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Boots RJ, Lipman J, Bellomo R, Stephens D, Heller RF. Disease Risk and Mortality Prediction in Intensive Care Patients with Pneumonia. Australian and New Zealand Practice in Intensive Care (ANZPIC II). Anaesth Intensive Care 2019; 33:101-11. [PMID: 15957699 DOI: 10.1177/0310057x0503300116] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study of ventilated patients investigated pneumonia risk factors and outcome predictors in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units within Australia and New Zealand. For community acquired pneumonia, mortality increased with immunosuppression (OR 5.32, CI 95% 1.58–17.99, P<0.01), clinical signs of consolidation (OR 2.43, CI 95% 1.09–5.44, P=0.03) and Sepsis-Related Organ Failure Assessment (SOFA) scores (OR 1.19, CI 95% 1.08–1.30, P<0.001) but improved if appropriate antibiotic changes were made within three days of intensive care unit admission (OR 0.42, CI 95% 0.20–0.86, P=0.02). For hospital-acquired pneumonia, immunosuppression (OR 6.98, CI 95% 1.16–42.2, P=0.03) and non-metastatic cancer (OR 3.78, CI 95% 1.20–11.93, P=0.02) were the principal mortality predictors. Alcoholism (OR 7.80, CI 95% 1.20–17.50, P<0.001), high SOFA scores (OR 1.44, CI 95% 1.20–1.75, P=0.001) and the isolation of “high risk” organisms including Pseudomonas aeruginosa, Acinetobacter spp, Stenotrophomonas spp and methicillin resistant Staphylococcus aureus (OR 4.79, CI 95% 1.43–16.03, P=0.01), were associated with increased mortality in ventilator-associated pneumonia. The use of non-invasive ventilation was independently protective against mortality for patients with community-acquired and hospital-acquired pneumonia (OR 0.35, CI 95% 0.18–0.68, P=0.002). Mortality was similar for patients requiring both invasive and non-invasive ventilation and non-invasive ventilation alone (21% compared with 20% respectively, P=0.56). Pneumonia risks and mortality predictors in Australian and New Zealand ICUs vary with pneumonia type. A history of alcoholism is a major risk factor for mortality in ventilator-associated pneumonia, greater in magnitude than the mortality effect of immunosuppression in hospital-acquired pneumonia or community-acquired pneumonia. Non-invasive ventilation is associated with reduced ICU mortality. Clinical signs of consolidation worsen, while rationalising antibiotic therapy within three days of ICU admission improves mortality for community-acquired pneumonia patients.
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Affiliation(s)
- R J Boots
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia
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Bouza E, Martínez-Alarcón J, Maseda E, Palomar M, Zaragoza R, Pérez-Granda MJ, Muñoz P, Burillo A. Quality of the aetiological diagnosis of ventilator-associated pneumonia in Spain in the opinion of intensive care specialists and microbiologists. Enferm Infecc Microbiol Clin 2016; 35:153-164. [PMID: 27743679 DOI: 10.1016/j.eimc.2016.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Current guidelines for the microbiological diagnosis of ventilator-associated pneumonia (VAP) are imprecise. Based on data provided by intensive care specialists (ICS) and microbiologists, this study defines the clinical practices and microbiological techniques currently used for an aetiological diagnosis of VAP and pinpoints deficiencies. METHODS Eighty hospitals in the national health network with intensive care and microbiology departments were sent two questionnaires, one for each department, in order to collect data on VAP diagnosis for the previous year. RESULTS Out of the 80 hospitals, 35 (43.8%) hospitals participated. These included 673 ICU beds, 32,020 ICU admissions, 173,820 ICU days stay, and generated 27,048 lower respiratory tract specimens in the year. A third of the hospitals (35%) had a microbiology department available 24/7. Most samples (83%) were tracheal aspirates. Gram stain results were immediately reported in around half (47%) of the hospitals. Quantification was made in 75% of hospitals. Molecular techniques and direct susceptibility testing were performed in 12% and one institution, respectively. Mean turnaround time for a microbiological report was 1.7 (SD; 0.7), and 2.2 (SD; 0.6) days for a negative and positive result, respectively. Telephone/in-person information was offered by 65% of the hospitals. Most (89%) ICS considered microbiological information as very useful. No written procedures were available in half the ICUs. CONCLUSIONS Both ICS and microbiologists agreed that present guidelines for the diagnosis of VAP could be much improved, and that a new set of consensus guidelines is urgently required. A need for guidelines to be more effectively implemented was also identified in order to improve outcomes in patients with VAP.
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Affiliation(s)
- Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain
| | - José Martínez-Alarcón
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; The present affiliation of José Martínez-Alarcón is Department of Microbiology, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
| | - Emilio Maseda
- Department of Anesthesia, Hospital General Universitario La Paz, Madrid, Spain
| | - Mercedes Palomar
- Intensive Care Dept., Hospital Universitari Arnau de Vilanova, Lérida, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0036), Spain
| | - Rafael Zaragoza
- Intensive Care Dept., Hospital Universitario Doctor Peset, Valencia, Spain
| | - María Jesús Pérez-Granda
- Department of Anesthesia, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain
| | - Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
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Is inhaled prophylactic heparin useful for prevention and management of pneumonia in ventilated ICU patients? J Crit Care 2016; 35:231-239. [PMID: 27591357 DOI: 10.1016/j.jcrc.2016.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE The purpose was to determine the efficacy of prophylactic inhaled heparin for the prevention and treatment of pneumonia in patients receiving mechanical ventilation (MV). METHODS A phase 2, double-blind, randomized controlled trial stratified for study center and patient type (nonoperative, postoperative) was conducted in 3 university-affiliated intensive care units. Patients aged at least 18 years and requiring invasive MV for more than 48 hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 U in 2 mL), or nebulization with 0.9% sodium chloride (2 mL) 4 times daily with the main outcome measures, the development of ventilator-associated pneumonia (VAP), ventilator-associated complication, and Sequential Organ Failure Assessment scores in patients with admission pneumonia or developing VAP. TRIAL REGISTRATION ACTRN12612000038897. RESULTS A total of 214 patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP using either Klompas criteria (6%-7%, P=1.00) or clinical diagnosis (24%-26%, P=.85). CONCLUSION Low-dose nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.
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Koulenti D, Tsigou E, Rello J. Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study. Eur J Clin Microbiol Infect Dis 2016; 36:1999-2006. [DOI: 10.1007/s10096-016-2703-z] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 05/29/2016] [Indexed: 11/25/2022]
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Bandeshe H, Boots R, Dulhunty J, Dunlop R, Holley A, Jarrett P, Gomersall CD, Lipman J, Lo T, O'Donoghue S, Paratz J, Paterson D, Roberts JA, Starr T, Stephens D, Stuart J, Thomas J, Udy A, White H. Is inhaled prophylactic heparin useful for prevention and Management of Pneumonia in ventilated ICU patients?: The IPHIVAP investigators of the Australian and New Zealand Intensive Care Society Clinical Trials Group. J Crit Care 2016; 34:95-102. [PMID: 27288618 DOI: 10.1016/j.jcrc.2016.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 03/02/2016] [Accepted: 04/02/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE To determine whether prophylactic inhaled heparin is effective for the prevention and treatment of pneumonia patients receiving mechanical ventilation (MV) in the intensive care unit. METHODS A phase 2, double blind randomized controlled trial stratified for study center and patient type (non-operative, post-operative) was conducted in three university-affiliated intensive care units. Patients aged ≥18years and requiring invasive MV for more than 48hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 units in 2mL) or placebo nebulization with 0.9% sodium chloride (2mL) four times daily with the main outcome measures of the development of ventilator associated pneumonia (VAP), ventilator associated complication (VAC) and sequential organ failure assessment scores in patients with pneumonia on admission or who developed VAP. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ACTRN12612000038897. RESULTS Two hundred and fourteen patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP, using either Klompas criteria (6-7%, P=1.00) or clinical diagnosis (24-26%, P=0.85). There was no difference in the clinical consistency (P=0.70), number (P=0.28) or the total volume of secretions per day (P=.54). The presence of blood in secretions was significantly less in the usual care group (P=0.005). CONCLUSION Nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.
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Affiliation(s)
- Hiran Bandeshe
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Rob Boots
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia.
| | - Joel Dulhunty
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Rachael Dunlop
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Anthony Holley
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Paul Jarrett
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Charles D Gomersall
- Prince of Wales Hospital, Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Jeff Lipman
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Thomas Lo
- Prince of Wales Hospital, Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Steven O'Donoghue
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Jenny Paratz
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia; Heart Foundation Research Centre, Griffith University
| | - David Paterson
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Jason A Roberts
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Therese Starr
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Di Stephens
- Intensive Care Unit. Royal Darwin Hospital, NT, Australia
| | - Janine Stuart
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia; Burns Trauma and Critical Care Research Centre, University of Queensland, QLD, Australia
| | - Jane Thomas
- Intensive Care Unit. Royal Darwin Hospital, NT, Australia
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Prahran, Victoria, Australia
| | - Hayden White
- Intensive Care Unit. Logan Hospital, Queensland, Australia
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Dulhunty JM, Paterson D, Webb SAR, Lipman J. Antimicrobial Utilisation in 37 Australian and New Zealand Intensive Care Units. Anaesth Intensive Care 2011; 39:231-7. [DOI: 10.1177/0310057x1103900212] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This multi-centre point prevalence study reports on antimicrobial dosing patterns, including dose, mode of administration and type of infection, in 37 Australian and New Zealand intensive care units. Of 422 patients admitted to an intensive care unit on 8 May 2007, 195 patients (46%) received antimicrobial treatment, 123 patients (29%) received no antimicrobials and 104 patients (25%) received prophylactic antimicrobials only. Dosing data were available for 331 antimicrobials used to treat 225 infections in 193 patients. Respiratory (40%), abdominal (13%) and blood stream (12%) infections were most common. For adult patients, ticarcillin/clavulanate (23% or 40/177), meropenem (20% or 35/177) and vancomycin (18% or 32/177) were the most frequently used antibiotics; vancomycin was most commonly used in children (31% or 5/16). The majority of antimicrobials were administered as bolus doses or infusions of less than two hours (98% or 317/323); only six patients received extended or continuous infusions. The mode of administration was unknown in eight cases (4.1%). The total defined daily dose for adult patients receiving antimicrobial therapy was 2051 defined daily doses per 1000 patient days. Our results confirm that the use of continuous infusions remains rare, despite increased interest in continuous infusions for time-dependent antibiotics.
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Affiliation(s)
- J. M. Dulhunty
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Research Fellow, Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, and The Burns, Trauma and Critical Care Research Centre, The University of Queensland
| | - D. Paterson
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Professor of Medicine, Department of Infectious Diseases, Royal Brisbane and Women's Hospital, and the University of Queensland Centre for Clinical Research
| | - S. A. R. Webb
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Senior Staff Specialist, Intensive Care Unit, Royal Perth Hospital, and School of Medicine and Pharmacology and School of Population Health, University of Western Australia, Perth, Western Australia
| | - J. Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, and The Burns, Trauma and Critical Care Research Centre, The University of Queensland
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Vincent JL, de Souza Barros D, Cianferoni S. Diagnosis, management and prevention of ventilator-associated pneumonia: an update. Drugs 2011; 70:1927-44. [PMID: 20883051 DOI: 10.2165/11538080-000000000-00000] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Ventilator-associated pneumonia (VAP) affects 10-20% of mechanically ventilated patients and is associated with increased morbidity and mortality and high costs. Early diagnosis is crucial for rapid appropriate antimicrobial therapy to be instituted, but debate remains as to the optimal diagnostic strategy. Noninvasive clinical-based diagnosis is rapid but may not be as accurate as invasive techniques. Increased use of biomarkers and advances in genomics and proteomics may help speed up diagnosis. Management of VAP relies principally on appropriate antimicrobial therapy, which should be selected according to individual patient factors, such as previous antibacterial therapy and length of hospitalization or mechanical ventilation, and local infection and resistance patterns. In addition, once bacterial culture and sensitivity results are available, broad-spectrum therapy should be de-escalated to provide a more specific, narrower-spectrum cover. Optimum duration of antibacterial therapy is difficult to define and should be tailored to clinical response. Biomarker levels may be useful to monitor response to therapy. With the high morbidity and mortality, prevention of VAP is important and several strategies have been shown to reduce the rates of VAP in mechanically ventilated patients, including using noninvasive ventilation where possible, and semi-recumbent positioning. Other potentially beneficial preventive techniques include subglottal suctioning, oral decontamination strategies and antimicrobial-coated endotracheal tubes, although further study is needed to confirm the cost effectiveness of these strategies.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Paul M, Shani V, Muchtar E, Kariv G, Robenshtok E, Leibovici L. Systematic review and meta-analysis of the efficacy of appropriate empiric antibiotic therapy for sepsis. Antimicrob Agents Chemother 2010; 54:4851-63. [PMID: 20733044 PMCID: PMC2976147 DOI: 10.1128/aac.00627-10] [Citation(s) in RCA: 484] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 07/06/2010] [Accepted: 08/14/2010] [Indexed: 11/20/2022] Open
Abstract
Quantifying the benefit of early antibiotic treatment is crucial for decision making and can be assessed only in observational studies. We performed a systematic review of prospective studies reporting the effect of appropriate empirical antibiotic treatment on all-cause mortality among adult inpatients with sepsis. Two reviewers independently extracted data. Risk of bias was assessed using the Newcastle-Ottawa score. We calculated unadjusted odds ratios (ORs) with 95% confidence intervals for each study and extracted adjusted ORs, with variance, methods, and covariates being used for adjustment. ORs were pooled using random-effects meta-analysis. We examined the effects of methodological and clinical confounders on results through subgroup analysis or mixed-effect meta-regression. Seventy studies were included, of which 48 provided an adjusted OR for inappropriate empirical antibiotic treatment. Inappropriate empirical antibiotic treatment was associated with significantly higher mortality in the unadjusted and adjusted comparisons, with considerable heterogeneity occurring in both analyses (I(2) > 70%). Study design, time of mortality assessment, the reporting methods of the multivariable models, and the covariates used for adjustment were significantly associated with effect size. Septic shock was the only clinical variable significantly affecting results (it was associated with higher ORs). Studies adjusting for background conditions and sepsis severity reported a pooled adjusted OR of 1.60 (95% confidence interval = 1.37 to 1.86; 26 studies; number needed to treat to prevent one fatal outcome, 10 patients [95% confidence interval = 8 to 15]; I(2) = 46.3%) given 34% mortality with inappropriate empirical treatment. Appropriate empirical antibiotic treatment is associated with a significant reduction in all-cause mortality. However, the methods used in the observational studies significantly affect the effect size reported. Methods of observational studies assessing the effects of antibiotic treatment should be improved and standardized.
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Affiliation(s)
- Mical Paul
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.
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Ventilator-associated pneumonia in trauma patients is associated with lower mortality: results from EU-VAP study. ACTA ACUST UNITED AC 2010; 69:849-54. [PMID: 20938271 DOI: 10.1097/ta.0b013e3181e4d7be] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Differences in trauma patients developing ventilator-associated pneumonia (VAP) are described regarding etiology and risk factors associated. We aim to describe the differences in outcomes in trauma and nontrauma patients with VAP. METHODS A prospective, observational study conducted in 27 intensive care units from nine European countries. We included patients requiring invasive mechanical ventilation for >48 hours who developed VAP. Logistic regression model was used to assess the factors independently associated with mortality in trauma patients with VAP. RESULTS A total of 2,436 patients were evaluated; 465 developed VAP and of these 128 (27.5%) were trauma patients. Trauma patients were younger than nontrauma (45.3 ± 19.4 vs. 61.1 ± 16.7, p < 0.0001). Nontrauma had higher simplified acute physiology score II compared with trauma patients (45.5 ± 16.3 vs. 41.1 ± 15.2, p = 0.009). Most prevalent pathogens in trauma patients with early VAP were Enterobacteriaceae spp. (46.9% vs. 27.8%, p = 0.06) followed by methicillin-susceptible Staphylococcus aureus (30.6% vs. 13%, p = 0.03) and then Haemophilus influenzae (14.3% vs. 1.9%, p = 0.02), and the most prevalent pathogen in late VAP was Acinetobacter baumannii (12.2% vs. 44.4%, p < 0.0001). Mortality was higher in nontrauma patients than in trauma patients (42.6% vs. 17.2%, p < 0.001, odds ratio [OR] = 3.55, 95%CI = 2.14-5.88). A logistic regression model adjusted for sex, age, severity of illness at intensive care unit admission, and sepsis-related organ failure assessment score at the day of VAP diagnosis confirmed that trauma was associated with a lower mortality compared with nontrauma patients (odds ratio [OR] = 0.37, 95%CI = 0.21-0.65). CONCLUSIONS Trauma patients developing VAP had different demographic characteristics and episodes of etiology. After adjustment for potential confounders, VAP episodes in trauma patients are associated with lower mortality when compared with nontrauma patients.
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Spectrum of practice in the diagnosis of nosocomial pneumonia in patients requiring mechanical ventilation in European intensive care units. Crit Care Med 2009; 37:2360-8. [PMID: 19531951 DOI: 10.1097/ccm.0b013e3181a037ac] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Information on clinical practice regarding the diagnosis of pneumonia in European intensive care units is limited. The aim of this study was to describe the spectrum of actual diagnostic practices in a large sample of European intensive care units. DESIGN Prospective, observational, multicenter study. SETTING Twenty-seven intensive care units of nine European countries. PATIENTS Consecutive patients requiring invasive mechanical ventilation for an admission diagnosis of pneumonia or receiving mechanical ventilation for >48 hrs irrespective of admission diagnosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 2,436 patients were evaluated; 827 were admitted with or developed nosocomial pneumonia (hospital-acquired pneumonia [HAP], 27.1%; ventilator-associated pneumonia [VAP], 56.2%; very early onset VAP, 16.7%). Mean age was 59.4 +/- 18.1 yrs, 65.0% were men, and mean admission Simplified Acute Physiology Score II was 46.7 +/- 17.1. Worsening oxygenation (76.8%), purulent/changing respiratory secretions (72.1%), and new temperature elevation (69.2%) were the most frequent clinical signs of nosocomial pneumonia. Etiological diagnosis was based on noninvasive respiratory specimens in 74.8% of episodes. Bronchoscopy was performed in 23.3% of episodes. Bronchoscopy performance, after adjustment by severity of illness, age, and type of hospital, were predicted by worsening oxygenation (odds ratio 2.03; 95% confidence interval, 1.27-3.24) and male sex (odds ratio 1.77; 95% confidence interval, 1.19-2.65). Definite cause was documented in 69.5% of nosocomial pneumonia cases. The most common isolates were Staphylococcus aureus (16.3% methicillin-sensitive S. aureus and 16.0% methicillin-resistant S. aureus), Pseudomonas aeruginosa (23.1%), and Acinetobacter baumannii (19.1%). Presence of nosocomial pneumonia significantly prolonged mean length of mechanical ventilation (10.3 days, p < .05) and mean intensive care unit length of stay (12.2 days, p < .05) in intensive care unit survivors. Mortality rate was 37.7% for nosocomial pneumonia vs. 31.6% for patients without pneumonia (p < .05). CONCLUSIONS Etiological diagnosis of nosocomial pneumonia in a large sample of European intensive care units was based mainly on noninvasive techniques. However, there was high variability in bronchoscopy use between the participating intensive care units.
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Boots RJ, Phillips GE, George N, Faoagali JL. Surveillance culture utility and safety using low-volume blind bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia. Respirology 2008; 13:87-96. [PMID: 18197916 DOI: 10.1111/j.1440-1843.2007.01211.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Surveillance cultures may improve the prediction of ventilator-associated pneumonia (VAP) and empirical antibiotic selection. This study examined the utility and patient safety of blind, non-protected, low-volume mini-bronchial lavage (BM-BAL) surveillance cultures in predicting VAP. METHODOLOGY A prospective, cohort study was performed in a large general intensive care unit. BM-BALs were collected within 12 h of admission then thrice weekly. Each BM-BAL was screened by Gram staining for intracellular organisms and then quantitatively cultured. VAP was diagnosed using the Clinical Pulmonary Infection Score. The concordance for isolates from the BM-BAL was assessed against concurrently collected endotracheal aspirates (EA). RESULTS Four hundred and twelve patients requiring a minimum of 48 h of mechanical ventilation were enrolled. Fifty patients developed 58 episodes of VAP. Concordant pathogens were found in 85% of BM-BAL specimens collected 2 days prior to VAP onset. Their antibiograms were stable over the preceding 4 days. The isolation of pathogens with colony counts >or=10(4) cfu/mL from BM-BAL performed 2 days prior to the clinical onset of VAP had a sensitivity of 84%, specificity of 50%, positive predictive value of 31% and a negative predictive value of 93% for predicting the development of VAP. BM-BAL WCC, quantification of bacterial growth and the percentage of intracellular organisms were not helpful in predicting VAP diagnosis. CONCLUSIONS BM-BAL surveillance cultures are well tolerated and useful in predicting the pathogens and their antibiograms causing VAP. Diagnostic specimen collection at the time of VAP onset is still required as surveillance cultures may be negative even one day prior to VAP onset.
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Affiliation(s)
- Robert J Boots
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia.
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Abstract
PURPOSE OF REVIEW This review highlights recent advances in the aetiology of nosocomial pneumonia, and in strategies to increase accuracy of diagnosis and antibiotic prescription while limiting unnecessary antibiotic consumption. RECENT FINDINGS Bacterial pathogens still cause the bulk of nosocomial pneumonia and are of concern because of ever-rising antimicrobial resistance. Yet, the pathogenic role of fungal and viral organisms is increasingly recognized. Since early appropriate antimicrobial therapy is the cornerstone of an effective treatment, further studies have been conducted to improve appropriateness of early antibiotic therapy. De-escalation strategies combine initial broad-spectrum antibiotics to maximize early antibiotic coverage with a subsequent focusing of the antibiotic spectrum when the cause is identified. Invasive techniques probably do not alter the immediate outcome but have the potential to reduce unnecessary antibiotic exposure. Decisions to stop or change antibiotic therapy are hampered due to a lack of reliable parameters to assess the resolution of pneumonia. SUMMARY Increasing antimicrobial resistance in nosocomial pneumonia both challenges treatment and mandates limitation of selection pressure by reducing antibiotic burden. Treating physicians should be both aggressive in initiating antimicrobials when suspecting nosocomial pneumonia but willing to discontinue antimicrobials when diagnostic results point to an alternative diagnosis. Efforts should be made to limit duration of antibiotic therapy when possible.
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Affiliation(s)
- Pieter Depuydt
- Department of Intensive Care, Ghent University, De Pintelaan, Belgium.
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Abstract
PURPOSE OF REVIEW Recent articles of clinical and investigational interest on Gram-negative pneumonia, particularly hospital-acquired and ventilator-associated pneumonia, are reviewed. RECENT FINDINGS The high rate of respiratory infections due to Gram-negative bacteria in late-onset ventilator-associated pneumonia has been repeatedly documented. The predominant pathogens are Pseudomonas aeruginosa and Acinetobacter baumannii. On the other hand, the frequency of Gram-negative bacteria in community-acquired pneumonia and in early-onset ventilator-associated pneumonia is increasing. Patients with risk factors for infection with resistant pathogens should initially receive a combination therapy that covers a broad spectrum, and, as soon as the pathogen and the susceptibilities are available, treatment should be simplified to a more targeted one (with the possible exception of P. aeruginosa pneumonia). Adequate dosing is of great importance and the use of pharmacodynamic/pharmacokinetic principles when prescribing antibiotics increases effectiveness. The optimal duration of therapy remains unknown; several studies have supported the use of shorter courses of treatment. Alternative treatment approaches (e.g. vaccines) are under investigation. SUMMARY The increasing frequency of resistant Gram-negative bacteria and the shortage of newer antibiotics in the pipeline with activity against Gram-negative bacteria is of concern. Early effective antimicrobial treatment is a key for the resolution of infection and improved survival.
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Affiliation(s)
- Despoina Koulenti
- Critical Care Department, Joan XXIII University Hospital, University Rovira y Virgili/Institut PereVirgili, Tarragona, Spain
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Duncan A. Pneumonia in Intensive Care—Another Frontier? Anaesth Intensive Care 2005; 33:11-2. [PMID: 15957685 DOI: 10.1177/0310057x0503300102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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