1
|
Mo Y, Booraphun S, Li AY, Domthong P, Kayastha G, Lau YH, Chetchotisakd P, Limmathurotsakul D, Tambyah PA, Cooper BS. Individualised, short-course antibiotic treatment versus usual long-course treatment for ventilator-associated pneumonia (REGARD-VAP): a multicentre, individually randomised, open-label, non-inferiority trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:399-408. [PMID: 38272050 DOI: 10.1016/s2213-2600(23)00418-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/09/2023] [Accepted: 11/01/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is associated with increased mortality, prolonged hospitalisation, excessive antibiotic use and, consequently, increased antimicrobial resistance. In this phase 4, randomised trial, we aimed to establish whether a pragmatic, individualised, short-course antibiotic treatment strategy for VAP was non-inferior to usual care. METHODS We did an individually randomised, open-label, hierarchical non-inferiority-superiority trial in 39 intensive care units in six hospitals in Nepal, Singapore, and Thailand. We enrolled adults (age ≥18 years) who met the US Centers for Disease Control and Prevention National Healthcare Safety Network criteria for VAP, had been mechanically ventilated for 48 h or longer, and were administered culture-directed antibiotics. In culture-negative cases, empirical antibiotic choices were made depending on local hospital antibiograms reported by the respective microbiology laboratories or prevailing local guidelines. Participants were assessed until fever resolution for 48 h and haemodynamic stability, then randomly assigned (1:1) to individualised short-course treatment (≤7 days and as short as 3-5 days) or usual care (≥8 days, with precise durations determined by the primary clinicians) via permuted blocks of variable sizes (8, 10, and 12), stratified by study site. Independent assessors for recurrent pneumonia and participants were masked to treatment allocation, but clinicians were not. The primary outcome was a 60-day composite endpoint of death or pneumonia recurrence. The non-inferiority margin was prespecified at 12% and had to be met by analyses based on both intention-to-treat (all study participants who were randomised) and per-protocol populations (all randomised study participants who fulfilled the eligibility criteria, met fitness criteria for antibiotic discontinuation, and who received antibiotics for the duration specified by their allocation group). This study is registered with ClinicalTrials.gov, number NCT03382548. FINDINGS Between May 25, 2018, and Dec 16, 2022, 461 patients were enrolled and randomly assigned to the short-course treatment group (n=232) or the usual care group (n=229). Median age was 64 years (IQR 51-74) and 181 (39%) participants were female. 460 were included in the intention-to-treat analysis after excluding one withdrawal (231 in the short-course group and 229 in the usual care group); 435 participants received the allocated treatment and fulfilled eligibility criteria, and were included in the per-protocol population. Median antibiotic treatment duration for the index episodes of VAP was 6 days (IQR 5-7) in the short-course group and 14 days (10-21) in the usual care group. 95 (41%) of 231 participants in the short-course group met the primary outcome, compared with 100 (44%) of 229 in the usual care group (risk difference -3% [one-sided 95% CI -∞ to 5%]). Results were similar in the per-protocol population. Non-inferiority of short-course antibiotic treatment was met in the analyses, although superiority compared with usual care was not established. In the per-protocol population, antibiotic side-effects occurred in 86 (38%) of 224 in the usual care group and 17 (8%) of 211 in the short-course group (risk difference -31% [95% CI -37 to -25%; p<0·0001]). INTERPRETATION In this study of adults with VAP, individualised shortened antibiotic duration guided by clinical response was non-inferior to longer treatment durations in terms of 60-day mortality and pneumonia recurrence, and associated with substantially reduced antibiotic use and side-effects. Individualised, short-course antibiotic treatment for VAP could help to reduce the burden of side-effects and the risk of antibiotic resistance in high-resource and resource-limited settings. FUNDING UK Medical Research Council; Singapore National Medical Research Council. TRANSLATIONS For the Thai and Nepali translations of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- Yin Mo
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; National University Hospital, Singapore; Infectious Diseases Translational Research Program, National University of Singapore, Singapore.
| | | | - Andrew Yunkai Li
- National University Hospital, Singapore; Infectious Diseases Translational Research Program, National University of Singapore, Singapore
| | | | - Gyan Kayastha
- Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Yie Hui Lau
- Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | | | - Direk Limmathurotsakul
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul Anantharajah Tambyah
- National University Hospital, Singapore; Infectious Diseases Translational Research Program, National University of Singapore, Singapore
| | - Ben S Cooper
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| |
Collapse
|
2
|
Li Y, Roberts JA, Walker MM, Aslan AT, Harris PNA, Sime FB. The global epidemiology of ventilator-associated pneumonia caused by multi-drug resistant Pseudomonas aeruginosa: A systematic review and meta-analysis. Int J Infect Dis 2024; 139:78-85. [PMID: 38013153 DOI: 10.1016/j.ijid.2023.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/08/2023] [Accepted: 11/19/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVES The objective of this systematic review and meta-analysis was to estimate the global prevalence of multi-drug resistant (MDR) Pseudomonas aeruginosa causing ventilator-associated pneumonia (VAP). METHODS The systematic search was conducted in four databases. Original studies describing MDR P. aeruginosa VAP prevalence in adults from 2012- 2022 were included. A meta-analysis, using the random effects model, was conducted for overall, subgroups (country, published year, study duration, and study design), and European data, respectively. Univariate meta-regression based on pooled estimates was also conducted. Systematic review registered in International Prospective Register of Systematic Review (CRD42022384035). RESULTS In total of 31 studies, containing a total of 7951 cases from 16 countries, were included. The overall pooled prevalence of MDR among P. aeruginosa causing VAP was 33% (95% confidence interval [CI] 27.7-38.3%). The highest prevalence was for Iran at 87.5% (95% CI 69-95.7%), and the lowest was for the USA at 19.7% (95% CI 18.6-20.7%). The European prevalence was 29.9% (95% CI 23.2-36.7%). CONCLUSIONS This review indicates that the prevalence of MDR P. aeruginosa in patients with VAP is generally high and varies significantly between countries; however, data are insufficient for many countries. The data in this study can provide a reference for VAP management and drug customisation strategies.
Collapse
Affiliation(s)
- Yixuan Li
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia; Departments of Phaemacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Herston, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Mikaela M Walker
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia
| | - Abdullah Tarik Aslan
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia; Hacettepe University, Faculty of Medicine, Department of Internal Medicine, Ankara, Turkey
| | - Patrick N A Harris
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia; Pathology Queensland, Health Support Queensland, Herston, Australia
| | - Fekade B Sime
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia.
| |
Collapse
|
3
|
van Duijnhoven M, Fleuren-Janssen M, van Osch F, LeNoble JLML. A Predominant Cause of Recurrence of Ventilator-Associated Pneumonia in Patients with COVID-19 Are Relapses. J Clin Med 2023; 12:5821. [PMID: 37762761 PMCID: PMC10531898 DOI: 10.3390/jcm12185821] [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: 07/31/2023] [Revised: 08/18/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
The diagnosis of ventilator-associated pneumonia (VAP) recurrence in patients with coronavirus disease 2019 (COVID-19) pneumonia is challenging, and the incidence of recurrence is high. This study aimed to investigate the incidence and recurrence of VAP. Furthermore, we investigated the causative microorganisms of VAP and recurrent VAPs in patients with COVID-19. This retrospective, single-centre case series study was conducted during the COVID-19 pandemic from October 2020 to June 2021 at VieCuri MC Venlo. VAP and recurrent VAP were defined based on three criteria (clinical, radiological, and microbiological). During the study period, 128 mechanically ventilated patients with COVID-19 were included. The incidence ranged from 9.2 to 14 VAP/1000 ventilator days, which was higher than that in the non-COVID-19 controls. The most commonly cultured microorganisms in VAP were Pseudomonas (9/28; 32%), Klebsiella (8/28; 29%), Escherichia coli (5/28; 18%), and Staphylococcus aureus (5/28; 18%). VAP recurred often (5/19, 26%). The overall VAP rate confirmed previous findings of an increased incidence of VAP in critically ill patients with severe COVID-19 requiring mechanical ventilation. VAP recurrences occur often and are mainly relapses. A duration of antibiotic therapy longer than 7 days and therapeutic drug monitoring should be considered for VAP caused by Gram-negative microorganisms.
Collapse
Affiliation(s)
- Mirella van Duijnhoven
- Department of Intensive Care, VieCuri Medical Centre, Tegelseweg 210, 5912 BL Venlo, The Netherlands; (M.F.-J.); (J.L.M.L.L.)
| | - Manon Fleuren-Janssen
- Department of Intensive Care, VieCuri Medical Centre, Tegelseweg 210, 5912 BL Venlo, The Netherlands; (M.F.-J.); (J.L.M.L.L.)
| | - Frits van Osch
- Department of Clinical Epidemiology, VieCuri Medical Centre, Tegelseweg 210, 5912 BL Venlo, The Netherlands;
- Department of Epidemiology, NUTRIM, Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Jos L. M. L. LeNoble
- Department of Intensive Care, VieCuri Medical Centre, Tegelseweg 210, 5912 BL Venlo, The Netherlands; (M.F.-J.); (J.L.M.L.L.)
- Department of Pharmacology and Toxicology, Maastricht University, 6200 MD Maastricht, The Netherlands
| |
Collapse
|
4
|
Foucrier A, Dessalle T, Tuffet S, Federici L, Dahyot-Fizelier C, Barbier F, Pottecher J, Monsel A, Hissem T, Lefrant JY, Demoule A, Constantin JM, Rousseau A, Simon T, Leone M, Bouglé A. Association between combination antibiotic therapy as opposed as monotherapy and outcomes of ICU patients with Pseudomonas aeruginosa ventilator-associated pneumonia: an ancillary study of the iDIAPASON trial. Crit Care 2023; 27:211. [PMID: 37254209 PMCID: PMC10230680 DOI: 10.1186/s13054-023-04457-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/20/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND The optimal treatment duration and the nature of regimen of antibiotics (monotherapy or combination therapy) for Pseudomonas aeruginosa ventilator‑associated pneumonia (PA-VAP) remain debated. The aim of this study was to evaluate whether a combination antibiotic therapy is superior to a monotherapy in patients with PA-VAP in terms of reduction in recurrence and death, based on the 186 patients included in the iDIAPASON trial, a multicenter, randomized controlled trial comparing 8 versus 15 days of antibiotic therapy for PA-VAP. METHODS Patients with PA-VAP randomized in the iDIAPASON trial (short-duration-8 days vs. long-duration-15 days) and who received appropriate antibiotic therapy were eligible in the present study. The main objective is to compare mortality at day 90 according to the antibiotic therapy received by the patient: monotherapy versus combination therapy. The primary outcome was the mortality rate at day 90. The primary outcome was compared between groups using a Chi-square test. Time from appropriate antibiotic therapy to death in ICU or to censure at day 90 was represented using Kaplan-Meier survival curves and compared between groups using a Log-rank test. RESULTS A total of 169 patients were included in the analysis. The median duration of appropriate antibiotic therapy was 14 days. At day 90, among 37 patients (21.9%) who died, 17 received monotherapy and 20 received a combination therapy (P = 0.180). Monotherapy and combination antibiotic therapy were similar for the recurrence rate of VAP, the number of extra pulmonary infections, or the acquisition of multidrug-resistant (MDR) bacteria during the ICU stay. Patients in combination therapy were exposed to mechanical ventilation for 28 ± 12 days, as compared with 23 ± 11 days for those receiving monotherapy (P = 0.0243). Results remain similar after adjustment for randomization arm of iDIAPASON trial and SOFA score at ICU admission. CONCLUSIONS Except longer durations of antibiotic therapy and mechanical ventilation, potentially related to increased difficulty in achieving clinical cure, the patients in the combination therapy group had similar outcomes to those in the monotherapy group. TRIAL REGISTRATION NCT02634411 , Registered 15 December 2015.
Collapse
Affiliation(s)
- Arnaud Foucrier
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, Clichy, France.
| | - Thomas Dessalle
- Department of Anesthesia, Critical Care and Perioperative Care, Pitié-Salpetrière Hospital, 47-83, Boulevard de l'Hôpital, 75013, Paris, France
| | - Sophie Tuffet
- Department of Clinical Pharmacology-Clinical Research Platform, AP-HP, Sorbonne University, Paris, France
| | - Laura Federici
- Service de Réanimation Polyvalente, Centre Hospitalier d'Ajaccio, Ajaccio, France
| | - Claire Dahyot-Fizelier
- Department of Anaesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
| | - François Barbier
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de l'Hôpital, 45100, Orléans, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Department of Anaesthesiology, Critical Care and Perioperative Medicine, Fédération de Médecine Translationnelle de Strasbourg, ER 3072, Strasbourg University Hospital, Strasbourg, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Tarik Hissem
- General Intensive Care Unit, Sud-Essonne Hospital, Étampes, France
| | - Jean-Yves Lefrant
- UR-UM103 IMAGINE, Univ. Montpellier, Division of Anesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France, Nîmes University Hospital, Montpellier, France
| | - Alexandre Demoule
- Service de Médecine Intensive et Réanimation (Département R3S), APHP, Site Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Jean-Michel Constantin
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Alexandra Rousseau
- Department of Clinical Pharmacology-Clinical Research Platform, AP-HP, Sorbonne University, Paris, France
| | - Tabassome Simon
- Department of Clinical Pharmacology-Clinical Research Platform, AP-HP, Sorbonne University, Paris, France
| | - Marc Leone
- Service d'anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Adrien Bouglé
- Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| |
Collapse
|
5
|
Albin OR, Kaye KS, McCreary EK, Pogue JM. Less Is More? Antibiotic Treatment Duration in Pseudomonas aeruginosa Ventilator-Associated Pneumonia. Clin Infect Dis 2023; 76:745-749. [PMID: 36130230 DOI: 10.1093/cid/ciac784] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/10/2022] [Accepted: 09/19/2022] [Indexed: 11/14/2022] Open
Abstract
Recommended antimicrobial treatment durations for ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa have evolved over the past few decades. In this Viewpoint, we provide a narrative review of landmark trials investigating antimicrobial treatment durations for VAP caused by P. aeruginosa, and appraise iterations of expert consensus guidelines based on these data. We highlight strengths and weaknesses of existing data on this topic and provide recommendations for future avenues of study.
Collapse
Affiliation(s)
- Owen R Albin
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| |
Collapse
|
6
|
Kaylor DM, Caminiti N, Harbrecht B, McPheeters C, Scherrer LA. Safety of De-Escalating Empiric Antimicrobial Agents in Trauma Patients with Indigenous Oral Flora Ventilator-Associated Pneumonia. Surg Infect (Larchmt) 2022; 23:597-603. [PMID: 35917387 DOI: 10.1089/sur.2022.126] [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: 11/13/2022] Open
Abstract
Background: Ventilator-associated pneumonia (VAP) is a frequently occurring nosocomial infection in critically ill trauma patients. When bronchoalveolar lavage (BAL) returns with indigenous oral flora (IOF), de-escalating antimicrobial therapy is challenging. Patients and Methods: This is a retrospective review of trauma patients who received broad-spectrum empiric antimicrobial therapy for clinical VAP, and whose BAL culture resulted with >100,000 CFU/mL of IOF from September 1, 2017 to September 1, 2020. Patients were identified using the trauma database and microbiology reports of BALs with IOF. This review evaluated the effect of antibiotic de-escalation on recurrent or persistent pneumonia. Results: Of 51 trauma patients with clinical VAP and IOF, 18 patients (35.3%) had antimicrobial agents de-escalated. De-escalation was driven primarily by the discontinuation of vancomycin, with the continuation of a β-lactam antibiotic as monotherapy for the remainder of the treatment course (n = 15; 86.7%). The overall rate of either persistent or recurrent VAP in the cohort was 10%, and this did not differ statistically between those who received de-escalation therapy after isolation of IOF and those who did not (16.7% vs. 6.1%; p = 0.224), however, the incidence of acute kidney injury (AKI) was higher in the non-de-escalation group (39.4% vs. 11.1%; p = 0.034). There was no statistical difference in ventilator days, intensive care unit (ICU) length of stay, or hospital length of stay between treatment groups. Conclusions: Trauma patients who develop VAP with isolated BAL cultures of IOF or mixed flora can safely have anti-methicilllin-resistant Staphylococcus aureus (MRSA) antimicrobial agents discontinued, and this may result in decreased rates of AKI.
Collapse
Affiliation(s)
- David Michael Kaylor
- Department of Pharmacy, University of Louisville Hospital, Louisville, Kentucky, USA
| | - Nicholas Caminiti
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Brian Harbrecht
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Chelsey McPheeters
- Department of Pharmacy, University of Louisville Hospital, Louisville, Kentucky, USA
| | - Leigh Ann Scherrer
- Department of Pharmacy, University of Louisville Hospital, Louisville, Kentucky, USA
| |
Collapse
|
7
|
Decavèle M, Gault N, Moyer JD, Gennequin M, Allain PA, Foucrier A. Prediction models of methicillin sensitive Staphylococcus aureus ventilator associated pneumonia relapse in trauma and brain injury patients: A retrospective analysis. J Crit Care 2021; 66:20-25. [PMID: 34399115 DOI: 10.1016/j.jcrc.2021.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/14/2021] [Accepted: 07/14/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To describe the incidence and risk factors of methicillin sensitive Staphylococcus aureus ventilator associated pneumonia (MSSA-VAP) relapse in trauma and non-traumatic brain injury patients. MATERIALS AND METHODS Retrospective observational monocentric cohort study of consecutive ICU patients who developed a first episode of MSSA-VAP after trauma and non-traumatic brain injury. MSSA-VAP relapse encompass MSSA-VAP treatment failure (persistence or recurrence of MSSA) or other pathogen - VAP. RESULTS A total of 165 patients (71% of trauma and 29% of non-traumatic brain injury) with MSSA-VAP were included. MSSA-VAP relapse occurred in 54 (33%) patients, including 28 (17%) MSSA-VAP treatment failure and 46 (28%) other pathogen-VAP. Empirical first-line antibiotic therapy was appropriate in 96% of cases. In multivariate analysis, the presence of Streptococcus species (Odds ratio [OR] 7.37) and oropharyngeal flora (OR 3.64) as initial MSSA co-pathogen, suggested aspiration at the time of admission and independently predicted MSSA-VAP treatment failure. Initial Glasgow coma scale (OR 0.89), need for emergent surgery (OR 5.71) and the presence of an acute respiratory distress syndrome at the time of the first MSSA-VAP (3.99), independently predicted the onset of other pathogen - VAP. CONCLUSION Early and simple factors may help to identify patients with high-risk of MSSA-VAP relapse.
Collapse
Affiliation(s)
- Maxens Decavèle
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France; Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), F-75013 Paris, France; Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France.
| | - Nathalie Gault
- APHP, Département Epidémiologie Biostatistiques et Recherche Clinique, Hôpital Beaujon, 92110 Clichy, France; INSERM, CIC-EC 1425, Hôpital Bichat, 75018 Paris, France
| | - Jean Denis Moyer
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France
| | - Maël Gennequin
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France
| | - Pierre-Antoine Allain
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France
| | - Arnaud Foucrier
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 92110 Clichy, France
| |
Collapse
|
8
|
Mo Y, West TE, MacLaren G, Booraphun S, Li AY, Kayastha G, Lau YH, Chew YT, Chetchotisakd P, Tambyah PA, Limmathurotsakul D, Cooper B. Reducing antibiotic treatment duration for ventilator-associated pneumonia (REGARD-VAP): a trial protocol for a randomised clinical trial. BMJ Open 2021; 11:e050105. [PMID: 33986070 PMCID: PMC8126270 DOI: 10.1136/bmjopen-2021-050105] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICUs). Using short-course antibiotics to treat VAP caused by Gram-negative non-fermenting bacteria has been reported to be associated with excess pneumonia recurrences. The "REducinG Antibiotic tReatment Duration for Ventilator-Associated Pneumonia" (REGARD-VAP) trial aims to provide evidence for using a set of reproducible clinical criteria to shorten antibiotic duration for individualised treatment duration of VAP. METHODS AND ANALYSIS This is a randomised controlled hierarchical non-inferiority-superiority trial being conducted in ICUs across Nepal, Thailand and Singapore. The primary outcome is a composite endpoint of death and pneumonia recurrence at day 60. Secondary outcomes include ventilator-associated events, multidrug-resistant organism infection or colonisation, total duration of antibiotic exposure, mechanical ventilation and hospitalisation. Adult patients who satisfy the US Centers for Disease Control and Prevention National Healthcare Safety Network VAP diagnostic criteria are enrolled. Participants are assessed daily until fever subsides for >48 hours and have stable blood pressure, then randomised to a short duration treatment strategy or a standard-of-care duration arm. Antibiotics may be stopped as early as day 3 if respiratory cultures are negative, and day 5 if respiratory cultures are positive in the short-course arm. Participants receiving standard-of-care will receive antibiotics for at least 8 days. Study participants are followed for 60 days after enrolment. An estimated 460 patients will be required to achieve 80% power to determine non-inferiority with a margin of 12%. All outcomes are compared by absolute risk differences. The conclusion of non-inferiority, and subsequently superiority, will be based on unadjusted and adjusted analyses in both the intention-to-treat and per-protocol populations. ETHICS AND DISSEMINATION The study has received approvals from the Oxford Tropical Research Ethics Committee and the respective study sites. Results will be disseminated to patients, their caregivers, physicians, the funders, the critical care societies and other researchers. TRIAL REGISTRATION NUMBER NCT03382548.
Collapse
Affiliation(s)
- Yin Mo
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, National University of Singapore, Singapore
| | - Timothy Eoin West
- International Respiratory and Severe Illness Center, University of Washington, Seattle, Washington, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Graeme MacLaren
- National University Heart Centre, National University Hospital, Singapore
| | - Suchart Booraphun
- Medical Department, Sunpasithiprasong Hospital, Ubon Ratchathani, Thailand
| | - Andrew Yunkai Li
- University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, National University of Singapore, Singapore
| | - Gyan Kayastha
- Patan Hospital, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Yie Hui Lau
- Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Yin Tze Chew
- Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Ploenchan Chetchotisakd
- Department of Medicine,Srinagarind Hospital, Faculty of Medicine and Research and Diagnostic Center for Emerging Infectious Diseases (RCEID), Khon Kaen University, Khon Kaen, Thailand
| | - Paul Anantharajah Tambyah
- University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, National University of Singapore, Singapore
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ben Cooper
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| |
Collapse
|
9
|
Albin OR, Henig O, Patel TS, Valley TS, Pogue JM, Petty LA, Mills JP, Brancaccio A, Martin ET, Kaye KS. Clinical Implications of Microbiologic Treatment Failure in the Setting of Clinical Cure of Bacterial Pneumonia. Clin Infect Dis 2020; 71:3033-3041. [PMID: 31832641 PMCID: PMC7819508 DOI: 10.1093/cid/ciz1187] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/11/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Microbiologic cure is a common outcome in pneumonia clinical trials, but its clinical significance is incompletely understood. METHODS We conducted a retrospective cohort study of adult patients hospitalized with bacterial pneumonia who achieved clinical cure. Rates of recurrent pneumonia and death were compared between patients with persistent growth of the index pathogen at the time of clinical cure (microbiologic failure) and those with pathogen eradication (microbiologic cure). RESULTS Among 441 patients, 237 experienced microbiologic cure and 204 experienced microbiologic failure. Prevalences of comorbidities, ventilator dependence, and severity of acute illness were similar between groups. Patients with microbiologic failure experienced significantly higher rates of recurrent pneumonia or death following clinical cure than patients with microbiologic cure, controlling for comorbid conditions, severity of acute illness, appropriateness of empiric antibiotics, intensive care unit placement, tracheostomy dependence, and immunocompromised status (90-day multivariable adjusted odds ratio [OR], 1.56; 95% confidence interval [CI], 1.04-2.35). This association was observed among patients with pneumonias caused by Staphylococcus aureus (90-day multivariable adjusted OR, 3.69; 95% CI, 1.73-7.90). A trend was observed among pneumonias caused by nonfermenting gram-negative bacilli, but not Enterobacteriaceae or other pathogens. CONCLUSIONS Microbiologic treatment failure was independently associated with recurrent pneumonia or death among patients with bacterial pneumonia following clinical cure. Microbiologic cure merits further study as a metric to guide therapeutic interventions for patients with bacterial pneumonia.
Collapse
Affiliation(s)
- Owen R Albin
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Oryan Henig
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Twisha S Patel
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan, USA
| | - Thomas S Valley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan, USA
| | - Lindsay A Petty
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - John P Mills
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Adamo Brancaccio
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan, USA
| | - Emily T Martin
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| |
Collapse
|
10
|
A Comparison of Outcomes of Trauma Patients With Ventilator-Associated Events by Diagnostic Criteria Set. Shock 2020; 51:599-604. [PMID: 29958241 DOI: 10.1097/shk.0000000000001214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Centers for Disease Control and Prevention replaced the definition for ventilator-associated pneumonia with an algorithm comprised of three categories: ventilator-associated condition (VAC), infection-related ventilator associated complication (IVAC), and possible ventilator-associated pneumonia (PVAP). We sought to compare the outcome of trauma patients with VAEs to those with no VAEs. METHODS Patients admitted from 2013 to 2017 were identified from trauma registry. Logistic regression was performed for the association between VAEs and mortality. RESULTS Two thousand six hundred eighty patients were admitted to our trauma center, 2,290 had no VAE, 100 had VACs, 85 had IVACs, and 205 had PVAPs. Adjusted for race, sex, blunt injury mechanisms, and Injury Severity Score, all VAEs had a longer hospital length of stay, intensive care unit stay, and days of ventilator support when compared with those with no VAE (all P < 0.0001). Nosocomial complication rates were not different by VAE group. Compared with patients with no VAE, an over 2-fold increased mortality odds was observed for VAC (OR 2.39, 95% CI 1.50-3.80) and IVAC patients (OR 2.07, 95% CI 1.23-3.47), and a 50% mortality increased was observed for PVAP patients (OR 1.46, 95% CI 1.00-2.12). These associations became similar with an approximate 2.5-fold increased mortality odds among patients with at least 1 week on ventilator support. CONCLUSION VAEs increase the odds of mortality, particularly for patients with VACs and IVACs. Among patients on ventilator support for at least a week, the associations are similar among VAE types, suggesting no single VAE type is more severe than others.
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW Whilst many guidelines recommend limiting the use of antibiotics because of the increase in antimicrobial resistance (AMR), this strategy becomes challenging when dealing with severe infections in critically ill patients. Moreover, some Gram-negative bacilli (GNB) can exhibit mechanisms of resistance that make the patient more vulnerable to recurrence of infections. We reviewed recent data on the optimal duration of antibiotic therapy in these patients. RECENT FINDINGS Apart from having no additional clinical benefit at a certain point after initiation, antibiotics might have negative effects. Prolonged antibiotic exposure has been associated to development of AMR and represents a strong reason to avoid long courses of antibiotic therapy in GNB infections. Recent data suggest that also patients with severe infections, in whom source control is adequate, can be managed with short-course antibiotic therapy. SUMMARY The optimal duration of antibiotic therapy depends on many factors, but overall, many infections in the critically ill can be treated with short-course antibiotic therapy (7 days or less). The integration of signs of resolution, biomarkers, clinical judgment, and microbiologic eradication might help to define this optimal duration in patients with life-threatening infections caused by GNB.
Collapse
|
12
|
Gutiérrez JMM, Borromeo AR, Dueño AL, Paragas ED, Ellasus RO, Abalos-Fabia RS, Abriam JA, Sonido AE, Hernandez MA, Generale AJA, Sombillo RC, Lacanaria MGC, Centeno MM, Laoingco JRC, Domantay JAA. Clinical epidemiology and outcomes of ventilator-associated pneumonia in critically ill adult patients: protocol for a large-scale systematic review and planned meta-analysis. Syst Rev 2019; 8:180. [PMID: 31325967 PMCID: PMC6642735 DOI: 10.1186/s13643-019-1080-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/25/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND An increasing number of studies have investigated the clinical epidemiology and outcomes of ventilator-associated pneumonia (VAP) in intensive care units. However, these findings have not been clearly defined in broad subgroups of mechanically ventilated adults. Hence, this protocol for a systematic review and meta-analysis is designed to better understand the clinical and epidemiological features of VAP in these patient populations by establishing its overall prognosis of and risk factors for morbidity and mortality and to determine the differences in clinical and economic outcomes between VAP and non-VAP patients. METHODS This present review will systematically search available full-text articles without date and language restrictions and indexed in PubMed, CENTRAL, CINAHL, Web of Science, and EMBASE databases. In addition, reference lists and citations of retrieved articles and relevant medical and nursing journals will be manually reviewed. Supplementary search in other databases involving trials, reviews, and grey literatures, including conference proceedings, theses, and dissertations, will be performed. Study investigators will be contacted to clarify missing or unpublished data. All prognostic studies meeting the pre-defined eligibility criteria will be included. The study selection, risk of bias assessment, data extraction, and grading of the quality of evidence will be carried out in duplicate, involving independent evaluation by two investigators with consensus or a third-party adjudication. The degree of inter-rater agreement will be calculated using the kappa statistic. For meta-analysis, dichotomous and continuous outcome measures will be pooled using odds ratios and standardized mean differences with 95% confidence intervals, respectively. The Mantel-Haenszel or inverse variance methods with random effects model will be used as a guide for analysis. The heterogeneity of each outcome measure will be assessed using both X2 and I2 statistics. In addition, sensitivity and subgroup analyses will be performed to ensure consistency of pooled results. The review protocol described herein is in accordance with the PRISMA-P standards. DISCUSSION The investigation of the epidemiological profiles, prognostic factors, and outcomes associated with VAP is critical for the identification of high-risk groups of mechanically ventilated patients and evaluation of possible clinical endpoints. This may provide substantial links for improved VAP prevention practices targeting modifiable risk factors. Implications for future research directions are discussed. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017048158.
Collapse
Affiliation(s)
- John Mark M Gutiérrez
- School of Advanced Studies, Saint Louis University, Baguio, Philippines.
- Department of Nursing, College of Applied Medical Sciences, Shaqra University, Shaqra, Saudi Arabia.
- Division of Epidemiology, Department of Clinical Laboratory Science, College of Applied Medical Sciences, Shaqra University, Shaqra, Saudi Arabia.
| | - Annabelle R Borromeo
- School of Advanced Studies, Saint Louis University, Baguio, Philippines
- Zone 3, Philippine Nurses Association, Quezon City and Marikina City, Philippines
| | - Allan L Dueño
- University of the Philippines Open University, Los Baños, Philippines
| | | | - Rosanta O Ellasus
- School of Advanced Studies, Saint Louis University, Baguio, Philippines
- Department of Nursing, College of Applied Medical Sciences, Shaqra University, Shaqra, Saudi Arabia
| | - Russel S Abalos-Fabia
- Department of Nursing, College of Applied Medical Sciences, Shaqra University, Shaqra, Saudi Arabia
| | - Jerry A Abriam
- Institute of Community Health and Allied Medical Sciences, Don Mariano Marcos Memorial State University, Agoo, Philippines
| | - Arnel E Sonido
- Institute of Community Health and Allied Medical Sciences, Don Mariano Marcos Memorial State University, Agoo, Philippines
| | | | | | | | - Mary Grace C Lacanaria
- School of Advanced Studies, Saint Louis University, Baguio, Philippines
- School of Nursing, Saint Louis University, Baguio, Philippines
| | | | - Jose Reinhard C Laoingco
- Graduate School of Nursing and Allied Medical Sciences, Holy Angel University, Angeles, Philippines
| | | |
Collapse
|
13
|
Garnier M, Gallah S, Vimont S, Benzerara Y, Labbe V, Constant AL, Siami S, Guerot E, Compain F, Mainardi JL, Montil M, Quesnel C. Multicentre randomised controlled trial to investigate usefulness of the rapid diagnostic βLACTA test performed directly on bacterial cell pellets from respiratory, urinary or blood samples for the early de-escalation of carbapenems in septic intensive care unit patients: the BLUE-CarbA protocol. BMJ Open 2019; 9:e024561. [PMID: 30782909 PMCID: PMC6367973 DOI: 10.1136/bmjopen-2018-024561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 11/23/2018] [Accepted: 11/29/2018] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION The dramatic increase of the incidence of infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) has led to an increase of 50% of carbapenem consumption all around Europe in only 5 years. This favours the spread of carbapenem-resistant Gram-negative bacilli (GNB), causing life-threatening infections. In order to limit use of carbapenems for infections actually due to ESBL-PE, health authorities promote the use of rapid diagnostic tests of bacterial resistance. The objective of this work conducted in the intensive care unit (ICU) is to determine whether an early de-escalation of empirical carbapenems guided by the result of the βLACTA test is not inferior to the reference strategy of de-escalating carbapenems after the antibiogram result has been rendered. METHODS AND ANALYSIS This multicentre randomised controlled open-label non-inferiority clinical trial will include patients suffering from respiratory and/or urinary and/or bloodstream infections documented with GNB on direct examination and empirically treated with carbapenems. Empirical carbapenems will be adapted before the second dose depending on the results of the βLACTA test performed directly on the microbiological sample (intervention group) or after 48-72 hours depending on the definite antibiogram (control group). The primary outcome will combine 90-day mortality and percentage of infection recurrence during the ICU stay. The secondary outcomes will include the number of carbapenems defined daily doses and carbapenem-free days after inclusion, the proportion of new infections during ICU stay, new colonisation of patients' digestive tractus with multidrug-resistant GNB, ICU and hospital length of stay and cost-effectiveness ratio. ETHICS AND DISSEMINATION This protocol has been approved by the ethics committee of Paris-Ile-de-France IV, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03147807.
Collapse
Affiliation(s)
- Marc Garnier
- Anesthesiology and Intensive Care Medicine Department, APHP—Tenon University Hospital, Paris, France
- Medico-surgical Intensive Care Unit, APHP—Tenon University Hospital, Paris, France
- Paris 6 School of Medicine, Sorbonne University, Paris, France
| | - Salah Gallah
- APHP—GHUEP—Microbiology Department, Paris, France
| | - Sophie Vimont
- Paris 6 School of Medicine, Sorbonne University, Paris, France
- APHP—GHUEP—Microbiology Department, Paris, France
| | | | - Vincent Labbe
- Medico-surgical Intensive Care Unit, APHP—Tenon University Hospital, Paris, France
| | - Anne-Laure Constant
- Cardio-thoracic Surgical Intensive Care Unit, APHP—European Georges Pompidou University Hospital, Paris, France
| | - Shidasp Siami
- Polyvalent Intensive Care Unit, Sud Essonne Hospital, Etampes, France
| | - Emmanuel Guerot
- APHP—European Georges Pompidou University Hospital, Medical Intensive Care Unit, Paris, France
| | - Fabrice Compain
- Microbiology Department, APHP—European Georges Pompidou University Hospital, Paris, France
| | - Jean-Luc Mainardi
- Microbiology Department, APHP—European Georges Pompidou University Hospital, Paris, France
| | - Mélissa Montil
- APHP—Clinical Research Platform (URCEst-CRCEst-CRB), St Antoine Hospital, Paris, France
| | - Christophe Quesnel
- Anesthesiology and Intensive Care Medicine Department, APHP—Tenon University Hospital, Paris, France
- Paris 6 School of Medicine, Sorbonne University, Paris, France
| |
Collapse
|
14
|
Elbrolosy AM, Labeeb AZ, Hassan DM. New Delhi metallo-β-lactamase-producing Acinetobacter isolates among late-onset VAP patients: multidrug-resistant pathogen and poor outcome. Infect Drug Resist 2019; 12:373-384. [PMID: 30809098 PMCID: PMC6377045 DOI: 10.2147/idr.s186924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Acinetobacter spp. are increasingly important microbes involved in late-onset ventilator-associated pneumonia (VAP). Purpose The aims of this study were to determine the prevalence of New Delhi metallo-β-lactamase (MβL) (blaNDM-1)-producing Acinetobacter spp. among late-onset VAP patients in different intensive care units (ICUs) of Menoufia and Kasr Al Ainy University Hospitals, to investigate the possible risk factors contributing to the acquisition of blaNDM-1-producing Acinetobacter infection, and to correlate between antimicrobial resistance pattern and therapeutic efficacy as well as clinical outcomes of these patients. Materials and methods Sixty-four Acinetobacter isolates were collected from mechanically ventilated patients with suspected late-onset VAP and subjected to antimicrobial susceptibility testing. The modified Hodge test (MHT) and combined disk tests (CDT) were applied for blaNDM-1 MβL detection. Acinetobacter isolates with phenotypically confirmed MβLs production were subjected to a PCR assay to verify the presence of blaNDM-1 gene. The most obvious risk factors for acquisition of carbapenem resistance in VAP patients and treatment outcomes were also analyzed. Results Out of 64 Acinetobacter isolates, 42 (65.6%) proved to be blaNDM-1 positive. The sensitivity and specificity of MHT were 52.38% and 41.67%, while for CDT they were 92.86% and 83.33%, respectively. Acinetobacter isolates showed high susceptibility to colistin (85.7%). The clinical response was better among VAP patients who received combined carbapenem plus colistin therapy than those who received colistin alone. Relapse of infection was detected in 12.5% (8/64) of VAP cases. The reported mortality reached 46.8% (30/64) of which 27 (64.3%) were infected with blaNDM-1-positive isolates. Prolonged duration of mechanical ventilation, longer hospital and ICU stays, and prior exposure to antibiotic therapy were by far the most important factors predisposing to carbapenem resistance among VAP patients. Conclusion A worldwide spread of Acinetobacter spp. expressing carbapenemases represents a significant threat to the medical community. The current study addressed the high prevalence of blaNDM-1-producing Acinetobacter isolates among late-onset VAP patients.
Collapse
Affiliation(s)
- Asmaa M Elbrolosy
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt,
| | - Azza Z Labeeb
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt,
| | - Dina M Hassan
- Department of Clinical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
15
|
Bouglé A, Foucrier A, Dupont H, Montravers P, Ouattara A, Kalfon P, Squara P, Simon T, Amour J. Impact of the duration of antibiotics on clinical events in patients with Pseudomonas aeruginosa ventilator-associated pneumonia: study protocol for a randomized controlled study. Trials 2017; 18:37. [PMID: 28114979 PMCID: PMC5260072 DOI: 10.1186/s13063-017-1780-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 01/02/2017] [Indexed: 11/16/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) accounts for 25% of infections in intensive care units. Compared to a long duration (LD) of antibiotic therapy, a short duration (SD) has a comparable clinical efficacy with less antibiotic use and less multidrug-resistant (MDR) pathogen emergence, with the exception of documented VAP of non-fermenting Gram-negative bacilli (NF-GNB), including Pseudomonas aeruginosa (PA). These results have led the American Thoracic Society to recommend SD therapy for VAP, except for PA-VAP. Thus the beneficial effect of SD therapy in PA-VAP is still a matter of debate. We aimed to assess the non-inferiority of a short duration of antibiotics (8 days) versus prolonged antibiotic therapy (15 days) in PA-VAP. Methods/design The impact of the duration of antibiotics on clinical events in patients with Pseudomonas aeruginosa ventilator-associated pneumonia (iDIAPASON) trial is a randomized, open-labeled non-inferiority controlled trial, conducted in 34 French intensive care units (ICUs), comparing two groups of patients with PA-VAP according to the duration (8 days or 15 days) of effective antibiotic therapy against PA. The primary outcome is a composite endpoint combining day 90 mortality and PA-VAP recurrence rate during hospitalization in the ICU. Furthermore, durations of mechanical ventilation and hospitalization, as well as number and types of extrapulmonary infections or acquisition of MDR pathogens during the hospitalization in the ICU will be recorded. Recurrence with predefined criteria (clinical suspicion of VAP associated with a positive quantitative culture of a respiratory sample) will be evaluated by two independent experts. Discussion Demonstrating that an SD (8 days) versus LD (15 days) therapy strategy in PA-VAP treatment is safe and not associated with an increased mortality or recurrence rate could lead to a change in practices and guidelines in the management of antibiotic therapy of this frequent ICU complication. This strategy could lead to decreased antibiotic exposure during hospitalization in the ICU and in turn reduce the acquisition and the spread of MDR pathogens. Trial registration ClinicalTrials.gov: NCT02634411. Registered on 19 November 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1780-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Adrien Bouglé
- Department of Anesthesiology and Critical Care, CHU La Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.
| | - Arnaud Foucrier
- Department of Anesthesiology and Critical Care, Hôpital Beaujon, APHP, Paris, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care, CHU Amiens, Amiens, France.,Université de Picardie Jules Verne, Amiens, France
| | - Philippe Montravers
- Department of Anesthesiology and Critical Care, CHU Bichat, APHP, Paris, France.,Université Diderot, Paris, France
| | - Alexandre Ouattara
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Sud, Pessac, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - Pierre Kalfon
- Intensive Care Unit, Hôpital Louis Pasteur, CH de Chartres, Chartres, France
| | - Pierre Squara
- Intensive Care Unit, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Tabassome Simon
- Unité de Recherche Clinique du GH HUEP (URC-Est), Hôpital Saint-Antoine, APHP, Paris, France.,UPMC - Sorbonne universités (Paris 6), Paris, France
| | - Julien Amour
- Department of Anesthesiology and Critical Care, CHU La Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.,UPMC - Sorbonne universités (Paris 6), Paris, France
| | | |
Collapse
|
16
|
The SAATELLITE and EVADE Clinical Studies Within the COMBACTE Consortium: A Public–Private Collaborative Effort in Designing and Performing Clinical Trials for Novel Antibacterial Drugs to Prevent Nosocomial Pneumonia: Table 1. Clin Infect Dis 2016; 63 Suppl 2:S46-51. [DOI: 10.1093/cid/ciw245] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
17
|
Early Trauma-Induced Coagulopathy is Associated with Increased Ventilator-Associated Pneumonia in Spinal Cord Injury Patients. Shock 2016; 45:502-5. [DOI: 10.1097/shk.0000000000000531] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
18
|
Sotillo-Díaz JC, Bermejo-López E, García-Olivares P, Peral-Gutiérrez JA, Sancho-González M, Guerrero-Sanz JE. [Role of plasma procalcitonin in the diagnosis of ventilator-associated pneumonia: systematic review and metaanalysis]. Med Intensiva 2013; 38:337-46. [PMID: 24035696 DOI: 10.1016/j.medin.2013.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 07/10/2013] [Accepted: 07/12/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the role of plasma procalcitonin (PCT) levels in diagnosing ventilator-associated pneumonia. DESIGN A systematic review of publications prospectively assessing the diagnostic role of PCT in ventilator-associated pneumonia was carried out. The search was performed using Medline, Embase, the Cochrane Collaboration and MEDION, with reviewing of the references of retrieved articles. We extracted data that allowed the calculation of sensitivity, specificity, likelihood ratios and diagnostic odds ratio. Intervention Metaregression was performed to determine whether exposure to previous antibiotic treatment, the time to occurrence of ventilator-associated pneumonia and the type of patients had an impact upon the diagnostic performance of procalcitonin. RESULTS Seven studies were considered (373 patients, 434 episodes). We found no publication bias or threshold effect. High plasma PCT levels were associated to an increased risk of suffering ventilator-associated pneumonia (OR: 8.39; 95% CI: 5.4-12.6). The pooled data on sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio found were 76% (69-82), 79% (74-84), 4.35 (2.48-7.62), 0.26 (0.15-0.46) and 17.9 (10.1-31.7), respectively. Diagnostic yield was modified by prior exposure to antibiotics (rDOR 0.11, 0.02-0.069), but not by the type of critically ill patient or the time to occurrence of ventilator-associated pneumonia. CONCLUSIONS Our results suggest that PCT provides additional information on the risk of VAP. Inclusion of PCT in diagnostic algorithms could improve their effectiveness.
Collapse
Affiliation(s)
- J C Sotillo-Díaz
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - E Bermejo-López
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - P García-Olivares
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J A Peral-Gutiérrez
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - M Sancho-González
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J E Guerrero-Sanz
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| |
Collapse
|
19
|
El-Saed A, Balkhy HH, Al-Dorzi HM, Khan R, Rishu AH, Arabi YM. Acinetobacter is the most common pathogen associated with late-onset and recurrent ventilator-associated pneumonia in an adult intensive care unit in Saudi Arabia. Int J Infect Dis 2013; 17:e696-701. [DOI: 10.1016/j.ijid.2013.02.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 01/30/2013] [Accepted: 02/02/2013] [Indexed: 01/12/2023] Open
|
20
|
Kohno S, Seki M, Takehara K, Yamada Y, Kubo K, Ishizaka A, Soma K. Prediction of Requirement for Mechanical Ventilation in Community-Acquired Pneumonia with Acute Respiratory Failure: A Multicenter Prospective Study. Respiration 2013; 85:27-35. [DOI: 10.1159/000335466] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 11/23/2011] [Indexed: 11/19/2022] Open
|
21
|
Agrafiotis M, Vardakas KZ, Gkegkes ID, Kapaskelis A, Falagas ME. Ventilator-associated sinusitis in adults: Systematic review and meta-analysis. Respir Med 2012; 106:1082-95. [DOI: 10.1016/j.rmed.2012.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 02/29/2012] [Accepted: 03/14/2012] [Indexed: 11/17/2022]
|
22
|
|
23
|
Aikawa N, Ishizaka A, Hirasawa H, Shimazaki S, Yamamoto Y, Sugimoto H, Shinozaki M, Taenaka N, Endo S, Ikeda T, Kawasaki Y. Reevaluation of the efficacy and safety of the neutrophil elastase inhibitor, Sivelestat, for the treatment of acute lung injury associated with systemic inflammatory response syndrome; a phase IV study. Pulm Pharmacol Ther 2011; 24:549-54. [PMID: 21540122 DOI: 10.1016/j.pupt.2011.03.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 02/17/2011] [Accepted: 03/01/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Sivelestat, a neutrophil elastase inhibitor, has been approved in Japan for the treatment of patients with acute lung injury (ALI) associated with systemic inflammatory response syndrome (SIRS). The Pharmaceuticals and Medical Devices Agency (PMDA) has ordered to conduct a postmarket clinical study in order to reevaluate the efficacy and safety of Sivelestat in actual clinical settings in Japan. METHODS According to the PMDA's order, we evaluated the efficacy and safety of Sivelestat in Japanese patients with ALI associated with SIRS using ventilator-free days (VFD) as the primary endpoint. The surrogate endpoints are ventilator-weaning rate, ICU discharge rate, and 180-day survival rate. Study design was an open-label, non-randomized, multi-center clinical trial. Sivelestat was intravenously administered at 0.2 mg/kg/h continuously for a maximum of 14 days. Sivelestat group and control group were compared by adjusting the outcome values using an inverse probability of treatment weighted method based on the propensity scores. RESULTS Four hundred and four Sivelestat group patients and 177 control group patients were enrolled. The adjusted mean number of VFD was 15.7 and 12.1 in the Sivelestat group and control group, respectively (P = 0.0022). Both the adjusted ventilator-weaning rate and ICU discharge rate were significantly higher in the Sivelestat group than in the control group (P = 0.0028 and P = 0.019, respectively). The adjusted 180-day survival rate was significantly higher in the Sivelestat group than in the control group (71.8 percent vs. 56.3 percent). CONCLUSIONS Sivelestat contributed to early weaning from the mechanical ventilation, while showing no negative effect on the long-term outcomes of ALI associated with SIRS. The results of this study suggest the clinical usefulness of Sivelestat in this patient population.
Collapse
Affiliation(s)
- Naoki Aikawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
|
25
|
Reed RL. Recurrent Ventilator-Associated Pneumonias: The Gift That Keeps on Giving or the Guest Who Won't Leave? Surg Infect (Larchmt) 2010; 11:319-24. [DOI: 10.1089/sur.2010.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- R. Lawrence Reed
- Department of Surgery, Indiana University, and Division of Trauma Services, Clarian Methodist Hospital Indianapolis, Indiana
| |
Collapse
|
26
|
|
27
|
Siempos II, Dimopoulos G, Falagas ME. Meta-analyses on the Prevention and Treatment of Respiratory Tract Infections. Infect Dis Clin North Am 2009; 23:331-53. [DOI: 10.1016/j.idc.2009.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
28
|
Grammatikos AP, Siempos II, Michalopoulos A, Falagas ME. Optimal duration of the antimicrobial treatment of ventilator-acquired pneumonia. Expert Rev Anti Infect Ther 2009; 6:861-6. [PMID: 19053899 DOI: 10.1586/14787210.6.6.861] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The optimal duration of antimicrobial treatment of patients with ventilator-associated pneumonia is a major concern for clinicians. We looked for the evidence that a short course of therapy (< or =10 days) is as effective as a traditional long-course therapy (14-21 days). Unfortunately, only one trial (PneumA trial) has focused directly on this question. To further evaluate this issue, we identified trials in which the duration of anti-infective treatment was used as the outcome. Such trials, by providing data on mortality, length of intensive care unit stay and recurrence, may allow for estimating the association between duration of therapy and the aforementioned outcomes. Nine such trials were identified; all reported a decrease in the total length of antibiotic administration (statistically significant in seven) with the application of the intervention studied. Short, as opposed to long, courses of antibiotics did not adversely affect mortality, length of intensive care unit stay or recurrence rates. In conclusion, the available evidence seems to support the use of short-course antimicrobial treatments (< or =10 days) for patients with ventilator-acquired pneumonia not caused by nonfermenting Gram-negative bacilli.
Collapse
|
29
|
What's new in Shock, November 2008? Shock 2008; 30:485-6. [PMID: 18923300 DOI: 10.1097/shk.0b013e318189122b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|