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Schaller SJ, Scheffenbichler FT, Bein T, Blobner M, Grunow JJ, Hamsen U, Hermes C, Kaltwasser A, Lewald H, Nydahl P, Reißhauer A, Renzewitz L, Siemon K, Staudinger T, Ullrich R, Weber-Carstens S, Wrigge H, Zergiebel D, Coldewey SM. Guideline on positioning and early mobilisation in the critically ill by an expert panel. Intensive Care Med 2024; 50:1211-1227. [PMID: 39073582 DOI: 10.1007/s00134-024-07532-2] [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: 02/28/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.
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Affiliation(s)
- Stefan J Schaller
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
| | | | | | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julius J Grunow
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Uwe Hamsen
- Ruhr University Bochum, Bochum, Germany
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Carsten Hermes
- Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Germany
- Akkon-Hochschule für Humanwissenschaften, Berlin, Germany
| | - Arnold Kaltwasser
- Academy of the District Hospitals Reutlingen, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Heidrun Lewald
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Nydahl
- University Hospital of Schleswig-Holstein, Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Salzburg, Austria
| | - Anett Reißhauer
- Department of Rehabilitation Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Renzewitz
- Department of Physiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten Siemon
- Department of Pneumology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
- Septomics Research Center, Jena University Hospital, Jena, Germany.
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Patterson H, Eady J, Sommerfield A, Sommerfield D, Hauser N, von Ungern-Sternberg BS. Patient positioning and its impact on perioperative outcomes in children: A narrative review. Paediatr Anaesth 2024; 34:507-518. [PMID: 38546348 DOI: 10.1111/pan.14883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 05/12/2024]
Abstract
Patient positioning interacts with a number of body systems and can impact clinically important perioperative outcomes. In this educational review, we present the available evidence on the impact that patient positioning can have in the pediatric perioperative setting. A literature search was conducted using search terms that focused on pediatric perioperative outcomes prioritized by contemporary research in this area. Several key themes were identified: the effects of positioning on respiratory outcomes, cardiovascular outcomes, enteral function, patient and carer-centered outcomes, and soft issue injuries. We encountered considerable heterogeneity in research in this area. There may be a role for lateral positioning to reduce respiratory adverse outcomes, head elevation for intubation and improved oxygenation, and upright positioning to reduce peri-procedural anxiety.
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Affiliation(s)
- Heather Patterson
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Jonathan Eady
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Department of Anaesthesia, Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Aine Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Neil Hauser
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
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Lorente L, Sabater-Riera J, Rello J. Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events. Expert Rev Anti Infect Ther 2024; 22:317-332. [PMID: 38642072 DOI: 10.1080/14787210.2024.2345877] [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: 02/12/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP. AREAS COVERED This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles. EXPERT OPINION Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Spain
| | - Joan Sabater-Riera
- IDIBELL, Hospitalet de Llobregat, Spain, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Jordi Rello
- CRIPS (Clinical Research in Pneumonia & Sepsis); Vall d'Hebron Institute of Research, Barcelona, Spain
- Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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Coxwell Matthewman M, Yanase F, Costa-Pinto R, Jones D, Karalapillai D, Modra L, Radford S, Ukor IF, Warrillow S, Bellomo R. Haemodynamic changes during prone versus supine position in patients with COVID-19 acute respiratory distress syndrome. Aust Crit Care 2024; 37:391-399. [PMID: 37160405 PMCID: PMC10063572 DOI: 10.1016/j.aucc.2023.03.006] [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: 06/13/2022] [Revised: 03/10/2023] [Accepted: 03/25/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood. OBJECTIVES The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position. METHODS We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively. RESULTS We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001). CONCLUSION Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.
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Affiliation(s)
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
| | | | - Daryl Jones
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | | | - Lucy Modra
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Sam Radford
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Ida-Fong Ukor
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia; Department of Critical Care, Department of Medicine and Radiology, University of Melbourne, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
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Mohammad EB, Al Eleiwah AA, Qurdahji BT, Rayan A, Alshraideh JA, Al Hadid LA, Al Kharabsheh MS, Hudhud HN, Jakalat S. Oral Care and Positioning to Prevent Ventilator-Associated Pneumonia: A Systematic Review. SAGE Open Nurs 2024; 10:23779608241271699. [PMID: 39130054 PMCID: PMC11311145 DOI: 10.1177/23779608241271699] [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: 09/23/2023] [Revised: 06/14/2024] [Accepted: 06/28/2024] [Indexed: 08/13/2024] Open
Abstract
Introduction Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in critical patients. The negative impacts of VAP on patient outcomes emphasize the importance of effective preventive measures such as oral care and patient positioning. The aim of this review was to investigate the impact of oral care and positioning on the prevention of VAP among patients in the intensive care unit. Methods This review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was performed. The methodological quality of included studies was appraised using Joanna Briggs Institute checklists. Results In total 13 studies were included, all of them were randomized controlled trials. Six out of nine studies about oral care have significant results on VAP incidence. Regarding the position, Patients positioned at a 45-degree were less likely to develop VAP than those positioned at a 30-degree and those in a supine position. Conclusion Although patients positioned at 45-degree angle were less likely to develop VAP than those at 30-degree, it is necessary to individualize this practice before recommending it, once there are some contraindications, such as neurocritical patients. Regarding oral care to prevent VAP, considering the current guidelines' recommendation not to use oral chlorexidine, further studies evaluating alternatives are needed.
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Affiliation(s)
- Eslam Bani Mohammad
- Department of Nursing/Faculty of Nursing, Al-Balqa Applied University, Al-Salt, Jordan
| | | | - Banan T. Qurdahji
- Department of Nursing, School of Nursing, University of Jordan, Amman, Jordan
| | - Ahmad Rayan
- Faculty of Nursing, Zarqa University, Zarqa, Jordan
| | - Jafar A. Alshraideh
- Clinical Nursing Department, School of Nursing, University of Jordan, Amman, Jordan
| | | | - Muna S. Al Kharabsheh
- Department of Nursing/Faculty of Nursing, Al-Balqa Applied University, Al-Salt, Jordan
| | - Heba N. Hudhud
- Department of Nursing/Faculty of Nursing, Al-Balqa Applied University, Al-Salt, Jordan
| | - Suad Jakalat
- Midwifery Department, School of Nursing, Al-Balqa Applied University, Al-Salt, Jordan
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Singh A, Jefferson J. Post-Cardiac Arrest Care. Emerg Med Clin North Am 2023; 41:617-632. [PMID: 37391254 DOI: 10.1016/j.emc.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
A structured approach to postcardiac arrest care is needed. Although immediate goals include obtaining a blood pressure reading and ECG immediately after return of spontaneous circulation, other more advanced goals include minimizing CNS injury, managing cardiovascular dysfunction, reducing systemic ischemic/reperfusion injury, and identifying and treating the underlying cause to the arrest. This article summarizes the current understanding of the hemodynamic, neurologic, and metabolic abnormalities encountered in postarrest patients.
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Affiliation(s)
- Amandeep Singh
- Department of Emergency Medicine, Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Jamal Jefferson
- Department of Emergency Medicine, Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA
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7
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Marrazzo F, Spina S, Zadek F, Forlini C, Bassi G, Giudici R, Bellani G, Fumagalli R, Langer T. PEEP Titration Is Markedly Affected by Trunk Inclination in Mechanically Ventilated Patients with COVID-19 ARDS: A Physiologic, Cross-Over Study. J Clin Med 2023; 12:3914. [PMID: 37373608 PMCID: PMC10299565 DOI: 10.3390/jcm12123914] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Changing trunk inclination affects lung function in patients with ARDS. However, its impacts on PEEP titration remain unknown. The primary aim of this study was to assess, in mechanically ventilated patients with COVID-19 ARDS, the effects of trunk inclination on PEEP titration. The secondary aim was to compare respiratory mechanics and gas exchange in the semi-recumbent (40° head-of-the-bed) and supine-flat (0°) positions following PEEP titration. METHODS Twelve patients were positioned both at 40° and 0° trunk inclination (randomized order). The PEEP associated with the best compromise between overdistension and collapse guided by Electrical Impedance Tomography (PEEPEIT) was set. After 30 min of controlled mechanical ventilation, data regarding respiratory mechanics, gas exchange, and EIT parameters were collected. The same procedure was repeated for the other trunk inclination. RESULTS PEEPEIT was lower in the semi-recumbent than in the supine-flat position (8 ± 2 vs. 13 ± 2 cmH2O, p < 0.001). A semi-recumbent position with optimized PEEP resulted in higher PaO2:FiO2 (141 ± 46 vs. 196 ± 99, p = 0.02) and a lower global inhomogeneity index (46 ± 10 vs. 53 ± 11, p = 0.008). After 30 min of observation, a loss of aeration (measured by EIT) was observed only in the supine-flat position (-153 ± 162 vs. 27 ± 203 mL, p = 0.007). CONCLUSIONS A semi-recumbent position is associated with lower PEEPEIT and results in better oxygenation, less derecruitment, and more homogenous ventilation compared to the supine-flat position.
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Affiliation(s)
- Francesco Marrazzo
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Stefano Spina
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Francesco Zadek
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
| | - Clarissa Forlini
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Gabriele Bassi
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Riccardo Giudici
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
- Department of Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Roberto Fumagalli
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
| | - Thomas Langer
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
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Reyes LF, Rodriguez A, Fuentes YV, Duque S, García-Gallo E, Bastidas A, Serrano-Mayorga CC, Ibáñez-Prada ED, Moreno G, Ramirez-Valbuena PC, Ospina-Tascon G, Hernandez G, Silva E, Díaz AM, Jibaja M, Vera-Alarcon M, Díaz E, Bodí M, Solé-Violán J, Ferrer R, Albaya-Moreno A, Socias L, Figueroa W, Lozano-Villanueva JL, Varón-Vega F, Estella Á, Loza-Vazquez A, Jorge-García R, Sancho I, Shankar-Hari M, Martin-Loeches I. Risk factors for developing ventilator-associated lower respiratory tract infection in patients with severe COVID-19: a multinational, multicentre study, prospective, observational study. Sci Rep 2023; 13:6553. [PMID: 37085552 PMCID: PMC10119842 DOI: 10.1038/s41598-023-32265-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 03/24/2023] [Indexed: 04/23/2023] Open
Abstract
Around one-third of patients diagnosed with COVID-19 develop a severe illness that requires admission to the Intensive Care Unit (ICU). In clinical practice, clinicians have learned that patients admitted to the ICU due to severe COVID-19 frequently develop ventilator-associated lower respiratory tract infections (VA-LRTI). This study aims to describe the clinical characteristics, the factors associated with VA-LRTI, and its impact on clinical outcomes in patients with severe COVID-19. This was a multicentre, observational cohort study conducted in ten countries in Latin America and Europe. We included patients with confirmed rtPCR for SARS-CoV-2 requiring ICU admission and endotracheal intubation. Only patients with a microbiological and clinical diagnosis of VA-LRTI were included. Multivariate Logistic regression analyses and Random Forest were conducted to determine the risk factors for VA-LRTI and its clinical impact in patients with severe COVID-19. In our study cohort of 3287 patients, VA-LRTI was diagnosed in 28.8% [948/3287]. The cumulative incidence of ventilator-associated pneumonia (VAP) was 18.6% [610/3287], followed by ventilator-associated tracheobronchitis (VAT) 10.3% [338/3287]. A total of 1252 bacteria species were isolated. The most frequently isolated pathogens were Pseudomonas aeruginosa (21.2% [266/1252]), followed by Klebsiella pneumoniae (19.1% [239/1252]) and Staphylococcus aureus (15.5% [194/1,252]). The factors independently associated with the development of VA-LRTI were prolonged stay under invasive mechanical ventilation, AKI during ICU stay, and the number of comorbidities. Regarding the clinical impact of VA-LRTI, patients with VAP had an increased risk of hospital mortality (OR [95% CI] of 1.81 [1.40-2.34]), while VAT was not associated with increased hospital mortality (OR [95% CI] of 1.34 [0.98-1.83]). VA-LRTI, often with difficult-to-treat bacteria, is frequent in patients admitted to the ICU due to severe COVID-19 and is associated with worse clinical outcomes, including higher mortality. Identifying risk factors for VA-LRTI might allow the early patient diagnosis to improve clinical outcomes.Trial registration: This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable.
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Affiliation(s)
- Luis Felipe Reyes
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia.
- Clinica Universidad de La Sabana, Chía, Colombia.
- Pandemic Sciences Institute, University of Oxford, Oxford, UK.
| | - Alejandro Rodriguez
- Critical Care Department, URV/IISPV/CIBERES, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Yuli V Fuentes
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
- Clinica Universidad de La Sabana, Chía, Colombia
| | - Sara Duque
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Esteban García-Gallo
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Alirio Bastidas
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Cristian C Serrano-Mayorga
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
- Clinica Universidad de La Sabana, Chía, Colombia
| | - Elsa D Ibáñez-Prada
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | - Gerard Moreno
- Critical Care Department, URV/IISPV/CIBERES, Hospital Universitari Joan XXIII, Tarragona, Spain
| | | | | | - Glenn Hernandez
- Critical Care Department, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Ana Maria Díaz
- Eugenio Espejo Hospital of Specialties, Quito, Pichincha, Ecuador
| | - Manuel Jibaja
- Eugenio Espejo Hospital of Specialties, Quito, Pichincha, Ecuador
| | | | - Emili Díaz
- Critical Care Department, Hospital Universitari Parc Taulí, Universitat Autonoma Barcelona, Sabadell, Spain
| | - María Bodí
- Critical Care Department, URV/IISPV/CIBERES, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Jordi Solé-Violán
- Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain
- Universidad Fernando Pessoa, Canarias, Spain
| | - Ricard Ferrer
- Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | | | - Lorenzo Socias
- Son Llatzer University Hospital, Palma de Mallorca, Spain
| | - William Figueroa
- Unisabana Center for Translational Science, Universidad de La Sabana, Chía, Colombia
| | | | | | - Ángel Estella
- Jerez University Hospital, Jerez de la Frontera, Spain
| | - Ana Loza-Vazquez
- Critical Care Department, Hospital Universitario Virgen del Valme, Sevilla, Spain
| | | | - Isabel Sancho
- Critical Care Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Manu Shankar-Hari
- Intensive Care Unit, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, UK
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Gao YC, Shi L, Zhang YW, Gao W, Tian X, Cao MM, Li YJ, Chen H, Rui YF. Postoperative awake prone position in geriatric patients with hip fractures: a protocol for a randomized controlled trial on the efficacy of postoperative prone position in reducing pulmonary complications and improving oxygenation. Trials 2023; 24:280. [PMID: 37069686 PMCID: PMC10110345 DOI: 10.1186/s13063-023-07308-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/11/2023] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION Postoperative pulmonary complications (PPCs) are prevalent in geriatric patients with hip fractures. Low oxygen level is one of the most important risk factors for PPCs. Prone position has been proven efficacy in improving oxygenation and delaying the progress of pulmonary diseases, especially in patients with acute respiratory distress syndrome induced by multiple etiologies. The application of awake prone position (APP) has also attracted widespread attention in recent years. A randomized controlled trial (RCT) will be carried out to measure the effect of postoperative APP in a population of geriatric patients undergoing hip fracture surgery. METHODS This is an RCT. Patients older than 65 years old admitted through the emergency department and diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrollment and assigned randomly to the control group with routine postoperative management of orthopedics or APP group with an additional prone position for the first three consecutive postoperative days (PODs). Patients receiving conservative treatment will not be eligible for enrollment. We will record the difference in the patient's room-air-breathing arterial partial pressure of oxygen (PaO2) values between the 4th POD (POD 4) and emergency visits, the morbidity of PPCs and other postoperative complications, and length of stay. The incidence of PPCs, readmission rates, and mortality rates will be followed up for 90 PODs. DISCUSSION We describe the protocol for a single-center RCT that will evaluate the efficacy of postoperative APP treatment in reducing pulmonary complications and improving oxygenation in geriatric patients with hip fractures. ETHICS AND DISSEMINATION This protocol was approved by the independent ethics committee (IEC) for Clinical Research of Zhongda Hospital, Affiliated to Southeast University, and is registered on the Chinese Clinical Trial Registry. The findings of the trial will be disseminated through peer-reviewed journals. ETHICS APPROVAL NUMBER 2021ZDSYLL203-P01 TRIAL REGISTRATION: ChiCTR ChiCTR2100049311 . Registered on 29 July 2021. TRIAL STATUS Recruiting. Recruitment is expected to be completed in December 2024.
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Affiliation(s)
- Yu-Cheng Gao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Liu Shi
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Wang Gao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Xie Tian
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Ying-Juan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China.
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China.
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China.
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, People's Republic of China.
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Yang X, Cao L, Zhang T, Qu X, Chen W, Cheng W, Qi M, Wang N, Song W, Wang N. More is less: Effect of ICF-based early progressive mobilization on severe aneurysmal subarachnoid hemorrhage in the NICU. Front Neurol 2022; 13:951071. [PMID: 36588882 PMCID: PMC9794623 DOI: 10.3389/fneur.2022.951071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Aneurysmal subarachnoid hemorrhage (aSAH) is a type of stroke that occurs due to a ruptured intracranial aneurysm. Although advanced therapies have been applied to treat aSAH, patients still suffer from functional impairment leading to prolonged stays in the NICU. The effect of early progressive mobilization as an intervention implemented in the ICU setting for critically ill patients remains unclear. Methods This retrospective study evaluated ICF-based early progressive mobilization's validity, safety, and feasibility in severe aSAH patients. Sixty-eight patients with aSAH with Hunt-Hess grades III-IV were included. They were divided into two groups-progressive mobilization and passive movement. Patients in the progressive mobilization group received progressive ICF-based mobilization intervention, and those in the passive movement group received passive joint movement training. The incidence of pneumonia, duration of mechanical ventilation, length of NICU stay, and incidence of deep vein thrombosis were evaluated for validity. In contrast, the incidence of cerebral vasospasm, abnormally high ICP, and other safety events were assessed for safety. We also described the feasibility of the early mobilization initiation time and the rate of participation at each level for patients in the progressive mobilization group. Results The results showed that the incidence of pneumonia, duration of mechanical ventilation, and length of NICU stay were significantly lower among patients in the progressive mobilization group than in the passive movement group (P = 0.031, P = 0.004, P = 0.012), but the incidence of deep vein thrombosis did not significantly differ between the two groups. Regarding safety, patients in the progressive mobilization group had a lower incidence of cerebral vasospasm than those in the passive movement group. Considering the effect of an external ventricular drain on cerebral vasospasm (P = 0.015), we further analyzed those patients in the progressive mobilization group who had a lower incidence of cerebral vasospasm in patients who did not have an external ventricular drain (P = 0.011). Although we found 2 events of abnormally increased intracranial pressure in the progressive mobilization group, there was no abnormal decrease in cerebral perfusion pressure in the 2 events. In addition, among other safety events, there was no difference in the occurrence of adverse events between the two groups (P = 0.073), but the number of potential adverse events was higher in the progressive mobilization group (P = 0.001). Regarding feasibility, patients in the progressive mobilization group were commonly initiated 72 h after admission to the NICU, and 47.06% were in the third level of the mobilization protocol. Discussion We conclude that the ICF-based early progressive mobilization protocol is an effective and feasible intervention tool. For validity, more mobilization interventions might lead to less pneumonia, duration of mechanical ventilation and length of stay for patients with severe aSAH in the NICU, Moreover, it is necessary to pay attention over potential adverse events (especially line problems), although we did not find serious safety events.
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Affiliation(s)
- Xiaolong Yang
- Department of Rehabilitation Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lei Cao
- Department of Rehabilitation Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tiantian Zhang
- Department of Rehabilitation Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Qu
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenjin Chen
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weitao Cheng
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng Qi
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Na Wang
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weiqun Song
- Department of Rehabilitation Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China,*Correspondence: Weiqun Song
| | - Ning Wang
- Intensive Care Unit, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,Ning Wang
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Tetaj N, Capone A, Stazi GV, Marini MC, Garotto G, Busso D, Scarcia S, Caravella I, Macchione M, De Angelis G, Di Lorenzo R, Carucci A, Antonica MV, Gaviano I, Inversi C, Agostini E, Canichella F, Taloni G, Evangelista F, Onnis I, Mogavero G, Lamanna ME, Rubino D, Di Frischia M, Porcelli C, Cesi E, Antinori A, Palmieri F, D’Offizi G, Taglietti F, Nisii C, Cataldo MA, Ianniello S, Campioni P, Vaia F, Nicastri E, Girardi E, Marchioni L, Grisaro A, Farina A, Merino RJC, Micarelli S, Petroselli V, Ragosta G, Zito S. Epidemiology of ventilator-associated pneumonia in ICU COVID-19 patients: an alarming high rate of multidrug-resistant bacteria. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC9389502 DOI: 10.1186/s44158-022-00065-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background COVID‑19 is a novel cause of acute respiratory distress syndrome (ARDS) that leads patients to intensive care unit (ICU) admission requiring invasive ventilation, who consequently are at risk of developing of ventilator‑associated pneumonia (VAP). The aim of this study was to assess the incidence, antimicrobial resistance, risk factors, and outcome of VAP in ICU COVID-19 patients in invasive mechanical ventilation (MV). Methods Observational prospective study including adult ICU admissions between January 1, 2021, and June 31, 2021, with confirmed COVID-19 diagnosis were recorded daily, including demographics, medical history, ICU clinical data, etiology of VAPs, and the outcome. The diagnosis of VAP was based on multi-criteria decision analysis which included a combination of radiological, clinical, and microbiological criteria in ICU patients in MV for at least 48 h. Results Two hundred eighty-four COVID-19 patients in MV were admitted in ICU. Ninety-four patients (33%) had VAP during the ICU stay, of which 85 had a single episode of VAP and 9 multiple episodes. The median time of onset of VAP from intubation were 8 days (IQR, 5–13). The overall incidence of VAP was of 13.48 episodes per 1000 days in MV. The main etiological agent was Pseudomonas aeruginosa (39.8% of all VAPs) followed by Klebsiella spp. (16.5%); of them, 41.4% and 17.6% were carbapenem resistant, respectively. Patients during the mechanical ventilation in orotracheal intubation (OTI) had a higher incidence than those in tracheostomy, 16.46 and 9.8 episodes per 1000-MV day, respectively. An increased risk of VAP was reported in patients receiving blood transfusion (OR 2.13, 95% CI 1.26–3.59, p = 0.005) or therapy with Tocilizumab/Sarilumab (OR 2.08, 95% CI 1.12–3.84, p = 0.02). The pronation and PaO2/FiO2 ratio at ICU admission were not significantly associated with the development of VAPs. Furthermore, VAP episodes did not increase the risk of death in ICU COVID-19 patients. Conclusions COVID-19 patients have a higher incidence of VAP compared to the general ICU population, but it is similar to that of ICU ARDS patients in the pre-COVID-19 period. Interleukin-6 inhibitors and blood transfusions may increase the risk of VAP. The widespread use of empirical antibiotics in these patients should be avoided to reduce the selecting pressure on the growth of multidrug-resistant bacteria by implementing infection control measures and antimicrobial stewardship programs even before ICU admission.
Supplementary Information The online version contains supplementary material available at 10.1186/s44158-022-00065-4.
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Ramadan RA, Bedawy AM, Negm EM, Hassan TH, Ibrahim DA, ElSheikh SM, Amer RM. Carbapenem-Resistant Klebsiella pneumoniae Among Patients with Ventilator-Associated Pneumonia: Evaluation of Antibiotic Combinations and Susceptibility to New Antibiotics. Infect Drug Resist 2022; 15:3537-3548. [PMID: 35833009 PMCID: PMC9271681 DOI: 10.2147/idr.s371248] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022] Open
Abstract
Background Carbapenemase-producing Gram-negative bacteria, particularly Klebsiella pneumoniae (K. pneumoniae), are at the forefront of the list of causative agents of ventilator-associated pneumonia (VAP). The treatment options for such infections are limited, and various antimicrobial combinations have been suggested as alternatives in clinical practice. New antibiotics, such as ceftazidime/avibactam, ceftolozane/tazobactam and cefiderocol, have shown advantages in both in vitro and clinical studies. Purpose To evaluate the in vitro effect of meropenem–ciprofloxacin and meropenem–colistin combinations on carbapenem-resistant (CR) K. pneumoniae VAP isolates and to determine their susceptibility to new antibiotics. Methods Seventy-three K. pneumoniae isolates from 176 endotracheal samples from VAP cases were studied. Antibiotic susceptibility testing and phenotypic detection of extended-spectrum β lactamase (ESBL) and carbapenemase production were done. CR K. pneumoniae isolates were tested for the five predominant carbapenemase genes (blaKPC, blaOXA-48, blaNDM,blaVIM, and blaIMP). In vitro evaluation of meropenem–ciprofloxacin and meropenem–colistin combinations was done by MIC test strips. Susceptibility to new antibiotics was tested by disk diffusion method. Results Sixty-three (86.3%) of the isolates were ESBL producers and 52 (71.2%) were carbapenem resistant. BlaNDM was the most prevalent carbapenemase gene (50%), followed by blaOXA-48, (36.5%) then blaKPC in (11.5%). BlaVIM and blaIMP were not detected. Meropenem–ciprofloxacin combination showed indifferent effect on all isolates, while meropenem–colistin combination showed 25% synergism, 15.4% addition and 59.6% indifference. All (100%) CR K. pneumoniae isolates were resistant to ceftolozane/tazobactam and 79% were resistant to ceftazidime/avibactam, while 96% were sensitive to cefiderocol. Conclusion A high rate of carbapenem resistance exists among VAP K. pneumoniae isolates. Meropenem–colistin combination and cefiderocol appear to be potential treatment options for infections caused by CR K. pneumoniae. Resistance to the tested new β-lactam/β-lactamase inhibitors was high, signifying a major threat.
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Affiliation(s)
- Raghdaa A Ramadan
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Aya M Bedawy
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Essamedin M Negm
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Tarek H Hassan
- Department of Chest Diseases, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Dalia A Ibrahim
- Department of Chest Diseases, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Somia M ElSheikh
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Rania M Amer
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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