Ventilator-associated pneumonia: a comprehensive review

Spatial Patterns in Hospital-Acquired Infections in Portugal (2014-2017)

BACKGROUND

Hospital-Acquired Infections (HAIs) represent the most frequent adverse event associated with healthcare delivery and result in prolonged hospital stays and deaths worldwide.

AIM

To analyze the spatial patterns of HAI incidence from 2014 to 2017 in Portugal.

METHODS

Data from the Portuguese Discharge Hospital Register were used. We selected episodes of patients with no infection on admission and with any of the following HAI diagnoses: catheter-related bloodstream infections, intestinal infections by Clostridium difficile, nosocomial pneumonia, surgical site infections, and urinary tract infections. We calculated age-standardized hospitalization rates (ASHR) by place of patient residence. We used empirical Bayes estimators to smooth the ASHR. The Moran Index and Local Index of Spatial Autocorrelation (LISA) were calculated to identify spatial clusters.

RESULTS

A total of 318,218 HAIs were registered, with men accounting for 49.8% cases. The median length of stay (LOS) was 9.0 days, and 15.7% of patients died during the hospitalization. The peak of HAIs (n = 81,690) occurred in 2015, representing 9.4% of the total hospital admissions. Substantial spatial inequalities were observed, with the center region presenting three times the ASHR of the north. A slight decrease in ASHR was observed after 2015. Pneumonia was the most frequent HAI in all age groups.

CONCLUSION

The incidence of HAI is not randomly distributed in the space; clusters of high risk in the central region were seen over the entire study period. These findings may be useful to support healthcare policymakers and to promote a revision of infection control policies, providing insights for improved implementation.

Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study

PURPOSE

Prone positioning (PP) improves oxygenation and outcome of patients with acute respiratory distress syndrome undergoing invasive ventilation. We evaluated feasibility and efficacy of PP in awake, non-intubated, spontaneously breathing patients with hypoxemic acute respiratory failure (ARF).

MATERIAL AND METHODS

We retrospectively studied non-intubated subjects with hypoxemic ARF treated with PP from January 2009 to December 2014. Data were extracted from medical records. Arterial blood gas analyses, respiratory rate, and hemodynamics were retrieved 1 to 2 hours before pronation (step PRE), during PP (step PRONE), and 6 to 8 hours after resupination (step POST).

RESULTS

Fifteen non-intubated ARF patients underwent 43 PP procedures. Nine subjects were immunocompromised. Twelve subjects were discharged from hospital, while 3 died. Only 2 maneuvers were interrupted, owing to patient intolerance. No complications were documented. PP did not alter respiratory rate or hemodynamics. In the subset of procedures during which the same positive end expiratory pressure and Fio2 were utilized throughout the pronation cycle (n=18), PP improved oxygenation (Pao2/Fio2 124±50 mmHg, 187±72 mmHg, and 140±61 mmHg, during PRE, PRONE, and POST steps, respectively, P<.001), while pH and Paco2 were unchanged.

CONCLUSIONS

PP was feasible and improved oxygenation in non-intubated, spontaneously breathing patients with ARF.

Microbial profile of early and late onset ventilator associated pneumonia in the intensive care unit of a tertiary care hospital in bangalore, India

INTRODUCTION

Ventilator-associated pneumonia (VAP), an important form of hospital-acquired pneumonia (HAP), specifically refers to pneumonia developing in a patient on mechanical ventilator for more than 48 h after intubation or tracheostomy. Despite the advancements in antimicrobial regimes, VAP continues to be an important cause of morbidity and mortality. VAP requires a rapid diagnosis and initiation of appropriate antibiotic treatment, as there is adverse effect of inadequate antibiotic treatment on patients' prognosis and the emergence of multidrug-resistant (MDR) pathogens.

AIMS

The present study was undertaken to assess the etiological agents of early-onset and late-onset VAP and to know their sensitivity pattern.

MATERIAL AND METHODS

VAP data over a period of 12 months (February 2012 -February 2013) in a tertiary care ICU was retrospectively analysed. The patients were stratified by age, sex, duration of VAP (Early/Late onset) and the identified pathogens with their sensitivity pattern.

RESULTS

Incidence of VAP was found to be 35.14%, out of which 44.23% had early-onset (<4 days MV) VAP and 55.77% had late-onset (>4 days MV) VAP. The most common organisms isolated in early onset and late onset VAP was Pseudomonas aeruginosa, E.coli and Acinetobacter baumanii. All enterobacteriaceal isolates were extended spectrum beta lactamase (ESBL) producing organisms and all Staphylococcus aureus isolates except one were methicillin resistant. The incidence of Multidrug resistant (MDR) Pseudomonas aeruginosa and Acinetobacter were 40% and 37.5% respectively.

CONCLUSION

Due to the increasing incidence of multidrug-resistant organisms in our ICU, early and correct diagnosis of VAP is an urgent challenge for an optimal antibiotic treatment and cure. Hence, knowing the local microbial flora causing VAP and effective infection control practices are essential to improve clinical outcomes.

Antibiotic susceptibility and genotype patterns of Pseudomonas aeruginosa from mechanical ventilation-associated pneumonia in intensive care units

Pseudomonas aeruginosa (P. aeruginosa) is a leading cause of morbidity and mortality in patients with ventilation-associated pneumonia (VAP). It is difficult to treat this infection due to acquired resistance to various antibiotics. In order to understand the potential route of transmission, it is important to have detailed knowledge of the genotypes and antibiotic susceptibility of P. aeruginosa. The aim of this study was to determine antibiotic susceptibility using the broth microdilution minimum inhibitory concentration (MIC) method and to apply the Randomly Amplified Polymorphic DNA (RAPD) typing method for VAP caused by P. aeruginosa in 16 patients (8 men and 8 women; average age at inclusion, 67.8 years; range, 53-76 years). To determine antibiotic susceptibility, imipenem (IPM), cefepime (FEP) and meropenem (MEM) were administered for the treatment of P. aeruginosa, yielding an effectiveness of 75, 62.5, and 62.5%, respectively. According to the National Committee for Clinical Laboratory Standards (NCCLS) breakpoints, 8 (50%) of the 16 mechanical ventilation (MV) isolates were resistant to ceftazidime (CAZ) and pipenacillin (PIP). Amikacin (AK) and aztreonam (AZT) were not as effective against P. aeruginosa (75%). In addition, P. aeruginosa was completely resistant to ciprofloxacin (CIP). The MV isolates were susceptible to polymyxin B (PB). RAPD analysis revealed 12 genotypes for all the isolated P. aeruginosa, separated into 4 patterns. The results demonstrated a high incidence of P. aeruginosa isolated from VAP, with endogenous and cross infections being potential reasons for P. aeruginosa isolated from VAP in the intensive care units.