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Stanley ND, Jeevan JA, Yadav B, Gunasekaran K, Pichamuthu K, Chandiraseharan VK, Sathyendra S, Hansdak SG, Iyyadurai R. Association of antibiotic duration and all-cause mortality in a prospective study of patients with ventilator-associated pneumonia in a tertiary-level critical care unit in Southern India. BMJ Open 2024; 14:e077428. [PMID: 38604633 PMCID: PMC11015278 DOI: 10.1136/bmjopen-2023-077428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 03/26/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVES To estimate all-cause mortality in ventilator-associated pneumonia (VAP) and determine whether antibiotic duration beyond 8 days is associated with reduction in all-cause mortality in patients admitted with VAP in the intensive care unit. DESIGN A prospective cohort study of patients diagnosed with VAP based on the National Healthcare Safety Network definition and clinical criteria. SETTING Single tertiary care hospital in Southern India. PARTICIPANTS 100 consecutive adult patients diagnosed with VAP were followed up for 28 days postdiagnosis or until discharge. OUTCOME MEASURES The incidence of mortality at 28 days postdiagnosis was measured. Tests for association and predictors of mortality were determined using χ2 test and multivariate Cox regression analysis. Secondary outcomes included baseline clinical parameters such as age, underlying comorbidities as well as measuring total length of stay, number of ventilator-free days and antibiotic-free days. RESULTS The overall case fatality rate due to VAP was 46%. There was no statistically significant difference in mortality rates between those receiving shorter antibiotic duration (5-8 days) and those on longer therapy. Among those who survived until day 9, the observed risk difference was 15.1% between both groups, with an HR of 1.057 (95% CI 0.26 to 4.28). In 70.4% of isolates, non-fermenting Gram-negative bacilli were identified, of which the most common pathogen isolated was Acinetobacter baumannii (62%). CONCLUSION In this hospital-based cohort study, there is insufficient evidence to suggest that prolonging antibiotic duration beyond 8 days in patients with VAP improves survival.
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Affiliation(s)
- Nivin Daniel Stanley
- Department of Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Jonathan Arul Jeevan
- Department of Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Karthik Gunasekaran
- Department of Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Critical Care Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | | | - Sowmya Sathyendra
- Department of Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Samuel George Hansdak
- Department of Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Ramya Iyyadurai
- Department of Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
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Ali SAA, Alsadaan N, Ameer M, Sayed-Ahmed M, Alanazi F. Impact of various solutions on the oral health status of critically ill patients. J Med Life 2024; 17:296-304. [PMID: 39044935 PMCID: PMC11262603 DOI: 10.25122/jml-2023-0495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/05/2024] [Indexed: 07/25/2024] Open
Abstract
Oral care is a crucial challenge of nursing care in orally intubated patients. Oropharyngeal colonization with microorganisms is probably the first step in the pathogenesis of most bacterial pulmonary infections. This study aimed to investigate the effect of different oral care solutions on the oral health status of critically ill patients. We conducted a quasi-experimental study involving a convenience sample of 60 adult orally intubated patients, distributed equally into three groups: 20 patients received 0.12% chlorhexidine gluconate (CHX) solution as an oral rinse; 20 patients received 0.1% hexetidine (HEX) solution as an oral rinse; and a control group of 20 patients received routine hospital oral care with 0.9% normal saline (NS) solution. Oropharyngeal and tracheal cultures were obtained from patients within 24-48 h of admission, before the administration of topical oral antimicrobial solutions and then repeated on day 4 and day 7 after the oral solutions. The study revealed that CHX has a more powerful effect than HEX and NS in improving the oral mucosa and decreasing colonization of both the oropharynx and trachea. On day 7, the improvements were statistically significant in the CHX group and the HEX group (P = 0.02 and P = 0.03, respectively), but not in the NS group. This research confirms the effect of CHX and HEX in lowering the risk of tracheal and oropharyngeal colonization, and recommends the use of a CHX solution as oral mouth care in critically ill patients.
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Affiliation(s)
- Shaimaa Ahmed Awad Ali
- Medical -Surgical Department, College of Nursing, Jouf University, Sakaka, Al-Jouf, Saudi Arabia
| | - Nourah Alsadaan
- College of Nursing, Jouf University, Sakaka, Al-Jouf, Saudi Arabia
| | - Mariam Ameer
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Jouf University, Sakaka, Al-Jouf, Saudi Arabia
- Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Mohamed Sayed-Ahmed
- Department of Clinical Pharmacy, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
- Department of Internal Medicine and Infectious Disease, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
| | - Fahad Alanazi
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Jouf University, Sakaka, Al-Jouf, Saudi Arabia
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Alnimr A. Antimicrobial Resistance in Ventilator-Associated Pneumonia: Predictive Microbiology and Evidence-Based Therapy. Infect Dis Ther 2023:10.1007/s40121-023-00820-2. [PMID: 37273072 DOI: 10.1007/s40121-023-00820-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/09/2023] [Indexed: 06/06/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) is a serious intensive care unit (ICU)-related infection in mechanically ventilated patients that is frequent, as more than half of antibiotics prescriptions in ICU are due to VAP. Various risk factors and diagnostic criteria for VAP have been referred to in different settings. The estimated attributable mortality of VAP can go up to 50%, which is higher in cases of antimicrobial-resistant VAP. When the diagnosis of pneumonia in a mechanically ventilated patient is made, initiation of effective antimicrobial therapy must be prompt. Microbiological diagnosis of VAP is required to optimize timely therapy since effective early treatment is fundamental for better outcomes, with controversy continuing regarding optimal sampling and testing. Understanding the role of antimicrobial resistance in the context of VAP is crucial in the era of continuously evolving antimicrobial-resistant clones that represent an urgent threat to global health. This review is focused on the risk factors for antimicrobial resistance in adult VAP and its novel microbiological tools. It aims to summarize the current evidence-based knowledge about the mechanisms of resistance in VAP caused by multidrug-resistant bacteria in clinical settings with focus on Gram-negative pathogens. It highlights the evidence-based antimicrobial management and prevention of drug-resistant VAP. It also addresses emerging concepts related to predictive microbiology in VAP and sheds lights on VAP in the context of coronavirus disease 2019 (COVID-19).
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Affiliation(s)
- Amani Alnimr
- Department of Microbiology, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia.
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Effect of ICU quality control indicators on VAP incidence rate and mortality: a retrospective study of 1267 hospitals in China. Crit Care 2022; 26:405. [PMID: 36581952 PMCID: PMC9798551 DOI: 10.1186/s13054-022-04285-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/17/2022] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To investigate the effects of ICU quality control indicators on the VAP incidence rate and mortality in China throughout 2019. METHODS This was a retrospective study. A total of 1267 ICUs from 30 provinces in mainland China were included. Data were collected using the National Clinical Improvement System Data that report ICU information. Ten related quality control indicators were analyzed, including 5 structural factors (patient-to-bed ratio, physician-to-bed ratio, nurse-to-bed ratio, patient-to-physician ratio, and patient-to-nurse ratio), 3 process factors (unplanned endotracheal extubation rate, reintubation rate within 48 h, and microbiology detection rate before antibiotic use), and 2 outcome factors (VAP incidence rate and mortality). The information on the most common infectious pathogens and the most commonly used antibiotics in ICU was also collected. The Poisson regression model was used to identify the impact of factors on the incidence rate and mortality of VAP. RESULTS The incidence rate of VAP in these hospitals in 2019 was 5.03 (2.38, 10.25) per 1000 ventilator days, and the mortality of VAP was 11.11 (0.32, 26.00) %. The most common causative pathogen was Acinetobacter baumannii (in 39.98% of hospitals), followed by Klebsiella pneumoniae (38.26%), Pseudomonas aeruginosa, and Escherichia coli. In 26.90% of hospitals, third-generation cephalosporin was the most used antibiotic, followed by carbapenem (24.22%), penicillin and beta-lactamase inhibitor combination (20.09%), cephalosporin with beta-lactamase inhibitor (17.93%). All the structural factors were significantly associated with VAP incidence rate, but not with the mortality, although the trend was inconsistent. Process factors including unplanned endotracheal extubation rate, reintubation rate in 48 h, and microbiology detection rate before antibiotic use were associated with higher VAP mortality, while unplanned endotracheal extubation rate and reintubation rate in 48 h were associated with higher VAP mortality. Furthermore, K. pneumoniae as the most common pathogen was associated with higher VAP mortality, and carbapenems as the most used antibiotics were associated with lower VAP mortality. CONCLUSION This study highlights the association between the ICU quality control (QC) factors and VAP incidence rate and mortality. The process factors rather than the structural factors need to be further improved for the QC of VAP in the ICU.
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Li HY, Wang HS, Wang YL, Wang J, Huo XC, Zhao Q. Management of Ventilator-Associated Pneumonia: Quality Assessment of Clinical Practice Guidelines and Variations in Recommendations on Drug Therapy for Prevention and Treatment. Front Pharmacol 2022; 13:903378. [PMID: 35668946 PMCID: PMC9163435 DOI: 10.3389/fphar.2022.903378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/29/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose: To assess the quality of clinical practice guidelines (CPGs) related to drug therapy for prevention and control of ventilator-associated pneumonia (VAP) and compare the differences and similarities between recommendations. Methods: Electronic databases (including PubMed, Cochrane library, Embase, Web of Science), guideline development organizations, and professional societies were searched to identify CPGs for VAP from 20 January 2012 to 20 January 2022. The Appraisal of Guidelines Research & Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. The recommendations on drug therapy for prevention and treatment for each guideline were extracted, and then a descriptive synthesis was performed to analyze the scope/topic, and consistency of the recommendations. Results: Thirteen CPGs were included. The median score and interquartile range (IQR) in each domain are shown below: scope and purpose 72.22% (63.89%,83.33%); stakeholder involvement 44.44% (38.89%,52.78%); rigor of development 43.75% (31.25%,57.29%); clarity and presentation 94.44% (77.78%,94.44%); applicability 20.83 (8.34%,33.34%) and editorial independence 50% (33.33%,66.67%). We extracted 21 recommendations on drug therapy for prevention of VAP and 51 recommendations on drugs used for treatment. Some controversies remained among the included guidelines. Conclusion: There is considerable variability in the development processes and reporting of VAP guidelines. Despite many similarities, the recommendations still had some inconsistencies in the details. For the prevention and treatment of VAP, local microbial epidemiology and antibiotic sensitivity must be considered, and recommendations should be regularly revised as new evidence emerges.
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Affiliation(s)
- Hong-Yan Li
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Hai-Shan Wang
- Department of Intensive Care Unit, Yantai YEDA Hospital, Yantai, China
| | - Ying-Lin Wang
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Jing Wang
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Xue-Chen Huo
- Department of Hepatobiliary Surgery, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
- *Correspondence: Xue-Chen Huo, ; Quan Zhao,
| | - Quan Zhao
- Department of Pharmacy, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
- *Correspondence: Xue-Chen Huo, ; Quan Zhao,
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A Narrative Review on the Approach to Antimicrobial Use in Ventilated Patients with Multidrug Resistant Organisms in Respiratory Samples—To Treat or Not to Treat? That Is the Question. Antibiotics (Basel) 2022; 11:antibiotics11040452. [PMID: 35453203 PMCID: PMC9031060 DOI: 10.3390/antibiotics11040452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 02/01/2023] Open
Abstract
Multidrug resistant organisms (MDRO) are commonly isolated in respiratory specimens taken from mechanically ventilated patients. The purpose of this narrative review is to discuss the approach to antimicrobial prescription in ventilated patients who have grown a new MDRO isolate in their respiratory specimen. A MEDLINE and PubMed literature search using keywords “multidrug resistant organisms”, “ventilator-associated pneumonia” and “decision making”, “treatment” or “strategy” was used to identify 329 references as background for this review. Lack of universally accepted diagnostic criteria for ventilator-associated pneumonia, or ventilator-associated tracheobronchitis complicates treatment decisions. Consideration of the clinical context including signs of respiratory infection or deterioration in respiratory or other organ function is essential. The higher the quality of respiratory specimens or the presence of bacteremia would suggest the MDRO is a true pathogen, rather than colonization, and warrants antimicrobial therapy. A patient with higher severity of illness has lower safety margins and may require initiation of antimicrobial therapy until an alternative diagnosis is established. A structured approach to the decision to treat with antimicrobial therapy is proposed.
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Cardona-Cardona YV, Regla I, Juárez-Díaz JA, Carrillo-Campos J, López-Ortiz M, Aguilera-Cruz A, Mújica-Jiménez C, Muñoz-Clares RA. The critical role of the aldehyde dehydrogenase PauC in spermine, spermidine, and diaminopropane toxicity in Pseudomonas aeruginosa: Its possible use as a drug target. FEBS J 2021; 289:2685-2705. [PMID: 34767295 DOI: 10.1111/febs.16277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/29/2021] [Accepted: 11/10/2021] [Indexed: 01/05/2023]
Abstract
The opportunistic human pathogen Pseudomonas aeruginosa exhibits great resistance to antibiotics; so, new therapeutic agents are urgently needed. Since polyamines levels are incremented in infected tissues, we explored whether the formation of a toxic aldehyde in polyamines degradation can be exploited in combating infection. We cloned the gene encoding the only aminoaldehyde dehydrogenase involved in P. aeruginosa polyamines-degradation routes, PaPauC, overexpressed this enzyme, and found that it oxidizes 3-aminopropionaldehyde (APAL) and 3-glutamyl-3-aminopropionaldehyde (GluAPAL) - produced in spermine (Spm), spermidine (Spd), and diaminopropane (Dap) degradation, as well as 4-aminobutyraldehyde (ABAL) and 4-glutamyl-4-aminobutyraldehyde (GluABAL) - formed in putrescine (Put) degradation. As the catalytic efficiency of PaPauC with APAL was 30-times lower than with GluAPAL, and GluAPAL is predominantly formed, APAL will be poorly oxidized 'in vivo'. We found polyamines-induced increases in the PaPauC activity of cell crude-extracts and in the expression of the PapauC gene that were diminished by glucose. Spm, Spd, or Dap, but not Put, were toxic to P. aeruginosa even in the presence of other carbon and nitrogen sources, particularly to a strain with the PapauC gene disrupted. APAL, but not GluAPAL, was highly toxic even to wild-type cells, suggesting that its accumulation, particularly in the absence of, or low, PaPauC activity is responsible for the toxicity of Spm, Spd, and Dap. Our results shed light on the toxicity mechanism of these three polyamines and strongly support the critical role of PaPauC in this toxicity. Thus, PaPauC emerges as a novel potential drug target whose inhibition might help in combating infection by this important pathogen.
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Affiliation(s)
- Yudy V Cardona-Cardona
- Departamento de Bioquímica, Facultad de Química, Universidad Nacional Autónoma de México, Ciudad Universitaria, Ciudad de México, México
| | - Ignacio Regla
- Facultad de Estudios Superiores Zaragoza, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Javier Andrés Juárez-Díaz
- Departamento de Biología Comparada, Facultad de Ciencias, Universidad Nacional Autónoma de México, Ciudad Universitaria, Ciudad de México, México
| | - Javier Carrillo-Campos
- Departamento de Bioquímica, Facultad de Química, Universidad Nacional Autónoma de México, Ciudad Universitaria, Ciudad de México, México
| | - Manuel López-Ortiz
- Facultad de Estudios Superiores Zaragoza, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Alejandro Aguilera-Cruz
- Facultad de Estudios Superiores Zaragoza, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Carlos Mújica-Jiménez
- Departamento de Bioquímica, Facultad de Química, Universidad Nacional Autónoma de México, Ciudad Universitaria, Ciudad de México, México
| | - Rosario A Muñoz-Clares
- Departamento de Bioquímica, Facultad de Química, Universidad Nacional Autónoma de México, Ciudad Universitaria, Ciudad de México, México
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