Impact of ventilator-associated pneumonia on mortality and epidemiological features of patients with secondary peritonitis

Intravenous combined with aerosolised polymyxins versus intravenous polymyxins monotherapy for ventilator-associated pneumonia: a systematic review and meta-analysis

Polymyxins was applied to treat ventilator associated pneumonia (VAP) caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) via different administration routes. The potential benefits of aerosolised polymyxins as adjunctive treatment for patients still were contradictory. This review assessed the safety and efficacy of intravenous combined with aerosolised polymyxins versus intravenous polymyxins monotherapy in patients with VAP caused by CR-GNB. Two reviewers independently evaluated and extracted date from Pubmed, Embase, Cochrane library and Web of science. The primary outcome was all-cause mortality and secondary outcomes included clinical cure rate, clinical improvement rate, microbiological eradication and nephrotoxicity. Differences for dichotomous outcomes were expressed as odds ratios (OR) with 95% confidence intervals (CI). Eleven eligible studies were included. The results showed that compared with intravenous polymyxins monotherapy, intravenous plus aerosolised polymyxins therapy significantly reduced all-cause mortality rate (OR = 0.75, 95% CI 0.57 - 0.99, P = 0.045) and improved clinical improvement rate (OR = 1.62, 95% CI 1.02 - 2.60, P = 0.043) and microbial eradication rate (OR = 2.07, 95% CI 1.40 - 3.05, P = 0.000). However, there were no significant difference in terms of clinical cure rate (OR = 1.59, 95% CI 0.96 - 2.63, P = 0.072) and nephrotoxicity (OR = 1.14, 95% CI 0.80 - 1.63, P = 0.467) for intravenous plus aerosolised polymyxins therapy. Subgroup analysis revealed that the clinical improvement rate was improved significantly in case-control studies. Aerosolised polymyxins maybe a useful adjunct to intravenous polymyxins for CR-GNB VAP patients.

Postoperative sepsis and septic shock after hip fracture surgery

INTRODUCTION

There is a paucity of research in the rates for sepsis and septic shock in the hip fracture population specifically, despite marked clinical and prognostic differences between these conditions. The purpose of this study was to determine the incidence, risk factors, and mortality rates for sepsis and septic shock as well as evaluate potential infectious causes in the surgical hip fracture population.

METHODS

The ACS-NSQIP (2015-2019) was queried for patients who underwent hip fracture surgery. A backward elimination multivariate regression model was used to identify risk factors for sepsis and septic shock. Multivariate regression that controlled for preoperative variables and comorbidities was used to calculate the odds of 30-day mortality.

RESULTS

Of 86,438 patients included, 871 (1.0%) developed sepsis and 490 (0.6%) developed septic shock. Risk factors for both postoperative sepsis and septic shock were male gender, DM, COPD, dependent functional status, ASA class ≥3, anemia, and hypoalbuminemia. Unique risk factors for septic shock were CHF and ventilator dependence. The 30-day mortality rate was 4.8% in aseptic patients, 16.2% in patients with sepsis, and 40.8% in patients who developed septic shock (p < 0.001). Patients with sepsis (OR 2.87 [95% CI 2.37-3.48], p < 0.001) and septic shock (OR 11.27 [95% CI 9.26-13.72], p < 0.001) had increased odds of 30-day mortality compared to patients without postoperative septicemia. Infections that preceded a diagnosis of sepsis or septic shock included urinary tract infections (24.7%, 16.5%), pneumonia (17.6%, 30.8%), and surgical site infections (8.5%, 4.1%).

CONCLUSIONS

The incidence of sepsis and septic shock after hip fracture surgery was 1.0% and 0.6%, respectively. The 30-day mortality rate was 16.2% in patients with sepsis and 40.8% in patients with septic shock. Potentially modifiable risk factors for both sepsis and septic shock were anemia and hypoalbuminemia. Urinary tract infections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock. Prevention, early identification, and successful treatment of sepsis and septic shock are paramount to lowering mortality after hip fracture surgery.

Analysis of Bacterial Pathogens Causing Complicating HAP in Patients with Secondary Peritonitis

Background: Diffuse peritonitis is an acute abdominal condition characterized by high mortality. The main treatment modality is surgery, requiring a subsequent prolonged hospital stay. These patients are, among other things, at risk of developing hospital-acquired pneumonia (HAP), which considerably worsens their treatment outcomes. This study aimed to extend the existing knowledge by providing more detailed microbiological characteristics of complicating HAP in patients with secondary peritonitis, including the identification of isolated bacterial pathogens and their potential sources. Methods: The 2015–2019 retrospective study comprised all patients with an intraoperatively confirmed diagnosis of secondary diffuse peritonitis who were classified in accordance with the quick Sepsis Related Organ Failure Assessment scoring system. Results: HAP developed in 15% of patients. The 90-day mortality rates were 53% and 24% in patients with and without HAP; respectively. The most frequent pathogens responsible for HAP were Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae complex and Enterococcus faecalis. Multidrug resistance to antibiotics was found in 38% of bacterial pathogens. Clonal spread of these bacterial pathogens among patients was not detected. Rather, the endogenous characteristic of HAP was confirmed. Conclusions: The initial antibiotic therapy of complicating HAP in patients with secondary peritonitis must be effective mainly against enterobacteria, including strains with the production of ESBL and AmpC beta-lactamases, Pseudomonas aeruginosa and Enterococcus faecalis. The study further highlighted the importance of monitoring the respiratory tract bacterial microflora in patients with secondary peritonitis. The results should be used for initial antibiotic treatment of complicating HAP instances.

Efficacy of Intermittent and Continuous Subglottic Secretion Drainage in Preventing the Risk of Ventilator-Associated Pneumonia: A Meta-Analysis of Randomized Control Trials

Ventilator-associated pneumonia (VAP) is hospital-acquired pneumonia that develops 48 h or longer following mechanical ventilation. However, cuff pressure fluctuates significantly due to patient or tube movement, which might result in microaspiration. Subglottic secretion drainage (SSD) has been suggested as a method for VAP prevention bundles. This systematic review and meta-analysis aims to investigate the efficacy and safety of subglottic SSD in preventing VAP. The secondary outcomes of this study are to investigate the intensive care unit (ICU) stay length and mortality rate regarding VAP. This study followed the Preferred Reporting Item for Systematic Review and Meta-Analysis guidelines. A thorough search of PubMed, Embase, and the Web of Science was conducted between June and August 2022. The study analysis used the Mantel-Haenszel method, and the quality of the included study was assessed using the Cochrane Risk of Bias 2. Eighteen randomized controlled trials with a total of 2537 intubated patients were included. It was found that SSD was associated with a lower risk of VAP (RR 1.44; 95% CI; 1.20-1.73; p < 0.0001). The subgroup analysis (utilizing intermittent and continuous methods) found no statistically significant difference between the two groups (p = 0.28). The secondary endpoints showed that there was no significant difference in mortality (RR 1.02; 95% CI; 0.87-1.20; p = 0.83), but there were substantial differences in ICU stays (mean difference, 3.42 days; 95% CI; 2.07-4.76; p < 0.00001) in favor of the SSD group. This was based on a very low certainty of evidence due to concerns linked to the risk of bias and inconsistency. The use of SSD was associated with a reduction in VAP incidence and ICU stay length, but there was no significant difference in the mortality rate.

The Susceptibility of MDR-K. Pneumoniae To Polymyxin B Plus Its Nebulised Form Versus Polymyxin B Alone in Critically Ill South Asian Patients

Introduction

Critically ill patients in intensive care units are at high risk of dying not only from the severity of their illness but also from secondary causes such as hospital-acquired infections. USA national medical record-data show that approximately 10% of patients on mechanical ventilation in an intensive care unit developed ventilator-associated pneumonia. Polymyxin B has been used intravenously in the treatment of multi-drug resistant gram-negative infections, either as a monotherapy or with other potentially effective antibiotics, and the recent international guidelines have emphasised the use of nebulised polymyxin B together with intravenous polymyxin B to gain the optimum clinical outcome in ventilator-associated pneumonia cases caused by multi-drug resistant gram-negative infections.

Methods

One hundred and seventy-eight patients with ventilator-associated pneumonia due to multi-drug resistant K. pneumoniae were identified during the study period. Following the inclusion and exclusion criteria, 121 patients were enrolled in the study and randomly allocated to two study groups. Group 1 patients were treated with intravenous Polymyxin B plus nebulised polymyxin B (n=64) and Group 2 patients with intravenous Polymyxin B alone (n=57). The study aimed to compare the use of Polymyxin B plus its nebulised form to polymyxin B alone, in the treatment of MDR-K. pneumoniae associated ventilator-associated pneumonia in critically ill patients.

Results

In Group 1, a complete clearance of K. pneumoniae was found in fifty-nine patients (92.1%; n=64) compared to forty patients (70.1%, n=57) in the Group 2 (P<0.003). The average time till extubation was significantly higher in Group 2 compared to Group 1 (P<0.05). The total length-of-stay in the ICU was significantly higher in Group 2 compared to Group 1. (P<0.05). These results support the view that the Polymyxin B dual-route regime may be considered as an appropriate antibiotic therapy, in critically ill South Asian patients with ventilator-associated pneumonia.

Healthcare workers' knowledge of evidence-based guidelines for prevention of ventilator-associated pneumonia in Hodeida, Yemen

OBJECTIVES

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in patients requiring mechanical ventilation in intensive care units (ICUs). VAP is associated with delayed extubation, prolonged hospital stays, increased healthcare costs and mortality rates. The aims of this study to evaluate the level of knowledge for the prevention of VAP among healthcare workers (HCWs) in ICUs and to assess their knowledge in relation to their socio-demographic characteristics.

METHODS

A descriptive, cross-sectional design was conducted to assess HCWs' knowledge of the guidelines for prevention of VAP in the ICUs of public and private hospitals in Hodeida city, Yemen. Around 140 self-administered multiple-choice questionnaires were distributed between April and July 2017.

RESULTS

A total of 120 (85.6%) HCWs completed questionnaire were obtained (20 physicians, 20 anesthesia technicians and 80 nurses) in this study. The total mean score of the HCWs' knowledge was low (41 ± 18). A statistically significant difference was found in the HCWs' knowledge scores according to their specialties and gender. Anesthesia technicians had the highest knowledge score followed by physicians and nurses (52.2 ± 16.2, 45.6 ± 21.2 and 37.1 ± 16.9, respectively, p=0.002). Males had higher scores than females (Median [IQR] 4 [3-5] vs. 3 [2-4], p<0.001). Participants who received information about the prevention of VAP had better knowledge than those who did not (46.2 ± 17.7 vs. 36.8 ± 17.3, p=0.006).

CONCLUSIONS

HCWs had a low knowledge level of the guidelines for the prevention of VAP, which may affect their practice. HCWs' knowledge was affected by their previous received information that increases the necessity to provide them with regular in-service education and training programs.

Comparison of three interventional approaches to prevent ventilator-associated pneumonia in intensive care units (ICUs): A clinical trial study

Background: Ventilator-associated pneumonia (VAP) is an infectious pulmonary disease that develops after 48 hours of ventilation. To date, several methods have been proposed to reduce VAP occurrence, such as the VAP prevention bundle, which involves raising the head of the bed, reducing sedation, avoiding deep vein thrombosis, and preventing peptic ulcer in the gastrointestinal system. The purpose of this study was to evaluate the role of personnel in hand washing, case airway suctioning, and systematic monitoring in the prevention of VAP.

Methods: In the current clinical trial, 129 patients hospitalized and intubated at Vali-e-Asr Hospital ICU in Arak, Iran, were included in the study and randomized to one of the three VAP prevention methods: group A, VAP prevention bundle measures; group B, group A measures plus washing of patients’ mouth with 0.12% chlorhexidine and suction of secretion every six hours; and finally group C, group B measures plus 72-hour suction package. Demographic information, VAP diagnosis, and outcome of each patient were recorded in the special checklist.

Results: The age of the patients ranged from 18 years to 93 years with a mean of 54.6 ± 21.8 years. There was no significant difference in age, sex, Clinical Pulmonary Infection Score (CPIS), and Glasgow Coma Scale (GCS) between the three groups. However, there is a significant relationship between chest X-ray (CXR) index and pneumonia in the three groups (p < 0.05). The prevalence of pneumonia is generally seen to be higher in patients who were local, diffuse, or patchy than those who had no infiltration (p < 0.05).

Conclusion: This study showed that the application of VAP prevention bundle measures, mouthwash with chlorhexidine, personnel hand washing, airway suctioning, and systematic monitoring is an efficient approach to the prevention of VAP in ICUs.

The effectiveness of Salvadora persica stick on the colonization of oral pathogens in mechanically ventilated patients in the intensive care unit (ICU): A pilot study

OBJECTIVE

To evaluate the effectiveness of antibacterial Salvadora persica stick on the colonization of oral pathogens in patients with mechanical ventilation.

METHOD

This research is quasi-experimental research with pre-test-post-test design. Oral care was administered every 12h on patients who required mechanical ventilation for less than 24h. The colonization of oral pathogen assessment was conducted with swab oral treatment before and 48h after mechanical ventilation. The data obtained were analyzed with a paired t-test.

RESULTS

The results of this research showed that the antibacterial effect of S. persica stick was significant in preventing the increase in the amount of oral pathogen colonization in mechanically ventilated patients (p<0.05). The colonization of oral pathogens decreased from 48×10⁶CFU/ml to 14×10⁶CFU/ml.

CONCLUSION

Oral care with S. persica can serve as a complementary therapy for patients with mechanical ventilation.

Postoperative Peritonitis After Digestive Tract Surgery: Surgical Management and Risk Factors for Morbidity and Mortality, a Cohort of 191 Patients

BACKGROUND

Postoperative peritonitis (POP) following gastrointestinal surgery is associated with significant morbidity and mortality, with no clear management option proposed. The aim of this study was to report our surgical management of POP and identify pre- and perioperative risk factors for morbidity and mortality.

METHODS

All patients with POP undergoing relaparotomy in our department between January 2004 and December 2013 were included. Pre- and perioperative data were analyzed to identify predictors of morbidity and mortality.

RESULTS

A total of 191 patients required relaparotomy for POP, of which 16.8% required >1 reinterventions. The commonest cause of POP was anastomotic leakage (66.5%) followed by perforation (20.9%). POP was mostly treated by anastomotic takedown (51.8%), suture with derivative stoma (11.5%), enteral resection and stoma (12%), drainage of the leak (8.9%), stoma on perforation (8.4%), duodenal intubation (7.3%) or intubation of the leak (3.1%). The overall mortality rate was 14%, of which 40% died within the first 48 h. Major complications (Dindo-Clavien > 2) were seen in 47% of the cohort. Stoma formation occurred in 81.6% of patients following relaparotomy. Independent risk factors for mortality were: ASA > 2 (OR = 2.75, 95% CI = 1.07-7.62, p = 0.037), multiorgan failure (MOF) (OR = 5.22, 95% CI = 2.11-13.5, p = 0.0037), perioperative transfusion (OR = 2.7, 95% CI = 1.05-7.47, p = 0.04) and upper GI origin (OR = 3.55, 95% CI = 1.32-9.56, p = 0.013). Independent risk factors for morbidity were: MOF (OR = 2.74, 95% CI = 1.26-6.19, p = 0.013), upper GI origin (OR = 3.74, 95% CI = 1.59-9.44, p = 0.0034) and delayed extubation (OR = 0.27, 95% CI = 0.14-0.55, p = 0.0027).

CONCLUSION

Mortality following POP remains a significant issue; however, it is decreasing due to effective and aggressive surgical intervention. Predictors of poor outcomes will help tailor management options.

Pre-intensive care unit intubation and subsequent delayed intensive care unit admission is independently associated with increased occurrence of ventilator-associated pneumonia

INTRODUCTION

Critically ill intubated patients are at risk for ventilator-associated pneumonia. However, intubation may not occur in intensive care unit (ICU) and subsequent ICU admission may be delayed.

OBJECTIVES

To evaluate whether intubation >24 h prior ICU admission and delay in ICU admission is associated with ventilator-associated pneumonia (VAP) in non-trauma critically ill patients.

MATERIALS AND METHODS

Prospective observational study conducted in a medical-surgical ICU of a tertiary hospital. Consecutive patients with >48 h of invasive mechanical ventilation and >72 h hospitalization, were recruited in the study. Pre-ICU intubation and delay in ICU admission, demographical, clinical, microbiological data and ICU interventions were assessed as risk factors for VAP and ICU mortality.

RESULTS

100 patients were included in the study. Pre-ICU intubation and delayed (>24 h) ICU admission (PDA patients) (P = 0.014, OR = 3.294, confidence interval 1.268-8.557) and SOFA score on ICU admission (P = 0.045, OR = 1.154, confidence interval 1.003-1.328) were independent risk factors for VAP in ICU care setting. Yet, PDA patients, presented significantly increased incidence of VAP due to MDR bacteria, mainly from Acinetobacter baumannii. Acinetobacter baumannii infection was the only independent risk factor for ICU mortality (P = 0.049, OR = 3.253, confidence interval 1.006-10.521). SOFA score on ICU admission, presented a fair prognostic accuracy of overall ICU mortality (SOFA ≥ 8.5, AUC = 0.850, P < 0.001).

CONCLUSIONS

Pre-ICU intubation and delayed ICU admission was independent risk factor for VAP Acinetobacter baumannii infection and a high SOFA score on ICU admission were predictors of increased ICU mortality.

Decreasing incidence and mortality among hospitalized patients suffering a ventilator-associated pneumonia: Analysis of the Spanish national hospital discharge database from 2010 to 2014

The aim of this study was to describe trends in the incidence and outcomes of ventilator-associated pneumonia (VAP) among hospitalized patients in Spain (2010-2014).This is a retrospective study using the Spanish national hospital discharge database from year 2010 to 2014. We selected all hospital admissions that had an ICD-9-CM code: 997.31 for VAP in any diagnosis position. We analyzed incidence, sociodemographic and clinical characteristics, procedures, pathogen isolations, and hospital outcomes.We identified 9336 admissions with patients suffering a VAP. Incidence rates of VAP decreased significantly over time (from 41.7 cases/100,000 inhabitants in 2010 to 40.55 in 2014). The mean Charlson comorbidity index (CCI) was 1.08 ± 0.98 and it did not change significantly during the study period. The most frequent causative agent was Pseudomonas and there were not significant differences in the isolation of this microorganism over time. Time trend analyses showed a significant decrease in in-hospital mortality (IHM), from 35.74% in 2010 to 32.81% in 2014. Factor associated with higher IHM included male sex, older age, higher CCI, vein or artery occlusion, pulmonary disease, cancer, undergone surgery, emergency room admission, and readmission.This study shows that the incidence of VAP among hospitalized patients has decreased in Spain from 2010 to 2014. The IHM has also decreased over the study period. Further investigations are needed to improve the prevention and control of VAP.

Incidence, characteristic and outcomes of ventilator-associated pneumonia among type 2 diabetes patients: An observational population-based study in Spain

BACKGROUND

To describe incidence, characteristics and outcomes of ventilator-associated pneumonia (VAP) during hospitalization among patients with or without type 2 diabetes (T2DM).

METHODS

We used the Spanish national hospital discharge database to select all hospitalization with VAP in subjects aged 40years or more from 2010 to 2014. We analyzed incidence, patient comorbidities, procedures, pneumonia pathogens and in-hospital outcomes according to diabetes status (T2DM and no-diabetes). We used propensity score analysis to estimate the effect of T2DM on in-hospital mortality RESULTS: In 7952 admissions, the patient developed a VAP (13.6% with T2DM). Adjusted incidence rate of VAP was slightly, but significantly, higher in T2DM than in non-diabetic patients (36.46[95% CI 34.41-38.51] vs. 32.57[95% CI 31.40-33.74] cases per 100,000/inhabitants). T2DM people were older and had higher Charlson comorbidity index than non-diabetic people. T2DM patients had a lower mean number of failing organs than non-diabetic patients (1.20 SD 1.17 vs. 1.45 SD 1.44, p<0.001). Pseudomonas was the most frequently isolated agent in both groups. IHM was 41.92% for T2DM patients and 37.91% for non-diabetic patients (p<0.05). Factors associated with a higher mortality in both groups included: older age, more comorbidities and primary diagnoses of vein or artery occlusion, pulmonary disease and cancer. T2DM was not associated with a higher in-hospital mortality after adjustment using a propensity score (OR 0.88; 95% CI 0.76-1.35).

CONCLUSIONS

VAP incidence rates were higher among T2DM patients. In-hospital mortality was higher among the older patients and those with more co-morbid conditions. T2DM does not predict higher mortality in VAP during hospitalization.