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Sendra E, Fernández-Muñoz A, Zamorano L, Oliver A, Horcajada JP, Juan C, Gómez-Zorrilla S. Impact of multidrug resistance on the virulence and fitness of Pseudomonas aeruginosa: a microbiological and clinical perspective. Infection 2024; 52:1235-1268. [PMID: 38954392 PMCID: PMC11289218 DOI: 10.1007/s15010-024-02313-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/30/2024] [Indexed: 07/04/2024]
Abstract
Pseudomonas aeruginosa is one of the most common nosocomial pathogens and part of the top emergent species associated with antimicrobial resistance that has become one of the greatest threat to public health in the twenty-first century. This bacterium is provided with a wide set of virulence factors that contribute to pathogenesis in acute and chronic infections. This review aims to summarize the impact of multidrug resistance on the virulence and fitness of P. aeruginosa. Although it is generally assumed that acquisition of resistant determinants is associated with a fitness cost, several studies support that resistance mutations may not be associated with a decrease in virulence and/or that certain compensatory mutations may allow multidrug resistance strains to recover their initial fitness. We discuss the interplay between resistance profiles and virulence from a microbiological perspective but also the clinical consequences in outcomes and the economic impact.
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Affiliation(s)
- Elena Sendra
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Passeig Marítim 25-27, 08003, Barcelona, Spain
| | - Almudena Fernández-Muñoz
- Research Unit, University Hospital Son Espases-Health Research Institute of the Balearic Islands (IdISBa), Microbiology Department, University Hospital Son Espases, Crtra. Valldemossa 79, 07010, Palma, Spain
| | - Laura Zamorano
- Research Unit, University Hospital Son Espases-Health Research Institute of the Balearic Islands (IdISBa), Microbiology Department, University Hospital Son Espases, Crtra. Valldemossa 79, 07010, Palma, Spain
| | - Antonio Oliver
- Research Unit, University Hospital Son Espases-Health Research Institute of the Balearic Islands (IdISBa), Microbiology Department, University Hospital Son Espases, Crtra. Valldemossa 79, 07010, Palma, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Pablo Horcajada
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Passeig Marítim 25-27, 08003, Barcelona, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Juan
- Research Unit, University Hospital Son Espases-Health Research Institute of the Balearic Islands (IdISBa), Microbiology Department, University Hospital Son Espases, Crtra. Valldemossa 79, 07010, Palma, Spain.
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | - Silvia Gómez-Zorrilla
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Passeig Marítim 25-27, 08003, Barcelona, Spain.
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
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Amarante ACA, Linck Junior A, Ferrari RAP, Lopes GK, Capobiango JD. Analysis of factors associated with mortality due to sepsis resulting from device-related infections. An Pediatr (Barc) 2024; 101:115-123. [PMID: 38997941 DOI: 10.1016/j.anpede.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/06/2024] [Indexed: 07/14/2024] Open
Abstract
INTRODUCTION Health care-associated infections (HAIs) contribute to morbidity and mortality and to the dissemination of multidrug-resistant organisms. Children admitted to the intensive care unit undergo invasive procedures that increase their risk of developing HAIs and sepsis. The aim of the study was to analyse factors associated with mortality due to sepsis arising from HAIs. PATIENTS AND METHODS We conducted a case-control study in a 7-bed multipurpose paediatric intensive care unit in a tertiary care teaching hospital. The sample consisted of 90 children admitted between January 2014 and December 2018. The case group consisted of patients who died from sepsis associated with the main health care-associated infections; the control group consisted of patients who survived sepsis associated with the same infections. RESULTS Death was associated with age less than or equal to 12 months, presence of comorbidity, congenital disease, recurrent ventilator-associated pneumonia and septic shock. In the multiple regression analysis, heart disease (OR, 12.48; CI 2.55-60.93; P = .002), infection by carbapenem-resistant bacteria (OR, 31.51; CI 4.01-247.25; P = .001), cancer (OR, 58.23; CI 4.54-746.27; P = .002), and treatment with adrenaline (OR, 13.14; CI 1.35-128.02; P = .003) continued to be significantly associated with death. CONCLUSIONS Hospital sepsis secondary to carbapenem-resistant bacteria contributed to a high mortality rate in this cohort. Children with heart disease or neoplasia or who needed vasopressor drugs had poorer outcomes.
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Affiliation(s)
- Ana Cristina Alba Amarante
- Programa de Posgrado en Fisiopatología Clínica y de Laboratorio, Departamento de Patología, Análisis Clínicos y Toxicológicos, Centro de Ciencias de la Salud, Universidad Estatal de Londrina, Londrina-Paraná, Brazil
| | - Arnildo Linck Junior
- Departamento de Pediatría y Cirugía Pediátrica, Centro de Ciencias de la Salud, Universidad Estatal de Londrina, Londrina-Paraná, Brazil
| | | | - Gilselena Kerbauy Lopes
- Departamento de Enfermería, Centro de Ciencias de la Salud, Universidad Estatal de Londrina, Londrina-Paraná, Brazil
| | - Jaqueline Dario Capobiango
- Departamento de Pediatría y Cirugía Pediátrica, Centro de Ciencias de la Salud, Universidad Estatal de Londrina, Londrina-Paraná, Brazil.
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Mo Y, Booraphun S, Li AY, Domthong P, Kayastha G, Lau YH, Chetchotisakd P, Limmathurotsakul D, Tambyah PA, Cooper BS. Individualised, short-course antibiotic treatment versus usual long-course treatment for ventilator-associated pneumonia (REGARD-VAP): a multicentre, individually randomised, open-label, non-inferiority trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:399-408. [PMID: 38272050 DOI: 10.1016/s2213-2600(23)00418-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/09/2023] [Accepted: 11/01/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is associated with increased mortality, prolonged hospitalisation, excessive antibiotic use and, consequently, increased antimicrobial resistance. In this phase 4, randomised trial, we aimed to establish whether a pragmatic, individualised, short-course antibiotic treatment strategy for VAP was non-inferior to usual care. METHODS We did an individually randomised, open-label, hierarchical non-inferiority-superiority trial in 39 intensive care units in six hospitals in Nepal, Singapore, and Thailand. We enrolled adults (age ≥18 years) who met the US Centers for Disease Control and Prevention National Healthcare Safety Network criteria for VAP, had been mechanically ventilated for 48 h or longer, and were administered culture-directed antibiotics. In culture-negative cases, empirical antibiotic choices were made depending on local hospital antibiograms reported by the respective microbiology laboratories or prevailing local guidelines. Participants were assessed until fever resolution for 48 h and haemodynamic stability, then randomly assigned (1:1) to individualised short-course treatment (≤7 days and as short as 3-5 days) or usual care (≥8 days, with precise durations determined by the primary clinicians) via permuted blocks of variable sizes (8, 10, and 12), stratified by study site. Independent assessors for recurrent pneumonia and participants were masked to treatment allocation, but clinicians were not. The primary outcome was a 60-day composite endpoint of death or pneumonia recurrence. The non-inferiority margin was prespecified at 12% and had to be met by analyses based on both intention-to-treat (all study participants who were randomised) and per-protocol populations (all randomised study participants who fulfilled the eligibility criteria, met fitness criteria for antibiotic discontinuation, and who received antibiotics for the duration specified by their allocation group). This study is registered with ClinicalTrials.gov, number NCT03382548. FINDINGS Between May 25, 2018, and Dec 16, 2022, 461 patients were enrolled and randomly assigned to the short-course treatment group (n=232) or the usual care group (n=229). Median age was 64 years (IQR 51-74) and 181 (39%) participants were female. 460 were included in the intention-to-treat analysis after excluding one withdrawal (231 in the short-course group and 229 in the usual care group); 435 participants received the allocated treatment and fulfilled eligibility criteria, and were included in the per-protocol population. Median antibiotic treatment duration for the index episodes of VAP was 6 days (IQR 5-7) in the short-course group and 14 days (10-21) in the usual care group. 95 (41%) of 231 participants in the short-course group met the primary outcome, compared with 100 (44%) of 229 in the usual care group (risk difference -3% [one-sided 95% CI -∞ to 5%]). Results were similar in the per-protocol population. Non-inferiority of short-course antibiotic treatment was met in the analyses, although superiority compared with usual care was not established. In the per-protocol population, antibiotic side-effects occurred in 86 (38%) of 224 in the usual care group and 17 (8%) of 211 in the short-course group (risk difference -31% [95% CI -37 to -25%; p<0·0001]). INTERPRETATION In this study of adults with VAP, individualised shortened antibiotic duration guided by clinical response was non-inferior to longer treatment durations in terms of 60-day mortality and pneumonia recurrence, and associated with substantially reduced antibiotic use and side-effects. Individualised, short-course antibiotic treatment for VAP could help to reduce the burden of side-effects and the risk of antibiotic resistance in high-resource and resource-limited settings. FUNDING UK Medical Research Council; Singapore National Medical Research Council. TRANSLATIONS For the Thai and Nepali translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Yin Mo
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; National University Hospital, Singapore; Infectious Diseases Translational Research Program, National University of Singapore, Singapore.
| | | | - Andrew Yunkai Li
- National University Hospital, Singapore; Infectious Diseases Translational Research Program, National University of Singapore, Singapore
| | | | - Gyan Kayastha
- Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Yie Hui Lau
- Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | | | - Direk Limmathurotsakul
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul Anantharajah Tambyah
- National University Hospital, Singapore; Infectious Diseases Translational Research Program, National University of Singapore, Singapore
| | - Ben S Cooper
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Poulain C, Launey Y, Bouras M, Lakhal K, Dargelos L, Crémet L, Gibaud SA, Corvec S, Seguin P, Rozec B, Asehnoune K, Feuillet F, Roquilly A. Clinical evaluation of the BioFire Respiratory Pathogen Panel for the guidance of empirical antimicrobial therapy in critically ill patients with hospital-acquired pneumonia: A multicenter, quality improvement project. Anaesth Crit Care Pain Med 2024; 43:101353. [PMID: 38355044 DOI: 10.1016/j.accpm.2024.101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/13/2024] [Accepted: 01/14/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND We aimed to determine whether implementing antimicrobial stewardship based on multiplex bacterial PCR examination of respiratory fluid can enhance outcomes of critically ill patients with hospital-acquired pneumonia (HAP). METHODS We conducted a quality improvement study in two hospitals in France. Adult patients requiring invasive mechanical ventilation with a diagnosis of HAP were included. In the pre-intervention period (August 2019 to April 2020), antimicrobial therapy followed European guidelines. In the «intervention» phase (June 2020 to October 2021), treatment followed a multiplex PCR-guided protocol. The primary endpoint was a composite endpoint made of mortality on day 28, clinical cure between days 7 and 10, and duration of invasive mechanical ventilation on day 28. The primary outcome was analyzed with a DOOR strategy. RESULTS A total of 443 patients were included in 3 ICUs from 2 hospitals (220 pre-intervention; 223 intervention). No difference in the ranking of the primary composite outcome was found (DOOR: 50.3%; 95%CI, 49.9%-50.8%). The number of invasive mechanical ventilation-free days at day 28 was 10.0 [0.0; 19.0] in the baseline period and 9.0 [0.0; 20.0] days during the intervention period (p = 0.95). The time-to-efficient antimicrobial treatment was 0.43 ± 1.29 days before versus 0.55 ± 1.13 days after the intervention (p = 0.56). CONCLUSION Implementation of Rapid Multiplex PCR to guide empirical antimicrobial therapy for critically ill patients with HAP was not associated with better outcomes. However, adherence to stewardship was low, and the study may have had limited power to detect a clinically important difference.
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Affiliation(s)
- Cécile Poulain
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 0004, F-44000 Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000, Nantes, France.
| | - Yoann Launey
- Univ Rennes, CHU Rennes, Department of Anaesthesia, Critical Care and Perioperative Medicine, F-35000 Rennes, France
| | - Marwan Bouras
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 0004, F-44000 Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000, Nantes, France
| | - Karim Lakhal
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 0004, F-44000 Nantes, France
| | - Laura Dargelos
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 0004, F-44000 Nantes, France
| | - Lise Crémet
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000, Nantes, France; Nantes Université, CHU Nantes, Service de bactériologie-hygiène, pôle de biologie, Nantes, France
| | - Sophie-Anne Gibaud
- Nantes Université, CHU Nantes, Service de bactériologie-hygiène, pôle de biologie, Nantes, France
| | - Stéphane Corvec
- Nantes Université, CHU Nantes, Service de bactériologie-hygiène, pôle de biologie, Nantes, France
| | - Philippe Seguin
- Univ Rennes, CHU Rennes, Department of Anaesthesia, Critical Care and Perioperative Medicine, F-35000 Rennes, France
| | - Bertrand Rozec
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 0004, F-44000 Nantes, France
| | - Karim Asehnoune
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 0004, F-44000 Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000, Nantes, France
| | - Fanny Feuillet
- Nantes Université, CHU de Nantes, DRI, Département promotion, cellule vigilances, Nantes, France; Nantes Université, CHU de Nantes, DRI, Plateforme de Méthodologie et de Biostatistique, Nantes, France
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 0004, F-44000 Nantes, France; Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000, Nantes, France
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Villaamil A, Han L, Eloy P, Bachelet D, Gennequin M, Jeantrelle C, Moyer JD, Weiss E, Foucrier A. Risk factors of second ventilator-associated pneumonia in trauma patients: a retrospective cohort study. Eur J Trauma Emerg Surg 2023; 49:1981-1988. [PMID: 37031437 DOI: 10.1007/s00068-023-02269-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/02/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Ventilator acquired pneumonia (VAP) is a frequent and serious complication in ICU. Second episodes of VAP are common in trauma patients and may be related to severity of underlying conditions, treatment or bacterial factors of the first VAP. The aim of this study was to identify risk factors of second VAP episodes in trauma injured patients (defined as the development of a new pulmonary infection during or remotely following the first episode). DESIGN This is a single-center, retrospective cohort study of trauma injured patients who underwent a first episode of VAP between January 1, 2013 and December 31, 2020 at Beaujon Hospital. RESULTS A total of 533 patients with a first episode of VAP were analyzed, mostly with head and/or thoracic traumatic injury. A second episode of VAP occurred in one hundred sixty-seven patients (31.3%). The main risk factors found was the degree of hypoxemia at the time of the first episode [PaO2/FiO2 ratio 100-200, OR 3.12 (1.77-5.69); < 100, OR 5.80 (2.70-12.8)] and severe traumatic brain injury characterized by an initial GCS ≤ 8 [OR 1.65 (1.01-2.74)]. CONCLUSION Depth of hypoxemia during the first VAP episode and severity of the initial brain injury are the main risk factors for VAP second episode in trauma injured patients.
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Affiliation(s)
- Alejandro Villaamil
- Department of Anaesthesiology and Critical Care Medecine, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
| | - Lien Han
- Département d'épidémiologieBiostatistiques et Recherche Clinique, Hôpital Bichat, AP-HP Nord, Université de Paris, 75018, Paris, France
| | - Philippine Eloy
- Département d'épidémiologieBiostatistiques et Recherche Clinique, Hôpital Bichat, AP-HP Nord, Université de Paris, 75018, Paris, France
| | - Delphine Bachelet
- Département d'épidémiologieBiostatistiques et Recherche Clinique, Hôpital Bichat, AP-HP Nord, Université de Paris, 75018, Paris, France
| | - Maël Gennequin
- Department of Anaesthesiology and Critical Care Medecine, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Caroline Jeantrelle
- Department of Anaesthesiology and Critical Care Medecine, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Jean-Denis Moyer
- Department of Anaesthesiology and Critical Care Medecine, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care Medecine, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Arnaud Foucrier
- Department of Anaesthesiology and Critical Care Medecine, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
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Daghmouri MA, Dudoignon E, Chaouch MA, Baekgaard J, Bougle A, Leone M, Deniau B, Depret F. Comparison of a short versus long-course antibiotic therapy for ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials. EClinicalMedicine 2023; 58:101880. [PMID: 36911269 PMCID: PMC9995933 DOI: 10.1016/j.eclinm.2023.101880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND For ventilator-associated pneumonia (VAP), the safety of short-course versus long-course antibiotic therapy is still debated, especially regarding documented VAP due to non-fermenting Gram-negative bacilli (NF-GNB). The aim of this meta-analysis was to assess the rates of recurrence and relapse of VAP in patients receiving short-course (≤8 days) and long-course (≥10-15 days) of antibiotic therapy. METHODS The protocol for this study was registered in the PROSPERO database (ID: CRD42022365138). We performed an electronic search of the relevant literature and limited our search to data published from 2000 until September 1, 2022. We searched for randomized controlled trials (RCTs) in the United States National Library of Medicine, Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, National Institutes of Health PubMed/MEDLINE, web of science and Google Scholar databases. The primary endpoint was the recurrence and relapses of VAP, secondary endpoints were 28-day mortality, mechanical ventilation duration, number of extra-pulmonary infections and length of ICU stay. FINDINGS We identified five relevant studies involving 1069 patients (530 patients in the short-course group and 539 patients in the long-course group). The meta-analysis did not reveal any significant difference between short and long-course antibiotic therapy for recurrence and relapses of VAP (odd ratio "OR" = 1.48, 95% confidence intervals (CI) [0.96, 2.28], p = 0.08 and OR = 1.45, 95% CI [0.94, 2.22], p = 0.09, respectively), including those due to NF-GNB (OR = 1.90, 95% CI [0.93, 3.33], p = 0.05 and OR = 1.76, 95% CI [0.93, 3.33], p = 0.08, respectively). No difference was found for 28 days-mortality (OR = 1.24, 95% CI [0.92, 1.67], p = 0.16), mechanical ventilation duration, number of extra-pulmonary infections and length of ICU stay. However, short-course therapy significantly increased the number of antibiotic-free days. INTERPRETATION Our meta-analysis showed that short-course antibiotic therapy did not result in increased number of recurence and relapses of VAP, suggesting that short-course should be preferred to reduce the exposure to antibiotics. FUNDING None.
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Affiliation(s)
- Mohamed Aziz Daghmouri
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
- Corresponding author. Hôpital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France.
| | - Emmanuel Dudoignon
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
| | - Mohamed Ali Chaouch
- Department of Visceral Surgery, University Hospital of Fattouma Bourguiba, Monastir, Tunisia
| | - Josefine Baekgaard
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Adrien Bougle
- Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, Sorbonne University, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Marc Leone
- Service d'anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
- Centre for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Aix Marseille University, Marseille, France
| | - Benjamin Deniau
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- Department of Visceral Surgery, University Hospital of Fattouma Bourguiba, Monastir, Tunisia
| | - François Depret
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
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Factors Affecting Incidence of Ventilator-Associated Pneumonia With Multidrug-Resistant Microbes in Intensive Care Unit. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Bouglé A, Tuffet S, Federici L, Leone M, Monsel A, Dessalle T, Amour J, Dahyot-Fizelier C, Barbier F, Luyt CE, Langeron O, Cholley B, Pottecher J, Hissem T, Lefrant JY, Veber B, Legrand M, Demoule A, Kalfon P, Constantin JM, Rousseau A, Simon T, Foucrier A. Comparison of 8 versus 15 days of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia in adults: a randomized, controlled, open-label trial. Intensive Care Med 2022; 48:841-849. [PMID: 35552788 DOI: 10.1007/s00134-022-06690-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/22/2022] [Indexed: 12/20/2022]
Abstract
PURPOSE Compared to long duration of antibiotic therapy, a short duration has a comparable clinical efficacy for ventilator-associated pneumonia (VAP), with the exception of documented VAP of non-fermenting Gram-negative bacilli (NF-GNB), including Pseudomonas aeruginosa (PA). We aimed to assess the non-inferiority of a short duration of antibiotics (8 days) vs. prolonged antibiotic therapy (15 days) in VAP due to PA (PA-VAP). METHODS We conducted a nationwide, randomized, open-labeled, multicenter, non-inferiority trial to evaluate optimal duration of antibiotic treatment in PA-VAP. Eligible patients were adults with diagnosis of PA-VAP and randomly assigned in 1:1 ratio to receive a short-duration treatment (8 days) or a long-duration treatment (15 days). A pre-specified analysis was used to assess a composite endpoint combining mortality and PA-VAP recurrence rate during hospitalization in the intensive care unit (ICU) within 90 days. RESULTS In intention-to-treat population (n = 186), the percentage of patients who reached the composite endpoint was 25.5% (N = 25/98) in the 15-day group versus 35.2% (N = 31/88) in the 8-day group (difference 9.7%, 90% confidence interval (CI) 0.0-21.2%). The percentage of recurrence of PA-VAP during the ICU stay was 9.2% in the 15-day group versus 17% in the 8-day group. The two groups had similar median days of mechanical ventilation, of ICU stay, number of extra pulmonary infections and acquisition of multidrug-resistant (MDR) pathogens during ICU stay. CONCLUSIONS Our study showed no differences in the composite or separate outcomes (90-day mortality or VAP recurrence) between short- and long-duration treatments for PA-VAP. However, the lack of power limits the interpretation of this study.
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Affiliation(s)
- Adrien Bouglé
- Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, Sorbonne University, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Sophie Tuffet
- Department of Clinical Pharmacology-Clinical Research Platform, Sorbonne University, AP-HP, Paris, France
| | - Laura Federici
- Service de Réanimation Polyvalente, Centre Hospitalier Sud Francilien, Corbeil, France
| | - Marc Leone
- Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesioloy and Critical Care, Sorbonne University, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Thomas Dessalle
- Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, Sorbonne University, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Julien Amour
- Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, Sorbonne University, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Claire Dahyot-Fizelier
- Department of Anaesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
| | - François Barbier
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France
| | - Charles-Edouard Luyt
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Sorbonne University, AP-HP, Paris, France
| | - Olivier Langeron
- Multidisciplinary Intensive Care Unit, Department of Anesthesioloy and Critical Care, Sorbonne University, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Bernard Cholley
- Département d'Anesthésie et Réanimation, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Julien Pottecher
- Anaesthesiology, Critical Care and Perioperative Medicine, Strasbourg University Hospital-EA3072, FMTS, Strasbourg, France
| | - Tarik Hissem
- General Intensive Care Unit, Sud-Essonne Hospital, Étampes, France
| | - Jean-Yves Lefrant
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, Nîmes, France
| | - Benoit Veber
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Rouen University Hospital, Rouen, France
| | - Matthieu Legrand
- Department of Anaesthesiology and Critical Care and Burn Unit, Groupe Hospitalier Lariboisière-Saint Louis, APHP, Paris, France
| | - Alexandre Demoule
- Service de Médecine Intensive Et Réanimation (Département R3S), APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
| | - Pierre Kalfon
- Service de Réanimation Polyvalente, Hôpital Louis Pasteur, CH de Chartres, Chartres, France
| | - Jean-Michel Constantin
- Department of Perioperative Medicine, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Alexandra Rousseau
- Department of Clinical Pharmacology-Clinical Research Platform, Sorbonne University, AP-HP, Paris, France
| | - Tabassome Simon
- Department of Clinical Pharmacology-Clinical Research Platform, Sorbonne University, AP-HP, Paris, France
| | - Arnaud Foucrier
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, Clichy, France
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9
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Shah H, Ali A, Patel AA, Abbagoni V, Goswami R, Kumar A, Velasquez Botero F, Otite E, Tomar H, Desai M, Maiyani P, Devani H, Siddiqui F, Muddassir S. Trends and Factors Associated With Ventilator-Associated Pneumonia: A National Perspective. Cureus 2022; 14:e23634. [PMID: 35494935 PMCID: PMC9051358 DOI: 10.7759/cureus.23634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Ventilator-associated pneumonia (VAP) is a hospital-acquired pneumonia that occurs more than 48 hours after mechanical ventilation. Studies showing temporal trends, predictors, and outcomes of VAP are very limited. Objective: We used the National database to delineate the trends and predictors of VAP from 2009 to 2017. Methods: We analyzed data from the Nationwide Inpatient Sample (NIS) for adult hospitalizations who received mechanical ventilation (MV) by using ICD-9/10-CM procedures codes. We excluded hospitalizations with length of stay (LOS) less than two days. VAP and other diagnoses of interest were identified by ICD-9/10-CM diagnosis codes. We then utilized the Cochran Armitage trend test and multivariate survey logistic regression models to analyze the data. Results: Out of a total of 5,155,068 hospitalizations who received mechanical ventilation, 93,432 (1.81%) developed VAP. Incidence of VAP decreased from 20/1000 in 2008 to 17/1000 in 2017 with a 5% decrease. Patients who developed VAP had lower mean age (59 vs 61; p<0.001) and higher LOS (25 days vs. 12 days; p<0.001). In multivariable regression analysis, we identified that males, African Americans, teaching hospitals and co-morbidities like neurological disorders, pulmonary circulation disorders and electrolyte disorders are associated with the increased odds of developing VAP. VAP was also associated with higher rates of discharge to facilities and increased LOS. Conclusion: Our study identified the trends along with the risk predictors of VAP in MV patients. Our goal is to lay the foundation for further in-depth analysis of this trend for better risk stratification and development of preventive strategies to reduce the incidence of VAP among MV patients.
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Le Pape M, Besnard C, Acatrinei C, Guinard J, Boutrot M, Genève C, Boulain T, Barbier F. Clinical impact of ventilator-associated pneumonia in patients with the acute respiratory distress syndrome: a retrospective cohort study. Ann Intensive Care 2022; 12:24. [PMID: 35290537 PMCID: PMC8922395 DOI: 10.1186/s13613-022-00998-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 02/27/2022] [Indexed: 12/15/2022] Open
Abstract
Background The clinical impact and outcomes of ventilator-associated pneumonia (VAP) have been scarcely investigated in patients with the acute respiratory distress syndrome (ARDS). Methods Patients admitted over an 18-month period in two intensive care units (ICU) of a university-affiliated hospital and meeting the Berlin criteria for ARDS were retrospectively included. The association between VAP and the probability of death at day 90 (primary endpoint) was appraised through a Cox proportional hazards model handling VAP as a delay entry variable. Secondary endpoints included (i) potential changes in the PaO2/FiO2 ratio and SOFA score values around VAP (linear mixed modelling), and (ii) mechanical ventilation (MV) duration, numbers of ventilator- and vasopressor-free days at day 28, and length of stay (LOS) in patients with and without VAP (median or absolute risk difference calculation). Subgroup analyses were performed in patients with COVID-19-related ARDS and those with ARDS from other causes. Results Among the 336 included patients (101 with COVID-19 and 235 with other ARDS), 176 (52.4%) experienced a first VAP. VAP induced a transient and moderate decline in the PaO2/FiO2 ratio without increase in SOFA score values. VAP was associated with less ventilator-free days (median difference and 95% CI, − 19 [− 20; − 13.5] days) and vasopressor-free days (− 5 [− 9; − 2] days) at day 28, and longer ICU (+ 13 [+ 9; + 15] days) and hospital (+ 11.5 [+ 7.5; + 17.5] days) LOS. These effects were observed in both subgroups. Overall day-90 mortality rates were 35.8% and 30.0% in patients with and without VAP, respectively (P = 0.30). In the whole cohort, VAP (adjusted HR 3.16, 95% CI 2.04–4.89, P < 0.0001), the SAPS-2 value at admission, chronic renal disease and an admission for cardiac arrest predicted death at day 90, while the COVID-19 status had no independent impact. When analysed separately, VAP predicted death in non-COVID-19 patients (aHR 3.43, 95% CI 2.11–5.58, P < 0.0001) but not in those with COVID-19 (aHR 1.19, 95% CI 0.32–4.49, P = 0.80). Conclusions VAP is an independent predictor of 90-day mortality in ARDS patients. This condition exerts a limited impact on oxygenation but correlates with extended MV duration, vasoactive support, and LOS. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00998-7.
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Affiliation(s)
- Marc Le Pape
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France.,Réanimation Chirurgicale, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Céline Besnard
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France
| | - Camelia Acatrinei
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France
| | - Jérôme Guinard
- Laboratoire de Bactériologie, Pôle de Biopathologies, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Maxime Boutrot
- Réanimation Chirurgicale, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Claire Genève
- Réanimation Chirurgicale, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Thierry Boulain
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France
| | - François Barbier
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France. .,Centre d'Étude des Pathologies Respiratoires (CEPR), INSERM U1100, Université de Tours, Tours, France.
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11
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Decavèle M, Gault N, Moyer JD, Gennequin M, Allain PA, Foucrier A. Prediction models of methicillin sensitive Staphylococcus aureus ventilator associated pneumonia relapse in trauma and brain injury patients: A retrospective analysis. J Crit Care 2021; 66:20-25. [PMID: 34399115 DOI: 10.1016/j.jcrc.2021.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/14/2021] [Accepted: 07/14/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To describe the incidence and risk factors of methicillin sensitive Staphylococcus aureus ventilator associated pneumonia (MSSA-VAP) relapse in trauma and non-traumatic brain injury patients. MATERIALS AND METHODS Retrospective observational monocentric cohort study of consecutive ICU patients who developed a first episode of MSSA-VAP after trauma and non-traumatic brain injury. MSSA-VAP relapse encompass MSSA-VAP treatment failure (persistence or recurrence of MSSA) or other pathogen - VAP. RESULTS A total of 165 patients (71% of trauma and 29% of non-traumatic brain injury) with MSSA-VAP were included. MSSA-VAP relapse occurred in 54 (33%) patients, including 28 (17%) MSSA-VAP treatment failure and 46 (28%) other pathogen-VAP. Empirical first-line antibiotic therapy was appropriate in 96% of cases. In multivariate analysis, the presence of Streptococcus species (Odds ratio [OR] 7.37) and oropharyngeal flora (OR 3.64) as initial MSSA co-pathogen, suggested aspiration at the time of admission and independently predicted MSSA-VAP treatment failure. Initial Glasgow coma scale (OR 0.89), need for emergent surgery (OR 5.71) and the presence of an acute respiratory distress syndrome at the time of the first MSSA-VAP (3.99), independently predicted the onset of other pathogen - VAP. CONCLUSION Early and simple factors may help to identify patients with high-risk of MSSA-VAP relapse.
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Affiliation(s)
- Maxens Decavèle
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France; Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), F-75013 Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France.
| | - Nathalie Gault
- APHP, Département Epidémiologie Biostatistiques et Recherche Clinique, Hôpital Beaujon, 92110 Clichy, France; INSERM, CIC-EC 1425, Hôpital Bichat, 75018 Paris, France
| | - Jean Denis Moyer
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France
| | - Maël Gennequin
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France
| | - Pierre-Antoine Allain
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France
| | - Arnaud Foucrier
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France
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12
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Mo Y, West TE, MacLaren G, Booraphun S, Li AY, Kayastha G, Lau YH, Chew YT, Chetchotisakd P, Tambyah PA, Limmathurotsakul D, Cooper B. Reducing antibiotic treatment duration for ventilator-associated pneumonia (REGARD-VAP): a trial protocol for a randomised clinical trial. BMJ Open 2021; 11:e050105. [PMID: 33986070 PMCID: PMC8126270 DOI: 10.1136/bmjopen-2021-050105] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICUs). Using short-course antibiotics to treat VAP caused by Gram-negative non-fermenting bacteria has been reported to be associated with excess pneumonia recurrences. The "REducinG Antibiotic tReatment Duration for Ventilator-Associated Pneumonia" (REGARD-VAP) trial aims to provide evidence for using a set of reproducible clinical criteria to shorten antibiotic duration for individualised treatment duration of VAP. METHODS AND ANALYSIS This is a randomised controlled hierarchical non-inferiority-superiority trial being conducted in ICUs across Nepal, Thailand and Singapore. The primary outcome is a composite endpoint of death and pneumonia recurrence at day 60. Secondary outcomes include ventilator-associated events, multidrug-resistant organism infection or colonisation, total duration of antibiotic exposure, mechanical ventilation and hospitalisation. Adult patients who satisfy the US Centers for Disease Control and Prevention National Healthcare Safety Network VAP diagnostic criteria are enrolled. Participants are assessed daily until fever subsides for >48 hours and have stable blood pressure, then randomised to a short duration treatment strategy or a standard-of-care duration arm. Antibiotics may be stopped as early as day 3 if respiratory cultures are negative, and day 5 if respiratory cultures are positive in the short-course arm. Participants receiving standard-of-care will receive antibiotics for at least 8 days. Study participants are followed for 60 days after enrolment. An estimated 460 patients will be required to achieve 80% power to determine non-inferiority with a margin of 12%. All outcomes are compared by absolute risk differences. The conclusion of non-inferiority, and subsequently superiority, will be based on unadjusted and adjusted analyses in both the intention-to-treat and per-protocol populations. ETHICS AND DISSEMINATION The study has received approvals from the Oxford Tropical Research Ethics Committee and the respective study sites. Results will be disseminated to patients, their caregivers, physicians, the funders, the critical care societies and other researchers. TRIAL REGISTRATION NUMBER NCT03382548.
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Affiliation(s)
- Yin Mo
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, National University of Singapore, Singapore
| | - Timothy Eoin West
- International Respiratory and Severe Illness Center, University of Washington, Seattle, Washington, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Graeme MacLaren
- National University Heart Centre, National University Hospital, Singapore
| | - Suchart Booraphun
- Medical Department, Sunpasithiprasong Hospital, Ubon Ratchathani, Thailand
| | - Andrew Yunkai Li
- University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, National University of Singapore, Singapore
| | - Gyan Kayastha
- Patan Hospital, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Yie Hui Lau
- Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Yin Tze Chew
- Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Ploenchan Chetchotisakd
- Department of Medicine,Srinagarind Hospital, Faculty of Medicine and Research and Diagnostic Center for Emerging Infectious Diseases (RCEID), Khon Kaen University, Khon Kaen, Thailand
| | - Paul Anantharajah Tambyah
- University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, National University of Singapore, Singapore
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ben Cooper
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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13
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Koulenti D, Armaganidis A, Arvaniti K, Blot S, Brun-Buisson C, Deja M, De Waele J, Du B, Dulhunty JM, Garcia-Diaz J, Judd M, Paterson DL, Putensen C, Reina R, Rello J, Restrepo MI, Roberts JA, Sjovall F, Timsit JF, Tsiodras S, Zahar JR, Zhang Y, Lipman J. Protocol for an international, multicentre, prospective, observational study of nosocomial pneumonia in intensive care units: the PneumoINSPIRE study. CRIT CARE RESUSC 2021; 23:59-66. [PMID: 38046390 PMCID: PMC10692553 DOI: 10.51893/2021.1.oa5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Nosocomial pneumonia in the critical care setting is associated with increased morbidity, significant crude mortality rates and high health care costs. Ventilator-associated pneumonia represents about 80% of nosocomial pneumonia cases in intensive care units (ICUs). Wide variance in incidence of nosocomial pneumonia and diagnostic techniques used has been reported, while successful treatment remains complex and a matter of debate. Objective: To describe the epidemiology, diagnostic strategies and treatment modalities for nosocomial pneumonia in contemporary ICU settings across multiple countries around the world. Design, setting and patients: PneumoINSPIRE is a large, multinational, prospective cohort study of adult ICU patients diagnosed with nosocomial pneumonia. Participating ICUs from at least 20 countries will collect data on 10 or more consecutive ICU patients with nosocomial pneumonia. Site-specific information, including hospital policies on antibiotic therapy, will be recorded along with patient-specific data. Variables that will be explored include: aetiology and antimicrobial resistance patterns, treatment-related parameters (including time to initiation of antibiotic therapy, and empirical antibiotic choice, dose and escalation or de-escalation), pneumonia resolution, ICU and hospital mortality, and risk factors for unfavourable outcomes. The concordance of ventilator-associated pneumonia diagnosis with accepted definitions will also be assessed. Results and conclusions: PneumoINSPIRE will provide valuable information on current diagnostic and management practices relating to ICU nosocomial pneumonia, and identify research priorities in the field. Trial registration:ClinicalTrials.gov identifier NCT02793141.
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Affiliation(s)
- Despoina Koulenti
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Second Critical Care Department, Attikon University Hospital, Medical School, University of Athens, Athens, Greece
| | - Apostolos Armaganidis
- Second Critical Care Department, Attikon University Hospital, Medical School, University of Athens, Athens, Greece
| | - Kostoula Arvaniti
- Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece
| | - Stijn Blot
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | - Christian Brun-Buisson
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases Mixed Research Unit (French Institute for Medical Research [INSERM], Université de Versailles Saint Quentin Medical School and Institut Pasteur), Paris-Saclay University, Montigny-Le-Bretonneux, France
| | - Maria Deja
- Lumbeck Klinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitatsklinikum Schleswig-Holstein, Campus Lübeck, Universität zu Lübeck, Lübeck, Germany
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Joel M. Dulhunty
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Research and Medical Education, Redcliffe Hospital, Brisbane, QLD, Australia
| | - Julia Garcia-Diaz
- Infectious Diseases Department, Ochsner Clinic Foundation, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland, New Orleans, LA, USA
| | - Matthew Judd
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - David L. Paterson
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Infectious Diseases Unit, Royal Brisbane and Women’s Hospital,Brisbane, QLD, Australia
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Rosa Reina
- Critical Care Department, Hospital San Martin de la Plata, Buenos Aires, Argentina
| | - Jordi Rello
- Clinical Research/Innovation in Pneumonia and Sepsis Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Efermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Clinical Research Department, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
| | - Marcos I. Restrepo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
- Pulmonary and Critical Care Fellowship Program, University of Texas Health Science Center, San Antonio, TX, USA
- Medical Intensive Care Unit, South Texas Veterans Health Care System, Audie L Murphy Division, San Antonio, TX, USA
- INnovation Science in Pulmonary Infections REsearch Network, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
- Pharmacy Department, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Fredrik Sjovall
- Department of Intensive Care and Perioperative Medicine, Skane University Hospital, Malmö, Sweden
| | - Jean-Francois Timsit
- Infection, Antimicrobials, Modelling, Evolution Research Centre, French Institute for Medical Research (INSERM), Université de Paris, Paris, France
- Medical and Infectious Diseases Intensive Care Unit (MI2), Hôpital Bichat, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Jean-Ralph Zahar
- Service de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, Assistance Publique — Hôpitaux de Paris, Bobigny, France
- Infection, Antimicrobials, Modelling, Evolution Research Centre, Unité Mixte de Recherche 1137, Université Paris 13, Sorbonne Paris Cité, Paris, France
| | - Yuchi Zhang
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Anesthesiology and Critical Care Department, Centre Hospitalier Universitaire de Nîmes, University of Montpellier, Nîmes, France
| | - On behalf of the Working Group on Pneumonia of the European Society of Intensive Care Medicine
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Second Critical Care Department, Attikon University Hospital, Medical School, University of Athens, Athens, Greece
- Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece
- Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases Mixed Research Unit (French Institute for Medical Research [INSERM], Université de Versailles Saint Quentin Medical School and Institut Pasteur), Paris-Saclay University, Montigny-Le-Bretonneux, France
- Lumbeck Klinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitatsklinikum Schleswig-Holstein, Campus Lübeck, Universität zu Lübeck, Lübeck, Germany
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Research and Medical Education, Redcliffe Hospital, Brisbane, QLD, Australia
- Infectious Diseases Department, Ochsner Clinic Foundation, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland, New Orleans, LA, USA
- Infectious Diseases Unit, Royal Brisbane and Women’s Hospital,Brisbane, QLD, Australia
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
- Critical Care Department, Hospital San Martin de la Plata, Buenos Aires, Argentina
- Clinical Research/Innovation in Pneumonia and Sepsis Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Efermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Clinical Research Department, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
- Pulmonary and Critical Care Fellowship Program, University of Texas Health Science Center, San Antonio, TX, USA
- Medical Intensive Care Unit, South Texas Veterans Health Care System, Audie L Murphy Division, San Antonio, TX, USA
- INnovation Science in Pulmonary Infections REsearch Network, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
- Pharmacy Department, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Department of Intensive Care and Perioperative Medicine, Skane University Hospital, Malmö, Sweden
- Infection, Antimicrobials, Modelling, Evolution Research Centre, French Institute for Medical Research (INSERM), Université de Paris, Paris, France
- Medical and Infectious Diseases Intensive Care Unit (MI2), Hôpital Bichat, Assistance Publique – Hôpitaux de Paris, Paris, France
- Fourth Department of Internal Medicine, Attikon University Hospital, Athens, Greece
- Service de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, Assistance Publique — Hôpitaux de Paris, Bobigny, France
- Infection, Antimicrobials, Modelling, Evolution Research Centre, Unité Mixte de Recherche 1137, Université Paris 13, Sorbonne Paris Cité, Paris, France
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
- Anesthesiology and Critical Care Department, Centre Hospitalier Universitaire de Nîmes, University of Montpellier, Nîmes, France
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Albin OR, Henig O, Patel TS, Valley TS, Pogue JM, Petty LA, Mills JP, Brancaccio A, Martin ET, Kaye KS. Clinical Implications of Microbiologic Treatment Failure in the Setting of Clinical Cure of Bacterial Pneumonia. Clin Infect Dis 2020; 71:3033-3041. [PMID: 31832641 PMCID: PMC7819508 DOI: 10.1093/cid/ciz1187] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/11/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Microbiologic cure is a common outcome in pneumonia clinical trials, but its clinical significance is incompletely understood. METHODS We conducted a retrospective cohort study of adult patients hospitalized with bacterial pneumonia who achieved clinical cure. Rates of recurrent pneumonia and death were compared between patients with persistent growth of the index pathogen at the time of clinical cure (microbiologic failure) and those with pathogen eradication (microbiologic cure). RESULTS Among 441 patients, 237 experienced microbiologic cure and 204 experienced microbiologic failure. Prevalences of comorbidities, ventilator dependence, and severity of acute illness were similar between groups. Patients with microbiologic failure experienced significantly higher rates of recurrent pneumonia or death following clinical cure than patients with microbiologic cure, controlling for comorbid conditions, severity of acute illness, appropriateness of empiric antibiotics, intensive care unit placement, tracheostomy dependence, and immunocompromised status (90-day multivariable adjusted odds ratio [OR], 1.56; 95% confidence interval [CI], 1.04-2.35). This association was observed among patients with pneumonias caused by Staphylococcus aureus (90-day multivariable adjusted OR, 3.69; 95% CI, 1.73-7.90). A trend was observed among pneumonias caused by nonfermenting gram-negative bacilli, but not Enterobacteriaceae or other pathogens. CONCLUSIONS Microbiologic treatment failure was independently associated with recurrent pneumonia or death among patients with bacterial pneumonia following clinical cure. Microbiologic cure merits further study as a metric to guide therapeutic interventions for patients with bacterial pneumonia.
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Affiliation(s)
- Owen R Albin
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Oryan Henig
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Twisha S Patel
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan, USA
| | - Thomas S Valley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan, USA
| | - Lindsay A Petty
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - John P Mills
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Adamo Brancaccio
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan, USA
| | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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15
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Moir DT, Bowlin NO, Berube BJ, Yabut J, Mills DM, Nguyen GT, Aron ZD, Williams JD, Mecsas J, Hauser AR, Bowlin TL. A Structure-Function-Inhibition Analysis of the Pseudomonas aeruginosa Type III Secretion Needle Protein PscF. J Bacteriol 2020; 202:e00055-20. [PMID: 32601072 PMCID: PMC7925083 DOI: 10.1128/jb.00055-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/19/2020] [Indexed: 01/10/2023] Open
Abstract
The Pseudomonas aeruginosa type III secretion system (T3SS) needle comprised of multiple PscF subunits is essential for the translocation of effector toxins into human cells, facilitating the establishment and dissemination of infection. Mutations in the pscF gene provide resistance to the phenoxyacetamide (PhA) series of T3SS inhibitory chemical probes. To better understand PscF functions and interactions with PhA, alleles of pscF with 71 single mutations altering 49 of the 85 residues of the encoded protein were evaluated for their effects on T3SS phenotypes. Of these, 37% eliminated and 63% maintained secretion, with representatives of both evenly distributed across the entire protein. Mutations in 14 codons conferred a degree of PhA resistance without eliminating secretion, and all but one were in the alpha-helical C-terminal 25% of PscF. PhA-resistant mutants exhibited no cross-resistance to two T3SS inhibitors with different chemical scaffolds. Two mutations caused constitutive T3SS secretion. The pscF allele at its native locus, whether wild type (WT), constitutive, or PhA resistant, was dominant over other pscF alleles expressed from nonnative loci and promoters, but mixed phenotypes were observed in chromosomal ΔpscF strains with both WT and mutant alleles at nonnative loci. Some PhA-resistant mutants exhibited reduced translocation efficiency that was improved in a PhA dose-dependent manner, suggesting that PhA can bind to those resistant needles. In summary, these results are consistent with a direct interaction between PhA inhibitors and the T3SS needle, suggest a mechanism of blocking conformational changes, and demonstrate that PscF affects T3SS regulation, as well as carrying out secretion and translocation.IMPORTANCEP. aeruginosa effector toxin translocation into host innate immune cells is critical for the establishment and dissemination of P. aeruginosa infections. The medical need for new anti-P. aeruginosa agents is evident by the fact that P. aeruginosa ventilator-associated pneumonia is associated with a high mortality rate (40 to 69%) and recurs in >30% of patients, even with standard-of-care antibiotic therapy. The results described here confirm roles for the PscF needle in T3SS secretion and translocation and suggest that it affects regulation, possibly by interaction with T3SS regulatory proteins. The results also support a model of direct interaction of the needle with PhA and suggest that, with further development, members of the PhA series may prove useful as drugs for P. aeruginosa infection.
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Affiliation(s)
| | | | - Bryan J Berube
- Department of Microbiology and Immunology, Northwestern University, Chicago, Illinois, USA
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jaden Yabut
- Microbiotix, Inc., Worcester, Massachusetts, USA
| | | | - Giang T Nguyen
- Tufts Graduate School in Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
| | | | | | - Joan Mecsas
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Alan R Hauser
- Department of Microbiology and Immunology, Northwestern University, Chicago, Illinois, USA
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16
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Shi Y, Huang Y, Zhang TT, Cao B, Wang H, Zhuo C, Ye F, Su X, Fan H, Xu JF, Zhang J, Lai GX, She DY, Zhang XY, He B, He LX, Liu YN, Qu JM. Chinese guidelines for the diagnosis and treatment of hospital-acquired pneumonia and ventilator-associated pneumonia in adults (2018 Edition). J Thorac Dis 2019; 11:2581-2616. [PMID: 31372297 PMCID: PMC6626807 DOI: 10.21037/jtd.2019.06.09] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/19/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Yi Shi
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Yi Huang
- Department of Pulmonary and Critical Care Medicine, Shanghai Changhai hospital, Navy Medical University, Shanghai 200433, China
| | - Tian-Tuo Zhang
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Hui Wang
- Department of Clinical Laboratory Medicine, Peking University People’s Hospital, Beijing 100044, China
| | - Chao Zhuo
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Feng Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Xin Su
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Hong Fan
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jin-Fu Xu
- Department of Pulmonary and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jing Zhang
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Guo-Xiang Lai
- Department of Pulmonary and Critical Care Medicine, Dongfang Hospital, Xiamen University, Fuzhou 350025, China
| | - Dan-Yang She
- Department of Pulmonary and Critical Care Medicine, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xiang-Yan Zhang
- Department of Pulmonary and Critical Care Medicine, Guizhou Provincial People’s Hospital, Guizhou 550002, China
| | - Bei He
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Li-Xian He
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - You-Ning Liu
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie-Ming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Heffernan AJ, Sime FB, Lipman J, Roberts JA. Individualising Therapy to Minimize Bacterial Multidrug Resistance. Drugs 2019; 78:621-641. [PMID: 29569104 DOI: 10.1007/s40265-018-0891-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The scourge of antibiotic resistance threatens modern healthcare delivery. A contributing factor to this significant issue may be antibiotic dosing, whereby standard antibiotic regimens are unable to suppress the emergence of antibiotic resistance. This article aims to review the role of pharmacokinetic and pharmacodynamic (PK/PD) measures for optimising antibiotic therapy to minimise resistance emergence. It also seeks to describe the utility of combination antibiotic therapy for suppression of resistance and summarise the role of biomarkers in individualising antibiotic therapy. Scientific journals indexed in PubMed and Web of Science were searched to identify relevant articles and summarise existing evidence. Studies suggest that optimising antibiotic dosing to attain defined PK/PD ratios may limit the emergence of resistance. A maximum aminoglycoside concentration to minimum inhibitory concentration (MIC) ratio of > 20, a fluoroquinolone area under the concentration-time curve to MIC ratio of > 285 and a β-lactam trough concentration of > 6 × MIC are likely required for resistance suppression. In vitro studies demonstrate a clear advantage for some antibiotic combinations. However, clinical evidence is limited, suggesting that the use of combination regimens should be assessed on an individual patient basis. Biomarkers, such as procalcitonin, may help to individualise and reduce the duration of antibiotic treatment, which may minimise antibiotic resistance emergence during therapy. Future studies should translate laboratory-based studies into clinical trials and validate the appropriate clinical PK/PD predictors required for resistance suppression in vivo. Other adjunct strategies, such as biomarker-guided therapy or the use of antibiotic combinations require further investigation.
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Affiliation(s)
- A J Heffernan
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - F B Sime
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Building 71/918, Herston Rd, Herston, Queensland, 4029, Australia
| | - J Lipman
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Building 71/918, Herston Rd, Herston, Queensland, 4029, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - J A Roberts
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia.
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Building 71/918, Herston Rd, Herston, Queensland, 4029, Australia.
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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18
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Heffernan AJ, Sime FB, Lipman J, Dhanani J, Andrews K, Ellwood D, Grimwood K, Roberts JA. Intrapulmonary pharmacokinetics of antibiotics used to treat nosocomial pneumonia caused by Gram-negative bacilli: A systematic review. Int J Antimicrob Agents 2019; 53:234-245. [DOI: 10.1016/j.ijantimicag.2018.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 11/09/2018] [Accepted: 11/17/2018] [Indexed: 01/31/2023]
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19
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Wongsurakiat P, Tulatamakit S. Clinical pulmonary infection score and a spot serum procalcitonin level to guide discontinuation of antibiotics in ventilator-associated pneumonia: a study in a single institution with high prevalence of nonfermentative gram-negative bacilli infection. Ther Adv Respir Dis 2019; 12:1753466618760134. [PMID: 29506460 PMCID: PMC5941665 DOI: 10.1177/1753466618760134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background We wanted to determine the impact of combined Clinical Pulmonary Infection Score (CPIS) and a spot serum procalcitonin (PCT)-guided protocol to shorten the duration of antibiotic treatment in patients with ventilator-associated pneumonia (VAP), mainly caused by nonfermentative gram-negative bacilli (NF-GNB). Methods Patients with VAP who received appropriate antibiotics for 7 days, temperature ⩽ 37.8°C, without shock, and CPIS ⩽ 6 were allocated to the PCT group or conventional group according to the treating physicians’ decisions. In the PCT group, antibiotics were stopped if the PCT level on day 8 < 0.5 ng/ml. In the conventional group, antibiotics were stopped according to physicians’ discretion. Results There were 24 patients in the PCT group and 26 patients in the conventional group. NF-GNB were responsible for VAP in 79.2% of the PCT group and 65.4% of the conventional group. PCT group had a greater number of antibiotic-free days alive during the 28 days after VAP onset than the conventional group (14.6 ± 5.4 days versus 5.9 ± 5.7 days, respectively; p <.001). In the multivariate, propensity score-adjusted analysis, the PCT group [coefficient = −9.1 (–12.2 to −6); p <.001] and extrapulmonary infections [coefficient = 6.4 (3.3–9.5); p <.001] were independent predictors of total antibiotic exposure days. There was no relapse in both groups. Meanwhile, 12.5% of the PCT group and 26.9% of the conventional group subsequently developed recurrent VAP compatible with superinfections. Conclusions CPIS and a spot serum PCT level appeared effective and safe to guide discontinuation of antibiotic treatment in patients with VAP caused by NF-GNB. Trial registration: TCTR20160726002
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Affiliation(s)
- Phunsup Wongsurakiat
- Division of Respiratory Disease, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok 10700, Thailand
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20
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Sangmuang P, Lucksiri A, Katip W. Factors Associated with Mortality in Immunocompetent Patients with Hospital-acquired Pneumonia. J Glob Infect Dis 2019; 11:13-18. [PMID: 30814830 PMCID: PMC6380105 DOI: 10.4103/jgid.jgid_33_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aim The aim of the study is to determine the factors associated with 28-day mortality in immunocompetent patients with hospital-acquired pneumonia (HAP). Methods This was a 42-month retrospective cohort study in Chiang Kham Hospital. Patients with HAP diagnosed between January 2013 and June 2016 who did not have an immunocompromised status were recruited into the study. Statistical Analysis Used Univariable and multivariable binary logistic regression analyses were performed to determine the factors associated with mortality in patients with HAP. Results A total of 181 HAP patients. The most causative pathogens were nonfermenting Gram-negative bacilli. Fifty-two (28.7%) patients had died within 28 days after HAP diagnosis. Multivariable analysis demonstrated that mechanical ventilation (MV) dependency (adjusted odds ratio [OR] = 3.58, 95% confidence interval [CI] 1.53-8.37, P = 0.003), antibiotic duration (adjusted OR = 0.79, 95% CI 0.70-0.88, P < 0.001), acute kidney injury (adjusted OR = 5.93, 95% CI 1.29-27.22, P = 0.022), and hematologic diseases (adjusted OR = 11.45, 95% CI 1.61-81.50, P = 0.015) were the significant factors associated with 28-day mortality. Conclusions The factors associated with mortality were MV dependency, HAP duration of treatment, acute kidney injury, and hematologic disease. Early recognition of these factors in immunocompetent patients with HAP and treatment with intensive care may improve the outcome.
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Affiliation(s)
- Pavaruch Sangmuang
- Department of Pharmaceutical Care, Faculty of Pharmacy, Graduate School, Chiang Mai University, Chiang Mai, Thailand.,Department of Pharmacy, Chiang Kham Hospital, Phayao, Thailand
| | - Aroonrut Lucksiri
- Department of Pharmaceutical Care Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Wasan Katip
- Department of Pharmaceutical Care Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand.,Pharmaceutical Research Center of Infectious Disease (PRCID), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
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21
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Bickenbach J, Schöneis D, Marx G, Marx N, Lemmen S, Dreher M. Impact of multidrug-resistant bacteria on outcome in patients with prolonged weaning. BMC Pulm Med 2018; 18:141. [PMID: 30126392 PMCID: PMC6102812 DOI: 10.1186/s12890-018-0708-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 08/09/2018] [Indexed: 12/05/2022] Open
Abstract
Background Pneumonia and septic pneumonic shock are the most common indications for long-term mechanical ventilation and prolonged weaning, independent of any comorbidities. Multidrug resistant (MDR) bacteria are emerging as a cause of pneumonia or occur as a consequence of antimicrobial therapy. The influence of MDR bacteria on outcomes in patients with prolonged weaning is unknown. Methods Patients treated in a specialized weaning unit of a university hospital between April 2013 and April 2016 were analyzed. Demographic data, clinical characteristics, length of stay (LOS) in the intensive care unit (ICU) and weaning unit, ventilator-free days and mortality rates were determined in prolonged weaning patients with versus without MDR bacteria (methicillin-resistant Staphylococcus aureus bacteria, [MRSA]; extended spectrum beta lactamase [ESBL]- and Gyrase-producing gram negative bacteria resistant to three of four antibiotic groups [3 MRGN]; panresistant Pseudomonas aeruginosa and other carbapenemase-producing gram-negative bacteria resistant to all four antibiotic groups [4 MRGN]). Weaning failure was defined as death or discharge with invasive ventilation. Results Of 666 patients treated in the weaning unit, 430 fulfilled the inclusion criteria and were included in the analysis. A total of 107 patients had isolates of MDR bacteria suspected as causative pathogens identified during the treatment process. Patients with MDR bacteria had higher SAPS II values at ICU admission and a significantly longer ICU LOS. Four MRGN P. aeruginosa and Acinetobacter baumanii were the most common MDR bacteria identified. Patients with versus without MDR bacteria had significantly higher arterial carbon dioxide levels at the time of weaning admission and a significantly lower rate of successful weaning (23% vs 31%, p < 0.05). Mortality rate on the weaning unit was 12.4% with no difference between the two patient groups. There were no significant differences between patient groups in secondary infections and ventilator-free days. Conclusions In patients with pneumonia or septic pneumonic shock undergoing prolonged weaning, infection with MDR bacteria may influence the weaning success rate but does not appear to impact on patient survival.
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Affiliation(s)
- Johannes Bickenbach
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, D-52074, Aachen, Germany.
| | - Daniel Schöneis
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, D-52074, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, D-52074, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Pneumology, Angiology and Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Sebastian Lemmen
- Department of Infection Control and Infectious Diseases, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Michael Dreher
- Department of Cardiology, Pneumology, Angiology and Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
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22
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Qiao Z, Yu J, Yu K, Zhang M. The benefit of daily sputum suction via bronchoscopy in patients of chronic obstructive pulmonary disease with ventilators: A randomized controlled trial. Medicine (Baltimore) 2018; 97:e11631. [PMID: 30075543 PMCID: PMC6081095 DOI: 10.1097/md.0000000000011631] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 06/28/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To compare the clinical values of bronchoscopic sputum suction and general sputum suction in respiratory failure patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) combined with sequential invasive-noninvasive mechanical ventilation at the pulmonary infection control (PIC) window (period of lower sputum production, with thinner viscosity and lighter color, and alleviated clinical signs of infection). METHODS Patients with AECOPD-induced respiratory failure received orotracheal intubation mechanical ventilation and were randomly divided into bronchoscopic sputum suction group or general sputum suction group, and who were then treated with sequential invasive-noninvasive mechanical ventilation at PIC window (both groups). Baseline data, postoperative blood gas conditions, and postoperative clinical parameters of the patients such as appearance of PIC window, time of invasive ventilation, total time of ventilation, hospital stay, weaning success rate, reintubation rate, ventilator-associated pneumonia (VAP) incidence, and fatality rate were measured to compare the effect of 2 different ways of sputum suction. RESULTS There was no significant difference in baseline characteristics, postoperative blood gas conditions, between 2 groups (all P > .05). Nevertheless, the bronchoscopic sputum suction group showed earlier appearance of PIC window, shorter time of invasive ventilation, total time of ventilation and hospital stay, lower reintubation rate, VAP incidence and fatality rate, and higher weaning success rate than the general sputum suction group (all P < .05). CONCLUSION Bronchoscopic sputum suction combined with sequential invasive-noninvasive mechanical ventilation at PIC window showed clinical effects in treating respiratory failure patients with AECOPD.
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Affiliation(s)
- Zhihao Qiao
- Department of Critical Care Medicine, Guangdong Tongjiang Hospital, Foshan, Guangdong
| | - Jianghong Yu
- Department of Critical Care Medicine, Guangdong Tongjiang Hospital, Foshan, Guangdong
| | - Kai Yu
- Department of Critical Care Medicine, The First Hospital of Quanzhou, Quanzhou, Fujian, China
| | - Mengya Zhang
- Department of Critical Care Medicine, Guangdong Tongjiang Hospital, Foshan, Guangdong
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23
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Montrucchio G, Sales G, Corcione S, De Rosa FG, Brazzi L. Choosing wisely: what is the actual role of antimicrobial stewardship in Intensive Care Units? Minerva Anestesiol 2018; 85:71-82. [PMID: 29991221 DOI: 10.23736/s0375-9393.18.12662-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
More than two-thirds of critically ill patients receive an antimicrobial therapy with a percentage between 30% and 50% of all prescribed antibiotics reported to be unnecessary, inappropriate or misused. Since inappropriate prescription of antibiotic drugs concurs to dissemination of the multidrug resistant organisms, a reasoned antibiotics use is crucial especially in Intensive Care Unit (ICU), where up to 60% of the admitted patients develops an infection during their ICU stay. Even if the concept of antimicrobial stewardship (AS) has been clearly described as a series of coordinated interventions designed to improve antimicrobial agents use, few studies are reporting about its effectiveness to improve outcomes, reduce adverse events and costs and decrease resistance rate spread. Moreover, although it is recognized that AS programs are particularly indicated in the critical setting due to the huge number of antimicrobial drugs used, the optimal characteristics of these interventions and the best system to evaluate their effectiveness are still unclear. Specific interventions, designed tacking into account the peculiarities of the ICU setting, are hence necessary to set-up an "in-ICU-stewardship," including prompt identification of infected patients, selection of appropriate empiric treatments, optimization of dosing and route of administration, improvement of diagnostic techniques, early de-escalation to achieve shorter duration and avoid unnecessary therapies. The present narrative review summarizes the "state of art" about AS programmes and discusses the effects of the interventions possibly applied in ICU setting to optimize the patient's treatment, reduce the micro-organisms resistance and contain the hospital resources utilization.
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Affiliation(s)
| | - Gabriele Sales
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Francesco G De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy.,Department of Anaesthesia, Intensive Care and Emergency, "Città della Salute e della Scienza" Hospital, Turin, Italy
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24
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Garnacho-Montero J, Gutiérrez-Pizarraya A, Lopez-García I, Miranda JC, González-Galán V, Corcia-Palomo Y, Alonso-Araujo I, Martín-Villén L, Aznar-Martín J, Amaya-Villar R. Pneumonia in mechanically ventilated patients: no diagnostic and prognostic value of different quantitative tracheal aspirates thresholds. Infect Dis (Lond) 2017; 50:44-51. [PMID: 28776434 DOI: 10.1080/23744235.2017.1362110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Diagnosis of pneumonia in ventilated patients is challenging due to the lack of specific and definitive clinical symptoms, laboratory data or radiological abnormalities. METHODS Based on quantitative tracheal aspirate (QTA) results, three groups of patients were compared: <105 cfu/ml, ≥105 cfu/ml and <106 cfu/ml, and ≥106 cfu/ml. We recorded demographic variables, underlying diseases and severity of illness at ICU admission. On the day of pneumonia diagnosis, we registered temperature, leukocyte count, C-reactive protein, Sequential Organ Failure Assessment (SOFA) score, clinical pulmonary infection score (CPIS) and adequacy of empirical antimicrobial therapy. RESULTS In 231 episodes, clinical presentation, laboratory data, severity of illness, CPIS, the presence of bacteremia and radiological score did not differ among the three groups. ICU and hospital mortalities were also similar in the three groups. Factors independently associated with in-hospital mortality were age, SOFA score and inappropriate antimicrobial therapy. The bacterial burden in the QTA was not included in the model. CONCLUSIONS Quantification of tracheal aspirate samples may not be necessary in ventilated patients clinically suspected of having nosocomial pneumonia.
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Affiliation(s)
- J Garnacho-Montero
- a Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen Macarena , Sevilla , Spain.,b Instituto de Biomedicina de Sevilla (IBIS) , Seville , Spain
| | - A Gutiérrez-Pizarraya
- b Instituto de Biomedicina de Sevilla (IBIS) , Seville , Spain.,c Infectious Disease, Microbiology and Preventive medicine Clinical Unit , Virgen Macarena University Hospital , Seville , Spain
| | - I Lopez-García
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - J C Miranda
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - V González-Galán
- e Infectious Disease, Microbiology and Preventive medicine Clinical Unit , Virgen del Rocío University Hospital , Seville , Spain
| | - Y Corcia-Palomo
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - I Alonso-Araujo
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - L Martín-Villén
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
| | - J Aznar-Martín
- e Infectious Disease, Microbiology and Preventive medicine Clinical Unit , Virgen del Rocío University Hospital , Seville , Spain
| | - R Amaya-Villar
- d Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen del Rocío , Seville , Spain
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Bouglé A, Foucrier A, Dupont H, Montravers P, Ouattara A, Kalfon P, Squara P, Simon T, Amour J. Impact of the duration of antibiotics on clinical events in patients with Pseudomonas aeruginosa ventilator-associated pneumonia: study protocol for a randomized controlled study. Trials 2017; 18:37. [PMID: 28114979 PMCID: PMC5260072 DOI: 10.1186/s13063-017-1780-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 01/02/2017] [Indexed: 11/16/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) accounts for 25% of infections in intensive care units. Compared to a long duration (LD) of antibiotic therapy, a short duration (SD) has a comparable clinical efficacy with less antibiotic use and less multidrug-resistant (MDR) pathogen emergence, with the exception of documented VAP of non-fermenting Gram-negative bacilli (NF-GNB), including Pseudomonas aeruginosa (PA). These results have led the American Thoracic Society to recommend SD therapy for VAP, except for PA-VAP. Thus the beneficial effect of SD therapy in PA-VAP is still a matter of debate. We aimed to assess the non-inferiority of a short duration of antibiotics (8 days) versus prolonged antibiotic therapy (15 days) in PA-VAP. Methods/design The impact of the duration of antibiotics on clinical events in patients with Pseudomonas aeruginosa ventilator-associated pneumonia (iDIAPASON) trial is a randomized, open-labeled non-inferiority controlled trial, conducted in 34 French intensive care units (ICUs), comparing two groups of patients with PA-VAP according to the duration (8 days or 15 days) of effective antibiotic therapy against PA. The primary outcome is a composite endpoint combining day 90 mortality and PA-VAP recurrence rate during hospitalization in the ICU. Furthermore, durations of mechanical ventilation and hospitalization, as well as number and types of extrapulmonary infections or acquisition of MDR pathogens during the hospitalization in the ICU will be recorded. Recurrence with predefined criteria (clinical suspicion of VAP associated with a positive quantitative culture of a respiratory sample) will be evaluated by two independent experts. Discussion Demonstrating that an SD (8 days) versus LD (15 days) therapy strategy in PA-VAP treatment is safe and not associated with an increased mortality or recurrence rate could lead to a change in practices and guidelines in the management of antibiotic therapy of this frequent ICU complication. This strategy could lead to decreased antibiotic exposure during hospitalization in the ICU and in turn reduce the acquisition and the spread of MDR pathogens. Trial registration ClinicalTrials.gov: NCT02634411. Registered on 19 November 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1780-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adrien Bouglé
- Department of Anesthesiology and Critical Care, CHU La Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.
| | - Arnaud Foucrier
- Department of Anesthesiology and Critical Care, Hôpital Beaujon, APHP, Paris, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care, CHU Amiens, Amiens, France.,Université de Picardie Jules Verne, Amiens, France
| | - Philippe Montravers
- Department of Anesthesiology and Critical Care, CHU Bichat, APHP, Paris, France.,Université Diderot, Paris, France
| | - Alexandre Ouattara
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Sud, Pessac, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - Pierre Kalfon
- Intensive Care Unit, Hôpital Louis Pasteur, CH de Chartres, Chartres, France
| | - Pierre Squara
- Intensive Care Unit, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Tabassome Simon
- Unité de Recherche Clinique du GH HUEP (URC-Est), Hôpital Saint-Antoine, APHP, Paris, France.,UPMC - Sorbonne universités (Paris 6), Paris, France
| | - Julien Amour
- Department of Anesthesiology and Critical Care, CHU La Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.,UPMC - Sorbonne universités (Paris 6), Paris, France
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Patil HV, Patil VC. Incidence, bacteriology, and clinical outcome of ventilator-associated pneumonia at tertiary care hospital. J Nat Sci Biol Med 2017; 8:46-55. [PMID: 28250674 PMCID: PMC5320823 DOI: 10.4103/0976-9668.198360] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Ventilator-associated pneumonia (VAP) is the most frequent Intensive Care Unit acquired infection. Aims: The aim is to determine the incidence, bacteriology and factors affecting VAP and to determine the multi-drug resistant (MDR) pathogens. Settings and Design: This was a prospective observational study conducted over a period of 1 year from April 1, 2011, to March 31, 2012. Materials and Methods: The patients fulfilling criteria of VAP were included in this study. Statistical Analysis: This was performed using SPSS trial version 11.0 software (SPSS Inc., Chicago, Illinois, USA) and the values of P < 0.05 were considered statistically significant. Results: Totally 74 (27.71%) patients were developed VAP. Of total 74 patients with VAP 53 (71.62%) were females and 21 (28.37%) were females (P < 0.0001). Total 13 (17.56%) patients had early-onset VAP and 61 (82.43%) had late-onset VAP (P < 0.0001). The overall incidence of VAP rate per 1000 ventilator days was 39.59. Total 126 bacterial isolates found in 74 patients with VAP. Predominant isolates were Gram-negative 52 (70.27%). Total 41 (55.40%) patients had polymicrobial VAP, and 33 (44.59%) had single isolate. Total 55 (43.65%) isolates were MDR organisms. Total 22 patients with VAP succumbed during treatment with overall case fatality rate of 29.72%. Of total 55 MDR isolates in VAP, 13 (26.63%) were Klebsiella spp., 11(20%) Pseudomonas aeruginosa, 14 (25.45%) Acinetobacter, 8 (14.54%) Escherichia coli, and 9 (16.36%) coagulase positive Staphylococcus aureus. Total 12 (21.41%) patients succumbed among MDR isolates. Conclusions: There was a high incidence of MDR pathogens in late-onset VAP. The Gram-negative organisms Klebsiella, PseudomonasE. coli and Acinetobacter were the most commonly isolated organisms with high mortality rates.
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Affiliation(s)
- Harsha V Patil
- Department of Microbiology, Krishna Institute of Medical Sciences University, Satara, Maharashtra, India
| | - Virendra C Patil
- Department of Medicine, Krishna Institute of Medical Sciences University, Satara, Maharashtra, India
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Mao Z, Gao L, Wang G, Liu C, Zhao Y, Gu W, Kang H, Zhou F. Subglottic secretion suction for preventing ventilator-associated pneumonia: an updated meta-analysis and trial sequential analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:353. [PMID: 27788682 PMCID: PMC5084404 DOI: 10.1186/s13054-016-1527-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/10/2016] [Indexed: 12/29/2022]
Abstract
Background Potential benefits of subglottic secretion suction for preventing ventilator-associated pneumonia (VAP) are not fully understood. Methods We searched Cochrane Central, PubMed, and EMBASE up to March 2016 to identify randomized controlled trials (RCTs) that compared subglottic secretion suction versus non-subglottic secretion suction in adults with mechanical ventilation. Meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. The primary outcome was incidence of VAP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the level of evidence. Results Twenty RCTs (N = 3544) were identified. Subglottic secretion suction was associated with reduction of VAP incidence in four high quality trials (relative risk (RR) 0.54, 95 % confidence interval (CI) 0.40–0.74; p < 0.00001) and in all trials (RR = 0.55, 95 % CI 0.48– 0.63; p < 0.00001). Sensitivity analyses did not show differences in the pooled results. Additionally, the results of the above-mentioned analyses were confirmed in TSA. GRADE level was high. Subglottic secretion suction significantly reduced incidence of early onset VAP, gram-positive or gram-negative bacteria causing VAP, and duration of mechanical ventilation. It delayed the time-to-onset of VAP. However, no significant differences in late onset VAP, intensive care unit (ICU) mortality, hospital mortality, or ICU length of stay were found. Conclusions Subglottic secretion suction decreased VAP incidence and duration of mechanical ventilation and delayed VAP onset. However, subglottic secretion suction did not reduce mortality and length of ICU stay. Subglottic secretion suction is recommended for preventing VAP and for reducing ventilation length, especially in the population at high risk of early onset VAP. Trial registration A protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42015015715); registered on 5 January 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1527-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhi Mao
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Ling Gao
- Department of Cardiovascular Surgery, Institute of Cardiac Surgery, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Guoqi Wang
- Department of Orthopaedics Chinese, People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Chao Liu
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Yan Zhao
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Wanjie Gu
- Department of Anesthesiology, Drum Tower Hospital, Medical College of Nanjing University, Nanjing, China
| | - Hongjun Kang
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Feihu Zhou
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China.
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Ranzani OT, Prina E, Torres A. Nosocomial pneumonia in the intensive care unit: how should treatment failure be predicted? Rev Bras Ter Intensiva 2016; 26:208-11. [PMID: 25295815 PMCID: PMC4188457 DOI: 10.5935/0103-507x.20140032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 07/18/2014] [Indexed: 11/20/2022] Open
Affiliation(s)
- Otavio T Ranzani
- Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Espanha
| | - Elena Prina
- Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Espanha
| | - Antoni Torres
- Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Espanha
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Yalçınsoy M, Salturk C, Takır HB, Kutlu SB, Oguz A, Aksoy E, Balcı M, Kargın F, Mocin OY, Adıguzel N, Gungor G, Karakurt Z. Case fatality rate related to nosocomial and ventilator-associated pneumonia in an ICU: a single-centre retrospective cohort study. Wien Klin Wochenschr 2015; 128:95-101. [PMID: 26542131 DOI: 10.1007/s00508-015-0884-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 10/12/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nosocomial pneumonia (NP) and ventilator associated pneumonia (VAP) have been associated with financially significant economic burden and increased case fatality rate in adult intensive care units (ICUs). This study was designed to evaluate case fatality rate among patients with NP and VAP in a respiratory ICU. METHODS In 2008-2013, VAP and NP in the ICUs were included in this retrospective single-centre cohort study. Data on demographics, co-morbidities, severity of illness, mechanical ventilation, empirical treatment, length of hospital stay and laboratory findings were recorded in each group, as were case fatality rate during ICU admission and after discharge including short-term (28-day) and long-term (a year) case fatality rate. RESULTS A total of 108 patients with VAP (n = 64, median (IQR) age: 70 (61-75) years, 67.2% were men) or NP (n = 44, median (IQR) age: 68 (62-74) years, 68.2% were men) were found. Appropriate empirical antibiotic therapy was identified only in 45.2 and 42.9% of patients with VAP and NP, respectively. Overall case fatality rate in VAP and NP (81.3 vs 84.1), ICU case fatality rate (42.2 vs 45.5%), short-term case fatality rate (15.6 vs 27.3%) and long-term case fatality rate (23.4 vs 11.4%) were similar between VAP and NP groups along with occurrence 50% of case fatality rate cases in the first 2 months and 90% within the first year of discharge. Multivariate analysis showed that chronic obstructive pulmonary disease (COPD) (HR: 3.15, 95% CI: 1.06-9.38; p = 0.039) and presence of septic shock (HR: 3.83, 95% CI: 1.26-11.60; p = 0.018) were independently associated with lower survival. CONCLUSION In conclusion, our findings in a retrospective cohort of respiratory ICU patients with VAP or NP revealed high ICU, short- and long-term case fatality rates within 1 year of diagnosis, regardless of the diagnosis of NP after 48 h of initial admission or after induction of ventilator support. COPD and presence of septic shock are associated with high fatality rate and our findings speculate that as increasing compliance with infection control programs and close monitoring especially in 2 months of discharge might reduce high-case fatality rate in patients with VAP and NP.
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Affiliation(s)
- Murat Yalçınsoy
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey.
| | - Cuneyt Salturk
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey
| | - Hurıye Berk Takır
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey
| | - Semra Batı Kutlu
- Infectious clinic, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ayşegul Oguz
- Nurse department, Infectious clinic, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Emine Aksoy
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey
| | - Merih Balcı
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey
| | - Feyza Kargın
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey
| | - Ozlem Yazıcıoglu Mocin
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey
| | - Nalan Adıguzel
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey
| | - Gokay Gungor
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey
| | - Zuhal Karakurt
- Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, bağlarbaşı mah. Atatürk cad. maral sok. yunus emre apt. No: 7/7 Maltepe, Istanbul, Turkey
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Aliberti S, Ramirez J, Cosentini R, Valenti V, Voza A, Rossi P, Stolz D, Legnani D, Pesci A, Richeldi L, Peyrani P, Massari FM, Blasi F. Acute myocardial infarction versus other cardiovascular events in community-acquired pneumonia. ERJ Open Res 2015; 1:00020-2015. [PMID: 27730139 PMCID: PMC5005139 DOI: 10.1183/23120541.00020-2015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/21/2015] [Indexed: 11/29/2022] Open
Abstract
The aim of the present study was to define the prevalence, characteristics, risk factors and impact on clinical outcomes of acute myocardial infarction (AMI) versus other cardiovascular events (CVEs) in patients with community-acquired pneumonia (CAP). This was an international, multicentre, observational, prospective study of CAP patients hospitalised in eight hospitals in Italy and Switzerland. Three groups were identified: those without CVEs, those with AMI and those with other CVEs. Among 905 patients, 21 (2.3%) patients experienced at least one AMI, while 107 (11.7%) patients experienced at least one other CVE. Patients with CAP and either AMI or other CVEs showed a higher severity of the disease than patients with CAP alone. Female sex, liver disease and the presence of severe sepsis were independent predictors for the occurrence of AMI, while female sex, age >65 years, neurological disease and the presence of pleural effusion predicted other CVEs. In-hospital mortality was significantly higher among those who experienced AMI in comparison to those experiencing other CVEs (43% versus 21%, p=0.039). The presence of AMI showed an adjusted odds ratio for in-hospital mortality of 3.57 (p=0.012) and for other CVEs of 2.63 (p=0.002). These findings on AMI versus other CVEs as complications of CAP may be important when planning interventional studies on cardioprotective medications. Acute myocardial infarction is associated with specific risk factors and accounts for worse outcomes in CAP patientshttp://ow.ly/QhT2t
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Affiliation(s)
- Stefano Aliberti
- Health Science Department, University of Milan Bicocca, Respiratory Unit, AO San Gerardo, Monza, Italy
| | - Julio Ramirez
- Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Roberto Cosentini
- Emergency Medicine Unit, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milan, Italy
| | - Vincenzo Valenti
- Pulmonary Unit, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Paolo Rossi
- Internal Medicine Department, Azienda Ospedaliero-Universitaria "S. Maria della Misericordia", Udine, Italy
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Delfino Legnani
- Department of Biomedical and Clinical Sciences, University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Alberto Pesci
- Health Science Department, University of Milan Bicocca, Respiratory Unit, AO San Gerardo, Monza, Italy
| | - Luca Richeldi
- National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK; Centre for Rare Lung Disease, University of Modena and Reggio Emilia, AO Policlinico, Modena, Italy
| | - Paula Peyrani
- Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Fernando Maria Massari
- UOC Malattie Cardiovascolari, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milan, Italy
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Pugh R, Grant C, Cooke RPD, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev 2015; 2015:CD007577. [PMID: 26301604 PMCID: PMC7025798 DOI: 10.1002/14651858.cd007577.pub3] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pneumonia is the most common hospital-acquired infection affecting patients in the intensive care unit (ICU). However, current national guidelines for the treatment of hospital-acquired pneumonia (HAP) are several years old and the diagnosis of pneumonia in mechanically ventilated patients (VAP) has been subject to considerable recent attention. The optimal duration of antibiotic therapy for HAP in the critically ill is uncertain. OBJECTIVES To assess the effectiveness of short versus prolonged-course antibiotics for HAP in critically ill adults, including patients with VAP. SEARCH METHODS We searched CENTRAL (2015, Issue 5), MEDLINE (1946 to June 2015), MEDLINE in-process and other non-indexed citations (5 June 2015), EMBASE (2010 to June 2015), LILACS (1982 to June 2015) and Web of Science (1955 to June 2015). SELECTION CRITERIA We considered all randomised controlled trials (RCTs) comparing a fixed 'short' duration of antibiotic therapy with a 'prolonged' course for HAP (including patients with VAP) in critically ill adults. DATA COLLECTION AND ANALYSIS Two review authors conducted data extraction and assessment of risk of bias. We contacted trial authors for additional information. MAIN RESULTS We identified six relevant studies involving 1088 participants. This included two new studies published after the date of our previous review (2011). There was substantial variation in participants, in the diagnostic criteria used to define an episode of pneumonia, in the interventions and in the reported outcomes. We found no evidence relating to patients with a high probability of HAP who were not mechanically ventilated. For patients with VAP, overall a short seven- or eight-day course of antibiotics compared with a prolonged 10- to 15-day course increased 28-day antibiotic-free days (two studies; N = 431; mean difference (MD) 4.02 days; 95% confidence interval (CI) 2.26 to 5.78) and reduced recurrence of VAP due to multi-resistant organisms (one study; N = 110; odds ratio (OR) 0.44; 95% CI 0.21 to 0.95), without adversely affecting mortality and other recurrence outcomes. However, for cases of VAP specifically due to non-fermenting Gram-negative bacilli (NF-GNB), recurrence was greater after short-course therapy (two studies, N = 176; OR 2.18; 95% CI 1.14 to 4.16), though mortality outcomes were not significantly different. One study found that a three-day course of antibiotic therapy for patients with suspected HAP but a low Clinical Pulmonary Infection Score (CPIS) was associated with a significantly lower risk of superinfection or emergence of antimicrobial resistance, compared with standard (prolonged) course therapy. AUTHORS' CONCLUSIONS On the basis of a small number of studies and appreciating the lack of uniform definition of pneumonia, we conclude that for patients with VAP not due to NF-GNB a short, fixed course (seven or eight days) of antibiotic therapy appears not to increase the risk of adverse clinical outcomes, and may reduce the emergence of resistant organisms, compared with a prolonged course (10 to 15 days). However, for patients with VAP due to NF-GNB, there appears to be a higher risk of recurrence following short-course therapy. These findings do not differ from those of our previous review and are broadly consistent with current guidelines. There are few data from RCTs comparing durations of therapy in non-ventilated patients with HAP, but on the basis of a single study, short-course (three-day) therapy for HAP appears not to be associated with worse clinical outcome, and may reduce the risk of subsequent infection or the emergence of resistant organisms when there is low probability of pneumonia according to the CPIS.
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Affiliation(s)
- Richard Pugh
- Glan Clwyd HospitalDepartment of AnaestheticsRhylDenbighshireUKLL18 5UJ
| | - Chris Grant
- University Hospital AintreeDepartment of Critical CareLower LaneLiverpoolMerseysideUKL9 7AL
| | - Richard PD Cooke
- Alder Hey Children's NHS Foundation TrustDepartment of MicrobiologyEaton RoadWest DerbyLiverpoolMerseysideUKL12 2AP
| | - Ged Dempsey
- University Hospital AintreeDepartment of Critical CareLower LaneLiverpoolMerseysideUKL9 7AL
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Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:480. [PMID: 25405992 PMCID: PMC4281952 DOI: 10.1186/s13054-014-0480-6] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.
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Tedja R, Nowacki A, Fraser T, Fatica C, Griffiths L, Gordon S, Isada C, van Duin D. The impact of multidrug resistance on outcomes in ventilator-associated pneumonia. Am J Infect Control 2014; 42:542-5. [PMID: 24630700 DOI: 10.1016/j.ajic.2013.12.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 12/09/2013] [Accepted: 12/09/2013] [Indexed: 10/25/2022]
Abstract
Multidrug-resistant (MDR) organisms in ventilator-associated pneumonia were found in 49 of 107 patients and were associated with home antibiotics, pre-ventilator-associated pneumonia hospital stay, and health care exposure. Overall, MDR organisms were associated with increased mortality (P = .006). On multivariate analysis, MDR status was modulated by organism class. In nonfermenting gram-negative rods, no association between MDR and mortality was found, but, in all other organisms, MDR was associated with increased mortality risk (hazard ratio, 6.15; 95% confidence interval: 1.80-21.05, P = .004).
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Timsit JF, Chemam S, Voiriot G, Mariotte E, Mourvillier B, Soubirou JF, Neuville M, Sonneville R, Bouadma L, Wolff M. Optimisation de la durée de traitement des pneumonies acquises sous ventilation mécanique. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0856-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Predictors of clinical success among a national Veterans Affairs cohort with methicillin-resistant Staphylococcus aureus pneumonia. Clin Ther 2014; 36:552-9. [PMID: 24631473 DOI: 10.1016/j.clinthera.2014.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/07/2014] [Accepted: 02/13/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND The treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is exceedingly complicated, which is concerning because of the high mortality rate associated with the infection. Identification of independent predictors of clinical success can optimize patient care by assisting clinicians in treatment decisions. OBJECTIVES Our goal was to identify independent predictors of clinical success in a national Veterans Affairs (VA) cohort of patients with MRSA pneumonia. METHODS A nested case-control study was conducted among a cohort of VA patients with MRSA pneumonia receiving linezolid or vancomycin between January 2002 and September 2010. Cases included those demonstrating clinical success, defined as discharge from the hospital or intensive care unit by day 14 after treatment initiation, in the absence of death, therapy change, or intubation by day 14. Control subjects represented nonsuccess, defined as therapy change, intubation, intensive care unit admission, readmission, or death between treatment initiation and day 14. The potential predictors assessed included treatment, patient demographic and admission characteristics, previous health care and medication exposures, comorbidities, and medical history. Odds ratios (ORs) and 95% CIs were calculated from logistic regression. RESULTS Our study included 2442 cases of clinical success and 1290 control subjects. Demographic characteristics varied between the clinical success and nonsuccess groups, including age, race, and region of facility. A current diagnosis of chronic respiratory disease (46% vs 42%) and diagnosis of pneumonia in the year before the MRSA pneumonia admission (37% vs 32%) were both more common in the clinical success group. Despite these significant differences, only 2 predictors of clinical success were identified in our study: previous complication of an implant or graft, including mechanical complications and infections, in the year before the MRSA pneumonia admission (adjusted OR, 1.55 [95% CI, 1.17-2.06]) and treatment with linezolid (adjusted OR, 1.53 [95% CI, 1.12-2.10]). Predictors of nonsuccess (adjusted OR [95% CI) included diagnosis of concomitant urinary tract infection (0.82 [0.70-0.96]), intravenous line (0.76 [0.66-0.89]), previous coagulopathy (0.74 [0.56-0.96]), previous amputation procedure (0.72 [0.53-0.98]), current coagulopathy diagnosis (0.71 [0.53-0.96]), dialysis (0.54 [0.38-0.76]), multiple inpatient procedures (0.53 [0.45-0.62]), inpatient surgery (0.48 [0.41-0.57]), and previous endocarditis (0.24 [0.07-0.81]). CONCLUSIONS MRSA pneumonia tends to affect patients with complex care, and identification of the predictors of clinical success is useful when considering different therapeutic approaches. In this national cohort of VA patients with MRSA pneumonia, treatment was the only modifiable variable predicting clinical success.
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Dimopoulos G, Poulakou G, Pneumatikos IA, Armaganidis A, Kollef MH, Matthaiou DK. Short- vs long-duration antibiotic regimens for ventilator-associated pneumonia: a systematic review and meta-analysis. Chest 2014; 144:1759-1767. [PMID: 23788274 DOI: 10.1378/chest.13-0076] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We performed a systematic review and meta-analysis of short- vs long-duration antibiotic regimens for ventilator-associated pneumonia (VAP). METHODS We searched PubMed and Cochrane Central Registry of Controlled Trials. Four randomized controlled trials (RCTs) comparing short (7-8 days) with long (10-15 days) regimens were identified. Primary outcomes included mortality, antibiotic-free days, and clinical and microbiologic relapses. Secondary outcomes included mechanical ventilation-free days, duration of mechanical ventilation, and length of ICU stay. RESULTS All RCTs included mortality data, whereas data on relapse and antibiotic-free days were provided in three and two out of four RCTs, respectively. No difference in mortality was found between the compared arms (fixed effect model [FEM]: OR = 1.20; 95% CI, 0.84-1.72; P = .32). There was an increase in antibiotic-free days in favor of the short-course treatment with a pooled weighted mean difference of 3.40 days (random effects model: 95% CI, 1.43-5.37; P < .001). There was no difference in relapses between the compared arms, although a strong trend to lower relapses in the long-course treatment was observed (FEM: OR = 1.67; 95% CI, 0.99-2.83; P = .06). No difference was found between the two arms regarding the remaining outcomes. Sensitivity analyses yielded similar results. CONCLUSIONS Short-course treatment of VAP was associated with more antibiotic-free days. No difference was found regarding mortality and relapses; however, a strong trend for fewer relapses was observed in favor of the long-course treatment, being mostly driven by one study in which the observed relapses were probably more microbiologic than clinical. Additional research is required to elucidate the issue.
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Affiliation(s)
- George Dimopoulos
- Department of Critical Care, Medical School, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Garyphallia Poulakou
- 4th Department of Internal Medicine, Medical School, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Ioannis A Pneumatikos
- The Department of Intensive Care, Medical School, Democritus University of Thrace, Alexandroupolis University Hospital, Alexandroupoli, Greece
| | - Apostolos Armaganidis
- Department of Critical Care, Medical School, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Dimitrios K Matthaiou
- Department of Critical Care, Medical School, University of Athens, "Attikon" University Hospital, Athens, Greece.
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Dudau D, Camous J, Marchand S, Pilorge C, Rézaiguia-Delclaux S, Libert JM, Fadel E, Stéphan F. Incidence of nosocomial pneumonia and risk of recurrence after antimicrobial therapy in critically ill lung and heart-lung transplant patients. Clin Transplant 2013; 28:27-36. [PMID: 24410732 DOI: 10.1111/ctr.12270] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 12/29/2022]
Abstract
Little is known about the resolution of symptoms of nosocomial pneumonia (NosoP) after lung and heart-lung transplantation. The aim of this study was to describe the clinical response to antimicrobial therapy in (ICU) patients with NosoP after lung or heart-lung transplantation. Between January 2008 and August 2010, 79 lung or heart-lung transplantations patients were prospectively studied. NosoPwas confirmed by quantitative cultures of bronchoalveolar lavage or endotracheal aspirates. Clinical variables, sequential organ failure assessment (SOFA) score, and radiologic score were recorded from start of therapy until day 9. Thirty-five patients (44%) experienced 64 episodes of NosoP in ICU. Fourteen patients (40%) had NosoP recurrence. Most frequently isolated organisms were Enterobacteriaceae (30%), Pseudomonas aeruginosa (25%), and Staphylococcus aureus (20%). Sequential organ failure assessment (SOFA) score improved significantly at day 6 and C-reactive protein level at day 9. SOFA and radiologic scores differed significantly between patients with and without NosoP recurrence at day 3 and 9. The ICU mortality rate did not differ between patients with and without NosoP recurrence, and free of NosoP (14.3%, 9.5%, 11.4%, respectively) (p = 0.91). Severities of illness and lung injury were the two major risk factors for NosoP recurrence. Occurrence of NosoP has no impact on ICU mortality.
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Affiliation(s)
- Daniela Dudau
- Surgical intensive care unit, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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Esperatti M, Ferrer M, Giunta V, Ranzani OT, Saucedo LM, Li Bassi G, Blasi F, Rello J, Niederman MS, Torres A. Validation of predictors of adverse outcomes in hospital-acquired pneumonia in the ICU. Crit Care Med 2013; 41:2151-61. [PMID: 23760154 DOI: 10.1097/ccm.0b013e31828a674a] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To validate a set of predictors of adverse outcomes in patients with ICU-acquired pneumonia in relation to clinically relevant assessment at 28 days. DESIGN Prospective, observational study. SETTING Six medical and surgical ICUs of a university hospital. PATIENTS Three hundred thirty-five patients with ICU-acquired pneumonia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Development of predictors of adverse outcomes was defined when at least one of the following criteria was present at an evaluation made 72-96 hours after starting treatment: no improvement of PaO2/FIO2, need for intubation due to pneumonia, persistence of fever or hypothermia with purulent respiratory secretions, greater than or equal to 50% increase in radiographic infiltrates, or occurrence of septic shock or multiple organ dysfunction syndrome. We also assessed the inflammatory response by different serum biomarkers. The presence of predictors of adverse outcomes was related to mortality and ventilator-free days at day 28. Sequential Organ Failure Assessment score was evaluated and related to mortality at day 28.One hundred eighty-four (55%) patients had at least one predictor of adverse outcomes. The 28-day mortality was higher for those with versus those without predictors of adverse outcomes (45% vs 19%, p<0.001), and ventilator-free days were lower (median [interquartile range], 0 [0-17] vs 22 [0-28]) for patients with versus patients without predictors of adverse outcomes (p<0.001). The lack of improvement of PaO2/FIO2 and lack of improvement in Sequential Organ Failure Assessment score from day 1 to day 5 were independently associated with 28-day mortality and fewer ventilator-free days. The marginal structural analysis showed an odds ratio of death 2.042 (95% CI, 1.01-4.13; p=0.047) in patients with predictors of adverse outcomes. Patients with predictors of adverse outcomes had higher serum inflammatory response accordingly to biomarkers evaluated. CONCLUSIONS The presence of any predictors of adverse outcomes was associated with mortality and decreased ventilator-free days at day 28. The lack of improvement in the PaO2/FIO2 and Sequential Organ Failure Assessment score was independently associated with mortality in the multivariate analysis.
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Affiliation(s)
- Mariano Esperatti
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
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Caceres F, Welch VL, Kett DH, Scerpella EG, Peyrani P, Ford KD, Ramirez JA. Absence of gender-based differences in outcome of patients with hospital-acquired pneumonia. J Womens Health (Larchmt) 2013; 22:1069-75. [PMID: 24128006 DOI: 10.1089/jwh.2013.4434] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The objective of this analysis was to evaluate the association between gender and clinical outcomes in intensive care unit (ICU) patients with hospital-acquired pneumonia (HAP) since data thus far are controversial. METHODS Data from a convenience sample of ICU patients with HAP, including ventilator-associated and health care-associated pneumonia, were retrospectively collected from four academic institutions (Improving Medicine through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia [IMPACT-HAP] study). Outcomes included 28-day mortality, clinical failure at day 14, hospital and ICU length of stay (LOS), and duration of mechanical ventilation. We compared baseline characteristics and performed multivariate analysis to identify factors independently associated with mortality. RESULTS Among 416 patients, 271 were men and 145 were women. Women were older (62.4±16.9 vs. 55.7±16.5 years, p<0.001) and more critically ill, with Acute Physiology and Chronic Health Evaluation (APACHE) II scores of 21 vs. 19 (p=0.004). Day-28 mortality was 30% for women and 24% for men (p=0.25). Increased 28-day mortality was associated with severity of illness, age, ventilator-associated pneumonia, vascular disease, and hospital LOS prior to pneumonia diagnosis. No significant differences were found in the distribution of bacteria pathogens or in clinical failure rates (36% vs. 31%) between genders. Duration in days of mechanical ventilation, ICU LOS and hospital LOS after the diagnosis of pneumonia were not significantly different between men and women. Analyzing data for women based on presumed pre- or postmenopausal status (age breakpoint of 50 years), showed an increased in ICU LOS (15 vs. 25 days; p=0.0026) and hospital LOS (22 vs. 30 days; p=0.05) for women ≤50 years. No differences were noted in 28-day mortality (24.3% vs. 13.1%; p=0.18) in women ≤50 years of age. CONCLUSIONS In ICU patients with pneumonia, female gender was not associated with worse outcomes or increased resource utilization compared to male gender. Further studies are needed to evaluate menopausal status and outcomes in women with pneumonia.
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Affiliation(s)
- Fernando Caceres
- 1 Division of Pulmonary and Critical Care Medicine, University of Miami Miller School of Medicine , Jackson Memorial Hospital, Miami, Florida
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Peña C, Gómez-Zorrilla S, Oriol I, Tubau F, Dominguez MA, Pujol M, Ariza J. Impact of multidrug resistance on Pseudomonas aeruginosa ventilator-associated pneumonia outcome: predictors of early and crude mortality. Eur J Clin Microbiol Infect Dis 2013; 32:413-20. [PMID: 23344827 DOI: 10.1007/s10096-012-1758-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 10/02/2012] [Indexed: 01/23/2023]
Abstract
The prevalence of multidrug-resistant (MDR) Pseudomonas aeruginosa has increased over the past decade and a significant rise in these isolates in ventilator-associated pneumonia (VAP) has been observed. However, the impact of MDR on VAP outcome has not been analysed in depth. We investigated the risk factors for early and crude mortality in a retrospective study of microbiologically and clinically documented VAP. Ninety-one VAP episodes in 83 patients were included, 31 caused by susceptible P. aeruginosa and 60 by MDR strains, of which 42 (70 %) were extensively drug-resistant (XDR) P. aeruginosa. Thirteen episodes concomitantly presented P. aeruginosa bacteraemia, in seven of which the origin was the respiratory tract. Whereas susceptible P. aeruginosa episodes were more likely than MDR episodes to receive adequate empirical (68 % vs. 30 %; p < 0.001) and definitive antimicrobial therapy (96 % vs. 50 %; p < 0.001), susceptible P. aeruginosa VAP presented a trend towards early mortality (29 % vs. 15 %; p = 0.06). A logistic regression model with early mortality as the dependent variable identified multiorgan dysfunction syndrome (MODS) [odds ratio (OR) 10.4; 95 % confidence interval (CI) 1.7-63.5; p = 0.01] and inadequate antibiotic therapy (OR 4.27; 95 % CI 0.98-18.4; p = 0.052) as independent risk factors for early mortality. A similar analysis identified MODS (OR 4.31; 95 % CI 1.14-16.2; p = 0.03) as the only independent predictor of crude mortality. The severity of acute illness clinical presentation was the main predictor of mortality. Despite adequate antibiotic therapy, susceptible P. aeruginosa seems to cause major early mortality. Although adequate therapy is essential to treat VAP, the severity of acute illness is a more important factor than drug resistance.
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Affiliation(s)
- C Peña
- Infectious Diseases Service, IDIBELL, Hospital Universitari de Bellvitge, C/ Feixa Llarga S/n., L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
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Capellier G, Mockly H, Charpentier C, Annane D, Blasco G, Desmettre T, Roch A, Faisy C, Cousson J, Limat S, Mercier M, Papazian L. Early-onset ventilator-associated pneumonia in adults randomized clinical trial: comparison of 8 versus 15 days of antibiotic treatment. PLoS One 2012; 7:e41290. [PMID: 22952580 PMCID: PMC3432026 DOI: 10.1371/journal.pone.0041290] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 06/19/2012] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The optimal treatment duration for ventilator-associated pneumonia is based on one study dealing with late-onset of the condition. Shortening the length of antibiotic treatment remains a major prevention factor for the emergence of multiresistant bacteria. OBJECTIVE To demonstrate that 2 different antibiotic treatment durations (8 versus 15 days) are equivalent in terms of clinical cure for early-onset ventilator-associated pneumonia. METHODS Randomized, prospective, open, multicenter trial carried out from 1998 to 2002. MEASUREMENTS The primary endpoint was the clinical cure rate at day 21. The mortality rate was evaluated on days 21 and 90. RESULTS 225 patients were included in 13 centers. 191 (84.9%) patients were cured: 92 out of 109 (84.4%) in the 15 day cohort and 99 out of 116 (85.3%) in the 8 day cohort (difference = 0.9%, odds ratio = 0.929). 95% two-sided confidence intervals for difference and odds ratio were [-8.4% to 10.3%] and [0.448 to 1.928] respectively. Taking into account the limits of equivalence (10% for difference and 2.25 for odds ratio), the objective of demonstrative equivalence between the 2 treatment durations was fulfilled. Although the rate of secondary infection was greater in the 8 day than the 15 day cohort, the number of days of antibiotic treatment remained lower in the 8 day cohort. There was no difference in mortality rate between the 2 groups on days 21 and 90. CONCLUSION Our results suggest that an 8-day course of antibiotic therapy is safe for early-onset ventilator-associated pneumonia in intubated patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01559753.
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Affiliation(s)
- Gilles Capellier
- Réanimation médicale adulte, Pôle Urgences-SAMU-Réanimation CHU, Besancon, Doubs, France.
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François B, Luyt CE, Dugard A, Wolff M, Diehl JL, Jaber S, Forel JM, Garot D, Kipnis E, Mebazaa A, Misset B, Andremont A, Ploy MC, Jacobs A, Yarranton G, Pearce T, Fagon JY, Chastre J. Safety and pharmacokinetics of an anti-PcrV PEGylated monoclonal antibody fragment in mechanically ventilated patients colonized with Pseudomonas aeruginosa. Crit Care Med 2012; 40:2320-6. [DOI: 10.1097/ccm.0b013e31825334f6] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Duan J, Guo S, Han X, Tang X, Xu L, Xu X, Liu Y, Jia J, Huang S, Wu Y. Dual-mode weaning strategy for difficult-weaning tracheotomy patients: a feasibility study. Anesth Analg 2012; 115:597-604. [PMID: 22696608 DOI: 10.1213/ane.0b013e31825c7dba] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Tracheotomy patients who are difficult to wean from ventilation consume a substantial portion of intensive care unit (ICU) resources. These patients also typically undergo a long period of mechanical ventilation (MV) and have a high mortality rate. The efficacy of a dual-mode weaning strategy (alternation of invasive and noninvasive MV) in tracheotomy patients who are difficult to wean is unknown. METHODS We performed this prospective, randomized, controlled trial in a 17-bed respiratory ICU from July 2009 to October 2011. After tracheotomy, patients who failed for 3 consecutive days in a spontaneous breathing trial were enrolled (n = 32) and randomly allocated to either the dual-mode (n = 15) or conventional (n = 17) weaning group. RESULTS Compared with the conventional group, patients in the dual-mode group had a shorter duration of MV during the entire study (median 38 days, interquartile range [IQR]: 28-53 vs 59, IQR: 39-88, P = 0.03) and after randomization (median 10 days, IQR: 4-21 vs 37, IQR: 16-51, P < 0.01). They also had a shorter ICU stay (median 44 days, IQR: 32-54 vs 72, IQR: 52-102, P = 0.01), a lower mortality rate during weaning (1 of 15 vs 7 of 17, P = 0.04), and a lower rate of pulmonary infection after randomization (3 of 15 vs 12 of 17, P < 0.01). CONCLUSIONS Dual-mode weaning is a promising strategy for treating tracheotomy patients who are difficult to wean. In a small cohort of patients with tracheotomies, we demonstrated that dual-mode weaning reduced the total duration of MV and ICU stay; we recommend additional studies to assess its effect on pulmonary infections and mortality.
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Affiliation(s)
- Jun Duan
- Department of Respiratory Medicine, the First Affiliated Hospital, Chongqing Medical University, Chongqing, P. R. China
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Abstract
PURPOSE OF REVIEW To critically discuss the attributable mortality of ventilator-associated pneumonia (VAP) and potential sources of variation. RECENT FINDINGS The review will cover the available estimates (0-50%). It will also explore the source of variation because of definition of VAP (being lower if inaccurate), case-mix issues (being lower for trauma patients), the severity of underlying illnesses (being maximal when the severity of underlying illness is intermediate), and on the characteristics and the severity of the VAP episode. Another important source of variation is the use of poorly appropriate statistical models (estimates biased by lead time bias and competing events). New extensions of survival models which take into account the time dependence of VAP occurrence and competing risks allow less biased estimation as compared with traditional models. SUMMARY Attributable mortality of VAP is about 6%. Accurate diagnostic methods are key to properly estimating it. Traditional statistical models should no longer be used to estimate it. Prevention efforts targeted on patients with intermediate severity may result in the most important outcome benefits.
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Abstract
Ventilator-associated pneumonia (VAP) is the most frequent and severe infection acquired in the intensive care unit, leading to prolonged mechanical ventilation and excess mortality. This article reviews the different aspects of VAP, such as risk factors, causative agents, and approaches to diagnosis, treatment, and prevention. Several aspects of VAP are still considered controversial.
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Affiliation(s)
- Jean-Louis Trouillet
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris 6-Pierre et Marie Curie, Paris, France.
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Analysis of pathogen and host factors related to clinical outcomes in patients with hospital-acquired pneumonia due to methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2012; 50:1640-4. [PMID: 22337980 DOI: 10.1128/jcm.06701-11] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of nosocomial pneumonia. To characterize pathogen-derived and host-related factors in intensive care unit (ICU) patients with MRSA pneumonia, we evaluated the Improving Medicine through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) database. We performed multivariate regression analyses of 28-day mortality and clinical response using univariate analysis variables at a P level of <0.25. In isolates from 251 patients, the most common molecular characteristics were USA100 (55.0%) and USA300 (23.9%), SCCmec types II (64.1%) and IV (33.1%), and agr I (36.7%) and II (61.8%). Panton-Valentine leukocidin (PVL) was present in 21.9%, and vancomycin heteroresistance was present in 15.9%. Mortality occurred in 37.1% of patients; factors in the univariate analysis were age, APACHE II score, AIDS, cardiac disease, vascular disease, diabetes, SCCmec type II, PVL negativity, and higher vancomycin MIC (all P values were <0.05). In multivariate analysis, independent predictors were APACHE II score (odds ratio [OR], 1.090; 95% confidence interval [CI], 1.041 to 1.141; P < 0.001) and age (OR, 1.024; 95% CI, 1.003 to 1.046; P = 0.02). Clinical failure occurred in 36.8% of 201 evaluable patients; the only independent predictor was APACHE II score (OR, 1.082; 95% CI, 1.031 to 1.136; P = 0.002). In summary, APACHE II score (mortality, clinical failure) and age (mortality) were the only independent predictors, which is consistent with severity of illness in ICU patients with MRSA pneumonia. Interestingly, our univariate findings suggest that both pathogen and host factors influence outcomes. As the epidemiology of MRSA pneumonia continues to evolve, both pathogen- and host-related factors should be considered when describing epidemiological trends and outcomes of therapeutic interventions.
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Effect of pravastatin on the frequency of ventilator-associated pneumonia and on intensive care unit mortality: Open-label, randomized study*. Crit Care Med 2011; 39:2440-6. [DOI: 10.1097/ccm.0b013e318225742c] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hennigs JK, Baumann HJ, Schmiedel S, Tennstedt P, Sobottka I, Bokemeyer C, Kluge S, Klose H. Characterization of Enterobacter cloacae Pneumonia: A Single-Center Retrospective Analysis. Lung 2011; 189:475-83. [DOI: 10.1007/s00408-011-9323-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 09/10/2011] [Indexed: 10/16/2022]
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Pugh R, Grant C, Cooke RP, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev 2011:CD007577. [PMID: 21975771 DOI: 10.1002/14651858.cd007577.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pneumonia is the most common hospital-acquired infection affecting patients in the intensive care unit (ICU). However, the optimal duration of antibiotic therapy for hospital-acquired pneumonia (HAP) is uncertain. OBJECTIVES To assess the effectiveness of short versus prolonged-course antibiotic administration for HAP in critically ill adults, including patients with ventilator-associated pneumonia (VAP). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to February week 4, 2011), EMBASE (1974 to March 2011), LILACS (1985 to March 2011) and Web of Science (1985 to March 2011). SELECTION CRITERIA We considered all randomised controlled trials (RCTs) comparing fixed durations of antibiotic therapy, or comparing a protocol intended to limit duration of therapy with standard care, for HAP (including patients with VAP) in critically ill adults. DATA COLLECTION AND ANALYSIS Two review authors conducted data extraction and assessment of risk of bias. We contacted trial authors for additional information. MAIN RESULTS Eight studies (1703 patients) were included. Methodology varied considerably and we found little evidence regarding patients with a high probability of HAP who were not mechanically ventilated. For patients with VAP, a short seven to eight-day course of antibiotics compared with a prolonged 10 to 15-day course (three studies, N = 508) increased 28-day antibiotic-free days (odds ratio (OR) 4.02; 95% confidence interval (CI) 2.26 to 5.78) and reduced recurrence of VAP due to multi-resistant organisms (OR 0.44; 95% CI 0.21 to 0.95), without adversely affecting other outcomes. However, for cases of VAP due to non-fermenting Gram-negative bacilli (NF-GNB), recurrence was greater after short-course therapy (OR 2.18; 95% CI 1.14 to 4.16; two studies, N = 176), though other outcome measures did not significantly differ. Discontinuation strategies utilising clinical features (one study; N = 302) or procalcitonin (three studies; N = 323) led to a reduction in duration of therapy and, in the procalcitonin studies, increased 28-day antibiotic-free days (mean difference (MD) 2.80; 95% CI 1.39 to 4.21) without negatively affecting other outcomes. AUTHORS' CONCLUSIONS We conclude that for patients with VAP not due to NF-GNB, a short fixed-course (seven or eight days) antibiotic therapy may be more appropriate than a prolonged course (10 to 15 days). Use of an individualised strategy (incorporating clinical features or serum procalcitonin) appears to safely reduce duration of antibiotic therapy for VAP.
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Affiliation(s)
- Richard Pugh
- Department of Anaesthetics, Glan Clwyd Hospital, Rhyl, Denbighshire, UK, LL18 5UJ
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