Risk factors for nosocomial pneumonia in critically ill trauma patients

Are the same parameters measured at admission and in the ICU comparable in their predictive values for complication and mortality in severely injured patients?

INTRODUCTION

Numerous studies have investigated variables that predict mortality and complications following severe trauma. These studies, however, mainly focus on admission values or a single variable. The aim of this study was to investigate the predictive quality of multiple routine clinical measurements (at admission and in the ICU).

METHODS

Retrospective cohort study of severely injured patients treated at one Level 1 academic trauma centre.

INCLUSION CRITERIA

severe injury (ISS ≥ 16 points), primary admission and complete data set. Exclusion criteria end-of-life treatment based on advanced directive, secondary transferred patients.

PRIMARY OUTCOME

mortality, pneumonia, sepsis. Routine clinical parameters were stratified based on measurement timepoint into Group TB (Trauma Bay, admission) and into Group intensive care unit (ICU, 72 h after admission). Prediction of complications and mortality were calculated using two prediction methods: adaptive boosting (AdaBoost, artificial intelligence, AI) and LASSO regression analysis.

RESULTS

Inclusion of 3668 cases. Overall mean age 45.5 ± 20 years, mean ISS 28.2 ± 15.1 points, incidence pneumonia 19.0%, sepsis 14.9%, death from haemorrhagic shock 4.1%, death from multiple organ failure 1.9%, overall mortality rate 26.8%. Highest predictive value for complications for Group TB include abbreviated injury scale (AIS), new injury severity score (NISS) and systemic Inflammatory Response Syndrome (SIRS) score. Highest predictive quality for complications for Group ICU include late lactate values, haematocrit, leukocytes, and CRP. Sensitivity and specificity of late prediction models using a 25% cutoff were 73.61% and 76.24%, respectively.

CONCLUSIONS

The predictive quality of routine clinical measurements strongly depends on the timepoint of the measurement. Upon admission, the injury severity and affected anatomical regions are more predictive, while during the ICU stay, laboratory parameters are better predictor of adverse outcomes. Therefore, the dynamics of pathophysiologic responses should be taken into consideration, especially during decision making of secondary definitive surgical interventions.

LEVEL OF EVIDENCE

III (retrospective cohort study).

Lung contusion complicated by pneumonia worsens lung injury via the inflammatory effect of alveolar small extracellular vesicles on macrophages and epithelial cells

BACKGROUND

Lung contusion (LC) complicated by pneumonia is associated with a higher risk of acute lung injury (ALI) mediated by activation of immune cells and injury to the lung epithelium. Small extracellular vesicles (sEVs) are essential mediators of cellular crosstalk; however, their role in the development of postinjury ALI remains unclear. We hypothesized that LC complicated by pneumonia increases the pro-inflammatory effect of alveolar sEVs on macrophages and the cytotoxicity of alveolar sEVs to pulmonary epithelial cells, worsening the severity of ALI.

METHODS

Studies in C57BL/6 mice were designed with four groups: sham, LC, Pneumonia (Pneu), and LC + Pneu. Lung contusion was induced by a cortical controlled impactor, while pneumonia was conducted by intratracheal injection of 10 5 cfu Pseudomonas aeruginosa . Bronchoalveolar lavage fluid (BAL) was harvested 24 hours postinfection, and sEVs were purified by centrifugation and size exclusion chromatography. To evaluate the effect of alveolar sEV on cells, sEVs from each group were cocultured with macrophages (RAW 264.7) to assess cytokine release and lung epithelial cells (MLE 12) to assess epithelial cytotoxicity.

RESULTS

The LC + Pneu group severely injured lungs histologically and increased the susceptibility to the bacteria. The LC + Pneu group showed higher concentrations of proteins, macrophage inflammatory protein 1-alpha (MIP1α), and intercellular adhesion molecule 1 (ICAM-1) in BAL. MIP1α and ICAM-1 expression in the macrophages increased after incubation with sEVs from the LC + Pneu group. Moreover, the sEVs demonstrated higher cytotoxicity to epithelial cells and increased apoptosis in epithelial cells after incubation with sEVs from the LC + Pneu group.

CONCLUSION

Lung contusion complicated by pneumonia increased the pro-inflammatory effect of alveolar sEVs on macrophages and the cytotoxicity of alveolar sEVs to pulmonary epithelial cells, worsening the severity of ALI. These results demonstrate the potential importance of alveolar sEVs in lung inflammation following a bacterial infection after trauma.

Predictors of sepsis in trauma patients: a National Trauma Data Bank analysis

Background

Trauma remains a global health issue being one of the leading causes of death worldwide. Sepsis and infections are common complications contributing to mortality, emphasizing the need to understand factors leading to such complications following trauma.

Aim

This study aimed to identify risk factors associated with post-trauma sepsis using data from the National Trauma Data Bank (NTDB).

Methods

Using the 2017 National Trauma Data Bank (NTDB), this is a retrospective case-control study that looked at pre-hospital and in-hospital patient data. Trauma patients aged over 15 years presenting to the emergency department (ED) and admitted to a tertiary care center were included. The primary outcome assessed was the development of sepsis post-trauma. Logistic regression analysis was used to identify risk factors, considering patient demographics, injury characteristics, and clinical variables.

Results

Among 997,970 trauma patients in the 2017 NTDB, 296,974 were excluded, leaving 700,996 patients for analysis, with 2,297 developing sepsis. Patients who developed sepsis were older than those who did not develop sepsis (mean age 57.57 vs. 53.42 years, p-value<0.001) and predominantly white males. Risk factors associated with sepsis development included: respiratory intubation with mechanical ventilation (OR = 11.99; 95% CI = 10.66-13.48), blood transfusion administration (OR = 2.03; 95% CI = 1.83-2.25), Injury Severity Score (ISS) ≥ 16 (OR = 1.69; 95% CI = 1.51-1.89), chronic obstructive pulmonary disease (COPD) (OR = 1.65; 95% CI = 1.44-1.89), diabetes mellitus (DM) (OR = 1.41; 95% CI = 1.26-1.58), male sex (OR = 1.42; 95% CI = 1.28-1.57), hypertension (HTN) (OR = 1.30; 95% CI = 1.16-1.45), anticoagulation therapy (OR = 1.21; 95% CI = 1.05-1.39), older age (OR = 1.02; 95% CI = 1.01-1.02), and current smoking status (OR = 1.18; 95% CI = 1.06-1.32).

Conclusion

This study identified key risk factors for post-trauma sepsis. Recognition of preexisting conditions and injury severity is crucial in trauma patient management to mitigate septic complications. Early identification of at-risk patients could facilitate timely interventions and potentially reduce mortality rates in trauma care settings.

Association of antimicrobial use and incidence of hospital-acquired pneumonia in critically ill trauma patients with pulmonary contusion: an observational study

BACKGROUND

Pneumonia occurs in about 20% of trauma patients with pulmonary contusions. This study aims to evaluate the association between empirical antibiotic therapy and nosocomial pneumonia in this population.

METHODS

Retrospective cohort of adult patients admitted to a trauma-surgical ICU. The Antibiotic Therapy Group (ATG) was defined by intravenous antibiotic use for more than 48 h starting on hospital admission, while the Conservative Group (CG) was determined by antibiotic use no longer than 48 h. Primary outcome was microbiologically documented nosocomial pneumonia within 14 days after hospital admission. Logistic regression was used to estimate the association between group allocation and primary outcome. Exploratory analyses evaluating the association between resistant strains in pneumonia and antibiotic use were performed.

RESULTS

The study included 177 patients with chest trauma and pulmonary contusion on CT scan. ATG were more severely ill than CG, as shown by higher Injury Severity Score, SAPS3, SOFA score, higher rates, and longer duration of mechanical ventilation. In the multivariate analysis, ATG was associated with a lower incidence of primary outcome (OR = 0.25, 95% CI 0.09-0.64; p < 0.01). Similar results were found in the sensitivity analysis with another set of variables. However, each day of antibiotic use was associated with an increased risk of pneumonia by resistant bacteria (OR = 1.18 per day, 95% CI 1.05-1.36; p < 0.01).

CONCLUSIONS

Empiric antibiotic therapy was independently associated with lower incidence of nosocomial pneumonia in critically ill patients with pulmonary contusion. However, each day of antibiotic use was associated with increased resistant strains in infected patients.

Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay

Could rebound explain the paradoxical lack of prevention effect against Staphylococcus aureus blood stream infections (BSIs) with antibiotic-based decontamination intervention (BDI) methods among studies of ICU patients within the literature? Two meta-regression models were applied, each versus the group mean length of stay (LOS). Firstly, the prevention effects against S. aureus BSI [and S. aureus VAP] among 136 studies of antibiotic-BDI versus other interventions were analyzed. Secondly, the S. aureus BSI [and S. aureus VAP] incidence in 268 control and intervention cohorts from studies of antibiotic-BDI versus that among 165 observational cohorts as a benchmark was modelled. In model one, the meta-regression line versus group mean LOS crossed the null, with the antibiotic-BDI prevention effect against S. aureus BSI at mean LOS day 7 (OR 0.45; 0.30 to 0.68) inverted at mean LOS day 20 (OR 1.7; 1.1 to 2.6). In model two, the meta-regression line versus group mean LOS crossed the benchmark line, and the predicted S. aureus BSI incidence for antibiotic-BDI groups was 0.47; 0.09-0.84 percentage points below versus 3.0; 0.12-5.9 above the benchmark in studies with 7 versus 20 days mean LOS, respectively. Rebound within the intervention groups attenuated and inverted the prevention effect of antibiotic-BDI against S. aureus VAP and BSI, respectively. This explains the paradoxical findings.

Risk factors and cost of nosocomial infections in pediatric patients with traumatic brain injury

OBJECTIVE

This study aimed to determine the factors that increase nosocomial infections (NIs) in pediatric patients with traumatic brain injury (TBI) and the effects on both treatment cost and length of hospital stay.

METHODS

We performed a case-control study on patients admitted to the pediatric intensive care unit (PICU) with (n=66) or without (n=120) TBI between 2012 and 2014. The risk factors, length of stay, and costs of NIs were determined.

RESULTS

Data for 186 patients were analyzed. One hundred and twenty patients were controls (54 males vs. 66 females), while 66 were cases (27 males vs. 39 females). Seventeen out of the 186 PICU patients had NIs. About 7.6% of TBI patients had infections whereas 10% of control groups had NIs (p=0.58). The most isolated microbial agent was Acinetobacterbaumannii (four cases). Thirteen (76.5%) out of the 17 infections were catheter-related bloodstream infections. The mean expenses per PICU patient were $762, with an additional cost of $2081 for patients with nosocomial contamination.

CONCLUSION

The use of catheters was the most critical risk factor for NIs in our study probably underestimated the cost for several reasons. Nevertheless, the findings supported our hypothesis about the additional burden of nosocomial spread on PICU patients. This study's results should help provide evidence on cost-effectiveness or calculate the cost-benefit ratio of reducing NIs in children.

Frailty predicts hospital acquired infections after brain tumor resection: Analysis of 27,947 patients' data from a prospective multicenter surgical registry

BACKGROUND

Hospital acquired infections (HAIs) present a significant source of economic burden in the United States. The role of frailty as a predictor of HAIs has not been illustrated among patients undergoing craniotomy for brain tumor resection (BTR).

METHODS

The American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2015 to 2019 to identify patients who underwent craniotomy for BTR. Patients were categorized as pre-frail, frail and severely frail using the 5-factor Modified Frailty Index (mFI-5). Demographics, clinical and laboratory parameters, and HAIs were assessed. A multivariate logistic regression model was created to predict the occurrence of HAIs using these variables.

RESULTS

A total of 27,947 patients were assessed. 1772 (6.3 %) of these patients developed an HAI after surgery. Severely frail patients were more likely to develop an HAI in comparison to pre-frail patients (OR = 2.48, 95 % CI = 1.65-3.74, p < 0.001 vs. OR = 1.43, 95 % CI = 1.18-1.72, p < 0.001). Ventilator dependence was the strongest predictor of developing an HAI (OR = 2.96, 95 % CI = 1.86-4.71, p < 0.001).

CONCLUSION

Baseline frailty, by virtue of its ability to predict HAIs, should be utilized in adopting measures to reduce the incidence of HAIs.

Clonal Diversity of Klebsiella spp. and Escherichia spp. Strains Isolated from Patients with Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is one of the most severe complications affecting mechanically ventilated patients. The condition is caused by microaspiration of potentially pathogenic bacteria from the upper respiratory tract into the lower respiratory tract or by bacterial pathogens from exogenous sources such as healthcare personnel, devices, aids, fluids and air. The aim of our prospective, observational study was to confirm the hypothesis that in the etiology of VAP, an important role is played by etiological agents from the upper airway bacterial microflora. At the same time, we studied the hypothesis that the vertical spread of bacterial pathogens is more frequent than their horizontal spread among patients. A total of 697 patients required mechanical ventilation for more than 48 h. The criteria for VAP were met by 47 patients. Clonality of bacterial isolates from 20 patients was determined by comparing their macrorestriction profiles obtained by pulsed-field gel electrophoresis (PFGE). Among these 20 patients, a total of 29 PFGE pulsotypes of Klebsiella spp. and Escherichia spp. strains were observed. The high variability of clones proves that there was no circulation of bacterial pathogens among hospitalized patients. Our finding confirms the development of VAP as a result of bacterial microaspiration and therefore the endogenous origin of VAP.

The Diagnostic Yield and Clinical Impact of a Chest X-Ray after Percutaneous Dilatational Tracheostomy: A Prospective Cohort Study

A chest X-ray (CXR) is routinely performed after percutaneous dilatational tracheostomy (PDT). The purpose of this study was to evaluate the diagnostic yield of routine CXR following PDT and its impact on patient management and to identify predictors of post-PDT CXR changes. Two-hundred-and-thirty-nine patients who underwent PDT in a 21-bed intensive care unit were included prospectively in the study. The following data were collected: patient demographics, APACHE III scores, pre-PDT FiO2 and PEEP, PDT technique, perioperative complications and the use of bronchoscopic guidance. We compared post-PDT CXR with the last pre-PDT CXR. We documented any post-PDT new radiographic findings including atelectasis, pneumothorax, pneumomediastinum, surgical emphysema, pulmonary infiltrates or tracheostomy tube malposition. We also recorded management modifications based on post-PDT radiographic changes, including increased PEEP, chest physiotherapy, therapeutic bronchoscopy or chest tube insertion. Atelectasis was the only new finding detected on post-PDT CXRs of 24 (10%) patients. The new radiographic findings resulted in a total of 14 modifications of management in 10 (4%) patients including increased PEEP in six, chest physiotherapy in six and bronchoscopy in two patients. Trauma and pre-PDT PEEP >5 cmH2O were independent predictors of post-PDT CXR changes. Routine CXR following PDT has a low diagnostic yield, detecting mainly atelectasis and leading to a change in the management in only a minority of patients. Routine CXR after apparently uncomplicated PDT performed by an experienced operator may not be necessary and selective use may improve its diagnostic yield. Further studies are required to validate the safety of selective versus routine post-PDT CXR.

Prevention of early ventilation-acquired pneumonia (VAP) in comatose brain-injured patients by a single dose of ceftriaxone: PROPHY-VAP study protocol, a multicentre, randomised, double-blind, placebo-controlled trial

INTRODUCTION

Ventilator-associated pneumonia (VAP) is the first cause of healthcare-associated infections in intensive care units (ICUs) and brain injury is one of the main risk factors for early-onset VAP. Antibiotic prophylaxis has been reported to decrease their occurrence in brain-injured patients, but a lack of controlled randomised trials and the risk of induction of bacterial resistance explain the low level of recommendations. The goal of this study is to determine whether a single dose of ceftriaxone within the 12 hours postintubation after severe brain injury can decrease the risk of early-onset VAP.

METHODS AND ANALYSIS

The PROPHY-VAP is a French multicentre, randomised, double-blind, placebo-controlled, clinical trial. Adult brain-injured patients (n=320) with a Glasgow Coma Scale ≤12, requiring mechanical ventilation for more than 48 hours, are randomised to receive either a single dose of ceftriaxone 2 g or a placebo within the 12 hours after tracheal intubation. The primary endpoint is the proportion of patients developing VAP from the 2nd to the 7th day after mechanical ventilation. Secondary endpoints include the proportion of patients developing late VAP (>7 days after tracheal intubation), the number of ventilator-free days, VAP-free days and antibiotic-free days, length of stay in the ICU, proportion of patients with ventilator-associated events and mortality during their ICU stay.

ETHICS AND DISSEMINATION

The initial research project was approved by the Institutional Review Board of OUEST III (France) on 20 October 2014 (registration No 2014-001668-36) and carried out according to the principles of the Declaration of Helsinki and the Clinical Trials Directive 2001/20/EC of the European Parliament relating to the Good Clinical Practice guidelines. The results of this study will be presented in national and international meetings and published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02265406; Pre-results.

World-Wide Variation in Incidence of Staphylococcus aureus Associated Ventilator-Associated Pneumonia: A Meta-Regression

Staphylococcus aureus (S. aureus) is a common Ventilator-Associated Pneumonia (VAP) isolate. The objective here is to define the extent and possible reasons for geographic variation in the incidences of S. aureus-associated VAP, MRSA-VAP and overall VAP. A meta-regression model of S. aureus-associated VAP incidence per 1000 Mechanical Ventilation Days (MVD) was undertaken using random effects methods among publications obtained from a search of the English language literature. This model incorporated group level factors such as admission to a trauma ICU, year of publication and use of bronchoscopic sampling towards VAP diagnosis. The search identified 133 publications from seven worldwide regions published over three decades. The summary S. aureus-associated VAP incidence was 4.5 (3.9–5.3) per 1000 MVD. The highest S. aureus-associated VAP incidence is amongst reports from the Mediterranean (mean; 95% confidence interval; 6.1; 4.1–8.5) versus that from Asian ICUs (2.1; 1.5–3.0). The incidence of S. aureus-associated VAP varies by up to three-fold (for the lowest versus highest incidence) among seven geographic regions worldwide, whereas the incidence of VAP varies by less than two-fold. Admission to a trauma unit is the most important group level correlate for S. aureus-associated VAP.

Unusually High Incidences of Staphylococcus aureus Infection within Studies of Ventilator Associated Pneumonia Prevention Using Topical Antibiotics: Benchmarking the Evidence Base

Selective digestive decontamination (SDD, topical antibiotic regimens applied to the respiratory tract) appears effective for preventing ventilator associated pneumonia (VAP) in intensive care unit (ICU) patients. However, potential contextual effects of SDD on Staphylococcus aureus infections in the ICU remain unclear. The S. aureus ventilator associated pneumonia (S. aureus VAP), VAP overall and S. aureus bacteremia incidences within component (control and intervention) groups within 27 SDD studies were benchmarked against 115 observational groups. Component groups from 66 studies of various interventions other than SDD provided additional points of reference. In 27 SDD study control groups, the mean S. aureus VAP incidence is 9.6% (95% CI; 6.9–13.2) versus a benchmark derived from 115 observational groups being 4.8% (95% CI; 4.2–5.6). In nine SDD study control groups the mean S. aureus bacteremia incidence is 3.8% (95% CI; 2.1–5.7) versus a benchmark derived from 10 observational groups being 2.1% (95% CI; 1.1–4.1). The incidences of S. aureus VAP and S. aureus bacteremia within the control groups of SDD studies are each higher than literature derived benchmarks. Paradoxically, within the SDD intervention groups, the incidences of both S. aureus VAP and VAP overall are more similar to the benchmarks.

Safety of minimizing preoperative starvation in critically ill and intubated trauma patients

BACKGROUND

Cessation of enteral nutrition prior to an operation/procedure is the most common reason for feeding interruption in critically ill trauma patients and contributes to substantial calorie deficits. This study reports on a strategy to increase calorie intake by continuing feeds until transfer for operations/procedures.

METHODS

Nutrition guidelines were modified in 2006 to allow continuation of feeding in intubated patients up until transfer to the operating room. Prior to 2006, enteral feeding was stopped at least 6 hours prior to surgery. A retrospective cohort design from 2003 to 2010 compared clinical outcomes in groups of adult trauma subjects before and after guideline changes and in subjects at other centers without guideline changes.

RESULTS

During the first week, subjects in the preimplementation cohort (n = 245) received a median of 3,787 kcal per person per week, while subjects in the postimplementation cohort (n = 368) received a median of 6,662 kcal per person per week (p < 0.001). There was no change in calorie intake for subjects at other centers (n = 1,002). The risks of acute respiratory distress syndrome, pneumonia, and mortality were decreased after implementation relative to the preimplementation cohort (acute respiratory distress syndrome: relative risk ratio [RR], 0.69; 95% confidence interval [CI], 0.59-0.81; pneumonia: RR, 0.82; 95% CI, 0.65-1.00; mortality: RR, 0.67; 95% CI, 0.46-0.99). Ventilator-free days increased by 1.4 days (95% CI, 0.1-2.7), while intensive care unit stay and hospital length of stay were unchanged. These outcomes showed similar trends over time at other participating centers.

CONCLUSIONS

Allowing intubated trauma patients to continue enteral nutrition until transfer for operations or procedures was associated with increased caloric intake without evidence of increased pulmonary complications. This represents an important strategy to reduce calorie deficits in the trauma intensive care unit.

LEVEL OF EVIDENCE

Therapeutic study/care management, level III.

World-wide variation in incidence of Acinetobacter associated ventilator associated pneumonia: a meta-regression

Background

Acinetobacter species such as Acinetobacter baumanii are of increasing concern in association with ventilator associated pneumonia (VAP). In the ICU, Acinetobacter infections are known to be subject to seasonal variation but the extent of geographic variation is unclear. The objective here is to define the extent and possible reasons for geographic variation for Acinetobacter associated VAP whether or not these isolates are reported as Acinetobacter baumanii.

Methods

A meta-regression model of VAP associated Acinetobacter incidence within the published literature was undertaken using random effects methods. This model incorporated group level factors such as proportion of trauma admissions, year of publication and reporting practices for Acinetobacter infection.

Results

The search identified 117 studies from seven worldwide regions over 29 years. There is significant variation in Acinetobacter species associated VAP incidence among seven world-wide regions. The highest incidence is amongst reports from the Middle East (mean; 95 % confidence interval; 8.8; 6 · 2–12 · 7 per 1000 mechanical ventilation days) versus that from North American ICU’s (1 · 2; 0 · 8–2 · 1). There is a similar geographic related disparity in incidence among studies reporting specifically as Acinetobacter baumanii. The incidence in ICU’s with a majority of admission being for trauma is >2.5 times that of other ICU’s.

Conclusion

There is greater than fivefold variation in Acinetobacter associated VAP among reports from various geographic regions worldwide. This variation is not explainable by variations in rates of VAP overall, admissions for trauma, publication year or Acinetobacter reporting practices as group level variables.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1921-4) contains supplementary material, which is available to authorized users.

Efficacy of Hi-Lo Evac Endotracheal Tube in Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Poisoned Patients

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.

Inapparent Outbreaks of Ventilator-Associated Pneumonia An Ecologic Analysis of Prevention and Cohort Studies

Objective:

To compare ventilator-associated pneumonia (VAP) rates and patterns of isolates across studies of antibiotic and non-antibiotic methods for preventing VAP.

Design:

With the use of 42 cohort study groups as the reference standard, the prevalence of VAP was modeled in two linear regressions: one with the control groups and the other with the intervention groups of 96 VAP prevention studies. The proportion of patients admitted with trauma and the VAP diagnostic criteria were used as ecologic correlates. Also, the patterns of pathogenic isolates were available for 117 groups.

Results:

In the first regression model, the VAP rates for the control groups of antibiotic-based prevention studies were at least 18 (CI95, 12 to 24) per 100 patients higher than those in the cohort study groups (P< .001). By contrast, comparisons of cohort study groups with all other control and intervention groups in the first and second regression models yielded differences that were less than 6 per 100 and not significant (P> .05). For control groups with VAP rates greater than 35%, the patterns of VAP isolates, such as the proportion ofStaphylococcus aureus,more closely resembled those in the corresponding intervention groups than in the cohort groups.

Conclusions:

The rates of VAP in the control groups of the antibiotic prevention studies were significantly higher than expected and the patterns of pathogenic isolates were unusual. These observations suggest that inapparent outbreaks of VAP occurred in these studies. The possibility remains that antibiotic-based VAP prevention presents a major cross-infection hazard.

Impact of an Infection Control Program in an Intensive Care Unit in France

Objective.

To evaluate the impact of an infection control program in an intensive care unit (ICU).

Design.

Prospective before-after study. Two 6-month study periods were compared; between these periods, an infection control program based on isolation was implemented.

Setting.

Polyvalent ICU of Montpellier Teaching Hospital.

Patients.

Any patient who was hospitalized in the ICU for >48 hours and was discharged during 1 of the 2 periods.

Main Outcome Measures.

The main patient-related variables were sex, age at admission, type of patient (surgical, medical, or trauma), Simplified Acute Physiology Score II, length of ICU stay, need for intubation, duration of exposure to invasive devices, onset of nosocomial infection and pathogens responsible, and death. We compared the 2 study periods with respect to the incidence of 4 nosocomial infections (pneumonia, urinary tract infection, bacteremia, and catheter-associated infection), the frequency of infection with the main multidrug-resistant pathogens, and patient survival.

Results.

Patients in periods 1 and 2 were similar with regard to sex, age, physiology score, and exposure to invasive devices. The rates of infection with multidrug-resistant pathogens were significandy lower during period 2 than during period 1 (infection rate: 28.1% of patients in period 1 and 9.6% of patients in period 2 [P = .01]; pneumonia rate: 32.6% of patients in period 1 and 4.2% of patients in period 2 [P = .008]). The mortality rate among patients with nosocomial pneumonia was 38.2% in period 1 and 4.3% in period 2 (P = .009).

Conclusions.

After implementation of an infection control program, the rate of infection with multidrug-resistant pathogens decreased, as did the mortality rate among patients with nosocomial pneumonia.

Regional Comparison of Enteral Nutrition-Related Admission Policies in Skilled Nursing Facilities

BACKGROUND

Nursing home admission policies are one driver of increased and earlier gastrostomy placement, a procedure that is not always medically or ethically indicated among patients needing short-term nutrition support. This important clinical decision should be based upon patient prognosis, goals, and needs. We compared nursing home enteral nutrition-related admission policies in New York City and other regions of the United States. We also explored motivations for these policies.

METHODS

We conducted a telephone survey with skilled nursing facility administrators in New York City and a random sample of facilities throughout the United States about enteral nutrition-related admission policies. Survey data were matched with publically available data about facility characteristics from the Centers for Medicare and Medicaid Services. The relationship between facility location and admission policies was described with regression models. Reasons for these policies were thematically analyzed.

RESULTS

New York City nursing homes were significantly less likely to admit patients with nasogastric feeding tubes than were nursing homes nationwide, after we controlled for facility characteristics (odds ratio = 0.111; 95% CI, 0.032-0.344). Reasons for refusing nasogastric tubes fell into 5 categories: safety, capacity, policy, perception of appropriate level of care, and patient quality of life.

CONCLUSION

Our findings indicate that enteral nutrition-related admission policies vary greatly between nursing homes in New York City and nationwide. Many administrators cited safety and policy as factors guiding their institutional policies and practices, despite a lack of evidence. This gap in research, practice, and policy has implications for quality and cost of care, length of hospital stay, and patient morbidity and mortality.

Epidemiology of hospital-acquired pneumonia: Results of a Central European multicenter, prospective, observational study compared with data from the European region

BACKGROUND

Hospital-acquired pneumonia (HAP) is associated with high mortality. In Central Europe, there is a dearth of information on the prevalence and treatment of HAP. This project was aimed at collecting multicenter epidemiological data on patients with HAP in the Czech Republic and comparing them with supraregional data.

METHODS

This prospective, multicenter, observational study processed data from a database supported by a Czech Ministry of Health grant project. Included were all consecutive patients aged 18 and over who were admitted to participating intensive care units (ICUs) between 1 May 2013 and 31 December 2014 and met the inclusion criterion of having HAP. The primary endpoint was to analyze the relationships between 30-day mortality (during the stay in or after discharge from ICUs) and the microbiological etiological agent and adequacy of initial empirical antibiotic therapy in HAP patients.

RESULTS

The group dataset contained data on 330 enrolled patients. The final validated dataset involved 214 patients, 168 males (78.5%) and 46 females (21.5%), from whom 278 valid lower airway samples were obtained. The mean patient age was 59.9 years. The mean APACHE II score at admission was 21. Community-acquired pneumonia was identified in 13 patients and HAP in 201 patients, of whom 26 (12.1%) had early-onset and 175 (81.8%) had late-onset HAP. Twenty-two bacterial species were identified as etiologic agents but only six of them exceeded a frequency of detection of 5% (Klebsiella pneumoniae 20.4%, Pseudomonas aeruginosa 20.0%, Escherichia coli 10.8%, Enterobacter spp. 8.1%, Staphylococcus aureus 6.2% and Burkholderia cepacia complex 5.8%). Patients infected with Staphylococcus aureus had significantly higher rates of early-onset HAP than those with other etiologic agents. The overall 30-day mortality rate for HAP was 29.9%, with 19.2% mortality for early-onset HAP and 31.4% mortality for late-onset HAP. Patients with late-onset HAP receiving adequate initial empirical antibiotic therapy had statistically significantly lower 30-day mortality than those receiving inadequate initial antibiotic therapy (23.8% vs 42.9%). Patients with ventilator-associated pneumonia (VAP) had significantly higher mortality than those who developed HAP with no association with mechanical ventilation (34.6% vs 12.7%). Patients having VAP treated with adequate initial antibiotic therapy had lower 30-day mortality than those receiving inadequate therapy (27.2% vs 44.8%).

CONCLUSIONS

The present study was the first to collect multicenter data on the epidemiology of HAP in the Central European Region, with respect to the incidence of etiologic agents causing HAP. It was concerned with relationships between 30-day patient mortality and the type of HAP, etiologic agent and adequacy of initial empirical antibiotic therapy.

[Nosocomial pneumonia in ICU CHU Hassan II of Fez]

L'objectif principal de notre étude était d'identifier les bactéries incriminées dans la pneumopathie nosocomiale (PN) au service de réanimation A1 du CHU Hassan II de Fès, en vue d'en améliorer la prise en charge et de diminuer la morbi-mortalité associée. Il s'agit d'une étude rétrospective et descriptive, menée du 1er janvier 2012 au 31 décembre 2013. Seules les infections pulmonaires survenant au-delà de 48 heures de l'admission du patient au service de réanimation ont été incluses. L'incidence de la PN était de 11,2%. Les Bacilles à Gram négatif (BGN) étaient retrouvés dans 48,5% des cas, le Staphylocoque Aureus dans 21,21% des cas et le Klebsiella Pneumoniae était dans 10,7% des cas. Le taux de mortalité était de 48,33%. L’âge, la gravité de la pathologie sous jacente et le retard de l'instauration d'une antibiothérapie adaptée étaient considérées comme facteurs de mauvais pronostic. L’étude de la résistance aux antibiotiques, montre une multirésistance surtout pour les BGN, dont il faut tenir compte en mettant en place une stratégie de prévention active.

Nosocomial infection in trauma intensive care

This editorial examines the epidemiology of nosocomial infection in trauma intensive care. Specifically, ventilator-associated pneumonia, central line-associated blood stream infection, and catheter-associated urinary tract infection rates are described. Two important trends are observed. Firstly, nosocomial infection rates have fallen with time. This trend is evident in all intensive care populations and is thought to be principally due to the adoption of preventative bundle strategies. Secondly, rates remain consistently higher in trauma patients than in other intensive care populations. The reasons for this are likely to be multifactorial. Recognizing the particular vulnerability of this patient group should prompt especially rigorous efforts at prevention, early diagnosis, and management.

Interdisciplinary position statement on management of hyperglycemia in peri-operative and intensive care

Hospitalized patients with diabetes pose numerous clinical challenges, including hyperglycemia, which may often be difficult to control. The therapeutic challenges are further accentuated by the difficulty in practical application of existing guidelines among Indian and South Asian patients. The present review highlights the various clinical challenges encountered during management of different diabetic hospitalized populations, and attempts to collate a set of practical, patient and physician friendly recommendations to manage hyperglycemia in such patients.

Prehospital oral chlorhexidine does not reduce the rate of ventilator-associated pneumonia among critically ill trauma patients: A prospective concurrent-control study

PURPOSE

The purpose of the study was to test the hypothesis that prehospital oral chlorhexidine administered to intubated trauma patients will decrease the Clinical Pulmonary Infection Score (CPIS) during the first 2 days of hospitalization.

MATERIALS AND METHODS

Prospective interventional concurrent-control study of all intubated adult trauma patients transported by air ambulance to a 711-bed Midwestern academic trauma center over a 1-year period. Patients transported by 2 university-based helicopters were treated with oral chlorhexidine after intubation, and the control group was patients transported by other air transport services.

RESULTS

Sixty-seven patients were enrolled, of which 23 received chlorhexidine (9 patients allocated to the intervention were not treated). The change in CPIS score was no different between the intervention and control groups by intention to treat (1.06- vs 1.40-point reduction, P = .520), and no difference was observed in tracheal colonization (29.0% vs 36.7%, P = .586). No differences were observed in the rate of clinical pneumonia (8.7% vs 8.6%, P = .987) or mortality (P = .196) in the per-protocol chlorhexidine group.

CONCLUSIONS

The prehospital administration of oral chlorhexidine does not reduce the CPIS score over the first 48 hours of admission for intubated trauma patients. Further study should explore other prehospital strategies of reducing complications of critical illness.

Usefulness of Severity-of-Illness Scores Based on Admission Data Only in Nosocomial Infection Surveillance Systems

Background.

Surveillance of nosocomial infection (NI) and the use of reference data for comparison is recommended to improve the quality of patient care. In addition to standardization according to device use, another stratification of reference data according to patients' severity-of-illness scores is often required for benchmarking in intensive care units (ICUs).

Objective.

To determine whether severity-of-illness scores on admission to the ICU are sufficient data for predicting the development of NI.

Methods.

This study was performed in an interdisciplinary ICU at a teaching hospital. Two scores were studied: the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Therapeutic Intervention Scoring System (TISS). The patient's clinical condition was evaluated on admission and reevaluated daily during the period before the development of NI. In addition, we recorded the number of intubations for every patient-day, the age and sex of the patients, and their history of operations. The Fisher exact test and the stepwise multiple logistic regression model were applied to identify significant predictors of NI.

Results.

During a 12-month period, 270 patients with ICU stays of more than 24 hours were included in the study. Sixty-nine NIs were identified (incidence, 25.6 cases per 100 patients [95% confidence interval, 19.9-32.3]). A mean APACHE II score and a mean TISS score above the median for these scores, duration of ventilation above the median in the period before the development of NI, and patient age were significantly associated with the development of NI; the score data on admission provided a clearly poorer prediction.

Conclusion.

The APACHE II and TISS scores on admission are not useful predictors for NI in ICUs.

Effect of a fever control protocol-based strategy on ventilator-associated pneumonia in severely brain-injured patients

Introduction

Fever is associated with a poor outcome in severely brain-injured patients, and its control is one of the therapies used in this condition. But, fever suppression may promote infection, and severely brain-injured patients are frequently exposed to infectious diseases, particularly ventilator-associated pneumonia (VAP). Therefore, we designed a study to explore the role of a fever control protocol in VAP development during neuro-intensive care.

Methods

An observational study was performed on severely brain-injured patients hospitalized in a university ICU. The primary goal was to assess whether fever control was a risk factor for VAP in a prospective cohort in which a fever control protocol was applied and in a historical control group. Moreover, the density of VAP incidence was compared between the two groups. The statistical analysis was based on a competing risk model multivariate analysis.

Results

The study included 189 brain-injured patients (intervention group, n = 98, and historical control group, n = 91). The use of a fever control protocol was an independent risk factor for VAP (hazard ratio 2.73, 95% confidence interval (1.38, 5.38; P = 0.005)). There was a significant increase in the incidence of VAP in patients treated with a fever control protocol (26.1 versus 12.5 VAP cases per 1000 days of mechanical ventilation). In cases in which a fever control protocol was applied for >3 days, we observed a higher rate of VAP in comparison with the rate among patients treated for ≤3 days.

Conclusions

Fever control in brain-injured patients was a major risk factor for VAP occurrence, particularly when applied for >3 days.

Duration of prehospital intubation is not a risk factor for development of early ventilator-associated pneumonia

PURPOSE

Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality among critically ill patients with trauma. Few VAP prevention strategies have been studied in the prehospital environment. The objectives of this study are to measure the association between duration of prehospital intubation and intubation location with subsequent incidence of early (within 5 days) VAP.

MATERIALS AND METHODS

Single-center retrospective cohort study of all intubated adult (age≥18 years) patients with trauma presenting to a 711-bed Midwestern Level I trauma center between January 2005 and December 2011 (n=860).

RESULTS

Thirty-five patients (6.4%) were diagnosed as having early VAP during the study period. Using multivariable logistic regression to adjust for age, injury severity score, and year (corresponding to VAP bundle implementation), the duration of intubation prior to hospital admission was not associated with subsequent diagnosis of VAP (adjusted odds ratio, 0.90 per hour; 95% confidence interval, 0.70-1.15). Location of intubation was similarly not associated with VAP.

CONCLUSIONS

Duration of prehospital intubation and intubation location were not different in patients with trauma who developed early VAP. Further prospective analyses should be conducted to better elucidate the effect of prehospital management on the development of traditionally in-hospital complications.

ERCP: the unresolved question of endotracheal intubation

The anesthesia community is still divided as to the appropriate airway management in patients undergoing endoscopic retrograde cholangiopancreatography. Increasingly, gastroenterologists are comfortable with deep sedation (normally propofol) without endotracheal intubation. There are no comprehensive reviews addressing the various pros and cons of an un-intubated airway management. It is hoped that the present review will benefit both anesthesia providers and gastroenterologists. The reasons to avoid routine endotracheal intubation and the approaches for an un-intubated anesthetic management are discussed. The special situations where endotracheal intubation is the preferred approach are mentioned. Many special techniques to manage airway are illustrated.

Ventilator-associated pneumonia in trauma patients with open tracheotomy: Predictive factors and prognosis impact

OBJECTIVE

To assess the predictive factors of ventilator associated pneumonia (VAP) occurrence following open tracheotomy in trauma patients.

MATERIALS AND METHODS

We conducted an observational, prospective study over 15 months, between 01/08/2010 and 30/11/2011. All trauma patients (except those with cervical spine trauma), older than 15 years, undergoing open tracheotomy during their ICU stay were included. All episode of VAP following tracheotomy were recorded. Predictive factor of VAP onset were studied.

RESULTS

We included 106 patients. Mean age was 37.9 ± 15.5 years. Mean Glasgow coma Scale (GCS) was 8.5 ± 3.7 and mean Injury Severity Score (ISS) was 53.1 ± 23.8. Tracheotomy was performed for 53 patients (50%) because of prolonged ventilation whereas 83 patients (78.3%) had tracheotomy because of projected long mechanical ventilation. Tracheotomy was performed within 8.6 ± 5.3 days. Immediate complications were bleeding events (22.6%) and barotrauma (0.9%). Late complications were stomal infection (28.3%) and VAP (52.8%). In multivariate analysis, independent factors predicting VAP onset were delayed tracheotomy (OR = 0.041; CI95% [1.02-7.87]; P = 0.041) and stomal infection (OR = 3.04; CI95% [1.02-9.93]; P = 0.045). Thirty three patients died in ICU (31.1%) without significant impact of VAP on mortality.

CONCLUSION

Late tracheotomy and stomal infection are independent factors predicting VAP onset after open tracheotomy in trauma patients. The occurrence of VAP prolongers mechanical ventilation duration and intensive care unit (ICU) length of stay (LOS) but doesn't increase mortality.

Risk factors for post-traumatic pneumonia in patients with retained haemothorax: results of a prospective, observational AAST study

INTRODUCTION

Retained haemothorax (RH) is a problematic sequela of thoracic trauma, reported in up to 20% of patients following chest injury. RH is associated with a higher severity of thoracic trauma and may portend the onset of other serious post-traumatic complications, including pneumonia. The development of pneumonia has previously been reported to be as high as 19.5% in the setting of traumatic RH. The purpose of this study was to identify risk factors for the development of pneumonia as a complication in RH.

METHODS

We utilized the American Association for the Surgery of Trauma Post-Traumatic Retained Haemothorax database. Patients with post-traumatic RH were prospectively enrolled from 2009 to 2011. Inclusion criteria were placement of a thoracostomy tube within 24h of admission for the evacuation of pneumothorax or haemothorax and subsequent chest computed tomography scan chest showing RH. Patients treated with thoracotomy before placement of tube thoracostomy were excluded. For univariate analysis, the Chi-square test with Yates correction was used for comparison of categorical risk factors and the Student's t-test or the Mann-Whitney test for comparison of continuous risk factors. To identify independent risk factors for the development of pneumonia, variables from the univariate analysis significant at p<0.2 were entered into a forward logistic regression model. Adjusted odds ratio and 95% confidence intervals (CI) were derived.

RESULTS

328 patients with post-traumatic RH from 20 United States centres were enrolled. After stepwise regression analysis, ISS>25 (adjusted OR: 7.1; 95% CI: 3.1, 16.4; p<0.001), blunt mechanism of injury (adjusted OR: 3.5; 95% CI: 1.7, 7.2; p=0.001), and failure to administer peri-procedural antibiotics on the initial thoracostomy tube placement (adjusted OR: 2.6; 95% CI: 1.30, 5.4; p=0.01) were found to be independent predictors of the pneumonia in patients with post-traumatic RH.

CONCLUSIONS

To our knowledge, our current study is the largest attempt to identify the independent predictors for pneumonia in this population. Our data show that elevated ISS, blunt thoracic trauma, and failure to administer peri-procedural antibiotics on tube thoracostomy placement are the statistically significant independent risk factors.

Noninvasive ventilation in chest trauma: systematic review and meta-analysis

PURPOSE

Single studies of Noninvasive Ventilation (NIV) in the management of acute respiratory failure in chest trauma patients have produced controversial findings. The aim of this study is to critically review the literature to investigate whether NIV reduces mortality, intubation rate, length of stay and complications in patients with chest trauma, compared to standard therapy.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials, prospective and retrospective observational studies, by searching PubMed, EMBASE and bibliographies of articles retrieved. We screened for relevance studies that enrolled adults with chest trauma who developed mild to severe acute respiratory failure and were treated with NIV. We included studies reporting at least one clinical outcome of interest to perform a meta-analysis.

RESULTS

Ten studies (368 patients) met the inclusion criteria and were included for the meta-analysis. Five studies (219 patients) reported mortality and results were quite homogeneous across studies, with a summary relative risk for patients treated with NIV compared with standard care (oxygen therapy and invasive mechanical ventilation) of 0.26 (95 % confidence interval 0.09-0.71, p = 0.003). There was no advantage in mortality of continuous positive airway pressure over noninvasive pressure support ventilation. NIV significantly increased arterial oxygenation and was associated with a significant reduction in intubation rate, in the incidence of overall complications and infections.

CONCLUSIONS

These results suggest that NIV could be useful in the management of acute respiratory failure due to chest trauma.

Prolonged emergency department length of stay is not associated with worse outcomes in patients with intracerebral hemorrhage

BACKGROUND

Prolonged emergency department length of stay (EDLOS) has been associated with worse patient outcomes, longer inpatient stays, and failure to meet quality measures in several acute medical conditions, but these findings have not been consistently reproduced. We performed this study to explore the hypothesis that longer EDLOS would be associated with worse outcomes in a large cohort of patients presenting with spontaneous intracerebral hemorrhage (ICH).

METHODS

We performed a secondary analysis of a prospective cohort of consecutive patients with spontaneous ICH who presented to a single academic referral center from February 2005 to October 2009. The primary exposure variable was EDLOS, and our primary outcome was neurologic status at hospital discharge, measured with a modified Rankin scale (mRS). Secondary outcomes were ICU length of stay, total hospital length of stay, and total hospital costs.

RESULTS

Our cohort included 616 visits of which 42 were excluded, leaving 574 patient encounters for analysis. Median age was 75 years (IQR 63-82), median EDLOS 5.1 h (IQR 3.7-7.1) and median discharge mRS 4 (IQR 3-6). Thirty percent of the subjects died in-hospital. Multivariable proportional odds logistic regression, controlling for age, initial Glasgow Coma Scale, initial hematoma volume, ED occupancy at registration, and the need for intubation or surgical intervention, demonstrated no association between EDLOS and outcome. Furthermore, multivariable analysis revealed no association of increased EDLOS with ICU or hospital length of stay or hospital costs.

CONCLUSION

We found no effect of EDLOS on neurologic outcome or resource utilization for patients presenting with spontaneous ICH.

Bronchopulmonary complications associated to enteral nutrition devices in patients admitted to internal medicine departments

BACKGROUND AND AIMS

Enteral nutrition using feeding devices such as nasogastric (NG) tube or percutaneous endoscopic gastrostomy (PEG) is an effective feeding method subject that may give rise to complications. We have studied the relationship between enteral nutrition feeding devices in patients admitted to the Internal Medicine Departments and the development of pulmonary complications (bronchial aspiration and aspiration pneumonia).

PATIENTS AND METHODS

All of the patients discharge between 2005 and 2009 from the Internal Medicine (IM) Departments of the public hospitals of the National Health System in Spain were analyzed. The data of patients with bronchial aspiration or aspiration pneumonia who also were carriers of NG tubes or PEG, were obtained from the Minimum Basic Data Set (MBDS).

RESULTS

From a total of 2,767,259 discharges, 26,066 (0.92%) patients with nasogastric tube (NG tube) or percutaneous gastrostomy (PEG) were identified. A total of 21.5% of patients with NG tube and 25.9% of patients with PEG had coding for a bronchopulmonary aspiration on their discharge report versus 1.2% of patients without an enteral feeding tube. In the multivariate analysis, the likelihood of suffering bronchoaspiration was 9 times greater in patients with SNG (OR: 9.1; 95% CI: 8.7-9.4) and 15 greater in subjects with PEG (OR: 15.2; 95% CI: 14.5-15.9) than in subjects without SNG or PEG. Mean stay (9.2 and 12.7 more days), diagnostic complexity and costs were much higher in patients with SNG or PEG compared to patients in hospital who did not require these devices.

CONCLUSIONS

An association was found between SNG and PEG for enteral feeding and pulmonary complications. Mean stay, diagnostic complexity and cost per admission of these patients was higher in patients who did not require enteral nutrition.

[Hypothermia at admission increases the risk of pulmonary contusion's infection in intubated trauma patients]

OBJECTIVES

Pulmonary contusion (PC) is common in cases of polytrauma. The aim of this study was to perform a multivariate analysis of risk factors associated with the occurrence of infection in PC and analyze the microbiological epidemiology.

PATIENTS AND METHODS

All patients with PC admitted to the intensive care unit (ICU) between January 2002 and December 2006 were included in this retrospective observational study. Patients with penetrating thoracic trauma or those who died in the 48hours following admission to hospital were excluded. Diagnosis of bacterial infection in PC was performed if hyperthermia was associated with a positive quantitative culture (103 colony forming units/mL) on the bronchial sample. Univariate analysis provided statistical difference between variables that were integrated in the multivariate analysis model. Multivariate analysis was then performed to determine the risk factors of bacterial infection in PC.

RESULTS

One hundred and seventeen patients were included. The incidence of bacterial infection in PC was 33.3% (39 patients). The most frequently encountered bacteria were Haemophilus sp., Staphylococcus aureus, Enterobacteriaceae, Pseudomonas sp. and Streptococcus sp. According to multivariate analysis, the existence of hypothermia at hospital admission increased the risk of PC infection (OR=2.61; IC 95% [4.2-13.3]).

CONCLUSION

In conclusion, PC was infected in 33.3% of cases. The existence of hypothermia was identified as a risk factor. A prospective study is warranted to confirm these results.

One evidence based protocol doesn't fit all: brushing away ventilator associated pneumonia in trauma patients

OBJECTIVES

Evaluate change in ventilator associated pneumonia (VAP) and nurse's attitudes, beliefs post implementation of an evidence based practice (EBP) oral hygiene protocol. METHODOLOGY/DESIGN/SETTING: Descriptive pre and post test design in two critical care units in a Level One Trauma Community Hospital. Oral hygiene protocol data was reanalysed to examine effects in medical surgical and trauma subgroups.

OUTCOME MEASURES

Oral care practices, attitudes and beliefs among nurses, and VAP rates according to Centers for Disease Control and Prevention guidelines.

RESULTS

Trauma rates increased from 6.4% to 10.0% (p=0.346), and medical/surgical rates decreased from 3.3% to 1.0% (p=0.042). Results revealed changes in nurses' beliefs regarding pre-admission colonisation (p=0.027) and having adequate training. Nurses' perception of facility support improved, by having suitable equipment and readily available supplies. Foam swabs with moisture agents at 4hours or less was 88.6% and toothbrush use at 12hours or less was 71%, with significant changes in frequency of oral care post intervention.

CONCLUSIONS

Trauma patients present with unique characteristics which compromise oral care. Understanding risk and prognostic factors, mechanisms of transmission and systemic inflammatory response are important when implementing EBP protocols. Nurses' attitudes, beliefs are important, and staff adherence considered when initiating EBP changes.

The age of red blood cells is associated with bacterial infections in critically ill trauma patients

BACKGROUND

Blood transfusion increases the risk of nosocomial infection in trauma patients. Specific patient- and transfusion-related risk factors are largely unknown. In this study, risk factors for developing a bacterial infection after transfusion of red blood cells (RBC) or platelets were determined in a cohort of transfused critically ill trauma patients.

MATERIAL AND METHODS

A retrospective study was conducted in a mixed medical-surgical Intensive Care Unit (ICU) of a level-1 university trauma centre, in trauma patients who received a RBC or platelet transfusion. Patients who developed a bacterial infection after transfusion were compared to transfused controls who did not develop such an infection. Multivariable logistic regression was used to determine risk factors for infection.

RESULTS

Of the 7,118 patients admitted to the ICU during the study period, 196 trauma patients met the inclusion criteria. An infection developed in 56 patients (29%). Infection occurred irrespective of the administration of antibiotics as part of selective digestive tract decontamination, surgery status or Injury Severity Score. Transfusion of RBC stored for more than 14 days was associated with infection in trauma patients (odds ratio 1.038, [95% CI: 1.01-1.07], p=0.036). Neither the amount of RBC nor that of platelets was associated with onset of infection.

CONCLUSIONS

Transfusion of RBC stored for more then 14 days is a risk factor for onset of bacterial infection after trauma, irrespective of the use of prophylactic antibiotics. Transfusion of platelets was not a risk factor. These results may contribute to designing prospective studies on transfusion of fresh RBC only in trauma patients.

Predicting hospital-acquired infections by scoring system with simple parameters

Background

Hospital-acquired infections (HAI) are associated with increased attributable morbidity, mortality, prolonged hospitalization, and economic costs. A simple, reliable prediction model for HAI has great clinical relevance. The objective of this study is to develop a scoring system to predict HAI that was derived from Logistic Regression (LR) and validated by Artificial Neural Networks (ANN) simultaneously.

Methodology/Principal Findings

A total of 476 patients from all the 806 HAI inpatients were included for the study between 2004 and 2005. A sample of 1,376 non-HAI inpatients was randomly drawn from all the admitted patients in the same period of time as the control group. External validation of 2,500 patients was abstracted from another academic teaching center. Sixteen variables were extracted from the Electronic Health Records (EHR) and fed into ANN and LR models. With stepwise selection, the following seven variables were identified by LR models as statistically significant: Foley catheterization, central venous catheterization, arterial line, nasogastric tube, hemodialysis, stress ulcer prophylaxes and systemic glucocorticosteroids. Both ANN and LR models displayed excellent discrimination (area under the receiver operating characteristic curve [AUC]: 0.964 versus 0.969, p = 0.507) to identify infection in internal validation. During external validation, high AUC was obtained from both models (AUC: 0.850 versus 0.870, p = 0.447). The scoring system also performed extremely well in the internal (AUC: 0.965) and external (AUC: 0.871) validations.

Conclusions

We developed a scoring system to predict HAI with simple parameters validated with ANN and LR models. Armed with this scoring system, infectious disease specialists can more efficiently identify patients at high risk for HAI during hospitalization. Further, using parameters either by observation of medical devices used or data obtained from EHR also provided good prediction outcome that can be utilized in different clinical settings.

Infectious complications after vehicular trauma in the United States

BACKGROUND

The purpose of this analysis was to evaluate and define the rates of infectious complications (IC) after vehicular trauma. Secondary goals were to identify the injuries associated with the greatest risk of nosocomial infection and to measure the utilization of hospital resources associated with IC and vehicular trauma.

METHODS

A secondary analysis of the Nationwide Inpatient Sample (2003-2007) was performed to classify major vehicular trauma injuries utilizing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Emergency (E) codes. The post-traumatic IC evaluated were pneumonia, urinary tract infection (UTI), sepsis, and surgical site infection (SSI). All data were analyzed by χ(2) analysis, multivariable logistic regression, and the Cochran-Armitage test for trends.

RESULTS

A total of 784,037 vehicular trauma patients were identified (462,543 [59.0%] motor vehicle drivers, 142,283 [18.2%] motor vehicle passengers, 98,767 [12.6%] motorcyclists; 6,568 [<1%] motorcycle passengers, and 73,876 [9.4%] pedestrians). Of those sustaining injuries, 44,331 [5.7%] had post-traumatic IC. Pneumonia and UTI were most common after spinal cord injury (SCI), whereas sepsis and SSI were most common after colon injuries. After adjustment by age, sex, and co-morbidities, patients with SCI were 4.4 times as likely (95% confidence interval [CI] 4.20-4.63) and those with cranial injuries were 2.1 times as likely (95% CI 2.06-2.19) to develop IC as patients without these injuries. Secondary infection increased significantly the length of stay and hospital charges in all groups.

CONCLUSIONS

Patients sustaining vehicular trauma in combination with SCI had the highest rate of IC. Infectious complications increased hospital resource utilization significantly after vehicular trauma. Future root-cause analysis of high-risk groups may decrease complications and hospital utilization.

Increases in mortality, length of stay, and cost associated with hospital-acquired infections in trauma patients

OBJECTIVE

To explore the clinical impact and economic burden of hospital-acquired infections (HAIs) in trauma patients using a nationally representative database.

DESIGN

Retrospective study.

SETTING

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample.

PATIENTS

Trauma patients.

MAIN OUTCOME MEASURES

We examined the association between HAIs (sepsis, pneumonia, Staphylococcus infections, and Clostridium difficile- associated disease) and in-hospital mortality, length of stay, and inpatient costs using logistic regression and generalized linear models.

RESULTS

After controlling for patient demographics, mechanism of injury, injury type, injury severity, and comorbidities, we found that mortality, cost, and length of stay were significantly higher in patients with HAIs compared with patients without HAIs. Patients with sepsis had a nearly 6-fold higher odds of death compared with patients without an HAI (odds ratio, 5.78; 95% confidence interval, 5.03-6.64; P < .001). Patients with other HAIs had a 1.5- to 1.9-fold higher odds of mortality compared with controls (P < .005). Patients with HAIs had costs that were approximately 2- to 2.5-fold higher compared with patients without HAIs (P < .001). The median length of stay was approximately 2-fold higher in patients with HAIs compared with patients without HAIs (P < .001).

CONCLUSIONS

Trauma patients with HAIs are at increased risk for mortality, have longer lengths of stay, and incur higher inpatient costs. In light of the preventability of many HAIs and the magnitude of the clinical and economic burden associated with HAIs, policies aiming to decrease the incidence of HAIs may have a potentially large impact on outcomes in injured patients.

Multidrug-resistant Pseudomonas aeruginosa bloodstream infections: risk factors and mortality

We retrospectively studied patients diagnosed with P. aeruginosa bloodstream infections (BSIs) in two Italian university hospitals. Risk factors for the isolation of multidrug-resistant (MDR) or non-MDR P. aeruginosa in blood cultures were identified by a case-case-control study, and a cohort study evaluated the clinical outcomes of such infections. We identified 106 patients with P. aeruginosa BSI over the 2-year study period; 40 cases with MDR P. aeruginosa and 66 cases with non-MDR P. aeruginosa were compared to 212 controls. Independent risk factors for the isolation of MDR P. aeruginosa were: presence of central venous catheter (CVC), previous antibiotic therapy, and corticosteroid therapy. Independent risk factors for non-MDR P. aeruginosa were: previous BSI, neutrophil count <500/mm3, urinary catheterization, and presence of CVC. The 21-day mortality rate of all patients was 33·9%. The variables independently associated with 21-day mortality were presentation with septic shock, infection due to MDR P. aeruginosa, and inadequate initial antimicrobial therapy.

Paradoxical ventilator associated pneumonia incidences among selective digestive decontamination studies versus other studies of mechanically ventilated patients: benchmarking the evidence base

Introduction

Selective digestive decontamination (SDD) appears to have a more compelling evidence base than non-antimicrobial methods for the prevention of ventilator associated pneumonia (VAP). However, the striking variability in ventilator associated pneumonia-incidence proportion (VAP-IP) among the SDD studies remains unexplained and a postulated contextual effect remains untested for.

Methods

Nine reviews were used to source 45 observational (benchmark) groups and 137 component (control and intervention) groups of studies of SDD and studies of three non-antimicrobial methods of VAP prevention. The logit VAP-IP data were summarized by meta-analysis using random effects methods and the associated heterogeneity (tau²) was measured. As group level predictors of logit VAP-IP, the mode of VAP diagnosis, proportion of trauma admissions, the proportion receiving prolonged ventilation and the intervention method under study were examined in meta-regression models containing the benchmark groups together with either the control (models 1 to 3) or intervention (models 4 to 6) groups of the prevention studies.

Results

The VAP-IP benchmark derived here is 22.1% (95% confidence interval; 95% CI; 19.2 to 25.5; tau² 0.34) whereas the mean VAP-IP of control groups from studies of SDD and of non-antimicrobial methods, is 35.7 (29.7 to 41.8; tau² 0.63) versus 20.4 (17.2 to 24.0; tau² 0.41), respectively (P < 0.001). The disparity between the benchmark groups and the control groups of the SDD studies, which was most apparent for the highest quality studies, could not be explained in the meta-regression models after adjusting for various group level factors. The mean VAP-IP (95% CI) of intervention groups is 16.0 (12.6 to 20.3; tau² 0.59) and 17.1 (14.2 to 20.3; tau² 0.35) for SDD studies versus studies of non-antimicrobial methods, respectively.

Conclusions

The VAP-IP among the intervention groups within the SDD evidence base is less variable and more similar to the benchmark than among the control groups. These paradoxical observations cannot readily be explained. The interpretation of the SDD evidence base cannot proceed without further consideration of this contextual effect.

Ventilator-associated pneumonia in trauma patients is associated with lower mortality: results from EU-VAP study

BACKGROUND

Differences in trauma patients developing ventilator-associated pneumonia (VAP) are described regarding etiology and risk factors associated. We aim to describe the differences in outcomes in trauma and nontrauma patients with VAP.

METHODS

A prospective, observational study conducted in 27 intensive care units from nine European countries. We included patients requiring invasive mechanical ventilation for >48 hours who developed VAP. Logistic regression model was used to assess the factors independently associated with mortality in trauma patients with VAP.

RESULTS

A total of 2,436 patients were evaluated; 465 developed VAP and of these 128 (27.5%) were trauma patients. Trauma patients were younger than nontrauma (45.3 ± 19.4 vs. 61.1 ± 16.7, p < 0.0001). Nontrauma had higher simplified acute physiology score II compared with trauma patients (45.5 ± 16.3 vs. 41.1 ± 15.2, p = 0.009). Most prevalent pathogens in trauma patients with early VAP were Enterobacteriaceae spp. (46.9% vs. 27.8%, p = 0.06) followed by methicillin-susceptible Staphylococcus aureus (30.6% vs. 13%, p = 0.03) and then Haemophilus influenzae (14.3% vs. 1.9%, p = 0.02), and the most prevalent pathogen in late VAP was Acinetobacter baumannii (12.2% vs. 44.4%, p < 0.0001). Mortality was higher in nontrauma patients than in trauma patients (42.6% vs. 17.2%, p < 0.001, odds ratio [OR] = 3.55, 95%CI = 2.14-5.88). A logistic regression model adjusted for sex, age, severity of illness at intensive care unit admission, and sepsis-related organ failure assessment score at the day of VAP diagnosis confirmed that trauma was associated with a lower mortality compared with nontrauma patients (odds ratio [OR] = 0.37, 95%CI = 0.21-0.65).

CONCLUSIONS

Trauma patients developing VAP had different demographic characteristics and episodes of etiology. After adjustment for potential confounders, VAP episodes in trauma patients are associated with lower mortality when compared with nontrauma patients.

Incidence of multidrug-resistant organisms causing ventilator-associated pneumonia in a tertiary care hospital: a nine months' prospective study

BACKGROUND:

Ventilator-associated pneumonia (VAP) is an important intensive care unit (ICU) infection in mechanically ventilated patients. VAP occurs approximately in 9-27% of all intubated patients. Due to the increasing incidence of multidrug-resistant organisms in ICUs, early and correct diagnosis of VAP is an urgent challenge for an optimal antibiotic treatment.

AIM OF THE STUDY:

The aim of the study was to assess the incidence of VAP caused by multidrug-resistant organisms in the multidisciplinary intensive care unit (MICU) of our tertiary care 1,400-bedded hospital.

MATERIALS AND METHODS:

This prospective study was done in the period from December 2005 to August 2006, enrolling patients undergoing mechanical ventilation (MV) for >48 h. Endotracheal aspirates (ETA) were collected from patients with suspected VAP, and quantitative cultures were performed on all samples. VAP was diagnosed by the growth of pathogenic organism ≥10⁵ cfu/ml.

RESULTS:

Incidence of VAP was found to be 45.4% among the mechanically ventilated patients, out of which 47.7% had early-onset (<5 days MV) VAP and 52.3% had late-onset (>5 days MV) VAP. Multiresistant bacteria, mainly Acinetobacter spp. (47.9%) and Pseudomonas aeruginosa (27%), were the most commonly isolated pathogens in both types of VAP. Most of the isolates of Escherichia coli (80%) and Klebsiella pneumoniae (100%) produced extended-spectrum beta lactamases (ESBLs). As many as 30.43% isolates of Acinetobacter spp. showed production of AmpC beta lactamases among all types of isolates. Metallo-beta lactamases (MBLs) were produced by 50% of Pseudomonas aeruginosa and 21.74% of Acinetobacter spp.

CONCLUSION:

High incidence (45.4%) of VAP and the potential multidrug-resistant organisms are the real threat in our MICU. This study highlighted high incidence of VAP in our setup, emphasizing injudicious use of antimicrobial therapy. Combined approaches of rotational antibiotic therapy and education programs might be beneficial to fight against these MDR pathogens and will also help to decrease the incidence of VAP.

Early onset pneumonia in severe chest trauma: a risk factor analysis

BACKGROUND

The development of an early-onset pneumonia (EOP), occurring within the first 72 hours after admission, represents a critical event in severe thoracic trauma population. The aim of this study was to determine risk factors associated with the occurrence of this complication in this specific population.

METHODS

A retrospective review of a prospective implemented trauma registry was conducted during a 4-year period in a Level I trauma center. Over the study period, 223 severely injured patients were admitted with severe thoracic trauma (Injury Severity Score >16 and Thorax Abbreviated Injury Score >2). Multiple logistic regression analysis was used to determine the independent predictors of EOP based on the clinical characteristics and the initial management both in the field and after admission in the trauma center.

RESULTS

Independent predictors of EOP were the necessity of intubation and mechanical ventilation in the field (adjusted odds ratio [OR]: 11.8; 95% confidence interval [CI]: 4.3-32.7), a history of aspiration (OR: 28.6; 95% CI: 4.0-203.5), the presence of pulmonary contusion (OR: 7.0; 95% CI: 2.0-23.9), and the occurrence of a hemothorax (OR: 3.2; 95% CI: 1.4-7.6).

CONCLUSION

These results emphasize the influence of prehospital and early factors in the further occurrence of EOP, which allows the development of early and specific clinical management to prevent it.