Nosocomial infections in the intensive care unit: Incidence, risk factors, outcome and associated pathogens in a public tertiary teaching hospital of Eastern India

High Prevalence of Multidrug-Resistant Bacteria in the Trachea of Intensive Care Units Admitted Patients: Evidence from a Bangladeshi Hospital

Recent research has shown that antibiotic-resistant microorganisms are becoming more prevalent in intensive care units (ICUs) at an exponential rate. Patients in the ICU can get infected by pathogens due to invasive operation procedures and critical health conditions. This study primarily emphasized tracheal samples from ICU patients due to their reliance on ventilators, increasing their susceptibility to Ventilator-Associated Pneumonia (VAP). Moreover, the rise of multidrug-resistant (MDR) pathogens makes treatment strategies more challenging for these patients. In this study, we tested 200 tracheal specimens to determine the prevalence of microorganisms and analyzed the antibiotic susceptibility of these isolates against regular antibiotics, including 4th generation drugs. Among the 273 isolates, 81% were gram-negative bacteria, 10% were gram-positive bacteria, and 9% were fungi. The most prevalent gram-negative bacteria were Acinetobacter spp. (34%), Klebsiella spp. (22%), Pseudomonas spp. (14%), and Escherichia coli (9.2%). The most prevalent gram-positive bacteria were Staphylococcus aureus (5.9%), and the fungi were Candida spp. (7.3%). Among the most prevalent bacteria, except Staphylococcus aureus isolates, around 90% were resistant to multiple drugs, whereas 60% of Acinetobacter spp. and Pseudomonas spp. were extensively drug resistant. Sensitivity analysis against the gram-negative and gram-positive drug panel using a one-way ANOVA test followed by Tukey's post hoc test showed that in the in vitro assay, colistin was the most effective antibiotic against all gram-negative bacteria. In contrast, linezolid, vancomycin, and fusidic acid were most effective against all gram-positive bacteria. Regular monitoring of nosocomial infections and safe management of highly resistant bacteria can help prevent future pandemics.

Retrospective Analysis of Hospital Acquired Infection and Antibiotic Resistance in Coronary Care Unit (CCU), Adult, and Pediatric Cardiology Wards

BACKGROUND

Antibiotics resistance is an paramount threat affecting the whole world but nowhere situation is as gloomy as in India. No study till date regarding epidemiology of hospital acquired infections in coronary care units(CCU) and cardiology wards from India. From Indian perspective it is the first observational study to analyse microbiological profile and antibiotic resistance in CCU. The purpose of this observational study is to explore the epidemiology and importance of infections in CCU patients.

METHODOLOGY

After ethics committee approval, the records of all patients who were admitted in coronary care units, adult and pediatric cardiology wards surgery between January 2020 and December 2021 were reviewed retrospectively. The type of organism,source of infection ,age wise distribution and seasonal variability among patients who developed hospital acquired infection (HAI) were determined.

RESULTS

271 patients developed microbiologically documented HAI during from January 2020 to December 2021. Maximum number of organisms(78/271 28.78%) are isolated from urinary samples ,followed by blood stream(60/271 22.14%) and Endotracheal tube (54/271 19.92%). Acinetobacter baumanii (53/271, 19.5%) being the most common isolate among all the samples taken . Acinetobacter was the most frequent pathogens isolated in patients with LRTI and blood stream infection while E. coli was from urinary tract infection . In the adult population, infection with E. coli(24.6%) is the most common followed by Klebsiella pneumoniae (12.8%) and Acinetobacter baumanii (10.1%). In the pediatric population Acinetobacter baumanii (38.6%%) is the most common followed by Klebsiella pneumoniae (20.5%) and Methicillin Resistant Staphylococcus aureus, MRSA (6.8%). Commonly used antibiotics eg ciprofloxacin,ceftazidime and amikacin were found to be resistant against the top three isolates.

CONCLUSION

Urinary tract was the most common site of infection and Gram-negative bacilli, the most common pathogens in adult as well as pediatric population. Antibiotic resistance was maximum with commonly isolated microorganisms.

Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis

OBJECTIVES

To assess the indications, timing, and clinical outcomes that result from the early tracheostomy (ET) administration, by causal inference models.

DESIGN

A retrospective observational study.

SETTING

Multiinstitutional intensive care unit in the United States PARTICIPANTS: The study comprised 626 trauma patients.

INTERVENTIONS

An ET versus late tracheostomy (LT).

MEASUREMENTS AND MAIN RESULTS

Trauma patients with tracheostomy were identified from 2 public databases named Medical Information Mart for the Intensive Care-IV and eICU Collaborative Research Database. Tracheostomy was defined as early (≤7 days) or late (>7 days) from intensive care unit admission. A marginal structural Cox model (MSCM) with inverse probability weighting was employed. For comparison, the authors also used time-dependent propensity-score matching (PSM) to account for differences in the probability of receiving an ET or LT. A total of 626 eligible patients were enrolled in the study, of whom 321 (51%) received a ET. The MSCM and time-dependent PSM indicated that the ET group was associated with reduced ventilation-associated pneumonia (VAP) and a shorter mechanical ventilation (MV) duration than the LT group. Yet, mortality did not show any difference between the two groups.

CONCLUSIONS

The authors' study observed that ET was not associated with reduced mortality in trauma patients, but it was associated with reduced VAP risk and MV duration. The results warrant further validation in randomized controlled trials.

Nosocomial infections in the surgical intensive care unit: an observational retrospective study from a large tertiary hospital in Palestine

BACKGROUND

Nosocomial infections or hospital-acquired infections are a growing public health threat that increases patient morbidity and mortality. Patients at the highest risk are those in intensive care units. Therefore, our objective was to provide a pattern analysis of nosocomial infections that occurred in an adult surgical intensive care unit (ICU).

METHODS

This study was a retrospective observational study conducted in a 6-bed surgical intensive care unit (SICU) at An-Najah National University Hospital (NNUH) to detect the incidence of nosocomial infections from January 2020 until December 2021. The study group included 157 patients who received antibiotics during their stay in the SICU.

RESULTS

The incidence of nosocomial infections, either suspected or confirmed, in the SICU was 26.9% (95 out of 352 admitted patients). Pneumonia (36.8%) followed by skin and soft tissue infections (35.8%) were the most common causes. The most common causative microorganisms were in the following order: Pseudomonas aeruginosa (26.3%), Acinetobacter baumannii (25.3%), extended-spectrum beta lactamase (ESBL)-Escherichia coli (23.2%) and Klebsiella pneumonia (15.8%). The average hospital stay of patients with nosocomial infections in the SICU was 18.5 days.

CONCLUSIONS

The incidence of nosocomial infections is progressively increasing despite the current infection control measures, which accounts for an increased mortality rate among critically ill patients. The findings of this study may be beneficial in raising awareness to implement new strategies for the surveillance and prevention of hospital-acquired infections in Palestinian hospitals and health care centers.

A Two-Year Surveillance of Central Line-Associated Bloodstream Infections in the Trauma ICU of a Tertiary Care Hospital in India

Aim The aim of the study is to identify the risk factors and mortality associated with central line-associated bloodstream infection (CLABSI) and to investigate the incidence and associated etiology in trauma patients admitted to the trauma ICU (TICU) of a tertiary care teaching hospital in Northern India. Materials and methods The study was a prospective study conducted in the trauma ICU of a tertiary care teaching hospital in India from November 2020 to October 2022. Adult patients >18 years of age who were on central line for >48 hours were included in the study. The automated blood culture system BacT/ALERT 3D (bioMérieux, Durham, NC) was used for microbial detection from blood samples. We recorded patients' daily progress, and catheter-related data was collected and used as variables. All the data was analyzed using the Statistical Package for Social Sciences (SPSS) version 22.0 (IBM SPSS Statistics, Armonk, NY) to evaluate the risk factors associated with CLABSI. Result A total of 516 admissions occurred during the surveillance period, out of which 352 patients fulfilled the inclusion criteria and were enrolled in the study. Out of these 352 patients, a total of 74 patients developed central line-associated bloodstream infection (CLABSI). Thus, the incidence of CLABSI was 16.4 per 1000 central line days and 13.2 per 1000 inpatient days with a 0.8 device utilization ratio (DUR). The most common organisms isolated from these CLABSI cases were Acinetobacter species (23%), followed by Escherichia coli (16.5%) and Staphylococcus aureus (15.6%). The independent healthcare-associated risk factors for CLABSI were longer length of ICU stay and prolonged duration of central venous catheterization. The most common comorbidity associated with CLABSI was diabetes mellitus (20.3%), followed by hypertension (14.8%), and the mortality rate was 41.9%. Conclusion The healthcare-associated risk factors such as longer length of ICU stay and prolonged duration of central venous catheterization are the risk factors for developing central line-associated bloodstream infections (BSI).

Incidence of Central Line-Associated Bloodstream Infection in a Tertiary Care Hospital in Northern India: A Prospective Study

Background Central line-associated bloodstream infection is the most common hospital-acquired infection and is associated with high morbidity and mortality along with increased healthcare cost. However, studies on the incidence of nosocomial infections are very limited in India. Aims To determine the incidence of central line-associate bloodstream infection (CLABSI), microorganisms associated and their antimicrobial sensitivity profile in the medical ICU of a tertiary care hospital. Material and methods A total of 186 patients who were admitted to the medical ICU and had a non-tunneled central venous catheter (CVC) implanted at admission in the emergency department or in the medical ICU for longer than 48 hours were monitored. By examining the blood culture reports, the patients were monitored every day for the emergence of new-onset sepsis after 48 hours following CVC insertion. The data were evaluated statistically using Microsoft Excel and SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Result Out of 186 catheterized patients, 37 developed CLABSI. The incidence of CLABSI was 9.3 per 1000 catheter days and 6.7 per 1000 inpatient days with a 0.7 device utilization ratio. The most common organism isolated was Acinetobacter species (22%) followed by K. pneumoniae (16%) and E. aerogenes (16%). The highest sensitivity was displayed by polymyxin B (100%) followed by tigecycline (85.48%) and minocycline (50.82%) in Gram-negative organisms. In Gram-positive organisms, the highest sensitivity was observed in S. aureus (100%) for vancomycin, linezolid and teicoplanin whereas Enterococcus species showed linezolid (100%) followed by vancomycin (93.75%) and teicoplanin (93.75%). Conclusion The prevention of CLABSI requires knowledge of the infection rates and of the sources, the pathogens involved as well as their antimicrobial profile. Due to rising antimicrobial resistance, surveillance programs are crucial in establishing the species distribution and resistance patterns of bacteria causing BSIs and thus providing the basis for appropriate empirical therapy.

Health care associated infections, antimicrobial resistance and outcomes in patients admitted to intensive care unit, India: A five-Year retrospective cohort study

Background

The present study was conducted to study the prevalence of HAIs in a newly established MICU, common microorganisms causing HAIs and their antibiotic-sensitivity profile, and antimicrobial utilization and mortality rate.

Methods

The present retrospective cohort study was carried out at AIIMS, Bhopal (2015-2019). The prevalence of HAIs was determined; sites of HAIs and common causative microorganisms were identified, and their antibiotic-sensitivity profiles were studied. The group of patients with HAIs was matched with a control group drawn from the pool of patients without HAIs; this matching was done with respect to age, gender, and clinical diagnosis. Antimicrobial utilization, Period of ICU stay, comorbidities and patient mortality rates in the two groups were analyzed. The clinical criteria by the CDC- National Nosocomial Infections Surveillance to diagnose HAIs.

Results

A total of 281 ICU patients' records were analyzed. The mean age was 47.21 ± 19.07 years. Of these 89 were found to have developed ICU-acquired HAIs (Prevalance:32%). Bloodstream infections (33%) and respiratory tract infections (30.68%), catheter-associated urinary tract infections (25.56%), and surgical site infections (6.76%) were the commonest. The most frequently isolated microorganism causing HAIs was K. pneumonia (18%), A. baumannii (14%) and E. coli (12%), 31% isolates of which were multidrug resistant. The average length of ICU stay was high in patients with HAIs (13.85 vs 8.2 days). The most common co-morbidity was type 2 diabetes mellitus (42.86%). Prolonged ICU stays [OR 1.13, (95% CI; 0.04-0.10)] and the presence of HAIs [OR 1.18(95%CI; (0.03-0.15)] were associated with an increased risk of mortality.

Conclusions

An increased prevalence of HAIs essentially bloodstream infections and respiratory infections with MDR organisms to antimicrobials in the watch group is highly considerable. Acquisition of HAIs with MDR organisms and increased length of hospital stay are considerable risk factors for increased mortality in ICU-admitted patients. Regular antimicrobial stewardship activities and revising existing hospital infection control policies accordingly may reduce HAIs.

Bacteria in the oral cavity of individuals consuming intoxicating substances

Food habits and oral hygiene are critical attributes for physiochemical environment of the oral cavity. Consumption of intoxicating substances such as betel nut ('Tamul'), alcohol, smoking and chewing tobacco may strongly influence the oral ecosystem including commensal microbes. Therefore, a comparative assessment of microbes in the oral cavity between individuals consuming intoxicating substances and non-consumers may indicate the influence of these substances. Oral swabs were collected from consumers of intoxicating substances and non- consumers of Assam, India, microbes were isolated by culturing on Nutrient agar and identified by phylogenetic analysis of their 16S rRNA gene sequences. The risks of consumption of intoxicating substance on occurrence of microbes and health conditions were estimated using binary logistic regression. Mostly pathogens and opportunistic pathogens were found in the oral cavity of consumers and oral cancer patients which included Pseudomonas aeruginosa, Serratia marcescens, Rhodococcus antrifimi, Paenibacillus dendritiformis, Bacillus cereus, Staphylococcus carnosus, Klebsiella michiganensis and Pseudomonas cedrina. Enterobacter hormaechei was found in the oral cavity of cancer patients but not in other cases. Pseudomonas sp. were found to be widely distributed. The risk of occurrence of these organisms were found in between 0.01 and 2.963 odds and health conditions between 0.088 and 10.148 odds on exposure to different intoxicating substances. When exposed to microbes, the risk of varying health conditions ranged between 0.108 and 2.306 odds. Chewing tobacco showed a higher risk for oral cancer (10.148 odds). Prolonged exposure to intoxicating substances conduce a favorable environment for the pathogens and opportunistic pathogens to colonize in the oral cavity of individuals consuming intoxicating substances.

Knowledge, Attitude, and Practice (KAP) Survey on the Management of Multidrug-Resistant Gram-Negative Infections With Innovative Antibiotics: Focus on Ceftazidime-Avibactam

BACKGROUND

Antimicrobial resistance (AMR) is a major public health dilemma and a chief health concern globally. The rising incidence of resistance against carbapenems, which are considered most effective against gram-negative bacteria, has added to the concern and has limited the number of available treatment options. Newer antibiotic options may be required to tackle the mounting concern of antibiotic resistance. However, only a few antimicrobials are in the pipeline for managing infections instigated by multidrug-resistant (MDR) gram-negative bacteria. This justifies the prudent application of already available antibiotics. Among newer antibiotics available to healthcare professionals (HCPs), ceftazidime-avibactam (CAZ-AVI) has shown good efficacy in the management of MDR gram-negative infections.

METHOD

A cross-sectional survey on the knowledge, attitude, and practices (KAP) among HCPs was carried out using a questionnaire comprising 21 parameters related to AMR patterns on the need for innovative antibiotics to manage MDR gram-negative infections and the usage of CAZ-AVI by HCPs while managing such infections. The KAP scores were calculated to rank respondents' KAP levels.

RESULT

Out of the 204 study respondents, the majority (~80%) (n=160) believed that renewed efforts should be made to seek antimicrobial agents that will add to the armamentarium of treatment options for MDR gram-negative infections. CAZ-AVI is an important treatment alternative for managing MDR gram-negative infections (n=90, 45%). Further, it can be the first choice of definitive therapy for oxacillinases (OXA)-48-producing carbapenem-resistant Enterobacterales (n=84, 42%). HCPs also believed that the use of CAZ-AVI in clinical practice will require high levels of antimicrobial stewardship (n=100, 49%).

CONCLUSION

Novel and innovative antibiotics are the need of the hour in the management of MDR gram-negative infections. CAZ-AVI has established its effectiveness in treating these infections; however, the molecule must be utilized prudently while keeping stewardship principles in mind.

Current Trends in Antimicrobial Resistance Patterns in Bacterial Pathogens among Adult and Pediatric Patients in the Intensive Care Unit in a Tertiary Care Hospital in Kolkata, India

Nosocomial infections by multidrug-resistant (MDR) bacteria are among the main causes of morbidity and death in patients hospitalized in intensive care units (ICUs) worldwide. Antibiotic resistance has become a major concern for treating the patients with nosocomial infections. The aim of this study was to describe the antibiotic resistance patterns of pathogens causing infections in adult and pediatric patients in the ICUs of a tertiary care hospital in Kolkata, India. A cross-sectional, retrospective study was conducted from January 2022 to October 2022 on a total of 139 adult and 146 pediatric patients. Depending on clinical symptoms of the patients, samples were collected and subjected to antibiotic sensitivity testing. The culture and sensitivity pattern of clinical isolates from blood, urine, sputum, endotracheal tube (ET) aspirate, and central line catheter insertion site swabs were analyzed. A total of 695 and 556 specimens were obtained from adult and pediatric ICU, respectively. Culture positivity rate among adults and pediatric patients were 37% and 40%, respectively. The most commonly isolated organisms were Gram-negative Enterobacterales and non-fermenters. Most of the bacterial isolates showed very high resistance against multiple antibiotics. Escherichia coli from adult and pediatricpatients were found to be resistant to second generation cephalosporins (95% and 96%, respectively), beta-lactams (95% and 63%, respectively), fluoroquinolones (95% and 81%, respectively), and cotrimoxazole (85% and 78%, respectively). Klebsiella spp. from adult patients were found to be resistant to aminoglycosides (75%), second generation cephalosporins (100%), beta-lactams (94%), fluoroquinolones (92%), carbapenems (88%), and cotrimoxazole (83%). Proteus spp., Acinetobacter baumannii, and Pseudomonas spp. werefound to be resistant to multiple antibiotics. Enterococcus spp. from ICUs showed more than 90% resistance against ampicillin and more than 75% resistance against fluoroquinolones. MDR bacterial infections are increasing in both adult and pediatric ICUs, leading to significant therapeutic challenges. A frequent study of antimicrobial resistance patterns is imperative for antibiotic stewardshipin combatting the deadly effect of the MDR bacteria in critically ill patients.

Pathogen Burden Among ICU Patients in a Tertiary Care Hospital in Hail Saudi Arabia with Particular Reference to β-Lactamases Profile

Purpose

Ventilator-associated pneumonia (VAP) is associated with a higher mortality risk for critical patients in the intensive care unit (ICU). Several strategies, including using β-lactam antibiotics, have been employed to prevent VAP in the ICU. However, the lack of a gold-standard method for VAP diagnosis and a rise in antibiotic-resistant microorganisms have posed challenges in managing VAP. The present study is designed to identify, characterize, and perform antimicrobial susceptibility of the microorganisms from different clinical types of infections in ICU patients with emphasis on VAP patients to understand the frequency of the latter, among others.

Patients and Methods

A 1-year prospective study was carried out on patients in the ICU unit at a tertiary care hospital, Hail, Saudi Arabia.

Results

A total of 591 clinically suspected hospital-acquired infections (HAI) were investigated, and a total of 163 bacterial isolates were obtained from different clinical specimens with a high proportion of bacteria found associated with VAP (70, 43%), followed by CAUTI (39, 24%), CLABSI (25, 15%), and SSI (14, 8.6%). Klebsiella pneumoniae was the most common isolate 39 (24%), followed by Acinetobacter baumannii 35 (21.5%), Pseudomonas aeruginosa 25 (15.3%), and Proteus spp 23 (14%). Among the highly prevalent bacterial isolates, extended-spectrum beta-lactamase was predominant 42 (42.4%).

Conclusion

Proper use of antibiotics, continuous monitoring of drug sensitivity patterns, and taking all precautionary measures to prevent beta-lactamase-producing organisms in clinical settings are crucial and significant factors in fending off life-threatening infections for a better outcome.

Risk Factors for Candidemia in Intensive Care Unit: A Matched Case Control Study from North-Western India

Candidemia is one of the significant causes of mortality amongst critically ill patients in Intensive Care Units (ICUs). This study aimed to assess the incidence, risk factors and antifungal susceptibility pattern in candidemia cases admitted in ICU in a tertiary care hospital in Jaipur, Rajasthan from June 2021 to November 2021. Candida species isolated from blood culture of clinically suspected patients of sepsis were defined as candidemia cases. Blood culture and antifungal susceptibility testing were performed as per standard laboratory protocol. Analyses of risk factors was done between candidemia cases and matched controls in a ratio of 1 : 3. Forty-six candidemic cases and 150 matched controls were included in the study. C. tropicalis was the most prevalent species (22/46; 48%) followed by C. auris (8/46; 17%) and C. albicans (7/46; 15%). Candida species showed good sensitivity to echinocandins (97%) followed by amphotericin B (87%) and voriconazole (80%). In multivariate analysis, longer stay in ICU, presence of an indwelling device, use of immunosuppressive drugs and positive SARS-CoV-2 infection were associated with increased risk of candidemia. The constant evaluation of risk factors is required as prediction of risks associated with candidemia may help to guide targeted preventive measures with reduced morbidity and mortality.

Severe Clinical Outcomes Among Adults Hospitalized With Respiratory Syncytial Virus Infections, New York City, 2017-2019

OBJECTIVES

Respiratory syncytial virus (RSV) causes substantial morbidity and mortality in older adults. We assessed severe clinical outcomes among hospitalized adults that were associated with RSV infections.

METHODS

We performed a nested retrospective study in 3 New York City hospitals during 2 respiratory viral seasons, October 2017-April 2018 and October 2018-April 2019, to determine the proportion of patients with laboratory-confirmed RSV infection who experienced severe outcomes defined as intensive care unit (ICU) admission, mechanical ventilation, and/or death. We assessed factors associated with these severe outcomes and explored the effect of RSV-associated hospitalizations on changes in the living situations of surviving patients.

RESULTS

Of the 403 patients studied (median age, 69 years), 119 (29.5%) were aged ≥80. Severe outcomes occurred in 19.1% of patients, including ICU admissions (16.4%), mechanical ventilation (12.4%), and/or death (6.7%). Patients admitted from residential living facilities had a 4.43 times higher likelihood of severe RSV infection compared with patients who were living in the community with or without assistance from family or home health aides. At discharge, 56 (15.1%) patients required a higher level of care than at admission.

CONCLUSIONS

RSV infection was associated with severe outcomes in adults. Living in a residential facility at admission was a risk factor for severe outcomes and could be a proxy for frailty rather than an independent risk factor. Our data support the development of prevention strategies for RSV infection in older populations, especially older adults living in residential living facilities.

Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies

Patients in intensive care units (ICUs) are at high risk for healthcare-acquired infections (HAI) due to the high prevalence of invasive procedures and devices, induced immunosuppression, comorbidity, frailty and increased age. Over the past decade we have seen a successful reduction in the incidence of HAI related to invasive procedures and devices. However, the rate of ICU-acquired infections remains high. Within this context, the ongoing emergence of new pathogens, further complicates treatment and threatens patient outcomes. Additionally, the SARS-CoV-2 (COVID-19) pandemic highlighted the challenge that an emerging pathogen provides in adapting prevention measures regarding both the risk of exposure to caregivers and the need to maintain quality of care. ICU nurses hold a special place in the prevention and management of HAI as they are involved in basic hygienic care, steering and implementing quality improvement initiatives, correct microbiological sampling, and aspects antibiotic stewardship. The emergence of more sensitive microbiological techniques and our increased knowledge about interactions between critically ill patients and their microbiota are leading us to rethink how we define HAIs and best strategies to diagnose, treat and prevent these infections in the ICU. This multidisciplinary expert review, focused on the ICU setting, will summarise the recent epidemiology of ICU-HAI, discuss the place of modern microbiological techniques in their diagnosis, review operational and epidemiological definitions and redefine the place of several controversial preventive measures including antimicrobial-impregnated medical devices, chlorhexidine-impregnated washcloths, catheter dressings and chlorhexidine-based mouthwashes. Finally, general guidance is suggested that may reduce HAI incidence and especially outbreaks in ICUs.

Candidemia Among ICU Patients: Species Characterisation, Resistance Pattern and Association With Candida Score: A Prospective Study

Introduction

Candidiasis is a significant cause of morbidity and mortality in immunocompromised patients admitted in intensive care units. Identification of Candida species is essential for effective treatment. However, in absence of proven fungemia, guidelines to initiate therapy are yet to be defined.

Materials and methods

During the study (16 months: September 2018 to December 2019), samples (urine, sputum, blood, tracheal aspirate, urinary catheter) were collected from ICU patients and prospectively evaluated. Microscopy, culture, and antifungal susceptibility testing were performed as per standard laboratory protocol. Demographic details and risk factors were noted from case records and correlated with Candida score.

Results

One hundred twenty-five non-duplicate samples (120 patients) positive on culture were included in the study. The most common co-morbid condition associated with fungemia was diabetes mellitus. The most common risk factor was total parenteral nutrition. Non-albicansCandida(C. tropicalis) was predominant. Candida species showed good sensitivity to voriconazole (80%) followed by fluconazole (67.78%) and amphotericin (62.22%). Twenty-nine patients had a Candida score of more than three.

Conclusion

Fluconazole available in both oral and parenteral formulations is an effective antifungal agent against the candida spp. Voriconazole should be reserved for non-responders. Rising resistance to common antifungals among Candida albicans is a matter of concern.

Pulmonary tuberculosis in intensive care setting, with a focus on the use of severity scores, a multinational collaborative systematic review

Background and aim

Tuberculosis (TB) is associated with a high mortality in the intensive care unit (ICU), especially in subjects with Acute Respiratory Distress Syndrome (ARDS) requiring mechanical ventilation. Despite its global burden on morbidity and mortality, TB is an uncommon cause of ICU admission, however mortality is disproportionate to the advances in diagnosis and treatment made. Herein we report a systematic review of published studies.

Methods

Our Literature search was conducted to identify studies on outcomes of individuals with TB admitted to ICU. We report and review in-hospital mortality, predictors of poorer outcomes, usefulness of severity scoring systems and potential benefits of intravenous antibiotics. Searches from Pubmed, Embase, Cochrane and Medline were conducted from inception to March 2020. Only literature in English was included.

Results

Out of 529 potentially relevant articles, 17 were included. Mortality across all studies ranged from 29-95% with an average of 52.9%. All severity scores underestimated average mortality. The most common indication for ICU admission was acute respiratory failure (36.3%). Negative predictors of outcome included hospital acquired infections, need of mechanical ventilation and vasopressors, delay in initiation of anti-TB treatment, more than one organ failure and a higher severity score. Low income, high incidence countries showed a 23.4% higher mortality rate compared to high income, low TB incidence countries.

Conclusion

Mortality in individuals with TB admitted to ICU is high. Earlier detection and treatment initiation is needed.

Nosocomial infections in an Iranian educational hospital: an evaluation study of the Iranian nosocomial infection surveillance system

Background

Nosocomial infection (NI) or cross-infection is a major health problem in hospitals worldwide.

Aim

This study aimed to report the status of NIs and to evaluate the Iranian nosocomial infection surveillance system (INISS) in a teaching hospital in the south of Iran.

Methods

This is a comparative historical study on the records of hospital admitted patients from 2018 to 2019. Data on patients who were diagnosed with NI was extracted from the INISS database. The database includes data on the incidence of different types of NIs in each hospital ward, the patient’s infection outcome, the agents involved, and the site of infection.

Results

The results indicated that the rate of NI (cases of NI/ 100 admissions) in the hospital was %2.95. The highest rate of NIs was reported from ICUs. Of the infected patients, 45.61% were female, 98.95% had underlying diseases, and 30.88% died due to nosocomial infections. The median (IQR) of the duration of hospital stay among infected patients was 13 (7–18). The most common site of infection was VAE (ventilator-associated events) (39.40%) and the most common isolated agent, irrespective of the organ involved, was Acinetobacter (spp.) (22.75%).

Conclusions

We reported ICU and Acinetobacter (spp.) as the most affected ward and most common agent involved in recorded NIs respectively. The rate of NI in the study hospital was exceptionally low when compared to its counterparts in a few other developed countries. The INISS needs to be further evaluated with regard to the completeness and representativeness of the surveillance system. Also, we need to evaluate the adherence to the INISS guidelines among staff and physicians in reporting the NIs.

Bacteriological Profile in Septicaemic Patients with Elevated C-reactive Protein in Intensive Care Units at A Tertiary Care Hospital

Sepsis, the second leading cause of death is due to infections. Intensive care units (ICUs) are having the highest burden of treating the patients with sepsis and nosocomial infections compared to other areas of hospitals. Our objective was to identify the bacteriological profile and their antibiogram of sepsis cases in all ICUs. A sum of 102 blood samples were collected from patients with clinically suspected sepsis with elevated CRP. Processed by an automated method using Bact/Alert & growth were identified by Standard guidelines. Out of 102 samples, 54 (53%) were shown positive by culture. Gram-negative bacilli were the predominant and their number were 33 (61.1% ) and the commonest organisms were from the Enterobacteriaceae family. Escherichia coli was the highest number with 15 (27.7%) followed by Klebsiella pneumoniae 10 (18.51%), & the rest were single isolates of Salmonella typhi, Proteus mirabilis and Citrobacter koseri. Nonfermenter isolated were Acinetobacter baumanii 3 (5.6%), Pseudomonas aeruginosa 2 (3.7%). The Gram-positive cocci were 17 & 32.4% of culture positivity. Coagulase-negative Staphylococcus was the highest isolated accounting for 9 (16.6%) followed by Staphylococcus aureus 6 (11.1%) and Enterococcus faecalis (3.7%). Culture positivity will be more when CRP is also included in the selection of samples for sepsis and Gram-negative bacilli are the leading cause in septicemia and organisms belonging to the Enterobacteriaceae family still dominate in septicemia infections in ICUs and a real challenge for treatment are MDRs which needs to be detected regularly by using screening tests.

Analysis of Medical Consultation Patterns in Medical and Surgical Intensive Care Units: Changes in the Pattern of Consultation after the Implementation of Intensivist-Directed Care

Purpose: Critically ill patients often require multidisciplinary treatment for both acute illnesses and pre-existing medical conditions. Since different medical conditions are managed in the intensive care unit (ICU), consultation is often required. This study aimed to identify the frequency and type of consultation required and analyze changes in consultation patterns after the introduction of intensivist-directed care in the surgical ICU (SICU).Methods: Between June 2006 and December 2013, a retrospective cohort study was conducted to identify the frequency and type of consultation at 3 different ICUs. Consultations for patients who were admitted to the ICUs for more than 48 consecutive hours were included. The pattern of consultations in each ICU was investigated. In addition, the pattern of consultations before and after the implementation of intensivist-directed care in the SICU was compared.Results: During the study, 11,053 consultations were requested for 7,774 critically ill patients in a total of 3 ICUs. Consultations with the Departments of Cardiology, Infectious Diseases, and Pulmonology were requested most frequently in the SICU. However, after the implementation of the intensivist-directed care approach, there was an increase in the frequency of consultation requests to the Department of Neurology, followed by the Departments of Cardiology, and Infectious Diseases.Conclusion: Analysis of consultation patterns is an important method of assessing the complexity and severity of illnesses, and of evaluating the needs of available health system resources. Based on our findings, we suggest the development of an appropriate protocol for frequently consulted services.

Improving the Efficacy of Antimicrobials against Biofilm-Embedded Bacteria Using Bovine Hyaluronidase Azoximer (Longidaza®)

While in a biofilm, bacteria are extremely resistant to both antimicrobials and the immune system, leading to the development of chronic infection. Here, we show that bovine hyaluronidase fused with a copolymer of 1,4-ethylenepiperazine N-oxide and (N-carboxymethyl) -1,4-ethylenepiperazinium bromide (Longidaza®) destroys both mono- and dual-species biofilms formed by various bacteria. After 4 h of treatment with 750 units of the enzyme, the residual biofilms of Staphylococcus aureus, Enterococcus faecalis, Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumoniae preserved about 50-70% of their initial mass. Biomasses of dual-species biofilms formed by S. aureus and the four latter species were reduced 1.5-fold after 24 h treatment, while the significant destruction of S. aureus-P. aeruginosa and S. aureus-K. pneumoniae was also observed after 4 h of treatment with Longidaza®. Furthermore, when applied in combination, Longidaza® increased the efficacy of various antimicrobials against biofilm-embedded bacteria, although with various increase-factor values depending on both the bacterial species and antimicrobials chosen. Taken together, our data indicate that Longidaza® destroys the biofilm structure, facilitating the penetration of antimicrobials through the biofilm, and in this way improving their efficacy, lowering the required dose and thus also potentially reducing the associated side effects.

The burden and characteristics of nosocomial infections in an intensive care unit: A cross-sectional study of clinical and nonclinical samples at a tertiary hospital of Nepal

Background

Patients at intensive care units (ICUs) are vulnerable to acquiring nosocomial infections. The main objective of this study was to explore and characterize the burden of nosocomial infections from an ICU of National Medical College and Teaching Hospital (NMCTH), Birgunj, Nepal.

Methods

A prospective hospital-based study was conducted between April and December 2018 at NMCTH, Birgunj, Province 2, of Nepal. A total of 374 specimens including clinical specimens (n = 190) from patients admitted in an ICU and animate and inanimate environmental samples (n = 184) from the ICU were collected. Collected specimens were cultured in specific microbiological media, and microbial isolates were identified and subjected to antibiotic susceptibility test.

Results

Altogether, 374 specimens (190 clinical specimens and 184 nonclinical) of an ICU were analyzed. Out of 190 clinical specimens, 51% (97/190) showed bacterial growth. Isolated bacteria were Staphylococcus aureus (33%; 32/97), Escherichia coli (20.6%; 20/97), Klebsiella spp. (15.5%; 15/97), Pseudomonas spp. (11.3%; 11/97), and Acinetobacter spp. (11.3%; 11/97). Out of 184 nonclinical specimens, 51.6% (95/184) of the samples showed microbial growth. Among the isolates, Klebsiella spp. predominated (30.6%; 26/85) the growth, followed by S. aureus (22.4%; 19/85), Acinetobacter spp. (21.2%; 18/85), and Pseudomonas spp. (17.6%; 15/85). Among all clinical and nonclinical isolates, 61.9% (60/97) of the clinical specimens and 65.9% (56/85) of the nonclinical specimens showed multidrug resistance (MDR).

Conclusion

Two-thirds of the specimens from both clinical and nonclinical specimens showed MDR. Urgent actions are required to address the augmented rate of nosocomial infections and MDR bacteria among ICUs in Nepal.

Antibiotics' susceptibility patterns of bacterial isolates causing lower respiratory tract infections in ICU patients at referral hospitals in Namibia

BACKGROUND

Lower respiratory tract infections (LRTIs) are a particular public health concern especially among sub-Saharan African countries. This is especially the case in Namibia, where LRTIs are currently the third leading cause of death, 300 deaths in children under 5 years of age. To reduce the burden of LRTIs on health systems and ensure appropriate patient management, it is critical to know the most prevalent pathogens leading to LRTIs and their susceptibility patterns in the local setting. Consequently, the objective of this study was to formulate cumulative antibiograms for Intensive Care Units (ICUs) of referral hospitals in Namibia to guide future antibiotic use.

METHODS

A retrospective analytical cross-sectional study was conducted over 2 years. The cumulative antibiograms were constructed in accordance with current guidelines.

RESULTS

A total of 976 first isolate cultures were obtained from ICUs of the different referral hospitals. K. pneumoniae (8.8%, 8.1%) was a predominant pathogen in Windhoek Central hospital ICU in 2017 and 2018. In Oshakati intermediate hospital ICU, Enterobacter sp. (22.2%) and P. aeruginosa (37.5%) were the common pathogens in 2017 and 2018, respectively. A. baumannii isolates were >90% susceptibility to colistin, carbapenems, and tigecycline in 2017. In 2017, K. pneumoniae isolates were more susceptible to carbapenems (94% and 93.8% among isolates), amikacin (89.3%), and tigecycline (88.7%). In 2018, K. pneumoniae isolates were 100% susceptible amikacin, colistin, and carbapenems. S. maltophilia isolates were more than 80% susceptible to all the tested antibiotics. S. aureus isolates were 100% susceptible to linezolid, rifampicin, teicoplanin, and vancomycin in 2017 and in 2018. Its susceptibility to these antibiotics did not change.

CONCLUSION

The susceptibility patterns of the common isolated gram-negative pathogens were highly variable. Meropenem in combination with gentamicin is now the recommended antibiotic combination for empiric therapy for patients with LRTIs in Windhoek Central Hospital ICU.

Association of Early vs Late Tracheostomy Placement With Pneumonia and Ventilator Days in Critically Ill Patients: A Meta-analysis

Importance

The timing of tracheostomy placement in adult patients undergoing critical care remains unestablished. Previous meta-analyses have reported mixed findings regarding early vs late tracheostomy placement for ventilator-associated pneumonia (VAP), ventilator days, mortality, and length of intensive care unit (ICU) hospitalization.

Objective

To compare the association of early (≤7 days) vs late tracheotomy with VAP and ventilator days in critically ill adults.

Data Sources

A search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, references of relevant articles, previous meta-analyses, and gray literature from inception to March 31, 2020, was performed.

Study Selection

Randomized clinical trials comparing early and late tracheotomy with any of our primary outcomes, VAP or ventilator days, were included.

Data Extraction and Synthesis

Two independent reviewers conducted all stages of the review. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Pooled odds ratios (ORs) or the mean difference (MD) with 95% CIs were calculated using a random-effects model.

Main Outcomes and Measures

Primary outcomes included VAP and duration of mechanical ventilation. Intensive care unit days and mortality (within the first 30 days of hospitalization) constituted secondary outcomes.

Results

Seventeen unique trials with a cumulative 3145 patients (mean [SD] age range, 32.9 [12.7] to 67.9 [17.6] years) were included in this review. Individuals undergoing early tracheotomy had a decrease in the occurrence of VAP (OR, 0.59 [95% CI, 0.35-0.99]; 1894 patients) and experienced more ventilator-free days (MD, 1.74 [95% CI, 0.48-3.00] days; 1243 patients). Early tracheotomy also resulted in fewer ICU days (MD, -6.25 [95% CI, -11.22 to -1.28] days; 2042 patients). Mortality was reported for 2445 patients and was comparable between groups (OR, 0.66 [95% CI, 0.38-1.15]).

Conclusions and Relevance

Compared with late tracheotomy, early intervention was associated with lower VAP rates and shorter durations of mechanical ventilation and ICU stay, but not with reduced short-term, all-cause mortality. These findings have substantial clinical implications and may result in practice changes regarding the timing of tracheotomy in severely ill adults requiring mechanical ventilation.

Coinfections with Bacteria, Fungi, and Respiratory Viruses in Patients with SARS-CoV-2: A Systematic Review and Meta-Analysis

Background: Coinfection with bacteria, fungi, and respiratory viruses in SARS-CoV-2 is of particular importance due to the possibility of increased morbidity and mortality. In this meta-analysis, we calculated the prevalence of such coinfections. Methods: Electronic databases were searched from 1 December 2019 to 31 March 2021. Effect sizes of prevalence were pooled with 95% confidence intervals (CIs). To minimize heterogeneity, we performed sub-group analyses. Results: Of the 6189 papers that were identified, 72 articles were included in the systematic review (40 case series and 32 cohort studies) and 68 articles (38 case series and 30 cohort studies) were included in the meta-analysis. Of the 31,953 SARS-CoV-2 patients included in the meta-analysis, the overall pooled proportion who had a laboratory-confirmed bacterial infection was 15.9% (95% CI 13.6–18.2, n = 1940, 49 studies, I² = 99%, p < 0.00001), while 3.7% (95% CI 2.6–4.8, n = 177, 16 studies, I² = 93%, p < 0.00001) had fungal infections and 6.6% (95% CI 5.5–7.6, n = 737, 44 studies, I² = 96%, p < 0.00001) had other respiratory viruses. SARS-CoV-2 patients in the ICU had higher co-infections compared to ICU and non-ICU patients as follows: bacterial (22.2%, 95% CI 16.1–28.4, I² = 88% versus 14.8%, 95% CI 12.4–17.3, I² = 99%), and fungal (9.6%, 95% CI 6.8–12.4, I² = 74% versus 2.7%, 95% CI 0.0–3.8, I² = 95%); however, there was an identical other respiratory viral co-infection proportion between all SARS-CoV-2 patients [(ICU and non-ICU) and the ICU only] (6.6%, 95% CI 0.0–11.3, I² = 58% versus 6.6%, 95% CI 5.5–7.7, I² = 96%). Funnel plots for possible publication bias for the pooled effect sizes of the prevalence of coinfections was asymmetrical on visual inspection, and Egger’s tests confirmed asymmetry (p values < 0.05). Conclusion: Bacterial co-infection is relatively high in hospitalized patients with SARS-CoV-2, with little evidence of S. aureus playing a major role. Knowledge of the prevalence and type of co-infections in SARS-CoV-2 patients may have diagnostic and management implications.

Fear of Hospital-Acquired Infections: The Combined Impact of Patient's Hygiene Sensitivity and Perceived Staff Preventive Behavior

Over the years, the public has paid growing attention to hospital-acquired infections (HAIs). Currently, infection prevention and control are considered a number one national priority in leading developed countries. However, while some hospital visitors are knowledgeable of the topic, others may be ignorant or careless as regards sterility and hygiene-related matters. This study, conducted in Israel, compared people cognizant of hygiene-related issues to those who are less so, in an attempt to account for differences in terms of attitudes and perceptions regarding the hospital environment. Based on Endsley's (in: Proceedings of the IEEE 1988 national aerospace and electronics conference, IEEE, 1988, 1995) situation awareness concept, we hypothesized that people attending the hospital with different hygiene schema would react differently when faced with HAI-related triggers. Based on a survey of 208 respondents, the results support the hypotheses, and showed a significant moderating effect of hygiene-sensitivity on the relationship between the staffs' hospital acquired infection-related proactive behavior and avoidance tendencies among hospital visitors. Theoretical as well as practical recommendations are discussed.

Ventilator-associated pneumonia among ICU patients in WHO Southeast Asian region: A systematic review

Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections and a leading cause of death among patients in Intensive Care Unit (ICU). The South East Asian Region is a part of the world with limited health resources where infectious diseases are still underestimated. We aimed to review the literature in this part of the world to describe incidence, mortality and microbiological evidence of VAP and explore preventive and control strategies. We selected 24 peer-reviewed articles published from January 1, 2000 to September 1, 2020 from electronic databases and manual searching for observational studies among adult patients diagnosed with VAP expressed per thousand days admitted in ICU. The VAP rates ranged from 2.13 to 116 per thousand days, varying among different countries of this region. A significant rate of mortality was observed in 13 studies ranging from 16.2% to 74.1%. Gram negative organisms like Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella pneumoniae and Gram-positive organisms like Staphylococcus aureus and Enterococcus species were frequently found. Our findings suggest an alarming situation of VAP among patients of most of the countries of this region with increasing incidence, mortality and antibiotic resistance. Thus, there is an urgent need for cost effective control and preventive measures like interventional studies and educational programs on staff training, hand hygiene, awareness on antibiotic resistance, implementation of antibiotic stewardship programs and appropriate use of ventilator bundle approach.

Multi-criteria risk evaluation model for developing ventilator-associated pneumonia

Ventilator-associated pneumonia is a hospital-acquired infection of the lungs occurring in mechanically ventilated patients. An active risk management approach can prevent the occurrence of the disease and promote positive organizational changes, subsequently decreasing mortality and hospitalization costs. Using scientific and clinical practice knowledge, a risk evaluation model was developed to identify patients more at risk of developing the disease. For this purpose, a Decision Expert qualitative multi-criteria decision method was used, in which alternatives are evaluated according to predetermined hierarchically arranged criteria. Characteristics of each evaluated alternative are described by the members of an interdisciplinary expert team and are represented by the values of the basic criteria. Values of hierarchically higher aggregated criteria are computed in an upwards fashion according to utility functions, which are defined as simple logical rules. This method is integrated into a software solution, DEXi. The approach is applicable to vastly diverse decision problems and has been successfully used before for health-related decision support. The designed model was tested using actual clinical data. Evaluations of alternatives that most distinctly demonstrated the functionality of the evaluation model were selected and are presented in the results. The evaluation model is intended to assist a holistic evaluation of the risk of developing ventilator-associated pneumonia, by considering patient-related risk factors and the use of preventive measures. The model incorporates nursing-specific data that have hitherto been poorly utilized in preventing ventilator-associated pneumonia and promotes the active engagement of nurses in confronting this interdisciplinary healthcare problem, which has gained more prominence with the onset of COVID-19 disease.

Should the Vancomycin Minimal Inhibitory Concentration be used as an Infant Critical Care Regular Criteria?

BACKGROUND

Vancomycin is the first-line antibiotic used for the treatment of staphylococcal infections. Because of its narrow therapeutic window and the pharmacokinetics variability, vancomycin trough serum concentration should be monitored. However, due to the increased cases of staphylococcus' commensal species infections and the case of vancomycin resistance, the minimal inhibitory concentration should be considered on antimicrobial therapy.

OBJECTIVE

This article aimed to show the importance of the minimal inhibitory concentration to infants on vancomycin therapy as regular criteria.

MATERIALS AND METHODS

Three infants in the use of vancomycin, hospitalized in the same maternity hospital, and that had at least one blood culture performed during the intensive-care-unit hospitalization were included in the study. Vancomycin serum concentrations were determined by particleenhanced- turbidimetric inhibition-immunoassay. The vancomycin minimal inhibitory concentration data were interpreted by following the Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST). The trough serum concentration range of 10 to 20 mg.L-1 was considered therapeutic.

RESULTS

All three patients had at least one infection by S. epidermidis, being one patient exhibit vancomycin- resistant S. epidermidis infection. All patients had stoppages in the vancomycin treatment, and the minimal inhibitory concentration was performed for only one patient.

CONCLUSION

The data obtained from these patients also showed the need to perform therapeutic monitoring by using minimal inhibitory concentration values, because, although the serum concentrations were within the reference range, they are insufficient to guarantee patient therapeutic success.

Evaluation of bacterial co-infections of the respiratory tract in COVID-19 patients admitted to ICU

Background

COVID-19 is known as a new viral infection. Viral-bacterial co-infections are one of the biggest medical concerns, resulting in increased mortality rates. To date, few studies have investigated bacterial superinfections in COVID-19 patients. Hence, we designed the current study on COVID-19 patients admitted to ICUs.

Methods

Nineteen patients admitted to our ICUs were enrolled in this study. To detect COVID-19, reverse transcription real-time polymerase chain reaction was performed. Endotracheal aspirate samples were also collected and cultured on different media to support the growth of the bacteria. After incubation, formed colonies on the media were identified using Gram staining and other biochemical tests. Antimicrobial susceptibility testing was carried out based on the CLSI recommendations.

Results

Of nineteen COVID-19 patients, 11 (58%) patients were male and 8 (42%) were female, with a mean age of ~ 67 years old. The average ICU length of stay was ~ 15 days and at the end of the study, 18 cases (95%) expired and only was 1 case (5%) discharged. In total, all patients were found positive for bacterial infections, including seventeen Acinetobacter baumannii (90%) and two Staphylococcus aureus (10%) strains. There was no difference in the bacteria species detected in any of the sampling points. Seventeen of 17 strains of Acinetobacter baumannii were resistant to the evaluated antibiotics. No metallo-beta-lactamases -producing Acinetobacter baumannii strain was found. One of the Staphylococcus aureus isolates was detected as methicillin-resistant Staphylococcus aureus and isolated from the patient who died, while another Staphylococcus aureus strain was susceptible to tested drugs and identified as methicillin-sensitive Staphylococcus aureus.

Conclusions

Our findings emphasize the concern of superinfection in COVID-19 patients due to Acinetobacter baumannii and Staphylococcus aureus. Consequently, it is important to pay attention to bacterial co-infections in critical patients positive for COVID-19.

Health Technology Assessment for Vaccines Against Rare, Severe Infections: Properly Accounting for Serogroup B Meningococcal Vaccination's Full Social and Economic Benefits

The high price of new generations of vaccines relative to their predecessors has become an important consideration in debates over whether the benefits of the new vaccines justify their costs. An increasingly central line of inquiry in the literature on valuing vaccination surrounds accounting for the full social and economic benefits of vaccination. This paper applies this emerging perspective to the particular case of vaccination against serogroup B meningococcal disease (MenB). We explore key issues involved in health technology assessments of MenB vaccination, which have led to pronounced heterogeneity in evaluation methods and recommendation outcomes across countries such as France, Germany, the US, and the UK. Accounting for typically neglected sources of socioeconomic benefit could potentially impact recommendation and reimbursement decisions. We propose a taxonomy of such benefits built around four dimensions: (i) internalized health benefits, (ii) internalized non-health benefits, (iii) externalized health benefits, and (iv) externalized non-health benefits. This approach offers a systematic, comprehensive evaluation framework that can be used in future assessment of MenB vaccines as well as other health technologies.

Nurses' attitude towards oral care and their practicing level for hospitalized patients in Orotta National Referral Hospital, Asmara-Eritrea: a cross-sectional study

BACKGROUND

Effective and routine mouth care is necessary for hospitalized patients as it helps to maintain the health of oral cavity and overall health. However, oral care is often overlooked and not prioritized in daily activity plan of nurses even when oral problems are apparent. Therefore, the aim of this study was to assess nurses' attitude towards oral care and their practicing level for hospitalized patients.

METHODS

A cross-sectional study design was conducted in adult medical-surgical department of Orotta hospital from December 2017 to January 2018. Data was collected from all (N = 73) diploma and associate nurses through face to face interview using a pretested and structured questionnaire. Kruskal-Wallis, Mann-Whitney U tests and spearman rank correlation coefficient tools were performed to analyze the data using SPSS (Version 22).

RESULTS

Out of the 79 participants, 73 completed the interview successfully with a response rate of 92.4%. Of the total, 56.2% were diploma nurses and 43.9% were associate nurses. The median attitude score was 68.89/100 (IQR = 48.89). The majority (94.5%) of the nurses agreed that oral cavity assessment is nurse's responsibility and 94.5% reported adequate training is needed to provide quality oral care. On the other hand, the median practice score was 50.00/100 (IQR = 17.86). Majority of the participants (76.7%) did not perform routine oral health assessment. Almost all (98.4%) used gauze and normal saline for oral care. Practice score was significantly different across the various wards (p < 0.001), however, it was not significantly correlated with attitude (p = 0.646).

CONCLUSIONS

The participants had poor level of oral care practice to hospitalized patients, nevertheless, they had favourable attitude. Therefore, Orotta National Referral Hospital needs to give further effort to train the nursing staff, ensure the availability of adequate oral care equipment and provide clear guidelines regarding oral care of hospitalized patients.

Healthcare-associated Infection in Intensive Care Units: Overall Analysis of Patient Criticality by Acute Physiology and Chronic Health Evaluation IV Scoring and Pathogenic Characteristics

Objectives

To compare the predicted vs observed mortality rate, criticality, and length of stay of the patients with healthcare-associated infections (HAIs) in intensive care units (ICUs) of a tertiary health center through acute physiology and chronic health evaluation (APACHE) IV scoring. To analyze the drug sensitivity pattern of the isolated pathogen.

Design

This is a prospective observational study involving the patients admitted to various ICUs of a tertiary care teaching hospital. Among 1,229 patients who were admitted in the ICUs for a period of 2.5 months (74 days), 767 patients stayed beyond 48 hours. They were monitored and 87 of them who developed HAIs were included in the study. The organisms isolated from the infection site were identified, and the drug resistance pattern was reported as per standard guidelines. The patients were followed up till their discharge, and adequate details pertaining to the study were collected including demographic details and physiological and biochemical parameters to calculate APACHE IV score, length of stay, and prognosis.

Setting

Intensive care units of JSS Hospital, Mysuru, Karnataka, India.

Subjects/patients

All patients who developed HAI in ICUs.

Interventions

Nil.

Measurements and main results

The HAI rate observed in this study was 15.7%. Ventilator-associated pneumonia (VAP) was the most common type of infection. Klebsiella and Acinetobacter were the frequently isolated organisms. There was a high prevalence of drug resistance among these pathogens. The ICU mortality in infected patients was 21.83%, roughly twice as that of uninfected patients. The observed length of stay was 11.66 (±8.53) days.

Conclusion

Healthcare-associated infection was associated with long duration of ICU stay. There was a high prevalence of drug resistance to various antibiotics. Acute physiology and chronic health evaluation IV score was not found to be good scoring system to predict the mortality and length of stay in the patients who had HAI.

How to cite this article

Gunasekaran S, Mahadevaiah S. Healthcare-associated Infection in Intensive Care Units: Overall Analysis of Patient Criticality by Acute Physiology and Chronic Health Evaluation IV Scoring and Pathogenic Characteristics. Indian J Crit Care Med 2020;24(4):252–257.

A Study of Multidrug-Resistant, Colistin-Only-Sensitive Infections in Intubated and Mechanically Ventilated Patients Over 2 Years

Background and Aims

Multidrug-resistant, Gram-negative infections are increasingly common in the intensive care unit (ICU). This study compares the occurrence and outcome of colistin-only-sensitive (COS) infections among mechanically ventilated patients at a tertiary hospital ICU.

Methods

The study included adult patients admitted over a period of 2 years, who were intubated and mechanically ventilated for more than 48 h. They were divided into two groups, those with COS infections and those without, and their GCS and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, ICU length of stay, leukocyte count, and mortality were compared. COS patients were divided into neurosurgery, neurology, respiratory, and sepsis with bacteremia groups. The COS organisms in each group, their sources, ICU length of stay, ventilator-free days, and mortality were analyzed.

Results

Three hundred and one patients were selected, of whom 41 (13.6%) had COS infections. COS patients had a longer ICU length of stay than non-COS patients (P = 0.001) but comparable APACHE II and GCS scores, leukocyte count, and mortality. The sepsis group accounted for 8 out of 15 (53%) deaths among COS patients (P = 0.03). Acinetobacter baumannii accounted for 61% of the COS infections, Klebsiella pneumonia: 24.4%, Pseudomonas aeruginosa: 12.2%, and Escherichia coli: 2.4%. Endotracheal secretion cultures accounted for 65.8% of COS isolates, urine cultures 17%, pus cultures 7.3%, and blood cultures 4.9%. ICU length of stay, ventilator-free days, and mortality were similar between each COS organism.

Conclusion

Intubated patients with multidrug-resistant, COS infections have a longer stay in ICU than non-COS patients. COS infections associated with bacteremia have high mortality.

Significant Clinical Presentation of Leptospirosis in Relation to Sociodemographic and Risk Factors in a Tertiary Hospital, Malaysia

Introduction: Incidence of leptospirosis has increased within the past few years in many countries. Its clinical presentations were generally nonspecific, making it difficult to assist in the diagnosis. Besides the determination of the common clinical features, the sociodemographic background is essential to identify high-risk populations to assist in prevention. Methods: Data for this study were obtained from electronic medical records among patients clinically diagnosed with leptospirosis at a tertiary hospital in Malaysia from the years 2011 to 2015 and were recorded using standard pro forma. Associations between clinical features and sociodemographics were performed using bivariate analysis and logistic regression. Results: Data were collected from 283 patients. Their mean age was 30.71 years old. Out of 283 patients, 206 (72.8%) were male. Involvement in outdoor events and water activities was the highest risk factor of acquiring leptospirosis in 64 (22.7%) patients followed by 59 (20.8%) patients who were staying in crowded housing areas with poor sanitation. Although fever was the main clinical presentation in 274 (96.8%) patients with leptospirosis, gastrointestinal (GIT) symptoms were the second most frequent in 159 (56.2%) patients followed by pulmonary symptoms, myalgia, headache, and jaundice. From the total number of 283 patients, only 21 (92.6%) presented with severe leptospirosis. GIT symptoms were a significant predictor for leptospirosis severity, while the age group was the significant sociodemographic factor toward GIT presentation in leptospirosis. The relationship between GIT symptoms and crowded housing areas with poor sanitation was also significant. Multivariable logistic regression showed that crowded housing areas with poor sanitation (odds ratio [OR] = 3.570, p < 0.001) and age between 20 and 40 years old (OR = 2.056, p = 0.014) were more likely to have GIT symptoms. Conclusions: Information regarding the clinical features of leptospirosis to the public is necessary, while targeted prevention by educational outreach among 20-40 year olds especially those participating in outdoor water activities are crucial to decrease the incidence and complications of leptospirosis.

Commentary: Why Has Uptake of Pneumococcal Vaccines for Children Been So Slow? The Perils of Undervaluation

Pediatric pneumococcal disease exacts a substantial burden on global health, much of which is vaccine-preventable. Despite this considerable burden and the demonstrably high efficacy of pneumococcal conjugate vaccines (PCVs), the overall level of PCV uptake remains concerningly low, especially compared with that of other childhood-recommended vaccines, such as tuberculosis and polio. A broad set of plausible explanations exists for this low uptake, including logistical challenges, psychosocial factors and affordability. One additional and systematic cause of low uptake, which is the focus of our discussion, is economists' and policymakers' tendency to undervalue vaccination in general by adopting a narrow health sector perspective when performing economic evaluations of vaccines. We present an alternative, societal framework for economic evaluations that encompasses a broader set of socioeconomic benefits in addition to health benefits. Quantifying a more comprehensive taxonomy of PCV's benefits will help to address potential undervaluation and may be sufficient not only to justify recommendation and reimbursement but also to stimulate efforts and investment toward closing coverage gaps.

Survey of isolation room equipment and resources in an academic hospital

PURPOSE

The purpose of this paper, a point prevalence study, is to quantify the incidence of isolation and identify the type of communicable diseases in isolation. The paper evaluates isolation precaution communication, availability of personal protective equipment (PPE) as well as other equipment necessary for maintaining isolation precautions.

DESIGN/METHODOLOGY/APPROACH

A standardised audit tool was developed in accordance with the National Standards for the Prevention and Control of Healthcare Associated Infections (May 2009). Data were collected from 14 March 2017 to 16 March 2017, through observation of occupied isolation rooms in an academic hospital in Dublin, Ireland. The data were subsequently used for additional analysis and discussion.

FINDINGS

In total, 14 per cent (125/869) of the total inpatient population was isolated at the time of the study. The most common isolation precaution was contact precautions (96.0 per cent). In all, 88 per cent of known contact precautions were due to multi-drug resistant organisms. Furthermore, 96 per cent of patients requiring isolation were isolated, 92.0 per cent of rooms had signage, 90.8 per cent had appropriate signs and 93.0 per cent of rooms had PPE available. Finally, 31 per cent of rooms had patient-dedicated and single-use equipment and 2.4 per cent had alcohol wipes available.

PRACTICAL IMPLICATIONS

The audit tool can be used to identify key areas of noncompliance associated with isolation and inform continuous improvement and education.

ORIGINALITY/VALUE

Currently, the rate of isolation is unknown in Ireland and standard guidelines are not established for the evaluation of isolation rooms. This audit tool can be used as an assessment for isolation room compliance.

SAFETY IN EQUIPMENT AND DRESSING CHANGES FOR CENTRAL VASCULAR CATHETERS: AN OBSERVATIONAL STUDY

ABSTRACT Objective: to evaluate the compliance of the nursing team's care practice in handling the central vascular catheter when changing dressings and equipment in an intensive care unit. Method: a descriptive, prospective, and observational research study. Data collection was conducted from January to March 2016 in an Intensive Care unit of a public hospital in Sergipe, northeastern Brazil. Direct observation of the professionals was conducted using a safe checklist. Descriptive statistics was used to determine the process indicators, and inferential statistics to determine the association between the variables, using the chi-square and Fisher's tests, with a 5% significance level. Results: 534 procedures corresponding to the exchange of equipment and dressings were observed, corresponding to 5,073 actions. As for the change of equipment, 2,136 actions were evaluated, most of them carried out by nursing technicians. Of the eight actions evaluated in each procedure, only two (25%) reached the desired compliance, with a positivity index between 90% and 99%. Regarding the dressing change, 2,937 actions were evaluated, all of which were performed by nurses. Of the eleven evaluated actions, eight (72%) achieved desired compliance, with a positivity index between 80% and 100%. Conclusion: the results analyzed are far from the desired compliances, demonstrating the need to implement strategies to ensure the safety culture during the care provided.

Microorganisms Profile and Antibiotics Sensitivity Patterns in the Only Medical Intensive Care Unit in Bosnia and Herzegovina

Treatment of critically ill patients entails a great risk for intrahospital infections. Systematic monitoring of intrahospital infection data is a widely used practice in developed countries, while in developing and underdeveloped countries these data are scarce. In Bosnia and Herzegovina, a developing country, precise data cannot be found; hence, this study was created with the aim to monitor the profile and resistance patterns of microorganisms isolated from patients being treated in the only medical intensive care unit (MICU) in the country. This is a retrospective observational study of microorganisms isolated from all patients treated at MICU in the University Clinical Center of Republic of Srpska from January 1 through December 31, 2017. Analysis of all samples was performed using standardized microbiological procedures, while sensitivity to antimicrobials was performed using the disk diffusion method. One thousand six hundred twenty-five samples were taken from 633 critically ill patients and sent off for analysis; 572 were positive for bacteria (35.2%). Gram-negative bacteria were isolated more frequently (65.2%), specifically Acinetobacter baumannii (25.5%), followed by Klebsiella spp. (10.8%). A. baumannii was resistant to all antibiotics except for colistin, to which it was highly sensitive (99.7%). It was moderately sensitive (76%) to rifampicin. Staphylococcus epidermidis, Staphylococcus aureus, and Enterococci were the most prevalent Gram-positive bacteria (15%, 7.3%, and 9.2%, respectively) isolated in this study. It is clear from this study that Gram-negative bacteria are predominant in the newly established MICU. A. baumannii was found to be the most prevalent Gram-negative bacteria, and S. epidermidis was the most prevalent Gram-positive bacteria.

The Effects of Oral Care Protocol on the Incidence of Ventilation-Associated Pneumonia in Selected Intensive Care Units in Jordan

PURPOSE

This study aims to evaluate the effects of oral care protocol on the incidence of ventilator-associated pneumonia (VAP) at selected intensive care units (ICUs) in Jordan using clinical pulmonary infection score.

METHODS

A quasi-experimental design was used, and 1 large teaching hospital from the Jordanian capital, along with 2 hospitals from the southern region, was selected. A total of 218 patients participated, among which VAP risk in 2 independent groups was evaluated through the Clinical Pulmonary Infection Score sheet.

RESULTS

The VAP incidence rate was significantly lower in the intervention group (n = 102) as compared with control group (n = 116) (21.6 vs 35.3, respectively; P = .018); in addition, ICU stay and intubation period were significantly shorter among the intervention group. A higher risk of VAP was independently predicted by previous lung diseases (odds ratio [OR], 1.441; 95% confidence interval [CI], 1.185-1.88), open suctioning system (OR, 2.536; 95% CI, 1.261-5.101), and duration of intubation (OR, 1.770; 95% CI, 0.845-2.220). The oral care protocol has effectively improved ventilated patients' oral health, which has statistically reduced the incidence of VAP. It occurred more frequently among patients who have lung disease and those who were intubated for more than 7 days and have an open suctioning system.

CONCLUSION

Health care teams should ensure that effective care protocol is implemented among patients.

Drug Prevention and Control of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is one of the most prevalent and serious complications of mechanical ventilation, which is considered a common nosocomial infection in critically ill patients. There are some great options for the prevention of VAP: (i) minimize ventilator exposure; (ii) intensive oral care; (iii) aspiration of subglottic secretions; (iv) maintain optimal positioning and encourage mobility; and (v) prophylactic probiotics. Furthermore, clinical management of VAP depends on appropriate antimicrobial therapy, which needs to be selected based on individual patient factors, such as previous antibacterial therapy, history of hospitalization or mechanical ventilation, and bacterial pathogens and antibiotic resistance patterns. In fact, antibiotic resistance has exponentially increased over the last decade, and the isolation of a multidrug-resistant (MDR) pathogen has been identified as an independent predictor of inadequate initial antibiotic therapy and which is significantly associated with increased mortality. Multiple attempts were used in the treatment of VAP, such as novel antibacterial agents, inhaled antibiotics and monoclonal antibodies. In this review, we summarize the current therapeutic options for the prevention and treatment of VAP, aiming to better management of VAP in clinical practice.

Intensive Care Units of a Tertiary Care Hospital: A Detailed Study of Patient Symptomatology

Introduction Nosocomial infection (NI) is a factor of considerable significance in determining the morbidity and mortality of patients admitted to the intensive care units (ICUs). Our aim was to study the frequencies of various symptoms that might emerge due to nosocomial infection (NI) among ICU patients. Materials and methods This was a cross-sectional study conducted in intensive care units of General Medicine, General Surgery and Paediatric wards in Ruth M. Pfau Civil Hospital Karachi, Pakistan, using well-structured questionnaire created after a thorough literature study. Patients who had an ICU admission for more than five days but less than two weeks were set as the inclusion criteria. The remaining patients were excluded from the study.  Results Among the patients who developed gastrointestinal disturbances while in the intensive units, loss of appetite had the highest ratio in the paediatric ICU, whereas vomiting was most prevalent in the surgical ICU and weight loss was the most recurring symptom in the medical ICU. With regard to the respiratory and cardiovascular symptoms, dyspnea stood out in medicine ICU while fatigue was the most evident symptom amidst the paediatrics and surgical ICU patients. Insomnia was the most common neuropsychiatric symptom in the surgical and paediatric ICUs. Insomnia also paralleled tremors frequently in the medical ICU. Conclusion Infections in patients under intensive care in a tertiary care setup are not restricted to a specific type but present variously, as indicated by the type of symptoms the patients develop during their stay.

Guidelines for Antibiotic Prescription in Intensive Care Unit

How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.