Attributable costs of ventilator-associated lower respiratory tract infection (LRTI) acquired on intensive care units: a retrospectively matched cohort study

Epidemiological characteristics of ventilator-associated pneumonia in neurosurgery: A 10-year surveillance study in a Chinese tertiary hospital

Background

Ventilator-associated pneumonia (VAP) is a significant and common health concern. The epidemiological landscape of VAP is poorly understood in neurosurgery patients. This study aimed to explore the epidemiology of VAP in this population and devise targeted surveillance, treatment, and control efforts.

Methods

A 10-year retrospective study spanning 2011 to 2020 was performed in a large Chinese tertiary hospital. Surveillance data was collected from neurosurgical patients and analyzed to map the demographic and clinical characteristics of VAP and describe the distribution and antimicrobial resistance profile of leading pathogens. Risk factors associated with the presence of VAP were explored using boosted regression tree (BRT) models.

Results

Three hundred ten VAP patients were identified. The 10-year incidence of VAP was 16.21 per 1000 ventilation days. All-cause mortality was 6.1%. The prevalence of gram-negative bacteria, fungi, and gram-positive bacteria among the 357 organisms isolated from VAP patients was 86.0%, 7.6%, and 6.4%, respectively; most were multidrug-resistant organisms. Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa were the most common pathogens. The prevalence of carbapenem-resistant A. baumannii, P. aeruginosa, and K. pneumoniae was high and increased over time in the study period. The BRT models revealed that VAP was associated with number of days of ventilator use (relative contribution, 47.84 ± 7.25), Glasgow Coma Scale score (relative contribution, 24.72 ± 5.67), and tracheotomy (relative contribution, 21.50 ± 2.69).

Conclusions

Our findings provide a better understanding of the epidemiology of VAP and its risk factors in neurosurgery patients.

Hand hygiene in emergencies: Multiprofessional perceptions from a mixed methods based online survey in Germany

Introduction

Despite high vulnerability to infection, hand disinfection compliance in emergencies is low. This is regularly justified as the disinfection procedure delays life support, and instead, wearing disposable gloves is preferred. Simulation studies showed higher achievable compliance than detected in real-life situations. This study aimed to explore healthcare providers' attitudes toward hand disinfection and using gloves in emergencies.

Methods

We conducted an anonymous online survey in Germany on the attitude and subjective behavior in the five moments of hand hygiene in a closed environment and an open convenience sampling survey. Statistics included paired student's t-tests corrected for multiple testing. For qualitative analysis, we employed a single-coder approach.

Results

In 400 participants, we detected low priority of WHO-1 (before touching a patient) and WHO-2 (before clean/aseptic procedure) hand hygiene moments, despite knowing the risks of omission of hand disinfection. For all moments, self-assessment exceeded the assessment of colleagues (p < 0.001). For WHO-3, we detected a lower disinfection priority for wearing gloves compared to contaminated bare hands. Qualitative analyses revealed five themes: basic conditions, didactic implementations, cognitive load, and uncertainty about feasibility and efficacy.

Discussion

Considering bias, the study's subjective nature, the unknown role of emergency-related infections contributing to hospital-acquired infections, and different experiences of healthcare providers, we conclude that hand disinfection before emergencies is de-prioritized and justified by the emergency situation regardless of the objective feasibility.

Conclusion

This study reveals subjective and objective barriers to implementation of WHO-1 and WHO-2 moments of hand disinfection to be further evaluated and addressed in educational programs.

[Automated surveillance and risk prediction with the aim of risk-stratified infection control and prevention (RISK PRINCIPE)]

Healthcare-associated infections (HCAIs) represent an enormous burden for patients, healthcare workers, relatives and society worldwide, including Germany. The central tasks of infection prevention are recording and evaluating infections with the aim of identifying prevention potential and risk factors, taking appropriate measures and finally evaluating them. From an infection prevention perspective, it would be of great value if (i) the recording of infection cases was automated and (ii) if it were possible to identify particularly vulnerable patients and patient groups in advance, who would benefit from specific and/or additional interventions.To achieve this risk-adapted, individualized infection prevention, the RISK PRINCIPE research project develops algorithms and computer-based applications based on standardised, large datasets and incorporates expertise in the field of infection prevention.The project has two objectives: a) to develop and validate a semi-automated surveillance system for hospital-acquired bloodstream infections, prototypically for HCAI, and b) to use comprehensive patient data from different sources to create an individual or group-specific infection risk profile.RISK PRINCIPE is based on bringing together the expertise of medical informatics and infection medicine with a focus on hygiene and draws on information and experience from two consortia (HiGHmed and SMITH) of the German Medical Informatics Initiative (MII), which have been working on use cases in infection medicine for more than five years.

Estimation of Additional Costs in Patients with Ventilator-Associated Pneumonia

Healthcare-associated infections (HAIs) present a global public health challenge, contributing to high morbidity and mortality and substantial economic burdens. Ventilator-associated pneumonia (VAP) ranks as the second most prevalent HAI in intensive care units (ICUs), emphasizing the need for economic analyses in this context. This retrospective cohort study, conducted at the General Hospital of Alicante from 2012 to 2019, aimed to assess additional costs related to VAP by comparing the extended length of stay for infected and non-infected ICU patients undergoing mechanical ventilation (MV) for more than 48 h. Employing propensity score association, 434 VAP patients were compared to an equal number without VAP. The findings indicate a significantly longer mechanical ventilation period for VAP patients (17.40 vs. 8.93 days, p < 0.001), resulting in an extra 13.56 days of stay and an additional cost of EUR 20,965.28 per VAP episode. The study estimated a total cost of EUR 12,348,965.28 for VAP during the study period, underscoring the economic impact of VAP. These findings underscore the urgent need for rigorous infection surveillance, prevention, and control measures to enhance healthcare quality and reduce overall expenditures.

Indications for hand and glove disinfection in Advanced Cardiovascular Life Support: A manikin simulation study

Background and aim

There are no investigations on hand hygiene during cardiopulmonary resuscitation (CPR), even though these patients are at high risk for healthcare-associated infections. We aimed to evaluate the number of indicated hand hygiene per CPR case in general and the fraction that could be accomplished without delay for other life-saving techniques through standardized observations.

Materials and methods

In 2022, we conducted Advanced Cardiovascular Life Support (ACLS) courses over 4 days, practicing 33 ACLS case vignettes with standard measurements of chest compression fractions and hand hygiene indications. A total of nine healthcare workers (six nurses and three physicians) participated.

Results

A total of 33 training scenarios resulted in 613 indications for hand disinfection. Of these, 150 (24%) occurred before patient contact and 310 (51%) before aseptic activities. In 282 out of 310 (91%) indications, which have the highest impact on patient safety, the medication administrator was responsible; in 28 out of 310 (9%) indications, the airway manager was responsible. Depending on the scenario and assuming 15 s to be sufficient for alcoholic disinfection, 56-100% (mean 84.1%, SD ± 13.1%) of all indications could have been accomplished without delaying patient resuscitation. Percentages were lower for 30-s of exposure time.

Conclusion

To the best of our knowledge, this is the first study investigating the feasibility of hand hygiene in a manikin CPR study. Even if the feasibility is overestimated due to the study setup, the fundamental conclusion is that a relevant part of the WHO indications for hand disinfection can be implemented without compromising quality in acute care, thus increasing the overall quality of patient care.

Investigating patient outcomes and healthcare costs associated with ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia is the most frequent infection seen in intensive care units. Of those patients with an endotracheal tube, many will develop ventilator-associated pneumonia within 48 hours of being mechanically ventilated. There are many issues related to mechanical ventilation including costs, patient outcomes and the amount of suffering patients experience during the process.

AIM

To determine the relationship between development of ventilator-associated pneumonia and patient outcomes and costs, including length of stay on mechanical ventilation, in intensive care units (ICU) and in hospital, and mortality rates and to compare results between ventilator-associated pneumonia and non-ventilator-associated pneumonia groups.

METHOD

Cross-sectional, observational design. A convenience sample of 151 patients on mechanical ventilation (101 with ventilator-associated pneumonia and 50 with non-ventilator-associated pneumonia) were recruited from ICUs in two public hospitals in Jordan. APACHE-II scores, SOFA scores and clinical pulmonary infection scores (CPIS) were assessed.

RESULTS

The incidence rate of ventilator-associated pneumonia was 50.9/1000 mechanical ventilation days and the cumulative incidence rate was 66.9% among patients on mechanical ventilation. The mean score of hospital length of stay and CPIS was significantly higher in the ventilator-associated pneumonia than the non-ventilator-associated pneumonia group. Higher disease severity and higher organ failure scores increase the risk of mortality in patients with ventilator-associated pneumonia.

CONCLUSION

A high ventilator-associated pneumonia incidence rate is associated with increased mechanical ventilation, ICU and hospital length of stays, higher mortality and attributed costs. There is a need for continuing education and training for ICU staff to reduce ventilator-associated pneumonia incidence in ICUs.

Can probiotics be an alternative to chlorhexidine for oral care in the mechanically ventilated patient? A multicentre, prospective, randomised controlled open trial

Background

Pathogenic enteric bacteria aspirated from the oropharynx are the main cause of ventilator-associated pneumonia (VAP). Using chlorhexidine (CHX) orally or selective decontamination has been shown to reduce VAP. In a pilot study we found that oral care with the probiotic bacterium Lactobacillus plantarum 299 (Lp299) was as effective as CHX in reducing enteric bacteria in the oropharynx. To confirm those results, in this expanded study with an identical protocol we increased the number of patients and participating centres.

Methods

One hundred and fifty critically ill patients on mechanical ventilation were randomised to oral care with either standard 0.1% CHX solution (control group) or a procedure comprising final application of an emulsion of Lp299. Samples for microbiological analyses were taken from the oropharynx and trachea at inclusion and subsequently at defined intervals.

Student’s t test was used for comparisons of parameters recorded daily and Fisher’s exact test was used to compare the results of microbiological cultures.

Results

Potentially pathogenic enteric bacteria not present at inclusion were identified in oropharyngeal samples from 29 patients in the CHX group and in 31 samples in the probiotic group. Considering cultures of tracheal secretions, enteric bacteria were found in 17 and 19 samples, respectively. Risk ratios show a difference in favour of the Lp group for fungi in oropharyngeal cultures. VAP was diagnosed in seven patients in the Lp group and in 10 patients among the controls.

Conclusions

In this multicentre study, we could not demonstrate any difference between Lp299 and CHX used in oral care procedures regarding their impact on colonisation with emerging potentially pathogenic enteric bacteria in the oropharynx and trachea.

Trial registration

ClinicalTrials.gov, NCT01105819. Registered on 9 April 2010.

First part: Current Controlled Trials, ISRCTN00472141. Registered on 22 November 2007 (published Critical Care 2008, 12:R136).

Cost assessment of a new oral care program in the intensive care unit to prevent ventilator-associated pneumonia

OBJECTIVES

Ventilator-associated pneumonia (VAP) is the most frequent hospital-acquired infections in intensive care units (ICU). In the bundle of care to prevent the VAP, the oral care is very important strategies, to decrease the oropharyngeal bacterial colonization and presence of causative bacteria of VAP. In view of the paucity of medical economics studies, our objective was to determine the cost of implementing this oral care program for preventing VAP.

MATERIALS AND METHODS

In five ICUs, during period 1, caregivers used a foam stick for oral care and, during period 2, a stick and tooth brushing with aspiration. Budgetary effect of the new program from the hospital's point of view was analyzed for both periods. The costs avoided were calculated from the incidence density of VAP (cases per 1000 days of intubation). The cost study included device cost, benefit lost, and ICU cost (medication, employer and employee contributions, blood sample analysis…).

RESULTS

A total of 2030 intubated patients admitted to the ICUs benefited from oral care. The cost of implementing the study protocol was estimated to be €11,500 per year. VAP rates decreased significantly between the two periods (p1 = 12.8% and p2 = 8.5%, p = 0.002). The VAP revenue was ranged from €28,000 to €45,000 and the average cost from €39,906 to €42,332. The total cost assessment calculated was thus around €1.9 million in favor of the new oral care program.

CONCLUSION AND CLINICAL RELEVANCE

Our study showed that the implementation of a simple strategy improved the quality of patient care is economically viable.

TRIAL REGISTRATION

NCT02400294.

Hospital-acquired lower respiratory tract infections among high risk hospitalized patients in a tertiary care teaching hospital in China: An economic burden analysis

BACKGROUND

Data on the economic burden of hospital-acquired lower respiratory tract infection (LRTI) among high risk hospitalized patients are lacking in China. This study aims to fill this knowledge gap.

METHODS

We used a prospective matched cohort design, comparing patients with LRTIs and 1:1 matched patients without LRTIs. Study period was from January 2013 to December 2015 analyzing inpatients from high risk wards - intensive care unit (ICU), dialysis, hematology, etc. - in a tertiary hospital. Hospital information system and hospital infection surveillance system were applied to extract necessary information. The primary outcome was incidence of hospital-acquired LRTIs, and the secondary was economic burden outcomes, including incremental medical costs and prolonged length of stay (LOS). Wilcoxon's signed rank test was used to explore the differences in the economic burden.

RESULTS

Among 5990 hospital visitors over the period of time, 895 (14.94%) had hospital-acquired LRTIs. We analyzed 340 patients with LRTIs and 340 respective controls without infections. The median hospital costs for patients with ICU-acquired LRTIs were significantly higher than those without LRTIs in other wards ($12,301.17 vs. $4674.64, P<0.01). The average attributable cost per patient was $2853.93 ($6916.48 vs. $4062.55, P<0.01). Patients from hematology department had the longest LOS, at 15days (25days vs. 10 days, P<0.01). An LRTI led to an attributable increase in LOS by 8days on average (P<0.01). Western medicine, treatment and laboratory test were the dominant contributors to the growth in overall medical costs in hospital-acquired LRTIs.

CONCLUSIONS

Hospital-acquired LRTI imposed considerable economic burden on patients hospitalized in high risk wards in China. This study provides the first data for economic evaluation of LRTI, highlighting the urgent need to establish targeted preventive strategies to minimize the occurrence of this complication to reduce economic burden.

[Hygiene measures in the intensive care station]

Medical personnel in intensive care units (ICU) deal with critically ill patients and a high work load. Patients face a higher risk of acquiring a nosocomial infection during their ICU stay. Especially, invasively ventilated patients are threatened. A catheter-related bloodstream infection might even lead to more severe complications. The number of multiresistant pathogens continues to rise; thus, comprehensive infection control measures are crucial to avoid pathogen transmission and infection. The most important measure is hand disinfection. With a proper personnel-patient ratio, educational programs, and infection control bundles, it is possible to reduce infection rates and enhance compliance among health care workers.

How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients

Microaspiration of subglottic secretions through channels formed by folds in high volume-low pressure poly-vinyl chloride cuffs of endotracheal tubes is considered a significant pathogenic mechanism of ventilator-associated pneumonia (VAP). Therefore a series of prevention measures target the avoidance of microaspiration. However, although some of these can minimize microaspiration, benefits in terms of VAP prevention are not always obvious. Polyurethane-cuffed endotracheal tubes successfully reduce microaspiration but high quality data demonstrating VAP rate reduction are lacking. An analogous conclusion can be made regarding taper-shaped cuffs compared with classic barrel-shaped cuffs. More clinical data regarding these endotracheal tube designs are needed to demonstrate clinical value in addition to in vitro-based evidence. The clinical usefulness of endotracheal tubes developed for subglottic secretions drainage is established in multiple studies and confirmed by meta-analysis. Any change in cuff design will fail to prevent microaspiration if the cuff is insufficiently inflated. At least one well-designed trial demonstrated that continuous cuff pressure monitoring and control decrease the risk of VAP. Gel lubrication of the cuff prior to intubation temporarily hampers microaspiration through sludging the channels formed by folds in high volume-low pressure cuffs. As the beneficial effect of gel lubrication is temporarily, its potential to reduce VAP risk is probably nonsignificant. A minimum positive end-expiratory pressure of at least 5 cmH₂O can be recommended as it reduces the risk of microaspiration in vitro and in vivo. One randomized controlled study demonstrated a reduced risk of VAP in patients ventilated with PEEP (5–8 cmH₂O). Regarding head-of-bed elevation, it can be recommended to avoid supine positioning. Whether a 45° head-of-bed elevation is to be preferred above 25-30° head-of-bed elevation remains unproven. Finally, the routine monitoring of gastric residual volumes in mechanically ventilated patients receiving enteral nutrition cannot be recommended.

European perspective and update on the management of nosocomial pneumonia due to methicillin-resistant Staphylococcus aureus after more than 10 years of experience with linezolid

Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of antimicrobial-resistant hospital-acquired infections worldwide and remains a public health priority in Europe. Nosocomial pneumonia (NP) involving MRSA often affects patients in intensive care units with substantial morbidity, mortality and associated costs. A guideline-based approach to empirical treatment with an antibacterial agent active against MRSA can improve the outcome of patients with MRSA NP, including those with ventilator-associated pneumonia. New methods may allow more rapid or sensitive diagnosis of NP or microbiological confirmation in patients with MRSA NP, allowing early de-escalation of treatment once the pathogen is known. In Europe, available antibacterial agents for the treatment of MRSA NP include the glycopeptides (vancomycin and teicoplanin) and linezolid (available as an intravenous or oral treatment). Vancomycin has remained a standard of care in many European hospitals; however, there is evidence that it may be a suboptimal therapeutic option in critically ill patients with NP because of concerns about its limited intrapulmonary penetration, increased nephrotoxicity with higher doses, as well as the emergence of resistant strains that may result in increased clinical failure. Linezolid has demonstrated high penetration into the epithelial lining fluid of patients with ventilator-associated pneumonia and shown statistically superior clinical efficacy versus vancomycin in the treatment of MRSA NP in a phase IV, randomized, controlled study. This review focuses on the disease burden and clinical management of MRSA NP, and the use of linezolid after more than 10 years of clinical experience.

[Nosocomial infections in intensive care units]

Nosocomial infections (NI) still have a high incidence in intensive care units (ICUs), and are becoming one of the most important problems in these units. It is well known that these infections are a major cause of morbidity and mortality in critically ill patients, and are associated with increases in the length of stay and excessive hospital costs. Based on the data from the ENVIN-UCI study, the rates and aetiology of the main nosocomial infections have been described, and include ventilator-associated pneumonia, urinary tract infection, and both primary and catheter related bloodstream infections, as well as the incidence of multidrug-resistant bacteria. A literature review on the impact of different nosocomial infections in critically ill patients is also presented. Infection control programs such as zero bacteraemia and pneumonia have been also analysed, and show a significant decrease in NI rates in ICUs.