1
|
Nohra E, Appelbaum RD, Farrell MS, Carver T, Jung HS, Kirsch JM, Kodadek LM, Mandell S, Nassar AK, Pathak A, Paul J, Robinson B, Cuschieri J, Stein DM. Fever and infections in surgical intensive care: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open 2024; 9:e001303. [PMID: 38835635 PMCID: PMC11149120 DOI: 10.1136/tsaco-2023-001303] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/11/2024] [Indexed: 06/06/2024] Open
Abstract
The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.
Collapse
Affiliation(s)
- Eden Nohra
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rachel D Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Thomas Carver
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Hee Soo Jung
- Department of Surgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jordan Michael Kirsch
- Department of Surgery, Westchester Medical Center/ New York Medical College, Valhalla, NY, USA
| | - Lisa M Kodadek
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samuel Mandell
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aussama Khalaf Nassar
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California, USA
| | - Abhijit Pathak
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jasmeet Paul
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Bryce Robinson
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Joseph Cuschieri
- Department of Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Deborah M Stein
- Department of Surgery, University of Maryland Baltimore, Baltimore, Maryland, USA
| |
Collapse
|
2
|
A J, S S S, K S, T S M. Extracellular vesicles in bacterial and fungal diseases - Pathogenesis to diagnostic biomarkers. Virulence 2023; 14:2180934. [PMID: 36794396 PMCID: PMC10012962 DOI: 10.1080/21505594.2023.2180934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Intercellular communication among microbes plays an important role in disease exacerbation. Recent advances have described small vesicles, termed as "extracellular vesicles" (EVs), previously disregarded as "cellular dust" to be vital in the intracellular and intercellular communication in host-microbe interactions. These signals have been known to initiate host damage and transfer of a variety of cargo including proteins, lipid particles, DNA, mRNA, and miRNAs. Microbial EVs, referred to generally as "membrane vesicles" (MVs), play a key role in disease exacerbation suggesting their importance in pathogenicity. Host EVs help coordinate antimicrobial responses and prime the immune cells for pathogen attack. Hence EVs with their central role in microbe-host communication, may serve as important diagnostic biomarkers of microbial pathogenesis. In this review, we summarize current research regarding the roles of EVs as markers of microbial pathogenesis with specific focus on their interaction with host immune defence and their potential as diagnostic biomarkers in disease conditions.
Collapse
Affiliation(s)
- Jnana A
- Department of Biotechnology, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Sadiya S S
- Department of Biotechnology, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Satyamoorthy K
- Department of Cell and Molecular Biology, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Murali T S
- Department of Biotechnology, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India
| |
Collapse
|
3
|
Giamarellou H, Galani L, Karavasilis T, Ioannidis K, Karaiskos I. Antimicrobial Stewardship in the Hospital Setting: A Narrative Review. Antibiotics (Basel) 2023; 12:1557. [PMID: 37887258 PMCID: PMC10604258 DOI: 10.3390/antibiotics12101557] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.
Collapse
Affiliation(s)
- Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Lamprini Galani
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Theodoros Karavasilis
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Konstantinos Ioannidis
- Clinical Pharmacists, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece;
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| |
Collapse
|
4
|
Natarajan R, Ramanathan V, Sistla S. Poor Sensorium at the Time of Intubation Predicts Polymicrobial Ventilator Associated Pneumonia. Ther Clin Risk Manag 2022; 18:125-133. [PMID: 35210780 PMCID: PMC8860453 DOI: 10.2147/tcrm.s337341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with a high mortality rate. Aim The study was conducted to estimate the frequency, outcomes, and predictors of polymicrobial VAP. Methods A prospective observational study was conducted in mechanically ventilated adult patients in the medical intensive care unit in a tertiary care hospital in India from July 2016 to July 2018 with a 30-day follow-up period. The patients were grouped into monomicrobial and polymicrobial VAP. We compared the 30-day outcome parameters such as discharge from hospital, in-hospital stay, death, and complications such as catheter associated urinary tract infection (CAUTI), central line associated blood stream infection (CRBSI), bacteremia and collapse of lung. The predictors of polymicrobial VAP were identified by multiple logistic regression. Results Out of 301 patients clinically diagnosed with VAP, 151 patients were excluded, and the remaining 150 developed 186 episodes of VAP during the study period. The incidence of polymicrobial VAP was 62.9%. Out of 150 patients, 51 patients had monomicrobial VAP, and 99 had polymicrobial VAP. On univariate analysis, diabetes mellitus and poor sensorium (Glasgow Coma Scale [GCS] score <8) during endotracheal intubation; 30-day outcome, mean days of mechanical ventilation after VAP diagnosis and days in ICU; and CAUTI were significantly associated with polymicrobial VAP. On multivariable logistic regression, poor sensorium (GCS score <8) at the time of endotracheal intubation was an independent predictor of polymicrobial VAP. Conclusion The incidence of polymicrobial VAP is high in the medical ICU and is associated with increased duration of mechanical ventilation, hospital stay, and incidence of CAUTI. Poor GCS score was the single independent predictor of polymicrobial VAP.
Collapse
Affiliation(s)
- Ramachandran Natarajan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Venkateswaran Ramanathan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
- Correspondence: Venkateswaran Ramanathan, Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, 605006, India, Email
| | - Sujatha Sistla
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| |
Collapse
|
5
|
Riccobono E, Bussini L, Giannella M, Viale P, Rossolini GM. Rapid diagnostic tests in the management of pneumonia. Expert Rev Mol Diagn 2021; 22:49-60. [PMID: 34894965 DOI: 10.1080/14737159.2022.2018302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Pneumonia is one of the main causes of mortality associated with infectious diseases worldwide. Several challenges have been identified in the management of patients with pneumonia, ranging from accurate and cost-effective microbiological investigations, prompt and adequate therapeutic management, and optimal treatment duration. AREAS COVERED In this review, an updated summary on the current management of pneumonia patients is provided and the epidemiological issues of infectious respiratory diseases, which in the current pandemic situation are of particular concern, are addressed. The clinical and microbiological approaches to pneumonia diagnosis are reviewed, including discussion about the new molecular assays pointing out both their strengths and limitations. Finally, the current recommendations about antibiotic treatment are examined and discussed depending on the epidemiological contexts, including those with high prevalence of multidrug-resistant bacteria. EXPERT OPINION We claim that rapid diagnostic tests, if well-positioned in the diagnostic workflow and reserved for the subset of patients who could most benefit from these technologies, may represent an interesting and feasible tool to optimize timing of targeted treatments especially in terms of early de-escalation or discontinuation of antibiotic therapy.
Collapse
Affiliation(s)
- Eleonora Riccobono
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Linda Bussini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant' Orsola, Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant' Orsola, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant' Orsola, Bologna, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Clinical Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| |
Collapse
|
6
|
Diagnostic and prognostic prediction models in ventilator-associated pneumonia: Systematic review and meta-analysis of prediction modelling studies. J Crit Care 2021; 67:44-56. [PMID: 34673331 DOI: 10.1016/j.jcrc.2021.10.001] [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: 04/14/2021] [Revised: 08/23/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Existing expert systems have not improved the diagnostic accuracy of ventilator-associated pneumonia (VAP). The aim of this systematic literature review was to review and summarize state-of-the-art prediction models detecting or predicting VAP from exhaled breath, patient reports and demographic and clinical characteristics. METHODS Both diagnostic and prognostic prediction models were searched from a representative list of multidisciplinary databases. An extensive list of validated search terms was added to the search to cover papers failing to mention predictive research in their title or abstract. Two authors independently selected studies, while three authors extracted data using predefined criteria and data extraction forms. The Prediction Model Risk of Bias Assessment Tool was used to assess both the risk of bias and the applicability of the prediction modelling studies. Technology readiness was also assessed. RESULTS Out of 2052 identified studies, 20 were included. Fourteen (70%) studies reported the predictive performance of diagnostic models to detect VAP from exhaled human breath with a high degree of sensitivity and a moderate specificity. In addition, the majority of them were validated on a realistic dataset. The rest of the studies reported the predictive performance of diagnostic and prognostic prediction models to detect VAP from unstructured narratives [2 (10%)] as well as baseline demographics and clinical characteristics [4 (20%)]. All studies, however, had either a high or unclear risk of bias without significant improvements in applicability. CONCLUSIONS The development and deployment of prediction modelling studies are limited in VAP and related outcomes. More computational, translational, and clinical research is needed to bring these tools from the bench to the bedside. REGISTRATION PROSPERO CRD42020180218, registered on 05-07-2020.
Collapse
|
7
|
E L, Zhao B, Liu H, Zheng C, Song X, Cai Y, Liang H. Image-based deep learning in diagnosing the etiology of pneumonia on pediatric chest X-rays. Pediatr Pulmonol 2021; 56:1036-1044. [PMID: 33331678 DOI: 10.1002/ppul.25229] [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: 05/05/2020] [Revised: 12/07/2020] [Accepted: 12/13/2020] [Indexed: 11/12/2022]
Abstract
PURPOSE Comparing the efficacy of a deep-learning model in classifying the etiology of pneumonia on pediatric chest X-rays (CXRs) with that of human readers. METHODS We built a clinical-pediatric CXR set containing 4035 patients to exploit a deep-learning model called Resnet-50 for differentiating viral from bacterial pneumonia. The dataset was split into training (80%) and validation (20%). Model performance was assessed by receiver operating characteristic curve and area under the curve (AUC) on the first test set of 400 CXRs collected from different studies. For the second test set composed of 100 independent examinations obtained from the daily clinical practice at our institution, the kappa coefficient was selected to measure the interrater agreement in a pairwise fashion for the reference standard, all reviewers, and the model. Gradient-weighted class activation mapping was used to visualize the significant areas contributing to the model prediction. RESULTS On the first test set, the best-performing classifier achieved an AUC of 0.919 (p < .001), with a sensitivity of 79.0% and specificity of 88.9%. On the second test set, the classifier achieved performance similar to that of human experts, which resulted in a sensitivity of 74.3% and specificity of 90.8%, positive and negative likelihood ratios of 8.1 and 0.3, respectively. Contingence tables and kappa values further revealed that expert reviewers and model reached substantial agreements on differentiating the etiology of pediatric pneumonia. CONCLUSIONS This study demonstrated that the model performed similarly as human reviewers and recognized the regions of pathology on CXRs.
Collapse
Affiliation(s)
- Longjiang E
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Baisong Zhao
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hongsheng Liu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Changmeng Zheng
- Department of Software Engineering, School of Software Engineering, South China University of Technology, Guangzhou, Guangdong, China
| | - Xingrong Song
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yi Cai
- Department of Software Engineering, School of Software Engineering, South China University of Technology, Guangzhou, Guangdong, China.,The Key Laboratory of Big Data and Intelligent Robot (South China University of Technology), Ministry of Education, Guangzhou, Guangdong, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| |
Collapse
|
8
|
Vallecoccia MS, Dominedò C, Cutuli SL, Martin-Loeches I, Torres A, De Pascale G. Is ventilated hospital-acquired pneumonia a worse entity than ventilator-associated pneumonia? Eur Respir Rev 2020; 29:29/157/200023. [PMID: 32759376 PMCID: PMC9488552 DOI: 10.1183/16000617.0023-2020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/14/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Nosocomial pneumonia develops after ≥48 h of hospitalisation and is classified as ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP); the latter may require mechanical ventilation (V-HAP) or not (NV-HAP). Main findings VAP and HAP affect a significant proportion of hospitalised patients and are characterised by poor clinical outcomes. Among them, V-HAP has the greatest 28-day mortality rate followed by VAP and NV-HAP (27.8% versus 18% versus 14.5%, respectively). However, no differences in terms of pathophysiology, underlying microbiological pathways and subsequent therapy have been identified. International guidelines suggest specific flow charts to help clinicians in the therapeutic management of such diseases; however, there are no specific recommendations beyond VAP and HAP classification. HAP subtypes are scarcely considered as different entities and the lack of data from the clinical scenario limits any final conclusion. Hopefully, recent understanding of the pathophysiology of such diseases, as well as the discovery of new therapies, will improve the outcome associated with such pulmonary infections. Conclusion Nosocomial pneumonia is a multifaced disease with features of pivotal interest in critical care medicine. Due to the worrisome data on mortality of patients with nosocomial pneumonia, further prospective studies focused on this topic are urgently needed. Due to the different mortality of each subtype of nosocomial pneumonia, including ventilator-associated pneumonia and hospital-acquired pneumonia requiring mechanical ventilation, new prospective studies are urgently neededhttps://bit.ly/3fFoZ6U
Collapse
Affiliation(s)
- Maria Sole Vallecoccia
- Dept of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy.,Joint first authors
| | - Cristina Dominedò
- Dept of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy.,Joint first authors
| | - Salvatore Lucio Cutuli
- Dept of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ignacio Martin-Loeches
- Dept of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland.,Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Gennaro De Pascale
- Dept of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy .,Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
9
|
An overview of guidelines for the management of hospital-acquired and ventilator-associated pneumonia caused by multidrug-resistant Gram-negative bacteria. Curr Opin Infect Dis 2020; 32:656-662. [PMID: 31567412 DOI: 10.1097/qco.0000000000000596] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Multidrug-resistant (MDR) Gram-negative pathogens in hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are associated with poor clinical outcomes. These pathogens represent a global threat with few therapeutic options. In this review, we discuss current guidelines for the empiric management of HAP/VAP caused by MDR Gram-negative pathogens. RECENT FINDINGS The incidence of MDR Gram-negative bacteria is rising among cases of nosocomial pneumonia, such that it is now becoming a significant challenge for clinicians. Adherence to international guidelines may ensure early and adequate antimicrobial therapy, guided by local microbiological data and awareness of the risk factors for MDR bacteria. SUMMARY Due to the increasing prevalence of HAP/VAP caused by MDR Gram-negative pathogens, management should be guided by the local ecology and the patient's risk factors for MDR pathogens. The main risk factors are prior hospitalization for at least 5 days, prior use of broad-spectrum antibiotics, prior colonization with resistant pathogens, admission to hospital settings with high rates of MDR pathogens, and septic shock at the time of diagnosis with nosocomial pneumonia.
Collapse
|
10
|
Chen CY, Lin WC, Yang HY. Diagnosis of ventilator-associated pneumonia using electronic nose sensor array signals: solutions to improve the application of machine learning in respiratory research. Respir Res 2020; 21:45. [PMID: 32033607 PMCID: PMC7006122 DOI: 10.1186/s12931-020-1285-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/07/2020] [Indexed: 01/07/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is a significant cause of mortality in the intensive care unit. Early diagnosis of VAP is important to provide appropriate treatment and reduce mortality. Developing a noninvasive and highly accurate diagnostic method is important. The invention of electronic sensors has been applied to analyze the volatile organic compounds in breath to detect VAP using a machine learning technique. However, the process of building an algorithm is usually unclear and prevents physicians from applying the artificial intelligence technique in clinical practice. Clear processes of model building and assessing accuracy are warranted. The objective of this study was to develop a breath test for VAP with a standardized protocol for a machine learning technique. Methods We conducted a case-control study. This study enrolled subjects in an intensive care unit of a hospital in southern Taiwan from February 2017 to June 2019. We recruited patients with VAP as the case group and ventilated patients without pneumonia as the control group. We collected exhaled breath and analyzed the electric resistance changes of 32 sensor arrays of an electronic nose. We split the data into a set for training algorithms and a set for testing. We applied eight machine learning algorithms to build prediction models, improving model performance and providing an estimated diagnostic accuracy. Results A total of 33 cases and 26 controls were used in the final analysis. Using eight machine learning algorithms, the mean accuracy in the testing set was 0.81 ± 0.04, the sensitivity was 0.79 ± 0.08, the specificity was 0.83 ± 0.00, the positive predictive value was 0.85 ± 0.02, the negative predictive value was 0.77 ± 0.06, and the area under the receiver operator characteristic curves was 0.85 ± 0.04. The mean kappa value in the testing set was 0.62 ± 0.08, which suggested good agreement. Conclusions There was good accuracy in detecting VAP by sensor array and machine learning techniques. Artificial intelligence has the potential to assist the physician in making a clinical diagnosis. Clear protocols for data processing and the modeling procedure needed to increase generalizability.
Collapse
Affiliation(s)
- Chung-Yu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Douliu, Taiwan
| | - Wei-Chi Lin
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Hsiao-Yu Yang
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan. .,Institute of Environmental and Occupational Health Sciences, National Taiwan University College of Public Health, Taipei, Taiwan. .,Department of Public Health, National Taiwan University College of Public Health, Taipei, Taiwan. .,Department of Environmental and Occupational Medicine, National Taiwan University Hospital, Taipei, Taiwan. .,Innovation and Policy Center for Population Health and Sustainable Environment, College of Public Health, National Taiwan University, Taipei, Taiwan.
| |
Collapse
|
11
|
Boattini M, Bianco G, Iannaccone M, Charrier L, Almeida A, De Intinis G, Cavallo R, Costa C. Accuracy of the ELITe MGB assays for the detection of carbapenemases, CTX-M, Staphylococcus aureus and mecA/C genes directly from respiratory samples. J Hosp Infect 2020; 105:306-310. [PMID: 31931044 DOI: 10.1016/j.jhin.2019.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/30/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Bacterial lower respiratory tract infections (BLRTI) may represent serious clinical conditions which can lead to respiratory failure, intensive care unit admission and high hospital costs. The detection of carbapenemase- and extended-spectrum β-lactamase (ESBL)-producing Enterobacterales, as well as meticillin-resistant Staphylococcus aureus (MRSA), has become a major issue, especially in healthcare-associated infections. This study aimed to determine whether molecular assays could detect genes encoding carbapenemases, ESBL and MRSA directly from respiratory samples in order to expedite appropriate therapy and infection control for patients with BLRTI. METHODS The carbapenem-resistant enterobacterales (CRE), ESBL and MRSA/SA ELITe MGB assays were performed directly on 354 respiratory specimens sampled from 318 patients admitted with BLRTI. Molecular results were compared with routine culture-based diagnostics results. RESULTS Positive (PPV) and negative (NPV) predictive values of the CRE ELITe MGB kit were 75.9% [95% confidence interval (CI) 60.3-86.7] and 100%, respectively. PPV and NPV of the ESBL ELITe MGB kit were 80.8% (95% CI 63.6-91.0) and 99.1% (95% CI 96.6-99.8), respectively. PPV and NPV of the MRSA/SA ELITe MGB kit were 91.7% (95% CI 73.7-97.7)/100% and 98.3% (95% CI 89.8-99.3)/96.8% (95% CI 81.6-99.5), respectively. DISCUSSION Validity assessment of molecular assays detecting the main antibiotic resistance genes directly from respiratory samples showed high accuracy compared with culture-based results. Molecular assays detecting the main carbapenemase, ESBL, S. aureus and meticillin resistance encoding genes provide an interesting tool with potential to expedite optimization of antibiotic therapy and infection control practices in patients with BLRTI.
Collapse
Affiliation(s)
- M Boattini
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy.
| | - G Bianco
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - M Iannaccone
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - L Charrier
- Department of Public Health and Paediatrics, University of Torino, Turin, Italy
| | - A Almeida
- Department of Internal Medicine 4, Hospital de Santa Marta, Central Lisbon Hospital Centre, Lisbon, Portugal; NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - G De Intinis
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - R Cavallo
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - C Costa
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| |
Collapse
|
12
|
Bakare OO, Fadaka AO, Klein A, Keyster M, Pretorius A. Diagnostic approaches of pneumonia for commercial-scale biomedical applications: an overview. ALL LIFE 2020. [DOI: 10.1080/26895293.2020.1826363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Olalekan Olanrewaju Bakare
- Bioinformatics Research Group, Department of Biotechnology, Faculty of Natural Sciences, University of the Western Cape, Bellville, South Africa
- Environmental Biotechnology Laboratory, Department of Biotechnology, Faculty of Natural Sciences, University of the Western Cape, Bellville, South Africa
| | - Adewale Oluwaseun Fadaka
- Bioinformatics Research Group, Department of Biotechnology, Faculty of Natural Sciences, University of the Western Cape, Bellville, South Africa
- Department of Science and Technology/Mintek Nanotechnology Innovation Centre, Bio-labels Node, Department of Biotechnology, Faculty of Natural Sciences, University of the Western Cape, Bellville, South Africa
| | - Ashwil Klein
- Environmental Biotechnology Laboratory, Department of Biotechnology, Faculty of Natural Sciences, University of the Western Cape, Bellville, South Africa
| | - Marshall Keyster
- Environmental Biotechnology Laboratory, Department of Biotechnology, Faculty of Natural Sciences, University of the Western Cape, Bellville, South Africa
| | - Ashley Pretorius
- Bioinformatics Research Group, Department of Biotechnology, Faculty of Natural Sciences, University of the Western Cape, Bellville, South Africa
| |
Collapse
|
13
|
Liapikou A, Cillóniz C, Torres A. Emerging strategies for the noninvasive diagnosis of nosocomial pneumonia. Expert Rev Anti Infect Ther 2019; 17:523-533. [PMID: 31237462 PMCID: PMC7103721 DOI: 10.1080/14787210.2019.1635010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Hospital-acquired pneumonia is a common and therapeutically challenging diagnosis that can lead to severe sepsis, critical illness, and respiratory failure. In this review, we focus on efforts to enhance microbiological diagnosis of hospital-acquired pneumonia, including ventilator-associated pneumonia. Areas covered: A systematic literature review was conducted by searching Medline from inception to December 2018, including hand-searching of the reference lists for additional studies. The search strategy comprised the following common search terms: hospital pneumonia OR nosocomial pneumonia OR noninvasive OR molecular diagnostic tests (OR point-of-care systems OR VOC [i.e. volatile organic compounds]) OR rapid (or simple or quick test), including brand names for the most common commercial tests. Expert opinion: In recent years, the microbiological diagnosis of respiratory pathogens has improved significantly by the development and implementation of molecular diagnostic tests for pneumonia. Real-time polymerase chain reaction, hybridization, and mass spectrometry-based platforms dominate the scene, with microarray-based assays, multiplex polymerase chain reaction, and MALDI-TOF mass spectrometry capable of detecting the determinants of antimicrobial resistance (mainly β-lactamase genes). Introducing these assays into routine clinical practice for rapid identification of the causative microbes and their resistance patterns could transform the care of pneumonia, improving antimicrobial selection, de-escalation, and stewardship.
Collapse
Affiliation(s)
- Adamantia Liapikou
- a 6th Respiratory Department , Sotiria Chest Diseases Hospital , Athens , Greece
| | - Catia Cillóniz
- b Servei de Pneumologia , Institut Clinic del Tòrax, Hospital Clinic, Barcelona, IDIBAPS, CIBER Enfermedades Respiratorias, University of Barcelona , Barcelona , Spain
| | - Antoni Torres
- b Servei de Pneumologia , Institut Clinic del Tòrax, Hospital Clinic, Barcelona, IDIBAPS, CIBER Enfermedades Respiratorias, University of Barcelona , Barcelona , Spain
| |
Collapse
|
14
|
Abstract
Pneumonia is a highly prevalent disease with considerable morbidity and mortality. However, diagnosis and therapy still rely on antiquated methods, leading to the vast overuse of antimicrobials, which carries risks for both society and the individual. Furthermore, outcomes in severe pneumonia remain poor. Genomic techniques have the potential to transform the management of pneumonia through deep characterization of pathogens as well as the host response to infection. This characterization will enable the delivery of selective antimicrobials and immunomodulatory therapy that will help to offset the disorder associated with overexuberant immune responses.
Collapse
Affiliation(s)
- Samir Gautam
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA
| | - Lokesh Sharma
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA
| | - Charles S Dela Cruz
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA.
| |
Collapse
|
15
|
Peña-López Y, Ramirez-Estrada S, Eshwara VK, Rello J. Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes. Expert Rev Respir Med 2018; 12:1037-1050. [PMID: 30460868 DOI: 10.1080/17476348.2018.1549492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
Collapse
Affiliation(s)
- Yolanda Peña-López
- a Pediatric Critical Care Department , Vall d'Hebron Barcelona Hospital Campus , Barcelona , Spain
| | | | - Vandana Kalwaje Eshwara
- c Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education , Manipal University , Manipal , India
| | - Jordi Rello
- d Clinical Research/epidemiology In Pneumonia & Sepsis , Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
| |
Collapse
|
16
|
Villiers L, Caspar Y, Marche H, Boccoz S, Maurin M, Marche P, Morand P, Marquette C, Corgier B. ReSynPlex: Respiratory Syndrome Linked Pathogens Multiplex Detection and Characterization. Ing Rech Biomed 2018. [DOI: 10.1016/j.irbm.2018.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
17
|
Li Bassi G, Prats RG, Artigas A, Xiol EA, Marti JD, Ranzani OT, Rigol M, Fernandez L, Meli A, Battaglini D, Luque N, Ferrer M, Martin-Loeches I, Póvoa P, Chiumello D, Pelosi P, Torres A. Appraisal of systemic inflammation and diagnostic markers in a porcine model of VAP: secondary analysis from a study on novel preventive strategies. Intensive Care Med Exp 2018; 6:42. [PMID: 30343359 PMCID: PMC6195872 DOI: 10.1186/s40635-018-0206-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/30/2018] [Indexed: 01/28/2023] Open
Abstract
Background We previously evaluated the efficacy of a ventilatory strategy to achieve expiratory flow bias and positive end-expiratory pressure (EFB + PEEP) or the Trendelenburg position (TP) for the prevention of ventilator-associated pneumonia (VAP). These preventive measures were aimed at improving mucus clearance and reducing pulmonary aspiration of bacteria-laden oropharyngeal secretions. This secondary analysis is aimed at evaluating the effects of aforementioned interventions on systemic inflammation and to substantiate the value of clinical parameters and cytokines in the diagnosis of VAP. Methods Twenty female pigs were randomized to be positioned in the semirecumbent/prone position, and ventilated with duty cycle 0.33 and without PEEP (control); positioned as in the control group, PEEP 5 cmH2O, and duty cycle to achieve expiratory flow bias (EFB+PEEP); ventilated as in the control group, but in the Trendelenburg position (Trendelenburg). Following randomization, P. aeruginosa was instilled into the oropharynx. Systemic cytokines and tracheal secretions P. aeruginosa concentration were quantified every 24h. Lung biopsies were collected for microbiological confirmation of VAP. Results In the control, EFB + PEEP, and Trendelenburg groups, lung tissue Pseudomonas aeruginosa concentration was 2.4 ± 1.5, 1.9 ± 2.1, and 0.3 ± 0.6 log cfu/mL, respectively (p = 0.020). Whereas, it was 2.4 ± 1.9 and 0.6 ± 0.9 log cfu/mL in animals with or without VAP (p < 0.001). Lower levels of interleukin (IL)-1β (p = 0.021), IL-1RA (p < 0.001), IL-4 (p = 0.005), IL-8 (p = 0.008), and IL-18 (p = 0.050) were found in Trendelenburg animals. VAP increased IL-10 (p = 0.035), tumor necrosis factor-α (p = 0.041), and endotracheal aspirate (ETA) P. aeruginosa concentration (p = 0.024). A model comprising ETA bacterial burden, IL-10, and TNF-α yielded moderate discrimination for the diagnosis of VAP (area of the receiver operating curve 0.82, 95% CI 0.61–1.00). Conclusions Our findings demonstrate anti-inflammatory effects associated with the Trendelenburg position. In this reliable model of VAP, ETA culture showed good diagnostic accuracy, whereas systemic IL-10 and TNF-α marginally improved accuracy. Further clinical studies will be necessary to confirm clinical value of the Trendelenburg position as a measure to hinder inflammation during mechanical ventilation and significance of systemic IL-10 and TNF-α in the diagnosis of VAP.
Collapse
Affiliation(s)
- Gianluigi Li Bassi
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - Raquel Guillamat Prats
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,Pathophysiological Laboratory, Institut de Investigacion Parc Tauli, Corporació Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Barcelona, Spain
| | - Antonio Artigas
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,Pathophysiological Laboratory, Institut de Investigacion Parc Tauli, Corporació Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Barcelona, Spain
| | - Eli Aguilera Xiol
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Joan-Daniel Marti
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain
| | - Otavio T Ranzani
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain
| | - Montserrat Rigol
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Cardiology Department, Hospital Clinic, Barcelona, Spain
| | - Laia Fernandez
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - Andrea Meli
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain.,Dipartimento di Anestesia e Rianimazione, ASST Santi Paolo e Carlo, Dipartimento di Scienza e Salute, Universita degli Studi di Milano, Milan, Italy
| | - Denise Battaglini
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain.,Dipartimento Scienze Chirurgiche e Diagnostiche Integrate (DISC), Università degli Studi di Genova, Genova, Italy
| | - Nestor Luque
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain
| | - Miguel Ferrer
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's University Hospital, Dublin, Ireland
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CEDOC, New University of Lisbon, Lisbon, Portugal
| | - Davide Chiumello
- Dipartimento di Anestesia e Rianimazione, ASST Santi Paolo e Carlo, Dipartimento di Scienza e Salute, Universita degli Studi di Milano, Milan, Italy
| | - Paolo Pelosi
- Dipartimento Scienze Chirurgiche e Diagnostiche Integrate (DISC), Università degli Studi di Genova, Genova, Italy
| | - Antoni Torres
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Thorax Institute, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Pl 2, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain. .,University of Barcelona, Barcelona, Spain.
| |
Collapse
|
18
|
Pulmonary infections in critical/intensive care - rapid diagnosis and optimizing antimicrobial usage. Curr Opin Pulm Med 2018; 23:198-203. [PMID: 28257317 DOI: 10.1097/mcp.0000000000000366] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Diagnosis of pulmonary infection, including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in the critically ill patient remains a common and therapeutically challenging diagnosis with significant attributable morbidity, mortality, and cost. Current clinical approaches to surveillance, early detection and, conventional culture-based microbiology are inadequate for optimal targeted antibiotic treatment and stewardship. Efforts to enhance diagnosis of HAP and VAP and the impact of these novel approaches on rational antimicrobial selection and stewardship are the focus of recent studies reviewed here. RECENT FINDINGS Recent consensus guidelines for diagnosis and management of HAP and VAP are relatively silent on the potential role of novel rapid microbiological techniques and reply heavily on conventional culture strategies of noninvasively obtained (including endotracheal aspirate samples). Novel rapid microbiological diagnostics, including nucleic acid amplification, mass spectrometry, and fluorescence microscopy-based technologies are promising approaches for the future. Exhaled breath biomarkers, including measurement of VOC represent a future approach. SUMMARY Further validation of novel diagnostic technology platforms will be required to evaluate their utility for enhancing diagnosis and guiding treatment of pulmonary infections in the critically ill. However, the integration of novel diagnostics for rapid microbial identification, resistance phenotyping, and antibiotic sensitivity testing into usual care practice could significantly transform the care of patients and potentially inform improved targeted antimicrobial selection, de-escalation, and stewardship.
Collapse
|
19
|
Paling FP, Troeman DPR, Wolkewitz M, Kalyani R, Prins DR, Weber S, Lammens C, Timbermont L, Goossens H, Malhotra-Kumar S, Sifakis F, Bonten MJM, Kluytmans JAJW. Rationale and design of ASPIRE-ICU: a prospective cohort study on the incidence and predictors of Staphylococcus aureus and Pseudomonas aeruginosa pneumonia in the ICU. BMC Infect Dis 2017; 17:643. [PMID: 28946849 PMCID: PMC5613521 DOI: 10.1186/s12879-017-2739-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/14/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The epidemiology of ICU pneumonia caused by Staphylococcus aureus (S. aureus) and Pseudomonas aeruginosa (P. aeruginosa) is not fully described, but is urgently needed to support the development of effective interventions. The objective of this study is to estimate the incidence of S. aureus and P. aeruginosa ICU pneumonia and to assess its association with patient-related and contextual risk factors. METHODS ASPIRE-ICU is a prospective, observational, multi-center cohort study nested within routine surveillance among ICU patients in Europe describing the occurrence of S. aureus and P. aeruginosa ICU pneumonia. Two thousand (2000) study cohort subjects will be enrolled (50% S. aureus colonized) in which specimens and data will be collected. Study cohort subjects will be enrolled from a larger surveillance population, in which basic surveillance data is captured. The primary outcomes are the incidence of S. aureus ICU acquired pneumonia and the incidence of P. aeruginosa ICU acquired pneumonia through ICU stay. The analysis will include advanced survival techniques (competing risks and multistate models) for each event separately as well as for the sub-distribution of ICU pneumonia to determine independent association of outcomes with risk factors.. A risk prediction model will be developed to quantify the risk for acquiring S. aureus or P. aeruginosa ICU pneumonia during ICU stay by using a composite score of independent risk factors. DISCUSSION The diagnosis of pathogen-specific ICU pneumonia is difficult, however, the criteria used in this study are objective and comparable to those in the literature. TRIAL REGISTRATION This study is registered on clinicaltrials.gov under identifier NCT02413242 .
Collapse
Affiliation(s)
- Fleur P Paling
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, HP Stratenum 6.131, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Darren P R Troeman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, HP Stratenum 6.131, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Martin Wolkewitz
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | | | - Daniël R Prins
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, HP Stratenum 6.131, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Susanne Weber
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Christine Lammens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium
| | - Leen Timbermont
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium
| | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium
| | | | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, HP Stratenum 6.131, PO Box 85500, 3508 GA, Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jan A J W Kluytmans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, HP Stratenum 6.131, PO Box 85500, 3508 GA, Utrecht, The Netherlands.,Amphia Hospital, Breda, The Netherlands
| |
Collapse
|
20
|
Roberts KL, Micek ST, Juang P, Kollef MH. Controversies and advances in the management of ventilator associated pneumonia. Expert Rev Respir Med 2017; 11:875-884. [PMID: 28891372 DOI: 10.1080/17476348.2017.1378574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Although national surveillance data suggests that the incidence of ventilator associated pneumonia (VAP) is down-trending, it remains one of the most commonly encountered hospital acquired infections in the United States and worldwide. Its association with increased healthcare costs and worsened patient outcomes warrants continued effort to improve the care of patients with VAP. Areas covered: The increasing prevalence of multi-drug resistant bacteria further drives the need to explore advances in diagnostic and treatment options. In this review, controversies pertaining to the definition and diagnosis of VAP as well as empiric treatment strategies will be discussed along with several developments related to rapid microbiologic testing methods and the use of non-traditional antimicrobial agents. Expert commentary: The application of rapid diagnostic techniques to identify microbial pathogens is perhaps one of the most impactful advancements in the treatment of serious nosocomial infections. This technology has the potential to reduce inappropriate initial antimicrobial therapy, unnecessary antimicrobial exposure, and mortality in patients with VAP. In addition, the anticipated approval of new antimicrobial agents within the next several years will provide a much-needed expansion of available treatment options in an era of growing antimicrobial resistance.
Collapse
Affiliation(s)
| | - Scott T Micek
- b Division of Pharmacy Practice , St Louis College of Pharmacy , St Louis , MO , USA
| | - Paul Juang
- b Division of Pharmacy Practice , St Louis College of Pharmacy , St Louis , MO , USA
| | - Marin H Kollef
- c Division of Pulmonary and Critical Care Medicine , Washington University School of Medicine , St Louis , MO , USA
| |
Collapse
|
21
|
Niederman MS, Martin-Loeches I, Torres A. The research agenda in VAP/HAP: next steps. Intensive Care Med 2017; 43:1389-1391. [PMID: 28197677 DOI: 10.1007/s00134-017-4695-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 01/25/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, 425 E. 61st St, 4th Floor, New York, NY, 10065, USA.
| | - Ignacio Martin-Loeches
- Intensive Care Medicine, Department of Clinical Medicine, St. James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
| | - Antoni Torres
- Pulmonary Intensive Care Unit, Respiratory Institute, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
22
|
Torres A, Lee N, Cilloniz C, Vila J, Van der Eerden M. Laboratory diagnosis of pneumonia in the molecular age. Eur Respir J 2016; 48:1764-1778. [PMID: 27811073 DOI: 10.1183/13993003.01144-2016] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 09/17/2016] [Indexed: 01/20/2023]
Abstract
Pneumonia remains a worldwide health problem with a high rate of morbidity and mortality. Identification of microbial pathogens which cause pneumonia is an important area for optimum clinical management of pneumonia patients and is a big challenge for conventional microbiological methods. The development and implementation of molecular diagnostic tests for pneumonia has been a major advance in the microbiological diagnosis of respiratory pathogens in recent years. However, with new knowledge regarding the microbiome, together with the recognition that the lungs are a dynamic microbiological ecosystem, our current concept of pneumonia is not totally realistic as this new concept of pneumonia involves a dysbiosis or alteration of the lung microbiome. A new challenge for microbiologists and clinicians has therefore arisen. There is much to learn regarding the information provided by this new diagnostic technology, which will lead to improvements in the time to antibiotic therapy, targeted antibiotic selection and more effective de-escalation and improved stewardship for pneumonia patients. This article provides an overview of current methods of laboratory diagnosis of pneumonia in the molecular age.
Collapse
Affiliation(s)
- Antoni Torres
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Nelson Lee
- Division of Infectious Diseases, Dept of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Catia Cilloniz
- Dept of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Jordi Vila
- Servei de Microbiologia, Hospital Clinic, ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Menno Van der Eerden
- Dept of Respiratory Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
23
|
The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia. Intensive Care Med 2016; 42:699-711. [PMID: 27040102 PMCID: PMC4828494 DOI: 10.1007/s00134-016-4325-4] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 03/10/2016] [Indexed: 12/28/2022]
Abstract
Purpose Severe ARDS is often associated with refractory hypoxemia, and early identification and treatment of hypoxemia is mandatory. For the management of severe ARDS ventilator settings, positioning therapy, infection control, and supportive measures are essential to improve survival. Methods and results A precise definition of life-threating hypoxemia is not identified. Typical clinical determinations are: arterial partial pressure of oxygen < 60 mmHg and/or arterial oxygenation < 88 % and/or the ratio of PaO2/FIO2 < 100. For mechanical ventilation specific settings are recommended: limitation of tidal volume (6 ml/kg predicted body weight), adequate high PEEP (>12 cmH2O), a recruitment manoeuvre in special situations, and a ‘balanced’ respiratory rate (20-30/min). Individual bedside methods to guide PEEP/recruitment (e.g., transpulmonary pressure) are not (yet) available. Prone positioning [early (≤ 48 hrs after onset of severe ARDS) and prolonged (repetition of 16-hr-sessions)] improves survival. An advanced infection management/control includes early diagnosis of bacterial, atypical, viral and fungal specimen (blood culture, bronchoalveolar lavage), and of infection sources by CT scan, followed by administration of broad-spectrum anti-infectives. Neuromuscular blockage (Cisatracurium ≤ 48 hrs after onset of ARDS), as well as an adequate sedation strategy (score guided) is an important supportive therapy. A negative fluid balance is associated with improved lung function and the use of hemofiltration might be indicated for specific indications. Conclusions A specific standard of care is required for the management of severe ARDS with refractory hypoxemia.
Collapse
|