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Liang Z, Liao Q, Xu J, Wang S, Liu Q, Liu Z, Wen D. Comparative analysis of open and closed tracheal suction systems on mechanical ventilation efficiency in adults: A systematic review and meta-analysis. Aust Crit Care 2024:S1036-7314(24)00243-1. [PMID: 39242302 DOI: 10.1016/j.aucc.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/19/2024] [Accepted: 08/08/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND There are two types of suction methods used clinically: closed tracheal suction system (CTSS) and open tracheal suction system (OTSS). However, the safety and efficacy of these two suction systems for patients remain to be analysed. OBJECTIVE The objective of this study was to assess the safety and efficacy of OTSSs and CTSSs in adult mechanical ventilation. METHODS Computer searches were conducted on PubMed, Web of science, MEDLINE, CINAHL, and Cochrane Library databases. The search spanned from the inception of each database to December 2023. Two researchers independently reviewed and extracted data from the literature. Quality assessment was performed using the Cochrane Manual of Systematic Reviews, and meta-analysis was conducted using RevMan 5.3 software. RESULTS A total of 13 articles, involving 2822 patients, were included in the analysis. The meta-analysis showed that the CTSS could reduce the incidence of ventilator-associated pneumonia (odds ratio [OR] = 0.77, 95% confidence interval [CI]: [0.61, 0.98], P = 0.03). However, no significant difference existed in the microbial colonisation rate in the respiratory tract (OR = 1.40, 95% CI: [0.91, 2.15], P = 0.13), mechanical ventilation time (mean difference = -0.33, 95% CI: [-1.43, 0.78], P = 0.56), length of intensive care unit stay (mean difference = 0.23, 95% CI: [-0.90, 1.35], P = 0.69), and mortality (OR = 1.01, 95% CI: [0.84, 1.22], P = 0.89). CONCLUSION In comparison to the OTSS, the CTSS proves effective in reducing the incidence of ventilator-associated pneumonia. However, additional high-quality evidence is needed to evaluate respiratory microbial colonisation rates, the duration of mechanical ventilation, length of intensive care unit stay, and mortality.
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Affiliation(s)
- Zhenghua Liang
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Qian Liao
- Gynecology and Obstetrics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Jinlong Xu
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Simei Wang
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Qiuyu Liu
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Zefang Liu
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Dan Wen
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China.
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Schechner V, Cohen A, Carmeli Y. Tailoring Interventions for Control of Endemic Carbapenem-Resistant Acinetobacter baumannii: An Interrupted Time Series Analysis. Open Forum Infect Dis 2024; 11:ofae301. [PMID: 38872846 PMCID: PMC11170493 DOI: 10.1093/ofid/ofae301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/26/2024] [Indexed: 06/15/2024] Open
Abstract
Background We examined temporal trends in carbapenem-resistant Acinetobacter baumannii (CRAB) infections in a hospital with hyperendemic CRAB and assessed the efficacy of varied infection control strategies in different ward types. Methods We retrospectively analyzed all CRAB clinical samples from 2006 to 2019 and categorized infections as hospital-onset (HO) or community-onset. We used interrupted time series analysis to assess the impact of interventions on the incidence of all HO-CRAB infections and bloodstream infections (BSIs) at the hospital and ward group levels. Results Over 14 years, 4009 CRAB infections were identified (89.7% HO), with 813 CRAB BSI (93.2% HO). The incidence per 100 000 patient-days of CRAB infections peaked in 2008 at 79.1, and that of CRAB BSI peaked in 2010 at 16.2. These rates decreased by two-thirds by 2019. In the general intensive care unit (ICU), hand hygiene and environmental cleaning interventions were followed by a significant reduction in the level of HO-CRAB infections, with an additional decrease in the slope after the introduction of active surveillance and 2% chlorhexidine bathing. In the surgical ICU and surgical department, a reduction in slope or level of CRAB infection was observed after moving ventilated patients to single rooms. In medical wards, a multimodal intervention was followed by a reduction in the slope of HO-CRAB infections and BSIs. In wards where CRAB infections were uncommon, the incidence of HO-CRAB infections decreased throughout the study period. Conclusions Ward-specific variables determine the success of interventions in reducing CRAB infections; therefore, interventions should be tailored to each setting.
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Affiliation(s)
- Vered Schechner
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
- School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Cohen
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Yehuda Carmeli
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
- School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Joo DH, Park HC, Kim JH, Yang SH, Kim TH, Kim HJ, Song MJ, Lim SY, Kim SA, Bae HW, Ahn YH, Yoon SM, Park J, Lee HY, Lee J, Lee SM, Lee JC, Cho YJ. Clinical Efficacy and Safety of an Automatic Closed-Suction System in Mechanically Ventilated Patients with Pneumonia: A Multicenter, Prospective, Randomized, Non-Inferiority, Investigator-Initiated Trial. Diagnostics (Basel) 2024; 14:1068. [PMID: 38893595 PMCID: PMC11172224 DOI: 10.3390/diagnostics14111068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/08/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Endotracheal suctioning is an essential but labor-intensive procedure, with the risk of serious complications. A brand new automatic closed-suction device was developed to alleviate the workload of healthcare providers and minimize those complications. We evaluated the clinical efficacy and safety of the automatic suction system in mechanically ventilated patients with pneumonia. In this multicenter, randomized, non-inferiority, investigator-initiated trial, mechanically ventilated patients with pneumonia were randomized to the automatic device (intervention) or conventional manual suctioning (control). The primary efficacy outcome was the change in the modified clinical pulmonary infection score (CPIS) in 3 days. Secondary outcomes were the frequency of additional suctioning and the amount of secretion. Safety outcomes included adverse events or complications. A total of 54 participants, less than the pre-determined number of 102, were enrolled. There was no significant difference in the change in the CPIS over 72 h (-0.13 ± 1.58 in the intervention group, -0.58 ± 1.18 in the control group, p = 0.866), but the non-inferiority margin was not satisfied. There were no significant differences in the secondary outcomes and safety outcomes, with a tendency for more patients with improved tracheal mucosal injury in the intervention group. The novel automatic closed-suction system showed comparable efficacy and safety compared with conventional manual suctioning in mechanically ventilated patients with pneumonia.
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Affiliation(s)
- Dong-Hyun Joo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea; (D.-H.J.); (H.C.P.); (J.H.K.); (S.H.Y.); (T.H.K.); (H.-J.K.); (M.J.S.); (S.Y.L.)
| | - Hyo Chan Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea; (D.-H.J.); (H.C.P.); (J.H.K.); (S.H.Y.); (T.H.K.); (H.-J.K.); (M.J.S.); (S.Y.L.)
- Department of Medical Device Development, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Joon Han Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea; (D.-H.J.); (H.C.P.); (J.H.K.); (S.H.Y.); (T.H.K.); (H.-J.K.); (M.J.S.); (S.Y.L.)
| | - Seo Hee Yang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea; (D.-H.J.); (H.C.P.); (J.H.K.); (S.H.Y.); (T.H.K.); (H.-J.K.); (M.J.S.); (S.Y.L.)
| | - Tae Hun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea; (D.-H.J.); (H.C.P.); (J.H.K.); (S.H.Y.); (T.H.K.); (H.-J.K.); (M.J.S.); (S.Y.L.)
| | - Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea; (D.-H.J.); (H.C.P.); (J.H.K.); (S.H.Y.); (T.H.K.); (H.-J.K.); (M.J.S.); (S.Y.L.)
| | - Myung Jin Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea; (D.-H.J.); (H.C.P.); (J.H.K.); (S.H.Y.); (T.H.K.); (H.-J.K.); (M.J.S.); (S.Y.L.)
| | - Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea; (D.-H.J.); (H.C.P.); (J.H.K.); (S.H.Y.); (T.H.K.); (H.-J.K.); (M.J.S.); (S.Y.L.)
| | - Sung A Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; (S.A.K.); (H.W.B.); (J.P.); (J.L.); (S.-M.L.)
| | - Hee Won Bae
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; (S.A.K.); (H.W.B.); (J.P.); (J.L.); (S.-M.L.)
| | - Yoon Hae Ahn
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; (Y.H.A.); (S.M.Y.); (H.Y.L.)
| | - Si Mong Yoon
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; (Y.H.A.); (S.M.Y.); (H.Y.L.)
| | - Jimyung Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; (S.A.K.); (H.W.B.); (J.P.); (J.L.); (S.-M.L.)
| | - Hong Yeul Lee
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; (Y.H.A.); (S.M.Y.); (H.Y.L.)
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; (S.A.K.); (H.W.B.); (J.P.); (J.L.); (S.-M.L.)
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; (S.A.K.); (H.W.B.); (J.P.); (J.L.); (S.-M.L.)
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; (Y.H.A.); (S.M.Y.); (H.Y.L.)
| | - Jung Chan Lee
- Department of Biomedical Engineering, Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University College of Medicine, Seoul 03080, Republic of Korea;
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea; (D.-H.J.); (H.C.P.); (J.H.K.); (S.H.Y.); (T.H.K.); (H.-J.K.); (M.J.S.); (S.Y.L.)
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Ramírez-Torres CA, Andrade-Gómez E, Giménez-Luzuriaga M, Lozano C, Sapiña-Beltrán E. Closed Suction System in Tracheal Suctioning in the Critically Ill Patient Connected to Mechanical Ventilation: A Systematic Review. Arch Bronconeumol 2024; 60:116-118. [PMID: 38044232 DOI: 10.1016/j.arbres.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023]
Affiliation(s)
| | - Elena Andrade-Gómez
- Predepartment of Nursing, Faculty of Health Sciences, University of La Rioja, Logroño, Spain.
| | - Marta Giménez-Luzuriaga
- Predepartment of Nursing, Faculty of Health Sciences, University of La Rioja, Logroño, Spain
| | - Carmen Lozano
- Area of Biochemistry and Molecular Biology, OneHealth-UR Research Group, University of La Rioja, Logroño, Spain
| | - Esther Sapiña-Beltrán
- Predepartment of Nursing, Faculty of Health Sciences, University of La Rioja, Logroño, Spain
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Fraenkel CJ, Starlander G, Tano E, Sütterlin S, Melhus Å. The First Swedish Outbreak with VIM-2-Producing Pseudomonas aeruginosa, Occurring between 2006 and 2007, Was Probably Due to Contaminated Hospital Sinks. Microorganisms 2023; 11:microorganisms11040974. [PMID: 37110397 PMCID: PMC10143745 DOI: 10.3390/microorganisms11040974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
Multidrug-resistant Pseudomonas aeruginosa is an increasing clinical problem worldwide. The aim of this study was to describe the first outbreak of a Verona integron-borne metallo-ß-lactamase (VIM)-2-producing P. aeruginosa strain in Sweden and its expansion in the region. A cluster of multidrug-resistant P. aeruginosa appeared at two neighbouring hospitals in 2006. The isolates were characterized by PCR, pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing. Patient charts, laboratory records, and hygiene routines were reviewed, and patients, staff, and the environment were screened. The investigation revealed a clonal outbreak of a VIM-2-producing P. aeruginosa strain belonging to the high-risk clonal complex 111, susceptible only to gentamicin and colistin. No direct contact between patients could be established, but most of them had stayed in certain rooms/wards weeks to months apart. Cultures from two sinks yielded growth of the same strain. The outbreak ended when control measures against the sinks were taken, but new cases occurred in a tertiary care hospital in the region. In conclusion, when facing prolonged outbreaks with this bacterium, sinks and other water sources in the hospital environment should be considered. By implementing proactive control measures to limit the bacterial load in sinks, the waterborne transmission of P. aeruginosa may be reduced.
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Affiliation(s)
- Carl-Johan Fraenkel
- Department of Infectious Diseases and Hospital Infection Control, Lund University Hospital, SE-22185 Lund, Sweden
| | - Gustaf Starlander
- Section of Clinical Microbiology, Department of Medical Sciences, Uppsala University, SE-75185 Uppsala, Sweden
| | - Eva Tano
- Section of Clinical Microbiology, Department of Medical Sciences, Uppsala University, SE-75185 Uppsala, Sweden
| | - Susanne Sütterlin
- Section of Clinical Microbiology, Department of Medical Sciences, Uppsala University, SE-75185 Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, SE-75185 Uppsala, Sweden
| | - Åsa Melhus
- Section of Clinical Microbiology, Department of Medical Sciences, Uppsala University, SE-75185 Uppsala, Sweden
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Rationale, Methodological Quality, and Reporting of Cluster-Randomized Controlled Trials in Critical Care Medicine: A Systematic Review. Crit Care Med 2021; 49:977-987. [PMID: 33591020 DOI: 10.1097/ccm.0000000000004885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Compared with individual-patient randomized controlled trials, cluster randomized controlled trials have unique methodological and ethical considerations. We evaluated the rationale, methodological quality, and reporting of cluster randomized controlled trials in critical care studies. DATA SOURCES Systematic searches of Medline, Embase, and Cochrane Central Register were performed. STUDY SELECTION We included all cluster randomized controlled trials conducted in adult, pediatric, or neonatal critical care units from January 2005 to September 2019. DATA EXTRACTION Two reviewers independently screened citations, reviewed full texts, protocols, and supplements of potentially eligible studies, abstracted data, and assessed methodology of included studies. DATA SYNTHESIS From 1,902 citations, 59 cluster randomized controlled trials met criteria. Most focused on quality improvement (24, 41%), antimicrobial therapy (9, 15%), or infection control (9, 15%) interventions. Designs included parallel-group (25, 42%), crossover (21, 36%), and stepped-wedge (13, 22%). Concealment of allocation was reported in 21 studies (36%). Thirteen studies (22%) reported at least one method of blinding. The median total sample size was 1,660 patients (interquartile range, 813-4,295); the median number of clusters was 12 (interquartile range, 5-24); and the median patients per cluster was 141 (interquartile range, 54-452). Sample size calculations were reported in 90% of trials, but only 54% met Consolidated Standards of Reporting Trials guidance for sample size reporting. Twenty-seven of the studies (46%) identified a fixed number of available clusters prior to trial commencement, and only nine (15%) prespecified both the number of clusters and patients required to detect the expected effect size. Overall, 36 trials (68%) achieved the total prespecified sample size. When analyzing data, 44 studies (75%) appropriately adjusted for clustering when analyzing the primary outcome. Only 12 (20%) reported an intracluster coefficient (median 0.047 [interquartile range, 0.01-0.13]). CONCLUSIONS Cluster randomized controlled trials in critical care typically involve a small and fixed number of relatively large clusters. The reporting of key methodological aspects of these trials is often inadequate.
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Blanco N, Harris AD, Magder LS, Jernigan JA, Reddy SC, O’Hagan J, Hatfield KM, Pineles L, Perencevich E, O’Hara LM. Sample Size Estimates for Cluster-Randomized Trials in Hospital Infection Control and Antimicrobial Stewardship. JAMA Netw Open 2019; 2:e1912644. [PMID: 31584684 PMCID: PMC6784749 DOI: 10.1001/jamanetworkopen.2019.12644] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE An important step in designing, executing, and evaluating cluster-randomized trials (CRTs) is understanding the correlation and thus nonindependence that exists among individuals in a cluster. In hospital epidemiology, there is a shortage of CRTs that have published their intraclass correlation coefficient or coefficient of variation (CV), making prospective sample size calculations difficult for investigators. OBJECTIVES To estimate the number of hospitals needed to power parallel CRTs of interventions to reduce health care-associated infection outcomes and to demonstrate how different parameters such as CV and expected effect size are associated with the sample size estimates in practice. DESIGN, SETTING, AND PARTICIPANTS This longitudinal cohort study estimated parameters for sample size calculations using national rates developed by the Centers for Disease Control and Prevention for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, central-line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and Clostridium difficile infections (CDI) from 2016. For MRSA and vancomycin-resistant enterococci (VRE) acquisition, outcomes were estimated using data from 2012 from the Benefits of Universal Glove and Gown study. Data were collected from June 2017 through September 2018 and analyzed from September 2018 through January 2019. MAIN OUTCOMES AND MEASURES Calculated number of clusters needed for adequate power to detect an intervention effect using a 2-group parallel CRT. RESULTS To study an intervention with a 30% decrease in daily rates, 73 total clusters were needed (37 in the intervention group and 36 in the control group) for MRSA bacteremia, 82 for CAUTI, 60 for CLABSI, and 31 for CDI. If a 10% decrease in rates was expected, 768 clusters were needed for MRSA bacteremia, 875 for CAUTI, 631 for CLABSI, and 329 for CDI. For MRSA or VRE acquisition, 50 or 40 total clusters, respectively, were required to observe a 30% decrease, whereas 540 or 426 clusters, respectively, were required to detect a 10% decrease. CONCLUSIONS AND RELEVANCE This study suggests that large sample sizes are needed to appropriately power parallel CRTs targeting infection prevention outcomes. Sample sizes are most associated with expected effect size and CV of hospital rates.
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Affiliation(s)
- Natalia Blanco
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Anthony D. Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Laurence S. Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - John A. Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sujan C. Reddy
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Justin O’Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kelly M. Hatfield
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Eli Perencevich
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
| | - Lyndsay M. O’Hara
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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Li YC, Lin HL, Liao FC, Wang SS, Chang HC, Hsu HF, Chen SH, Wan GH. Potential risk for bacterial contamination in conventional reused ventilator systems and disposable closed ventilator-suction systems. PLoS One 2018; 13:e0194246. [PMID: 29547638 PMCID: PMC5856346 DOI: 10.1371/journal.pone.0194246] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 02/27/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Few studies have investigated the difference in bacterial contamination between conventional reused ventilator systems and disposable closed ventilator-suction systems. The aim of this study was to investigate the bacterial contamination rates of the reused and disposable ventilator systems, and the association between system disconnection and bacterial contamination of ventilator systems. METHODS The enrolled intubated and mechanically ventilated patients used a conventional reused ventilator system and a disposable closed ventilator-suction system, respectively, for a week; specimens were then collected from the ventilator circuit systems to evaluate human and environmental bacterial contamination. The sputum specimens from patients were also analyzed in this study. RESULTS The detection rate of bacteria in the conventional reused ventilator system was substantially higher than that in the disposable ventilator system. The inspiratory and expiratory limbs of the disposable closed ventilator-suction system had higher bacterial concentrations than the conventional reused ventilator system. The bacterial concentration in the heated humidifier of the reused ventilator system was significantly higher than that in the disposable ventilator system. Positive associations existed among the bacterial concentrations at different locations in the reused and disposable ventilator systems, respectively. The predominant bacteria identified in the reused and disposable ventilator systems included Acinetobacter spp., Bacillus cereus, Elizabethkingia spp., Pseudomonas spp., and Stenotrophomonas (Xan) maltophilia. CONCLUSIONS Both the reused and disposable ventilator systems had high bacterial contamination rates after one week of use. Disconnection of the ventilator systems should be avoided during system operation to decrease the risks of environmental pollution and human exposure, especially for the disposable ventilator system. TRIAL REGISTRATION ClinicalTrials.gov PRS / NCT03359148.
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Affiliation(s)
- Ya-Chi Li
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Hui-Ling Lin
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Fang-Chun Liao
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Sing-Siang Wang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Hsiu-Chu Chang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Hung-Fu Hsu
- Department of Industrial Design, College of Management, Chang Gung University, Taoyuan, Taiwan
| | - Sue-Hsien Chen
- Department of Nursing, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Gwo-Hwa Wan
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
- Department of Obstetrics and Gynaecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan
- * E-mail:
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Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, Magill SS, Maragakis LL, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 2016; 35:915-36. [DOI: 10.1086/677144] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Prevention and control of multi-drug-resistant Gram-negative bacteria: recommendations from a Joint Working Party. J Hosp Infect 2015; 92 Suppl 1:S1-44. [PMID: 26598314 DOI: 10.1016/j.jhin.2015.08.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Indexed: 12/25/2022]
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The role of systemic antibiotics in acquiring respiratory tract colonization with gram-negative bacteria in intensive care patients: a nested cohort study. Crit Care Med 2015; 43:774-80. [PMID: 25493969 DOI: 10.1097/ccm.0000000000000768] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Colonization of the respiratory tract with Gram-negative bacteria in intensive care patients increases the risk of subsequent infections. Application of systemic antibiotics may prevent colonization with Gram-negative bacteria, but this effect has never been quantified. The objective of this study was to determine associations between systemic antibiotic use and acquisition of respiratory tract colonization with Gram-negative bacteria in ICUs. DESIGN A nested cohort study. SETTING A university hospital and a teaching hospital. PATIENTS Patients with ICU stay of more than 48 hours and absence of respiratory tract colonization with Gram-negative bacteria on ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Acquisition was determined through protocolized surveillance. Associations were investigated with Cox regression models with antibiotics as a time-dependent covariate. In all, 250 of 481 patients (52%) acquired respiratory tract colonization with Gram-negative bacteria after a median of 5 days (interquartile range, 3-8 d) (acquisition rate, 77.1/1,000 patient-days at risk). Antibiotic exposure during ICU admission was present in 78% and 72% of the patients with and without acquired Gram-negative bacteria colonization, respectively. In Kaplan-Meier curve analysis, the median times to acquisition of Gram-negative bacteria were 9 days (95% CI, 7.9-10.1) and 6 days (95% CI, 4.8-7.2) in patients receiving and not receiving antibiotics, respectively. In time varying Cox regression analysis, however, the association between acquired colonization and systemic antibiotics was not statistically significant (hazard ratio, 0.90; 95% CI, 0.70-1.16). CONCLUSIONS Among patients not colonized with Gram-negative bacteria in the respiratory tract at admission to ICU, systemic antibiotics during ICU stay were not associated with a reduction in acquisition of Gram-negative bacteria carriage in the respiratory tract during the ICU stay.
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Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2015; 35 Suppl 2:S133-54. [PMID: 25376073 DOI: 10.1017/s0899823x00193894] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Molecular mechanism of sustained inflation in acute respiratory distress syndrome. J Trauma Acute Care Surg 2013; 73:1106-13. [PMID: 22976418 DOI: 10.1097/ta.0b013e318265cc6f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this study was to investigate the effect and the potential molecular mechanism of sustained inflation (SI) recruitment maneuvers in acute respiratory distress syndrome (ARDS) in beagle dog following endotracheal suctioning. METHODS ARDS was induced in 24 beagle dogs with oleic acid. They had mechanical ventilation support. They were randomized into four groups after the establishment of the ARDS model: non-SI-open group where no SI was applied in beagle dogs with ARDS following open endotracheal suctioning; non-SI-closed group where no SI was applied in beagle dogs with ARDS following closed endotracheal suctioning; SI-open group where SI was applied in beagle dogs with ARDS following open endotracheal suctioning; and SI-closed group where SI was applied in beagle dogs with ARDS following closed endotracheal suctioning. Oxygenation, indexes of respiratory mechanics, and hemodynamic indexes were serially measured during the procedure. The serum protein level, or the messenger RNA in the heart and lung, of inflammation-related cytokines was investigated. RESULTS SI in ARDS improved oxygenation, lung compliance, and airway resistance but had no significant effect in the hemodynamic indexes. At molecular level, SI in ARDS neutralized the increases of pro-inflammatory cytokines (tumor necrosis factor α, interleukin 1β [IL-1β], and IL-6), and anti-inflammatory cytokine (IL-10) in the serum. Furthermore, SI in ARDS increased aquaporin 1 and aquaporin 5 messenger RNA in the lung tissue, and decreased IL-6 messenger RNA in the lung and heart tissue. CONCLUSION SI in ARDS could improve oxygenation, lung compliance, and airway resistance, which was related to the improved degree of inflammation and better maintained aquaporins.
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Åkerman E, Larsson C, Ersson A. Clinical experience and incidence of ventilator-associated pneumonia using closed versus open suction-system. Nurs Crit Care 2013; 19:34-41. [DOI: 10.1111/nicc.12010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 10/08/2012] [Accepted: 11/27/2012] [Indexed: 01/04/2023]
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Changes in heart rate, mean arterial pressure, and oxygen saturation after open and closed endotracheal suctioning: A prospective observational study. J Crit Care 2012; 27:647-54. [DOI: 10.1016/j.jcrc.2012.02.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 02/20/2012] [Accepted: 02/26/2012] [Indexed: 11/19/2022]
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Antibiotic exposure and resistance development in Pseudomonas aeruginosa and Enterobacter species in intensive care units. Crit Care Med 2011; 39:2458-63. [PMID: 21705892 DOI: 10.1097/ccm.0b013e318225756d] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES We quantified the association between antibiotic exposure and acquisition of antibiotic resistance in Pseudomonas aeruginosa and Enterobacter species in intensive care unit patients. DESIGN Prospective cohort study. SETTING AND PATIENTS In 1,201 patients, respiratory tract colonization was determined through regular screening on admission, twice weekly, and on discharge. Primary outcome was the acquisition of antibiotic resistance in previous antibiotic sensitive P. aeruginosa and Enterobacter species, with acquisition attributable to cross-transmission excluded based on genotyping and epidemiologic linkage. Cox regression analysis, adjusted for covariates, was performed to calculate hazard ratios of patients exposed to antibiotics compared to patients not exposed to antibiotics. MEASUREMENTS AND MAIN RESULTS In total, 194 and 171 patients were colonized with P. aeruginosa and Enterobacter species, respectively. Two or more cultures per episode were available for 126 and 108 patients. For P. aeruginosa, ceftazidime exposure was associated with 6.3 acquired antibiotic resistance events per 100 days of exposure, whereas incidence rates were lower for ciprofloxacin, meropenem, and piperacillin-tazobactam. In multivariate analysis, meropenem, ciprofloxacin, and ceftazidime were significantly associated with risk of resistance development in P. aeruginosa (adjusted hazard ratio, 11.1; 95% confidence interval, 2.4-51.5 for meropenem; adjusted hazard ratio, 4.1; 95% confidence interval, 1.1-16.2 for ciprofloxacin; adjusted hazard ratio, 2.5; 95% confidence interval, 1.1-5.5 for ceftazidime). For Enterobacter, ceftriaxone and ciprofloxacin exposure were associated with most antibiotic resistance acquisitions. No significant associations were found in multivariate analysis. CONCLUSIONS Meropenem exposure is associated with the highest risk of resistance development in P. aeruginosa. Increasing carbapenem use attributable to emergence of Gram-negative bacteria producing extended-spectrum β-lactamases will enhance antibiotic resistance in P. aeruginosa.
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