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Quarton S, Livesey A, Pittaway H, Adiga A, Grudzinska F, McNally A, Dosanjh D, Sapey E, Parekh D. Clinical challenge of diagnosing non-ventilator hospital-acquired pneumonia and identifying causative pathogens: a narrative review. J Hosp Infect 2024; 149:189-200. [PMID: 38621512 DOI: 10.1016/j.jhin.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024]
Abstract
Non-ventilated hospital-acquired pneumonia (NV-HAP) is associated with a significant healthcare burden, arising from high incidence and associated morbidity and mortality. However, accurate identification of cases remains challenging. At present, there is no gold-standard test for the diagnosis of NV-HAP, requiring instead the blending of non-specific signs and investigations. Causative organisms are only identified in a minority of cases. This has significant implications for surveillance, patient outcomes and antimicrobial stewardship. Much of the existing research in HAP has been conducted among ventilated patients. The paucity of dedicated NV-HAP research means that conclusions regarding diagnostic methods, pathology and interventions must largely be extrapolated from work in other settings. Progress is also limited by the lack of a widely agreed definition for NV-HAP. The diagnosis of NV-HAP has large scope for improvement. Consensus regarding a case definition will allow meaningful research to improve understanding of its aetiology and the heterogeneity of outcomes experienced by patients. There is potential to optimize the role of imaging and to incorporate novel techniques to identify likely causative pathogens. This would facilitate both antimicrobial stewardship and surveillance of an important healthcare-associated infection. This narrative review considers the utility of existing methods to diagnose NV-HAP, with a focus on the significance and challenge of identifying pathogens. It discusses the limitations in current techniques, and explores the potential of emergent molecular techniques to improve microbiological diagnosis and outcomes for patients.
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Affiliation(s)
- S Quarton
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK.
| | - A Livesey
- National Institute for Health Research/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham, Birmingham, UK
| | - H Pittaway
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - A Adiga
- Warwick Hospital, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - F Grudzinska
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - A McNally
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - D Dosanjh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - E Sapey
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK; National Institute for Health Research Midlands Patient Safety Research Collaboration, University of Birmingham, Birmingham, UK; National Institute for Health Research Midlands Applied Research Collaborative, University of Birmingham, Birmingham, UK
| | - D Parekh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Tang F, Zhu F, Wang Y, Zha X, Lyu L, Ma D. Role of bronchoscopy in the management of patients with suspected or suffering from ventilator-associated pneumonia: A meta-analysis. Heliyon 2024; 10:e32751. [PMID: 39183884 PMCID: PMC11341318 DOI: 10.1016/j.heliyon.2024.e32751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/22/2024] [Accepted: 06/07/2024] [Indexed: 08/27/2024] Open
Abstract
Background The utility of bronchoscopy in the treatment of patients with ventilator-associated pneumonia (VAP) has been proposed, although prior research has yielded inconclusive findings. This systematic review and meta-analysis were conducted to examine the impact of bronchoscopy on mortality rates, duration of mechanical ventilation (MV), and length of stay in the intensive care unit (ICU) among patients with VAP. Methods Relevant randomized controlled trials (RCTs) and cohort studies were acquired by conducting a comprehensive search in the PubMed, Embase, and Cochrane Library databases. To account for the potential heterogeneity, a random-effects model was utilized to combine the findings and incorporate its potential influence. Results Eight RCTs and three cohort studies, including 3907 patients with highly suspected or clinically diagnosed VAP, were included. Compared to the controls, bronchoscopy use was not associated with a significant effect on all-cause mortality (relative risk [RR]: 0.81, 95 % confidence interval [CI]: 0.62 to 1.05, p = 0.12; I2 = 57 %). Subgroup analysis showed that bronchoscopy used for the microbiological diagnosis of VAP was not associated with reduced mortality (RR: 0.92, 95 % CI: 0.75 to 1.13), while therapeutic bronchoscopy use was associated with significantly reduced mortality (RR: 0.53, 95 % CI: 0.35 to 0.81). The duration of MV or length of ICU stay was not significantly different between groups. Conclusions Bronchoscopy use for the purpose of the microbiological diagnosis of VAP did not reduce short-term mortality compared to diagnosis without bronchoscopy use, while therapeutic bronchoscopy use was associated with reduced mortality in these patients.
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Affiliation(s)
- Fei Tang
- Department of Interventional Pulmonology and Endoscopic Diagnosis and Treatment Center, Anhui Chest Hospital, Hefei, 230031, China
| | - Feng Zhu
- Department of Thoracic Surgery, Anhui Chest Hospital, Hefei, 230031, China
| | - Yueming Wang
- Department of Interventional Pulmonology and Endoscopic Diagnosis and Treatment Center, Anhui Chest Hospital, Hefei, 230031, China
| | - Xiankui Zha
- Department of Interventional Pulmonology and Endoscopic Diagnosis and Treatment Center, Anhui Chest Hospital, Hefei, 230031, China
| | - Liping Lyu
- Department of Interventional Pulmonology and Endoscopic Diagnosis and Treatment Center, Anhui Chest Hospital, Hefei, 230031, China
| | - Dongchun Ma
- Department of Thoracic Surgery, Anhui Chest Hospital, Hefei, 230031, China
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Jeng M, Orsini EM, Yerke J, Mehkri O, Mireles-Cabodevila E, Khouli H, Mujanovic S, Wang X, Duggal A, Vachharajani V, Scheraga RG. Nonbronchoscopic Bronchoalveolar Lavage Improves Respiratory Culture Accuracy in Critically Ill Patients. Crit Care Explor 2023; 5:e1008. [PMID: 38020848 PMCID: PMC10656098 DOI: 10.1097/cce.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVES Diagnosis of pneumonia is challenging in critically ill, intubated patients due to limited diagnostic modalities. Endotracheal aspirate (EA) cultures are standard of care in many ICUs; however, frequent EA contamination leads to unnecessary antibiotic use. Nonbronchoscopic bronchoalveolar lavage (NBBL) obtains sterile, alveolar cultures, avoiding contamination. However, paired NBBL and EA sampling in the setting of a lack of gold standard for airway culture is a novel approach to improve culture accuracy and limit antibiotic use in the critically ill patients. DESIGN We designed a pilot study to test respiratory culture accuracy between EA and NBBL. Adult, intubated patients with suspected pneumonia received concurrent EA and NBBL cultures by registered respiratory therapists. Respiratory culture microbiology, cell counts, and antibiotic prescribing practices were examined. SETTING We performed a prospective pilot study at the Cleveland Clinic Main Campus Medical ICU in Cleveland, Ohio for 22 months from May 2021 through March 2023. PATIENTS OR SUBJECTS Three hundred forty mechanically ventilated patients with suspected pneumonia were screened. Two hundred fifty-seven patients were excluded for severe hypoxia (Fio2 ≥ 80% or positive end-expiratory pressure ≥ 12 cm H2O), coagulopathy, platelets less than 50,000, hemodynamic instability as determined by the treating team, and COVID-19 infection to prevent aerosolization of the virus. INTERVENTIONS All 83 eligible patients were enrolled and underwent concurrent EA and NBBL. MEASUREMENTS AND MAIN RESULTS More EA cultures (42.17%) were positive than concurrent NBBL cultures (26.51%, p = 0.049), indicating EA contamination. The odds of EA contamination increased by eight-fold 24 hours after intubation. EA was also more likely to be contaminated with oral flora when compared with NBBL cultures. There was a trend toward decreased antibiotic use in patients with positive EA cultures if paired with a negative NBBL culture. Alveolar immune cell populations were recovered from NBBL samples, indicating successful alveolar sampling. There were no major complications from NBBL. CONCLUSIONS NBBL is more accurate than EA for respiratory cultures in critically ill, intubated patients. NBBL provides a safe and effective technique to sample the alveolar space for both clinical and research purposes.
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Affiliation(s)
- Margaret Jeng
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Erica M Orsini
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Jason Yerke
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Omar Mehkri
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | - Hassan Khouli
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Samin Mujanovic
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Xiaofeng Wang
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Abhijit Duggal
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Vidula Vachharajani
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Rachel G Scheraga
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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Martin-Loeches I, Chastre J, Wunderink RG. Bronchoscopy for diagnosis of ventilator-associated pneumonia. Intensive Care Med 2023; 49:79-82. [PMID: 36171440 PMCID: PMC9517962 DOI: 10.1007/s00134-022-06898-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 09/19/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James's street, James' St, Saint James' (part of Phoenix Park), Dublin 8, Dublin, D08 NHY1, Republic of Ireland. .,Pulmonary Intensive Care Unit, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), University of Barcelona, CIBERes, Barcelona, Spain.
| | - Jean Chastre
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Zhang L, Li S, Yuan S, Lu X, Li J, Liu Y, Huang T, Lyu J, Yin H. The Association Between Bronchoscopy and the Prognoses of Patients With Ventilator-Associated Pneumonia in Intensive Care Units: A Retrospective Study Based on the MIMIC-IV Database. Front Pharmacol 2022; 13:868920. [PMID: 35754471 PMCID: PMC9214225 DOI: 10.3389/fphar.2022.868920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background: In intensive care units (ICUs), the morbidity and mortality of ventilator-associated pneumonia (VAP) are relatively high, and this condition also increases medical expenses for mechanically ventilated patients, which will seriously affect the prognoses of critically ill patients. The purpose of this study was to determine the impact of bronchoscopy on the prognosis of patients with VAP undergoing invasive mechanical ventilation (IMV). Methods: This was a retrospective study based on patients with VAP from the Medical Information Mart for Intensive Care IV database. The outcomes were ICU and in-hospital mortality. Patients were divided based on whether or not they had undergone bronchoscopy during IMV. Kaplan-Meier (KM) survival curves and Cox proportional-hazards regression models were used to analyze the association between groups and outcomes. Propensity score matching (PSM) and propensity score based inverse probability of treatment weighting (IPTW) were used to further verify the stability of the results. The effect of bronchoscopy on prognosis was further analyzed by causal mediation analysis (CMA). Results: This study enrolled 1,560 patients with VAP: 1,355 in the no-bronchoscopy group and 205 in the bronchoscopy group. The KM survival curve indicated a significant difference in survival probability between the two groups. The survival probabilities in both the ICU and hospital were significantly higher in the bronchoscopy group than in the no bronchoscopy group. After adjusting all covariates as confounding factors in the Cox model, the HRs (95% CI) for ICU and in-hospital mortality in the bronchoscopy group were 0.33 (0.20–0.55) and 0.40 (0.26–0.60), respectively, indicating that the risks of ICU and in-hospital mortality were 0.67 and 0.60 lower than in the no-bronchoscopy group. The same trend was obtained after using PSM and IPTW. CMA showed that delta-red blood cell distribution width (RDW) mediated 8 and 7% of the beneficial effects of bronchoscopy in ICU mortality and in-hospital mortality. Conclusion: Bronchoscopy during IMV was associated with reducing the risk of ICU and in-hospital mortality in patients with VAP in ICUs, and this beneficial effect was partially mediated by changes in RDW levels.
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Affiliation(s)
- Luming Zhang
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shaojin Li
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
| | - Shiqi Yuan
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
| | - Xuehao Lu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jieyao Li
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yu Liu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Tao Huang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
| | - Haiyan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
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The Role of Lung Ultrasound Monitoring in Early Detection of Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Observational Study. J Clin Med 2022; 11:jcm11113001. [PMID: 35683392 PMCID: PMC9181291 DOI: 10.3390/jcm11113001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/11/2022] [Accepted: 05/21/2022] [Indexed: 02/08/2023] Open
Abstract
Specific lung ultrasound signs combined with clinical parameters allow for early diagnosis of ventilator-associated pneumonia in the general ICU population. This retrospective cohort study aimed to determine the accuracy of lung ultrasound monitoring for ventilator-associated pneumonia diagnosis in COVID-19 patients. Clinical (i.e., clinical pulmonary infection score) and ultrasound (i.e., presence of consolidation and a dynamic linear−arborescent air bronchogram, lung ultrasound score, ventilator-associated lung ultrasound score) data were collected on the day of the microbiological sample (pneumonia-day) and 48 h before (baseline) on 55 bronchoalveolar lavages of 33 mechanically-ventilated COVID-19 patients who were monitored daily with lung ultrasounds. A total of 26 samples in 23 patients were positive for ventilator-associated pneumonia (pneumonia cases). The onset of a dynamic linear−arborescent air bronchogram was 100% specific for ventilator-associated pneumonia. The ventilator-associated lung ultrasound score was higher in pneumonia-cases (2.5 (IQR 1.0 to 4.0) vs. 1.0 (IQR 1.0 to 1.0); p < 0.001); the lung ultrasound score increased from baseline in pneumonia-cases only (3.5 (IQR 2.0 to 6.0) vs. −1.0 (IQR −2.0 to 1.0); p = 0.0001). The area under the curve for clinical parameters, ventilator-associated pneumonia lung ultrasound score, and lung ultrasound score variations were 0.472, 0.716, and 0.800, respectively. A newly appeared dynamic linear−arborescent air bronchogram is highly specific for ventilator-associated pneumonia in COVID-19 patients. A high ventilator-associated pneumonia lung ultrasound score (or an increase in the lung ultrasound score) orients to ventilator-associated pneumonia.
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7
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A Narrative Review on the Approach to Antimicrobial Use in Ventilated Patients with Multidrug Resistant Organisms in Respiratory Samples—To Treat or Not to Treat? That Is the Question. Antibiotics (Basel) 2022; 11:antibiotics11040452. [PMID: 35453203 PMCID: PMC9031060 DOI: 10.3390/antibiotics11040452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 02/01/2023] Open
Abstract
Multidrug resistant organisms (MDRO) are commonly isolated in respiratory specimens taken from mechanically ventilated patients. The purpose of this narrative review is to discuss the approach to antimicrobial prescription in ventilated patients who have grown a new MDRO isolate in their respiratory specimen. A MEDLINE and PubMed literature search using keywords “multidrug resistant organisms”, “ventilator-associated pneumonia” and “decision making”, “treatment” or “strategy” was used to identify 329 references as background for this review. Lack of universally accepted diagnostic criteria for ventilator-associated pneumonia, or ventilator-associated tracheobronchitis complicates treatment decisions. Consideration of the clinical context including signs of respiratory infection or deterioration in respiratory or other organ function is essential. The higher the quality of respiratory specimens or the presence of bacteremia would suggest the MDRO is a true pathogen, rather than colonization, and warrants antimicrobial therapy. A patient with higher severity of illness has lower safety margins and may require initiation of antimicrobial therapy until an alternative diagnosis is established. A structured approach to the decision to treat with antimicrobial therapy is proposed.
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8
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Cheng YN, Huang WC, Wang CY, Fu PK. Compared the Microbiota Profiles between Samples from Bronchoalveolar Lavage and Endotracheal Aspirates in Severe Pneumonia: A Real-World Experience. J Clin Med 2022; 11:jcm11020327. [PMID: 35054022 PMCID: PMC8778781 DOI: 10.3390/jcm11020327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/26/2021] [Accepted: 01/04/2022] [Indexed: 02/06/2023] Open
Abstract
Lower respiratory tract sampling from endotracheal aspirate (EA) and bronchoalveolar lavage (BAL) are both common methods to identify pathogens in severe pneumonia. However, the difference between these two methods in microbiota profiles remains unclear. We compared the microbiota profiles of pairwise EA and BAL samples in ICU patients with respiratory failure due to severe pneumonia. We prospectively enrolled 50 ICU patients with new onset of pneumonia requiring mechanical ventilation. EA and BAL were performed on the first ICU day, and samples were analyzed for microbial community composition via 16S rRNA metagenomic sequencing. Pathogens were identified in culture medium from BAL samples in 21 (42%) out of 50 patients. No difference was observed in the antibiotic prescription pattern, ICU mortality, or hospital mortality between BAL-positive and BAL-negative patients. The microbiota profiles in the EA and BAL samples are similar with respect to diversity, microbial composition, and microbial community correlations. The antibiotic treatment regimen was rarely changed based on the BAL findings. The samples from BAL did not provide more information than EA in the microbiota profiles. We suggest that EA is more useful than BAL for microbiome identification in mechanically ventilated patients.
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Affiliation(s)
- Yeong-Nan Cheng
- Institute of Bioinformatics and Systems Biology, College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu 300, Taiwan; (Y.-N.C.); (W.-C.H.)
- Department of Biological Science and Technology, College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu 300, Taiwan
| | - Wei-Chih Huang
- Institute of Bioinformatics and Systems Biology, College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu 300, Taiwan; (Y.-N.C.); (W.-C.H.)
- Department of Biological Science and Technology, College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu 300, Taiwan
| | - Chen-Yu Wang
- Department of Nursing, Hungkuang University, Taichung 43302, Taiwan;
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Pin-Kuei Fu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- College of Human Science and Social Innovation, Hungkuang University, Taichung 433304, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402010, Taiwan
- Correspondence: ; Tel.: +886-937-701-592
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Scala R, Guidelli L. Clinical Value of Bronchoscopy in Acute Respiratory Failure. Diagnostics (Basel) 2021; 11:diagnostics11101755. [PMID: 34679452 PMCID: PMC8534926 DOI: 10.3390/diagnostics11101755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/16/2022] Open
Abstract
Bronchoscopy may be considered the “added value” in the diagnostic and therapeutic pathway of different clinical scenarios occurring in acute respiratory critically ill patients. Rigid bronchoscopy is mainly employed in emergent clinical situations due to central airways obstruction, haemoptysis, and inhaled foreign body. Flexible bronchoscopy (FBO) has larger fields of acute applications. In intensive care settings, FBO is useful to facilitate intubation in difficult airways, guide percutaneous dilatational tracheostomy, and mucous plugs causing lobar/lung atelectasis. FBO plays a central diagnostic role in acute respiratory failure caused by intra-thoracic tumors, interstitial lung diseases, and suspected severe pneumonia. “Bronchoscopic” sampling has to be considered when “non-invasive” techniques are not diagnostic in suspected ventilator-associated pneumonia and in non-ventilated immunosuppressed patients. The combined use of either noninvasive ventilation (NIV) or High-flow nasal cannula (HFNC) with bronchoscopy is useful in different scenarios; the largest body of proven successful evidence has been found for NIV-supported diagnostic FBO in non-ventilated high risk patients to prevent and avoid intubation. The expected diagnostic/therapeutic goals of acute bronchoscopy should be balanced against the potential severe risks (i.e., cardio-pulmonary complications, bleeding, and pneumothorax). Expertise of the team is fundamental to achieve the best rate of success with the lowest rate of complications of diagnostic and therapeutic bronchoscopic procedures in acute clinical circumstances.
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Shah H, ElSaygh J, Raheem A, Yousuf MA, Nguyen LH, Nathani PS, Sharma V, Theli A, Desai MK, Moradiya DV, Devani H, Karki A. Utilization Trends and Predictors of Non-invasive and Invasive Ventilation During Hospitalization Due to Community-Acquired Pneumonia. Cureus 2021; 13:e17954. [PMID: 34660142 PMCID: PMC8515501 DOI: 10.7759/cureus.17954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality. Non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV) are most important interventions for patients with severe CAP associated with respiratory failure. We analysed utilization trends and predictors of non-invasive and invasive ventilation in patients hospitalized with CAP. METHODS Nationwide Inpatient Sample and Healthcare Cost and Utilization Project data for years 2008-2017 were analysed. Adult hospitalizations due to CAP were identified by previously validated International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. We then utilized the Cochran-Armitage trend test and multivariate survey logistic regression models to analyse temporal incidence trends, predictors, and outcomes. We used SAS 9.4 software (SAS Institute Inc., Cary, NC, USA) for analysing data. RESULTS Out of a total of 8,385,861 hospitalizations due to CAP, ventilation assistance was required in 552,395 (6.6%). The overall ventilation use increased slightly; however, IMV utilization decreased, while NIV utilization increased. In multivariable regression analysis, males, Asian/others and weekend admissions were associated with higher odds of any ventilation utilization. Concurrent diagnoses of septicemia, congestive heart failure, alcoholism, chronic lung diseases, pulmonary circulatory diseases, diabetes mellitus, obesity and cancer were associated with increased odds of requiring ventilation assistance. Ventilation requirement was associated with high odds of in-hospital mortality and discharge to facility. CONCLUSION The use of NIV among CAP patients has increased while IMV use has decreased over the years. We observed numerous factors linked with a higher use of ventilation support. The requirement of ventilation support is also associated with very high chances of mortality and morbidity.
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Affiliation(s)
- Harshil Shah
- Internal Medicine, Guthrie Robert Packer Hospital, Sayre, USA
| | - Jude ElSaygh
- Internal Medicine, University of Debrecen, Debrecen, HUN
| | - Abdur Raheem
- Internal Medicine, Texas Tech University Health Sciences Center at Permian Basin, Odessa, USA
| | | | - Lac Han Nguyen
- Internal Medicine, University of Medicine and Pharmacy of Ho Chi Minh City, Ho Chi Minh City, VNM
| | | | - Venus Sharma
- Internal Medicine, Punjab Institute of Medical Sciences, Jalandhar, IND
| | - Abhinay Theli
- Internal Medicine, Guthrie Cortland Medical Center, Cortland, USA
| | - Maheshkumar K Desai
- Internal Medicine, Hamilton Medical Center, Medical College of Georgia/Augusta University, Augusta, USA
| | | | - Hiteshkumar Devani
- Dental Medicine, University of Pittsburgh School of Dental Medicine, Pittsburgh, USA
| | - Apurwa Karki
- Critical Care, Guthrie Cortland Medical Center, Cortland, USA
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11
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Accuracy of Molecular Amplification Assays for Diagnosis of Staphylococcal Pneumonia: a Systematic Review and Meta-analysis. J Clin Microbiol 2021; 59:e0300320. [PMID: 33568465 DOI: 10.1128/jcm.03003-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rapid and accurate identification of staphylococcal pneumonia is crucial for effective antimicrobial stewardship. We performed a meta-analysis to evaluate the diagnostic value of nucleic acid amplification tests (NAAT) from lower respiratory tract (LRT) samples from suspected pneumonia patients to avoid superfluous empirical methicillin-resistant Staphylococcus aureus (MRSA) treatment. PubMed, Scopus, Embase, Web of Science, and the Cochrane Library Database were searched from inception to 2 September 2020. Data analysis was carried out using a bivariate random-effects model to estimate pooled sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR). Of 1,808 citations, 24 publications comprising 32 data sets met our inclusion criteria. Twenty-two studies (n = 4,630) assessed the accuracy of the NAAT for methicillin-sensitive S. aureus (MSSA) detection, while 10 studies (n = 2,996) demonstrated the accuracy of the NAAT for MRSA detection. The pooled NAAT sensitivity and specificity (with 95% confidence interval [CI]) for all MSSA detection were higher (sensitivity of 0.91 [95% CI, 0.89 to 0.94], specificity of 0.94 [95% CI, 0.94 to 0.95]) than those of MRSA (sensitivity of 0.75 [95% CI, 0.69 to 0.80], specificity of 0.88 [95% CI, 0.86 to 0.89]) in lower respiratory tract (LRT) samples. NAAT pooled sensitivities differed marginally among different LRT samples, including sputum, endotracheal aspirate (ETA), and bronchoalveolar lavage (BAL) fluid. Noticeably, NAAT pooled specificity against microbiological culture was consistently ≥88% across various types of LRT samples. A meta-regression and subgroup analysis of study design, sample condition, and patient selection method could not explain the heterogeneity (P > 0.05) in the diagnostic efficiency. This meta-analysis has demonstrated that the NAAT can be applied as the preferred initial test for timely diagnosis of staphylococcal pneumonia in LRT samples for successful antimicrobial therapy.
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Impact of Cardiovascular Failure in Intensive CareUnit-Acquired Pneumonia: A Single-Center, Prospective Study. Antibiotics (Basel) 2021; 10:antibiotics10070798. [PMID: 34209181 PMCID: PMC8300830 DOI: 10.3390/antibiotics10070798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 01/20/2023] Open
Abstract
Background: Cardiovascular failure (CVF) may complicate intensive care unit-acquired pneumonia (ICUAP) and radically alters the empirical treatment of this condition. The aim of this study was to determine the impact of CVF on outcome in patients with ICUAP. Methods: A prospective, single-center, observational study was conducted in six medical and surgical ICUs at a University Hospital. CVS was defined as a score of 3 or more on the cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score. At the onset of ICUAP, CVF was reported as absent, transient (if lasting ≤ 3 days) or persistent (>3 days). The primary outcome was 90-day mortality modelled through a Cox regression analysis. Secondary outcomes were 28-day mortality, hospital mortality, ICU length of stay (LOS) and hospital LOS. Results: 358 patients were enrolled: 203 (57%) without CVF, 82 (23%) with transient CVF, and 73 (20%) with persistent CVF. Patients with transient and persistent CVF were more severely ill and presented higher inflammatory response than those without CVF. Despite having similar severity and aetiology, the persistent CVF group more frequently received inadequate initial antibiotic treatment and presented more treatment failures than the transient CVF group. In the persistent CVF group, at day 3, a bacterial superinfection was more frequently detected. The 90-day mortality was significantly higher in the persistent CVF group (62%). The 28-day mortality rates for patients without CVF, with transient and with persistent CVF were 19, 35 and 41% respectively and ICU mortality was 60, 38 and 19% respectively. In the multivariate analysis chronic pulmonary conditions, lack of Pa02/FiO2 improvement at day 3, pulmonary superinfection at day 3 and persistent CVF were independently associated with 90-day mortality in ICUAP patients. Conclusions: Persistent CVF has a significant impact on the outcome of patients with ICUAP. Patients at risk from persistent CVF should be promptly recognized to optimize treatment and outcomes.
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Impact of Invasive Quantitative Respiratory Cultures on Antimicrobial Therapy for Suspected Pneumonia in Trauma. J Trauma Nurs 2020; 27:355-359. [PMID: 33156252 DOI: 10.1097/jtn.0000000000000543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Invasive quantitative respiratory cultures are generally not recommended because of a lack of demonstrated benefit. There is insufficient literature regarding specific populations such as trauma. The objective of this study was to evaluate the effect of invasive quantitative respiratory sampling on de-escalation to targeted antimicrobial therapy for the management of pneumonia in a trauma population. METHODS This was a single-center retrospective cohort study conducted at an American College of Surgeons-verified Level II Trauma Center in Nashville, TN. Adult patients admitted to the trauma service and diagnosed with pneumonia from July 2013 to August 2018 were divided into 2 groups: invasive quantitative respiratory sampling versus noninvasive respiratory sampling. The primary endpoint was rate of targeted antimicrobial therapy. Secondary endpoints included in-hospital mortality, antibiotic days of therapy, and frequency of discontinuation of antibiotics when quantitative cultures were below the diagnostic threshold. RESULTS A total of 88 patients were sampled, with 27 in the invasive quantitative group and 66 in the noninvasive group. There was no difference in rates of targeted therapy in patients with invasive quantitative sampling (17 [63%] vs. 35 [57%]; relative risk = 1.10; 95% confidence interval [0.76, 1.57]). No statistically significant differences were observed for in-hospital mortality (8 patients vs. 6 patients, p = .35) or antimicrobial days of therapy (10.3 ± 8.8 vs. 7.8 ± 3.6, p = .161). Only 2 patients (17%) had antibiotics withheld when below the diagnostic threshold. CONCLUSIONS Invasive quantitative respiratory sampling did not result in significant changes in targeted antibiotic therapy in a trauma population.
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14
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Hou D, Ju M, Wang Y, Zhang D, Zhu D, Zhong M, Zhou C, Song Y, Cheng X. PCR coupled to electrospray ionization mass spectrometry for microbiological diagnosis and surveillance of ventilator-associated pneumonia. Exp Ther Med 2020; 20:3587-3594. [PMID: 32855712 PMCID: PMC7444324 DOI: 10.3892/etm.2020.9103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 03/02/2020] [Indexed: 12/29/2022] Open
Abstract
Etiological diagnosis is essential for anti-infective therapy in patients with ventilator-associated pneumonia (VAP). The present study aimed to evaluate the capacity of sequential PCR coupled to electrospray ionization mass spectrometry (PCR/ESI-MS) tests as a rapid diagnostic technique for patients with VAP. A total of 12 patients diagnosed with VAP were enrolled at the intensive care unit in Zhongshan Hospital, Fudan University. Mini-bronchoalveolar lavage fluid specimens were prospectively collected on VAP 0, 5 and 10 days following the beginning of mechanical ventilation. Routine clinical culture and PCR/ESI-MS were compared for identification of microorganisms in the specimens. A total of 51 bacterial species were detected by either of the two methods. The positive rates of routine clinical culture and PCR/ESI-MS were 38.2 and 88.2%, respectively. Out of the 16 specimens positive in routine cultures, 15 were also positive on PCR/ESI-MS, except for one, from which a mix of three distinct bacterial isolates were reported by culture. Among the 50 bacterial species identified by PCR/ESI-MS, 15 (35.7%) of the common VAP pathogens were confirmed by paired culture. Furthermore, of the 16 bacterial isolates that were finally confirmed to be responsible for VAP, 14 were identified by a sequential PCR/ESI-MS test concurrently when the culture results were obtained. PCR/ESI-MS identified pathogens that may cause VAP in 8 subjects prior to the occurrence of associated clinical manifestations. To conclude, PCR/ESI-MS was a potential rapid technique for diagnosis of VAP within 6 h. Regular respiratory specimen monitoring using PCR/ESI-MS provides information for selecting appropriate and adequate antibiotic therapies in ventilated patients.
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Affiliation(s)
- Dongni Hou
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Shanghai Respiratory Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Mohan Ju
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, P.R. China
| | - Ying Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Shanghai 200032, P.R. China
| | - Donghui Zhang
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Shanghai Respiratory Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Duming Zhu
- Department of Critical Care Medicine, Zhongshan Hospital, Shanghai 200032, P.R. China
| | - Ming Zhong
- Department of Critical Care Medicine, Zhongshan Hospital, Shanghai 200032, P.R. China
| | - Chenjun Zhou
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Yuanlin Song
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Shanghai Respiratory Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Department of Pulmonary Medicine, Zhongshan Hospital, Qingpu Branch, Shanghai 201700, P.R. China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Shanghai 200040, P.R. China
| | - Xunjia Cheng
- Department of Medical Microbiology and Parasitology, Institute of Biomedical Sciences, School of Basic Medical Sciences, Fudan University, Shanghai 200032, P.R. China
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15
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Arulkumaran N, Routledge M, Schlebusch S, Lipman J, Conway Morris A. Antimicrobial-associated harm in critical care: a narrative review. Intensive Care Med 2020; 46:225-235. [PMID: 31996961 PMCID: PMC7046486 DOI: 10.1007/s00134-020-05929-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/09/2020] [Indexed: 12/12/2022]
Abstract
The belief that, for the individual patient, the benefit of prompt and continued use of antimicrobials outweighs any potential harm is a significant barrier to improved stewardship of these vital agents. Antimicrobial stewardship may be perceived as utilitarian rationing, seeking to preserve the availability of effective antimicrobials by limiting the development of resistance in a manner which could conflict with the immediate treatment of the patient in need. This view does not account for the growing evidence of antimicrobial-associated harm to individual patients. This review sets out the evidence for antimicrobial-associated harm and how this should be balanced with the need for prompt and appropriate therapy in infection. It describes the mechanisms by which antimicrobials may harm patients including: mitochondrial toxicity; immune cell toxicity; adverse drug reactions; selection of resistant organisms within a given patient; and disruption of the microbiome. Finally, the article indicates how the harms of antimicrobials may be mitigated and identifies areas for research and development in this field.
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Affiliation(s)
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Sanmarié Schlebusch
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Forensic and Scientific Services, Queensland Health, Brisbane, Australia
| | - Jeffrey Lipman
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Intensive Care Services, Royal Brisbane and Womens' Hospital, Brisbane, Australia
- Scientific Consultant, Nimes University Hospital University of Montpellier, Nimes, France
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge, UK.
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Level 4, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
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Toksöz V, Yılmaz M. Ventilatör İlişkili Pnömoni Hastalarından İzole Edilen Mikroorganizmaların Antimikrobiyal Duyarlılıkları. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.661216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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17
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Ventilator-Associated Pneumonia: Diagnostic Test Stewardship and Relevance of Culturing Practices. Curr Infect Dis Rep 2019; 21:50. [PMID: 31754887 DOI: 10.1007/s11908-019-0708-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW Ventilator-associated pneumonia (VAP) is one of the most common infections in the ICU. Prompt diagnosis is vital as mortality increases with delayed antibiotic therapy. However, accurate diagnosis is challenging due to non-specific clinical features in a complicated patient cohort. Microbiological culture data remains a crucial aspect in confirming diagnosis. RECENT FINDINGS Literature data comparing the benefit of invasive respiratory sampling to non-invasive is inconclusive. Differences in culturing practices translate in overidentification of organisms of unclear significance. Positive culture data in a low pre-test probability does not differentiate between true infection and colonization resulting in overtreatment. Furthermore, there are also opportunities for modifying the reporting of respiratory tract cultures that can better guide antimicrobial therapy. Under the umbrella of antimicrobial stewardship, diagnostic stewardship can be incorporated to create a systematic approach that would target culturing practices to match the right pre-test probability. Ideal outcome will be targeting cultures to the right patient population and minimizing unnecessary treatment.
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18
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Ventilator-Associated Pneumonia and PaO 2/F IO 2 Diagnostic Accuracy: Changing the Paradigm? J Clin Med 2019; 8:jcm8081217. [PMID: 31416285 PMCID: PMC6722826 DOI: 10.3390/jcm8081217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/01/2019] [Accepted: 08/06/2019] [Indexed: 02/03/2023] Open
Abstract
Background: Ventilator-associated pneumonia (VAP) is associated to longer stay and poor outcomes. Lacking definitive diagnostic criteria, worsening gas exchange assessed by PaO2/FIO2 ≤ 240 in mmHg has been proposed as one of the diagnostic criteria for VAP. We aim to assess the adequacy of PaO2/FIO2 ≤ 240 to diagnose VAP. Methods: Prospective observational study in 255 consecutive patients with suspected VAP, clustered according to PaO2/FIO2 ≤ 240 vs. > 240 at pneumonia onset. The primary analysis was the association between PaO2/FIO2 ≤ 240 and quantitative microbiologic confirmation of pneumonia, the most reliable diagnostic gold-standard. Results: Mean PaO2/FIO2 at VAP onset was 195 ± 82; 171 (67%) cases had PaO2/FIO2 ≤ 240. Patients with PaO2/FIO2 ≤ 240 had a lower APACHE-II score at ICU admission; however, at pneumonia onset they had higher CPIS, SOFA score, acute respiratory distress syndrome criteria and incidence of shock, and less microbiological confirmation of pneumonia (117, 69% vs. 71, 85%, p = 0.008), compared to patients with PaO2/FIO2 > 240. In multivariate logistic regression, PaO2/FIO2 ≤ 240 was independently associated with less microbiological confirmation (adjusted odds-ratio 0.37, 95% confidence interval 0.15–0.89, p = 0.027). The association between PaO2/FIO2 and microbiological confirmation of VAP was poor, with an area under the ROC curve 0.645. Initial non-response to treatment and length of stay were similar between both groups, while hospital mortality was higher in patients with PaO2/FIO2 ≤ 240. Conclusion: Adding PaO2/FIO2 ratio ≤ 240 to the clinical and radiographic criteria does not help in the diagnosis of VAP. PaO2/FIO2 ratio > 240 does not exclude this infection. Using this threshold may underestimate the incidence of VAP.
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19
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Walter JM, Ren Z, Yacoub T, Reyfman PA, Shah RD, Abdala-Valencia H, Nam K, Morgan VK, Anekalla KR, Joshi N, McQuattie-Pimentel AC, Chen CI, Chi M, Han S, Gonzalez-Gonzalez FJ, Soberanes S, Aillon RP, Watanabe S, Williams KJN, Lu Z, Paonessa J, Hountras P, Breganio M, Borkowski N, Donnelly HK, Allen JP, Amaral LA, Bharat A, Misharin AV, Bagheri N, Hauser AR, Budinger GRS, Wunderink RG. Multidimensional Assessment of the Host Response in Mechanically Ventilated Patients with Suspected Pneumonia. Am J Respir Crit Care Med 2019; 199:1225-1237. [PMID: 30398927 PMCID: PMC6519857 DOI: 10.1164/rccm.201804-0650oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 11/02/2018] [Indexed: 12/14/2022] Open
Abstract
Rationale: The identification of informative elements of the host response to infection may improve the diagnosis and management of bacterial pneumonia. Objectives: To determine whether the absence of alveolar neutrophilia can exclude bacterial pneumonia in critically ill patients with suspected infection and to test whether signatures of bacterial pneumonia can be identified in the alveolar macrophage transcriptome. Methods: We determined the test characteristics of alveolar neutrophilia for the diagnosis of bacterial pneumonia in three cohorts of mechanically ventilated patients. In one cohort, we also isolated macrophages from alveolar lavage fluid and used the transcriptome to identify signatures of bacterial pneumonia. Finally, we developed a humanized mouse model of Pseudomonas aeruginosa pneumonia to determine if pathogen-specific signatures can be identified in human alveolar macrophages. Measurements and Main Results: An alveolar neutrophil percentage less than 50% had a negative predictive value of greater than 90% for bacterial pneumonia in both the retrospective (n = 851) and validation cohorts (n = 76 and n = 79). A transcriptional signature of bacterial pneumonia was present in both resident and recruited macrophages. Gene signatures from both cell types identified patients with bacterial pneumonia with test characteristics similar to alveolar neutrophilia. Conclusions: The absence of alveolar neutrophilia has a high negative predictive value for bacterial pneumonia in critically ill patients with suspected infection. Macrophages can be isolated from alveolar lavage fluid obtained during routine care and used for RNA-Seq analysis. This novel approach may facilitate a longitudinal and multidimensional assessment of the host response to bacterial pneumonia.
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Affiliation(s)
- James M. Walter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Ziyou Ren
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Tyrone Yacoub
- Department of Chemical and Biological Engineering, Northwestern University, Evanston, Illinois
| | - Paul A. Reyfman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Raj D. Shah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - Kiwon Nam
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Vince K. Morgan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Kishore R. Anekalla
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Nikita Joshi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - Ching-I Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Monica Chi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - SeungHye Han
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - Saul Soberanes
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Raul P. Aillon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Satoshi Watanabe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - Ziyan Lu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Joseph Paonessa
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Peter Hountras
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Madonna Breganio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Nicole Borkowski
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Helen K. Donnelly
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Jonathan P. Allen
- Department of Microbiology and Immunology, Northwestern University, Chicago, Illinois; and
| | - Luis A. Amaral
- Department of Chemical and Biological Engineering, Northwestern University, Evanston, Illinois
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, and
| | | | - Neda Bagheri
- Department of Chemical and Biological Engineering, Northwestern University, Evanston, Illinois
| | - Alan R. Hauser
- Department of Microbiology and Immunology, Northwestern University, Chicago, Illinois; and
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20
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Paonessa JR, Shah RD, Pickens CI, Lizza BD, Donnelly HK, Malczynski M, Qi C, Wunderink RG. Rapid Detection of Methicillin-Resistant Staphylococcus aureus in BAL: A Pilot Randomized Controlled Trial. Chest 2019; 155:999-1007. [PMID: 30776365 DOI: 10.1016/j.chest.2019.02.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/31/2018] [Accepted: 02/01/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Guidelines recommend empirical vancomycin or linezolid for patients with suspected pneumonia at risk for methicillin-resistant Staphylococcus aureus (MRSA). Unneeded vancomycin or linezolid use may unnecessarily alter host flora and expose patients to toxicity. We therefore sought to determine if rapid testing for MRSA in BAL can safely decrease use of vancomycin or linezolid for suspected MRSA pneumonia. METHODS Operating characteristics of the assay were initially validated against culture on residual BAL. A prospective, unblinded, randomized clinical trial to assess the effect of antibiotic management made on the basis of rapid diagnostic testing (RDT) compared with usual care was subsequently conducted, with primary outcome of duration of vancomycin or linezolid administration. Secondary end points focused on safety. RESULTS Sensitivity of RPCR was 95.7%, with a negative likelihood ratio of 0.04 for MRSA. The clinical trial randomized 45 patients: 22 to antibiotic management made on the basis of RDT and 23 to usual care. Duration of vancomycin or linezolid administration was significantly reduced in the intervention group (32 h [interquartile range, 22-48] vs 72 h [interquartile range, 50-113], P < .001). Proportions with complications and length of stay trended lower in the intervention group. Hospital mortality was 13.6% in the intervention group and 39.1% for usual care (95% CI of difference, -3.3 to 50.3, P = .06). Standardized mortality ratio was 0.48 for the intervention group and 1.18 for usual care. CONCLUSIONS A highly sensitive BAL RDT for MRSA significantly reduced use of vancomycin and linezolid in ventilated patients with suspected pneumonia. Management made on the basis of RDT had no adverse effects, with a trend to lower hospital mortality. TRIAL REGISTRY ClinicalTrials.gov; No. NCT02660554; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Joseph R Paonessa
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Raj D Shah
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwest Hospital and Medical Center, University of Washington Medicine, Seattle, WA
| | - Chiagozie I Pickens
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bryan D Lizza
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL
| | - Helen K Donnelly
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Chao Qi
- Department of Pathology, Northwestern Memorial Hospital, Chicago, IL; Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Richard G Wunderink
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL.
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21
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Hurley JC. Worldwide variation in Pseudomonas associated ventilator associated pneumonia. A meta-regression. J Crit Care 2019; 51:88-93. [PMID: 30771693 DOI: 10.1016/j.jcrc.2019.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/01/2019] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The objective here is to define the extent and possible reasons for geographic variation in Pseudomonas aeruginosa associated with Ventilator Associated Pneumonia (VAP). METHODS A random effects meta-regression model of Pseudomonas associated VAP incidence within the published literature was undertaken incorporating group level factors such trauma admission, year of publication and use of bronchoscopic sampling towards VAP diagnosis. RESULTS Pseudomonas associated VAP incidence was reported in 162 studies from seven worldwide regions published over 30 years. The highest incidence is among reports from the Middle East and Mediterranean being respectively 6.8; 5.2-9.0 (mean; 95% CI) and 6.9; 5.4-8.8 per 1000 mechanical ventilation (MV) days, versus that from North American ICU's (3.7; 2.3-5.9). In a meta-regression model, the variation in the incidence of Pseudomonas associated VAP was not significantly associated with bronchoscopic sampling in the diagnosis of VAP (p = 0.12) nor with admission to a trauma ICU (p = 0.13). CONCLUSION Pseudomonas associated VAP incidence among reports from six geographic regions worldwide varies by less than twofold with some decline by year of publication. Trauma ICU admission is a significant factor underlying variations in incidence of VAP overall but not Pseudomonas associated VAP.
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Affiliation(s)
- James C Hurley
- Department of Rural Health, Melbourne Medical School, University of Melbourne, Internal Medicine Service, Ballarat Health Services, Victoria, Australia.
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22
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[Hospital-acquired pneumonia]. Med Klin Intensivmed Notfmed 2018; 113:685-695. [PMID: 30302527 DOI: 10.1007/s00063-018-0494-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/10/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Abstract
Hospital-acquired pneumonia (HAP) is a frequent complication of hospitalisation. Due to rising multidrug resistant bacteria an appropriate, empiric and targeted therapy is essential and requires an accurate assessment of risk for multidrug resistant bacteria. A targeted, temporal therapy is indispensable and should begin after a focussed diagnosis. Re-evaluation of therapy is important, as clinical course, microbiological and laboratory results might lead to de-escalation of therapy. In this review article the current German guidelines on the diagnosis and therapy of hospital-acquired pneumonia are summarized. Special focus is put on targeted, risk-adapted therapy.
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23
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Freedberg DE, Zhou MJ, Cohen ME, Annavajhala MK, Khan S, Moscoso DI, Brooks C, Whittier S, Chong DH, Uhlemann AC, Abrams JA. Pathogen colonization of the gastrointestinal microbiome at intensive care unit admission and risk for subsequent death or infection. Intensive Care Med 2018; 44:1203-1211. [PMID: 29936583 DOI: 10.1007/s00134-018-5268-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/05/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Loss of colonization resistance within the gastrointestinal microbiome facilitates the expansion of pathogens and has been associated with death and infection in select populations. We tested whether gut microbiome features at the time of intensive care unit (ICU) admission predict death or infection. METHODS This was a prospective cohort study of medical ICU adults. Rectal surveillance swabs were performed at admission, selectively cultured for vancomycin-resistant Enterococcus (VRE), and assessed using 16S rRNA gene sequencing. Patients were followed for 30 days for death or culture-proven bacterial infection. RESULTS Of 301 patients, 123 (41%) developed culture-proven infections and 76 (25%) died. Fecal biodiversity (Shannon index) did not differ based on death or infection (p = 0.49). The presence of specific pathogens at ICU admission was associated with subsequent infection with the same organism for Escherichia coli, Pseudomonas spp., Klebsiella spp., and Clostridium difficile, and VRE at admission was associated with subsequent Enterococcus infection. In a multivariable model adjusting for severity of illness, VRE colonization and Enterococcus domination (≥ 30% 16S reads) were both associated with death or all-cause infection (aHR 1.46, 95% CI 1.06-2.00 and aHR 1.47, 95% CI 1.00-2.19, respectively); among patients without VRE colonization, Enterococcus domination was associated with excess risk of death or infection (aHR 2.13, 95% CI 1.06-4.29). CONCLUSIONS Enterococcus status at ICU admission was associated with risk for death or all-cause infection, and rectal carriage of common ICU pathogens predicted specific infections. The gastrointestinal microbiome may have a role in risk stratification and early diagnosis of ICU infections.
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Affiliation(s)
- Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.
| | - Margaret J Zhou
- Department of Medicine, Columbia University Medical Center, New York, USA
| | - Margot E Cohen
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Medini K Annavajhala
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Sabrina Khan
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Dagmara I Moscoso
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Christian Brooks
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Susan Whittier
- Division of Laboratory Medicine, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, USA
| | - David H Chong
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Anne-Catrin Uhlemann
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA.,Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.,Mailman School of Public Health, New York, USA
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24
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Hurley JC. World-Wide Variation in Incidence of Staphylococcus aureus Associated Ventilator-Associated Pneumonia: A Meta-Regression. Microorganisms 2018; 6:microorganisms6010018. [PMID: 29495472 PMCID: PMC5874632 DOI: 10.3390/microorganisms6010018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/13/2018] [Accepted: 02/25/2018] [Indexed: 01/21/2023] Open
Abstract
Staphylococcus aureus (S. aureus) is a common Ventilator-Associated Pneumonia (VAP) isolate. The objective here is to define the extent and possible reasons for geographic variation in the incidences of S. aureus-associated VAP, MRSA-VAP and overall VAP. A meta-regression model of S. aureus-associated VAP incidence per 1000 Mechanical Ventilation Days (MVD) was undertaken using random effects methods among publications obtained from a search of the English language literature. This model incorporated group level factors such as admission to a trauma ICU, year of publication and use of bronchoscopic sampling towards VAP diagnosis. The search identified 133 publications from seven worldwide regions published over three decades. The summary S. aureus-associated VAP incidence was 4.5 (3.9–5.3) per 1000 MVD. The highest S. aureus-associated VAP incidence is amongst reports from the Mediterranean (mean; 95% confidence interval; 6.1; 4.1–8.5) versus that from Asian ICUs (2.1; 1.5–3.0). The incidence of S. aureus-associated VAP varies by up to three-fold (for the lowest versus highest incidence) among seven geographic regions worldwide, whereas the incidence of VAP varies by less than two-fold. Admission to a trauma unit is the most important group level correlate for S. aureus-associated VAP.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Ballarat, VIC 3350, Australia.
- Division of Internal Medicine, Ballarat Health Services, Ballarat, VIC 3350, Australia.
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Klompas M. Vive la difference! France's new guidelines on hospital-acquired pneumonia. Anaesth Crit Care Pain Med 2018; 37:13-15. [PMID: 29362160 DOI: 10.1016/j.accpm.2017.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, United States; Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States.
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26
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Goerens A, Lehnick D, Büttcher M, Daetwyler K, Fontana M, Genet P, Lurà M, Morgillo D, Pilgrim S, Schwendener-Scholl K, Regamey N, Neuhaus TJ, Stocker M. Neonatal Ventilator Associated Pneumonia: A Quality Improvement Initiative Focusing on Antimicrobial Stewardship. Front Pediatr 2018; 6:262. [PMID: 30320046 PMCID: PMC6165906 DOI: 10.3389/fped.2018.00262] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/03/2018] [Indexed: 12/24/2022] Open
Abstract
Background and Aims: Neonatal ventilator associated pneumonia (VAP) is a common nosocomial infection and a frequent reason for empirical antibiotic therapy in NICUs. Nonetheless, there is no international consensus regarding diagnostic criteria and management. In a first step, we analyzed the used diagnostic criteria, risk factors and therapeutic management of neonatal VAP by a literature review. In a second step, we aimed to compare suspected vs. confirmed neonatal VAP episodes in our unit according to different published criteria and to analyze interrater-reliability of chest x-rays. Additionally, we aimed to evaluate the development of VAP incidence and antibiotic use after implementation of multifaceted quality improvement changes regarding antimicrobial stewardship and infection control (VAP-prevention-bundle, early-extubation policy, antimicrobial stewardship rounds). Methods: Neonates until 44 weeks of gestation with suspected VAP, hospitalized at our level-III NICU in Lucerne from September 2014 to December 2017 were enrolled. VAP episodes were analyzed according to 4 diagnostic frameworks. Agreement regarding chest x-ray interpretation done by 10 senior physicians was assessed. Annual incidence of suspected and confirmed neonatal VAP episodes and antibiotic days were calculated and compared for the years 2015, 2016, and 2017. Results: 17 studies were identified in our literature review. Overall, CDC-guidelines or similar criteria, requesting radiographic changes as main criteria, are mostly used. Comparison of suspected vs. confirmed neonatal VAP episodes showed a great variance (20.4 vs. 4.5/1,000 ventilator-days). The interrater-reliability of x-ray interpretation was poor (intra-class correlation 0.25). Implemented changes resulted in a gradual decline in annual VAP incidence and antibiotic days from 2015 compared with 2017 (28.8 vs. 7.4 suspected episodes/1,000 ventilator-days, 5.5 vs. 0 confirmed episodes/1,000 ventilator-days and 211 vs. 34.7 antibiotic days/1,000 ventilation-days, respectively). Conclusion: The incidence of suspected VAP and concomitant antibiotic use is much higher than for confirmed VAP, therefore inclusion of suspected episodes should be considered for accurate evaluation. There is a high diagnostic inconsistency and a low reliability of interpretation of chest x-rays regarding VAP. Implementation of combined antimicrobial stewardship and infection control measures may lead to an effective decrease in VAP incidence and antibiotic use.
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Affiliation(s)
- Anouk Goerens
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Dirk Lehnick
- Clinical Trial Unit, University of Lucerne, Lucerne, Switzerland
| | - Michael Büttcher
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Infectious Diseases Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Karin Daetwyler
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Matteo Fontana
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Petra Genet
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Marco Lurà
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric Pulmonology Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Davide Morgillo
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Sina Pilgrim
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Katharina Schwendener-Scholl
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Nicolas Regamey
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric Pulmonology Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Thomas J Neuhaus
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Martin Stocker
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
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Diagnostic Value of Endotracheal Aspirates Sonication on Ventilator-Associated Pneumonia Microbiologic Diagnosis. Microorganisms 2017; 5:microorganisms5030062. [PMID: 28930178 PMCID: PMC5620653 DOI: 10.3390/microorganisms5030062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/15/2017] [Accepted: 09/17/2017] [Indexed: 12/21/2022] Open
Abstract
Microorganisms are able to form biofilms within respiratory secretions. Methods to disaggregate such biofilms before utilizing standard, rapid, or high throughput diagnostic technologies may aid in pathogen detection during ventilator associated pneumonia (VAP) diagnosis. Our aim was to determine if sonication of endotracheal aspirates (ETA) would increase the sensitivity of qualitative, semi-quantitative, and quantitative bacterial cultures in an animal model of pneumonia caused by Pseudomonas aeruginosa or by methicillin resistant Staphylococcus aureus (MRSA). Material and methods: P. aeruginosa or MRSA was instilled into the lungs or the oropharynx of pigs in order to induce severe VAP. Time point assessments for qualitative and quantitative bacterial cultures of ETA and bronchoalveolar lavage (BAL) samples were performed at 24, 48, and 72 h after bacterial instillation. In addition, at 72 h (autopsy), lung tissue was harvested to perform quantitative bacterial cultures. Each ETA sample was microbiologically processed with and without applying sonication for 5 min at 40 KHz before bacterial cultures. Sensitivity and specificity were determined using BAL as a gold-standard. Correlation with BAL and lung bacterial burden was also determined before and after sonication. Assessment of biofilm clusters and planktonic bacteria was performed through both optical microscopy utilizing Gram staining and Confocal Laser Scanning Microscopy utilizing the LIVE/DEAD®BacLight kit. Results: 33 pigs were included, 27 and 6 from P. aeruginosa and MRSA pneumonia models, respectively. Overall, we obtained 85 ETA, 69 (81.2%) from P. aeruginosa and 16 (18.8%) from MRSA challenged pigs. Qualitative cultures did not significantly change after sonication, whereas quantitative ETA cultures did significantly increase bacterial counting. Indeed, sonication consistently increased bacterial burden in ETAs at 24, 48, and 72 h after bacterial challenge. Sonication also improved sensitivity of ETA quantitative cultures and maintained specificity at levels previously reported and accepted for VAP diagnosis. Conclusion: The use of sonication in ETA respiratory samples needs to be clinically validated since sonication could potentially improve pathogen detection before standard, rapid, or high throughput diagnostic methods used in routine microbial diagnostics.
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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.
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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
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Dahyot S, Lemee L, Pestel-Caron M. [Description and role of bacteriological techniques in the management of lung infections]. Rev Mal Respir 2017; 34:1098-1113. [PMID: 28688757 PMCID: PMC7134997 DOI: 10.1016/j.rmr.2016.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/28/2016] [Indexed: 01/07/2023]
Abstract
Les pneumopathies aiguës recouvrent des contextes cliniques variés et les étiologies bactériennes impliquées le sont tout autant. Aucun outil microbiologique n’est 100 % sensible ni 100 % spécifique et malgré les investigations, plus de 30 % des pneumopathies restent sans étiologie identifiée. Si aucun prélèvement n’est indiqué pour les patients traités en ambulatoire, les prélèvements respiratoires non invasifs sont à privilégier pour les pneumopathies aiguës hospitalisées (communautaires ou associées aux soins), tandis que les prélèvements invasifs sont indiqués en seconde ligne pour les pneumopathies aiguës communautaires en réanimation, et en première ligne pour les pneumopathies aiguës de l’immunodéprimé. La culture microbiologique garde une place importante, à condition que le malade soit prélevé avant instauration de l’antibiothérapie. Certains contextes peuvent justifier le recours aux hémocultures, à la recherche d’antigènes urinaires ou aux sérologies. Les PCR rendent déjà service au quotidien mais l’avenir à court terme appartient probablement aux panels moléculaires multiplex capables de détecter de nombreux micro-organismes en quelques heures, surtout dans les pneumopathies communautaires sévères de réanimation et les pneumopathies aiguës de l’immunodéprimé. Le séquençage nucléotidique haut débit révolutionnera bientôt le diagnostic microbiologique, en pneumologie comme dans les autres domaines de l’infectiologie.
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Affiliation(s)
- S Dahyot
- UNIROUEN, GRAM EA2656, laboratoire de bactériologie, CHU de Rouen, Normandie université, 76000 Rouen, France.
| | - L Lemee
- UNIROUEN, GRAM EA2656, laboratoire de bactériologie, CHU de Rouen, Normandie université, 76000 Rouen, France
| | - M Pestel-Caron
- UNIROUEN, GRAM EA2656, laboratoire de bactériologie, CHU de Rouen, Normandie université, 76000 Rouen, France
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Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratalà J, El Solh AA, Ewig S, Fey PD, File TM, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61-e111. [PMID: 27418577 PMCID: PMC4981759 DOI: 10.1093/cid/ciw353] [Citation(s) in RCA: 2003] [Impact Index Per Article: 250.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.
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Affiliation(s)
- Andre C. Kalil
- Departmentof Internal Medicine, Division of Infectious Diseases,
University of Nebraska Medical Center,
Omaha
| | - Mark L. Metersky
- Division of Pulmonary and Critical Care Medicine,
University of Connecticut School of Medicine,
Farmington
| | - Michael Klompas
- Brigham and Women's Hospital and Harvard Medical School
- Harvard Pilgrim Health Care Institute, Boston,
Massachusetts
| | - John Muscedere
- Department of Medicine, Critical Care Program,Queens University, Kingston, Ontario,
Canada
| | - Daniel A. Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine,
University of California, San
Diego
| | - Lucy B. Palmer
- Department of Medicine, Division of Pulmonary Critical Care and Sleep
Medicine, State University of New York at Stony
Brook
| | - Lena M. Napolitano
- Department of Surgery, Division of Trauma, Critical Care and Emergency
Surgery, University of Michigan, Ann
Arbor
| | - Naomi P. O'Grady
- Department of Critical Care Medicine, National
Institutes of Health, Bethesda
| | - John G. Bartlett
- Johns Hopkins University School of Medicine,
Baltimore, Maryland
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari
de Bellvitge, Bellvitge Biomedical Research Institute, Spanish Network for Research in
Infectious Diseases, University of Barcelona,
Spain
| | - Ali A. El Solh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep
Medicine, University at Buffalo, Veterans Affairs Western New
York Healthcare System, New York
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious
Diseases, EVK Herne and Augusta-Kranken-Anstalt
Bochum, Germany
| | - Paul D. Fey
- Department of Pathology and Microbiology, University of
Nebraska Medical Center, Omaha
| | | | - Marcos I. Restrepo
- Department of Medicine, Division of Pulmonary and Critical Care
Medicine, South Texas Veterans Health Care System and University
of Texas Health Science Center at San Antonio
| | - Jason A. Roberts
- Burns, Trauma and Critical Care Research Centre, The
University of Queensland
- Royal Brisbane and Women's Hospital,
Queensland
| | - Grant W. Waterer
- School of Medicine and Pharmacology, University of
Western Australia, Perth,
Australia
| | - Peggy Cruse
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Shandra L. Knight
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Jan L. Brozek
- Department of Clinical Epidemiology and Biostatistics and Department of
Medicine, McMaster University, Hamilton,
Ontario, Canada
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Evaluation of a Mixing versus a Cycling Strategy of Antibiotic Use in Critically-Ill Medical Patients: Impact on Acquisition of Resistant Microorganisms and Clinical Outcomes. PLoS One 2016; 11:e0150274. [PMID: 26982807 PMCID: PMC4794237 DOI: 10.1371/journal.pone.0150274] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 02/11/2016] [Indexed: 11/22/2022] Open
Abstract
Objective To compare the effect of two strategies of antibiotic use (mixing vs. cycling) on the acquisition of resistant microorganisms, infections and other clinical outcomes. Methods Prospective cohort study in an 8-bed intensive care unit during 35- months in which a mixing-cycling policy of antipseudomonal beta-lactams (meropenem, ceftazidime/piperacillin-tazobactam) and fluoroquinolones was operative. Nasopharyngeal and rectal swabs and respiratory secretions were obtained within 48h of admission and thrice weekly thereafter. Target microorganisms included methicillin-resistant S. aureus, vancomycin-resistant enterococci, third-generation cephalosporin-resistant Enterobacteriaceae and non-fermenters. Results A total of 409 (42%) patients were included in mixing and 560 (58%) in cycling. Exposure to ceftazidime/piperacillin-tazobactam and fluoroquinolones was significantly higher in mixing while exposure to meropenem was higher in cycling, although overall use of antipseudomonals was not significantly different (37.5/100 patient-days vs. 38.1/100 patient-days). There was a barely higher acquisition rate of microorganisms during mixing, but this difference lost its significance when the cases due to an exogenous Burkholderia cepacia outbreak were excluded (19.3% vs. 15.4%, OR 0.8, CI 0.5–1.1). Acquisition of Pseudomonas aeruginosa resistant to the intervention antibiotics or with multiple-drug resistance was similar. There were no significant differences between mixing and cycling in the proportion of patients acquiring any infection (16.6% vs. 14.5%, OR 0.9, CI 0.6–1.2), any infection due to target microorganisms (5.9% vs. 5.2%, OR 0.9, CI 0.5–1.5), length of stay (median 5 d for both groups) or mortality (13.9 vs. 14.3%, OR 1.03, CI 0.7–1.3). Conclusions A cycling strategy of antibiotic use with a 6-week cycle duration is similar to mixing in terms of acquisition of resistant microorganisms, infections, length of stay and mortality.
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Afify MH, Shaheen EA, El-Dahdouh SS, El-Feky HM. Comparison between bronchoscopic BAL and non-bronchoscopic BAL in patients with VAP. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2016. [DOI: 10.1016/j.ejcdt.2015.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ferrer M, Difrancesco LF, Liapikou A, Rinaudo M, Carbonara M, Li Bassi G, Gabarrus A, Torres A. Polymicrobial intensive care unit-acquired pneumonia: prevalence, microbiology and outcome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:450. [PMID: 26703094 PMCID: PMC4699341 DOI: 10.1186/s13054-015-1165-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/10/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Microbial aetiology of intensive care unit (ICU)-acquired pneumonia (ICUAP) determines antibiotic treatment and outcomes. The impact of polymicrobial ICUAP is not extensively known. We therefore investigated the characteristics and outcomes of polymicrobial aetiology of ICUAP. METHOD Patients with ICUAP confirmed microbiologically were prospectively compared according to identification of 1 (monomicrobial) or more (polymicrobial) potentially-pathogenic microorganisms. Microbes usually considered as non-pathogenic were not considered for the etiologic diagnosis. We assessed clinical characteristics, microbiology, inflammatory biomarkers and outcome variables. RESULTS Among 441 consecutive patients with ICUAP, 256 (58%) had microbiologic confirmation, and 41 (16%) of them polymicrobial pneumonia. Methicillin-sensitive Staphylococcus aureus, Haemophilus influenzae, and several Enterobacteriaceae were more frequent in polymicrobial pneumonia. Multi-drug and extensive-drug resistance was similarly frequent in both groups. Compared with monomicrobial, patients with polymicrobial pneumonia had less frequently chronic heart disease (6, 15% vs. 71, 33%, p = 0.019), and more frequently pleural effusion (18, 50%, vs. 54, 25%, p = 0.008), without any other significant difference. Appropriate empiric antimicrobial treatment was similarly frequent in the monomicrobial (185, 86%) and the polymicrobial group (39, 95%), as were the initial response to the empiric treatment, length of stay and mortality. Systemic inflammatory response was similar comparing monomicrobial with polymicrobial ICUAP. CONCLUSION The aetiology of ICUAP confirmed microbiologically was polymicrobial in 16% cases. Pleural effusion and absence of chronic heart disease are associated with polymicrobial pneumonia. When empiric treatment is frequently appropriate, polymicrobial aetiology does not influence the outcome of ICUAP.
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Affiliation(s)
- Miquel Ferrer
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-Instituto de Salud Carlos III (ISCiii), Madrid, Spain.
| | - Leonardo Filippo Difrancesco
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Department of Internal Medicine, Ospedale Sant'Andrea, "Sapienza" University, Via di Grottarossa 1035-1039, Rome, Italy.
| | - Adamantia Liapikou
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Sotiria Chest Diseases Hospital, 6rd Respiratory Department, Mesogion 152, Athens, Greece.
| | - Mariano Rinaudo
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain.
| | - Marco Carbonara
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Department of Anesthesia, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda Milano, Milan, Italy.
| | - Gianluigi Li Bassi
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-Instituto de Salud Carlos III (ISCiii), Madrid, Spain.
| | - Albert Gabarrus
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
| | - Antoni Torres
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-Instituto de Salud Carlos III (ISCiii), Madrid, Spain.
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Martin-Loeches I, Povoa P, Rodríguez A, Curcio D, Suarez D, Mira JP, Cordero ML, Lepecq R, Girault C, Candeias C, Seguin P, Paulino C, Messika J, Castro AG, Valles J, Coelho L, Rabello L, Lisboa T, Collins D, Torres A, Salluh J, Nseir S. Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study. THE LANCET RESPIRATORY MEDICINE 2015; 3:859-68. [PMID: 26472037 DOI: 10.1016/s2213-2600(15)00326-4] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/11/2015] [Accepted: 08/12/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Ventilator-associated tracheobronchitis has been suggested as an intermediate process between tracheobronchial colonisation and ventilator-associated pneumonia in patients receiving mechanical ventilation. We aimed to establish the incidence and effect of ventilator-associated tracheobronchitis in a large, international patient cohort. METHODS We did a multicentre, prospective, observational study in 114 intensive care units (ICU) in Spain, France, Portugal, Brazil, Argentina, Ecuador, Bolivia, and Colombia over a preplanned time of 10 months. All patients older than 18 years admitted to an ICU who received invasive mechanical ventilation for more than 48 h were eligible. We prospectively obtained data for incidence of ventilator-associated lower respiratory tract infections, defined as ventilator-associated tracheobronchitis or ventilator-associated pneumonia. We grouped patients according to the presence or absence of such infections, and obtained data for the effect of appropriate antibiotics on progression of tracheobronchitis to pneumonia. Patients were followed up until death or discharge from hospital. To account for centre effects with a binary outcome, we fitted a generalised estimating equation model with a logit link, exchangeable correlation structure, and non-robust standard errors. This trial is registered with ClinicalTrials.gov, number NCT01791530. FINDINGS Between Sept 1, 2013, and July 31, 2014, we obtained data for 2960 eligible patients, of whom 689 (23%) developed ventilator-associated lower respiratory tract infections. The incidence of ventilator-associated tracheobronchitis and that of ventilator-associated pneumonia at baseline were similar (320 [11%; 10·2 of 1000 mechanically ventilated days] vs 369 [12%; 8·8 of 1000 mechanically ventilated days], p=0·48). Of the 320 patients with tracheobronchitis, 250 received appropriate antibiotic treatment and 70 received inappropriate antibiotics. 39 patients with tracheobronchitis progressed to pneumonia; however, the use of appropriate antibiotic therapy for tracheobronchitis was associated with significantly lower progression to pneumonia than was inappropriate treatment (19 [8%] of 250 vs 20 [29%] of 70, p<0·0001; crude odds ratio 0·21 [95% CI 0·11-0·41]). Significantly more patients with ventilator-associated pneumonia died (146 [40%] of 369) than those with tracheobronchitis (93 [29%] of 320) or absence of ventilator-associated lower respiratory tract infections (673 [30%] of 2271, p<0·0001). Median time to discharge from the ICU for survivors was significantly longer in the tracheobronchitis (21 days [IQR 15-34]) and pneumonia (22 [13-36]) groups than in the group with no ventilator-associated lower respiratory tract infections (12 [8-20]; hazard ratio 1·65 [95% CI 1·38-1·97], p<0·0001). INTERPRETATION This large database study emphasises that ventilator-associated tracheobronchitis is a major health problem worldwide, associated with high resources consumption in all countries. Our findings also show improved outcomes with use of appropriate antibiotic treatment for both ventilator-associated tracheobronchitis and ventilator-associated pneumonia, underlining the importance of treating both infections, since inappropriate treatment of tracheobronchitis was associated with a higher risk of progression to pneumonia. FUNDING None.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Clinical Medicine, St James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland.
| | - Pedro Povoa
- Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Alejandro Rodríguez
- Hospital Joan XXIII, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Bunyola, Mallorca, Spain
| | - Daniel Curcio
- Hospital Municipal de Chivilcoy, Chivilcoy Nueva, Buenos Aires, Argentina
| | - David Suarez
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Jean-Paul Mira
- Cochin University Hospital, APHP, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Medical Faculty, Paris, France
| | | | | | | | | | | | - Carolina Paulino
- Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | | | - Alejandro G Castro
- Hospital Universitario Marques de Valdecilla, Santander, Cantabria, Spain
| | - Jordi Valles
- Corporacion Sanitaria Parc Tauli CIBER Enfermedades respiratorias, Parc Tauli, University Institute, Sabadell, Spain
| | | | - Ligia Rabello
- Intensive Care Unit, Instituto Nacional de Câncer, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Thiago Lisboa
- Critical Care Department and Infection Control Committee, Hospital de Clinicas de Porto Alegre, Rede Institucional de Pesquisa e Inovação em Medicina Intensiva, Complexo Hospitalar Santa Casa, Porto Alegre, Brazil
| | - Daniel Collins
- Department of Clinical Medicine, St James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | | | - Jorge Salluh
- Intensive Care Unit, Instituto Nacional de Câncer, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Saad Nseir
- Centre Hospitalier Régional Universitaire de Lille, Lille, France
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Terraneo S, Ferrer M, Martín-Loeches I, Esperatti M, Di Pasquale M, Giunta V, Rinaudo M, de Rosa F, Li Bassi G, Centanni S, Torres A. Impact of Candida spp. isolation in the respiratory tract in patients with intensive care unit-acquired pneumonia. Clin Microbiol Infect 2015; 22:94.e1-94.e8. [PMID: 26369603 DOI: 10.1016/j.cmi.2015.09.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/31/2015] [Accepted: 09/02/2015] [Indexed: 10/23/2022]
Abstract
In immunocompetent patients with nosocomial pneumonia, the relationship between Candida spp. isolation in respiratory samples and outcomes or association with other pathogens is controversial. We therefore compared the characteristics and outcomes of patients with intensive care unit-acquired pneumonia (ICUAP), with or without Candida spp. isolation in the respiratory tract. In this prospective non-interventional study, we assessed 385 consecutive immunocompetent patients with ICUAP, according to the presence or absence of Candida spp. in lower respiratory tract samples. Candida spp. was isolated in at least one sample in 82 (21%) patients. Patients with Candida spp. had higher severity scores and organ dysfunction at admission and at onset of pneumonia. In multivariate analysis, previous surgery, diabetes mellitus and higher Simplified Acute Physiology Score II at ICU admission independently predicted isolation of Candida spp. There were no significant differences in the rate of specific aetiological pathogens, the systemic inflammatory response, and length of stay between patients with and without Candida spp. Mortality was also similar, even adjusted for potential confounders in propensity-adjusted multivariate analyses (adjusted hazard ratio 1.08, 95% CI 0.57-2.05, p 0.80 for 28-day mortality and adjusted hazard ratio 1.38, 95% CI 0.81-2.35, p 0.24 for 90-day mortality). Antifungal therapy was more frequently prescribed in patients with Candida spp. in respiratory samples but did not influence outcomes. Candida spp. airway isolation in patients with ICUAP is associated with more initial disease severity but does not influence outcomes in these patients, regardless of the use or not of antifungal therapy.
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Affiliation(s)
- S Terraneo
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Respiratory Unit, San Paolo Hospital, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - M Ferrer
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Ireland.
| | - I Martín-Loeches
- St. James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | - M Esperatti
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - M Di Pasquale
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda Milano, Italy
| | - V Giunta
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - M Rinaudo
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - F de Rosa
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda Milano, Italy
| | - G Li Bassi
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Ireland
| | - S Centanni
- Respiratory Unit, San Paolo Hospital, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - A Torres
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Ireland
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Corrêa RDA, Luna CM, Anjos JCFVD, Barbosa EA, Rezende CJD, Rezende AP, Pereira FH, Rocha MODC. Quantitative culture of endotracheal aspirate and BAL fluid samples in the management of patients with ventilator-associated pneumonia: a randomized clinical trial. J Bras Pneumol 2015; 40:643-51. [PMID: 25610505 PMCID: PMC4301249 DOI: 10.1590/s1806-37132014000600008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 05/12/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To compare 28-day mortality rates and clinical outcomes in ICU patients with ventilator-associated pneumonia according to the diagnostic strategy used. METHODS: This was a prospective randomized clinical trial. Of the 73 patients included in the study, 36 and 37 were randomized to undergo BAL or endotracheal aspiration (EA), respectively. Antibiotic therapy was based on guidelines and was adjusted according to the results of quantitative cultures. RESULTS: The 28-day mortality rate was similar in the BAL and EA groups (25.0% and 37.8%, respectively; p = 0.353). There were no differences between the groups regarding the duration of mechanical ventilation, antibiotic therapy, secondary complications, VAP recurrence, or length of ICU and hospital stay. Initial antibiotic therapy was deemed appropriate in 28 (77.8%) and 30 (83.3%) of the patients in the BAL and EA groups, respectively (p = 0.551). The 28-day mortality rate was not associated with the appropriateness of initial therapy in the BAL and EA groups (appropriate therapy: 35.7% vs. 43.3%; p = 0.553; and inappropriate therapy: 62.5% vs. 50.0%; p = 1.000). Previous use of antibiotics did not affect the culture yield in the EA or BAL group (p = 0.130 and p = 0.484, respectively). CONCLUSIONS: In the context of this study, the management of VAP patients, based on the results of quantitative endotracheal aspirate cultures, led to similar clinical outcomes to those obtained with the results of quantitative BAL fluid cultures.
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Affiliation(s)
- Ricardo de Amorim Corrêa
- Federal University of Minas Gerais, School of Medicine, Department of Pulmonology and Thoracic Surgery, Belo Horizonte, Brazil. Department of Pulmonology and Thoracic Surgery, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Carlos Michel Luna
- University of Buenos Aires, Hospital de Clínicas, Buenos Aires, Argentina. Hospital de Clínicas, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Eurípedes Alvarenga Barbosa
- Hospital Madre Teresa, Belo Horizonte, Brazil. Laboratory of Microbiology, Hospital Madre Teresa, Belo Horizonte, Brazil
| | - Cláudia Juliana de Rezende
- Hospital Madre Teresa, Department of Radiology, Belo Horizonte, Brazil. Department of Radiology, Hospital Madre Teresa, Belo Horizonte, Brazil
| | - Adriano Pereira Rezende
- Hospital Madre Teresa, Department of Pulmonology and Thoracic Surgery, Belo Horizonte, Brazil. Department of Pulmonology and Thoracic Surgery, Hospital Madre Teresa, Belo Horizonte, Brazil
| | - Fernando Henrique Pereira
- Federal University of Minas Gerais, School of Medicine, Postgraduate Center, Belo Horizonte, Brazil. Postgraduate Center, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Manoel Otávio da Costa Rocha
- Federal University of Minas Gerais, School of Medicine, Belo Horizonte, Brazil. Postgraduate Program in Health Sciences, Infectology and Tropical Medicine, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
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Edelsberg J, Berger A, Weber DJ, Mallick R, Kuznik A, Oster G. Clinical and Economic Consequences of Failure of Initial Antibiotic Therapy for Hospitalized Patients With Complicated Skin and Skin-Structure Infections. Infect Control Hosp Epidemiol 2015; 29:160-9. [DOI: 10.1086/526444] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objective.To estimate the consequences of failure of initial antibiotic therapy for patients with complicated skin and skin-structure infections.Design.Retrospective cohort study.Setting.Large US multihospital database.Patients.We identified a total of 47,219 patients (age 18 years or older) who were admitted to the hospital for complicated skin and skin-structure infections from April 1, 2003, through March 31, 2004, and who received intravenous antibiotics during the first 2 hospital-days (ie, initial antibiotic therapy). Failure of therapy was defined as drainage, debridement, or receipt of other intravenous antibiotics at any subsequent time (except for changes to narrower-spectrum agents or any therapy change immediately before discharge). Predictors of failure of antibiotic therapy and mortality were examined using multivariate logistic regression. Analysis of covariance was used to estimate the impact of treatment failure on duration of intravenous antibiotic therapy, length of stay, and total inpatient charges.Results.For 10,782 admitted patients (22.8%), there was evidence of failure of initial antibiotic therapy. In multivariate analyses, treatment failure was associated with receipt of vasoactive medications during the first 2 hospital-days (odds ratio [OR], 1.66 [95% confidence interval {CI}, 1.19-2.31]), initiation of antibiotic therapy in the intensive care unit (OR, 1.53 [95% CI, 1.28-1.84]), and the patient's Charlson comorbidity index (OR per 1-point increase, 1.06 [95% CI, 1.04-1.08]); treatment failure was also was associated with a 3-fold increase in mortality (OR, 2.91 [95% CI, 2.34-3.62]). Compared with patients for whom initial treatment was successful, patients who experienced treatment failure received intravenous antibiotic therapy for a mean of 5.7 additional days, were hospitalized for a mean of 5.4 additional days, and incurred a mean of $5,285 (in 2003 dollars) in additional inpatient charges (all P <.01).Conclusion.Failure of initial antibiotic therapy in the treatment of complicated skin and skin-structure infections is associated with significantly worse clinical and economic outcomes.
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Berton DC, Kalil AC, Teixeira PJZ. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database Syst Rev 2014; 2014:CD006482. [PMID: 25354013 PMCID: PMC11064766 DOI: 10.1002/14651858.cd006482.pub4] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a common infectious disease in intensive care units (ICUs). The best diagnostic approach to resolve this condition remains uncertain. OBJECTIVES To evaluate whether quantitative cultures of respiratory secretions and invasive strategies are effective in reducing mortality in immunocompetent patients with VAP, compared with qualitative cultures and non-invasive strategies. We also considered changes in antibiotic use, length of ICU stay and mechanical ventilation. SEARCH METHODS We searched CENTRAL (2014, Issue 9), MEDLINE (1966 to October week 2, 2014), EMBASE (1974 to October 2014) and LILACS (1982 to October 2014). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing respiratory samples processed quantitatively or qualitatively, obtained by invasive or non-invasive methods from immunocompetent patients with VAP and which analysed the impact of these methods on antibiotic use and mortality rates. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed the trials identified in the search results and assessed studies for suitability, methodology and quality. We analysed data using Review Manager software. We pooled the included studies to yield the risk ratio (RR) for mortality and antibiotic change with 95% confidence intervals (CI). MAIN RESULTS Of the 5064 references identified from the electronic databases (605 from the updated search in October 2014), five RCTs (1367 patients) met the inclusion criteria. Three studies compared invasive methods using quantitative cultures versus non-invasive methods using qualitative cultures, and we used them to answer the main objective of this review. The other two studies compared invasive versus non-invasive methods, both using quantitative cultures. We combined all five studies to compare invasive versus non-invasive interventions for diagnosing VAP. The studies that compared quantitative and qualitative cultures (1240 patients) showed no statistically significant differences in mortality rates (RR 0.91; 95% CI 0.75 to 1.11). The analysis of all five RCTs showed there was no evidence of reduction in mortality in the invasive group versus the non-invasive group (RR 0.93; 95% CI 0.78 to 1.11). There were no significant differences between the interventions with respect to the number of days on mechanical ventilation, length of ICU stay or antibiotic change. AUTHORS' CONCLUSIONS There is no evidence that the use of quantitative cultures of respiratory secretions results in reduced mortality, reduced time in ICU and on mechanical ventilation, or higher rates of antibiotic change when compared to qualitative cultures in patients with VAP. We observed similar results when invasive strategies were compared with non-invasive strategies.
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Affiliation(s)
- Danilo Cortozi Berton
- Federal University of Health Sciences of Porto Alegre (UFCSPA) and Feevale UniversityDepartment of Pulmonary Medicine ‐ Pavilhão Pereira Filho ‐ Santa Casa de Porto AlegreRua Prof Annes Dias, 295Porto AlegreRio Grande do SulBrazilCEP 90020‐090
| | - Andre C Kalil
- Infectious Diseases Division, University of Nebraska Medical CenterDepartment of Internal MedicineOmahaNebraskaUSA985400
| | - Paulo José Zimermann Teixeira
- Federal University of Health Sciences of Porto Alegre (UFCSPA) and Feevale UniversityDepartment of Pulmonary Medicine ‐ Pavilhão Pereira Filho ‐ Santa Casa de Porto AlegreRua Prof Annes Dias, 295Porto AlegreRio Grande do SulBrazilCEP 90020‐090
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Charles MP, Kali A, Easow JM, Joseph NM, Ravishankar M, Srinivasan S, Kumar S, Umadevi S. Ventilator-associated pneumonia. Australas Med J 2014; 7:334-44. [PMID: 25279009 DOI: 10.4066/amj.2014.2105] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia that occurs in patients who receive mechanical ventilation (MV). According to the International Nosocomial Infection Control Consortium (INICC), the overall rate of VAP is 13.6 per 1,000 ventilator days. The incidence varies according to the patient group and hospital setting. The incidence of VAP ranges from 13-51 per 1,000 ventilation days. Early diagnosis of VAP with appropriate antibiotic therapy can reduce the emergence of resistant organisms. METHOD The aim of this review was to provide an overview of the incidence, risk factors, aetiology, pathogenesis, treatment, and prevention of VAP. A literature search for VAP was done through the PUBMED/MEDLINE database. This review outlines VAP's risk factors, diagnostic methods, associated organisms, and treatment modalities. CONCLUSION VAP is a common nosocomial infection associated with ventilated patients. The mortality associated with VAP is high. The organisms associated with VAP and their resistance pattern varies depending on the patient group and hospital setting. The diagnostic methods available for VAP are not universal; however, a proper infection control policy with appropriate antibiotic usage can reduce the mortality rate among ventilated patients.
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Affiliation(s)
- Mv Pravin Charles
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Arunava Kali
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Joshy M Easow
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Noyal Maria Joseph
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - M Ravishankar
- Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Srirangaraj Srinivasan
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Shailesh Kumar
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Sivaraman Umadevi
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
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Guidry CA, Mallicote MU, Petroze RT, Hranjec T, Rosenberger LH, Davies SW, Sawyer RG. Influence of bronchoscopy on the diagnosis of and outcomes from ventilator-associated pneumonia. Surg Infect (Larchmt) 2014; 15:527-32. [PMID: 24841750 DOI: 10.1089/sur.2013.142] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection affecting as many as 27% of mechanically ventilated patients. Ventilator-associated pneumonia is an important source of morbidity and mortality in the surgical intensive care unit (SICU). The optimal diagnostic method for VAP has remained controversial and the role of therapeutic bronchoscopy in the clearance of pulmonary secretions with VAP, in essence source control, remains unknown. Our unit utilizes bronchoscopy inconsistently for these purposes and we chose to evaluate its effectiveness in our patient population with the hypothesis that bronchoscopic diagnosis and therapy results in lower mortality rates and faster clinical resolution. METHODS We analyzed retrospectively all patients treated for VAP in a single SICU between September 2003 and December 2011. Patients were divided into groups based upon diagnostic method and receipt of therapeutic bronchoscopy, and were analyzed for differences in time to clinical resolution and mortality. RESULTS A total of 360 patients were included in the study, including 493 episodes of VAP. The diagnostic bronchoscopy group had statistically higher APACHE II scores (p=0.02) and fewer days in hospital prior to diagnosis (p=0.02) when compared with the non-invasive diagnosis group. Diagnostic bronchoscopy was associated with shorter length of stay and shorter duration of antibiotics whereas receipt of a therapeutic bronchoscopy was associated with the opposite effects by multivariable analysis. CONCLUSION Our hypothesis was disproved and our findings are similar to those found in recent publications. This study supports no definitive conclusions, but further consideration of the role of bronchoscopy is urged in both the diagnosis and treatment of VAP. In our population, bronchoscopy for diagnostic or therapeutic purposes in VAP was not associated with better outcomes. However, differences in baseline characteristics suggest a randomized trial may be needed to answer more completely this question.
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Affiliation(s)
- Christopher A Guidry
- 1 Division of Acute Care and Trauma Surgery, The University of Virginia Health System , Charlottesville, Virginia
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Bowers DR, Tam VH. Pseudomonas aeruginosatreatment and transmission reduction. Expert Rev Anti Infect Ther 2014; 11:831-7. [DOI: 10.1586/14787210.2013.816463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Peppard WJ, Weigelt JA. Role of linezolid in the treatment of complicated skin and soft tissue infections. Expert Rev Anti Infect Ther 2014; 4:357-66. [PMID: 16771613 DOI: 10.1586/14787210.4.3.357] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Staphylococcus aureus is the most common cause of complicated skin and soft tissue infections (cSSTIs). Antibiotic choices for these infections continue to evolve. History has seen penicillin progress to antistaphylococcal penicillins and cephalosporins, but these drugs are now giving way to drugs that are effective against methicillin-resistant S. aureus (MRSA). While vancomycin has been the gold standard to treat MRSA infections, newer therapeutic options have been developed over the last 5 years. These include quinupristin-dalfopristin, daptomycin, tigecycline and linezolid, which is the focus for this review. Linezolid is efficacious in the treatment of cSSTIs (including diabetic foot infections) caused by Gram-positive organisms (including MRSA), with a well-defined safety profile and straightforward dosing. It is also approved for nosocomial pneumonia, community-acquired pneumonia and uncomplicated skin and skin structure infections. Linezolid has an oral and parenteral formulation, which are equivalent. The oral formulation has the potential to offer economic benefits as compared with other therapies. Currently, there are only a few new antibiotics in development with MRSA activity. The proper use of all antibiotics, including these newer agents, is increasingly important if we are to slow the evolution of microbial resistance.
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Affiliation(s)
- William J Peppard
- Froedtert Hospital, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Golia S, K T S, C L V. Microbial profile of early and late onset ventilator associated pneumonia in the intensive care unit of a tertiary care hospital in bangalore, India. J Clin Diagn Res 2013; 7:2462-6. [PMID: 24392373 DOI: 10.7860/jcdr/2013/6344.3580] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 07/29/2013] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP), an important form of hospital-acquired pneumonia (HAP), specifically refers to pneumonia developing in a patient on mechanical ventilator for more than 48 h after intubation or tracheostomy. Despite the advancements in antimicrobial regimes, VAP continues to be an important cause of morbidity and mortality. VAP requires a rapid diagnosis and initiation of appropriate antibiotic treatment, as there is adverse effect of inadequate antibiotic treatment on patients' prognosis and the emergence of multidrug-resistant (MDR) pathogens. AIMS The present study was undertaken to assess the etiological agents of early-onset and late-onset VAP and to know their sensitivity pattern. MATERIAL AND METHODS VAP data over a period of 12 months (February 2012 -February 2013) in a tertiary care ICU was retrospectively analysed. The patients were stratified by age, sex, duration of VAP (Early/Late onset) and the identified pathogens with their sensitivity pattern. RESULTS Incidence of VAP was found to be 35.14%, out of which 44.23% had early-onset (<4 days MV) VAP and 55.77% had late-onset (>4 days MV) VAP. The most common organisms isolated in early onset and late onset VAP was Pseudomonas aeruginosa, E.coli and Acinetobacter baumanii. All enterobacteriaceal isolates were extended spectrum beta lactamase (ESBL) producing organisms and all Staphylococcus aureus isolates except one were methicillin resistant. The incidence of Multidrug resistant (MDR) Pseudomonas aeruginosa and Acinetobacter were 40% and 37.5% respectively. CONCLUSION Due to the increasing incidence of multidrug-resistant organisms in our ICU, early and correct diagnosis of VAP is an urgent challenge for an optimal antibiotic treatment and cure. Hence, knowing the local microbial flora causing VAP and effective infection control practices are essential to improve clinical outcomes.
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Affiliation(s)
- Saroj Golia
- Professor & HOD, Department of Microbiology, Dr. B.R Ambedkar Medical College , Bangalore, Karnataka, India
| | - Sangeetha K T
- Professor & HOD, Department of Microbiology, Dr. B.R Ambedkar Medical College , Bangalore, Karnataka, India
| | - Vasudha C L
- Professor & HOD, Department of Microbiology, Dr. B.R Ambedkar Medical College , Bangalore, Karnataka, India
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Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, Fridkin S, Greene L, Guh A, Gutterman D, Hammer B, Henderson D, Hess D, Hill NS, Horan T, Kollef M, Levy M, Septimus E, VanAntwerpen C, Wright D, Lipsett P. Developing a new, national approach to surveillance for ventilator-associated events*. Crit Care Med 2013; 41:2467-75. [PMID: 24162674 PMCID: PMC10847970 DOI: 10.1097/ccm.0b013e3182a262db] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop and implement an objective, reliable approach to surveillance for ventilator-associated events in adult patients. DESIGN The Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group in September 2011. Working Group members included representatives of stakeholder societies and organizations and federal partners. MAIN RESULTS The Working Group finalized a three-tier, adult surveillance definition algorithm for ventilator-associated events. The algorithm uses objective, readily available data elements and can identify a broad range of conditions and complications occurring in mechanically ventilated adult patients, including but not limited to VAP. The first tier definition, ventilator-associated condition (VAC), identifies patients with a period of sustained respiratory deterioration following a sustained period of stability or improvement on the ventilator, defined by changes in the daily minimum fraction of inspired oxygen or positive end-expiratory pressure. The second tier definition, infection-related ventilator-associated complication (IVAC), requires that patients with VAC also have an abnormal temperature or white blood cell count, and be started on a new antimicrobial agent. The third tier definitions, possible and probable VAP, require that patients with IVAC also have laboratory and/or microbiological evidence of respiratory infection. CONCLUSIONS Ventilator-associated events surveillance was implemented in January 2013 in the CDC's National Healthcare Safety Network. Modifications to improve surveillance may be made as additional data become available and users gain experience with the new definitions.
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Affiliation(s)
- Shelley S Magill
- 1Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA. 2Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA. 3Infection Control Department, Brigham and Women's Hospital, Boston, MA. 4Society for Healthcare Epidemiology of America, Arlington, VA. 5Division of Pulmonary and Critical Care Medicine, Rush University School of Medicine, Chicago, IL. 6Critical Care Societies Collaborative-American Association of Critical-Care Nurses, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine. 7School of Nursing, Critical and Acute Care, University of Virginia, Charlottesville, VA. 8Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 9Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA. 10Healthcare Infection Control Practices Advisory Committee Surveillance Working Group, Atlanta, GA. 11Infection Prevention and Control Department, Rochester General Health System, Rochester, NY. 12Association for Professionals in Infection Control and Epidemiology, Washington, DC. 13Department of Medicine, Medical College of Wisconsin, Milwaukee, WI. 14Department of Cardiology, Zablocki VA Medical Center, Milwaukee, WI. 15Hospital Epidemiology and Quality Improvement, The Clinical Center, National Institutes of Health, Bethesda, MD. 16Department of Respiratory Care, Massachusetts General Hospital, Boston, MA. 17Department of Anesthesia, Harvard Medical School, Boston, MA. 18American Association for Respiratory Care, Irving, TX. 19Division of Pulmonary and Critical Care Medicine, Tufts Medical Center, Boston, MA. 20Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, MO. 21Division of Pulmonary, Critical Care, and Sleep, Warren Alpert Medical School at Brown University, Rhode Island Hospital, Providenc
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Abstract
OBJECTIVES The impact of ICU-acquired pneumonia without etiologic diagnosis on patients' outcomes is largely unknown. We compared the clinical characteristics, inflammatory response, and outcomes between patients with and without microbiologically confirmed ICU-acquired pneumonia. DESIGN Prospective observational study. SETTING ICUs of a university teaching hospital. PATIENTS We prospectively collected 270 consecutive patients with ICU-acquired pneumonia. Patients were clustered according to positive or negative microbiologic results. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared the characteristics and outcomes between both groups. Negative microbiology was found in 82 patients (30%). Both groups had similar baseline severity scores. Patients with negative microbiology presented more frequently chronic renal failure (15 [18%] vs 11 [6%]; p=0.003), chronic heart disorders (35 [43%] vs 55 [29%]; p=0.044), less frequently previous intubation (44 [54%] vs 135 [72%]; p=0.006), more severe hypoxemia (PaO2/FIO2: 165±73 mm Hg vs 199±79 mm Hg; p=0.001), and shorter ICU stay before the onset of pneumonia (5±5 days vs 7±9 days; p=0.001) compared with patients with positive microbiology. The systemic inflammatory response was similar between both groups. Negative microbiology resulted in less changes of empiric treatment (33 [40%] vs 112 [60%]; p=0.005) and shorter total duration of antimicrobials (13±6 days vs 17±12 days; p=0.006) than positive microbiology. Following adjustment for potential confounders, patients with positive microbiology had higher hospital mortality (adjusted odds ratio 2.96, 95% confidence interval 1.24-7.04, p=0.014) and lower 90-day survival (adjusted hazard ratio 0.50, 95% confidence interval 0.27-0.94, p=0.031), with a nonsignificant lower 28-day survival. CONCLUSIONS Although the possible influence of previous intubation in mortality of both groups is not completely discarded, negative microbiologic findings in clinically suspected ICU-acquired pneumonia are associated with less frequent previous intubation, shorter duration of antimicrobial treatment, and better survival. Future studies should corroborate the presence of pneumonia in patients with suspected ICU-acquired pneumonia and negative microbiology.
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Hashimoto S, Shime N. Evaluation of semi-quantitative scoring of Gram staining or semi-quantitative culture for the diagnosis of ventilator-associated pneumonia: a retrospective comparison with quantitative culture. J Intensive Care 2013; 1:2. [PMID: 25705397 PMCID: PMC4336129 DOI: 10.1186/2052-0492-1-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 09/13/2013] [Indexed: 12/02/2022] Open
Abstract
Background Semi-quantitative Gram stain and culture methods are still commonly used for diagnosing ventilator-associated pneumonia (VAP), due to its convenience. Only a few studies, however, have assessed the reliability of these methods when compared with quantitative cultures, a current standard for the diagnosis of VAP. The objective of this study was to assess the utility of semi-quantitative scores obtained using Gram stains and cultures of endotracheal aspirates when compared with quantitative cultures in the diagnosis of VAP. Methods A retrospective chart review of mechanically ventilated patients with clinically suspected VAP in a single intensive care unit was performed. Semi-quantitative scores of Gram stains or culture results were compared with quantitative culture results of endotracheal aspirate for the diagnosis of VAP in 136 samples for 51 patients. Results The semi-quantitative scores of Gram stains and the semi-quantitative culture results significantly correlated with the log value of the quantitative culture results (rs = 0.64 and 0.75). When using a log count ≥6 of quantitative cultures as the reference standard for the diagnosis of VAP, the sensitivity and specificity was 95% and 61% for Gram stain score of ≥1+, and was 42% and 96% for Gram stain score ≥3+, respectively. The sensitivity and specificity was 96% and 40% for the semi-quantitative culture score of ≥2+, and was 59% and 86% for the semi-quantitative culture score of ≥3+, respectively. Conclusions Absence of bacteria in semi-quantitative Gram stain and poor growth (≤1+) in semi-quantitative culture method could be utilized to exclude the possibility of VAP, whereas detection of abundant (≥3+) bacteria in semi-quantitative Gram stain could be utilized to strongly suspect VAP.
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Affiliation(s)
- Soshi Hashimoto
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan ; Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan
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Cobos-Trigueros N, Rinaudo M, Solé M, Castro P, Pumarol J, Hernández C, Fernández S, Nicolás JM, Mallolas J, Vila J, Morata L, Gatell JM, Soriano A, Mensa J, Martínez JA. Acquisition of resistant microorganisms and infections in HIV-infected patients admitted to the ICU. Eur J Clin Microbiol Infect Dis 2013; 33:611-20. [DOI: 10.1007/s10096-013-1995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 10/07/2013] [Indexed: 11/29/2022]
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Shahin J, Bielinski M, Guichon C, Flemming C, Kristof AS. Suspected ventilator-associated respiratory infection in severely ill patients: a prospective observational study. Crit Care 2013; 17:R251. [PMID: 24148702 PMCID: PMC4056611 DOI: 10.1186/cc13077] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 09/27/2013] [Indexed: 11/23/2022] Open
Abstract
Introduction Ventilator-associated respiratory infection (VARI) is an important cause of morbidity in critically-ill patients. Clinical trials performed in heterogeneous populations have suggested there are limited benefits from invasive diagnostic testing to identify patients at risk or to target antimicrobial therapy. However, multiple patient subgroups (for example, immunocompromised, antibiotic-treated) have traditionally been excluded from randomization. We hypothesized that a prospective surveillance study would better identify patients with suspected VARI (sVARI) at high risk for adverse clinical outcomes, and who might be specifically targeted in future trials. Methods We performed a prospective observational study in all patients ventilated for greater than 48 hours. sVARI was identified by surveillance for changes in white blood cell count, temperature, sputum, and/or new chest X-ray infiltrates. Indices of disease co-morbidity, as well as mortality, duration of mechanical ventilation, and length of hospital or ICU stay were correlated with sVARI. Results Of 1806 patients admitted to the ICU over 14 months, 267 were ventilated for greater than 48 hours, and 77 developed sVARI. Incidence of sVARI was associated with iatrogenic immunosuppression or admission for respiratory illness. Any sVARI, whether suspected ventilator-associated pneumonia (sVAP) or ventilator-associated tracheobronchitis (sVAT), was associated with increased length of stay and duration of mechanical ventilation. Conclusions Clinical surveillance for sVARI identifies patients at risk for increased morbidity. Iatrogenically immunosuppressed patients, a subgroup previously excluded from randomized clinical trials, represent a growing proportion of the critically-ill at risk for sVARI who might be targeted for future investigations on diagnostic or therapeutic modalities.
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Abstract
Although bronchoscopy technology continues to evolve at a fairly rapid pace, basic procedures, such as bronchoalveolar lavage, transbronchial lung biopsy, and transbronchial needle aspiration, continue to play a paramount role in the diagnosis of bronchopulmonary diseases. Pulmonologists should be trained in these basic bronchoscopic procedures.
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Affiliation(s)
- Roberto F Casal
- Interventional Pulmonology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX 77030, USA
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