Bronchial colonization and postoperative respiratory infections in patients undergoing lung cancer surgery

Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: Effect on Pulmonary Function

Introduction: Cryoablation of intercostal nerves is performed for pain control after minimally invasive repair of pectus excavatum (MIRPE). Cryoablation affects both sensory and motor neurons, resulting in temporary anesthesia to the chest wall and loss of intercostal motor function. The study objective is to determine the effect of cryoablation on incentive spirometry (IS) volumes, as a measure of pulmonary function, after MIRPE. Materials and Methods: A single-institution retrospective review of pediatric patients undergoing MIRPE was performed. All patients received a multimodal regimen (MMR) of analgesics postoperatively. Three groups were compared-cryoablation (CRYO), elastomeric pain pump (EPP), and MMR alone. The primary outcomes were postoperative IS volumes and IS volumes as a ratio of preoperative forced vital capacity (FVC). Secondary outcomes included pain scores, opioid use, length of stay (LOS), and infectious complications. Results: MIRPE was performed in 115 patients: 50 CRYO, 50 EPP, and 15 MMR alone. Groups were similar for demographics and pectus excavatum severity. Postoperative spirometry measurements were similar across groups: IS (CRYO 750 mL [500,961] versus EPP 750 mL [590,1019] versus MMR 696 mL [500,1037], P = .77); IS/FVC (CRYO 0.19 [0.14,0.26] versus EPP 0.20 [0.16,0.26] versus MMR 0.16 [0.15,0.24], P = .69). Although pain scores were also similar across groups, CRYO patients used less opioid (P < .05) and had shorter LOS (P < .05). Postoperative pneumonia was rare and similar across groups (P = 1.00). Conclusion: Intercostal nerve cryoablation during MIRPE does not adversely affect postoperative IS volumes or increase pneumonia rate, despite the temporary loss of motor innervation to intercostal muscles. Cryoablation provides effective pain control with less opioid use.

Occurrence of influenza and bacterial infections in cancer patients receiving radiotherapy in Ghana

Background

Influenza co-infection with bacteria is a leading cause of influenza-related deaths and severe respiratory infections, especially among high-risk groups like cancer patients undergoing treatment. However, acute respiratory infection (ARI)-like symptoms developed by upper-torso cancer (UTC) patients receiving radiotherapy are considered as side-effects of the radiation. Hence influenza and bacterial pathogens implicated in ARI are not investigated.

Methods

This prospective cohort study examined 85 in-patients with upper-torso cancers undergoing radiotherapy at the National Radiotherapy, Oncology and Nuclear Medicine Centre (NRONMC) of Korle-Bu Teaching Hospital (KBTH) in Accra, Ghana. Eligible patients who consented were recruited into the study from September 2018 to April 2019. Influenza viruses A and B in addition to the following bacteria species Streptococcus pneumonia, Haemophilus influenzae, Neisseria meningitidis and Staphylococcus aureus were detected from oropharyngeal and nasopharyngeal swab specimens collected at three different time points. Presence of respiratory pathogens were investigated by influenza virus isolation in cell culture, bacterial culture, polymerase chain reaction (PCR) and next generation sequencing (NGS) assays.

Results

Of the 85 eligible participants enrolled into the study, 87% were females. Participants were 17 to 77 years old, with a median age of 49 years. Most of the participants (88%) enrolled had at least one pathogen present. The most prevalent pathogen was N. meningitidis (63.4%), followed by H. influenzae (48.8%), Influenza viruses A and B (32.9%), S. pneumoniae (32.9%) and S. aureus (12.2%). Approximately, 65% of these participants developed ARI-like symptoms. Participants with previous episodes of ARI, did not live alone, HNC and total radiation less than 50 Gy were significantly associated with ARI. All treatment forms were also significantly associated with ARI.

Conclusion

Data generated from the study suggests that ARI-like symptoms observed among UTC patients receiving radiotherapy in Ghana, could be due to influenza and bacterial single and co-infections in addition to risk factors and not solely the side-effects of radiation as perceived. These findings will be prime importance for diagnosis, prevention, treatment and control for cancer patients who present with such episodes during treatment.

[Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]

The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.

Clinical significance of microbial colonization identified by initial bronchoscopy in patients with lung cancer requiring chemotherapy

Background

There are limited data on the association between bronchial colonization and respiratory infections in people with lung cancer requiring cytotoxic chemotherapy. We investigated whether bronchial colonization in initial bronchoscopy specimens can predict the development of pneumonia after chemotherapy in patients with lung cancer.

Methods

Four hundred thirteen patients with lung cancer included in the Catholic Medical Center lung cancer registry were enrolled from March 2015 to August 2018. Demographic data, microbiology results, development of pneumonia after chemotherapy, and clinical information about lung cancer were analyzed retrospectively.

Results

A total of 206 lung cancer patients treated with chemotherapy were included in the analysis. Forty patients (19.4%) had positive results for the bronchial washing culture during the initial evaluation of lung cancer. The most common organisms were Klebsiella pneumoniae (n=14) and Streptococcus pneumoniae (n=6) in the surveillance culture, and Pneumocystis jirovecii (n=12) and Staphylococcus aureus (n=8) at the time of pneumonia development. Eighty-nine patients (43.2%) had pneumonia after chemotherapy, but the occurrence of pneumonia did not differ according to the colonization. There were no patients for whom the initial isolated organism was a causative microbe for the development of pneumonia after or during chemotherapy. The pneumonia group had poorer prognosis than the non-pneumonia group (378 vs. 705 days, P=0.0004).

Conclusions

Microbial colonization in bronchoscopy specimens was not associated with pneumonia development or mortality after chemotherapy for lung cancer. This finding suggests that testing surveillance culture may not be helpful for predicting pneumonia or improving survival in lung cancer patients with chemotherapy.

Pharmacokinetics and pharmacodynamics of levofloxacin in bronchial mucosa and lung tissue of patients undergoing pulmonary operation

Levofloxacin is a major antimicrobial agent that is used for the treatment of community-acquired lower respiratory tract infections (LRTIs). The present study was designed to investigate the pharmacokinetics (PK) and pharmacodynamics (PD) of levofloxacin in bronchial mucosa and lung tissue. A total of 32 patients undergoing pulmonary surgery were randomly assigned to one of four groups (8 subjects/group). All patients received a single dose of 500 mg levofloxacin orally prior to the operation. Blood, lung tissue and bronchial mucosa samples were collected prior to treatment and at 1.5, 4, 8, 12 and 24 h following treatment. The drug concentration was determined and PK and PD profiles were calculated using MATLAB software. The peak concentration of levofloxacin was 7.0±1.2 µg/g in lung tissues and 9.4±2.1 µg/g in bronchial mucosa. The corresponding area under the curve between 0 and 24 h (AUC0-24) was 85.7±8.5 and 137.3±19.4 µg h/g. The mean permeability of levofloxacin (ratio of concentration in tissue to that in plasma) was 2.4 in lung tissue and 4.4 in the bronchial mucosa. The PK profiles of levofloxacin in the plasma, lung and bronchial mucosa were described using an integrated one-compartment model. The probability of fAUC0-24/minimal inhibitory concentration (MIC) target attainment of levofloxacin against Streptococcus pneumoniae in the lung and bronchial mucosa was maintained at 100% when MIC ≤1 mg/l, while the cumulative fraction of fAUC0-24/MIC in the corresponding tissues was 94.4 and 98.1%, respectively. The present study demonstrated the high permeability of levofloxacin in the lung and bronchial mucosa of patients undergoing pulmonary surgery. In conclusion, treatment using 500 mg levofloxacin exhibits good clinical and microbiological efficacy for use in LRTIs that are caused by S. pneumoniae. This trial was registered retrospectively in the Chinese Clinical Trial Registry on January 13, 2020 (registration no. ChiCTR2000029096).

Effect of oral plaque control on postoperative pneumonia following lung cancer surgery

Background

There have been few studies on the relationship between oral status and postoperative pneumonia (POP) in patients with lung cancer, and whether improving their oral condition assists with a lower incidence of POP before lung cancer surgery remains controversial. This retrospective study was conducted by a stomatologist to assess the effect of controlling oral pathogenic bacteria of patients with lung cancer to prevent POP.

Methods

A total of 235 patients with lung cancer who underwent lobectomy by open thoracotomy between July 2015 and December 2018 were selected and given the choice of being in the experimental or control group. A total of 122 participants in the experimental group received professional oral plaque control, and 113 participants in the control group did not receive plaque control. All clinical data of participants in both groups were retrospectively studied to determine the incidence of POP at the thirtieth day of discharge from hospital.

Results

Eight in the experimental group and six in the control group were excluded from the study. It was found that four of 114 patients suffered from POP in the experimental group (incidence = 3.51%). A total of 17 of 107 patients in the control group had pulmonary infection (incidence = 15.89%). Odds ratio was 0.19. The incidence of POP in the experimental group was significantly lower than that of the control group (P < 0.05).

Conclusions

Professional oral plaque control is associated with a lower incidence of POP following lung cancer surgery and is therefore a favorable factor for preventing POP, and should be carried out before the surgical treatment of lung cancer.

Key points

Professional oral plaque control was associated with a lower incidence of POP following lung cancer surgery, and it is recommended this should be carried out before the surgical treatment of lung cancer.

Excessive intravenous crystalloid infusion after video-assisted thoracoscopic surgery lobectomy is associated with postoperative pneumonia

Background

Video-assisted thoracoscopic surgery has been widely used in thoracic surgery worldwide. Our goal was to identify the risk factors for postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery lobectomy.

Methods

A retrospective analysis of adult patients undergoing video-assisted thoracoscopic surgery lobectomy between 2016 and 05 and 2017–04 was performed. We used univariate analyses and multivariate analyses to examine risk factors for postoperative pneumonia after lobectomy.

Results

The incidence of postoperative pneumonia was 19.7% (n = 143/727). Patients with postoperative pneumonia had a higher postoperative length of stay and total hospital care costs when compared to those without postoperative pneumonia. Multivariate analysis showed that body mass index grading ≥24.0 kg/m² (vs. <24.0 kg/m²: odds ratio 1.904, 95% confidence interval 1.294–2.802, P = 0.001) and right lung lobe surgery (vs. left lung lobe surgery: odds ratio 1.836, 95% confidence interval 1.216–2.771, P = 0.004) were independent risk factors of postoperative pneumonia. Total intravenous crystalloid infusion grading in the postoperative 24 h ≥ 1500 mL was also identified as the risk factors (vs. 1000 to < 1500 mL: odds ratio 2.060, 95% confidence interval 1.302–3.260, P = 0.002).

Conclusions

Major risk factors for postoperative pneumonia following video-assisted thoracoscopic surgery lobectomy are body mass index grading ≥24.0 kg/m², right lung lobe surgery and total intravenous crystalloid infusion grading in the postoperative 24 h ≥ 1500 mL.

Postoperative outcomes of frequent exacerbator patients with Chronic Obstructive Pulmonary Disease after resection of Non-Small Cells Lung Cancer

Chronic obstructive pulmonary disease (COPD) is a risk factor of post-operative complications after lung cancer resection. The influence of the "frequent exacerbator (FE)" phenotype (at least three exacerbations per year) is unknown. Postoperative outcomes of frequent exacerbators (POFE) was a prospective observational study of patients with COPD undergoing lung resection for cancer. The inclusion criteria were: age >40 years, FEV1/FVC <70%, non-urgent surgery for lung cancer, filled out self-questionnaires. The primary outcome was assessment of postoperative pulmonary complications (purulent tracheobronchitis, atelectasis, pneumonia, acute respiratory failure, need of mechanical ventilation). Secondary outcomes encompassed the prevalence of the FE phenotype and its impact on postoperative complications. A total of 682 patients were screened from June 2014 to October 2015. 93 patients with COPD were included, 21 (23%) were FE. Postoperative tracheobronchitis, atelectasis pneumonia or respiratory failure (isolated or associated) occurred in 47%, 48%, 26%, and 38% of patients, respectively. Non-invasive and invasive mechanical ventilation were necessary in 4 (4%) and 22 (23%) patients. Purulent tracheobronchitis, pneumonia and hypercapnia (this last requiring noninvasive mechanical ventilation) were more frequent in FE (p = 0.043, 0.042, 0.015); however the number of patients wth at least one respiratory complication was not different (76% vs. 52%, p = 0.056). In all patients, multivariate logistic regression identified two independent factors of postoperative respiratory complications: male sex (OR 10.6 [95% CI 1.97-57.6], p = 0.006) and the FE phenotype (OR 6.33 [1.04-38.39], p = 0.045). Occurrence of postoperative complications in patients with COPD is high. FE phenotype is an independent risk factor.

Comparison of traditional microbiological culture and 16S polymerase chain reaction analyses for identification of preoperative airway colonization for patients undergoing lung resection

PURPOSE

Preoperative airway colonization is associated with increased risk of postoperative respiratory complications following lung resection. This study compares the rates of preoperative lower respiratory tract colonization identified by traditional culture and novel 16S polymerase chain reaction (PCR) tests.

MATERIALS AND METHODS

Preoperative sputum and bronchoalveolar lavage (BAL) samples for 49 lung resection patients underwent culture and 16S PCR analyses. Rates of positive test results were determined and relationships between test results and suspected postoperative respiratory tract infection and hospital length of stay (LOS) were investigated.

RESULTS

Preoperative BAL cultures were positive for 29 (59.2%) patients (population estimate 95%CI 45.2%-71.8%). 16S PCR tests were positive for 28 (57.1%) patients (population estimate 95%CI 43.3%-70.0%). 17 (34.7%) patients suffered suspected postoperative respiratory tract infection (population estimate 95%CI 22.9%-48.7%). Positive 16S PCR results tended to be associated with longer LOS (median 7.5 days vs 4.0 days for negative, p = 0.08) and increased risk of suspected postoperative respiratory tract infection (46.4% for positive vs 19.0% for negative, p = 0.07).

CONCLUSIONS

Rates of colonization identified by culture and 16S PCR analyses of BAL samples were similar. Future research should attempt to clarify associations between airway colonization identified by 16S PCR and outcomes. 16S PCR may be useful when stratifying risk of postoperative respiratory complications.

The role of bacterial culture by bronchoscopy in patients with lung cancer: a prospective study

Background

Patients with lung cancer undergoing surgical and medical treatment are at increased risk for pulmonary complications. The importance of routine bronchoscopy procedure in populations with lung cancer has rarely been defined. We aimed to determine the growth of potentially pathogenic microorganisms (PPM) among patients evaluated by bronchoscopy for lung cancer.

Methods

This prospective study included 155 consecutive patients with lung mass or radiologic findings suspicious for malignancy. Baseline demographic, clinical and radiologic features were collected. Clinical features of infection were compared to microbiologic and histologic results.

Results

The bacterial spectrum of lung cancer patients was similar to those without malignancy. The most frequently isolated organisms were Pseudomonas sp. and Staphylococcus aureus. Among all patients, bronchial bacterial positive PPM growth was noted in 30% (46/155). The significant PPM growth rate was three-fold higher among those with clinical signs of infection (P<0.001). Interestingly, 30 of these 46 patients (66%) did not show signs of clinical infection.

Conclusions

Bronchoscopic evaluations should include bacterial cultures for direct targeted antibiotic therapy only in the symptomatic patients.

Managing the oncologic patient with suspected pneumonia in the intensive care unit

INTRODUCTION

Solid cancer patients are frequently admitted in intensive care units for critical events. Improving survival rates in this setting is considered an achievable goal today. Respiratory failure is the main reason for admission, representing a primary target for research.

AREAS COVERED

This review presents a diagnostic and therapeutic algorithm for pneumonia and other severe respiratory events in the solid cancer population. It aims to increase awareness of the risk factors and the different etiologies in this changing scenario in which neutropenia no longer seems to be a decisive factor in poor outcome. Bacterial pneumonia is the leading cause, but opportunistic diseases and non-infectious etiologies, especially unexpected adverse effects of radiation, biological drugs and monoclonal antibodies, are becoming increasingly frequent. Options for respiratory support and diagnostics are discussed and indications for antibiotics in the management of pneumonia are detailed. Expert commentary: Prompt initiation of critical care to facilitate optimal decision-making in the management of respiratory failure, early etiological assessment and appropriate antibiotic therapy are cornerstones in management of severe pneumonia in oncologic patients.

[Preoperatiove Airway Bacterial Colonization: the Missing Link between Non-small Cell Lung Cancer Following Lobectomy and Postoperative Pneumonia?]

背景与目的

外科手术是目前治疗肺癌的主要手段，肺癌患者围术期死亡的主要原因仍是术后肺炎。已有的研究结果显示致病性气道定植菌被认为是术后肺部并发症的一个独立危险因素，本研究旨在探讨术前致病性气道定植菌的存在与术后发生肺炎的关系及其危险因素。

方法

横断面调查2014年5月至2015年1月连续收治于成都市6家三级甲等医院胸外科行手术治疗的125例非小细胞肺癌患者，术前经纤维支气管镜取气管及支气管内液细菌学标本，并检测术前血清肺表面活性蛋白D（surfactant protein D, SP-D）水平，术后肺部相关并发症进行分析。

结果

肺癌患者术前合并致病性气道定植菌的发生率为15.2%（19/125），以革兰氏阴性菌为主（19/22, 86.36%）；肺癌患者术前合并致病性气道定植菌的高危因素为：高龄（≥75岁）和长期吸烟史（吸烟指数≥400支/年）；术后肺部相关并发症和术后肺炎发生率在肺癌合并致病性气道定植菌组（42.11%, 26.32%）均显著高于非合并组（16.04%, 6.60%）（P=0.021, P=0.019）。术前血清SP-D浓度在肺癌合并致病性气道定植菌（31.25±6.09）显著高于非合并组（28.17±5.23）（P=0.023）。并发术后肺炎患者中气道致病性定值菌发生率为41.67%（5/12），其发生率是无手术后肺炎患者的3.4倍（OR=3.363, 95%CI: 1.467-7.711）。

结论

肺癌患者合并致病性气道定植菌与术后肺炎发生密切相关，且高危险因素是高龄和长期吸烟史。

Risk factors of surgical site infections in patients with Crohn's disease complicated with gastrointestinal fistula

PURPOSE

Surgical site infection (SSI) is the most common complication following surgical procedures. This study aimed to determine risk factors associated with SSI in patients with Crohn's disease (CD) complicated with gastrointestinal fistula.

METHODS

This was a retrospective review of patients who underwent surgical resection in gastrointestinal fistula patients with CD between January 2013 and January 2015, identified from a prospectively maintained gastrointestinal fistula database. Demographic information, preoperative medication, intraoperative findings, and postoperative outcome data were collected. Univariate and multivariate analysis was carried out to assess possible risk factors for SSI.

RESULTS

A total of 118 patients were identified, of whom 75.4% were men, the average age of the patients was 34.1 years, and the average body mass index (BMI) was 18.8 kg/m². The rate of SSI was 31.4%. On multivariate analysis, preoperative anemia (P = 0.001, OR 7.698, 95% CI 2.273-26.075), preoperative bacteria present in fistula tract (P = 0.029, OR 3.399, 95% CI 1.131-10.220), and preoperative enteral nutrition (EN) <3 months (P < 0.001, OR 11.531, 95% CI 3.086-43.079) were predictors of SSI. Notably, preoperative percutaneous abscess drainage was shown to exert protection against SSI in fistulizing CD (P = 0.037, OR 0.258, 95% CI 0.073-0.920).

CONCLUSION

Preoperative anemia, bacteria present in fistula tract, and preoperative EN <3 months significantly increased the risk of postoperative SSI in gastrointestinal fistula complicated with CD. Preoperative identification of these risk factors may assist in risk assessment and then to optimize preoperative preparation and perioperative care.

Preoperative airway colonization prior to transthoracic esophagectomy predicts postoperative pulmonary complications

PURPOSE

Respiratory complications are responsible to a high degree for postoperative morbidity and mortality after Ivor-Lewis esophagectomy. The etiology of respiratory failure is known to be multifactorial with preoperative impaired lung function being the most important one. The aim of this study was to investigate the correlation between preoperative airway colonization (PAC) and postoperative respiratory complications.

METHODS

In this observational study, 64 patients with esophageal cancer were included. All patients underwent Ivor-Lewis esophagectomy with laparoscopic or open gastric mobilization. After induction of anesthesia and intubation with a double-lumen tube, bronchial exudate was collected by random endoluminal suction for further microbiological work-up. Length of postoperative mechanical ventilation (<24 h, 24-72 h, >72 h), re-intubation, and tracheostomy were recorded as primary and secondary study endpoints.

RESULTS

In 13 of 64 study patients (20.3 %), pathological colonization of the bronchial airways could be proved prior to esophagectomy. Haemophilus species was the most frequently identified pathogen. PAC was associated with a longer history of smoking (p = 0.025), a lower preoperative forced expiratory volume (FEV1, p = 0.009) or vital capacity (VC, p = 0.038), a prolonged postoperative mechanical ventilation (p < 0.001), and a higher frequency of re-intubation (p < 0.001) and tracheostomy (p = 0.017). In the multivariate analysis, PAC was identified as an independent predictor of respiratory failure (hazard ratio 11.4, 95 % confidence interval 2.6-54, p = 0.002). Mortality in the PAC group was 30.8 % compared to 0 % in patients without PAC (p < 0.0001).

CONCLUSION

PAC is a significant risk factor for postoperative respiratory failure. A routine bronchoscopy and bronchoalveolar lavage as part of preoperative management prior to esophagectomy need to be discussed.

Risk factors for postoperative pneumonia after lung cancer surgery and impact of pneumonia on survival

OBJECTIVE

Little is known about risk factors and prognosis for postoperative pneumonia (POP) in patients undergoing therapeutic lung cancer (LC) surgery.

METHODS

We followed a nationwide population-based cohort of 7479 patients with LC surgery in Denmark 1995-2011. We used logistic regression analysis to examine risk factors for POP within 30 days after surgery. Subsequent survival in patients with POP was analyzed with Cox regression.

RESULTS

We identified 268 (3.6%) patients with POP. Important risk factors included advanced age (age ≥80 years: (adjusted odds ratio [aOR] = 3.64; 95% CI: 2.17-6.12) as compared to patients aged 50-59 years), previous pneumonia (aOR = 2.68; 95% CI: 2.02-3.56), obesity (aOR = 1.91; 95% CI: 0.99-3.69), chronic pulmonary disease (aOR = 1.90; 95% CI: 1.40-2.57), alcoholism (aOR = 1.56; 95% CI: 0.81-3.01), and atrial fibrillation (aOR = 1.42; 95% CI: 0.82-2.45). Overall thoracoscopic surgery halved the risk of POP and the highest risk of POP was seen in pneumonectomy performed in open thoracotomy. Among patients surviving the 30-day postoperative period, 31-365 day mortality was 21.6% in POP patients vs. 16.8% in non-POP patients, and 1-5-year mortality was 62.2% vs. 53.0%. Adjusted 31-365 day hazard ratio (HR) of death with POP was 1.31 (95% CI: 1.00-1.73), and 1-5 year HR was 1.22 (95% CI 0.98-1.53).

CONCLUSION

Major risk factors for POP following LC surgery are advanced age, previous pneumonia, obesity, chronic pulmonary disease, alcoholism, and atrial fibrillation. POP is a clinical marker for decreased LC survival.

Dental and microbiological risk factors for hospital-acquired pneumonia in non-ventilated older patients

Hospital acquired pneumonia (HAP) is often fatal in older patients. The mouth is the main reservoir of infection and studies have suggested that oral hygiene interventions may prevent HAP. The aim of this study was to investigate associations between HAP and preceding a) heavy dental plaque and b) oral carriage of potential respiratory pathogens in older patients with lower limb fracture to determine the target for intervention studies.

Risk factors of postoperative nosocomial pneumonia in stage I-IIIa lung cancer patients

BACKGROUND

To investigate the related risk factors of postoperative nosocomial pneumonia (POP) in patients with I-IIIa lung cancer.

METHODS

Medical records of 511 patients who underwent resection for lung cancer between January 2012 to December 2012 were retrospectively reviewed. Risk factors of postoperative pneumonia were identified and evaluated by univariate and multivariate analyses.

RESULTS

The incidence of postoperative pneumonia in these lung cancer patients was 2.9% (15 cases). Compared with 496 patients who had no pneumonia infection after operation, older age (>60), histopathological type of squamous cell carcinoma and longer surgery time (>3h) were significant risk factors by univariate analysis. Other potential risk factors such as alcohol consumption, history of smoking, hypersensitivity, hypertension, diabetes mellitus and so on were not showed such significance in this study. Further, the multivariate analysis revealed that old age (>60 years) (OR 5.813, p=0.018) and histopathological type of squamous cell carcinoma (OR 5.831, p<0.001) were also statistically significant independent risk factors for postoperative pneumonia.

CONCLUSIONS

This study demonstrated that being old aged (>60 years) and having squamous cell carcinoma histopathological type might be important factors in determining the risk of postoperative pneumonia in lung cancer patients after surgery.

Airway bacterial colonization in patients with non-small cell lung cancer and the alterations during the perioperative period

BACKGROUND

To observe the alterations in airway bacterial colonization during the perioperative period in patients with non-small cell lung cancer (NSCLC) and evaluate their clinical implications.

METHODS

Patients with resectable primary NSCLC were enrolled from October 2011 to April 2012. Airway secretions were harvested for microbiological study after admission, immediately after surgery, and before endotracheal extubation. Spontaneous sputum was collected when patients presented with signs of postoperative pneumonia (POP). Detailed data on the isolated pathogens were carefully recorded. Risk factors for airway colonization and POP were analyzed.

RESULTS

A total of 78 consecutive patients were enrolled. Fourteen patients (17.9%) had airway colonization at admission, including four cases of fungi and ten cases of Gram-negative bacilli (GNB). Five patients (6.4%) had colonized pathogens at the end of surgery, including three cases of GNB and two cases of Gram-positive cocci. Nine (11.5%) patients had positive culture of airway secretions collected before extubation, including seven cases of GNB and two cases of fungi. Eighteen patients (23.1%) had POP, of whom one suffered from bronchopleural fistula and one died of POP. Pathogens of POP were confirmed in 11 patients, including nine cases of GNB and two cases of fungi. Three patients had the same pathogens as preoperative colonization. The proportion of more antibiotic-resistant strains increased gradually. Advanced age [odds ratio (OR), 2.263; 95% confidence interval (95% CI), 1.030-4.970] and smoking (OR, 2.163; 95% CI, 1.059-4.429) were risk factors for airway colonization. Decreased diffusion capacity of the lung for carbon monoxide (OR, 5.838; 95% CI, 1.318-25.854), prolonged operation time (OR, 6.366; 95% CI, 1.349-30.033), and preoperative airway colonization (OR, 9.448; 95% CI, 2.206-40.465) were risk factors of POP.

CONCLUSIONS

Airway colonized pathogens altered and more antibiotic-resistant GNB emerged during the perioperative period. These pathogens played an important role in the presence of POP.

Airway bacterial colonization and serum C-reactive protein are associated with chronic obstructive pulmonary disease exacerbation following bronchoscopic lung volume reduction

INTRODUCTION

Stable chronic obstructive pulmonary disease (COPD) patients often have lower airway bacterial colonization (ABC) which may modulate exacerbation frequency. Data regarding the association between ABC and post-procedural COPD exacerbations following bronchoscopic lung volume reduction (BLVR) are scant.

OBJECTIVES

Our aim was to explore the correlation among ABC, serum C-reactive protein (CRP) level and the risk of COPD exacerbation within a month following BLVR.

METHODS

Pre-procedure bronchoalveolar lavage (BAL) quantitative bacterial cultures and serum levels of CRP were evaluated in severe COPD patients (N = 70, mean FEV1  = 34.6%) before BLVR by polymeric lung sealant.

RESULTS

Colonization with potential pathogenic microorganism (PPM) was observed in 40 (57.1%) patients. Out of 28 patients (40%) who had COPD exacerbation within 30 days of BLVR, 23 (82.1%) had PPM in BAL culture compared with only 14 (33.3%) out of 42 patients who had uneventful procedure (P = 0.0027). Serum CRP level was significantly higher in patients with exacerbation compared with those with no exacerbation (mean 47.8 ± 66.0 mg/L vs 13.05 ± 27.7 mg/L, respectively, P = 0.0063). The combination of CRP level above 3.12 mg/L and PPM growth in BAL was observed in 89.2% of patients with exacerbation compared with only 52.3% of patients without exacerbation (P = 0.0031).

CONCLUSIONS

ABC is common in severe COPD patients undergoing BLVR, and along with elevated CRP level both are associated with high risk of immediate post-procedural COPD exacerbation. These patients should be identified, carefully observed and possibly benefit from prophylactic microbiologically directed antibiotic treatment.

Antimicrobial peptides are highly abundant and active in postoperative pleural drainage fluids

BACKGROUND

The human lung is considered a nonsterile organ, and surgical interventions therefore take place in a more or less contaminated operating field. Nevertheless, infectious complications of the pleural cavity are low after major lung resections. Antimicrobial peptides (AMPs) are part of the innate immunity and display a broad capacity to kill pathogens. We hypothesized that the pleural space must have a high natural antimicrobial barrier and that AMPs might effectively protect the pleural cavity.

METHODS

Pleural effusions were collected after lung operations. Antimicrobial activity of the fluids against gram-positive and gram-negative pathogens was analyzed by microdilution assays. AMPs were determined by enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR), and immunohistochemical analysis. The impact of proinflammatory triggers on AMP release from pleural mesothelial cells was evaluated.

RESULTS

Antimicrobial activity assays revealed high bactericidal properties of postoperative pleural drainage fluids. They effectively killed gram-negative pathogens (Escherichia coli, Pseudomonas aeruginosa) as well as gram-positive pathogens (Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes). A variety of AMPs was detected at constantly high concentrations in the pleural fluids. They mainly derived from leukocytes and pleural epithelium. Although proinflammatory cytokine levels were elevated in the postoperative pleural fluids, AMP expression could not be augmented by Toll-like receptor (TLR) triggering or by the proinflammatory cytokines interleukin (IL)-1β and tumor necrosis factor (TNF)α.

CONCLUSIONS

We provide the first evidence of a high abundance of AMPs in postoperative pleural fluids. Our findings might explain the broad protection against infectious complications of the pleural space after major lung operations.

Chest tube tip culture as a predictor of postoperative infection in lung cancer operations

BACKGROUND

Postoperative infection is one of the most frequently observed complications after lung resection and should be addressed in perioperative management. This study evaluated the clinical significance of chest tube tip culture relevant to postoperative infection.

METHODS

From September 2002 to December 2011, 1,438 patients who underwent lung cancer operations in Shizuoka Cancer Center Hospital were evaluated. Postoperative infections, including surgical site infection, postoperative pneumonia, and postoperative empyema without fistula, were defined as those occurring within 30 days of thoracotomy.

RESULTS

Postoperative infections developed in 84 of the 1,438 patients (5.8%), including 42 (2.9%) with surgical site infection, 36 (2.5%) with pneumonia, and 13 (0.9%) with empyema. The sensitivity, specificity, and positive predictive value of chest tube tip culture were 23%, 98%, and 41.3%, respectively. Multivariate analysis demonstrated that the independent risk factors associated with the development of postoperative infections were coexisting diabetes mellitus and positive chest tube tip culture. Positive chest tube tip culture was the only independent risk factor associated with surgical site infection. The independent risk factors associated with postoperative pneumonia were age 70 years or older, coexisting diabetes mellitus, and positive chest tube tip culture. Finally, positive chest tube tip culture was the only independent risk factor associated with postoperative empyema.

CONCLUSIONS

Positive chest tube tip culture strongly predicts postoperative infections in lung cancer surgery and necessitates careful observation in the perioperative period.

Impact of previous gastrectomy on postoperative pneumonia after pulmonary resection in lung cancer patients

Postoperative pneumonia is a serious complication following pulmonary resection. Aspiration of oesophageal reflux contents is known to cause pulmonary complications in patients with a history of gastrectomy. In this study, we compared the incidence of postoperative pneumonia in patients with or without previous gastrectomy. A retrospective review was conducted of clinical charts for patients who underwent radical pulmonary resection for non-small cell lung cancer from January 2006 to December 2010. Pneumonia was diagnosed with chest computed tomography findings in all cases. A total of 333 patients underwent pulmonary resections during the study period. Twenty-seven patients (8.1%) had a history of gastrectomy. Eight patients (2.2%) had postoperative pneumonia. All eight patients who developed postoperative pneumonia did not have pneumonia before pulmonary resection. Of the aforementioned 27 patients, five (18.5%) developed pneumonia postoperatively, whereas only three of 325 patients who did not have a history of gastrectomy (0.9%) had pneumonia (P < 0.001). In multivariate analysis, a history of gastrectomy had the highest impact on the odds ratio (8.81) for postoperative pneumonia. A significantly higher incidence of postoperative pneumonia was found in patients with a history of gastrectomy. Prophylactic treatment, such as premedication with ranitidine, should be considered in those patients.

Molecular detection of microorganisms in distal airways of patients undergoing lung cancer surgery

BACKGROUND

Whereas proximal airways of patients undergoing lung cancer surgery are known to present specific microbiota incriminated in the occurrence of postoperative respiratory complications, little attention has been paid to distal airways and lung parenchyma considered to be free from bacteria. We have hypothesized that molecular culture-independent techniques applied to distal airways should allow identification of uncultured bacteria, virus, or emerging pathogens and predict the occurrence of postoperative respiratory complications.

METHODS

Microbiological assessments were obtained from the distal airways of resected lung specimens from a prospective cohort of patients undergoing major lung resections for cancer. Microorganisms were detected using real-time polymerase chain reaction (PCR) assays targeting the bacterial 16s ribosomal RNA gene and Herpesviridae, cytomegalovirus (CMV), and herpesvirus simplex. All postoperative microbiological assessments were compared with the PCR results.

RESULTS

In all, 240 samples from 87 patients were investigated. Colonizing agents were exclusively Herpesviridae (CMV, n=13, and herpesvirus simplex, n=1). All 16s ribosomal RNA PCR remained negative. Thirteen patients (15%) had a positive CMV PCR (positive-PCR group), whereas the remaining 74 patients constituted the negative-PCR group. Postoperative pneumonia occurred in 24% of the negative-PCR group and in 69% of the positive-PCR group (p=0.003). Upon stepwise logistic regression, performance status, percent of predicted diffusion lung capacity for carbon monoxide, and positive PCR were the risk factors of postoperative respiratory complications. The CMV PCR had a positive predictive value of 0.70 in prediction of respiratory complications.

CONCLUSIONS

When tested by molecular techniques, lung parenchyma and distal airways are free of bacteria, but CMV was found in a high proportion of the samples. Molecular CMV detection in distal airways should be seen as a reliable marker to identify patients at risk for postoperative respiratory complications.

Risk factors of postoperative pneumonia after lung cancer surgery

The purpose of this study was to investigate risk factors of postoperative pneumonia (POP) after lung cancer surgery. The 417 lung cancer patients who underwent surgical resection in a tertiary referral hospital were included. Clinical, radiological and laboratory data were reviewed retrospectively. Male and female ratio was 267:150 (median age, 65 yr). The incidence of POP was 6.2% (26 of 417) and in-hospital mortality was 27% among those patients. By univariate analysis, age ≥ 70 yr (P < 0.001), male sex (P = 0.002), ever-smoker (P < 0.001), anesthesia time ≥ 4.2 hr (P = 0.043), intraoperative red blood cells (RBC) transfusion (P = 0.004), presence of postoperative complications other than pneumonia (P = 0.020), forced expiratory volume in 1 second/forced vital capacity (FEV(1)/FVC) < 70% (P = 0.002), diffusing capacity of the lung for carbon monoxide < 80% predicted (P = 0.015) and preoperative levels of serum C-reactive protein ≥ 0.15 mg/dL (P = 0.001) were related with risk of POP. Multivariate analysis showed that age ≥ 70 yr (OR = 3.563, P = 0.014), intraoperative RBC transfusion (OR = 4.669, P = 0.033), the presence of postoperative complications other than pneumonia (OR = 3.032, P = 0.046), and FEV(1)/FVC < 70% (OR = 3.898, P = 0.011) were independent risk factors of POP. In conclusion, patients with advanced age, intraoperative RBC transfusion, postoperative complications other than pneumonia and a decreased FEV(1)/FVC ratio have a higher risk for pneumonia after lung cancer surgery.

[Infective complications in patients with lung cancer]

INTRODUCTION

This study was aimed at analyzing the site, kind and type of infection which develop in patients having lung cancer at hospital treatment.

MATERIAL AND METHODS

Clinical data of the patients hospitalized for lung cancer were analyzed at the Clinic for Lung Diseases and Tuberculosis in Knez Selo in the period from January 2002 till December 2007. A great number of patients (1296-75.9%) had non-small cell lung cancer. In 1708 patients with lung cancer, 773 febrile episodes were recorded, i.e. 687 states of infections.

RESULTS

Most of the infections were recorded in the tracheobronchial tree (60.9%). The infection was confirmed microbiologically in 38% of infectious states. Predominant Gram positive pathogens were Staphylococcus aureus and Streptococcus, but among Gram negative pathogens there were Escherichia coli and Haemophilus influenzae.

DISCUSSION

A significantly better therapy response to antibiotics was found in the group of patients where microbiological agents were isolated (p < 0.05). The predominant site of infection in the patients with lung cancer is the tracheobronchial tree without a significant difference between frequency of Gram positive and Gram negative pathogens.

[Incidence and characteristics of bronchial colonisation in patient with lung cancer: a retrospective study of 388 cases]

INTRODUCTION

Bronchial colonisation is frequently reported in patients with lung cancer. These colonisations could influence patient therapeutic management and prognosis. The aim of our study is refine incidence and nature of bronchial colonisations in patients presenting with lung cancer.

METHODS

Three hundred and eighty-eight patients with lung cancer underwent a flexible bronchoscopy at the time of diagnosis. Among them, 216 patients had a bacteriological, mycobacteriological and fungal investigation. Type and frequency of these colonisations were analyzed.

RESULTS

Potential pathogens were found in 39.8% of samples, including mainly 39.8% of Gram-negative bacilli (Haemophilus influenzae, Enterobacter sp., Escherichia coli). In addition, we found 0.9% of mycobacteria and 13.9% of Candida albicans. Among these 216 patients where microbiological analysis was performed, patient features and tumor stage were not significantly correlated to microbial colonisation.

CONCLUSIONS

Colonisation of airways is frequently reported when a lung cancer is diagnosed. Our data suggest that bronchial colonisation should be prospectively collected due to its potential interest in the management of lung cancer patients.

Risk Factors of Postoperative Respiratory Infections in Lung Cancer Surgery

BACKGROUND

Postoperative infections have been a major issue in lung cancer surgery. We changed our perioperative prophylactic antibiotic policy to a single dose of cefazolin before and after surgery in July 2002.

OBJECTIVE

To identify the risk factors of postoperative pneumonia and empyema in lung cancer patients undergoing surgical resection.

METHODS

From July 1992 through September 2003, 2105 patients underwent primary lung cancer resection at our division. We reviewed 1855 eligible patients for possible risk factors of pneumonia and empyema.

RESULTS

Postoperative respiratory infections developed in 69 (3.7%) patients. There were 58 (3.1%) pneumonia cases and 18 (1.0%) cases of empyema. The mortality rate was 0.8% (15 patients). Nine (0.5%) patients died from postoperative respiratory infections. Multivariate analysis showed age 75 years or older, forced expiratory volume in 1 second as a percentage of forced vital capacity (FEV1%) less than 70%, advanced pathologic stage, and induction therapy to be independent risk factors of pneumonia. For postoperative empyema, advanced age was the significant factor. Twelve of 18 patients (67%) with empyema were complicated with bronchopleural fistula. The infection incidence rate did not change significantly after we modified our prophylactic antibiotic policy to a single dose of cefazolin before and after surgery.

CONCLUSIONS

Lung cancer patients with advanced age, low FEV1%, advanced pathologic stage, or induction therapy had a risk for pneumonia after lung cancer surgery. Postoperative empyema was associated with advanced age.

Postoperative Pneumonia after Major Lung Resection

BACKGROUND

Postoperative pneumonia (POP) is a life-threatening complication of lung resection. The incidence, causative bacteria, predisposing factors, and outcome are poorly understood.

DESIGN

Prospective observational study.

METHODS

A prospective study of all patients undergoing major lung resections for noninfectious disease was performed over a 6-mo period. Culture of intraoperative bronchial aspirates was systematically performed. All patients with suspicion of pneumonia underwent bronchoscopic sampling and culture before antibiotherapy.

RESULTS

One hundred and sixty-eight patients were included in the study. Bronchial colonization was identified in 31 of 136 patients (22.8%) on analysis of intraoperative samples. The incidence of POP was 25% (42 of 168). Microbiologically documented and nondocumented pneumonias were recorded in 24 and 18 cases, respectively. Haemophilus species, Streptococcus species, and, to a much lesser extent, Pseudomonas and Serratia species were the most frequently identified pathogens. Among colonized and noncolonized patients, POP occurred in 15 of 31 and 20 of 105 cases, respectively (p = 0.0010; relative risk, 2.54). Death occurred in 8 of 42 patients who developed POP and in 3 of 126 of patients who did not (p = 0.0012). Patients with POP required noninvasive ventilation or reintubation more frequently than patients who did not develop POP (p < 0.0000001 and p = 0.00075, respectively). POP was associated with longer intensive care unit and hospital stay (p < 0.0000001 and p = 0.0000005, respectively). Multivariate analysis showed that chronic obstructive pulmonary disease, extent of resection, presence of intraoperative bronchial colonization, and male sex were independent risk factors for POP.

CONCLUSIONS

Pneumonia acquired in-hospital represents a relatively frequent complication of lung resections, associated with an important percentage of postoperative morbidity and mortality.