Effects of diaphragm electrical stimulation in treating respiratory dysfunction on mechanical ventilation after intracerebral hemorrhage: A single-center retrospective study

Intracerebral hemorrhage (ICH) is a major cause of death and disability worldwide. The benefits of electrical stimulation in the treatment of respiratory dysfunction in patients on mechanical ventilation is unknown. Nevertheless, there is a dearth of evidence-based medical research concerning its clinical efficacy. From January 2019 to January 2023, every enrolled patients experienced respiratory dysfunction after ICH while being supported by mechanical ventilation. A total of 205 eligible patients were enrolled and then allocated into 2 groups: control group and observation group. 133 patients was selected and administered standard treatment as control group. Based on conventional treatment, other 72 patients were administered diaphragm electrical stimulation (DES) treatment. We examined information from current medical records, encompassing all initial data and predictive follow-up data, such as the weaning success rate, occurrence of ventilator-associated pneumonia (VAP), duration of stay in the intensive care unit (ICU) and hospital, expenses related to hospitalization, and mortality within 30 days. The baseline clinical data of the 2 groups did not exhibit any statistically significant disparities (all P > .05). The rate of successful weaning showed a significant increase in the DES group when compared to the control group (P = .025). In patients with respiratory dysfunction due to ICH, treatment with DES resulted in a significant reduction in the duration of invasive ventilation (9.8 ± 2.1 vs 11.2 ± 2.6, P < .01) and total ventilation time (9.8 ± 2.1 vs 11.2 ± 2.6, P < .01). It also led to a decrease in the length of stay in the ICU (15.67 ± 3.76 vs 17.53 ± 4.28, P = .002) and hospitalization cost (11500 vs 13600, P = .001). Additionally, DES treatment resulted in a lower incidence of VAP (73.61% vs 86.46%, P = .022) and improved 30-day mortality (P < .05), without any significant adverse effects. The findings of this research indicate that DESs have a positive impact on enhancing the rate of successful weaning and reducing the incidence of VAP. It decreases the duration of invasive ventilation and total ventilation time while also improving the mortality rate within 30 days. This therapy could offer a fresh alternative for respiratory impairment in patients undergoing mechanical ventilation.

Ventilator-associated pneumonia is linked to a worse prognosis than community-acquired pneumonia in children

BACKGROUND

Around 12-20% of patients with community-acquired pneumonia (CAP) require critical care. Ventilator-associated pneumonia (VAP) is the second cause of nosocomial infection in Paediatric Intensive Care Units (PICU). As far as we know, there are no studies comparing both types of pneumonia in children, thus it remains unclear if there are differences between them in terms of severity and outcomes.

OBJECTIVE

The aim was to compare clinical and microbiological characteristics and outcomes of patients with severe CAP and VAP.

METHODS

A retrospective descriptive study, including patients diagnosed of VAP and CAP, with a positive respiratory culture and under mechanical ventilation, admitted to the PICU from 2015 to 2019.

RESULTS

238 patients were included; 163 (68.4%) with CAP, and 75 (31.5%) with VAP. Patients with VAP needed longer mechanical ventilation (14 vs. 7 days, p<0.001) and more inotropic support (49.3 vs. 30.7%, p = 0.006). Patients with VAP had higher mortality (12 vs. 2.5%, p = 0.005). Enterobacterales were more involved with VAP than with CAP (48 vs. 9%, p<0.001). Taking into account only the non-drug sensitive microorganisms, patients with VAP tended to have more multidrug-resistant bacteria (30 vs. 10.8%, p = 0.141) than patients with CAP.

CONCLUSION

Patients with VAP had worse prognosis than patients with CAP, needing longer mechanical ventilation, more inotropic support and had higher mortality. Patients with VAP were mainly infected by Enterobacterales and had more multidrug resistant microorganisms than patients with CAP.

Reconsidering ventilator-associated pneumonia from a new dimension of the lung microbiome

Complex microbial communities that reside in the lungs, skin and gut are now appreciated for their role in maintaining organ, tissue and immune homoeostasis. As lungs are currently seen as an ecosystem, the shift in paradigm calls for the consideration of new algorithms related to lung ecology in pulmonology. Evidence of lung microbiota does not solely challenge the traditional physiopathology of ventilator-associated pneumonia (VAP); indeed, it also reinforces the need to include molecular techniques in VAP diagnosis and accelerate the use of immunomodulatory drugs, including corticosteroids, and other supplements such as probiotics for VAP prevention and/or treatment. With that stated, both microbiome and virome, including phageome, can lead to new opportunities in further understanding the relationship between health and dysbiosis in VAP. Previous knowledge may be, however, reconsidered at a microbiome scale.

Consensus on Language for Advance Informed Consent in Health Care-Associated Pneumonia Clinical Trials Using a Delphi Process

IMPORTANCE

Information to be included in advance informed consent forms for health care-associated pneumonia treatment trials remains to be determined.

OBJECTIVE

To identify and determine how to describe information to be included in an advance informed consent form for an early-enrollment noninferiority hospital-acquired and/or ventilator-associated bacterial pneumonia (HABP/VABP) clinical trial.

DESIGN, SETTING, AND PARTICIPANTS

A Delphi consensus process with stakeholders in HABP/VABP clinical trials was conducted using qualitative semistructured telephone interviews from June to August 2016, followed by 2 online surveys, the first from April to May 2017, and the second from September to October 2017. All stakeholders who participated in the interview were invited to participate in the first survey. Stakeholders who participated in the first survey were invited to participate in the second survey. Stakeholders were patients at risk of pneumonia, caregivers, representatives of institutional review boards, investigators, and study coordinators.

MAIN OUTCOMES AND MEASURES

Description and consensus of information to be included in advance informed consent forms for early enrollment in noninferiority HABP/VABP clinical trials.

RESULTS

Suggestions from 52 stakeholders about what key informed consent concepts to include and how to explain them were used to create 3 categories to be included in an advance consent form: (1) reassurances on patient health and treatment, (2) rationale for advance consent and early enrollment, and (3) an explanation of noninferiority. At the end of the Delphi process, at least 80% consensus was reached among the 40 stakeholders who participated in the second online survey on each of the statements to include in the proposed consent text. Throughout the process, however, describing and reaching consensus on statements about noninferiority was more problematic than the other categories.

CONCLUSIONS AND RELEVANCE

The stakeholders endorsed consent language to be used in combination with a strategy for enrolling patients at highest risk for pneumonia before infection onset. Data-driven consent language may help potential participants make informed decisions about their involvement in clinical research and improve enrollment rates, which are necessary to evaluate new treatments and improve patient care. The proposed consent language may be adapted for other trials using an early enrollment strategy and for noninferiority trials.

The etiology of neonatal pneumonia, complicated by bronchopulmonary dysplasia

BACKGROUND

The frequency of bronchopulmonary dysplasia (BPD) in preterm infants with a "ventilator-associated" pneumonia (VAP) ranges between 7 to 50%.

OBJECTIVE

To investigate the features of the etiological structure of neonatal pneumonia complicated by BPD, and to determine the sensitivity of pathogens to antibiotics.

METHODS

A retrospective chart review of 194 preterm infants with VAP, birth weight from 780 to 2820 g and gestational age from 27 to 37 weeks was conducted. A microbiological study of washings from the respiratory tract was conducted by standard qualitative and quantitative methods.

RESULTS

Respiratory tract infections caused by E. coli (with hemolytic properties), Enterococcus spp. (with hemolytic properties), Pseudomonas aeruginosa, Stenotrophomonas maltophilia, various types of mycoplasmas, Staphylococcus aureus, and Candida krusei were found 4- 13 times more frequent in preterm infants with BPD than in preterm infants without BPD and more mature infants with or without this complication. BPD developed 7- 11 times more frequent in preterm infants with prolonged VAP and change in pathogens than in preterm infants with VAP without change of agent. BPD developed 5- 7 times more frequent in preterm infants with the association of pathogens than in preterm infants with a monoinfection. Massive colonization of respiratory tract pathogens by 1- 3 days of life (lg4 colony forming units in 1 ml and above) was an unfavorable prognostic factor for the development of VAP, complicated by BPD.

CONCLUSION

The reduction in the frequency of BPD is might be possible with timeous and adequate antibacterial therapy of VAP.

Infectious Disease: Health Care-Associated Infections

Health care-associated infections (HAIs) are a major cause of morbidity and mortality, with 2 million US patients per year developing HAIs. This results in 90,000 deaths and billions of dollars in preventable expenses annually. Common HAIs include central line-associated bloodstream infection, catheter-related urinary tract infection, surgical site infection, hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), methicillin-resistant Staphylococcus aureus (MRSA) infection, Clostridium difficile infection (CDI), and others. Many factors contribute to HAIs, including inadequate hand hygiene by health care workers, inappropriate antibiotic use, increasing prevalence of multidrug-resistant organisms (MDROs), suboptimal disinfection and cleaning of hospital rooms and equipment, and use of invasive medical devices. HAP and VAP together represent the most common HAIs. Control of HAIs involves high- and low-tech solutions, including pulsed xenon light as a room disinfection adjunct, improving health care worker adherence to hand hygiene and standard precautions, as well as regular cleaning of cell phones and stethoscopes. Antibiotic stewardship programs have been shown to reduce inappropriate prescribing of antibiotics, a significant contributor to MDROs and CDI. Bundled interventions to control MRSA and CDI have been effective. Artificial intelligence applications likely will be involved in identification of patients at risk of HAIs in the future.

Ventilator-associated pneumonia in patients assisted by veno-arterial extracorporeal membrane oxygenation support: Epidemiology and risk factors of treatment failure

INTRODUCTION

Ventilator-associated pneumonia (VAP) is frequent in Intensive Care Unit (ICU) patients. In the specific case of patients treated with Veno-Arterial Extracorporeal Membrane Oxygenation Support (VA-ECMO), VAP treatment failures (VAP-TF) have been incompletely investigated.

METHODS

To investigate the risk factors of treatment failure (VAP-TF) in a large cohort of ICU patients treated with VA-ECMO, we conducted a retrospective study in a Surgical ICU about patients assisted with VA-ECMO between January 1, 2013, and December 31, 2014. Diagnosis of VAP was confirmed by a positive quantitative culture of a respiratory sample. VAP-TF was defined as composite of death attributable to pneumonia and relapse within 28 days of the first episode.

RESULTS

In total, 152 patients underwent ECMO support for > 48h. During the VA-ECMO support, 85 (55.9%) patients developed a VAP, for a rate of 60.6 per 1000 ECMO days. The main pathogens identified were Pseudomonas aeruginosa and Enterobacteriaceae. VAP-TF occurred in 37.2% of patients and was associated with an increased 28-day mortality (Hazard Ratio 3.05 [1.66; 5.63], P<0.001), and VA-ECMO assistance duration (HR 1.47 [1.05-2.05], P = 0.025). Risk factors for VAP-TF were renal replacement therapy (HR 13.05 [1.73; 98.56], P = 0.013) and documentation of Pseudomonas aeruginosa (HR 2.36 [1.04; 5.35], P = 0.04).

CONCLUSIONS

VAP in patients treated with VA-ECMO is associated with an increased morbidity and mortality. RRT and infection by Pseudomonas aeruginosa appear as strong risks factors of treatment failure. Further studies seem necessary to precise the best antibiotic management in these patients.

Knowledge and practices of critical care health professionals related to ventilator associated pneumonia in tertiary care hospitals of Islamabad and Rawalpindi

OBJECTIVE

To assess knowledge and practices of critical care health professionals related to ventilator associated pneumonia.

METHODS

This cross-sectional survey was conducted at eight tertiary care public and private hospitals of Islamabad/Rawalpindi, Pakistan, from September 2015 to March 2016, and comprised healthcare professionals. Stratified random sampling was used. Data was collected using close-ended validated questionnaire. SPSS 22 was used for data analysis.

RESULTS

Of the 153 participants, 45(29.4%) were doctors, 91(59.4%) were nurses and 17(11.1%) were respiratory therapists. The overall mean age was 31±8.14 years. The overall mean knowledge and practice scores regarding prevention of ventilator-associated pneumonia were 11.14±3.12 and 8.83±1.53, respectively. The mean knowledge score was 11.77±3.84 for physicians, 10.84± 2.91 for nurses and 10.82±1.94 for respiratory therapists. However, the best practice scores were seen in the respiratory therapists 9.64±0.78 (p=0.008).

CONCLUSIONS

The majority of the participants had adequate knowledge and even better practices, particularly respiratory therapists.

International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT)

The most recent European guidelines and task force reports on hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) were published almost 10 years ago. Since then, further randomised clinical trials of HAP and VAP have been conducted and new information has become available. Studies of epidemiology, diagnosis, empiric treatment, response to treatment, new antibiotics or new forms of antibiotic administration and disease prevention have changed old paradigms. In addition, important differences between approaches in Europe and the USA have become apparent.The European Respiratory Society launched a project to develop new international guidelines for HAP and VAP. Other European societies, including the European Society of Intensive Care Medicine and the European Society of Clinical Microbiology and Infectious Diseases, were invited to participate and appointed their representatives. The Latin American Thoracic Association was also invited.A total of 15 experts and two methodologists made up the panel. Three experts from the USA were also invited (Michael S. Niederman, Marin Kollef and Richard Wunderink).Applying the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology, the panel selected seven PICO (population-intervention-comparison-outcome) questions that generated a series of recommendations for HAP/VAP diagnosis, treatment and prevention.

Outcomes and risk factors of ventilator-associated pneumonia in neonates

BACKGROUND

Ventilator-associated pneumonia (VAP) in neonates has been associated with high mortality and poor outcome. This study aimed to compare the incidence, risk factors, and outcomes of VAP and non- VAP conditions in neonates.

METHODS

We performed a prospective cohort study in a neonatal intensive care unit (NICU) in Thailand from January 2014 to December 2014. All neonatal patients who were ventilated more than 48 hours were enrolled.

RESULTS

There were 128 enrolled patients. The median (inter quartile range) gestational age and birthweight were 35 (30.2, 37.8) weeks and 2380 (1323.8, 3020.0) g. There were 17 VAP patients (19 episodes) and 111 non-VAP ones. The VAP rate was 13.3% or 10.1 per 1000 ventilator days. According to the multivariate analysis, a birthweight less than 750 g [adjusted odds ratio (aOR)=10.75, 95% confidence interval (CI)=2.35-49.16; P=0.002] and sedative medication use (aOR=4.00, 95% CI=1.23-12.50; P=0.021) were independent risk factors for VAP. Compared with the non-VAP group, the median difference in the VAP group yielded a significantly longer duration of NICU stay (18 days, P=0.001), total length of hospital stay (16 days, P=0.002) and higher hospital costs ($5113, P=0.001). The inhospital mortality rate in the VAP and non-VAP groups was 17.6% and 15.3% (P=0.73), respectively.

CONCLUSIONS

A neonatal birthweight less than 750 g and sedative medication use were independent risk factors for VAP. Our VAP patients experienced a longer duration of both NICU and hospital stay, and incurred higher hospitalization costs.

Decreasing incidence and mortality among hospitalized patients suffering a ventilator-associated pneumonia: Analysis of the Spanish national hospital discharge database from 2010 to 2014

The aim of this study was to describe trends in the incidence and outcomes of ventilator-associated pneumonia (VAP) among hospitalized patients in Spain (2010-2014).This is a retrospective study using the Spanish national hospital discharge database from year 2010 to 2014. We selected all hospital admissions that had an ICD-9-CM code: 997.31 for VAP in any diagnosis position. We analyzed incidence, sociodemographic and clinical characteristics, procedures, pathogen isolations, and hospital outcomes.We identified 9336 admissions with patients suffering a VAP. Incidence rates of VAP decreased significantly over time (from 41.7 cases/100,000 inhabitants in 2010 to 40.55 in 2014). The mean Charlson comorbidity index (CCI) was 1.08 ± 0.98 and it did not change significantly during the study period. The most frequent causative agent was Pseudomonas and there were not significant differences in the isolation of this microorganism over time. Time trend analyses showed a significant decrease in in-hospital mortality (IHM), from 35.74% in 2010 to 32.81% in 2014. Factor associated with higher IHM included male sex, older age, higher CCI, vein or artery occlusion, pulmonary disease, cancer, undergone surgery, emergency room admission, and readmission.This study shows that the incidence of VAP among hospitalized patients has decreased in Spain from 2010 to 2014. The IHM has also decreased over the study period. Further investigations are needed to improve the prevention and control of VAP.

CO2 driven endotracheal tube cuff control in critically ill patients: A randomized controlled study

Background

To determine the safety and clinical efficacy of an innovative integrated airway system (AnapnoGuard^™ 100 system) that continuously monitors and controls the cuff pressure (P_cuff), while facilitating the aspiration of subglottic secretions (SS).

Methods

This was a prospective, single centre, open-label, randomized, controlled feasibility and safety trial. The primary endpoint of the study was the rate of device related adverse events (AE) and serious AE (SAE) as a result of using AnapnoGuard (AG) 100 during mechanical ventilation. Secondary endpoints were: (1) mechanical complications rate (2) ICU staff satisfaction; (3) VAP occurrence; (4) length of mechanical ventilation; (5) length of Intensive Care Unit stay and mortality; (6) volume of evacuated subglottic secretions.

Sixty patients were randomized to be intubated with the AG endotracheal-tube (ETT) and connected to the AG 100 system allowing P_cuff adjustment and SS aspiration; or with an ETT combined with SS drainage and P_cuff controlled manually.

Results

No difference in adverse events rate was identified between the groups. The use of AG system was associated with a significantly higher incidence of P_cuff determinations in the safety range (97.3% vs. 71%; p<0.01) and a trend to a greater volume of aspirated SS secretions: (192.0[64–413] ml vs. 150[50–200], p = 0.19 (total)); (57.8[20–88.7] ml vs. 50[18.7–62] ml, p = 0.11 (daily)). No inter-group difference was detected using AG system vs. controls in terms of post-extubation throat pain level (0 [0–2] vs. 0 [0–3]; p = 0.7), hoarseness (42.9% vs. 75%; p = 0.55) and tracheal mucosa oedema (16.7% vs. 10%; p = 0.65).

Patients enrolled in the AG group had a trend to reduced VAP risk of ventilator-associated pneumonia(VAP) (14.8% vs. 40%; p = 0.06), which were more frequently monomicrobial (25% vs. 70%; p = 0.03).

No statistically significant difference was observed in duration of mechanical ventilation, ICU stay, and mortality.

Conclusions

The use AG 100 system and AG tube in critically ill intubated patients is safe and effective in P_cuff control and SS drainage. Its protective role against VAP needs to be confirmed in a larger randomized trial.

Trial registration

ClinicalTrials.gov NCT01550978. Date of registration: February 21, 2012.

Ventilator-Associated Pneumonia: A Review

Ventilator-associated pneumonia is the most frequent intensive care unit (ICU)-related infection in patients requiring mechanical ventilation. In contrast to other ICU-related infections, which have a low mortality rate, the mortality rate for ventilator-associated pneumonia ranges from 20% to 50%. These clinically significant infections prolong duration of mechanical ventilation and ICU length of stay, underscoring the financial burden these infections impose on the health care system. The causes of ventilator-associated pneumonia are varied and differ across different patient populations and different types of ICUs. This varied presentation underscores the need for the intensivist treating the patient with ventilator-associated pneumonia to have a clear knowledge of the ambient microbiologic flora in their ICU. Prevention of this disease process is of paramount importance and requires a multifaceted approach. Once a diagnosis of ventilator-associated pneumonia is suspected, early broad-spectrum antibiotic administration decreases morbidity and mortality and should be based on knowledge of the sensitivities of common infecting organisms in the ICU. De-escalation of therapy, once final culture results are available, is necessary to minimize development of resistant pathogens. Duration of therapy should be based on the patient’s clinical response, and every effort should be made to minimize duration of therapy, thus further minimizing the risk of resistance.

THE IMPACT OF TRACHEOTOMY ON THE CLINICAL COURSE OF VENTILATOR-ASSOCIATED PNEUMONIA

Ventilator-associated pneumonia (VAP) is the most common infection among intensive care unit (ICU) patients. The aim of the present study was to evaluate the impact of tracheotomy on VAP clinical course. The study was conducted in a 15-bed Surgical and Neurosurgical ICU, Department of Anesthesiology and Intensive Care, Sestre milosrdnice University Hospital Center in Zagreb, Croatia. All patients developing VAP during ICU stay were eligible for the study. In VAP patients not tracheotomized during ICU stay, the mortality rate was approximately two times higher as compared with patients tracheotomized either before or after VAP onset (crude risk ratio 1.83, 95% confidence interval (95% CI) 1.15-2.91, p = 0.01; crude odds ratio 3.47, 95% CI 1.52-7.94; p = 0.003). In the surviving VAP patients, the duration of mechanical ventilation before VAP onset was higher in the "T before VAP" group as compared with the "no T before VAP" group (8, 6-10 vs. 3, 2-5; p < 0.001), but the number of post-VAP days on mechanical ventilation was shorter in "T before VAP" patients than in "no T before VAP" patients (0, 0-1 vs. 4, 3-9; p < 0.001). The duration of mechanical ventilation after VAP onset in the "T after VAP" group was longer as compared with the "T before VAP" group (4, 3-12 vs. 0, 0-1; p < 0.001). The present study indicated tracheotomy to be associated with a reduced duration of mechanical ventilation after VAP onset, but only if patients were tracheotomized at the moment of VAP onset.

[THE UTILITY OF BRONCHOSCOPY IN INTENSIVE CARE UNIT PATIENTS WITH VENTILATOR ASSOCIATED PNEUMONIA]

BACKGROUND

Ventilator associated pneumonia (VAPI is a common complication leading to lengthier hospitalizations and higher mortality. Prompt adequate initial antibiotic coverage is the crucial issue affecting survival. Currently, there is no gold standard diagnostic test. No conclusive data regarding the benefit of bronchoscopy exists in the literature reviewed.

AIM

This study aims to evaluate the change of prognosis for patients who developed VAP, following a positive culture from bronchoalveolar lavage (BAL).

DESIGN

This is a retrospective cohort study.

SETTING

General intensive care unit in a tertiary university healthcare center.

PARTICIPANTS

All patients who were admitted to Surgical ICU and developed VAP and who then underwent diagnostic bronchoscopy with BAL between the period 01/02/2007 - 31/02/2011.

MEASUREMENTS AND RESULTS

A total of 66 patients who were admitted to the ICU, developed VAP and underwent bronchoscopy while ventilated; 30 patients were excluded. The positive BAL culture group was compared to the negative BAL culture group; there was no difference between demographic and clinical characteristics, mortality rates (for 30 days) or therapy change between the two groups. No complications were reported regarding the bronchoscopy procedure.

CONCLUSIONS

Our findings demonstrate that performing y a diagnostic bronchoscopy with BAL does not improve the prognosis of patients with VAP. Furthermore, expanded prospective studies will be needed to conclude regarding its benefit in diagnosis and subsequent rectifying of therapy.

[THE DIAGNOSTIC AND THERAPEUTIC BRONCHOSCOPY IN CARDIAC PATIENTS UNDERGOING MECHANICAL VENTILATION IN THE POSTOPERATIVE PERIOD]

The review presents an analysis of domestic and foreign literature on the use of bronchoscopy in patients with obstructive respiratory failure in the ICU. Separately considered the issue of additional research when performing bronchoscopy and create an algorithmfor the application of diagnostic and therapeutic bronchoscopy in cardiac surgical patients undergoing mechanical ventilation.

Treatment of ventilator-associated pneumonia and ventilator-associated tracheobronchitis in the intensive care unit. A national survey of clinicians and pharmacists in Saudi Arabia

OBJECTIVES

To assess current practices of different healthcare providers for treating extensively drug-resistant (XDR)  Acinetobacter baumannii (AB) infections  in tertiary-care centers in Saudi Arabia. 

METHODS

This cross-sectional study was performed in  tertiary-care centers of Saudi Arabia between March and June 2014. A questionnaire consisting of 3 parts (respondent characteristics; case scenarios on ventilator-associated pneumonia [VAP] and tracheobronchitis [VAT], and antibiotic choices in each scenario) was developed and sent electronically to participants in 34 centers across Saudi Arabia. 

RESULTS

One-hundred and eighty-three respondents completed the survey. Most of the respondents (54.6%) preferred to use colistin-based combination therapy to treat VAP caused by XDR AB, and 62.8% chose to continue treatment for 2 weeks. Most of the participants (80%) chose to treat VAT caused by XDR AB with intravenous antibiotics. A significant percentage of intensive care unit (ICU) fellows (41.3%) and clinical pharmacists (35%) opted for 2 million units (mu) of colistin every 8 hours without a loading dose, whereas 60% of infectious disease consultants, 45.8% of ICU consultants, and 44.4% of infectious disease fellows preferred a 9 mu loading dose followed by 9 mu daily in divided doses. The responses for the scenarios were different among healthcare providers (p less than 0.0001). 

CONCLUSION

Most of the respondents in our survey preferred to use colistin-based combination therapy and intravenous antibiotics to treat VAP and VAT caused by XDR AB. However, colistin dose and duration varied among the healthcare providers.

Ventilator-associated pneumonia: present understanding and ongoing debates

INTRODUCTION

Ventilator-associated pneumonia (VAP) is a common cause of nosocomial infection, and is related to significant utilization of health-care resources. In the past decade, new data have emerged about VAP epidemiology, diagnosis, treatment and prevention.

RESULTS

Classifying VAP strictly based on time since hospitalization (early- and late-onset VAP) can potentially result in undertreatment of drug-resistant organisms in ICUs with a high rate of drug resistance, and overtreatment for patients not infected with resistant pathogens. A combined strategy incorporating diagnostic scoring systems, such as the Clinical Pulmonary Infection Score (CPIS), and either a quantitative or qualitative microbiological specimen, plus serial measurement of biomarkers, leads to responsible antimicrobial stewardship. The newly proposed ventilator-associated events (VAE) surveillance definition, endorsed by the Centers for Disease Control and Prevention, has low sensitivity and specificity for diagnosing VAP and the ability to prevent VAE is uncertain, making it a questionable surrogate for the quality of ICU care. The use of adjunctive aerosolized antibiotic treatment can provide high pulmonary concentrations of the drug and may facilitate shorter durations of therapy for multi-drug-resistant pathogens. A group of preventive strategies grouped as a 'ventilator bundle' can decrease VAP rates, but not to zero, and several recent studies show that there are potential barriers to implementation of these prevention strategies.

CONCLUSION

The morbidity and mortality related to VAP remain high and, in the absence of a gold standard test for diagnosis, suspected VAP patients should be started on antibiotics based on recommendations per the 2005 ATS guidelines and knowledge of local antibiotic susceptibility patterns. Using a combination of clinical severity scores, biomarkers, and cultures might help with reducing the duration of therapy and achieving antibiotic de-escalation.

[Experience of using endotoxin selective adsorption in patients with severe sepsis after open-heart surgery]

PURPOSE OF THE STUDY

To evaluate the safety and effectiveness of selective lipopolysaccharide (LPS)-adsorption therapy using polymyxin B immobilised fibre cartridges in adult patients complicated with severe sepsis after cardiac surgery.

METHODS

105 patients received extracorporeal LPS-adsorption procedures using Toraymyxin columns--PMX (Toray, Japan) in addition to the standard treatment according to the Surviving Sepsis Campaign guideline study group. For control group we selected 40 patients, comparable by PMX group in age, body weight, severity of illness, and the duration of cardiopulmonary bypass, received only standard therapy. All patients received significant doses of vasoactive drugs for hemodynamic support, mechanical ventilation and broad-spectrum antibiotics. Mean APACHE II and SOFA scores were comparable for both groups. Inclusion criteria were: clinical signs of severe sepsis, endotoxin activity assay (EAA) > or = 0.6, elevated blood plasma procalcitonin (PCT) > 2 ng ml(-1). The inclusion criteria were clinical signs of severe sepsis, endotoxin activity assay (EAA) > or = 0.6, and blood plasma procalcitonin (PCT) > 2 ng ml(-1).

RESULTS

Extracorporeal treatment was administered within 24 h of a severe sepsis diagnosis. Each patient in PMX group received 2 LPS-adsorption procedures and each session of hemoperfusion lasted for 120 minutes. After the LPS-adsorption course, we noted any indices of haemodynamic improvements, including an increase in mean arterial pressure on 22% (p < 0.001), mean oxygenation index (on 24.5%, p < 0.001), normalisation of leukocytosis and a decrease in mean body temperature. After the procedures of LPS-adsorption we found the statistically significant decreasing of LPS concentrations according to LAL-test and EAA. In the control group, there were no significant changes in any of the studied parameters except body temperature. Moreover, the 28-day mortality was 42% in the study group and 65% in the control group (p = 0.032). The endotoxin adsorption procedures were not associated with any adverse reactions, and specifically no extracorporeal circuit thrombosis cases were noted.

CONCLUSION

Selective LPS-adsorption is a safe and effective additional treatment method for severe sepsis patients.

Healthcare-associated infections in the hospitalized neonate: a review

Healthcare-associated infections in the neonatal intensive care unit add considerably to hospital stays and costs, and contribute to numerous adverse outcomes, including death. The relatively high prevalence of healthcare-associated infections among neonates is secondary to the newborn's underdeveloped immune system, the need for frequent invasive procedures, and generally prolonged hospitalization. Central line associated bloodstream infections (CLABSI) are the most common form of healthcare-associated infection, with coagulase-negative Staphylococcus species (CONS) being the most commonly cultured microorganism. Interpretation of culture results in the setting of any suspected healthcare-associated infection can be made difficult by the possibility that a recovered organism represents a commensal contaminant, rather than an actual cause of infection. This is especially true in the case of a blood culture that grows CONS during evaluation for suspected CLABSI. This article provides an overview of the epidemiology, diagnosis, prevention, and treatment of healthcare-associated infections in the NICU.

Clinical analysis of optimal timing for application of noninvasive positive pressure ventilation in treatment of AECOPD patients

OBJECTIVES

This study is conducted to investigate an optimal timing of sequential noninvasive positive pressure ventilation (NPPV) applied for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

PATIENTS AND METHODS

Application of NPPV for 102 patients was randomly observed in the conditions of a 2-hour spontaneous breathing trial (SBT-2) and pulmonary infection control (PIC) window. Efficiency of NPPV in treatment of the patients, an incidence rate of tracheal reintubation, length of time for patients received invasive mechanical ventilation, and a morbidity rate of ventilator-associated pneumonia were examined in each group of 51 patients.

RESULTS

The incidence rates for the patients treated successfully with NPPV and for tracheal reintubation were shown as 88.2 and 60.8, and 11.8 and 39.2 in SBT-2 and PIC, respectively (both p < 0.05). Length of time (hour) for use of the invasive ventilation was 116 and 82.5 in SBT-2 and PIC, respectively (p < 0.05). There was a similar morbidity rate of ventilator-associated pneumonia seen in both groups.

CONCLUSIONS

SBT-2 would be the optimal timing considered to use NPPV for AECOPD patients based on a high success rate and a low risk of tracheal reintubation.

Role of combined procalcitonin and lipopolysaccharide-binding protein as prognostic markers of mortality in patients with ventilator-associated pneumonia

AIM

to investigate the role of combined Lipopolysaccharide-Binding Protein (LBP) and Procalcitonin (PCT) ) as prognostic marker of mortality in patients with Ventilator-Associated Pneumonia (VAP).

METHODS

this prospective cohort study was held in ICU/HCU of Cipto Mangunkusumo hospital between 2006 to 2007 by taking the subjects consecutively. Thirty five patients with VAP were studied. For analysing the data, chi-square or its alternative Fisher exact test were used. Based on a previous study for evaluation, we used cut off pants of 5 ng/ml and 0.5 ng/ml for PCT and 30 µg/ml and 25 µg/ml for LBP after three-day and seven-day treatment respectively. Receiver operating curve was made to determine the sensitivity and specificity of PCT and LBP as infection markers.

RESULTS

35 patients participated in this study. After three days of therapy, if the level of PCT >5 ng/mL and LBP >30 µg/mL the prognosis would be bad (p<0.05) with a sensitivity of 88.5%, specificity of 53.2% and AUC value 0.69. Poor prognosis was also found if after seven day therapy PCT level was >0.5 ng/mL and LBP level >25 µg/mL (p<0.05) with sensitivity of 96.3%, specificity of 66.7% and AUC value 0.81.

CONCLUSION

examination of combined PCT and LBP can be taken as a good prognostic markers to predict mortality in patients with VAP.

Potentially resistant microorganisms in intubated patients with hospital-acquired pneumonia: the interaction of ecology, shock and risk factors

PURPOSE

As per 2005 American Thoracic Society and Infectious Disease Society of America (ATS/IDSA) guidelines for managing hospital-acquired pneumonia, patients with early-onset pneumonia and without risk factors do not need to be treated for potentially resistant microorganisms (PRM).

METHODS

This was a secondary analysis of a prospective, observational, cohort, multicentre study conducted in 27 ICUs from nine European countries.

RESULTS

From a total of 689 patients with nosocomial pneumonia who required mechanical ventilation, 485 patients with confirmed etiology and antibiotic susceptibility were further analysed. Of these patients, 152 (31.3 %) were allocated to group 1 with early-onset pneumonia and no risk factors for PRM acquisition, and 333 (68.7 %) were classified into group 2 with early-onset pneumonia with risk factors for PRM or late-onset pneumonia. Group 2 patients were older and had more chronic renal failure and more severe illness (SAPS II score, 44.6 ± 16.5 vs. 47.4 ± 17.8, p = 0.04) than group 1 patients. Trauma patients were more frequent and surgical patients less frequent in group 1 than in group 2 (p < 0.01). In group 1, 77 patients (50.7 %) had PRM in spite of the absence of classic risk factors recognised by the current guidelines. A logistic regression analysis identified that presence of severe sepsis/septic shock (OR = 3.7, 95 % CI 1.5-8.9) and pneumonia developed in centres with greater than 25 % prevalence of PRM (OR = 11.3, 95 % CI 2.1-59.3) were independently associated with PRM in group 1 patients.

CONCLUSIONS

In patients admitted to ICUs with a prevalence of PRM greater than 25 % or with severe sepsis/septic shock, empiric therapy for group 1 nosocomial pneumonia requiring mechanical ventilation should also include agents likely to be effective for PRM pathogens.

Protective ventilation in experimental acute respiratory distress syndrome after ventilator-induced lung injury: a randomized controlled trial

Background

Low tidal volume (V_T), PEEP, and low plateau pressure (P_PLAT) are lung protective during acute respiratory distress syndrome (ARDS). This study tested the hypothesis that the aspiration of dead space (ASPIDS) together with computer simulation can help maintain gas exchange at these settings, thus promoting protection of the lungs.

Methods

ARDS was induced in pigs using surfactant perturbation plus an injurious ventilation strategy. One group then underwent 24 h protective ventilation, while control groups were ventilated using a conventional ventilation strategy at either high or low pressure. Pressure–volume curves (P_el/V), blood gases, and haemodynamics were studied at 0, 4, 8, 16, and 24 h after the induction of ARDS and lung histology was evaluated.

Results

The P_el/V curves showed improvements in the protective strategy group and deterioration in both control groups. In the protective group, when respiratory rate (RR) was ≈60 bpm, better oxygenation and reduced shunt were found. Histological damage was significantly more severe in the high-pressure group. There were no differences in venous oxygen saturation and pulmonary vascular resistance between the groups.

Conclusions

The protective ventilation strategy of adequate pH or Pa_CO2 with minimal V_T, and high/safe P_PLAT resulting in high PEEP was based on the avoidance of known lung-damaging phenomena. The approach is based upon the optimization of V_T, RR, PEEP, I/E, and dead space. This study does not lend itself to conclusions about the independent role of each of these features. However, dead space reduction is fundamental for achieving minimal V_T at high RR. Classical physiology is applicable at high RR. Computer simulation optimizes ventilation and limiting of dead space using ASPIDS. Inspiratory P_el/V curves recorded from PEEP or, even better, expiratory P_el/V curves allow monitoring in ARDS.

Fighting fire with fire: is it time to use probiotics to manage pathogenic bacterial diseases?

Probiotics, when considered in clinical practice, have traditionally been used for prophylaxis; however, there is growing data suggesting treatment benefits in numerous disease states. In this review, we focus on probiotics as treatment for and prevention of several acute and chronic infectious processes including Helicobacter pylori, Clostridium difficile, necrotizing enterocolitis, ventilator-associated pneumonia, vancomycin-resistant enterococci, and nonalcoholic fatty liver disease. It is inaccurate to generalize findings observed in a single probiotic species to all probiotics. This reasoning is due to the variability of colonizing abilities of native intestinal floras, probiotic or otherwise, secondary to different combinations, doses, and duration of treatments. Given these limitations, multiple animal and human studies have shown anti-inflammatory and selective antimicrobial effects of specific probiotics. Some studies suggest a role for probiotics as supplemental treatment, in combination with antibiotics, for the aforementioned disease processes. It is apparent from this review that the efficacy of probiotics is widely variable and multifaceted. More focused clinical and basic science research is necessary to better understand the treatment potential of various probiotics.

Positive end-expiratory pressure following coronary artery bypass grafting

BACKGROUND

Cardiac surgery-related pulmonary complications include alterations in lung mechanics and anomalies in gas exchange. Higher levels of positive end-expiratory pressure (PEEP) have been suggested to benefit cardiac surgical patients. We compared respiratory compliance, arterial oxygenation and time till tracheal extubation in 2 cohorts of patients weaned from mechanical ventilation with different levels of PEEP after elective and uncomplicated coronary artery bypass grafting (CABG). We hypothesized that higher PEEP levels improve pulmonary compliance and gas exchange in the first hours of weaning from mechanical ventilation, but not to shorten time till tracheal extubation.

METHODS

Secondary retrospective analysis of 2 randomized controlled trials: in the first trial patients were weaned with PEEP levels of 10 cmH2O for the first 4 hours followed by PEEP levels of 5 cmH2O until tracheal extubation (high PEEP, HP); and the second trial patients were weaned with PEEP levels of 5 cmH2O during the entire weaning phase (low PEEP, LP). The primary endpoint was pulmonary compliance. Secondary endpoints included arterial oxygenation, duration of mechanical ventilation and postoperative pulmonary complications.

RESULTS

The analysis included 121 patients; 60 HP patients and 61 LP patients. Baseline characteristics were similar. Compared to LP patients, HP patients had a better pulmonary compliance, 47.2±14.1 versus 42.7±10.2 ml/cmH2O (P<0.05), and higher levels of PaO2, 18.5±6.6 (138.75±49.5) versus 16.7±5.4 (125.25±40.5) kPa (mmHg) (P<0.05). Patients in the HP group were less frequent in need of supplementary oxygen after ICU discharge. These differences remained present during the entire weaning phase, even after reduction of PEEP. However, HP patients had a longer time till tracheal extubation, 16.9±6.1 versus 10.5±5.0 hours (P<0.001). HP patients had longer durations of postoperative infusion of propofol, 4.9 (2.6-7.4) versus 3.5 (1.8-5.8) hours (P<0.05). There were no differences in use of inotropes. Cumulative fluid balances were slightly higher in HP patients.

CONCLUSION

Use of higher PEEP levels after elective uncomplicated CABG improves pulmonary compliance and oxygenation but seems to be associated with a delay in tracheal extubation.

Synbiotics and probiotics in the critically ill after the PROPATRIA trial

PURPOSE OF REVIEW

Recent clinical trials have furthered our understanding of the role of probiotic and synbiotic therapy across a variety of diverse diseases including antibiotic-associated diarrhea, Clostridium difficile associated diarrhea, acute pancreatitis, ventilator-associated pneumonia, and sepsis among others. Although each of these conditions has implications for critically ill patients, relatively few studies have specifically studied this vulnerable population.

RECENT FINDINGS

One recent clinical trial studying probiotics in severe pancreatitis (the PROPATRIA trial) found an unexpected increase in mortality in probiotic-treated patients. These results stimulated an immediate, extensive, and badly overdue discussion focused on the need for improved safety monitoring during the execution of all clinical trials using probiotics. However, issues with the design, execution, and analysis of PROPATRIA ultimately created more questions than it answered.

SUMMARY

Regardless of technical issues with the study, the increased mortality seen with probiotics cannot be ignored. As a result, various regulatory agencies have clarified their stance on the safety of probiotic research and the legacy of PROPATRIA is increasingly stringent regulation of this fledgling niche.

Effects of hypercapnia and hypercapnic acidosis on attenuation of ventilator-associated lung injury

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are associated with impaired gas exchange, severe inflammation and alveolar damage including cell death. Patients with ALI or ARDS typically experience respiratory failure and thus require mechanical ventilation for support, which itself can aggravate lung injury. Recent developments in this field have revealed several therapeutic strategies that improve gas exchange, increase survival and minimize the deleterious effects of mechanical ventilation. Among those strategies is the reduction in tidal volume and allowing hypercapnia to develop during ventilation, or actively inducing hypercapnia. Here, we provide an overview of hypercapnia and the hypercapnic acidosis that typically follows, as well as the therapeutic effects of hypercapnia and acidosis in clinical studies and experimental models of ALI. Specifically, we review the effects of hypercapnia and acidosis on the attenuation of pulmonary inflammation, reduction of apoptosis in alveolar epithelial cells, improvement in sepsis-induced ALI and the therapeutic effects on other organ systems, as well as the potentially harmful effects of these strategies. The clinical implications of hypercapnia and hypercapnic acidosis are still not entirely clear. However, future research should focus on the intracellular signaling pathways that mediate ALI development, potentially focusing on the role of reactive biological species in ALI pathogenesis. Future research can also elucidate how such pathways may be targeted by hypercapnia and hypercapnic acidosis to attenuate lung injury.

Bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia: to quantitate or not, that is the question

Quantitative bronchoalveolar lavage (BAL) is used to diagnose ventilator-associated pneumonia (VAP). We prospectively compared semiquantitative (SQ) and quantitative (Qu) culture of BAL for VAP diagnosis. Ventilated patients suspected of VAP underwent bronchoscopic BAL. BAL fluid was examined by both Qu (colony-forming units [CFUs]/mL) and SQ culture (none, sparse, moderate, or heavy) and results were compared. VAP was defined as 10⁵ CFU/mL or greater on Qu culture. Over 36 months, 319 BALs were performed. Sixty-three of 319 (20%) showed diagnostic growth by Qu culture identifying a total of 81 organisms causing VAP. All 63 specimens showed growth of some organism(s) on SQ culture with 79 of 81 causative organisms identified and two (Pseudomonas, one; Corynebacterium, one) not identified. The remaining 256 specimens did not meet the threshold for VAP by the Qu method. Among these, 79 did not show any growth on SQ culture. Among the 240 specimens showing some growth on SQ culture, a total of 384 organisms were identified. VAP rates in relation to strength of growth on SQ culture were: sparse, 10 of 140 (7%); moderate, 24 of 147 (16%); and heavy, 45 of 97 (46%). Sensitivity (Sn), specificity (Sp), positive (PPV), and negative (NPV) predictive values of SQ culture of BAL fluid for the diagnosis of VAP were 97, 21, 21, and 97 per cent, respectively. Nonquantitative culture of BAL fluid is fairly accurate in ruling out VAP (high Sn and NPV). It however has poor Sp and PPV and using this method will lead to unnecessary antimicrobial use with its attendant complications of toxicity, cost, and resistance.

[Early diagnosis and tactics of respiratory therapy in patients with ventilation-associated pneumonia]

The study included 70 patients undergone prolonged artificial ventilation (AV) in the early postoperative period. The early diagnosis of pneumonia was established on the basis of the maximum light flux rate (MLFR) of an expired air condensate. In this study 36 hours after the initiation of respiratory support there was a significant increase in MLFR of spontaneous and induced luminescence in the group in which the patients subsequently developed ventilation-associated pneumonia as compared with that in which the patients did not develop pneumonia, which allowed its early diagnosis to be made. Various AV modes were comparatively analyzed in patients with ventilation-associated pneumonia. Respiratory support was used in tandem in the following modes: controlled volume ventilation (IPPV), volume- and pressure-regulated ventilation (IPPV Auto Follow), and biphasic pressure support ventilation (BPSV). In each mode of ventilation, blood gas composition was studied and the resultant values of AV were recorded. As compared with IPPV and BPSV, IPPV Auto Follow was significantly characterized by the least pressure drop in the respiratory circuit (p < 0.05), which corresponded to the concept of safe respiratory support.

[Application of endotracheal lavage in neonatal ventilator-associated pneumonia]

OBJECTIVE

To study the efficacy of endotracheal lavage in neonatal ventilator-associated pneumonia (VAP).

METHODS

Fifty-eight neonates with VAP between January 2002 and December 2008 were randomly assigned to two groups: lavage and control (n=29 each). After withdrawal from ventilator, both groups received sensitive antibiotics therapy according to sputum culture results as well as supportive treatment. The lavage group was additionally treated with endotracheal lavage (2-3 times daily). The therapeutic effects were compared between the two groups.

RESULTS

There were no significant differences in the average time of mechanical ventilation between the lavage and the control groups. The effective rate in the lavage group (93%) was significantly higher than that in the control group (69%; p<0.05). Three percent of patients in the lavage group required twice or more mechanical ventilation compared with 24% in the control group (p<0.05). Blood gas analysis results were obviously improved in the lavage group 2 hrs after treatment (p<0.01).

CONCLUSIONS

Endotracheal lavage can decrease the number in mechanical ventilation and improve therapeutic effects in neonates with VAP.

[Problem of infection in the ICU]

There are many infectious diseases related to the treatment such as ventilator-associated pneumonia, catheter-associated urinary tract infection, catheter-related bloodstream infection, surgical site infection, and clostridium difficile-associated diarrhea, characteristic of the infectious disease in the ICU. As a complication of the use of the medical devices, you should consider the risk of the infection. For infection caused by multi-drug resistant bacteria such as MRSA, Pseudomonas aeruginosa, attention for horizontal infection in the ICU is necessary, and proper use of antibiotics and enforcement of the standard precaution are important.

Hospital-acquired pneumonia and ventilator-associated pneumonia in adults at Siriraj Hospital: etiology, clinical outcomes, and impact of antimicrobial resistance

BACKGROUND

Nosocomial pneumonia (NP), hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), is an important cause of morbidity and mortality in hospitalized patients. One of the factors contributing to a high mortality rate of HAP and VAP could be antibiotic resistance among the causative agents.

OBJECTIVE

To determine prevalence of bacterial pathogens clinical features, risk factors of HAP and VAP, antimicrobial resistance among major respiratory pathogens, clinical implication of antimicrobial resistance, antimicrobial regimens used, and treatment outcomes of adult patients with HAP and VAP at Siriraj Hospital.

MATERIAL AND METHOD

This was a prospective, hospital-based, active surveillance study on HAP and VAP in hospitalized adults at Siriraj Hospital from December 2007 to March 2009. The patients with HAP and VAP were followed prospectively until they expired or were discharged from the hospital.

RESULTS

One hundred and forty-six adult patients were included. Seventy percent of the patients were males with the mean age of 70.8 years. HAP was accounted for 24.7% and VAP 75.3%. Most of the patients (82.9%) had late-onset HAP or VAP with the median day of onset of pneumonia of 11 days. Two third of the patients were hospitalized in general medical wards. Bronchopneumonia was observed in 53.4% and multilobar pneumonia in 24.7%. A. baumanni was the most common isolated pathogen and 92.3% of them were multidrug-resistant (MDR) or pandrug-resistant (PDR). The other common isolated pathogens were K. pneumoniae, P. aeruginosa and methicillin-resistant S. aureus (MRSA). Carbapenem was the most commonly used initial antibiotic (45.9%) followed by colistin (21.9%) and cephalosporins (21.1%). The concordance of initial antibiotics was 58.9%. Antibiotics were modified 43.8% of the patients. Colistin was the most commonly used modified antibiotic followed by carbapenem. The modified antibiotics were concordant with isolated bacteria in 98.4%. The patients received mechanical ventilators in 81.5% with the median ventilator day of 10 days. At the initial response (72 hours after antibiotic therapy), an improvement was 56.8% and a mortality rate due to pneumonia was 14.4%. Death due to pneumonia at the end of treatment was 42.5%. The 30-day mortality from pneumonia was 45.9%. There were no significant differences in the outcomes of pneumonia between HAP and VAP. The factors associated with PDR-organisms were late-onset hospital-acquired pneumonia and previous carbapenem usage within 72 hours. Septic shock and bilateral lung involvement were significantly associated with unfavorable outcomes at 72 hours. Septic shock, severe sepsis, and previous carbapenem usage within 72 hours were significantly associated with mortality at the end of treatment and at 30 days after developing pneumonia.

CONCLUSION

HAP and VAP remain to be very important hospital-acquired infections at Siriraj Hospital. The isolated pathogens are usually multidrug-resistant and the mortality rate remains high. The local data on prevalence of the isolated pathogens and their antibiotic susceptibility may help clinicians choose more appropriate initial antibiotics in order to improve the outcome and to decrease the emergence of resistant organisms.

[Multidrug-resistant Acinetobacter baumannii infection in respiratory intensive care unit]

Multidrug-resistant Acinetobacter boumannii is a challenge in the treatment and control of nosocomial infections. This retrospective study was aimed to investigate the prevalence of multidrug resistant A. boumannii in a respiratory intensive care unit (ICU), related risk factors and its impact on disease prognosis. Of 218 patients who were hospitalized in our ICU during the last two years; 37 (17%) patients (21 males, mean age 61.6 +/- 19.8 years) developed pneumonia and/or bacteremia due to multidrug-resistant A. baumannii. Previous antibiotic therapy was detected in 51.4% and hospitalization in 70.3% of the cases. Pneumonia (59.5%) was the most frequent cause of hospitalization and chronic obstructive pulmonary disease (21.6%) was the second one; 81.1% of patients had co-morbidity. Invasive mechanical ventilation was performed in 31 (83.7%) patients during the follow-up. Ventilator-associated pneumonia developed in 22 (59.5%) patients and bacteraemia in 9 (24.3%) patients. Multidrug-resistance was observed in 23 (62.2%) of patients. Highest rates of resistance (100%) was detected against piperacillin-tazobactam, ampicillin-sulbactam and ciprofloxacin, followed by imipenem and cefepime (78%), meropenem and ceftazidime (55%), cefoperazone-sulbactam (43%) and netilmicin (35.1). The rates of re-intubation and tracheotomy were higher in patients infected with A. boumannii compared to the control group (59.5% vs. 7.7%, p < 0.0001 and 21.6% vs. 3.9%, p = 0.001, respectively). There was no significant difference between two groups in terms of mortality, however, durations of ICU and hospital stays were longer in patients with multidrug-resistant A. baumannii infection than without infection (24.2 +/- 18.3 vs. 8.2 +/- 8.3 days, p < 0.001 and 33.3 +/- 19.8 vs. 15.4 +/- 11.4 days, p < 0.001, respectively). In conclusion, due to the high rates of drug-resistance in nosocomial A.baumannii isolates, the use of invasive procedures and durations of ICU and hospital stays exhibit an increasing trend.

Collaborative strategies for improving clinical resource utilization: how pharmacists can make a difference

BACKGROUND

Ventilator-associated pneumonia (VAP) is associated with substantial health care costs that place a significant burden on scarce hospital resources. Preventative measures and appropriate management strategies can be effective in reducing the incidence of VAP and in improving VAPrelated resource utilization.

OBJECTIVE

To provide an overview of the economic costs associated with VAP and of strategies that can be used to meet the goals of improving the efficiency of resource utilization without negatively impacting clinical outcomes.

SUMMARY

The substantial costs attributed to VAP are mainly due to the prolonged hospital length of stay (LOS) associated with these patients. Initial appropriate antimicrobial therapy is critical in achieving successful outcomes-including reducing LOS, mechanical ventilation days, and mortality. Initial treatment includes combination therapy when a multidrug-resistant pathogen or Pseudomonas aeruginosa is suspected. Once microbiologic results are available, de-escalation of therapy should be considered to reduce the unnecessary use of antimicrobials without impacting clinical outcomes. VAP prevention programs can also be an effective means to improve resource utilization in hospitals, although it is important to adopt a multidisciplinary team approach for acceptance of such programs and adherence to them.

CONCLUSION

In the current health care environment of increased transparency and accountability, renewed efforts must be made to not only prevent VAP but also to appropriately manage patients with VAP. All health care personnel involved in the management of patients with VAP must take a proactive role in reducing its incidence.

[Ventilator-associated pneumonia]

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in critical care medicine and has been shown to be an independent risk factor for mortality. However, ventilator induced lung injury itself is probably only a minor factor predisposing to VAP. In contrast, invasive ventilation using an endotracheal tube is obviously a more important measure. Thus, microaspiration of potentially infectious secretion from the oropharynx into the trachea along the tube has been suggested to be the most critical pathophysiological event in the process of VAP development. Accordingly, non-invasive ventilation provides a decreased risk of VAP. Therefore, all measures aimed at averting microaspiration or shorten the duration of mechanical ventilation are appropriate to prevent VAP. Moreover, oropharyngeal decontamination may be helpful by reducing bacterial colonisation. Effectiveness of therapy depends on early treatment and therefore requires early diagnosis. With this aim combined clinical, radiologic, and microbiological parameters should be taken into account. Adequate antimicrobial therapy in due consideration for individual risk factors and local antibiotic resistance is the most important therapeutic measure.

Evidence-based algorithms for diagnosing and treating ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia (VAP) is widely recognized as a serious and common complication associated with high morbidity and high costs. Given the complexity of caring for heterogeneous populations in the intensive care unit (ICU), however, there is still uncertainty regarding how to diagnose and manage VAP.

OBJECTIVE

We recently conducted a national collaborative aimed at reducing health care-associated infections in ICUs of hospitals operated by the Hospital Corporation of America (HCA). As part of this collaborative, we developed algorithms for diagnosing and treating VAP in mechanically ventilated patients. In the current article, we (1) review the current evidence for diagnosing VAP, (2) describe our approach for developing these algorithms, and (3) illustrate the utility of the diagnostic algorithms using clinical teaching cases.

DESIGN

This was a descriptive study, using data from a national collaborative focused on reducing VAP and catheter-related bloodstream infections.

SETTING

The setting of the study was 110 ICUs at 61 HCA hospitals.

INTERVENTION

None.

MEASUREMENTS AND RESULTS

We assembled an interdisciplinary team that included infectious disease specialists, intensivists, hospitalists, statisticians, critical care nurses, and pharmacists. After reviewing published studies and the Centers for Disease Control and Prevention VAP guidelines, the team iteratively discussed the evidence, achieved consensus, and ultimately developed these practical algorithms. The diagnostic algorithms address infant, pediatric, immunocompromised, and adult ICU patients.

CONCLUSIONS

We present practical algorithms for diagnosing and managing VAP in mechanically ventilated patients. These algorithms may provide evidence-based real-time guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem.

Health care-associated pneumonia: identification and initial management in the ED

Traditionally, pneumonia is categorized by epidemiologic factors into community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Microbiologic studies have shown that the organisms which cause infections in HAP and VAP differ from CAP in epidemiology and resistance patterns. Patients with HAP or VAP are at higher risk for harboring resistant organisms. Other historical features that potentially place patients at a higher risk for being infected with resistant pathogens and organisms not commonly associated with CAP include history of recent admission to a health care facility, residence in a long-term care or nursing home facility, attendance at a dialysis clinic, history of recent intravenous antibiotic therapy, chemotherapy, and wound care. Because these "risk factors" have health care exposure as a common feature, patients presenting with pneumonia having these historical features have been more recently categorized as having health care-associated pneumonia (HCAP). This publication was prepared by the HCAP Working Group, which is comprised of nationally recognized experts in emergency medicine, infectious diseases, and pulmonary and critical care medicine. The aim of this article is to create awareness of the entity known as HCAP and to provide knowledge of its identification and initial management in the emergency department.