056 DOI: 10.5935/0103-507x.20160019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/14/2016] [Indexed: 01/04/2023] Open
Abstract
Lower respiratory tract infections are common and potentially lethal conditions
and are a major cause of inadequate antibiotic prescriptions. Characterization
of disease severity and prognostic prediction in affected patients can aid
disease management and can increase accuracy in determining the need for and
place of hospitalization. The inclusion of biomarkers, particularly
procalcitonin, in the decision taken process is a promising strategy. This study
aims to present a narrative review of the potential applications and limitations
of procalcitonin as a prognostic marker in hospitalized patients with lower
respiratory tract infections. The studies on this topic are heterogeneous with
respect to procalcitonin measurement techniques, cutoff values, clinical
settings, and disease severity. The results show that procalcitonin delivers
moderate performance for prognostic prediction in patients with lower
respiratory tract infections; its predictive performance was not higher than
that of classical methods, and knowledge of procalcitonin levels is most useful
when interpreted together with other clinical and laboratory results. Overall,
repeated measurement of the procalcitonin levels during the first days of
treatment provides more prognostic information than a single measurement;
however, information on the cost-effectiveness of this procedure in intensive
care patients is lacking. The results of studies that evaluated the prognostic
value of initial procalcitonin levels in patients with community-acquired
pneumonia are more consistent and have greater potential for practical
application; in this case, low procalcitonin levels identify those patients with
a low risk of adverse outcomes.
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Affiliation(s)
- Vandack Nobre
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Programa de Pós-Graduação em Infectologia e Medicina Tropical, Belo Horizonte MG , Brazil, Programa de Pós-Graduação em Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais - Belo Horizonte (MG), Brasil., Universidade Federal de Minas Gerais.,Universidade Federal de Minas Gerais, Hospital das Clínicas, Unidade de Cuidados Intensivos do Adulto, Belo Horizonte MG , Brazil, Unidade de Cuidados Intensivos do Adulto, Hospital das Clínicas, Universidade Federal de Minas Gerais - Belo Horizonte (MG), Brasil., Universidade Federal de Minas Gerais
| | - Isabela Borges
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Programa de Pós-Graduação em Infectologia e Medicina Tropical, Belo Horizonte MG , Brazil, Programa de Pós-Graduação em Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais - Belo Horizonte (MG), Brasil., Universidade Federal de Minas Gerais
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Pneumonia after cardiac surgery: Experience of the National Institutes of Health/Canadian Institutes of Health Research Cardiothoracic Surgical Trials Network. J Thorac Cardiovasc Surg 2017; 153:1384-1391.e3. [PMID: 28341473 DOI: 10.1016/j.jtcvs.2016.12.055] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/16/2016] [Accepted: 12/28/2016] [Indexed: 01/30/2023]
Abstract
RATIONALE Pneumonia remains the most common major infection after cardiac surgery despite numerous preventive measures. OBJECTIVES To prospectively examine the timing, pathogens, and risk factors, including modifiable management practices, for postoperative pneumonia and estimate its impact on clinical outcomes. METHODS A total of 5158 adult cardiac surgery patients were enrolled prospectively in a cohort study across 10 centers. All infections were adjudicated by an independent committee. Competing risk models were used to assess the association of patient characteristics and management practices with pneumonia within 65 days of surgery. Mortality was assessed by Cox proportional hazards model and length of stay by a multistate model. MEASUREMENTS AND MAIN RESULTS The cumulative incidence of pneumonia was 2.4%, 33% of which occurred after discharge. Older age, lower hemoglobin level, chronic obstructive pulmonary disease, steroid use, operative time, and left ventricular assist device/heart transplant were risk factors. Ventilation time (24-48 vs ≤24 hours; hazard ratio [HR], 2.83; 95% confidence interval [95% CI], 1.72-4.66; >48 hours HR, 4.67; 95% CI, 2.70-8.08), nasogastric tubes (HR, 1.80; 95% CI, 1.10-2.94), and each unit of blood cells transfused (HR, 1.16; 95% CI, 1.08-1.26) increased the risk of pneumonia. Prophylactic use of second-generation cephalosporins (HR, 0.66; 95% CI, 0.45-0.97) and platelet transfusions (HR, 0.49, 95% CI, 0.30-0.79) were protective. Pneumonia was associated with a marked increase in mortality (HR, 8.89; 95% CI, 5.02-15.75) and longer length of stay of 13.55 ± 1.95 days (bootstrap 95% CI, 10.31-16.58). CONCLUSIONS Pneumonia continues to impose a major impact on the health of patients after cardiac surgery. After we adjusted for baseline risk, several specific management practices were associated with pneumonia, which offer targets for quality improvement and further research.
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Liu H, Fei CN, Zhang Y, Liu GW, Liu J, Dong J. Presence, distribution and molecular epidemiology of multi-drug-resistant Gram-negative bacilli from medical personnel of intensive care units in Tianjin, China, 2007-2015. J Hosp Infect 2017; 96:101-110. [PMID: 28268024 DOI: 10.1016/j.jhin.2017.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 01/21/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Multi-drug-resistant Gram-negative bacteria (MDRGNB) have become an important cause of nosocomial infection in intensive care units (ICUs). AIMS To investigate the molecular epidemiology of MDRGNB isolated from medical personnel (MP) and non-medical personnel (NMP) at 69 ICUs in Tianjin, China. METHODS From April 2007 to October 2015, 2636 nasal and hand swab samples from 1185 MP and 133 NMP were cultured for GNB (including MDRGNB), meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The susceptibilities of GNB to 14 antimicrobial agents were determined, and 80 MDRGNB were characterized using pulsed-field gel electrophoresis (PFGE) and dendrogram analysis. FINDINGS In total, 301 GNB were identified in 269 MP, including 109 MDRGNB isolates in 104 MP. Forty-two GNB were isolated from 39 NMP, which included 20 NMP with MDRGNB. Overall, 8.8% of MP were colonized with MDRGNB, which greatly exceeded colonization rates with MRSA (0.9%) and VRE (0.1%). Three pairs of Klebsiella pneumoniae and one pair of Enterobacter aerogenes were indistinguishable from each other, but the majority of isolate tests had distinct PFGE profiles. CONCLUSIONS The prevalence of MDRGNB was high among ICU MP in Tianjin, and greatly exceeded that of VRE and MRSA. There was no difference in the rates of nasal carriage of MDRGNB between MP and NMP, but NMP were significantly more likely to have hand colonization with MDRGNB. PFGE profiles showed that there was only limited sharing of strains of MDR E. aerogenes and K. pneumoniae between personnel.
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Affiliation(s)
- H Liu
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China.
| | - C N Fei
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
| | - Y Zhang
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
| | - G W Liu
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
| | - J Liu
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
| | - J Dong
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
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15
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Huang HP, Chen B, Wang HY, He M. The efficacy of daily chlorhexidine bathing for preventing healthcare-associated infections in adult intensive care units. Korean J Intern Med 2016; 31:1159-1170. [PMID: 27048258 PMCID: PMC5094930 DOI: 10.3904/kjim.2015.240] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/23/2015] [Accepted: 09/06/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Healthcare-associated infections (HAIs) in critically ill patients with prolonged length of hospital stay and increased medical costs. The aim of this study is to assess whether daily chlorhexidine gluconate (CHG) bathing will significantly reduce the rates of HAIs in adult intensive care units (ICUs). METHODS PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched until December 31, 2014 to identify relevant studies. Two authors independently reviewed and extracted data from included studies. All data was analyzed by Review Manager version 5.3. RESULTS Fifteen studies including three randomized controlled trials and 12 quasi-experimental studies were available in this study. The outcomes showed that daily CHG bathing were associated with significant reduction in the rates of primary outcomes: catheter-related bloodstream infection (risk ratio [RR], 0.44; 95% confidence interval [CI], 0.32 to 0.63; p < 0.00001), catheter-associated urinary tract infection (RR, 0.68; 95% CI, 0.52 to 0.88; p = 0.004), ventilator-associated pneumonia (RR, 0.73; 95% CI, 0.57 to 0.93; p = 0.01), acquisition of methicillin-resistant Staphylococcus aureus (RR, 0.78; 95% CI, 0.68 to 0.91; p = 0.001) and vancomycin-resistant Enterococcus (RR, 0.56; 95% CI, 0.31 to 0.99; p = 0.05). CONCLUSIONS Our study suggests that the use of daily CHG bathing can significantly prevent HAIs in ICUs. However, more well-designed studies are needed to confirm these findings.
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Affiliation(s)
- Hua-ping Huang
- Nursing Administration, Mianyang Central Hospital, Mianyang, China
- Correspondence to Hua-ping Huang, R.N. Nursing Administration, Mianyang Central Hospital, No. 12, Changjia Alley, Jingzhong Street, Fucheng District, Mianyang 621000, China Tel: +86-816-223-9671 Fax: +86-816-222-2566 E-mail:
| | - Bin Chen
- Intensive Care Unit, Mianyang Central Hospital, Mianyang, China
| | - Hai-Yan Wang
- Nursing Administration, Mianyang Central Hospital, Mianyang, China
| | - Me He
- Nursing Administration, Mianyang Central Hospital, Mianyang, China
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16
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Ghoochani Khorasani A, Shadnia S, Mashayekhian M, Rahimi M, Aghabiklooei A. Efficacy of Hi-Lo Evac Endotracheal Tube in Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Poisoned Patients. SCIENTIFICA 2016; 2016:4901026. [PMID: 27651976 PMCID: PMC5019940 DOI: 10.1155/2016/4901026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 05/20/2016] [Accepted: 07/13/2016] [Indexed: 06/06/2023]
Abstract
Background. Ventilator-associated pneumonia (VAP) is the most common health care-associated infection. To prevent this complication, aspiration of subglottic secretions using Hi-Lo Evac endotracheal tube (Evac ETT) is a recommended intervention. However, there are some reports on Evac ETT dysfunction. We aimed to compare the incidence of VAP (per ventilated patients) in severely ill poisoned patients who were intubated using Evac ETT versus conventional endotracheal tubes (C-ETT) in our toxicology ICU. Materials and Methods. In this clinical randomized trial, 91 eligible patients with an expected duration of mechanical ventilation of more than 48 hours were recruited and randomly assigned into two groups: (1) subglottic secretion drainage (SSD) group who were intubated by Evac ETT (n = 43) and (2) control group who were intubated by C-ETT (n = 48). Results. Of the 91 eligible patients, 56 (61.5%) were male. VAP was detected in 24 of 43 (55.8%) patients in the case group and 23 of 48 (47.9%) patients in the control group (P = 0.45). The most frequently isolated microorganisms were S. aureus (54.10%) and Acinetobacter spp. (19.68%). The incidence of VAP and ICU length of stay were not significantly different between the two groups, but duration of intubation was statistically different and was longer in the SSD group. Mortality rate was less in SSD group but without a significant difference (P = 0.68). Conclusion. The SSD procedure was performed intermittently with one-hour intervals using 10 mL syringe. Subglottic secretion drainage does not significantly reduce the incidence of VAP in patients receiving MV. This strategy appears to be ineffective in preventing VAP among ICU patients.
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Affiliation(s)
- Ahmad Ghoochani Khorasani
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Medical Sciences, Amin Police University, Tehran, Iran
| | - Shahin Shadnia
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Mashayekhian
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Medical Sciences, Amin Police University, Tehran, Iran
| | - Mitra Rahimi
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Aghabiklooei
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Legal Medicine, Iran University of Medical Sciences, Tehran, Iran
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17
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Priyendu A, Vandana KE, Nilima, Varma M, Prabhu N, Rahim AA, Nagappa AN. Antibiotic prophylaxis in organophosphorus poisoning: A study of health and economic outcomes. Saudi Pharm J 2016; 25:332-336. [PMID: 28344486 PMCID: PMC5357088 DOI: 10.1016/j.jsps.2016.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 07/25/2016] [Indexed: 11/16/2022] Open
Abstract
Objective: Organophosphorus poisoning (OPP) is a major concern for developing countries. There are no guidelines for the prophylactic use of antibiotics in the management of OPP which in such critical cases might add to the economic burden of the patients as well as antibiotic resistance. We compared the health and economic outcomes in patients prescribed with prophylactic antibiotics with respect to the patients not prescribed with any antibiotics. Methods: A retrospective observational study was carried out for two years for patients admitted to ICU with OPP. Patients were graded for severity of OPP, and divided into two groups based on prophylactic prescription and no prescription of antibiotics. The length of stay (LOS), hospitalization cost and outcomes were measured and compared between the two groups using statistical tests. Results: Out of the 254 patients observed, 108 were prescribed with prophylactic antibiotics and 94 were not prescribed with any antibiotic. There was a significant difference between LOS, cost of treatment and outcomes in the two groups (p < 0.001). When antibiotics were not prescribed, the odds of improvement was 1.854 times higher compared to those who received prophylactic antibiotics although after adjusting for severity of poisoning, significance was lost. On an average, 2-3 antibiotics were prescribed to every patient in the first group. Conclusion: OPP is an important health concern where issues of antibiotic misuse and overuse are practiced. Our study suggested that systemic antibiotic prophylaxis did not offer any advantage over non-use of any antibiotics in patients with OPP.
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Affiliation(s)
- Asim Priyendu
- Department of Pharmacy Management, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
| | - K E Vandana
- Department of Microbiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Nilima
- Department of Statistics, Manipal University, Manipal, Karnataka, India
| | - Muralidhar Varma
- Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Nishitha Prabhu
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
| | - Alsha Abdul Rahim
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
| | - Anantha Naik Nagappa
- Department of Pharmacy Management, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
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18
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Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 2016; 35:915-36. [DOI: 10.1086/677144] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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19
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Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2015; 35 Suppl 2:S133-54. [PMID: 25376073 DOI: 10.1017/s0899823x00193894] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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20
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McGovern Murphy F, Raymond M, Menard PA, Bejar-Ardiles KR, Carignan A, Lesur O. Ventilator associated pneumonia and endotracheal tube repositioning: an underrated risk factor. Am J Infect Control 2014; 42:1328-30. [PMID: 25465265 DOI: 10.1016/j.ajic.2014.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 08/26/2014] [Accepted: 09/02/2014] [Indexed: 10/24/2022]
Abstract
Aspiration of secretions toward lower airways potentially occurs during endotracheal tube (ETT) repositioning in mechanically ventilated patients in the intensive care unit and may be a risk factor for developing ventilator-associated pneumonia (VAP). This case-control study confirms that repositioning of the ETT is an independent risk factor for VAP.
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21
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Meng K, Li Y, Li S, Zhao H, Chen L. The Survey on Implementation of Evidence-Based Nursing in Preventing Ventilator-Associated Pneumonia and the Effect Observation. Cell Biochem Biophys 2014; 71:375-81. [DOI: 10.1007/s12013-014-0208-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Klompas M. Editorial commentary: Evidence vs instinct for pneumonia prevention in hospitalized patients. Clin Infect Dis 2014; 60:76-8. [PMID: 25252683 PMCID: PMC4264582 DOI: 10.1093/cid/ciu744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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23
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Lewis SC, Li L, Murphy MV, Klompas M. Risk factors for ventilator-associated events: a case-control multivariable analysis. Crit Care Med 2014; 42:1839-48. [PMID: 24751498 PMCID: PMC4451208 DOI: 10.1097/ccm.0000000000000338] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The Centers for Disease Control and Prevention recently released new surveillance definitions for ventilator-associated events, including the new entities of ventilator-associated conditions and infection-related ventilator-associated complications. Both ventilator-associated conditions and infection-related ventilator-associated complications are associated with prolonged mechanical ventilation and hospital death, but little is known about their risk factors and how best to prevent them. We sought to identify risk factors for ventilator-associated conditions and infection-related ventilator-associated complications. DESIGN Retrospective case-control study. SETTING Medical, surgical, cardiac, and neuroscience units of a tertiary care teaching hospital. PATIENTS Hundred ten patients with ventilator-associated conditions matched to 110 controls without ventilator-associated conditions on the basis of age, sex, ICU type, comorbidities, and duration of mechanical ventilation prior to ventilator-associated conditions. INTERVENTIONS None. MEASUREMENTS We compared cases with controls with regard to demographics, comorbidities, ventilator bundle adherence rates, sedative exposures, routes of nutrition, blood products, fluid balance, and modes of ventilatory support. We repeated the analysis for the subset of patients with infection-related ventilator-associated complications and their controls. MAIN RESULTS Case and control patients were well matched on baseline characteristics. On multivariable logistic regression, significant risk factors for ventilator-associated conditions were mandatory modes of ventilation (odds ratio, 3.4; 95% CI, 1.6-8.0) and positive fluid balances (odds ratio, 1.2 per L positive; 95% CI, 1.0-1.4). Possible risk factors for infection-related ventilator-associated complications were starting benzodiazepines prior to intubation (odds ratio, 5.0; 95% CI, 1.3-29), total opioid exposures (odds ratio, 3.3 per 100 μg fentanyl equivalent/kg; 95% CI, 0.90-16), and paralytic medications (odds ratio, 2.3; 95% CI, 0.79-80). Traditional ventilator bundle elements, including semirecumbent positioning, oral care with chlorhexidine, venous thromboembolism prophylaxis, stress ulcer prophylaxis, daily spontaneous breathing trials, and sedative interruptions, were not associated with ventilator-associated conditions or infection-related ventilator-associated complications. CONCLUSIONS Mandatory modes of ventilation and positive fluid balance are risk factors for ventilator-associated conditions. Benzodiazepines, opioids, and paralytic medications are possible risk factors for infection-related ventilator-associated complications. Prospective studies are needed to determine if targeting these risk factors can lower ventilator-associated condition and infection-related ventilator-associated complication rates.
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Affiliation(s)
- Sarah C Lewis
- 1Division of Infectious Disease, University of California San Francisco, San Francisco, CA. 2Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA. 3Department of Medicine, Brigham and Women's Hospital, Boston, MA
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24
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Klein Klouwenberg PMC, van Mourik MSM, Ong DSY, Horn J, Schultz MJ, Cremer OL, Bonten MJM. Electronic implementation of a novel surveillance paradigm for ventilator-associated events. Feasibility and validation. Am J Respir Crit Care Med 2014; 189:947-55. [PMID: 24498886 DOI: 10.1164/rccm.201307-1376oc] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Accurate surveillance of ventilator-associated pneumonia (VAP) is hampered by subjective diagnostic criteria. A novel surveillance paradigm for ventilator-associated events (VAEs) was introduced. OBJECTIVES To determine the validity of surveillance using the new VAE algorithm. METHODS Prospective cohort study in two Dutch academic medical centers (2011-2012). VAE surveillance was electronically implemented and included assessment of (infection-related) ventilator-associated conditions (VAC, IVAC) and VAP. Concordance with ongoing prospective VAP surveillance was assessed, along with clinical diagnoses underlying VAEs and associated mortality of all conditions. Consequences of minor differences in electronic VAE implementation were evaluated. MEASUREMENTS AND MAIN RESULTS The study included 2,080 patients with 2,296 admissions. Incidences of VAC, IVAC, VAE-VAP, and VAP according to prospective surveillance were 10.0, 4.2, 3.2, and 8.0 per 1000 ventilation days, respectively. The VAE algorithm detected at most 32% of the patients with VAP identified by prospective surveillance. VAC signals were most often caused by volume overload and infections, but not necessarily VAP. Subdistribution hazards for mortality were 3.9 (95% confidence interval, 2.9-5.3) for VAC, 2.5 (1.5-4.1) for IVAC, 2.0 (1.1-3.6) for VAE-VAP, and 7.2 (5.1-10.3) for VAP identified by prospective surveillance. In sensitivity analyses, mortality estimates varied considerably after minor differences in electronic algorithm implementation. CONCLUSIONS Concordance between the novel VAE algorithm and VAP was poor. Incidence and associated mortality of VAE were susceptible to small differences in electronic implementation. More studies are needed to characterize the clinical entities underlying VAE and to ensure comparability of rates from different institutions.
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25
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Boots AW, Smolinska A, van Berkel JJBN, Fijten RRR, Stobberingh EE, Boumans MLL, Moonen EJ, Wouters EFM, Dallinga JW, Van Schooten FJ. Identification of microorganisms based on headspace analysis of volatile organic compounds by gas chromatography-mass spectrometry. J Breath Res 2014; 8:027106. [PMID: 24737039 DOI: 10.1088/1752-7155/8/2/027106] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The identification of specific volatile organic compounds (VOCs) produced by microorganisms may assist in developing a fast and accurate methodology for the determination of pulmonary bacterial infections in exhaled air. As a first step, pulmonary bacteria were cultured and their headspace analyzed for the total amount of excreted VOCs to select those compounds which are exclusively associated with specific microorganisms. Development of a rapid, noninvasive methodology for identification of bacterial species may improve diagnostics and antibiotic therapy, ultimately leading to controlling the antibiotic resistance problem. Two hundred bacterial headspace samples from four different microorganisms (Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus and Klebsiella pneumoniae) were analyzed by gas chromatography-mass spectrometry to detect a wide array of VOCs. Statistical analysis of these volatiles enabled the characterization of specific VOC profiles indicative for each microorganism. Differences in VOC abundance between the bacterial types were determined using ANalysis of VAriance-principal component analysis (ANOVA-PCA). These differences were visualized with PCA. Cross validation was applied to validate the results. We identified a large number of different compounds in the various headspaces, thus demonstrating a highly significant difference in VOC occurrence of bacterial cultures compared to the medium and between the cultures themselves. Additionally, a separation between a methicillin-resistant and a methicillin-sensitive isolate of S. aureus could be made due to significant differences between compounds. ANOVA-PCA analysis showed that 25 VOCs were differently profiled across the various microorganisms, whereas a PCA score plot enabled the visualization of these clear differences between the bacterial types. We demonstrated that identification of the studied microorganisms, including an antibiotic susceptible and resistant S. aureus substrain, is possible based on a selected number of compounds measured in the headspace of these cultures. These in vitro results may translate into a breath analysis approach that has the potential to be used as a diagnostic tool in medical microbiology.
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Affiliation(s)
- A W Boots
- Department of Toxicology, Maastricht University, Maastricht, The Netherlands
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Oliveira J, Zagalo C, Cavaco-Silva P. Prevention of ventilator-associated pneumonia. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:152-61. [PMID: 24674617 DOI: 10.1016/j.rppneu.2014.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/06/2014] [Accepted: 01/08/2014] [Indexed: 12/29/2022] Open
Abstract
Invasive mechanical ventilation (IMV) represents a risk factor for the development of ventilator-associated pneumonia (VAP), which develops at least 48h after admission in patients ventilated through tracheostomy or endotracheal intubation. VAP is the most frequent intensive-care-unit (ICU)-acquired infection among patients receiving IMV. It contributes to an increase in hospital mortality, duration of MV and ICU and length of hospital stay. Therefore, it worsens the condition of the critical patient and increases the total cost of hospitalization. The introduction of preventive measures has become imperative, to ensure control and to reduce the incidence of VAP. Preventive measures focus on modifiable risk factors, mediated by non-pharmacological and pharmacological evidence based strategies recommended by guidelines. These measures are intended to reduce the risk associated with endotracheal intubation and to prevent microaspiration of pathogens to the lower airways.
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Affiliation(s)
- J Oliveira
- CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal; TechnoPhage S.A., Lisbon, Portugal
| | - C Zagalo
- CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal; Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - P Cavaco-Silva
- CIIEM, Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal; TechnoPhage S.A., Lisbon, Portugal.
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27
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Lambert ML, Silversmit G, Savey A, Palomar M, Hiesmayr M, Agodi A, Van Rompaye B, Mertens K, Vansteelandt S. Preventable proportion of severe infections acquired in intensive care units: case-mix adjusted estimations from patient-based surveillance data. Infect Control Hosp Epidemiol 2014; 35:494-501. [PMID: 24709717 DOI: 10.1086/675824] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND More than 10% of patients admitted to intensive care units (ICUs) experience a severe, healthcare-associated infection, such as ventilator-associated pneumonia (VAP) or bloodstream infection (BSI). What could be a public health target for prevention is hotly debated, because properly adjusting for intrinsic risk factors in the patient population is difficult. We aimed to estimate the proportion of ICU-acquired VAP and BSI cases that are amenable to prevention in routine conditions. METHODS We analyzed routine data collected prospectively according to the European standard protocol for patient-based surveillance of healthcare-acquired infections in ICUs. We computed the number of infections to be expected if, after adjustment for case mix, the infection incidence in ICUs with higher infection rates could be reduced to that of the top-tenth-percentile-ranked ICU. Computations came from model-based simulation of individual patient profiles over time in the ICU. The preventable proportion was computed as the number of observed cases minus the number of expected cases divided by the number of observed cases. RESULTS Data for 78,222 patients admitted for more than 2 days to 525 ICUs in 6 European countries from 2005 to 2008 were available for analysis. We calculated that 52% of VAP and 69% of BSI was preventable. CONCLUSIONS Our pragmatic, if highly conservative, estimates quantify the potential for prevention of VAP and BSI in routine conditions, assuming that variation in infection incidence between ICUs can be eliminated with improved quality of care, apart from variation attributable to differential case mix.
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Affiliation(s)
- Marie-Laurence Lambert
- Healthcare Associated Infections Unit, Scientific Institute of Public Health, Brussels, Belgium
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Erdem H, Inan A, Altındis S, Carevic B, Askarian M, Cottle L, Beovic B, Csomos A, Metodiev K, Ahmetagic S, Harxhi A, Raka L, Grozdanovski K, Nechifor M, Alp E, Bozkurt F, Hosoglu S, Balik I, Yilmaz G, Jereb M, Moradi F, Petrov N, Kaya S, Koksal I, Aslan T, Elaldi N, Akkoyunlu Y, Moravveji SA, Csato G, Szedlak B, Akata F, Oncu S, Grgic S, Cosic G, Stefanov C, Farrokhnia M, Müller M, Luca C, Koluder N, Korten V, Platikanov V, Ivanova P, Soltanipour S, Vakili M, Farahangiz S, Afkhamzadeh A, Beeching N, Ahmed SS, Cami A, Shiraly R, Jazbec A, Mirkovic T, Leblebicioglu H, Naber K. Surveillance, control and management of infections in intensive care units in Southern Europe, Turkey and Iran--a prospective multicenter point prevalence study. J Infect 2013; 68:131-40. [PMID: 24269951 DOI: 10.1016/j.jinf.2013.11.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 10/01/2013] [Accepted: 11/01/2013] [Indexed: 12/29/2022]
Abstract
OBJECTIVE We aimed to compare the features of intensive care units (ICUs), their antimicrobial resistance patterns, infection control policies, and distribution of infectious diseases from central Europe to Mid-West Asia. METHODS A cross-sectional point prevalence study was performed in 88 ICUs from 12 countries. Characteristics of ICUs, patient and antibiotic therapy data were collected with a standard form by infectious diseases specialists. RESULTS Out of 749, 305 patients at least with one infectious disease were assessed and 254 patients were reported to have coexistent medical problems. When primary infectious diseases diagnoses of the patients were evaluated, 69 had community-acquired, 61 had healthcare-associated, and 176 had hospital-acquired infections. Pneumonia was the most frequent ICU infection seen in half of the patients. Distribution of frequent pathogens was as follows: Enteric Gram-negatives (n = 62, 28.8%), Acinetobacter spp. (n = 47, 21.9%), Pseudomonas aeruginosa (n = 29, 13.5%). Multidrug resistance profiles of the infecting microorganisms seem to have a uniform pattern throughout Southern Europe and Turkey. On the other hand, active and device-associated infection surveillance was performed in Turkey more than Iran and Southeastern Europe (p < 0.05). However, designing antibiotic treatment according to culture results was highest in Southeastern Europe (p < 0.05). The most frequently used antibiotics were carbapenems (n = 92, 30.2%), followed by anti-gram positive agents (vancomycin, teicoplanin, linezolid, daptomycin, and tigecycline; n = 79, 25.9%), beta-lactam/beta lactamase inhibitors (n = 78, 25.6%), and extended-spectrum cephalosporins (n = 73, 23.9%). CONCLUSION ICU features appears to have similar characteristics from the infectious diseases perspective, although variability seems to exist in this large geographical area.
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Affiliation(s)
- Hakan Erdem
- GATA Haydarpasa Training Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey.
| | - Asuman Inan
- Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Selma Altındis
- Sakarya University, Faculty of Management, Department of Health Administration, Sakarya, Turkey
| | - Biljana Carevic
- Clinical Center of Serbia (CCS), Department for Hospital Epidemiology, Belgrade, Serbia
| | - Mehrdad Askarian
- Department of Community Medicine, School of Medicine, Medicinal & Natural Products Chemistry Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Lucy Cottle
- Royal Liverpool University Hospital, United Kingdom
| | - Bojana Beovic
- University Medical Centre, Department of Infectious Diseases, Ljubljana, Slovenia
| | - Akos Csomos
- Semmelweis University, Department of Anaesthesia and Intensive Care, Budapest, Hungary
| | - Krassimir Metodiev
- Medical University, Department of Preclinical and Clinical Sciences, Varna, Bulgaria
| | - Sead Ahmetagic
- University Clinical Center Tuzla, Department for Infectious Diseases, Tuzla, Bosnia and Herzegovina
| | - Arjan Harxhi
- University Hospital Center of Tirana, Service of Infectious Disease, Tirana, Albania
| | - Lul Raka
- University of Prishtina, School of Medicine & National Institute of Public Health of Kosova, Prishtina, Kosova, Serbia
| | - Krsto Grozdanovski
- University Clinic for Infectious Diseases, Department of Intensive Care, Skopje, Macedonia
| | - Mihai Nechifor
- Gr. T. Popa University of Medicine and Pharmacy, Department of Pharmacology, Iasi, Romania
| | - Emine Alp
- Erciyes University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Kayseri, Turkey
| | - Fatma Bozkurt
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Salih Hosoglu
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Ismail Balik
- Ankara University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Gulden Yilmaz
- Ankara University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Matjaz Jereb
- University Medical Centre, Department of Infectious Diseases, Ljubljana, Slovenia
| | - Fatemeh Moradi
- Clinical Research Center on Infectious Diseases and Tropical Medicine, Bandar Abbas, Iran
| | - Nikolay Petrov
- Military Medical Academy, Department Anaesthesiology and Intensive Care, Sofia, Bulgaria
| | - Selcuk Kaya
- Karadeniz Technical University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Trabzon, Turkey
| | - Iftihar Koksal
- Karadeniz Technical University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Trabzon, Turkey
| | - Turan Aslan
- Bezmi Alem University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Nazif Elaldi
- Cumhuriyet University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Sivas, Turkey
| | - Yasemin Akkoyunlu
- Bezmi Alem University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Seyyed Alireza Moravveji
- Kashan University of Medical Sciences, Trauma Research Center, Department of Community Medicine, Kashan, Iran
| | - Gabor Csato
- Kenézy Hospital, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Balazs Szedlak
- Borsod County Hospital and Teaching Hospital, Department of Anaesthesiology and Intensive Therapy, Miskolc, Hungary
| | - Filiz Akata
- Trakya University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Edirne, Turkey
| | - Serkan Oncu
- Adnan Menderes University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Aydin, Turkey
| | - Svjetlana Grgic
- University Hospital Clinic for Infectious Diseases, Mostar, Bosnia and Herzegovina
| | - Gorana Cosic
- IPH of Vojvodina, Department of Prevention and Control of Diseases, Medical Faculty, University of Novi Sad, Serbia
| | - Chavdar Stefanov
- University Multiprofile Hospital for Active Treatment, Department of Anesthesiology and Intensive Treatment, St. Georgi, Plovdiv, Bulgaria
| | - Mehrdad Farrokhnia
- Kerman University of Medical Sciences, Department of Internal Medicine, Kerman, Iran
| | - Mária Müller
- Markhot Hospital, Department of Anaesthesiology and Intensive Care, Eger, Hungary
| | - Catalina Luca
- Gr. T. Popa University of Medicine and Pharmacy, Department of Pharmacology, Iasi, Romania
| | - Nada Koluder
- Clinic for Infectious Diseases, Sarajevo, Bosnia and Herzegovina
| | - Volkan Korten
- Marmara University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Viliyan Platikanov
- University Hospital "St. Marina", Department of Anesthesiology and ICM, Varna, Bulgaria
| | - Petja Ivanova
- University Hospital "St. Marina", Department of Anesthesiology and ICM, Varna, Bulgaria
| | - Soheil Soltanipour
- Guilan University of Medical Sciences, School of Medicine, Department of Community Medicine, Rasht, Iran
| | - Mahmood Vakili
- Shahid Sadoughi University School of Medicine, Department of Community Medicine, Yazd, Iran
| | - Saman Farahangiz
- Department of Community Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdorrahim Afkhamzadeh
- Department of Community Medicine, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | | | - Salman Shaheer Ahmed
- Erciyes University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Kayseri, Turkey
| | - Alma Cami
- University Hospital of Pulmonary Disease, Intensive Care Clinic, Tirana, Albania
| | - Ramin Shiraly
- Ilam University of Medical Sciences, Department of Community Medicine, Yazd, Iran
| | - Anja Jazbec
- University Clinical Center Ljubljana, Center for Intensive Internal Medicine, Ljubljana, Slovenia
| | - Tomislav Mirkovic
- University Medical Centre Ljubljana, Department of Anestesiology and Surgical Intensive Care, Ljubljana, Slovenia
| | - Hakan Leblebicioglu
- Ondokuz Mayis University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Samsun, Turkey
| | - Kurt Naber
- Technical University of Munich, Munich, Germany
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Walsh TS, Morris AC, Simpson AJ. Ventilator associated pneumonia: can we ensure that a quality indicator does not become a game of chance? Br J Anaesth 2013; 111:333-7. [PMID: 23946358 DOI: 10.1093/bja/aet131] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Prävention der nosokomialen beatmungsassoziierten Pneumonie. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013. [DOI: 10.1007/s00103-013-1846-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Mertens K, Morales I, Catry B. Infections acquired in intensive care units: results of national surveillance in Belgium, 1997-2010. J Hosp Infect 2013; 84:120-5. [PMID: 23639819 DOI: 10.1016/j.jhin.2013.02.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 02/10/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIM To describe the methodology and output of the Belgian surveillance for infections acquired in intensive care units (ICUs) between 1997 and 2010. METHODS Since 1997, ICUs in acute care hospitals in Belgium have been encouraged by federal law to participate in a national multi-centre prospective observational surveillance programme. A protocol and software tool for data collection was developed, and the case definitions and methodology follow those of the European Centre for Disease Prevention and Control. FINDINGS For 2010, 18 hospitals provided data on 59 observation quarters, 6478 ICU patients and 52,593 ICU patient-days. The mean incidence rates of ICU-acquired pneumonia and intubation-associated pneumonia were 13 per 1000 patient-days and 12 per 1000 intubation-days, respectively. The mean incidence rates of ICU-acquired bloodstream infections, central vascular catheter (CVC)-associated bloodstream infections and CVC-associated primary bloodstream infections were 3.2 per 1000 patient-days, 2.6 per 1000 catheter-days and 2.3 per 1000 catheter-days, respectively. Between 1997 and 2010, stable trends in ICU-acquired pneumonia and bloodstream infections were observed, together with decreasing trends for intubation-associated pneumonia and CVC-associated bloodstream infections, and a stable trend for CVC-associated primary bloodstream infections. CONCLUSIONS In Belgium, national surveillance of ICU-acquired infections allows acute care hospitals to track the incidence of infections at local level, enabling comparison with national and European reference data. Between 1997 and 2010, the incidence of ICU-acquired infections increased and the incidence of device-associated infections decreased.
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Affiliation(s)
- K Mertens
- Scientific Institute of Public Health, Brussels, Belgium.
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Frost SA, Azeem A, Alexandrou E, Tam V, Murphy JK, Hunt L, O'Regan W, Hillman KM. Subglottic secretion drainage for preventing ventilator associated pneumonia: a meta-analysis. Aust Crit Care 2013; 26:180-8. [PMID: 23583261 DOI: 10.1016/j.aucc.2013.03.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 03/17/2013] [Accepted: 03/19/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ventilator associated pneumonia (VAP) in the intensive care unit (ICU) has been shown to be associated with significant morbidity and mortality.(1-3) It has been reported to affect between 9 and 27% of intubated patients receiving mechanical ventilation.(4-6) OBJECTIVE: A meta-analysis was undertaken to combine information from published studies of the effect of subglottic drainage of secretions on the incidence of ventilated associated pneumonia in adult ICU patients. DATA SOURCES Studies were identified by searching MEDLINE (1966 to January 2011), EMBASE (1980-2011), and CINAHL (1982 to January 2011). REVIEW METHODS Randomized trials of subglottic drainage of secretions compared to usual care in adult mechanically ventilated ICU patients were included in the meta-analysis. RESULTS Subglottic drainage of secretions was estimated to reduced the risk of VAP by 48% (fixed-effect relative risk (RR)=0.52, 95% confidence interval (CI), 0.42-0.65). When comparing subglottic drainage and control groups, the summary relative risk for ICU mortality was 1.05 (95% CI, 0.86-1.28) and for hospital mortality was 0.96 (95% CI, 0.81-1.12). Overall subglottic drainage effect on days of mechanical ventilation was -1.04 days (95% CI, -2.79-0.71). CONCLUSION This meta-analysis of published randomized control trials shows that almost one-half of cases of VAP may be prevented with the use of specialized endotracheal tubes designed to drain subglottic secretions. Time on mechanical ventilation may be reduced and time to development of VAP may be increased, but no reduction in ICU or hospital mortality has been observed in published trials.
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Affiliation(s)
- Steven A Frost
- Intensive Care Liverpool Hospital, Australia; University of Western Sydney, Australia.
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Improvements in pulmonary and general critical care reduces mortality following ventilator-associated pneumonia. J Trauma Acute Care Surg 2013; 74:568-74. [PMID: 23354252 DOI: 10.1097/ta.0b013e3182789312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit, with substantial subsequent mortality. The mortality following VAP declined in the 1980s and 1990s. Experts suggest that little progress has been made in the outcomes from VAP since several novel interventions have failed. We nonetheless hypothesized that mortality following VAP has continued to decrease owing to advances in pulmonary critical care. METHODS We identified all adult patients with Centers for Disease Control and Prevention-defined, intensive care unit-acquired VAP between January 1, 1997, and December 31, 2008, from a prospectively collected database. RESULTS A total of 793 cases of VAP occurred in the study period. Cases were divided into four periods (1997-1999, 2000-2002, 2003-2005, or 2006-2008) to compare outcomes over time. Acute Physiology and Chronic Health Evaluation II scores were stable, while mortality was significantly lower in Period 4 when compared with Periods 1 and 2 (p = 0.004 and 0.009, respectively). A logistic regression model predicting death (c statistic = 0.871) revealed age (odds ratio, 1.03; 95% confidence interval, 1.02-1.05), Acute Physiology and Chronic Health Evaluation II score (1.09, 1.05-1.14), white blood cell count (1.03, 1.00-1.06), transplant recipient (3.45, 1.40-8.53), transfusions (3.25, 1.37-7.68), and pulmonary disease (3.01, 1.67-5.45) were independent predictors of death, as was the presence of trauma (0.10, 0.06-0.18), chronic steroid therapy (0.39, 0.17-0.91), and patient length of stay (0.99, 0.98-0.99), with odds ratios less than 1.0. In addition, those patients treated in Period 1 (2.23, 1.16-4.29) or Period 2 (2.13, 1.12-4.06) had twice the risk of death following an episode of VAP when compared with those treated in the most recent period. CONCLUSION We have shown that mortality following an episode of VAP continues to decrease over time and attribute this to advancements in pulmonary and general critical care rather than any specific interventions. LEVEL OF EVIDENCE Prognostic study, level II.
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Leistner R, Kankura L, Bloch A, Sohr D, Gastmeier P, Geffers C. Attributable costs of ventilator-associated lower respiratory tract infection (LRTI) acquired on intensive care units: a retrospectively matched cohort study. Antimicrob Resist Infect Control 2013; 2:13. [PMID: 23556425 PMCID: PMC3620937 DOI: 10.1186/2047-2994-2-13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 03/29/2013] [Indexed: 01/07/2023] Open
Abstract
Background Lower respiratory tract infections (LRTI) are the most common hospital-acquired infections on ICUs. They have not only an impact on each patient’s individual health but also result in a considerable financial burden for the healthcare system. Our aim was to determine the costs and the length of stay of patients with ICU-acquired LRTI. Methods We used a retrospectively matched cohort design, comparing patients with ICU-acquired LRTI and ICU patients without LRTI. LRTI was diagnosed using the definitions of the Centers for Disease Control and Prevention (CDC). Study period was from January to December 2010 analyzing patients from 10 different ICUs (medical, surgical, interdisciplinary). The device utilization ratio was defined as number of ventilator days divided by number of patient days and the device-associated LRTI rate was defined as number of ventilator associated LRTI divided by number of ventilator days. Patients were matched by age, sex, and prospectively obtained Simplified Acute Physiology Score II (SAPS II). The length of ICU stay of control patients needed to be at least as long as that of LRTI-patients before onset of LRTI. We used the Wilcoxon signed-rank test for continuous variables and the McNemar’s test for categorical variables. Results The analyzed ICUs had 40,772 patient days in the study period with a median ventilation utilization ratio of 56 (IQR 42–65). The median device-associated LRTI rate was 3.35 (IQR 0.96-5.36) per 1,000 ventilation days. We analyzed 49 patients with ICU-acquired LRTI and 49 respective controls without LRTI. The median hospital costs for LRTI patients were significantly higher than for patients without LRTI (45,041 € vs. 26,467 €; p < .001). The attributable costs per LRTI patient were 17,015 € (p < .001). Patients with ICU acquired LRTI stayed longer in the hospital than patients without (36 days vs. 24 days; p = 0.011). An LRTI lead to an attributable increase in length of stay by 9 days (p = 0.011). Conclusions ICU-acquired LRTI is associated with increased hospital costs and prolonged hospital stay. Hospital management should therefore implement control measurements to keep the incidence of ICU-acquired LRTI as low as possible.
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Affiliation(s)
- Rasmus Leistner
- Institute of Hygiene and Environmental Medicine, National Reference Center for the Surveillance of nosocomial Infections, Charité, University Medicine Berlin, Hindenburgdamm 27, Berlin, 12203, Germany.
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Ledgerwood LG, Salgado MD, Black H, Yoneda K, Sievers A, Belafsky PC. Tracheotomy tubes with suction above the cuff reduce the rate of ventilator-associated pneumonia in intensive care unit patients. Ann Otol Rhinol Laryngol 2013; 122:3-8. [PMID: 23472309 DOI: 10.1177/000348941312200102] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We evaluated the effect of tracheotomy tubes that enable suction immediately above the cuff on the development of ventilator-associated pneumonia (VAP). METHODS Patients without preexisting pneumonia who required tracheotomy were randomly assigned to receive a tracheotomy tube with or without above-the-cuff suction. The suction tube provided 10 mm Hg of continuous wall suction while the tracheotomy tube cuff was inflated. Data regarding the development of VAP, time on the ventilator, and length of stay in the intensive care unit (ICU) were recorded and compared between groups. RESULTS Eighteen patients were randomized and prospectively evaluated. Nine patients received standard tracheotomy tubes, and 9 received suction-above-the-cuff tracheotomy tubes. The prevalences of VAP were 56% in the control group and 11% in the suction tracheotomy group (p = 0.02). The mean times on the ventilator were 18 +/- 14 days in the control group and 11 +/- 11 days in the suction group (p = 0.12). The mean lengths of ICU stay were 26 +/- 15 days in the control group and 18 +/- 15 days in the suction group (p = 0.14). CONCLUSIONS Use of suction-above-the-cuff tracheotomy tubes significantly decreases the incidence of VAP in ICU patients. There were trends toward decreased time on the ventilator and decreased length of stay in the ICU.
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Affiliation(s)
- Levi G Ledgerwood
- Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, CA 95817, USA
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De Francesco MA, Ravizzola G, Peroni L, Bonfanti C, Manca N. Prevalence of multidrug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa in an Italian hospital. J Infect Public Health 2013; 6:179-85. [PMID: 23668462 DOI: 10.1016/j.jiph.2012.11.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 11/30/2012] [Accepted: 11/30/2012] [Indexed: 11/25/2022] Open
Abstract
The severity and extent of disease caused by multidrug-resistant organisms (MDROs) varies by the population(s) affected and the institution(s) at which these organisms are found; therefore, preventing and controlling MDROs are extremely important. A retrospective study of patients who were infected with Acinetobacter baumannii or Pseudomonas aeruginosa was performed at the Spedali Civili Hospital in Brescia, Italy, from 2007 to 2010. A total of 167 (0.52%) A. baumannii isolates and 2797 P. aeruginosa (8.7%) isolates were identified among 31,850 isolates. Amikacin and colistin were the most active agents against A. baumannii strains. Multidrug resistance (MDR) was observed in 57 isolates (54%). Most MDR isolates (42 out of 57, 73%) were resistant to four classes of antibiotics. P. aeruginosa was recovered more frequently from the respiratory tract, followed by the skin/soft tissue, urine and blood. Colistin, amikacin and piperacillin/tazobactam were active against 100%, 86% and 75% of P. aeruginosa isolates, respectively. A total of 20% (n=316) of P. aeruginosa isolates were MDR. In summary, A. baumannii was more rare than P. aeruginosa but was more commonly MDR. Epidemiological data will help to implement better infection control strategies, and developing a local antibiogram database will improve the knowledge of antimicrobial resistance patterns in our region.
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Abstract
OBJECTIVES The subjectivity and complexity of surveillance definitions for ventilator-associated pneumonia preclude meaningful internal or external benchmarking and therefore hamper quality improvement initiatives for ventilated patients. We explored the feasibility of creating objective surveillance definitions for ventilator-associated pneumonia. DESIGN We identified clinical signs suitable for inclusion in objective definitions, proposed candidate definitions incorporating these objective signs, and then applied these definitions to retrospective clinical data to measure their frequencies and associations with adverse outcomes using multivariate regression models for cases and matched controls. SETTING Medical and surgical intensive care units in eight U.S. hospitals (four tertiary centers, three community hospitals, and one Veterans Affairs institution). PATIENTS Eight thousand seven hundred thirty-five consecutive episodes of mechanical ventilation for adult patients. INTERVENTIONS We evaluated 32 different candidate definitions composed of different combinations of the following signs: three thresholds for respiratory deterioration defined by sustained increases in daily minimum positive end-expiratory pressure or FIO2 after either 2 or 3 days of stable or decreasing ventilator settings, abnormal temperature, abnormal white blood cell count, purulent pulmonary secretions defined by neutrophils on Gram stain, and positive cultures for pathogenic organisms. MEASUREMENTS AND MAIN RESULTS Ventilator-associated pneumonia incidence, attributable ventilator days, hospital days, and hospital mortality. All candidate definitions were significantly associated with increased ventilator days and hospital days, but only definitions requiring objective evidence of respiratory deterioration were significantly associated with increased hospital mortality. Significant odds ratios for hospital mortality ranged from 1.9 (95% confidence interval 1.2-2.9) to 6.1 (95% confidence interval 2.2-17). Requiring additional clinical signs beyond respiratory deterioration alone decreased event rates, had little impact on attributable lengths of stay, and diminished sensitivity and positive predictive values for hospital mortality. CONCLUSIONS Objective surveillance definitions that include quantitative evidence of respiratory deterioration after a period of stability strongly predict increased length of stay and hospital mortality. These definitions merit further evaluation of their utility for hospital quality and safety improvement programs.
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Bénet T, Allaouchiche B, Argaud L, Vanhems P. Impact of surveillance of hospital-acquired infections on the incidence of ventilator-associated pneumonia in intensive care units: a quasi-experimental study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R161. [PMID: 22909033 PMCID: PMC3580751 DOI: 10.1186/cc11484] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 08/21/2012] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The preventive impact of hospital-acquired infection (HAI) surveillance is difficult to assess. Our objective was to investigate the effect of HAI surveillance disruption on ventilator-associated pneumonia (VAP) incidence. METHODS A quasi-experimental study with an intervention group and a control group was conducted between 1 January 2004 and 31 December 2010 in two intensive care units (ICUs) of a university hospital that participated in a national HAI surveillance network. Surveillance was interrupted during the year 2007 in unit A (intervention group) and was continuous in unit B (control group). Period 1 (pre-test period) comprised patients hospitalized during 2004 to 2006, and period 2 (post-test period) involved patients hospitalized during 2008 to 2010. Patients hospitalized ≥ 48 hours and intubated during their stay were included. Multivariate Poisson regression was fitted to ascertain the influence of surveillance disruption. RESULTS A total of 2,771 patients, accounting for 19,848 intubation-days at risk, were studied; 307 had VAP. The VAP attack rate increased in unit A from 7.8% during period 1 to 17.1% during period 2 (P <0.001); in unit B, it was 7.2% and 11.2% for the two periods respectively (P = 0.17). Adjusted VAP incidence rose in unit A after surveillance disruption (incidence rate ratio = 2.17, 95% confidence interval 1.05 to 4.47, P = 0.036), independently of VAP trend; no change was observed in unit B. All-cause mortality and length of stay increased (P = 0.028 and P = 0.038, respectively) in unit A between periods 1 and 2. In unit B, no change in mortality was observed (P = 0.22), while length of stay decreased between periods 1 and 2 (P = 0.002). CONCLUSIONS VAP incidence, length of stay and all-cause mortality rose after HAI surveillance disruption in ICU, which suggests a specific effect of HAI surveillance on VAP prevention and reinforces the role of data feedback and counselling as a mechanism to facilitate performance improvement.
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Community-acquired, health care-associated, and ventilator-associated pneumonia: three variations of a serious disease. Crit Care Nurs Clin North Am 2012; 24:431-41. [PMID: 22920467 DOI: 10.1016/j.ccell.2012.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pneumonia affects millions of people every year in the United States. Hospital-acquired pneumonia is associated with a mortality rate as high as 50%. Pneumonia is classified according to where it was acquired or by the infecting organism. This article explores the similarities and differences in three types of pneumonia seen routinely in the intensive care unit: community-acquired pneumonia, ventilator-associated pneumonia, and health care-associated pneumonia.
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Semenov YR, Starmer HM, Gourin CG. The effect of pneumonia on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 2012; 122:1994-2004. [PMID: 22777881 DOI: 10.1002/lary.23446] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 04/15/2012] [Accepted: 04/26/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services has threatened to discontinue reimbursements for ventilator-associated pneumonia (VAP) as a preventable "never event." We sought to determine the relationship between pneumonia and in-hospital mortality, complications, length of hospitalization and costs in head and neck cancer (HNCA) surgery. STUDY DESIGN Retrospective cross-sectional study. METHODS Discharge data from the Nationwide Inpatient Sample for 93,663 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2003 to 2008 were analyzed using cross-tabulations and multivariate regression modeling. RESULTS VAP was rarely coded. Infectious pneumonia was significantly associated with chronic pulmonary disease (odds ratio [OR], 1.5; P < .001), while aspiration pneumonia was associated with dysphagia (OR, 2.0; P < .001). Pneumonia from any cause was associated with weight loss (OR, 3.3; P < .001), age >80 years (OR, 2.0; P = .007), comorbidity (OR, 2.3; P < .001), and major procedures (OR, 1.6; P < .001), with increased in-hospital mortality for infectious (OR, 2.9; P < .001) and aspiration pneumonia (OR, 5.3; P < .001). Both infectious and aspiration pneumonia were associated with postoperative medical and surgical complications, increased length of hospitalization, and hospital-related costs. CONCLUSIONS Postoperative pneumonia is associated with increased mortality, complications, length of hospitalization, and hospital-related costs in HNCA surgical patients. Variables associated with an increased risk of pneumonia are inherent comorbidities in HNCA and known risk factors for VAP, making this a high-risk group for this never event. Caution must be used in the institution of reforms that threaten to inadequately reimburse the provision of care to this vulnerable population. Aggressive preoperative identification and treatment of underlying pulmonary disease, weight loss, and dysphagia may reduce morbidity and mortality.
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Affiliation(s)
- Yevgeniy R Semenov
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
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Derde LPG, Dautzenberg MJD, Bonten MJM. Chlorhexidine body washing to control antimicrobial-resistant bacteria in intensive care units: a systematic review. Intensive Care Med 2012; 38:931-9. [PMID: 22527065 PMCID: PMC3351589 DOI: 10.1007/s00134-012-2542-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 03/06/2012] [Indexed: 01/18/2023]
Abstract
PURPOSE Infections caused by antimicrobial-resistant bacteria (AMRB) are increasing worldwide, especially in intensive care units (ICUs). Chlorhexidine body washing (CHG-BW) has been proposed as a measure to limit the spread of AMRB. We have systematically assessed the evidence on the effectiveness of CHG-BW in reducing colonization and infection with AMRB in adult ICU patients. METHODS PubMed, Embase, CINAHL, and OpenSigle databases were searched using synonyms for "intensive care unit," "hospital," and "chlorhexidine." All potentially relevant articles were examined by two independent reviewers. Inclusion was limited to studies with ICU patients as domain, providing outcomes related to colonization or infection with AMRB. Data from 16 studies were extracted; 9 were excluded because of assessed high risk of bias or inadequate analyses. The remaining studies differed markedly in (co-)interventions and case mix, which precluded pooling of data in a formal meta-analysis. RESULTS Incidences of MRSA acquisition were reduced significantly in three studies in which this was the primary endpoint. Significant reduction in MRSA infection rates was observed in only one of five studies. Carriage and bacteremia rates of VRE were assessed in one study, and both significantly declined. There were hardly any data on the effects of CHG-BW on antibiotic-resistant gram-negative bacteria (ARGNB). CONCLUSIONS CHG-BW may be effective in preventing carriage, and possibly bloodstream infections, with MRSA and VRE in different ICU settings. As CHG-BW protocols, co-interventions and case mix varied widely, attribution of these effects to CHG-BW alone should be done with care. Evidence that CHG-BW reduces carriage of or infections with ARGNB is lacking.
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Affiliation(s)
- Lennie P G Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
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Abstract
PURPOSE OF REVIEW The increasing number of hospitals reporting ventilator-associated pneumonia (VAP) rates at or close to zero begs the question of whether zero should become the national benchmark for VAP. This article explores the significance of very low VAP rates, reviews differences in surveillance and clinical rates, proposes reasons for their discrepancies, and suggests possible objective alternatives for surveillance. RECENT FINDINGS Surveillance rates of VAP are decreasing, whereas clinical diagnoses and antibiotic prescribing remain prevalent. This growing discrepancy reflects the lack of objective and definitive signs to diagnose VAP. External reporting pressures may be encouraging stricter interpretation of subjective signs and other surveillance initiatives that can artifactually lower rates. It is impossible to disentangle the relative contribution of care improvements versus surveillance effects to currently observed low VAP rates. SUMMARY The increasing mismatch between surveillance rates and clinical diagnoses limits the utility of official VAP rates to estimate disease burden and guide quality improvement. Advocates are advised to consider objective alternatives such as average duration of mechanical ventilation, length of stay, mortality, and antibiotic prescribing. Emerging surveillance definitions that use more objective criteria may better reflect and inform future clinical practice.
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Tsai HC, Lin FC, Chen YC, Chang SC. The role of total bile acid in oral secretions in ventilator-associated pneumonia. J Crit Care 2012; 27:526.e1-6. [PMID: 22300490 DOI: 10.1016/j.jcrc.2011.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 11/14/2011] [Accepted: 12/08/2011] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of this study was to investigate the role of inflammatory biomarkers and total bile acid (TBA) in oral secretions in the development of ventilator-associated pneumonia (VAP). MATERIALS This prospective study was conducted in an intensive care unit. Oral secretions were collected from mechanically ventilated patients who met the selection criteria for VAP prevention protocol. The levels of interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor α, soluble intercellular adhesion molecule-1, monocyte chemoattractant protein-1, C-reactive protein, surfactant protein D, and TBA in oral secretions were measured and compared between the patients with and those without VAP. RESULTS Thirty-nine patients with and 39 patients without VAP were studied. The levels of inflammatory biomarkers in oral secretions showed no significant difference between the 2 groups. However, the patients with VAP had significantly higher values of TBA in oral secretions than did those without VAP (median and 25th-75th interquartile range, 9.59 and 1.37-24.66 μmol/L vs 2.74 and 0.00-8.22 μmol/L; P < .003). No significant correlations were found between TBA and inflammatory biomarkers in oral secretions. CONCLUSIONS Duodenogastroesophageal reflux as evidenced by the presence of TBA in oral secretions is common in mechanically ventilated patients and may play a role in the development of VAP.
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Affiliation(s)
- Han-Chen Tsai
- Respiratory Care Unit, Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
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Bailey JL, Yeung SY. Probiotics for disease prevention: a focus on ventilator-associated pneumonia. Ann Pharmacother 2011; 45:1425-32. [PMID: 21954447 DOI: 10.1345/aph.1q241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To summarize published data regarding the safety and efficacy of probiotics in the prevention of ventilator-associated pneumonia (VAP). DATA SOURCES PubMed databases (January 2000-August 2011) were searched and a bibliographic review of published articles was performed to identify original reports of probiotic administration for the prevention of VAP using the search terms probiotics, synbiotics, and ventilator-associated pneumonia. STUDY SELECTION AND DATA EXTRACTION Two pilot studies, 2 randomized controlled trials (RCTs), and 1 meta-analysis have addressed probiotic use for VAP prevention and were included in the review. DATA SYNTHESIS VAP frequently occurs in mechanically ventilated patients. Given the lack of new antimicrobial agents, probiotics have been studied for their ability to modify human microflora colonization. Two studies examining pathogen colonization rates favored probiotics, with reduced incidence and increased duration until the emergence of new species. One prospective RCT found significant reduction in the incidence of VAP and colonization rates, but no significant difference in patient disposition outcomes. Another RCT examining 28-day mortality found no overall benefit with probiotic use and no reduction in colonization rates. CONCLUSIONS Clinical trials have failed to demonstrate a consistent beneficial effect of probiotics in mechanically ventilated patients; thus, they are not recommended for routine clinical use. However, heterogeneity among study designs may hinder this assessment and the designs should be unified in future research.
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