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Symonds NE, Meng EXM, Boyd JG, Boyd T, Day A, Hobbs H, Maslove DM, Norman PA, Semrau JS, Sibley S, Muscedere J. Ceragenin-coated endotracheal tubes for the reduction of ventilator-associated pneumonia: a prospective, longitudinal, cross-over, interrupted time, implementation study protocol (CEASE VAP study). BMJ Open 2024; 14:e076720. [PMID: 38309761 PMCID: PMC10840065 DOI: 10.1136/bmjopen-2023-076720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/11/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Critically ill patients are at high risk of acquiring ventilator-associated pneumonia (VAP), which occurs in approximately 20% of mechanically ventilated patients. VAP results either from aspiration of pathogen-contaminated oropharyngeal secretions or contaminated biofilms that form on endotracheal tubes (ETTs) after intubation. VAP results in increased duration of mechanical ventilation, increased intensive care unit and hospital length of stay, increased risk of death and increased healthcare costs. Because of its impact on patient outcomes and the healthcare system, VAP is regarded as an important patient safety issue and there is an urgent need for better evidence on the efficacy of prevention strategies. Modified ETTs that reduce aspiration of oropharyngeal secretions with subglottic secretion drainage or reduce the occurrence of biofilm with a coating of ceragenins (CSAs) are available for clinical use in Canada. In this implementation study, we will evaluate the efficacy of these two types of Health Canada-licensed ETTs on the occurrence of VAP, and impact on patient-centred outcomes. METHODS In this ongoing, pragmatic, prospective, longitudinal, interrupted time, cross-over implementation study, we will compare the efficacy of a CSA-coated ETT (CeraShield N8 Pharma) with an ETT with subglottic secretion drainage (Taper Guard, Covidien). The study periods consist of four alternating time periods of 11 or 12 weeks or a total of 23 weeks for each ETT. All patients intubated with the study ETT in each time period will be included in an intention-to-treat analysis. Outcomes will include VAP incidence, mortality and health services utilisation including antibiotic use and length of stay. ETHICS AND DISSEMINATION This study has been approved by the Health Sciences Research Ethics Board at Queen's University. The results of this study will be actively disseminated through manuscript publication and conference presentations. TRIAL REGISTRATION NUMBER NCT05761613.
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Affiliation(s)
| | | | - John Gordon Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Tracy Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Andrew Day
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Hailey Hobbs
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Joanna S Semrau
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie Sibley
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
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Marcut L, Manescu Paltanea V, Antoniac A, Paltanea G, Robu A, Mohan AG, Grosu E, Corneschi I, Bodog AD. Antimicrobial Solutions for Endotracheal Tubes in Prevention of Ventilator-Associated Pneumonia. MATERIALS (BASEL, SWITZERLAND) 2023; 16:5034. [PMID: 37512308 PMCID: PMC10386556 DOI: 10.3390/ma16145034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/14/2023] [Accepted: 07/15/2023] [Indexed: 07/30/2023]
Abstract
Ventilator-associated pneumonia is one of the most frequently encountered hospital infections and is an essential issue in the healthcare field. It is usually linked to a high mortality rate and prolonged hospitalization time. There is a lack of treatment, so alternative solutions must be continuously sought. The endotracheal tube is an indwelling device that is a significant culprit for ventilator-associated pneumonia because its surface can be colonized by different types of pathogens, which generate a multispecies biofilm. In the paper, we discuss the definition of ventilator-associated pneumonia, the economic burdens, and its outcomes. Then, we present the latest technological solutions for endotracheal tube surfaces, such as active antimicrobial coatings, passive coatings, and combinatorial methods, with examples from the literature. We end our analysis by identifying the gaps existing in the present research and investigating future possibilities that can decrease ventilator-associated pneumonia cases and improve patient comfort during treatment.
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Affiliation(s)
- Lavinia Marcut
- Faculty of Medicine and Pharmacy, University of Oradea, 10 P-ta 1 December Street, RO-410073 Oradea, Romania
- Intensive Care Unit, Clinical Emergency Hospital Oradea, 65 Gheorghe Doja Street, RO-410169 Oradea, Romania
| | - Veronica Manescu Paltanea
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania
- Faculty of Electrical Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania
| | - Aurora Antoniac
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania
| | - Gheorghe Paltanea
- Faculty of Electrical Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania
| | - Alina Robu
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania
| | - Aurel George Mohan
- Faculty of Medicine and Pharmacy, University of Oradea, 10 P-ta 1 December Street, RO-410073 Oradea, Romania
- Department of Neurosurgery, Clinical Emergency Hospital Oradea, 65 Gheorghe Doja Street, RO-410169 Oradea, Romania
| | - Elena Grosu
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, RO-060042 Bucharest, Romania
| | - Iuliana Corneschi
- Romfire Protect Solutions SRL, 39 Drumul Taberei, RO-061359 Bucharest, Romania
| | - Alin Danut Bodog
- Faculty of Medicine and Pharmacy, University of Oradea, 10 P-ta 1 December Street, RO-410073 Oradea, Romania
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Alves D, Grainha T, Pereira MO, Lopes SP. Antimicrobial materials for endotracheal tubes: A review on the last two decades of technological progress. Acta Biomater 2023; 158:32-55. [PMID: 36632877 DOI: 10.1016/j.actbio.2023.01.001] [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: 10/17/2022] [Revised: 12/21/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
Ventilator-associated pneumonia (VAP) is an unresolved problem in nosocomial settings, remaining consistently associated with a lack of treatment, high mortality, and prolonged hospital stay. The endotracheal tube (ETT) is the major culprit for VAP development owing to its early surface microbial colonization and biofilm formation by multiple pathogens, both critical events for VAP pathogenesis and relapses. To combat this matter, gradual research on antimicrobial ETT surface coating/modification approaches has been made. This review provides an overview of the relevance and implications of the ETT bioburden for VAP pathogenesis and how technological research on antimicrobial materials for ETTs has evolved. Firstly, certain main VAP attributes (definition/categorization; outcomes; economic impact) were outlined, highlighting the issues in defining/diagnosing VAP that often difficult VAP early- and late-onset differentiation, and that generate misinterpretations in VAP surveillance and discrepant outcomes. The central role of the ETT microbial colonization and subsequent biofilm formation as fundamental contributors to VAP pathogenesis was then underscored, in parallel with the uncovering of the polymicrobial ecosystem of VAP-related infections. Secondly, the latest technological developments (reported since 2002) on materials able to endow the ETT surface with active antimicrobial and/or passive antifouling properties were annotated, being further subject to critical scrutiny concerning their potentialities and/or constraints in reducing ETT bioburden and the risk of VAP while retaining/improving the safety of use. Taking those gaps/challenges into consideration, we discussed potential avenues that may assist upcoming advances in the field to tackle VAP rampant rates and improve patient care. STATEMENT OF SIGNIFICANCE: The use of the endotracheal tube (ETT) in patients requiring mechanical ventilation is associated with the development of ventilator-associated pneumonia (VAP). Its rapid surface colonization and biofilm formation are critical events for VAP pathogenesis and relapses. This review provides a comprehensive overview on the relevance/implications of the ETT biofilm in VAP, and on how research on antimicrobial ETT surface coating/modification technology has evolved over the last two decades. Despite significant technological advances, the limited number of gathered reports (46), highlights difficulty in overcoming certain hurdles associated with VAP (e.g., persistent colonization/biofilm formation; mechanical ventilation duration; hospital length of stay; VAP occurrence), which makes this an evolving, complex, and challenging matter. Challenges and opportunities in the field are discussed.
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Affiliation(s)
- Diana Alves
- CEB - Centre of Biological Engineering, University of Minho, 4710-057 Braga, Portugal; LABBELS - Associate Laboratory, Braga/Guimarães, Portugal.
| | - Tânia Grainha
- CEB - Centre of Biological Engineering, University of Minho, 4710-057 Braga, Portugal; LABBELS - Associate Laboratory, Braga/Guimarães, Portugal.
| | - Maria Olívia Pereira
- CEB - Centre of Biological Engineering, University of Minho, 4710-057 Braga, Portugal; LABBELS - Associate Laboratory, Braga/Guimarães, Portugal.
| | - Susana Patrícia Lopes
- CEB - Centre of Biological Engineering, University of Minho, 4710-057 Braga, Portugal; LABBELS - Associate Laboratory, Braga/Guimarães, Portugal.
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Tincu RC, Cobilinschi C, Tincu IF, Macovei RA. Efficacy of Noble Metal-alloy Endotracheal Tubes in Ventilator-associated Pneumonia Prevention: a Randomized Clinical Trial. Balkan Med J 2022; 39:167-171. [PMID: 35332771 PMCID: PMC9136541 DOI: 10.4274/balkanmedj.galenos.2021.2021-7-86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Endotracheal tube (ETT) is an important risk factor for the development of Ventilator-associated pneumonia (VAP), as it acts as a reservoir for infectious microorganisms and bypasses the host’s defenses. One of the preventive measures for VAP is endotracheal tube composition. It has been reported that biofilm formation is reduced by using ETTs coated with pure silver or silver compounds. However, noble metal-alloy ETTs have not been adequately studied. Aims: To evaluate the efficacy of noble metal alloy ETT (coated Bactiguard Infection Protection ETTs) in preventing VAP compared to standard non-coated ETTs in patients requiring ≥ 48 hours of mechanical ventilation and presenting for coma due to drug intoxication. Study Design: Randomized controlled study. Methods: Participants were randomized using sealed envelopes with a concealed 1:1 allocation to either the intervention group or the control group. The intervention group used a noble metal–alloy ETT, while the control group received standard ETT. The primary outcomes were the incidence of VAP (per ventilated patients) and the duration of mechanical ventilation. Results: Initially, a total of 188 patients were assessed for eligibility, and the final allocation group consisted of 180 patients, who were subsequently randomized into the intervention group (n = 97) and control group (n = 83). The incidence of VAP in the intervention and control groups was 27.83% and 43.16% (P = 0.03), and the VAP ratio per 1000 ventilation days was 51.26/1000 and 83.38/1000 (P = 0.01), respectively. The mean durations of mechanical ventilation were 3.2 ± 0.78 in the intervention group and 5.03 ± 1.88 in the control group (P = 0.22). There was no statistically significant difference between groups in terms of mortality and duration of hospital stay. Conclusion: Noble metal-alloy ETT reduces the incidence of VAP, ventilation days, and ICU stay for patients in mechanical ventilation.
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Affiliation(s)
- Radu Ciprian Tincu
- Toxicology and Intensive Care Unit Clinical Emergency Hospital Bucharest, Bucharest, Romania
| | - Cristian Cobilinschi
- Anestesiology and Intensive Care Clinical Emergency Hospital Bucharest, Bucharest, Romania
| | - Iulia Florentina Tincu
- Gastroenterology Department "Dr Victor Gomoiu" Clinical Children Hospital, Bucharest, Romania
| | - Radu Alexandru Macovei
- Gastroenterology Department "Dr Victor Gomoiu" Clinical Children Hospital, Bucharest, Romania
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Wang Y, Cai B, Ni D, Sun Y, Wang G, Jiang H. A novel antibacterial and antifouling nanocomposite coated endotracheal tube to prevent ventilator-associated pneumonia. J Nanobiotechnology 2022; 20:112. [PMID: 35248076 PMCID: PMC8897767 DOI: 10.1186/s12951-022-01323-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/21/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The endotracheal tube (ETT) is an essential medical device to secure the airway patency in patients undergoing mechanical ventilation or general anesthesia. However, long-term intubation eventually leads to complete occlusion, ETTs potentiate biofilm-related infections, such as ventilator-associated pneumonia. ETTs are mainly composed of medical polyvinyl chloride (PVC), which adheres to microorganisms to form biofilms. Thus, a simple and efficient method was developed to fabricate CS-AgNPs@PAAm-Gelatin nanocomposite coating to achieve dual antibacterial and antifouling effects.
Results
The PAAm-Gelatin (PAAm = polyacrylamide) molecular chain gel has an interpenetrating network with a good hydrophilicity and formed strong covalent bonds with PVC-ETTs, wherein silver nanoparticles were used as antibacterial agents. The CS-AgNPs@PAAm-Gelatin coating showed great resistance and antibacterial effects against Staphylococcus aureus and Pseudomonas aeruginosa. Its antifouling ability was tested using cell, protein, and platelet adhesion assays. Additionally, both properties were comprehensively evaluated using an artificial broncho-lung model in vitro and a porcine mechanical ventilation model in vivo. These remarkable results were further confirmed that the CS-AgNPs@PAAm-Gelatin coating exhibited an excellent antibacterial capacity, an excellent stain resistance, and a good biocompatibility.
Conclusions
The CS-AgNPs@PAAm-Gelatin nanocomposite coating effectively prevents the occlusion and biofilm-related infection of PVC-ETTs by enhancing the antibacterial and antifouling properties, and so has great potential for future clinical applications.
Graphical Abstract
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Damas P, Legrain C, Lambermont B, Dardenne N, Guntz J, Kisoka G, Demaret P, Rousseau AF, Jadot L, Piret S, Noirot D, Bertrand A, Donneau AF, Misset B. Prevention of ventilator-associated pneumonia by noble metal coating of endotracheal tubes: a multi-center, randomized, double-blind study. Ann Intensive Care 2022; 12:1. [PMID: 34981245 PMCID: PMC8723906 DOI: 10.1186/s13613-021-00961-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/28/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) causes increased mortality, prolonged hospital stay and increased healthcare costs. Prevention of VAP in intensive care units (ICUs) is currently based on several measures, and application of noble metal coating on medical devices has been shown to inhibit the bacterial adherence of microorganisms to the surface. The objective of this study was to evaluate the potential benefit of noble metal coating of endotracheal tubes for the prevention of VAP. METHODS This was a multi-center, randomized, controlled, double-blind, prospective study including ventilated patients from nine ICUs from four hospital sites in Belgium. Patients were randomly intubated with identical appearing noble metal alloy (NMA) coated (NMA-coated group) or non-coated (control group) endotracheal tubes (ETT). Primary endpoint was the incidence of VAP. Secondary endpoints were the proportion of antibiotic days during ICU stay and tracheal colonization by pathogenic bacteria. RESULTS In total, 323 patients were enrolled, 168 in the NMA-coated group and 155 in the control group. During ventilation, VAP occurred in 11 patients (6.5%) in the NMA-coated group and in 18 patients (11.6%) in the control group (p = 0.11). A higher delay in VAP occurrence was observed in the NMA-coated group compared with the control group by Cox proportional hazards regression analysis (HR 0.41, 95% CI 0.19-0.88, p = 0.02). The number of antibiotic days was 58.8% of the 1,928 ICU days in the NMA-coated group and 65.4% of the 1774 ICU days in the control group (p = 0.06). Regarding tracheal colonization, bacteria occurred in 38 of 126 patients in the NMA-coated group (30.2%) and in 37 of 109 patients in the control group (33.9%) (p = 0.57). CONCLUSIONS This study provides preliminary evidence to support the benefit of noble metal coating in the prevention of VAP. A confirmatory study in a larger population would be valuable. TRIAL REGISTRATION Clinical trial number: NCT04242706 ( http://www.clinicaltrials.gov ).
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Affiliation(s)
- Pierre Damas
- Department of Intensive Care, University Hospital of Liège, Domaine Universitaire de Liège, B-4000, Liege, Belgium.
| | - Caroline Legrain
- Department of Intensive Care, Mont Legia Hospital, Groupe Santé CHC, B-4000, Liege, Belgium
| | - Bernard Lambermont
- Department of Intensive Care, University Hospital of Liège, Domaine Universitaire de Liège, B-4000, Liege, Belgium
| | - Nadia Dardenne
- Department of Biostatistics, University Hospital of Liège, Domaine Universitaire de Liège, B-4000, Liege, Belgium
| | - Julien Guntz
- Department of Intensive Care, Mont Legia Hospital, Groupe Santé CHC, B-4000, Liege, Belgium
| | - Grâce Kisoka
- Department of Intensive Care, University Hospital of Liège, Domaine Universitaire de Liège, B-4000, Liege, Belgium
| | - Pierre Demaret
- Department of Intensive Care, Mont Legia Hospital, Groupe Santé CHC, B-4000, Liege, Belgium
| | - Anne-Françoise Rousseau
- Department of Intensive Care, University Hospital of Liège, Domaine Universitaire de Liège, B-4000, Liege, Belgium
| | - Laurent Jadot
- Department of Intensive Care, Mont Legia Hospital, Groupe Santé CHC, B-4000, Liege, Belgium
| | - Sonia Piret
- Department of Intensive Care, University Hospital of Liège, Domaine Universitaire de Liège, B-4000, Liege, Belgium
| | - Didier Noirot
- Department of Intensive Care, Mont Legia Hospital, Groupe Santé CHC, B-4000, Liege, Belgium
| | - Axelle Bertrand
- Department of Intensive Care, University Hospital of Liège, Domaine Universitaire de Liège, B-4000, Liege, Belgium
| | - Anne-Françoise Donneau
- Department of Biostatistics, University Hospital of Liège, Domaine Universitaire de Liège, B-4000, Liege, Belgium
| | - Benoît Misset
- Department of Intensive Care, University Hospital of Liège, Domaine Universitaire de Liège, B-4000, Liege, Belgium
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Latorre MC, Pérez-Granda MJ, Savage PB, Alonso B, Martín-Rabadán P, Samaniego R, Bouza E, Muñoz P, Guembe M. Endotracheal tubes coated with a broad-spectrum antibacterial ceragenin reduce bacterial biofilm in an in vitro bench top model. J Antimicrob Chemother 2021; 76:1168-1173. [PMID: 33544817 DOI: 10.1093/jac/dkab019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/08/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia is one of the most common nosocomial infections, caused mainly by bacterial/fungal biofilm. Therefore, it is necessary to develop preventive strategies to avoid biofilm formation based on new compounds. OBJECTIVES We performed an in vitro study to compare the efficacy of endotracheal tubes (ETTs) coated with the ceragenin CSA-131 and that of uncoated ETTs against the biofilm of clinical strains of Pseudomonas aeruginosa (PA), Escherichia coli (EC) and Staphylococcus aureus (SA). METHODS We applied an in vitro bench top model using coated and uncoated ETTs that were treated with three different clinical strains of PA, EC and SA for 5 days. After exposure to biofilm, ETTs were analysed for cfu count by culture of sonicate and total number of cells by confocal laser scanning microscopy. RESULTS The median (IQR) cfu/mL counts of PA, EC and SA in coated and uncoated ETTs were, respectively, as follows: 1.00 × 101 (0.0-3.3 × 102) versus 3.32 × 109 (6.6 × 108-3.8 × 109), P < 0.001; 0.0 (0.0-5.4 × 103) versus 1.32 × 106 (2.3 × 103-5.0 × 107), P < 0.001; and 8.1 × 105 (8.5 × 101-1.4 × 109) versus 2.7 × 108 (8.6 × 106-1.6 × 1011), P = 0.058. The median (IQR) total number of cells of PA, EC and SA in coated and non-coated ETTs were, respectively, as follows: 11.0 [5.5-not applicable (NA)] versus 87.9 (60.5-NA), P = 0.05; 9.1 (6.7-NA) versus 62.6 (42.0-NA), P = 0.05; and 97.7 (94.6-NA) versus 187.3 (43.9-NA), P = 0.827. CONCLUSIONS We demonstrated significantly reduced biofilm formation in coated ETTs. However, the difference for SA was not statistically significant. Future clinical studies are needed to support our findings.
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Affiliation(s)
- María Consuelo Latorre
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - María Jesús Pérez-Granda
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Paul B Savage
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, USA
| | - Beatriz Alonso
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Pablo Martín-Rabadán
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES, (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Rafael Samaniego
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Confocal Laser Scanning Microscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emilio Bouza
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES, (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES, (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Avoiding ventilator-associated pneumonia: Curcumin-functionalized endotracheal tube and photodynamic action. Proc Natl Acad Sci U S A 2020; 117:22967-22973. [PMID: 32868444 DOI: 10.1073/pnas.2006759117] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Hospital-acquired infections are a global health problem that threatens patients' treatment in intensive care units, causing thousands of deaths and a considerable increase in hospitalization costs. The endotracheal tube (ETT) is a medical device placed in the patient's trachea to assist breathing and delivering oxygen into the lungs. However, bacterial biofilms forming at the surface of the ETT and the development of multidrug-resistant bacteria are considered the primary causes of ventilator-associated pneumonia (VAP), a severe hospital-acquired infection for significant mortality. Under these circumstances, there has been a need to administrate antibiotics together. Although necessary, it has led to a rapid increase in bacterial resistance to antibiotics. Therefore, it becomes necessary to develop alternatives to prevent and combat these bacterial infections. One possibility is to turn the ETT itself into a bactericide. Some examples reported in the literature present drawbacks. To overcome those issues, we have designed a photosensitizer-containing ETT to be used in photodynamic inactivation (PDI) to avoid bacteria biofilm formation and prevent VAP occurrence during tracheal intubation. This work describes ETT's functionalization with curcumin photosensitizer, as well as its evaluation in PDI against Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli A significant photoinactivation (up to 95%) against Gram-negative and Gram-positive bacteria was observed when curcumin-functionalized endotracheal (ETT-curc) was used. These remarkable results demonstrate this strategy's potential to combat hospital-acquired infections and contribute to fighting antimicrobial resistance.
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9
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Mahmoodpoor A, Sanaie S, Parthvi R, Shadvar K, Hamishekar H, Iranpour A, Nuri H, Rahnemayan S, Nader ND. A clinical trial of silver-coated and tapered cuff plus supraglottic suctioning endotracheal tubes in preventing ventilator-associated pneumonia. J Crit Care 2019; 56:171-176. [PMID: 31935605 DOI: 10.1016/j.jcrc.2019.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/24/2019] [Accepted: 12/27/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE Novel designs of the endotracheal tube (ETT) are emerged to reduce the risk of ventilator-associated pneumonia (VAP). We evaluated the effect of two different types, namely silver-coated (Bactiguard) and subglottic suctioning (Taperguard) ETTs, on the incidence of VAP in critically-ill patients. METHODS A total of 90 patients, mechanically ventilated for >72 h, were randomly assigned to Bactiguard and Taperguard groups. They otherwise received routine care, including VAP prevention measures during their intensive care unit (ICU) stay. Subglottic suctioning was performed in Taperguard group. Statistical analyses were performed using SPSS 25 for iMacs. RESULTS Both groups had similar demographics and did not differ in the prevalence of comorbidities and the severity of underlying illness. There was no difference in the frequency of reintubation (P = .565), the duration of ventilation, ICU and total hospital length of stay. VAP developed in 31% of the Bactiguard group and 20% of the Taperguard group (P = .227). Nearly twice the number of patients died in the Bactiguard group compared to the Taperguard group. This difference was not significant either (P = .352). CONCLUSIONS The use of Bactiguard or Taperguard ETTs was not associated with any difference in the incidence of VAP or ICU mortality.
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Affiliation(s)
- Ata Mahmoodpoor
- Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sarvin Sanaie
- Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rukma Parthvi
- University at Buffalo, Jacob's School of Medicine and Biomedical Sciences, Buffalo, NY, United States of America.
| | - Kamran Shadvar
- Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hadi Hamishekar
- Drug Applied research center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Afshin Iranpour
- Dept. of Anesthesiology, Al-Garhoud Hospital, Dubai, United Arab Emirates
| | - Hamidreza Nuri
- Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sama Rahnemayan
- Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nader D Nader
- University at Buffalo, Jacob's School of Medicine and Biomedical Sciences, Buffalo, NY, United States of America.
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Rouzé A, Martin-Loeches I, Nseir S. Airway Devices in Ventilator-Associated Pneumonia Pathogenesis and Prevention. Clin Chest Med 2019; 39:775-783. [PMID: 30390748 DOI: 10.1016/j.ccm.2018.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Airway devices play a major role in the pathogenesis of microaspiration of contaminated oropharyngeal and gastric secretions, tracheobronchial colonization, and ventilator-associated pneumonia (VAP) occurrence. Subglottic secretion drainage is an effective measure for VAP prevention, and no routine change of ventilator circuit. Continuous control of cuff pressure, silver-coated tracheal tubes, low-volume low-pressure tracheal tubes, and the mucus shaver are promising devices that should be further evaluated by large randomized controlled trials. Polyurethane-cuffed, conical-shaped cuff, and closed tracheal suctioning system are not effective and should not be used for VAP prevention.
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Affiliation(s)
- Anahita Rouzé
- CHU Lille, Critical Care Center, bd du Pr Leclercq, Lille F-59000, France
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Trinity College, Welcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin 94568, Ireland
| | - Saad Nseir
- CHU Lille, Critical Care Center, bd du Pr Leclercq, Lille F-59000, France; Lille University, Medicine School, 1 Place de Verdun, Lille F-59000, France.
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11
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Barnes M, Feit C, Grant TA, Brisbois EJ. Antimicrobial polymer modifications to reduce microbial bioburden on endotracheal tubes and ventilator associated pneumonia. Acta Biomater 2019; 91:220-234. [PMID: 31022549 DOI: 10.1016/j.actbio.2019.04.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 12/26/2022]
Abstract
Hospital associated infections (HAIs), infections acquired by patients during care in a hospital, remain a prevalent issue in the healthcare field. These infections often occur with the use of indwelling medical devices, such as endotracheal tubes (ETTs), that can result in ventilator-associated pneumonia (VAP). When examining the various routes of infection, VAP is associated with the highest incidence, rate of morbidity, and economic burden. Although ETTs are essential for the survival of patients requiring mechanical ventilation, their use comes with complications. The presence of an ETT in the airway impairs physiological host defense mechanisms for clearance of pathogens and provides a platform for oropharynx microorganism transport to the sterile tracheobronchial network. Antibiotics are administered to treat lower respiratory infections; however, they are not always effective and consequently can result in increased antibiotic resistance. Prophylactic approaches by altering the surface of ETTs to prevent the establishment and growth of bacteria have exhibited promising results. In addition, passive surface modifications that prevent bacterial establishment and growth, or active coatings that possess a bactericidal effect have also proven effective. In this review we aim to highlight the importance of preventing biofilm establishment on indwelling medical devices, focusing on ETTs. We will investigate successful antimicrobial modifications to ETTs and the future avenues that will ultimately decrease HAIs and improve patient care. STATEMENT OF SIGNIFICANCE: Infections that occur with indwelling medicals devices remain a constant concern in the medical field and can result in hospital-acquired infections. Specifically, ventilator associated pneumonia (VAP) occurs with the use of an endotracheal tube (ETT). Infections often require use of antibiotics and can result in patient mortality. Our review includes a summary of the recent collective work of antimicrobial ETT modifications and potential avenues for further investigations in an effort to reduce VAP associated with ETTs. Polymer modifications with antibacterial nature have been developed and tested; however, a focus on ETTs is lacking and clinical availability of new antimicrobial ETT devices is limited. Our collective work shows the successful and prospective applications to the surfaces of ETTs that can support researchers and physicians to create safer medical devices.
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Odeberg J, Wirsén A, Norberg Å, Frie J, Printz G, Lagercrantz H, Gudmundsson GH, Agerberth B, Jonsson B. A novel cysteine-linked antibacterial surface coating significantly inhibits bacterial colonization of nasal silicone prongs in a phase one pre-clinical trial. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2018; 93:782-789. [PMID: 30274112 DOI: 10.1016/j.msec.2018.08.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 07/09/2018] [Accepted: 08/18/2018] [Indexed: 01/18/2023]
Abstract
Ventilator associated pneumonia and sepsis are frequent complications in neonatal care. Bacterial colonization of medical devices and interfaces used for respiratory support may contribute by functioning as a bacterial reservoir seeding bacteria into airways. We have developed an antibacterial surface coating based on a cysteine ligand covalently coupled via a spacer to a carboxylic backbone layer on an acrylic acid grafted silicone surface. This coating was applied on a commercially available nasal prong and the antibacterial effect was evaluated both in vitro and in vivo in a first-in-human phase 1 trial. The coated nasal prongs had strong antibacterial activity against both Gram-negative and Gram-positive bacteria in vitro. In a randomized pre-clinical trial study of 24 + 24 healthy adult volunteers who carried coated or non-coated nasal prongs for 18 h, a 10log difference in mean bacterial colonization of 5.82 (p < 0.0001) was observed. These results show that this coating technique can prevent colonization by the normal skin and mucosal flora, and thus represent a promising novel technology for reduction of medical device-associated hospital acquired infections.
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Affiliation(s)
- Jacob Odeberg
- School of Biotechnology, Royal Institute of Technology (KTH), Science for Life Laboratory (SciLifeLab) Stockholm, Sweden; CytaCoat AB, Stockholm, Sweden; Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Hematology, Karolinska University Hospital, Stockholm, Sweden.
| | | | | | - Jakob Frie
- Department of Women's and Children's Health Karolinska Institutet, Sweden
| | - Gordana Printz
- Department of Women's and Children's Health Karolinska Institutet, Sweden
| | - Hugo Lagercrantz
- Department of Women's and Children's Health Karolinska Institutet, Sweden
| | | | - Birgitta Agerberth
- CytaCoat AB, Stockholm, Sweden; Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Baldvin Jonsson
- Department of Women's and Children's Health Karolinska Institutet, Sweden
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13
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Póvoa FCC, Cardinal-Fernandez P, Maia IS, Reboredo MM, Pinheiro BV. Effect of antibiotics administered via the respiratory tract in the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. J Crit Care 2017; 43:240-245. [PMID: 28942198 DOI: 10.1016/j.jcrc.2017.09.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/10/2017] [Accepted: 09/13/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE We evaluated the effect of antibiotics administered via the respiratory tract to prevent the ventilator-associated pneumonia (VAP) in mechanically ventilated (MV) patients. METHODS We searched relevant articles for trials that evaluated the impact of prophylactic antibiotics administered through the respiratory tract on the occurrence of VAP. The end-point was the occurrence of VAP in MV patients. RESULTS We included 6 comparative trials involving 1158 patients (632 received prophylactic antibiotic). Our meta-analysis revealed that prophylactic antibiotics administered through the respiratory tract reduced the occurrence of VAP when compared to placebo or no treatment (OR 0.53; 95% CI 0.34-0.84). This effect was seen when the antibiotics were given by nebulization (OR 0.46; 95% CI 0.22-0.97), but not when they were administered by intratracheal instillation (OR 0.57; 95% CI 0.28-1.15). We did not find a significant difference between the compared groups in the intensive care unit (ICU) mortality (OR 0.89; 95% CI 0.64-1.25). Antibiotic prophylaxis did not impact occurrence of VAP due to multidrug resistant (MDR) pathogens (OR 0.67; 95% CI 0.17-2.62). CONCLUSIONS Prophylactic antibiotics administered through the respiratory tract by nebulization reduce the occurrence of VAP, without a significant effect on either the ICU mortality or occurrence of VAP due to MDR pathogens.
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Affiliation(s)
- Frederico Castro Costa Póvoa
- Pulmonary and Critical Care Division, University Hospital of Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil
| | - Pablo Cardinal-Fernandez
- Emergency Department, Hospital Universitario HM Sanchinarro, Madrid, Spain; HM Research Foundation, Spain
| | - Israel Silva Maia
- General Medicine Department, Health Sciences Center, Hospital Universitário da Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Maycon Moura Reboredo
- Pulmonary and Critical Care Division, University Hospital of Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil
| | - Bruno Valle Pinheiro
- Pulmonary and Critical Care Division, University Hospital of Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil.
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Ciofu O, Rojo-Molinero E, Macià MD, Oliver A. Antibiotic treatment of biofilm infections. APMIS 2017; 125:304-319. [PMID: 28407419 DOI: 10.1111/apm.12673] [Citation(s) in RCA: 237] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 01/10/2017] [Indexed: 12/24/2022]
Abstract
Bacterial biofilms are associated with a wide range of infections, from those related to exogenous devices, such as catheters or prosthetic joints, to chronic tissue infections such as those occurring in the lungs of cystic fibrosis patients. Biofilms are recalcitrant to antibiotic treatment due to multiple tolerance mechanisms (phenotypic resistance). This causes persistence of biofilm infections in spite of antibiotic exposure which predisposes to antibiotic resistance development (genetic resistance). Understanding the interplay between phenotypic and genetic resistance mechanisms acting on biofilms, as well as appreciating the diversity of environmental conditions of biofilm infections which influence the effect of antibiotics are required in order to optimize the antibiotic treatment of biofilm infections. Here, we review the current knowledge on phenotypic and genetic resistance in biofilms and describe the potential strategies for the antibiotic treatment of biofilm infections. Of note is the optimization of PK/PD parameters in biofilms, high-dose topical treatments, combined and sequential/alternate therapies or the use antibiotic adjuvants.
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Affiliation(s)
- Oana Ciofu
- Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
| | - Estrella Rojo-Molinero
- Servicio de Microbiología, Hospital Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Spain
| | - María D Macià
- Servicio de Microbiología, Hospital Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Spain
| | - Antonio Oliver
- Servicio de Microbiología, Hospital Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Spain
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Roch A, Thomas G, Hraiech S, Papazian L, Powderly WG. Hospital-Acquired, Healthcare-Associated and Ventilator-Associated Pneumonia. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00029-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
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16
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Pneumonia prevention in intubated patients given sucralfate versus proton-pump inhibitors and/or histamine II receptor blockers. J Surg Res 2016; 206:398-404. [PMID: 27884335 DOI: 10.1016/j.jss.2016.08.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/07/2016] [Accepted: 08/04/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a common cause of infectious morbidity and mortality in the intensive care unit (ICU). The type of stress-ulcer prophylaxis (SUP) given to ventilated patients may, in part, be responsible. We observed an increase in VAP as ventilator bundle compliance increased and a decrease in VAP when bundle compliance decreased. We reasoned that SUP which raises gastric pH such as proton-pump inhibitors (PPIs) and histamine II (H2) receptor antagonists as opposed to SUP which does not raise pH such as sucralfate (S) may be responsible and also may alter the causative bacteria. MATERIALS AND METHODS This is a single-center retrospective cohort analysis of all intubated, adult surgical patients admitted to the surgical ICU between January and June during the 3-y period 2012-2014. Demographics, APACHE II, Injury Severity Score, VAP occurrence, culprit bacteria, ventilator days, and ICU days were recorded based on the type of SUP given. RESULTS There were 45 instances of VAP in the 504 study patients, 33 in the PPI/H2 group, and 12 in the S group (P < 0.01). VAP per 1000 ventilator days were 10.2 for PPI/H2 and 3.7 for S (P < 0.01). Culprit bacteria were mostly Pseudomonas, gram-negative bacilli, and methicillin-resistant Staphylococcus aureus in PPI/H2 patients (n = 29) compared with oropharyngeal flora in S patients (n = 6; P < 0.001). CONCLUSIONS There was a substantial difference in VAP occurrence and in the culprit bacteria between S and PPI/H2 treated patients due perhaps to gastric alkalization.
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Using New Technology to Prevent Healthcare-Associated Infection in Pediatric Patients. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2016. [DOI: 10.1007/s40506-016-0068-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Aguilera Xiol E, Li Bassi G, Wyncoll D, Ntoumenopoulos G, Fernandez-Barat L, Marti JD, Comaru T, De Rosa F, Rigol M, Rinaudo M, Ferrer M, Torres A. Tracheal tube biofilm removal through a novel closed-suctioning system: an experimental study. Br J Anaesth 2016; 115:775-83. [PMID: 26475806 DOI: 10.1093/bja/aev340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Tracheal tube biofilm develops during mechanical ventilation. We compared a novel closed-suctioning system vs standard closed-suctioning system in the prevention of tracheal tube biofilm. METHODS Eighteen pigs, on mechanical ventilation for 76 h, with P. aeruginosa pneumonia were randomized to be tracheally suctioned via the KIMVENT* closed-suctioning system (control group) or a novel closed-suctioning system (treatment group), designed to remove tracheal tube biofilm through saline jets and an inflatable balloon. Upon autopsy, two tracheal tube hemi-sections were dissected for confocal and scanning electron microscopy. Biofilm area, maximal and minimal thickness were computed. Biofilm stage was assessed. RESULTS Sixteen animals were included in the final analysis. In the treatment and control group, the mean (sd) pulmonary burden was 3.34 (1.28) and 4.17 (1.09) log cfu gr(-1), respectively (P=0.18). Tracheal tube P. aeruginosa colonization was 5.6 (4.9-6.3) and 6.2 (5.6-6.9) cfu ml(-1) (median and interquartile range) in the treatment and control group, respectively (P=0.23). In the treatment group, median biofilm area was 3.65 (3.22-4.21) log10 μm2 compared with 4.49 (4.27-4.52) log10 μm2 in the control group (P=0.031). In the treatment and control groups, the maximal biofilm thickness was 48.3 (26.7-71.2) µm (median and interquartile range) and 88.8 (43.8-125.7) µm, respectively. The minimal thickness in the treatment and control group was 0.6 (0-4.0) µm and 23.7 (5.3-27.8) µm (P=0.040) (P=0.017). Earlier stages of biofilm development were found in the treatment group (P<0.001). CONCLUSIONS The novel CSS reduces biofilm accumulation within the tracheal tube. A clinical trial is required to confirm these findings and the impact on major outcomes.
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Affiliation(s)
- E Aguilera Xiol
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Mallorca, Spain
| | - G Li Bassi
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Mallorca, Spain University of Barcelona, Barcelona, Spain
| | - D Wyncoll
- Critical Care Unit, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - G Ntoumenopoulos
- Critical Care Unit, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom Physiotherapy Department, Guy's & St Thomas' NHS Foundation Trust, United Kingdom School of Physiotherapy, Australian Catholic University, North Sydney Campus, North Sydney, Australia
| | - L Fernandez-Barat
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Mallorca, Spain
| | - J D Marti
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Mallorca, Spain
| | - T Comaru
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Mallorca, Spain
| | - F De Rosa
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain University of Milan, Milan, Italy
| | - M Rigol
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Mallorca, Spain Department of Cardiology, Hospital Clinic, Barcelona, Spain
| | - M Rinaudo
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Mallorca, Spain
| | - M Ferrer
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Mallorca, Spain University of Barcelona, Barcelona, Spain
| | - A Torres
- Department of Pulmonary and Critical Care Medicine, Division of Animal Experimentation, Thorax Institute, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Mallorca, Spain University of Barcelona, Barcelona, Spain
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Isaiah A, Pereira KD, Correa AG. Tracheal Infections. INFECTIOUS DISEASES IN PEDIATRIC OTOLARYNGOLOGY 2016. [PMCID: PMC7153446 DOI: 10.1007/978-3-319-21744-4_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Infectious processes of the trachea represent a distinct clinical entity with an evolving landscape owing to advances in airway management and vaccination practices. Untreated inflammatory processes of the trachea may present in the form of acute airway obstruction, potentially resulting in significant morbidity and even mortality. Therefore it is important to recognize the cardinal features of some of the common tracheal infectious processes to differentiate them from non-infectious pathology, as the latter is associated with a more indolent course. As with most other infectious processes of the airway, pathogens causing tracheal infection can be bacterial, viral or fungal in nature. Viral etiology represents the most common cause of laryngotracheal infection in a child. Bacterial infections of the trachea are responsible for more significant morbidity, including prolonged hospitalization, need for endotracheal intubation and even an occasional tracheostomy. The current chapter describes the clinical features and microbiology of tracheal infections at large, explores the utility of diagnostic tests, and provides an algorithm for management.
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Björling G, Johansson D, Bergström L, Jalal S, Kohn I, Frostell C, Kalman S. Tolerability and performance of BIP endotracheal tubes with noble metal alloy coating--a randomized clinical evaluation study. BMC Anesthesiol 2015; 15:174. [PMID: 26625869 PMCID: PMC4667467 DOI: 10.1186/s12871-015-0156-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 11/24/2015] [Indexed: 11/12/2022] Open
Abstract
Background Hospital acquired infections worsen the outcome of patients treated in intensive care units and are costly. Coatings with silver or metal alloys may reduce or alter the formation of biofilm on invasive medical devices. An endotracheal tube (ETT) is used to connect the patient to a ventilator and coated tubes have been tested in relation to bacterial colonization and respiratory infection. In the present study, we aimed to evaluate and compare a coated and uncoated ETT for patient symptoms and local tracheal tolerability during short term clinical use. Degree of bacterial colonization was also described. Methods A silver-palladium-gold alloy coating (‘Bactiguard®’Infection Protection, BIP) has been extensively used on urinary tract catheters and lately also on central venous catheters. We performed a randomised, single-blinded, controlled, first in man, post Conformité Européenne (EC) certification and CE marking study, focused on Bactiguard® coated ETTs (BIP ETT). Thirty patients at a tertiary university hospital scheduled for upper abdominal elective surgery with an expected duration of anaesthesia of at least 3 h were randomised; BIP ETT (n = 20) or standard ETT (n = 10). The tolerability was assessed with a modified version of Quality of Life Head and Neck Module, QLQ-H&N35 and by inspection of the tracheal mucosa with a fibre-optic bronchoscope before intubation and at extubation. Adverse Events (AE) and bacterial adherence were also studied. Statistical evaluations were carried out with the Fisher’s Exact Test, the Clopper-Pearson method, as well as a Proportional Odds Model. Results Differences between groups were identified in 2 of 8 patient related symptoms with regard to tolerability by QLQ-H&N35 (cough, p = 0.022 and dry mouth, p = 0.014 in the treatment group.). No mucosal damage was identified with bronchoscopy. A low level of bacterial colonization with normal flora, equal between groups, was seen after short-term of intubation (median 5 h). No serious Adverse Events related to the use of an ETT were observed. The results should be treated with caution due to statistical confounders, a small study size and large inter-individual variability in bacterial adhesion. Conclusions The new device BIP ETT is well tolerated and has good clinical performance during short-term intubation. Studies with larger sample sizes and longer intubation periods (>24 h) in the ICU-setting are needed and can now be planned in order to identify possible differences in clinical outcomes. Trial registration Registered in ClinicalTrials.gov, Registration number: NCT01682486, Date of Registration: August, 30, 2012
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Affiliation(s)
- Gunilla Björling
- The Swedish Red Cross University College, P.O. Box 55676, SE-10215, Stockholm, Sweden. .,Karolinska Institutet, Department of Clinical Sciences, Division of Anaesthesia and Intensive Care, Danderyd Hospital, SE-18288, Stockholm, Sweden.
| | - Dorota Johansson
- Bactiguard AB, Stockholm, Sweden. .,, P.O Box 15, SE-146 21, Tullinge, Sweden.
| | - Linda Bergström
- Bactiguard AB, Stockholm, Sweden. .,, P.O Box 15, SE-146 21, Tullinge, Sweden.
| | - Shah Jalal
- Karolinska Institutet, Division of Clinical Microbiology, Department of Laboratory Medicine, SE-14186, Stockholm, Sweden.
| | - Ivar Kohn
- Department Anesthesia and Intensive Care, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden.
| | - Claes Frostell
- Karolinska Institutet, Department of Clinical Sciences, Division of Anaesthesia and Intensive Care, Danderyd Hospital, SE-18288, Stockholm, Sweden.
| | - Sigridur Kalman
- Department Anesthesia and Intensive Care, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden. .,CLINTEC, Karolinska Institutet, SE-14186, Stockholm, Sweden.
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Tokmaji G, Vermeulen H, Müller MCA, Kwakman PHS, Schultz MJ, Zaat SAJ. Silver-coated endotracheal tubes for prevention of ventilator-associated pneumonia in critically ill patients. Cochrane Database Syst Rev 2015; 2015:CD009201. [PMID: 26266942 PMCID: PMC6517140 DOI: 10.1002/14651858.cd009201.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in intubated and mechanically ventilated patients. Endotracheal tubes (ETTs) appear to be an independent risk factor for VAP. Silver-coated ETTs slowly release silver cations. It is these silver ions that appear to have a strong antimicrobial effect. Because of this antimicrobial effect of silver, silver-coated ETTs could be an effective intervention to prevent VAP in people who require mechanical ventilation for 24 hours or longer. OBJECTIVES Our primary objective was to investigate whether silver-coated ETTs are effective in reducing the risk of VAP and hospital mortality in comparison with standard non-coated ETTs in people who require mechanical ventilation for 24 hours or longer. Our secondary objective was to ascertain whether silver-coated ETTs are effective in reducing the following clinical outcomes: device-related adverse events, duration of intubation, length of hospital and intensive care unit (ICU) stay, costs, and time to VAP onset. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10, MEDLINE, EMBASE, EBSCO CINAHL, and reference lists of trials. We contacted corresponding authors for additional information and unpublished studies. We did not impose any restrictions on the basis of date of publication or language. The date of the last search was October 2014. SELECTION CRITERIA We included all randomized controlled trials (RCTs) and quasi-randomized trials that evaluated the effects of silver-coated ETTs or a combination of silver with any antimicrobial-coated ETTs with standard non-coated ETTs or with other antimicrobial-coated ETTs in critically ill people who required mechanical ventilation for 24 hours or longer. We also included studies that evaluated the cost-effectiveness of silver-coated ETTs or a combination of silver with any antimicrobial-coated ETTs. DATA COLLECTION AND ANALYSIS Two review authors (GT, HV) independently extracted the data and summarized study details from all included studies using the specially designed data extraction form. We used standard methodological procedures expected by The Cochrane Collaboration. We performed meta-analysis for outcomes when possible. MAIN RESULTS We found three eligible randomized controlled trials, with a total of 2081 participants. One of the three included studies did not mention the amount of participants and presented no outcome data. The 'Risk of bias' assessment indicated that there was a high risk of detection bias owing to lack of blinding of outcomes assessors, but we assessed all other domains to be at low risk of bias. Trial design and conduct were generally adequate, with the most common areas of weakness in blinding. The majority of participants were included in centres across North America. The mean age of participants ranged from 61 to 64 years, and the mean duration of intubation was between 3.2 and 7.7 days. One trial comparing silver-coated ETTs versus non-coated ETTs showed a statistically significant decrease in VAP in favour of the silver-coated ETT (1 RCT, 1509 participants; 4.8% versus 7.5%, risk ratio (RR) 0.64, 95% confidence interval (CI) 0.43 to 0.96; number needed to treat for an additional beneficial outcome (NNTB) = 37; low-quality evidence). The risk of VAP within 10 days of intubation was significantly lower with the silver-coated ETTs compared with non-coated ETTs (1 RCT, 1509 participants; 3.5% versus 6.7%, RR 0.51, 95% CI 0.31 to 0.82; NNTB = 32; low-quality evidence). Silver-coated ETT was associated with delayed time to VAP occurrence compared with non-coated ETT (1 RCT, 1509 participants; hazard ratio 0.55, 95% CI 0.37 to 0.84). The confidence intervals for the results of the following outcomes did not exclude potentially important differences with either treatment. There were no statistically significant differences between groups in hospital mortality (1 RCT, 1509 participants; 30.4% versus 26.6%, RR 1.09, 95% CI 0.93 to 1.29; low-quality evidence); device-related adverse events (2 RCTs, 2081 participants; RR 0.65, 95% CI 0.37 to 1.16; low-quality evidence); duration of intubation; and length of hospital and ICU stay. We found no clinical studies evaluating the cost-effectiveness of silver-coated ETTs. AUTHORS' CONCLUSIONS This review provides limited evidence that silver-coated ETT reduces the risk of VAP, especially during the first 10 days of mechanical ventilation.
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Affiliation(s)
- George Tokmaji
- Academic Medical Center, University of AmsterdamDepartment of Medical Microbiology, Center for Infection and Immunity Amsterdam (CINIMA)Meibergdreef 9AmsterdamNetherlands1105 AZ
| | - Hester Vermeulen
- Academic Medical Centre at the University of AmsterdamDepartment of SurgeryMeibergdreef 9AmsterdamNetherlands1100 AZ
- Amsterdam School of Health Professions, University of Applied Sciences AmsterdamFaculty of NursingAmsterdamNetherlands
| | - Marcella CA Müller
- Academic Medical Center, University of AmsterdamDepartment of Intensive CareMeibergdreef 9AmsterdamNetherlands1100 DD
| | - Paulus HS Kwakman
- Academic Medical Center, University of AmsterdamDepartment of Medical Microbiology, Center for Infection and Immunity Amsterdam (CINIMA)Meibergdreef 9AmsterdamNetherlands1105 AZ
| | - Marcus J Schultz
- Academic Medical Center, University of AmsterdamDepartment of Intensive CareMeibergdreef 9AmsterdamNetherlands1100 DD
- Academic Medical Center, University of AmsterdamLaboratory of Experimental Intensive Care and AnesthesiologyMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Sebastian AJ Zaat
- Academic Medical Center, University of AmsterdamDepartment of Medical Microbiology, Center for Infection and Immunity Amsterdam (CINIMA)Meibergdreef 9AmsterdamNetherlands1105 AZ
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Jones DS, McCoy CP, Andrews GP, McCrory RM, Gorman SP. Hydrogel Antimicrobial Capture Coatings for Endotracheal Tubes: A Pharmaceutical Strategy Designed to Prevent Ventilator-Associated Pneumonia. Mol Pharm 2015; 12:2928-36. [PMID: 26111258 DOI: 10.1021/acs.molpharmaceut.5b00208] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This paper presents a novel strategy for the prevention of ventilator-associated pneumonia that involves coating poly(vinyl chloride, PVC) endotracheal tubes (ET) with hydrogels that may be subsequently used to entrap nebulized antimicrobial solutions. Candidate hydrogels were prepared containing a range of ratios of hydroxyethyl methacrylate (HEMA) and methacrylic acid (MAA) from 100:0 to 70:30 using free radical polymerization and, when required, simultaneous attachment to PVC was performed. The mechanical properties, glass transition temperatures, swelling kinetics, uptake of gentamicin from an aqueous medium, and gentamicin release were characterized. Increasing the MAA content of the hydrogels significantly decreased the ultimate tensile strength, % elongation at break, Young's modulus, and increased the glass transition temperature, the swelling ratio, and gentamicin uptake. Microbial (Staphylococcus aureus and Pseudomonas aeruginosa) adherence to control (drug-free) hydrogels was observed; however, while adherence to gentamicin-containing p(HEMA) occurred, no adherence occurred to gentamicin-containing HEMA:MAA copolymers. Antimicrobial persistence of gentamicin-containing hydrogels was examined by determining the zone of inhibition against each microorganism on successive days. Hydrogel composition affected the observed antimicrobial persistence, with the hydrogel composed of 70:30 HEMA:MAA exhibiting >20 days persistence against S. aureus and P. aeruginosa, respectively. To simulate clinical use, the hydrogels (coated onto PVC) were first exposed to a nebulized solution of gentamicin (4 mL, 80 mg for 20 min), and then to nebulized bacteria (4 mL ca. 1×10(9) colony forming units mL(-1), 30 min). Viable bacteria were not observed on the gentamicin-treated p(HEMA: MAA) copolymers, whereas growth was observed on gentamicin-treated p(HEMA). In light of the excellent antimicrobial activity and physicochemical properties, p(HEMA: MAA) copolymers composed of ratios of 80:20 or 70:30 HEMA: MAA were identified as potentially useful coatings of endotracheal tubes to be used in conjunction with the clinical nebulization of gentamicin and designed for the prevention of ventilator-associated pneumonia.
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Affiliation(s)
- David S Jones
- School of Pharmacy, The Queen's University of Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland, United Kingdom
| | - Colin P McCoy
- School of Pharmacy, The Queen's University of Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland, United Kingdom
| | - Gavin P Andrews
- School of Pharmacy, The Queen's University of Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland, United Kingdom
| | - Roisin M McCrory
- School of Pharmacy, The Queen's University of Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland, United Kingdom
| | - Sean P Gorman
- School of Pharmacy, The Queen's University of Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland, United Kingdom
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A 2015 Update on Ventilator-Associated Pneumonia: New Insights on Its Prevention, Diagnosis, and Treatment. Curr Infect Dis Rep 2015; 17:496. [PMID: 26115700 DOI: 10.1007/s11908-015-0496-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Ventilator-associated pneumonia (VAP), an infection of the lower respiratory tract which occurs in association with mechanical ventilation, is one of the most common causes of nosocomial infection in the intensive care unit (ICU). VAP causes significant morbidity and mortality in critically ill patients including increased duration of mechanical ventilation, ICU stay and hospitalization. Current knowledge for its prevention, diagnosis and management is therefore important clinically and is the basis for this review. We discuss recent changes in VAP surveillance nomenclature incorporating ventilator-associated conditions and ventilator-associated events, terms recently proposed by the Centers for Disease Control. To the extent possible, we rely predominantly on data from randomized control trials (RCTs) and meta-analyses.
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Høiby N, Bjarnsholt T, Moser C, Bassi G, Coenye T, Donelli G, Hall-Stoodley L, Holá V, Imbert C, Kirketerp-Møller K, Lebeaux D, Oliver A, Ullmann A, Williams C. ESCMID∗ guideline for the diagnosis and treatment of biofilm infections 2014. Clin Microbiol Infect 2015; 21 Suppl 1:S1-25. [DOI: 10.1016/j.cmi.2014.10.024] [Citation(s) in RCA: 451] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 01/22/2023]
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25
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Loo CY, Lee WH, Young PM, Cavaliere R, Whitchurch CB, Rohanizadeh R. Implications and emerging control strategies for ventilator-associated infections. Expert Rev Anti Infect Ther 2015; 13:379-93. [DOI: 10.1586/14787210.2015.1007045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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26
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May RM, Hoffman MG, Sogo MJ, Parker AE, O'Toole GA, Brennan AB, Reddy ST. Micro-patterned surfaces reduce bacterial colonization and biofilm formation in vitro: Potential for enhancing endotracheal tube designs. Clin Transl Med 2014; 3:8. [PMID: 24739529 PMCID: PMC3996152 DOI: 10.1186/2001-1326-3-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/10/2014] [Indexed: 12/20/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is a leading hospital acquired infection in intensive care units despite improved patient care practices and advancements in endotracheal tube (ETT) designs. The ETT provides a conduit for bacterial access to the lower respiratory tract and a substratum for biofilm formation, both of which lead to VAP. A novel microscopic ordered surface topography, the Sharklet micro-pattern, has been shown to decrease surface attachment of numerous microorganisms, and may provide an alternative strategy for VAP prevention if included on the surface of an ETT. To evaluate the feasibility of this micro-pattern for this application, the microbial range of performance was investigated in addition to biofilm studies with and without a mucin-rich medium to simulate the tracheal environment in vitro. Methods The top five pathogens associated with ETT-related pneumonia, Methicillin-Resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Klebsiella pneumonia, Acinetobacter baumannii, and Escherichia coli, were evaluated for attachment to micro-patterned and un-patterned silicone surfaces in a short-term colonization assay. Two key pathogens, MRSA and Pseudomonas aeruginosa, were evaluated for biofilm formation in a nutrient rich broth for four days and minimal media for 24 hours, respectively, on each surface type. P. aeruginosa was further evaluated for biofilm formation on each surface type in a mucin-modified medium mimicking tracheal mucosal secretions. Results are reported as percent reductions and significance is based on t-tests and ANOVA models of log reductions. All experiments were replicated at least three times. Results Micro-patterned surfaces demonstrated reductions in microbial colonization for a broad range of species, with up to 99.9% (p < 0.05) reduction compared to un-patterned controls. Biofilm formation was also reduced, with 67% (p = 0.12) and 52% (p = 0.05) reductions in MRSA and P. aeruginosa biofilm formation, respectively. Further, a 58% (p < 0.01) reduction was demonstrated on micro-patterned surfaces for P. aeruginosa biofilms under clinically-simulated conditions when compared to un-patterned controls. Conclusions This engineered micro-pattern reduces the colonization and biofilm formation of key VAP-associated pathogens in vitro. Future application of this micro-pattern on endotracheal tubes may prevent or prolong the onset of VAP without the need for antimicrobial agents.
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Affiliation(s)
- Rhea M May
- Sharklet Technologies, Inc., Aurora, 12635 E. Montview Blvd. Suite 155, CO 80045 Aurora, CO USA
| | - Matthew G Hoffman
- Sharklet Technologies, Inc., Aurora, 12635 E. Montview Blvd. Suite 155, CO 80045 Aurora, CO USA
| | - Melinda J Sogo
- Sharklet Technologies, Inc., Aurora, 12635 E. Montview Blvd. Suite 155, CO 80045 Aurora, CO USA
| | - Albert E Parker
- Center for Biofilm Engineering, and the Department of Mathematical Sciences, Montana State University, Bozeman, MT, USA
| | | | - Anthony B Brennan
- Department of Materials Science and Engineering, University of Florida, Gainesville, FL, USA
| | - Shravanthi T Reddy
- Sharklet Technologies, Inc., Aurora, 12635 E. Montview Blvd. Suite 155, CO 80045 Aurora, CO USA
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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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28
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De Souza PR, De Andrade D, Cabral DB, Watanabe E. Endotracheal tube biofilm and ventilator-associated pneumonia with mechanical ventilation. Microsc Res Tech 2014; 77:305-12. [PMID: 24519948 DOI: 10.1002/jemt.22344] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 12/20/2013] [Accepted: 01/24/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To analyze biofilm on internal and external surfaces of endotracheal tubes after their use in critical care patients, and to produce evidence of association between use of the tube, presence of biofilm, and the occurrence of pneumonia. METHODS This was a clinical study performed at the Intensive Care Unit of an emergency hospital in the interior of São Paulo state, Brazil. Data collection involved 30 endotracheal tubes used on adult patients for a period of ≥48 h of mechanical ventilation for scanning electron microscopy. RESULTS Analysis of the biofilm on the 30 tubes by scanning electron microscopy showed various abiotic and biotic structures, predominantly on the internal surface, such as: fibrin network, erythrocytes, leukocytes, cocci, bacilli, and molds, among others. The intubation period of the endotracheal tube for ≥8 days represented one of the risk factors for ventilator-associated pneumonia (RR 7.41, P < 0.001). CONCLUSIONS The presence of the endotracheal tube permits microbial colonization, overall contributing to the development of biofilm and the occurrence of pneumonia.
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Boyer A, Clouzeau B, Bui HN, Vargas F, Hilbert G, Gruson D. Nouvelles techniques pour lutter contre le biofilm de la sonde d’intubation. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0689-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rello J, Afonso E, Lisboa T, Ricart M, Balsera B, Rovira A, Valles J, Diaz E, FADO Project Investigators. A care bundle approach for prevention of ventilator-associated pneumonia. Clin Microbiol Infect 2013; 19:363-9. [DOI: 10.1111/j.1469-0691.2012.03808.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ferrer MCC, Hickok NJ, Eckmann DM, Composto RJ. Antibacterial Biomimetic Hybrid Films. SOFT MATTER 2013; 8:2423-2431. [PMID: 23807896 PMCID: PMC3691068 DOI: 10.1039/c2sm06969e] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
In this work, we present a novel method to prepare a hybrid coating based on dextran grafted to a substrate and embedded with silver nanoparticles (Ag NPs). First, the Ag NPs are synthesized in situ in the presence of oxidized dextran in solution. Second, the oxidized dextran is exposed to an amine functionalized surface resulting in the simultaneous grafting of dextran and the trapping of Ag NPs within the layer. The NP loading is controlled by the concentration of silver nitrate, which is 2 mM (DEX-Ag2) and 5 mM (DEX-Ag5). The dried film thickness increases with silver nitrate concentration from 2 nm for dextran to 7 nm and 12 nm for DEX-Ag2 and DEX-Ag5, respectively. The grafted dextran film displays features with a diameter and height of ~ 50 nm and 2 nm, respectively. For the DEX-Ag2 and DEX-Ag5, the dextran features as well as individual Ag NPs (~ 5 nm) and aggregates of Ag NPs are observed. Larger and more irregular aggregates are observed for DEX-Ag5. Overall, the Ag NPs are embedded in the dextran film as suggested by AFM and UVO studies. In terms of its antimicrobial activity, DEX-Ag2 resists bacterial adhesion to a greater extent than DEX-Ag5, which in turn is better than dextran and silicon. Because these antibacterial hybrid coatings can be grafted to a variety of surfaces, many biomedical applications can be envisioned, ranging from coating implants to catheters.
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Affiliation(s)
- M. Carme Coll Ferrer
- The Institute for Medicine and Engineering, University of Pennsylvania, Philadelphia, PA 19104, US
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, PA 19104, US
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA 19107, US
| | - David M. Eckmann
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, US
- Russell J. Composto Phone: (215)-898-4451; Fax: (215)-573-2128; ; David M. Eckmann Phone: (215)-349-5348; Fax: (215)-349-5078;
| | - Russell J. Composto
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, PA 19104, US
- Russell J. Composto Phone: (215)-898-4451; Fax: (215)-573-2128; ; David M. Eckmann Phone: (215)-349-5348; Fax: (215)-349-5078;
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Politano AD, Campbell KT, Rosenberger LH, Sawyer RG. Use of silver in the prevention and treatment of infections: silver review. Surg Infect (Larchmt) 2013; 14:8-20. [PMID: 23448590 DOI: 10.1089/sur.2011.097] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The use of silver for the treatment of various maladies or to prevent the transmission of infection dates back to at least 4000 b.c.e. Medical applications are documented in the literature throughout the 17th and 18th centuries. The bactericidal activity of silver is well established. Silver nitrate was used topically throughout the 1800 s for the treatment of burns, ulcerations, and infected wounds, and although its use declined after World War II and the advent of antibiotics, Fox revitalized its use in the form of silver sulfadiazine in 1968. METHOD Review of the pertinent English-language literature. RESULTS Since Fox's work, the use of topical silver to reduce bacterial burden and promote healing has been investigated in the setting of chronic wounds and ulcers, post-operative incision dressings, blood and urinary catheter designs, endotracheal tubes, orthopedic devices, vascular prostheses, and the sewing ring of prosthetic heart valves. The beneficial effects of silver in reducing or preventing infection have been seen in the topical treatment of burns and chronic wounds and in its use as a coating for many medical devices. However, silver has been unsuccessful in certain applications, such as the Silzone heart valve. In other settings, such as orthopedic hardware coatings, its benefit remains unproved. CONCLUSION Silver remains a reasonable addition to the armamentarium against infection and has relatively few side effects. However, one should weigh the benefits of silver-containing products against the known side effects and the other options available for the intended purpose when selecting the most appropriate therapy.
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Affiliation(s)
- Amani D Politano
- Department of Surgery, University of Virginia, Charlottesville, Virginia 22908, USA.
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Fernandez JF, Levine SM, Restrepo MI. Technologic advances in endotracheal tubes for prevention of ventilator-associated pneumonia. Chest 2012; 142:231-238. [PMID: 22796845 DOI: 10.1378/chest.11-2420] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) is associated with high morbidity, mortality, and costs. Interventions to prevent VAP are a high priority in the care of critically ill patients requiring mechanical ventilation (MV). Multiple interventions are recommended by evidence-based practice guidelines to prevent VAP, but there is a growing interest in those related to the endotracheal tube (ETT) as the main target linked to VAP. Microaspiration and biofilm formation are the two most important mechanisms implicated in the colonization of the tracheal bronchial tree and the development of VAP. Microaspiration occurs when there is distal migration of microorganisms present in the secretions accumulated above the ETT cuff. Biofilm formation has been described as the development of a network of secretions and attached microorganisms that migrate along the ETT cuff polymer and inside the lumen, facilitating the transfer to the sterile bronchial tree. Therefore, our objective was to review the literature related to recent advances in ETT technologies regarding their impact on the control of microaspiration and biofilm formation in patients on MV, and the subsequent impact on VAP.
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Affiliation(s)
- Juan F Fernandez
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, the University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Stephanie M Levine
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, the University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Marcos I Restrepo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, the University of Texas Health Science Center at San Antonio, San Antonio, TX; Veterans Evidence Based Research Dissemination and Implementation Center (VERDICT), Audie L. Murphy VA Hospital, San Antonio, TX.
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Advanced endotracheal tube biofilm stage, not duration of intubation, is related to pneumonia. J Trauma Acute Care Surg 2012; 72:916-23. [DOI: 10.1097/ta.0b013e3182493a10] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ventilator-associated Pneumonia: The Potential Critical Role of Emergency Medicine in Prevention. J Emerg Med 2012; 42:353-62. [DOI: 10.1016/j.jemermed.2010.05.042] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 12/11/2009] [Accepted: 05/09/2010] [Indexed: 02/07/2023]
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Li X, Yuan Q, Wang L, Du L, Deng L. Silver-coated endotracheal tube versus non-coated endotracheal tube for preventing ventilator-associated pneumonia among adults: a systematic review of randomized controlled trials. J Evid Based Med 2012; 5:25-30. [PMID: 23528117 DOI: 10.1111/j.1756-5391.2012.01165.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the effects of using silver-coated endotracheal tube (ETT) versus non-coated ETT on the incidence of ventilator-associated pneumonia (VAP) and mortality in adult patients. METHOD We searched MEDLINE, the Cochrane Library, EMBASE, and the Chinese Biomedical Literature Database from inception to June 30, 2011. We also retrieved the reference lists of included studies and reviews. Randomized controlled trials (RCTs) comparing silver-coated ETTs versus non-coated ETTs were included. We pooled the results using a random-effect model and conducted subgroup analyses and sensitivity analyses to address the heterogeneity between studies. RESULTS We identified two eligible RCTs with a total of 1630 participants. The studies were of high quality according to Cochrane Collaboration's tool for assessing risk of bias. Compared with non-coated ETTs, silver-coated ETTs resulted in lower incidence of VAP (RR=0.64, 95% CI 0.43 to 0.96), device-related adverse events (RR=0.53, 95% CI 0.32 to 0.88), and microbiologic burden (≥10,000 CFU/mL: 0.64, 0.48 to 0.86; ≥100,000 CFU/mL: 0.62, 0.43 to 0.89). However, there was no significant difference in total mortality (RR=1.14, 95% CI 0.99 to 1.30). CONCLUSION The limited evidence from meta-analysis of two RCTs showed that using silver-coated ETTs reduced the incidence of VAP, microbiologic burden, and device-related adverse events among adult patients. Additional rigorous randomized trials are needed to confirm these findings.
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Affiliation(s)
- Xiao Li
- Chinese Cochrane Centre/ Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China
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Normativa SEPAR: neumonía nosocomial. Arch Bronconeumol 2011; 47:510-20. [DOI: 10.1016/j.arbres.2011.05.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 05/24/2011] [Indexed: 01/18/2023]
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Tokmaji G, Vermeulen H, Müller MCA, Kwakman PHS, Schultz MJ, Zaat SAJ. Silver coated endotracheal tubes for prevention of ventilator-associated pneumonia in critically ill patients. Cochrane Database Syst Rev 2011. [DOI: 10.1002/14651858.cd009201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Kollef MH. Prevention of Nosocomial Pneumonia in the Intensive Care Unit: Beyond the Use of Bundles. Surg Infect (Larchmt) 2011; 12:211-20. [DOI: 10.1089/sur.2010.060] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Marin H. Kollef
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Abstract
PURPOSE OF REVIEW The endotracheal tube (ETT) is the main avenue leading to airway contamination and subsequent ventilator-associated pneumonia (VAP) during mechanical ventilation. A number of modifications to the ETT are available, aimed at reducing the incidence of VAP. We review here available systems and devices, and clinical data regarding their efficacy. RECENT FINDINGS Three main modifications of ETTs have been developed: coating with antimicrobials, adding a suction channel for the removal of oro-pharyngeal secretions, and modifying the design of the cuff. Each of these interventions has been shown to limit bacterial colonization of the distal airways and to decrease the incidence of VAP. Data on their ultimate effect on related clinical outcomes are still lacking. SUMMARY Modifications of ETTs aimed at decreasing the onset of VAP show promising results. However, the lack of a significant effect on outcomes prompts us to use caution before recommending their widespread use.
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Fontenoy C, Kamel S. Silver in the medical devices/equipments: Marketing or real clinical interest? ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.phhp.2010.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Maselli DJ, Restrepo MI. Strategies in the prevention of ventilator-associated pneumonia. Ther Adv Respir Dis 2011; 5:131-41. [PMID: 21300737 DOI: 10.1177/1753465810395655] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) remains a significant problem in the hospital setting, with very high morbidity, mortality, and cost. We performed an evidence-based review of the literature focusing on clinically relevant pharmacological and nonpharmacological interventions to prevent VAP. Owing to the importance of this condition the implementation of preventive measures is paramount in the care of mechanically ventilated patients. There is evidence that these measures decrease the incidence of VAP and improve outcomes in the intensive care unit. A multidisciplinary approach, continued education, and ventilator protocols ensure the implementation of these measures. Future research will continue to investigate cost/benefit relationships, antibiotic resistance, as well as newer technologies to prevent contamination and aspiration in mechanically ventilated patients.
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Affiliation(s)
- Diego J Maselli
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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Raad II, Mohamed JA, Reitzel RA, Jiang Y, Dvorak TL, Ghannoum MA, Hachem RY, Chaftari AM. The prevention of biofilm colonization by multidrug-resistant pathogens that cause ventilator-associated pneumonia with antimicrobial-coated endotracheal tubes. Biomaterials 2011; 32:2689-94. [PMID: 21295343 DOI: 10.1016/j.biomaterials.2010.12.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 12/10/2010] [Indexed: 10/18/2022]
Abstract
Ventilator-associated pneumonia (VAP) continues to be the nosocomial infection associated with the highest mortality in critically ill patients. Since silver-coated endotracheal tubes (ETT) was shown in a multicenter prospective randomized trials to decrease the risk of VAP, we compared the efficacy of two antiseptic agents such as gardine- and gendine-coated ETTs with that of silver-coated ETTs in preventing biofilm. The ETTs were tested for their ability to prevent the biofilm formation of methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, Enterobacter cloacae, and Candida albicans. Scanning electron microscopy studies revealed a heavy biofilm on uncoated and silver-coated ETT but not on the gardine-coated ETT. The gardine and gendine ETTs completely inhibited the formation of biofilms by all organisms tested and were more effective in preventing biofilm growth than the silver ETTs (p < 0.001). The gardine- and gendine-coated ETTs were more durable against MRSA than either the silver-coated or uncoated ETTs for up to 2 weeks (p < 0.0001). We have therefore shown that gardine- and gendine-coated ETTs are superior to silver-coated ETTs in preventing biofilm. Future animal and clinical studies are warranted to determine whether the gardine- and gendine-coated ETTs can significantly reduce the risk of VAP.
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Affiliation(s)
- Issam I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, United States.
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Abstract
OBJECTIVE To describe relevant pathogen-related characteristics and their impact on sepsis pathogenesis and prognosis. DATA SOURCE Current literature regarding genomic bacterial load and virulence factors, with an emphasis on the impact of these factors on pathophysiology and prognosis of sepsis. DATA EXTRACTION AND SYNTHESIS The current paradigm on sepsis pathophysiology and management overlooks aspects concerning the nature and characteristics of the infecting pathogen. Our findings suggest that evaluation of genomic bacterial load might be useful to assess severity and predict prognosis in septic patients; its use during treatment for monitoring clinical response is another interesting potential application. Virulence factors identification might help to develop pathogen-specific therapeutic strategies for higher-risk septic patients. CONCLUSIONS The recognition of the importance of quantifying the pathogen has major clinical implications and will open up a new field of exploration of therapies targeted at anticipating development and appropriate treatment in severe sepsis. The improved detection and understanding of bacterial virulence factors may lead to specific therapies.
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Afessa B, Anzueto AR, Craven DE, Kollef MH. Increased Mortality in Patients Without Ventilator-Associated Pneumonia: Response. Chest 2010. [DOI: 10.1378/chest.10-1724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Alavi MR, Ravizee A, Burgess R, Antonic V, Izadjoo M, Stojadinovic A. Resistance carrying plasmid in a traumatic wound. J Wound Care 2010; 19:306-10. [PMID: 20616773 DOI: 10.12968/jowc.2010.19.7.48904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To isolate and identify antibiotic-resistant bacteria from the exudate of a complex wound and determine if antibiotic resistance genes are chromosomal or plasmid borne. METHOD Antibiotic resistant bacteria from wound exudate of a single clinical sample were selected on agar media with ampicillin. A single colony was further screened for resistance to kanamycin by antibiotic-supplemented agar and to other antibiotics by an automated Phoenix instrument. Identification of the isolate was carried out by biochemical profiling and by 16S rDNA analysis. RESULTS Approximately 51% of total bacteria in the wound exudate with identical colony morphotype were resistant to 100 microg/ml of ampicillin. A single colony from this population also demonstrated resistance to 50 microg/ml of kanamycin on kanamycin-supplemented agar. Further antimicrobial sensitivity testing by the Phoenix instrument indicated resistance to inhibitory concentrations of amoxicillin-clavulanate, ampicillin-sulbactam, cefazolin, gentamicin, nitrofurantoin, tobramycin, and trimethoprim-sulfamethoxazole. Biochemical and 16S rDNA analysis identified this bacterial isolate as a member of genus Enterobacter. A plasmid preparation from this isolate successfully transferred ampicillin and kanamycin resistance to E. coli competent cells. E. coli transformants displayed two resistance phenotypes and the plasmids from these transformants displayed two different restriction type patterns, with one correlating to ampicillin and kanamycin resistance and the other only to ampicillin resistance. CONCLUSION A multiple antibiotic-resistant Enterobacter spp. from the wound fluid of a clinical sample was found to carry an antibiotic-resistant plasmid in a closely related species E. coli. The presence of antibiotic resistance plasmid in Enterobacteria that are part of the normal microbial flora of the human gut and skin could lead to the spread of resistance phenotype and emergence of antibiotic resistant pathogens. This study suggests normal human microbial fl ora could be a potential reservoir for resistance genes.
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Affiliation(s)
- M R Alavi
- Wound Biology and Translational Research Division, Armed Forces Institute of Pathology, Washington DC, USA.
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Recognition and prevention of nosocomial pneumonia in the intensive care unit and infection control in mechanical ventilation. Crit Care Med 2010; 38:S352-62. [PMID: 20647793 DOI: 10.1097/ccm.0b013e3181e6cc98] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Nosocomial pneumonia (NP) is a difficult diagnosis to establish in the critically ill patient due to the presence of underlying cardiopulmonary disorders (e.g., pulmonary contusion, acute respiratory distress syndrome, atelectasis) and the nonspecific radiographic and clinical signs associated with this infection. Additionally, the classification of NP in the intensive care unit setting has become increasingly complex, as the types of patients who develop NP become more diverse. The occurrence of NP is especially problematic as it is associated with a greater risk of hospital mortality, longer lengths of stay on mechanical ventilation and in the intensive care unit, a greater need for tracheostomy, and significantly increased medical care costs. The adverse effects of NP on healthcare outcomes has increased pressure on clinicians and healthcare systems to prevent this infection, as well as other nosocomial infections that complicate the hospital course of patients with respiratory failure. This manuscript will provide a brief overview of the current approaches for the diagnosis of NP and focus on strategies for prevention. Finally, we will provide some guidance on how standardized or protocolized care of mechanically ventilated patients can reduce the occurrence of and morbidity associated with complications like NP.
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Lorente L, Blot S, Rello J. New issues and controversies in the prevention of ventilator-associated pneumonia. Am J Respir Crit Care Med 2010; 182:870-6. [PMID: 20448095 DOI: 10.1164/rccm.201001-0081ci] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
In the past 2 years, American, Canadian, and European scientific societies have published their new evidence-based guidelines for ventilator-associated pneumonia (VAP) prevention. However, these guidelines did not review some potentially useful strategies, such as the use of an endotracheal tube with an ultrathin cuff membrane, an endotracheal tube with a low-volume/low-pressure cuff, a device for continuous monitoring of the endotracheal tube cuff pressure, a device to remove biofilm from the inner site of the endotracheal tube, and saline instillation before tracheal suctioning. Only a few guidelines analyze the time of tracheostomy, and so no firm recommendations can be made regarding its importance. In addition, the guidelines diverge on the use of heat and moisture exchangers or heated humidifiers and on the use of an endotracheal tube coated with antimicrobial agents. The current review focuses on measures of VAP prevention for which there is no clear recommendation, or the use of which is controversial. A review of the literature suggests that the use of an endotracheal tube with an ultrathin and tapered-shape cuff membrane and coated in antimicrobial agents may reduce the risk of VAP. These features offer an attractive way to optimize the VAP prevention capacity of endotracheal tubes with a lumen for subglottic secretion drainage. We believe that early tracheostomy should be considered, based on the length reduction of mechanical ventilation and intensive care unit stay, reduction of mortality, and on patient comfort, although early tracheostomy has not yet been shown to favorably impact the incidence of VAP. We believed that heat and moisture exchangers should be considered based on the benefits in terms of cost savings. More research is necessary to clarify the role of continuous cuff pressure monitoring, removal of biofilm formation in the endotracheal tubes, and routine saline instillation before tracheal suctioning.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
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Afessa B, Shorr AF, Anzueto AR, Craven DE, Schinner R, Kollef MH. Association Between a Silver-Coated Endotracheal Tube and Reduced Mortality in Patients With Ventilator-Associated Pneumonia. Chest 2010; 137:1015-21. [DOI: 10.1378/chest.09-0391] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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