Optimizing Diagnosis and Management of Community-acquired Pneumonia in the Emergency Department

Pneumonia is split into 3 diagnostic categories: community-acquired pneumonia (CAP), health care-associated pneumonia, and ventilator-associated pneumonia. This classification scheme is driven not only by the location of infection onset but also by the predominant associated causal microorganisms. Pneumonia is diagnosed in over 1.5 million US emergency department visits annually (1.2% of all visits), and most pneumonia diagnosed by emergency physicians is CAP.

Ventilator-associated pneumonia related to extended-spectrum beta-lactamase producing Enterobacterales during severe acute respiratory syndrome coronavirus 2 infection: risk factors and prognosis

BACKGROUND

Patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) and requiring mechanical ventilation suffer from a high incidence of ventilator associated pneumonia (VAP), mainly related to Enterobacterales. Data regarding extended-spectrum beta-lactamase producing Enterobacterales (ESBL-E) VAP are scarce. We aimed to investigate risk factors and outcomes of ESBL-E related VAP among critically ill coronavirus infectious disease-19 (COVID-19) patients who developed Enterobacterales related VAP.

PATIENTS AND METHODS

We performed an ancillary analysis of a multicenter prospective international cohort study (COVID-ICU) that included 4929 COVID-19 critically ill patients. For the present analysis, only patients with complete data regarding resistance status of the first episode of Enterobacterales related VAP (ESBL-E and/or carbapenem-resistant Enterobacterales, CRE) and outcome were included.

RESULTS

We included 591 patients with Enterobacterales related VAP. The main causative species were Enterobacter sp (n = 224), E. coli (n = 111) and K. pneumoniae (n = 104). One hundred and fifteen patients (19%), developed a first ESBL-E related VAP, mostly related to Enterobacter sp (n = 40), K. pneumoniae (n = 36), and E. coli (n = 31). Eight patients (1%) developed CRE related VAP. In a multivariable analysis, African origin (North Africa or Sub-Saharan Africa) (OR 1.7 [1.07-2.71], p = 0.02), time between intubation and VAP (OR 1.06 [1.02-1.09], p = 0.002), PaO2/FiO2 ratio on the day of VAP (OR 0.997 [0.994-0.999], p = 0.04) and trimethoprim-sulfamethoxazole exposure (OR 3.77 [1.15-12.4], p = 0.03) were associated with ESBL-E related VAP. Weaning from mechanical ventilation and mortality did not significantly differ between ESBL-E and non ESBL-E VAP.

CONCLUSION

ESBL-related VAP in COVID-19 critically-ill patients was not infrequent. Several risk factors were identified, among which some are modifiable and deserve further investigation. There was no impact of resistance of the first Enterobacterales related episode of VAP on outcome.

Exploring the impact of dexmedetomidine on short-term outcomes in critically ill sepsis-associated encephalopathy patients

OBJECTIVE

Dexmedetomidine has demonstrated potential in preclinical medical research as a protective agent against inflammatory injuries and a provider of neuroprotective benefits. However, its effect on the short-term prognosis of patients with sepsis-associated encephalopathy remains unclear. This study aims to explore the underlying value of dexmedetomidine in these patients.

PATIENTS AND METHODS

This study enrolled patients with sepsis-associated encephalopathy from the Medical Information Mart for Intensive Care (MIMIC)-IV database, and they were divided into two groups based on dexmedetomidine therapy during hospitalization. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were utilized to balance the inter-group baseline differences. Kaplan-Meier (KM) curves with log-rank test and subgroup analysis were also employed. The primary outcome was 28-day mortality, and the secondary outcomes were in-hospital mortality, intensive care unit (ICU) stay time, hospital stay time, and the incidence of ventilator-associated pneumonia (VAP).

RESULTS

After PSM, 1,075 pairs of patients were matched. In contrast to the non-dexmedetomidine cohort, the dexmedetomidine cohort did not exhibit a shortened ICU [4.65 (3.16, 8.55) vs. 6.14 (3.66, 11.04), p<0.001] and hospital stay duration [10.04 (6.55, 15.93) vs. 12.76 (7.92, 19.95), p<0.001], and there was an elevated incidence of VAP [90 (8.4%) vs. 135 (12.6%), p=0.002]. The log-rank test for the KM curves of dexmedetomidine use and 28-day mortality was statistically significant (p<0.001). The results showed that dexmedetomidine was associated with improved 28-day mortality [hazard ratio (HR) 0.46, 95% confidence interval (CI) 0.35-0.61, p<0.001] and in-hospital mortality (HR 0.50, 95% CI 0.37-0.67, p<0.001) after adjusting for various confounders. In the following subgroup analysis, dexmedetomidine infusion was associated with decreased 28-day mortality in most subgroups.

CONCLUSIONS

Dexmedetomidine administration was significantly associated with reduced short-term mortality among patients with sepsis-associated encephalopathy in the ICU. However, it also prolonged ICU and hospital stays and increased the incidence of VAP.

Automated surveillance of non-ventilator-associated hospital-acquired pneumonia (nvHAP): a systematic literature review

BACKGROUND

Hospital-acquired pneumonia (HAP) and its specific subset, non-ventilator hospital-acquired pneumonia (nvHAP) are significant contributors to patient morbidity and mortality. Automated surveillance systems for these healthcare-associated infections have emerged as a potentially beneficial replacement for manual surveillance. This systematic review aims to synthesise the existing literature on the characteristics and performance of automated nvHAP and HAP surveillance systems.

METHODS

We conducted a systematic search of publications describing automated surveillance of nvHAP and HAP. Our inclusion criteria covered articles that described fully and semi-automated systems without limitations on patient demographics or healthcare settings. We detailed the algorithms in each study and reported the performance characteristics of automated systems that were validated against specific reference methods. Two published metrics were employed to assess the quality of the included studies.

RESULTS

Our review identified 12 eligible studies that collectively describe 24 distinct candidate definitions, 23 for fully automated systems and one for a semi-automated system. These systems were employed exclusively in high-income countries and the majority were published after 2018. The algorithms commonly included radiology, leukocyte counts, temperature, antibiotic administration, and microbiology results. Validated surveillance systems' performance varied, with sensitivities for fully automated systems ranging from 40 to 99%, specificities from 58 and 98%, and positive predictive values from 8 to 71%. Validation was often carried out on small, pre-selected patient populations.

CONCLUSIONS

Recent years have seen a steep increase in publications on automated surveillance systems for nvHAP and HAP, which increase efficiency and reduce manual workload. However, the performance of fully automated surveillance remains moderate when compared to manual surveillance. The considerable heterogeneity in candidate surveillance definitions and reference standards, as well as validation on small or pre-selected samples, limits the generalisability of the findings. Further research, involving larger and broader patient populations is required to better understand the performance and applicability of automated nvHAP surveillance.

Inter-Hospital Transfer Is an Independent Risk Factor for Hospital-Associated Infection

Background: Regionalization of surgical care shifts higher acuity patients to larger centers. Hospital-associated infections (HAIs) are important quality measures with financial implications. In our ongoing efforts to eliminate HAIs, we examined the potential role for inter-hospital transfer in our cases of HAI across a multihospital system. Hypothesis: Surgical patients transferred to a regional multihospital system have a higher risk of National Healthcare Safety Network (NHSN)-labeled HAIs. Patients and Methods: The analysis cohort of adult surgical inpatients was filtered from a five-hospital health system administration registry containing encounters from 2014 to 2021. The dataset contained demographics, health characteristics, and acuity variables, along with the NHSN defined HAIs of central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI). Univariable and multivariable statistics were performed. Results: The surgical cohort identified 92,832 patients of whom 3,232 (3.5%) were transfers. The overall HAI rate was 0.6% (528): 86 (0.09%) CLABSI, 133 (0.14%) CAUTI, and 325 (0.35%) CDI. Across the three HAIs, the rate was higher in transfer patients compared with non-transfer patients (CLABSI: n = 18 (1.3%); odds ratio [OR], 4.79; CAUTI: n = 25 (1.8%); OR, 4.20; CDI: n = 37 (1.1%); OR, 3.59); p < 0.001 for all. Multivariable analysis found transfer patients had an increased rate of HAIs (OR, 1.56; p < 0.001). Conclusions: There is an increased risk-adjusted rate of HAIs in transferred surgical patients as reflected in the NHSN metrics. This phenomenon places a burden on regional centers that accept high-risk surgical transfers, in part because of the downstream effects of healthcare reimbursement programs.

[The dynamic monitoring of gastric residual volume by ultrasound was used to guide the early nutritional treatment of patients with severe mechanical ventilation to gradually achieve the standard]

OBJECTIVE

To explore the application value of dynamic monitoring of gastric residual volume (GRV) in achieving different target energy in severe mechanical ventilation patients.

METHODS

A prospective randomized controlled study was conducted. Forty-two patients with mechanical ventilation admitted to the department of critical care medicine of General Hospital of Ningxia Medical University from July to December 2022 were enrolled. According to the random number table method, patients were divided into GRV guided enteral nutrition by traditional gastric juice pumpback method (control group, 22 patients) and GRV guided enteral nutrition by bedside ultrasound (test group, 20 patients). General data were collected from both groups, and clinical indicators such as hypersensitive C-reactive protein (hs-CRP), interleukin-6 (IL-6), neutrophil percentage (Neut%), procalcitonin (PCT), absolute lymphocytes (LYM), prealbumin (PA), and retinol-binding protein (RBP) were dynamically observed. Inflammation, infection, immunity, nutritional indicators, and the incidence of reflux/aspiration, ventilator-associated pneumonia (VAP) were compared between the two groups, and further compared the proportion of patients with respectively to reach the target energy 25%, 50%, and 70% on days 1, 3, and 5 of initiated enteral nutrition.

RESULTS

(1) There were no significant differences in gender, age, body mass index (BMI), duration of mechanical ventilation, and acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), severe nutritional risk score (NUTRIC) at admission between the two groups, indicating comparability. (2) On day 1 of initiated enteral nutrition, there were no significant differences in infection, inflammation, immunity and nutrition indicators between the two groups. On day 3 of initiated enteral nutrition, the hs-CRP in the test group was lower than that control group, LYM and PA were higher than those control group [hs-CRP (mg/L): 129.60±75.18 vs. 185.20±63.74, LYM: 1.00±0.84 vs. 0.60±0.41, PA (mg/L): 27.30±3.66 vs. 22.30±2.55, all P < 0.05]. On day 5 of initiated enteral nutrition, the hs-CRP, Neut%, PCT in the test group were lower than those control group, LYM and PA were higher than those control group [hs-CRP (mg/L): 101.70±54.32 vs. 148.40±36.35, Neut%: (85.50±7.66)% vs. (92.90±6.01)%, PCT (μg/L): 0.7 (0.3, 2.7) vs. 3.6 (1.2, 7.5), LYM: 1.00±0.68 vs. 0.50±0.38, PA (mg/L): 27.10±4.57 vs. 20.80 ± 3.51, all P < 0.05]. There were no significantly differences in IL-6 and RBP between the two groups at different time points. (3) The proportion of 50% and 70% of achieved target energy in the test group on day 3, day 5 of initiated enteral nutrition were higher than those of the control group (70.0% vs. 36.4%, 70.0% vs. 36.4%, both P < 0.05). (4) The incidence of reflux/aspiration and VAP in the test group on day 5 of initiated enteral nutrition were significantly lower than those control group (incidence of reflux/aspiration: 5.0% vs. 28.6%, incidence of VAP: 10.0% vs. 36.4%, both P < 0.05).

CONCLUSIONS

Dynamic monitoring of GRV by bedside ultrasound can accurately improve the proportion of 50% of achieved target energy on day 3 and 75% on day 5 in severe mechanical ventilation patients, improve the patient's inflammation, immune and nutritional status, and can prevent the occurrence of reflux/aspiration and VAP.

Surface functionalization of endotracheal tubes coated with laccase-gadolinium phosphate hybrid nanoparticles for antibiofilm activity and contrasting properties

Ventilator-associated pneumonia (VAP) is a severe hospital-acquired infection that endangers patients' treatment in intensive care units (ICUs). One of the leading causes of VAP is biofilm formation on the endotracheal tube (ETT) during ventilation. This study reports a combination of laccase-gadolinium phosphate hybrid nanoparticles (laccase@GdPO4·HNPs) and enzyme mediator with an antibiofilm property coated on the surface of the ETT. The hybrid nanostructures were fabricated through a simple, rapid, and facile laccase immobilization method, resulting in efficiency and yield percentages of 82 ± 6% and 83 ± 5%, respectively. The surface of the ETT was then functionalized and coated with the constructed HNP/catechol. The layered ETT was able to reduce the surface adhesion of Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus by 82.1%, 84.5%, and 77.1%, respectively. The prepared ETT did not affect the viability of human lung epithelial cells L929 and A549 at concentrations of 1-5 mg mL-1. The layered ETT produced a strong computed tomography (CT) signal in comparison with iobitridol. The HNP/catechol-coated ETT exhibited a Gd3+ release of 0.45 ppm over 72 h, indicating reduced risks of cytotoxicity arising from the metal ions. In this research we develop a biofilm-resistant and contrasting agent-based ETT coated with green synthesized laccase@GdPO4·HNPs.

A Path towards Timely VAP Diagnosis: Proof-of-Concept Study on Pyocyanin Sensing with Cu-Mg Doped Graphene Oxide

In response to the urgent requirement for rapid, precise, and cost-effective detection in intensive care units (ICUs) for ventilated patients, as well as the need to overcome the limitations of traditional detection methods, researchers have turned their attention towards advancing novel technologies. Among these, biosensors have emerged as a reliable platform for achieving accurate and early diagnoses. In this study, we explore the possibility of using Pyocyanin analysis for early detection of pathogens in ventilator-associated pneumonia (VAP) and lower respiratory tract infections in ventilated patients. To achieve this, we developed an electrochemical sensor utilizing a graphene oxide-copper oxide-doped MgO (GO - Cu - Mgo) (GCM) catalyst for Pyocyanin detection. Pyocyanin is a virulence factor in the phenazine group that is produced by Pseudomonas aeruginosa strains, leading to infections such as pneumonia, urinary tract infections, and cystic fibrosis. We additionally investigated the use of DNA aptamers for detecting Pyocyanin as a biomarker of Pseudomonas aeruginosa, a common causative agent of VAP. The results of this study indicated that electrochemical detection of Pyocyanin using a GCM catalyst shows promising potential for various applications, including clinical diagnostics and drug discovery.

Airway Pressure Release Ventilation in COVID-19-Associated Acute Respiratory Distress Syndrome-A Multicenter Propensity Score-Matched Analysis

Background: There are limited and partially contradictory data on the effects of airway pressure release ventilation (APRV) in COVID-19-associated acute respiratory distress syndrome (CARDS). Therefore, we analyzed the clinical outcome, complications, and longitudinal course of ventilation parameters and laboratory values in patients with CARDS, who were mechanically ventilated using APRV. Methods: Respective data from 4 intensive care units (ICUs) were collected and compared to a matched cohort of patients receiving conventional low tidal volume ventilation (LTV). Propensity score matching was performed based on age, sex, blood gas analysis, and APACHE II score at admission, as well as the implementation of prone positioning. Findings: Forty patients with CARDS, who were mechanically ventilated using APRV, and 40 patients receiving LTV were matched. No significant differences were detected for tidal volumes per predicted body weight, peak pressure values, and blood gas analyses on admission, 6 h post admission as well as on day 3 and day 7. Regarding ICU survival, no significant difference was identified between APRV patients (40%) and LTV patients (42%). Median duration of mechanical ventilation and duration of ICU treatment were comparable in both groups. Similar complication rates with respect to ventilator-associated pneumonia, septic shock, thromboembolic events, barotrauma, as well as the necessity for hemodialysis were detected for both groups. Clinical characteristics that were associated with increased mortality in a Cox proportional hazards regression analysis included age (hazard ratio [HR] 1.08, 95% confidence interval [CI] 1.04-1.1; P < .001), severe acute respiratory distress syndrome (HR 2.62, 95% CI 1.02-6.7; P = .046) and the occurrence of septic shock (HR 17.18, 95% CI 2.06-143.2; P = .009), but not the ventilation mode. Interpretation: Intensive care unit survival, duration of mechanical ventilation, and ICU treatment as well as ventilation-associated complication rates were equivalent using APRV compared to conventional LTV in patients with CARDS.

Investigating a pulmonary Mycobacterium abscessus infection outbreak among elderly inpatients in the intensive care ward

INTRODUCTION

Mycobacterium abscessus is an opportunistic nontuberculous mycobacteria pathogen; however, the prevalence of nosocomial and community infections is increasing. In January 2016, several bedridden inpatients in the intensive care unit of a hospital had positive sputum smears for acid-fast bacilli, suggesting a mycobacteria outbreak.

METHODOLOGY

Acid-fast bacilli smear microscopy, isolation, and culturing were performed twice using sputa from each suspected intensive care unit inpatient (n = 13); in addition, medical history was obtained for each inpatient with suspected infection. Furthermore, environmental specimens were surveyed, collected, and cultured. We used DNA microarray chip analysis to identify positive mycobacterial isolates at the species level and performed whole-genome sequencing and phylogenetic tree construction.

RESULTS

Seven inpatients had M. abscessus pulmonary infection, confirmed by 2 positive cultures; five of the inpatients had only one positive culture, while one had two negative cultures. Six of 13 ventilator condensate samples were mycobacterial culture-positive, identified as M. abscessus; the other environmental samples were negative. The M. abscessus isolates (15 sputa and 4 environmental samples) clustered together in the phylogenic analysis with only one single-nucleotide polymorphism difference. All patients were symptom-free after 8 months of multi-drug treatment.

CONCLUSIONS

We confirmed a pulmonary M. abscessus outbreak among 12 bedridden patients in the intensive care unit through microbiological, molecular epidemiological, and environmental investigations. The possible infection source was contaminated ventilator condensate. This outbreak reemphasizes the importance of standardized ventilator maintenance and disinfection for preventing ventilator-associated pneumonia and is a reminder that nontuberculous mycobacteria-related ventilator-associated pneumonia is possible.

Association between ventilator-associated events and implementation of acute respiratory distress syndrome (ARDS) ventilator weaning protocol

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a severe and life-threatening condition that can occur in critically ill patients. Mechanical ventilation is a commonly used intervention with ARDS patients, but weaning patients off the ventilator can be challenging. An ARDSnet-like ventilator weaning protocol was implemented with the goal of reducing triggers for ventilator-associated events (VAEs).

METHODS

The implementation of the new protocol was used to complete a retrospective investigation of patient outcomes for 1,233 ventilator periods. Periods were included between April and December 2022 for any ventilated patient lasting at least 4 days. National Health Care Safety Network VAE criteria were used to surveille the patient data. Triggers were based on the positive end-expiratory pressure increases or fraction of inspired oxygen (FiO₂) increases. The preset weaning criteria was a reduction by 2 cmH2O per 24 hours.

RESULTS

Of the total 1,233 individual ventilator periods, VAE criteria were met in 10%. Of the total 126 periods with VAE, 39.2% met the criteria for appropriate protocol implementation. There was a statistically significant relationship between VAE identification and implementation of the protocol.

CONCLUSIONS

The implementation of a protocol for ventilator weaning affects the outcome of developing a VAE. The findings emphasize the importance of implementing the ARDS weaning protocol as a template to reduce the triggers for VAEs and improve overall patient outcomes.

Early versus late tracheostomy in critically ill COVID-19 patients

BACKGROUND

The role of early tracheostomy as an intervention for critically ill COVID-19 patients is unclear. Previous reports have described prolonged intensive care stays and difficulty weaning from mechanical ventilation in critically ill COVID-19 patients, particularly in those developing acute respiratory distress syndrome. Pre-pandemic evidence on the benefits of early tracheostomy is conflicting but suggests shorter hospital stays and lower mortality rates compared to late tracheostomy.

OBJECTIVES

To assess the benefits and harms of early tracheostomy compared to late tracheostomy in critically ill COVID-19 patients.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register, which comprises CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv, as well as Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index) and WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions. We conducted the searches on 14 June 2022.

SELECTION CRITERIA

We followed standard Cochrane methodology. We included randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) evaluating early tracheostomy compared to late tracheostomy during SARS-CoV-2 infection in critically ill adults irrespective of gender, ethnicity, or setting.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. To assess risk of bias in included studies, we used the Cochrane RoB 2 tool for RCTs and the ROBINS-I tool for NRSIs. We used the GRADE approach to assess the certainty of evidence for outcomes of our prioritized categories: mortality, clinical status, and intensive care unit (ICU) length of stay. As the timing of tracheostomy was very heterogeneous among the included studies, we applied GRADE only to studies that defined early tracheostomy as 10 days or less, which was chosen according to clinical relevance.

MAIN RESULTS

We included one RCT with 150 participants diagnosed with SARS-CoV-2 infection and 24 NRSIs with 6372 participants diagnosed with SARS-CoV-2 infection. All participants were admitted to the ICU, orally intubated and mechanically ventilated. The RCT was a multicenter, parallel, single-blinded study conducted in Sweden. Of the 24 NRSIs, which were mostly conducted in high- and middle-income countries, eight had a prospective design and 16 a retrospective design. We did not find any ongoing studies. RCT-based evidence We judged risk of bias for the RCT to be of low or some concerns regarding randomization and measurement of the outcome. Early tracheostomy may result in little to no difference in overall mortality (RR 0.82, 95% CI 0.52 to 1.29; RD 67 fewer per 1000, 95% CI 178 fewer to 108 more; 1 study, 150 participants; low-certainty evidence). As an indicator of improvement of clinical status, early tracheostomy may result in little to no difference in duration to liberation from invasive mechanical ventilation (MD 1.50 days fewer, 95%, CI 5.74 days fewer to 2.74 days more; 1 study, 150 participants; low-certainty evidence). As an indicator of worsening clinical status, early tracheostomy may result in little to no difference in the incidence of adverse events of any grade (RR 0.94, 95% CI 0.79 to 1.13; RD 47 fewer per 1000, 95% CI 164 fewer to 102 more; 1 study, 150 participants; low-certainty evidence); little to no difference in the incidence of ventilator-associated pneumonia (RR 1.08, 95% CI 0.23 to 5.20; RD 3 more per 1000, 95% CI 30 fewer to 162 more; 1 study, 150 participants; low-certainty evidence). None of the studies reported need for renal replacement therapy. Early tracheostomy may result in little benefit to no difference in ICU length of stay (MD 0.5 days fewer, 95% CI 5.34 days fewer to 4.34 days more; 1 study, 150 participants; low-certainty evidence). NRSI-based evidence We considered risk of bias for NRSIs to be critical because of possible confounding, study participant enrollment into the studies, intervention classification and potentially systematic errors in the measurement of outcomes. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases overall mortality (RR 1.47, 95% CI 0.43 to 5.00; RD 143 more per 1000, 95% CI 174 less to 1218 more; I2 = 79%; 2 studies, 719 participants) or duration to liberation from mechanical ventilation (MD 1.98 days fewer, 95% CI 0.16 days fewer to 4.12 more; 1 study, 50 participants), because we graded the certainty of evidence as very low. Three NRSIs reported ICU length of stay for 519 patients with early tracheostomy (≤ 10 days) as a median value, which we could not include in the meta-analyses. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases the ICU length of stay, because we graded the certainty of evidence as very low.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that early tracheostomy may result in little to no difference in overall mortality in critically ill COVID-19 patients requiring prolonged mechanical ventilation compared with late tracheostomy. In terms of clinical improvement, early tracheostomy may result in little to no difference in duration to liberation from mechanical ventilation compared with late tracheostomy. We are not certain about the impact of early tracheostomy on clinical worsening in terms of the incidence of adverse events, need for renal replacement therapy, ventilator-associated pneumonia, or the length of stay in the ICU. Future RCTs should provide additional data on the benefits and harms of early tracheostomy for defined main outcomes of COVID-19 research, as well as of comparable diseases, especially for different population subgroups to reduce clinical heterogeneity, and report a longer observation period. Then it would be possible to draw conclusions regarding which patient groups might benefit from early intervention. Furthermore, validated scoring systems for more accurate predictions of the need for prolonged mechanical ventilation should be developed and used in new RCTs to ensure safer indication and patient safety. High-quality (prospectively registered) NRSIs should be conducted in the future to provide valuable answers to clinical questions. This could enable us to draw more reliable conclusions about the potential benefits and harms of early tracheostomy in critically ill COVID-19 patients.

REVISE: Re-Evaluating the Inhibition of Stress Erosions in the ICU: a randomised trial protocol

INTRODUCTION

The Re-Evaluating the Inhibition of Stress Erosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE.

METHODS AND ANALYSIS

REVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial.

ETHICS AND DISSEMINATION

All participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to - Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide.

TRIAL REGISTRATION NUMBER

NCT03374800.

Phenotypic and genetic characterization of hypervirulent Klebsiella pneumoniae in patients with liver abscess and ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) and pyogenic liver abscess (PLA) due to Klebsiella pneumoniae infection can trigger life-threatening malignant consequences, however, there are few studies on the strain-associated clinical pathogenic mechanisms between VAP and PLA. A total of 266 patients consist of 129 VAP and 137 PLA were included for analysis in this study. We conducted a comprehensive survey for the two groups of K. pneumoniae isolates, including phenotypic experiments, clinical epidemiology, genomic analysis, and instrumental analysis, i.e., to obtain the genomic differential profile of K. pneumoniae strains responsible for two distinct infection outcomes. We found that PLA group had a propensity for specific underlying diseases, especially diabetes and cholelithiasis. The resistance level of VAP was significantly higher than that of PLA (78.57% vs. 36%, P < 0.001), while the virulence results were opposite. There were also some differences in key signaling pathways of biochemical processes between the two groups. The combination of iucA, rmpA, hypermucoviscous phenotype, and ST23 presented in K. pneumoniae infection is more important and highly prudent for timely treatment. The present study may contribute a benchmark for the K. pneumoniae clinical screening, epidemiological surveillance, and effective therapeutic strategies.

Early tracheostomy versus late tracheostomy in severe traumatic brain injury or stroke: A systematic review and meta-analysis

OBJECTIVES

We aim to ascertain whether the benefit of early tracheostomy can be found in patients with severe traumatic brain injury (TBI) and stroke and if the benefit will remain considering distinct pathologies.

DATA SOURCES

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, a search through Lilacs, PubMed, and Cochrane databases was conducted.

REVIEW METHODS

Included studies were those written in English, French, Spanish, or Portuguese, with a formulated question, which compared outcomes between early and late trach (minimum of two outcomes), such as intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), hospital LOS, mortality rates, or ventilator-associated pneumonia (VAP). Likewise, patients presented exclusively with head injury or stroke had minimum hospital stay follow-up, and as for severe TBI patients, they presented Glasgow Coma Scale ≤8 at admission. Evaluated outcomes were the risk ratio (RR) of VAP, risk difference (RD) of mortality, and mean difference (MD) of the duration of MV, ICU LOS, and hospital LOS.

RESULTS

The early and late tracheostomy cohorts were composed of 6211 and 8140 patients, respectively. The meta-analysis demonstrated that the early tracheostomy cohort had a lower risk for VAP (RR: 0.73 [95% confidence interval {CI}, 0.66, 0.81] p < 0.00001), shorter duration of MV (MD: -4.40 days [95% CI, -8.28, -0.53] p = 0.03), and shorter ICU (MD: -6.93 days [95% CI, -8.75, -5.11] p < 0.00001) and hospital LOS (MD: -7.05 days [95% CI, -8.27, -5.84] p < 0.00001). The mortality rate did not demonstrate a statistical difference.

CONCLUSION

Early tracheostomy could optimise patient outcomes by patients' risk for VAP and decreasing MV durationand ICU and hospital LOS.

Association between oral microbial dysbiosis and poor functional outcomes in stroke-associated pneumonia patients

BACKGROUND

Despite advances in our understanding of the critical role of the microbiota in stroke patients, the oral microbiome has rarely been reported to be associated with stroke-associated pneumonia (SAP). We sought to profile the oral microbial composition of SAP patients and to determine whether microbiome temporal instability and special taxa are associated with pneumonia progression and functional outcomes.

METHODS

This is a prospective, observational, single-center cohort study that examined patients with acute ischemic stroke (AIS) who were admitted within 24 h of experiencing a stroke event. The patients were divided into three groups based on the occurrence of pneumonia and the use of mechanical ventilation: nonpneumonia group, SAP group, and ventilator-associated pneumonia (VAP) group. We collected oral swabs at different time points post-admission and analyzed the microbiota using 16 S rRNA high-throughput sequencing. The microbiota was then compared among the three groups.

RESULTS

In total, 104 nonpneumonia, 50 SAP and 10 VAP patients were included in the analysis. We found that SAP and VAP patients exhibited significant dynamic differences in the diversity and composition of the oral microbiota and that the magnitude of this dysbiosis and instability increased during hospitalization. Then, by controlling the potential effect of all latent confounding variables, we assessed the changes associated with pneumonia after stroke and explored patients with a lower abundance of Streptococcus were more likely to suffer from SAP. The logistic regression analysis revealed that an increase in specific taxa in the phylum Actinobacteriota was linked to a higher risk of poor outcomes. A model for SAP patients based on oral microbiota could accurately predict 30-day clinical outcomes after stroke onset.

CONCLUSIONS

We concluded that specific oral microbiota signatures could be used to predict illness development and clinical outcomes in SAP patients. We proposed the potential of the oral microbiota as a non-invasive diagnostic biomarker in the clinical management of SAP patients.

CLINICAL TRIAL REGISTRATION

NCT04688138. Registered 29/12/2020, https://clinicaltrials.gov/ct2/show/NCT04688138 .

Risk factors for bronchopulmonary dysplasia infants with respiratory score greater than four: a multi-center, prospective, longitudinal cohort study in China

Bronchopulmonary dysplasia (BPD) is the most common complication of prematurity involving both pre- and post-natal factors. A large, prospective, longitudinal cohort study was conducted to determine whether inflammation-related factors are associated with an increased risk of BPD in preterm infants who were born at a gestational age < 32 weeks, < 72 h after birth and respiratory score > 4. The study included infants from 25 participating hospitals in China between March 1, 2020 and March 31, 2022. The primary outcomes were BPD and severity of BPD at 36 weeks post-menstrual age. A total of 1362 preterm infants were enrolled in the study. After exclusion criteria, the remaining 1088 infants were included in this analysis, of whom, 588 (54.0%) infants were in the BPD group and 500 (46.0%) were in the non-BPD group. In the BPD III model, the following six factors were identified: birth weight (OR 0.175, 95% CI 0.060-0.512; p = 0.001), surfactant treatment (OR 8.052, 95% CI 2.658-24.399; p < 0.001), mean airway pressure (MAP) ≥ 12 cm H2O (OR 3.338, 95% CI 1.656-6.728; p = 0.001), late-onset sepsis (LOS) (OR 2.911, 95% CI 1.514-5.599; p = 0.001), ventilator-associated pneumonia (VAP) (OR 18.236, 95% CI 4.700-70.756; p < 0.001) and necrotizing enterocolitis (NEC) (OR 2.725, 95% CI 1.182-6.281; p = 0.019). Premature infants remained at high risk of BPD and with regional variation. We found that post-natal inflammation-related risk factors were associated with an increased risk of severe BPD, including LOS, VAP, NEC, MAP ≥ 12 cm H2O and use of surfactant.

Relation between red blood cell distribution width and 30-day in-hospital mortality of patients with ventilator-associated pneumonia

BACKGROUND

Epidemiological studies have demonstrated an association between red blood cell distribution width (RDW) and the prognosis of pneumonia-associated diseases. However, prognostic value of RDW in patients with ventilator-associated pneumonia (VAP) has yet to be investigated. This study aimed to explore the association between RDW and in-hospital mortality in VAP patients and explore predictive value of RDW for VAP patients.

METHODS

This retrospective cohort study included 1,543 VAP patients from the Medical Information Mart for Intensive Care IV database 2008-2019. The primary outcome was considered to 30-day in-hospital mortality of VAP patients in this study. Non-high RDW level group was defined as <15 %, and high RDW level group as ≥15%. The possible confounding factors were screened by least absolute shrinkage and selection operator regression. Univariate and multivariate COX regression analyses were used for the assessment on the association of RDW and 30-day in-hospital mortality in VAP patients. We also performed subgroup analyses. Furthermore, a comparative analysis of RDW and sequential organ failure assessment (SOFA) score and simplified acute physiology score II (SAPS II) were performed by receiver operating characteristic (ROC) curves.

RESULTS

The 30-day in-hospital mortality of VAP patients was approximately 19.05%. After adjusting all confounding factors, high RDW was associated with 30-day in-hospital mortality among VAP patients by using non-high RDW as the reference [hazard ratio (HR) =1.29, 95% confidence interval (CI): 1.01-1.63]. Additionally, the relationship was also robust in several populations, such as patients were younger than 60 years, or had not a history of congestive heart failure, or had a history of sepsis, or had not received renal replacement therapy, or had a duration of mechanical ventilation for more than 7 days. The result of ROC indicated that RDW had a better prognostic value in predicting 30-day in-hospital mortality for VAP patients than SOFA score and SAPS II score.

CONCLUSION

High RDW level is associated with an increased 30-day in-hospital mortality. The RDW is a promising biomarker in predicting 30-day in-hospital mortality for patients admitted to the ICU, regardless of VAP.

Evaluation of the combination treatments with intravenous fosfomycin for carbapenem-resistant Klebsiella pneumoniae

OBJECTIVE

The aim of this study was to evaluate the combination treatments with intravenous fosfomycin for carbapenem-resistant Klebsiella pneumoniae infections in a tertiary-care center.

METHODS

Between December 24, 2018 and November 21, 2022, adult patients diagnosed with bloodstream infection or ventilator-associated pneumonia due to culture-confirmed carbapenem-resistant Klebsiella pneumoniae in the anesthesiology and reanimation intensive care units were investigated retrospectively.

RESULTS

There were a total of 62 patients fulfilling the study inclusion criteria. No significant difference was recorded in 14- and 30-day mortality among different types of combination regimens such as fosfomycin plus one or two antibiotic combinations. Hypokalemia (OR:5.651, 95%CI 1.019-31.330, p=0.048) was found to be a significant risk factor for 14-day mortality, whereas SOFA score at the time of diagnosis (OR:1.497, 95%CI 1.103-2.032, p=0.010) and CVVHF treatment (OR:6.409, 95%CI 1.395-29.433, p=0.017) were associated with 30-day mortality in multivariate analysis.

CONCLUSION

In our study, high mortality rates were found in patients with bloodstream infection or ventilator-associated pneumonia due to carbapenem-resistant Klebsiella pneumoniae, and no significant difference was recorded in 14- and 30-day mortality among different types of combination regimens such as fosfomycin plus one or two antibiotic combinations.

Timing of regional analgesia in elderly patients with blunt chest-wall injury

BACKGROUND

Rib fractures represent a typical injury pattern in older people and are associated with respiratory morbidity and mortality. Regional analgesia modalities are adjuncts for pain management, but the optimal timing for their initiation remains understudied. We hypothesized that early regional analgesia would have similar outcomes to late regional analgesia.

METHODS

We retrospectively reviewed the American College of Surgeons Trauma Quality Improvement Program database from 2017 to 2019. We included patients ≥65 years old admitted with blunt chest wall trauma who received regional analgesia. We divided patients into 2 groups: (1) early regional analgesia (within 24 hours of admission) and (2) late regional analgesia (>24 hours). The outcomes evaluated were ventilator-associated pneumonia, mortality, unplanned intensive care unit admission, unplanned intubation, discharge to home, and duration of stay. Univariable analysis and multivariable logistic regression adjusting for patient and injury characteristics, trauma center level, and respiratory interventions were performed.

RESULTS

In the study, 2,248 patients were included. The mean (standard deviation) age was 75.3 (6.9), and 52.7% were male. The median injury severity score (interquartile range) was 13 (9-17). The early regional analgesia group had a decreased incidence of unplanned intubation (2.7% vs 5.3%, P = .002), unplanned intensive care unit admission (4.9% vs 8.4%, P < .001), and shorter mean duration of stay (5.5 vs 6.5 days, P = .002). In multivariable analysis, early regional analgesia was associated with decreased odds of unplanned intubation (odds ratio, 0.58; 95% confidence interval, 0.36-0.94; P = .026), unplanned intensive care unit admission (odds ratio, 0.60; 95% confidence interval, 0.041-0.86; P = .006), and increased odds of discharge to home (odds ratio, 1.27; 95% confidence interval, 1.04-1.55; P = .019). After multivariable adjustment, no significant difference was found for ventilator-associated pneumonia or mortality (odds ratio, 0.60; 95% confidence interval, 0.34-1.04; P = .070).

CONCLUSION

Early regional analgesia initiation is associated with improved outcomes in older people with blunt chest wall injuries. Geriatric trauma care bundles targeting early initiation of regional analgesia can potentially decrease complications and resource use.

Macrophages depletion alleviates lung injury by modulating AKT3/GXP4 following ventilator associated pneumonia

Background

AKT3 appears to play a role in lung cancer. However, its role in ventilator-associated pneumonia is still unclear. Therefore, this study aimed to investigate the role of AKT3 in macrophages during ventilator-associated pneumonia.

Methods

The mRNA level of AKT3, Data from The Cancer Genome Atlas (TCGA), Gene Expression Omnibus (GEO), The data is analyzed using the Xiantao academic analysis tool. Additionally, the roles of AKT3 in ventilator-associated pneumonia (VAP) were investigated through in vivo experiments.

Results

AKT3 was differentially expressed in various normal and tumor tissues. Functional enrichment analysis indicated the immunomodulatory function and inflammatory response of AKT3 in lung cancer. Depletion of macrophages protected against lung epithelial cells and significantly decreased MMP9, MMP19, FTH, and FTL expression levels and increased GPX4 expression levels, while partially reversing the changes in macrophage. Mechanistically, macrophage depletion attenuates ferroptosis of lung epithelial cells by modulating AKT3 following VAP.

Conclusion

Collectively, this study suggests the need for further validation of the immunoregulatory function of AKT3 in lung cancer. Additionally, macrophage depletion mitigates lung injury by modulating the AKT3/GPX4 pathway in the context of VAP.

Random variation drives a critical bias in the comparison of healthcare-associated infections

OBJECTIVE

To evaluate random effects of volume (patient days or device days) on healthcare-associated infections (HAIs) and the standardized infection ratio (SIR) used to compare hospitals.

DESIGN

A longitudinal comparison between publicly reported quarterly data (2014-2020) and volume-based random sampling using 4 HAI types: central-line-associated bloodstream infections, catheter-associated urinary tract infections, Clostridioides difficile infections, methicillin-resistant Staphylococcus aureus infections.

METHODS

Using 4,268 hospitals with reported SIRs, we examined relationships of SIRs to volume and compared distributions of SIRs and numbers of reported HAIs to the outcomes of simulated random sampling. We included random expectations into SIR calculations to produce a standardized infection score (SIS).

RESULTS

Among hospitals with volumes less than the median, 20%-33% had SIRs of 0, compared to 0.3%-5% for hospitals with volumes higher than the median. Distributions of SIRs were 86%-92% similar to those based on random sampling. Random expectations explained 54%-84% of variation in numbers of HAIs. The use of SIRs led hundreds of hospitals with more infections than either expected at random or predicted by risk-adjusted models to rank better than other hospitals. The SIS mitigated this effect and allowed hospitals of disparate volumes to achieve better scores while decreasing the number of hospitals tied for the best score.

CONCLUSIONS

SIRs and numbers of HAIs are strongly influenced by random effects of volume. Mitigating these effects drastically alters rankings for HAI types and may further alter penalty assignments in programs that aim to reduce HAIs and improve quality of care.

[Research progress on the role of respiratory microbiome in ventilator-associated pneumonia]

Respiratory microbiome is extensively involved in human life activities and affects lung health and disease states through metabolism and immune regulation. Based on 16S rRNA gene sequencing and other methods, it is obvious that the diversity and the changes in the structure of respiratory microbiome and the dominant proliferation of pathogens are strongly related to the occurrence, development and clinical prognosis of ventilator-associated pneumonia (VAP). The mechanism by which respiratory microbiota promotes the clearance of pathogens may include the following aspects: (1) pre-stimulating innate immune system to increase the number of immune effector cells; (2) regulating pattern recognition receptor (PRR) to moderately promote the production of cytokines; (3) inducing the differentiation of neutrophils into specific subtypes and increasing the expression of antimicrobial genes; (4) producing free fatty acids and organic compounds that are capable of positively modulating the immune system. In conclusion, intervention of microbiome is beneficial to VAP patients. Therefore, this review illustrates the changes of respiratory flora in VAP and its effect on host immunity. At the same time, based on the review of the adjuvant treatment of VAP with probiotics, we put forward the prospect of respiratory commensal bacteria as a new clinical probiotic, in order to deepen the clinical understanding of the role of respiratory flora in VAP, and then provide new ideas for the evaluation of treatment and prognosis.

Risk factors for mortality over 18 years in 317 ICUs in 9 Asian countries: The impact of healthcare-associated infections

OBJECTIVE

To identify risk factors for mortality in intensive care units (ICUs) in Asia.

DESIGN

Prospective cohort study.

SETTING

The study included 317 ICUs of 96 hospitals in 44 cities in 9 countries of Asia: China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam.

PARTICIPANTS

Patients aged >18 years admitted to ICUs.

RESULTS

In total, 157,667 patients were followed during 957,517 patient days, and 8,157 HAIs occurred. In multiple logistic regression, the following variables were associated with an increased mortality risk: central-line-associated bloodstream infection (CLABSI; aOR, 2.36; P < .0001), ventilator-associated event (VAE; aOR, 1.51; P < .0001), catheter-associated urinary tract infection (CAUTI; aOR, 1.04; P < .0001), and female sex (aOR, 1.06; P < .0001). Older age increased mortality risk by 1% per year (aOR, 1.01; P < .0001). Length of stay (LOS) increased mortality risk by 1% per bed day (aOR, 1.01; P < .0001). Central-line days increased mortality risk by 2% per central-line day (aOR, 1.02; P < .0001). Urinary catheter days increased mortality risk by 4% per urinary catheter day (aOR, 1.04; P < .0001). The highest mortality risks were associated with mechanical ventilation utilization ratio (aOR, 12.48; P < .0001), upper middle-income country (aOR, 1.09; P = .033), surgical hospitalization (aOR, 2.17; P < .0001), pediatric oncology ICU (aOR, 9.90; P < .0001), and adult oncology ICU (aOR, 4.52; P < .0001). Patients at university hospitals had the lowest mortality risk (aOR, 0.61; P < .0001).

CONCLUSIONS

Some variables associated with an increased mortality risk are unlikely to change, such as age, sex, national economy, hospitalization type, and ICU type. Some other variables can be modified, such as LOS, central-line use, urinary catheter use, and mechanical ventilation as well as and acquisition of CLABSI, VAE, or CAUTI. To reduce mortality risk, we shall focus on strategies to reduce LOS; strategies to reduce central-line, urinary catheter, and mechanical ventilation use; and HAI prevention recommendations.

Results following implementation of a cardiac surgery ERAS protocol

INTRODUCTION

Adequate peri-operative care is essential to ensuring a satisfactory outcome in cardiac surgery. In this study, we look at the impact of evidence-based protocols implemented at Stanford Hospital.

METHODS

This study is a single-center, retrospective analysis. Enhanced recovery after surgery (ERAS) protocols were implemented for CABG/Valve and open Aortic operations on 11/1/2017 and 6/1/2018, respectively. Propensity-score matched analysis was used to compare 30-day mortality and morbidity of patients from the pre- and post-implementation cohorts. Secondary endpoints included the following: total hospital length of stay (LOS), ICU LOS, time until extubation, and time until urinary catheter removal.

RESULTS

After the implementation of the ERAS protocols for CABG/Valve operations, the median post-op LOS decreased from 7.0 days to 6.1 days (p<0.001), and median ICU LOS decreased from 69.9 hours to 54.0 (p = 0.098). There was no significant decrease in 30-day mortality (4% to 3.3%, p = 0.47). However, the incidence of post-op ventilator associated pneumonia (VAP) decreased from 5.0% to 2.1% (p = 0.003) and post-op urinary tract infections (UTIs) from 8.3% to 3.6% (p<0.001). Patients who underwent open aortic procedures experienced an improvement in 30-day mortality (7% to 3.5%, p = 0.012), decrease in median ICU LOS (91.7 hours to 69.6 hours, p<0.001), and a decrease in duration of mechanical ventilation (79.3 hours to 46.3 hours, p = 0.003). There was a decrease in post-op LOS, post-op VAP, and post-op UTI, although statistical significance was not attained.

CONCLUSION

At Stanford Hospital, ERAS pathways have led to decreased morbidity and LOS while simultaneously improving mortality amongst our critically ill patient population.

Exploring the complex relationship between the lung microbiome and ventilator-associated pneumonia

INTRODUCTION

Understanding the presence and function of a diverse lung microbiome in acute lung infections, particularly ventilator-associated pneumonia (VAP), is still limited, evidencing significant gaps in our knowledge.

AREAS COVERED

In this comprehensive narrative review, we aim to elucidate the contribution of the respiratory microbiome in the development of VAP by examining the current knowledge on the interactions among microorganisms. By exploring these intricate connections, we endeavor to enhance our understanding of the disease's pathophysiology and pave the way for novel ideas and interventions in studying the respiratory tract microbiome.

EXPERT OPINION

The conventional perception of lungs as sterile is deprecated since it is currently recognized the existence of a diverse microbial community within them. However, despite extensive research on the role of the respiratory microbiome in healthy lungs, respiratory chronic diseases and acute lung infections such as pneumonia are not fully understood. It is crucial to investigate further the relationship between the pathophysiology of VAP and the pulmonary microbiome, elucidating the mechanisms underlying the interactions between the microbiome, host immune response and mechanical ventilation for the development of VAP.

Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review

BACKGROUND

Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days).

METHODS

Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0.

RESULTS

For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia.

CONCLUSION

In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Efficacy of Intermittent and Continuous Subglottic Secretion Drainage in Preventing the Risk of Ventilator-Associated Pneumonia: A Meta-Analysis of Randomized Control Trials

Ventilator-associated pneumonia (VAP) is hospital-acquired pneumonia that develops 48 h or longer following mechanical ventilation. However, cuff pressure fluctuates significantly due to patient or tube movement, which might result in microaspiration. Subglottic secretion drainage (SSD) has been suggested as a method for VAP prevention bundles. This systematic review and meta-analysis aims to investigate the efficacy and safety of subglottic SSD in preventing VAP. The secondary outcomes of this study are to investigate the intensive care unit (ICU) stay length and mortality rate regarding VAP. This study followed the Preferred Reporting Item for Systematic Review and Meta-Analysis guidelines. A thorough search of PubMed, Embase, and the Web of Science was conducted between June and August 2022. The study analysis used the Mantel-Haenszel method, and the quality of the included study was assessed using the Cochrane Risk of Bias 2. Eighteen randomized controlled trials with a total of 2537 intubated patients were included. It was found that SSD was associated with a lower risk of VAP (RR 1.44; 95% CI; 1.20-1.73; p < 0.0001). The subgroup analysis (utilizing intermittent and continuous methods) found no statistically significant difference between the two groups (p = 0.28). The secondary endpoints showed that there was no significant difference in mortality (RR 1.02; 95% CI; 0.87-1.20; p = 0.83), but there were substantial differences in ICU stays (mean difference, 3.42 days; 95% CI; 2.07-4.76; p < 0.00001) in favor of the SSD group. This was based on a very low certainty of evidence due to concerns linked to the risk of bias and inconsistency. The use of SSD was associated with a reduction in VAP incidence and ICU stay length, but there was no significant difference in the mortality rate.

Factors predicting mortality among patients with COVID-19 associated hospital acquired pneumonia: insights from a tertiary care center

Hospital acquired pneumonia (HAP) is a severe and dangerous complication in patients admitted with COVID-19, causing significant morbidity and mortality globally. However, the early detection and subsequent management of high-risk cases may prevent disease progression and improve clinical outcomes. This study was undertaken in order to identify predictors of mortality in COVID-19 associated HAP. A retrospective study was performed on all patients who were admitted to a tertiary care center with COVID-19 associated HAP from July 2020 till November 2020. Data was collected on relevant demographic, clinical and laboratory parameters to determine their association with in-hospital mortality; 1574 files were reviewed, out of which 162 were included in the final study. The mean age of subjects was 59.4±13.8 and a majority were male (78.4%). There were 71 (48.3%) mortalities in the study sample. Klebsiella pneumoniae (31.5%) and Pseudomonas aeruginosa (30.2%) were the most common organisms overall. Clinically significant growth of Aspergillus sp. was observed in 41 (29.0%) of patients. On univariate analysis, several factors were found to be associated with mortality, including male gender (p=0.04), D-dimers >1.3 mg/L (p<0.001), ferritin >1000 µg/mL (p<0.001), LDH >500I.U/mL (p<0.001) and procalcitonin >2.0 µg/mL (p<0.001). On multivariate analysis, ferritin >1000ng/mL, initial site of care in Special Care Units or Intensive Care Units, developing respiratory failure and developing acute kidney injury were factors independently associated with mortality in our patient sample. These results indicate that serum ferritin levels may be a potentially useful biomarker in the management of COVID-19 associated HAP.

Descriptive epidemiology of hospitalized patients with bacterial nosocomial pneumonia who experience 30-day readmission in the US, 2014-2019

INTRODUCTION

Nosocomial pneumonia (NP) remains associated with excess morbidity and mortality. The effect of NP on measures such as re-admission at 30 days remains unclear. Moreover, differing types of NP may have varying impacts on re-admissions.

METHODS

We conducted a multicenter retrospective cohort study within the Premier Research database, a source containing administrative, pharmacy, and microbiology data. We compared NP patients readmitted with pneumonia (RaP) as the principal diagnosis to those readmitted for other reasons (RaO) with respect to the type of NP (ventilator-associated bacterial pneumonia [VABP], ventilated hospital-acquired bacterial pneumonia [vHABP], and non-ventilated HABP [nvHABP]), and characteristics and outcomes of the index hospitalization.

RESULTS

Among 17,819 patients with NP, 14,123 (79.3%) survived to discharge, of whom 2,151 (15.2%) required an acute readmission within 30 days of index discharge. Of these, 106 (4.9%) were RaP, and the remainder were RaO. At index hospitalization, RaP patients were older (mean age [SD] 67.4 (13.9] vs. 63.0 [15.2] years), more likely medical (44.3% vs. 36.7%), and less chronically ill (median [IQR] Charlson scores (3 [2-5] vs. 4 [2-5]) than persons with RaO. Bacteremia (10.4% vs. 17.5%), need for vasopressors (15.1% vs. 20.0%), dialysis (9.4% vs. 16.5%), and/or sepsis (9.4% vs. 16.5%) or septic shock 14.2% vs. 17.1%) occurred less frequently in the RaP group. With respect to NP type, nvHABP was most common in RaP (47.2%) and VABP in RaO (38.1%).

CONCLUSIONS

One in seven survivors of a hospitalization complicated by NP requires an acute rehospitalization within 30 days. However, few of these readmissions had a principal diagnosis of pneumonia, irrespective of NP type. Of the 5% of NP subjects with RaP, the plurality initially suffered from nvHABP.

What happened during COVID-19 in African ICUs? An observational study of pulmonary co-infections, superinfections, and mortality in Morocco

BACKGROUND

There is a growing literature showing that critically ill COVID-19 patients have an increased risk of pulmonary co-infections and superinfections. However, studies in developing countries, especially African countries, are lacking. The objective was to describe the prevalence of bacterial co-infections and superinfections in critically ill adults with severe COVID-19 pneumonia in Morocco, the micro-organisms involved, and the impact of these infections on survival.

METHODS

This retrospective study included severe COVID-19 patients admitted to the intensive care unit (ICU) between April 2020 and April 2021. The diagnosis of pulmonary co-infections and superinfections was based on the identification of pathogens from lower respiratory tract samples. Co-infection was defined as the identification of a respiratory pathogen, diagnosed concurrently with SARS-Cov2 pneumonia. Superinfections include hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). A multivariate regression analysis was performed to identify factors independently associated with mortality.

RESULTS

Data from 155 patients were analyzed. The median age was 68 years [62-72] with 87% of patients being male. A large proportion of patients (68%) received antibiotics before ICU admission. Regarding ventilatory management, the majority of patients (88%) underwent non-invasive ventilation (NIV). Sixty-five patients (42%) were placed under invasive mechanical ventilation, mostly after failure of NIV. The prevalence of co-infections, HAP and VAP was respectively 4%, 12% and 40% (64 VAP/1000 ventilation days). The most isolated pathogens were Enterobacterales for HAP and Acinetobacter sp. for VAP. The proportion of extra-drug resistant (XDR) bacteria was 78% for Acinetobacter sp. and 24% for Enterobacterales. Overall ICU mortality in this cohort was 64.5%. Patients with superinfection showed a higher risk of death (OR = 6.4, 95% CI: 1.8-22; p = 0.004).

CONCLUSIONS

In this single-ICU Moroccan COVID-19 cohort, bacterial co-infections were relatively uncommon. Conversely, high rates of superinfections were observed, with an increased frequency of antimicrobial resistance. Patients with superinfections showed a higher risk of death.

Application of improved Glasgow coma scale score as switching point for sequential invasive-noninvasive mechanical ventilation on chronic obstructive pulmonary disease (COPD) with respiratory failure

BACKGROUND

To compare the efficacy and feasibility of using a modified Glasgow coma scale (GCS) score of 13 or 15 as the criterion for switching chronic obstructive pulmonary disease (COPD) patients with respiratory failure to sequential invasive-noninvasive ventilation.

METHODS

COPD patients with respiratory failure who had undergone endotracheal intubation and invasive mechanical ventilation (IMV) between June 2017 and June 2020 at 4 different hospitals in China were included. A total of 296 patients were randomly divided into 2 groups. In group A, the patients were extubated and immediately placed on noninvasive ventilation (NIV) when the modified GCS score reached 13. In group B, the same was done when the modified GCS score reached 15.

RESULTS

No significant differences in the mean blood pressure, oxygenation index, arterial partial pressure of oxygen, and arterial partial pressure of carbon dioxide were seen between groups A and B before extubation and 3 hours after NIV. The re-intubation times were also similar in the 2 groups. Compared to group B, the length of hospital stay, incidence of ventilator associated pneumonia, and time of invasive ventilation were all significantly lower in group A (P = .041, .001, <.001).

CONCLUSION

Using a modified GCS score of 13 as the criterion for switching from IMV to NIV can significantly reduce the duration of IMV, length of hospital stay, and incidence of ventilator associated pneumonia in COPD patients with respiratory failure.

Characteristics and outcomes of SARS-COV 2 critically ill patients after emergence of the variant of concern 20H/501Y.V2: A comparative cohort study

There are currently no data regarding characteristics of critically ill patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) variant of concern (VOC) 20H/501Y.V2. We therefore aimed to describe changes of characteristics in critically ill patients with Covid-19 between the first and the second wave when viral genome sequencing indicated that VOC was largely dominant in Mayotte Island (Indian Ocean). Consecutive patients with Covid-19 and over 18 years admitted in the unique intensive care unit (ICU) of Mayotte during wave 2 were compared with an historical cohort of patients admitted during wave 1. We performed a LR comparing wave 1 and wave 2 as outcomes. To complete analysis, we built a Random Forest model (RF), that is, a machine learning classification tool- using the same variable set as that of the LR. We included 156 patients, 41 (26.3%) and 115 (73.7%) belonging to the first and second waves respectively. Univariate analysis did not find difference in demographic data or in mortality. Our multivariate LR found that patients in wave 2 had less fever (absence of fever aOR 5.23, 95% confidence interval (CI) 1.89-14.48, p = .001) and a lower simplified acute physiology score (SAPS II) (aOR 0.95, 95% CI 0.91-0.99, p = .007) at admission; at 24 hours, the need of invasive mechanical ventilation was higher (aOR 3.49, 95% CI 0.98-12.51, p = .055) and pO2/FiO2 ratio was lower (aOR 0.99, 95 % CI 0.98-0.99, p = .03). Patients in wave 2 had also an increased risk of ventilator-associated pneumonia (VAP) (aOR 4.64, 95% CI 1.54-13.93, p = .006). Occurrence of VAP was also a key variable to classify patients between wave 1 and wave 2 in the variable importance plot of the RF model. Our data suggested that VOC 20H/501Y.V2 could be associated with a higher severity of respiratory failure at admission and a higher risk for developing VAP. We hypothesized that the expected gain in survival brought by recent improvements in critical care management could have been mitigated by increased transmissibility of the new lineage leading to admission of more severe patients. The immunological role of VOC 20H/501Y.V2 in the propensity for VAP requires further investigations.

Bayesian analysis of a systematic review of early versus late tracheostomy in ICU patients

Background

A recent systematic review and meta-analysis of RCTs of early vs late tracheostomy in mechanically ventilated patients suggest that early tracheostomy reduces the duration of ICU stay and mechanical ventilation, but does not reduce short-term mortality or ventilator-associated pneumonia (VAP). Meta-analysis of randomised trials is typically performed using a frequentist approach, and although reporting confidence intervals, interpretation is usually based on statistical significance. To provide a robust basis for clinical decision-making, we completed the search used from the previous review and analysed the data using Bayesian methods to estimate posterior probabilities of the effect of early tracheostomy on clinical outcomes.

Methods

The search was completed for RCTS comparing early vs late tracheostomy in the databases PubMed, EMBASE, and Cochrane library in June 2022. Effect estimates and 95% confidence intervals were calculated for the outcomes short-term mortality, VAP, duration of ICU stay, and mechanical ventilation. A Bayesian meta-analysis was performed with uninformative priors. Risk ratios (RRs) and standardised mean differences (SMDs) with 95% credible intervals were reported alongside posterior probabilities for any benefit (RR<1; SMD<0), a small benefit (number needed to treat, 200; SMD<–0.5), or modest benefit (number needed to treat, 100; SMD<–1).

Results

Nineteen RCTs with 3508 patients were included. Comparing patients with early vs late tracheostomy, the posterior probabilities for any benefit, small benefit, and modest benefit, respectively, were: 99%, 99%, and 99% for short-term mortality; 94%, 78%, and 51% for VAP; 97%, 43%, and 1% for duration of mechanical ventilation; and 97%, 75%, and 27% and for length of ICU stay.

Conclusions

Bayesian meta-analysis suggests a high probability that early tracheostomy compared with delayed tracheostomy has at least some benefit across all clinical outcomes considered.

Application of Visual Artificial Airway in Patients with ARDS Assisted by Pulmonary Ultrasound

Objective

To explore the application of pulmonary ultrasound in visual nursing of artificial airway in patients with acute respiratory distress syndrome (ARDS).

Methods

Seventy-eight ARDS patients with mechanical ventilation admitted from February 2021 to January 2022 were included and divided into the intervention group and the control group. The control group was given routine airway nursing, and the intervention group was given visual airway nursing management through lung ultrasound. The arterial blood gas analysis indexes, mechanical ventilation time, ICU treatment time, total hospitalization time, aspiration, and the incidence of ventilator-associated pneumonia (VAP) were compared between the two groups.

Results

After treatment, PaO2, PaCO2, SPO2, and oxygenation indexes were significantly improved compared with those before treatment, and the indexes in the intervention group were better than those in the control group after treatment, and the differences were statistically significant (P < 0.05). The mechanical ventilation time (5.39 ± 0.68 vs. 7.92 ± 0.59 days), ICU treatment time (8.05 ± 1.14 vs. 10.71 ± 1.16 days), and total hospitalization time (12.05 ± 2.20 vs. 15.68 ± 2.18 days) in the intervention group were significantly shorter than those in the control group (P < 0.05). The incidences of aspiration (2.56% vs. 15.38%) and VAP (5.13% vs. 20.51%) in the intervention group was significantly lower than that in the control group (P < 0.05).

Conclusion

The application of visual artificial airway management assisted by lung ultrasound in ARDS patients can shorten the treatment time and hospitalization time of mechanical ventilation, reduce the incidence of aspiration and VAP, and improve the prognosis of patients.

Factors Associated With Neonatal Pneumonia and its Mortality in India: A Systematic Review and Meta-Analysis

Background

Neonatal pneumonia remains a significant contributor to infant mortality in India and responsible for increased prevalence of infant deaths globally.

Objective

To identify risk factors associated with neonatal pneumonia and its mortality in India.

Study design

A systematic review was conducted including both analytic study designs and descriptive study designs, which reported a quantitative analysis of factors associated with all the three types of pneumonia among neonates. The search was conducted from August to December, 2016 on the following databases; CINAHL, EMBASE, Ovid MEDLINE, PubMed, ProQuest, SCOPUS, Web of Science, WHO IMSEAR and IndMED. The search was restricted to Indian setting.

Participants

The population of interest was neonates.

Outcomes

The outcome measures included risk factors for incidences and mortality predictors of neonatal pneumonia. These could be related to neonate, maternal and pregnancy, caregiver, family, environment, healthcare system, iatrogenic and others.

Results

A total of three studies were included. For risk factors, two studies on ventilator-associated pneumonia were included with 194 neonates; whereas for mortality predictors, only one study with 150 neonates diagnosed with pneumonia was included. 11 risk factors were identified from two studies: duration of mechanical ventilation, postnatal age, birth weight, prematurity, sex of the neonate, length of stay in NICU, primary diagnosis, gestational age, number of re-intubation, birth asphyxia, and use of nasogastric tube. Metaanalysis with random-effects model was possible only for prematurity (<37 week) and very low birth weight (<1500 g) and very low birth weight was found to be significant (OR 5.61; 95% CI 1.76, 17.90). A single study was included on predictors of mortality. Mean alveolar arterial oxygen gradient (AaDO2) >250 mm Hg was found to be the single most significant predictor of mortality due to pneumonia in neonates.

Conclusion

The study found scant evidence from India on risk factors of neonatal pneumonia other than ventilator-associated pneumonia.

Electronic Supplementary Material

Supplementary material is available in the online version of this article at 10.1007/s13312-021-2374-4

Hospital Readmissions and Mortality Among Intubated and Mechanically Ventilated Adult Subjects With Pneumonia Due to Gram-Negative Bacteria

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections in ICUs and is associated with significant morbidity and mortality. Gram-negative bacteria cause 55-85% of hospital-acquired pneumonia and are associated with increased mortality.

METHODS

This study sought to describe mortality rates and 30-d readmission rates among intubated and mechanically ventilated subjects with Gram-negative pneumonia and to explore associated risk factors for mortality and rehospitalization using data from the 2013 Healthcare Cost and Utilization Project (HCUP) National Readmission Database. The study sample included adults age ≥ 18 y who were hospitalized with invasive, continuous mechanical ventilation; were discharged between February 1, 2013, and November 30, 2013; and had a primary or secondary diagnosis of Gram-negative bacterial pneumonia. Logistic regression was used to identify subject characteristics significantly associated with mortality and readmissions.

RESULTS

Using the HCUP projected sample of 32,683 intubated and mechanically ventilated subjects with Gram-negative pneumonia, the mortality rate during the index hospitalization was 24.3%. More than one fifth of subjects (22.9%) who survived the index hospitalization were readmitted within 30 d of discharge. Among subjects with readmissions, 18% occurred within 3 d of discharge, 39% occurred within 7 d of discharge, and 65% occurred within 14 d of discharge. Subjects with prior hospitalization within 30 d of the index hospitalization had a higher risk of readmission with an odds ratio of 1.70 (95% CI 1.48-1.94).

CONCLUSIONS

Mortality was high and readmissions were substantial among intubated and mechanically ventilated subjects with Gram-negative pneumonia.

Short-Acting Sedative-Analgesic Drugs Protect Against Development of Ventilator-Associated Events in Children: Secondary Analysis of the EUVAE Study

BACKGROUND

The U.S. Centers for Disease Control and Prevention proposed a shift in its surveillance paradigm from ventilator-associated pneumonia to ventilator-associated events (VAE) to broaden the focus of prevention and achieve a greater impact on outcomes. The main objective of the present study was to identify factors associated with pediatric VAEs in children undergoing mechanical ventilation ≥ 48 h.

METHODS

This was a secondary analysis of a pediatric cohort of a multicenter prospective study. Children who underwent mechanical ventilation ≥ 48 h were included. Exclusion criteria were previous ventilation, extracorporeal life support, and right-to-left shunt or pulmonary hypertension. In the subjects with multiple episodes of mechanical ventilation, only the first episode was considered. Remifentanil and propofol are classified as short-acting sedative and analgesic agents. Pediatric VAE is defined as an "increase in PEEP ≥ 2 cm of H₂O, an increase in [Formula: see text] of 0.20, or an increase in [Formula: see text] of 0.15 plus an increase in PEEP ≥ 1 cm of H₂O sustained for ≥1 d. Associations with pediatric VAE were estimated through multivariate Cox proportional hazards analysis. Hazard ratios and 95% CI were computed.

RESULTS

In a cohort of 90 children, 24 pediatric VAEs were documented in 906 ventilator-days. Pediatric VAEs developed after a median of 4.5 (interquartile range, 4-7.25) d. Surgical admissions, spontaneous breathing trials, early mobility, vasopressors, red blood cell units transfusion, type of sedation (continuous vs intermittent), benzodiazepine use for >3 d, and pharmacologic paralysis were not associated with pediatric VAE, whereas the use of continuous short-acting sedative-analgesic agents was identified as a strong protective factor against pediatric VAE (hazard ratio 0.06 [95% CI 0.007-0.5]).

CONCLUSIONS

Treatment with short-acting sedative-analgesic agents should be preferred for sedation of mechanically ventilated children in intensive care.

The Incidence of Healthcare-Associated Infections, Their Clinical Forms, and Microbiological Agents in Intensive Care Units in Southern Poland in a Multicentre Study from 2016 to 2019

INTRODUCTION

Healthcare-associated infections (HAIs) are a serious problem of modern medicine. Patients hospitalized in intensive care units (ICUs) develop HAI significantly more often than patients in other hospital units.

MATERIALS AND METHODS

Analysis involved HAIs from three ICUs in southern Poland. The study was conducted in 2016-2019 on the basis of methodology recommended by the Healthcare-Associated Infections Surveillance Network (HAI-Net) and European Centre for Disease Prevention and Control (ECDC). The objective was to analyse HAIs, their clinical forms, and microbiological agents.

RESULTS

The study included 3028 patients hospitalized for 26,558 person-days (pds) in ICU. A total of 540 HAIs were detected; incidence per 100 hospitalizations was 17.8%, incidence density per 1000 pds was 20.3. The mortality of patients with HAI was 16%, and in Clostridioidesdifficile infection (CDI), the mortality was 28%. The most common clinical form of HAI was bloodstream infection (BSI): 209 cases (incidence rate 6.9%), followed by pneumonia (PN): 131 (incidence rate 4.3%), and urinary tract infection (UTI): 110 cases (incidence rate 3.6%). The most frequently isolated bacteria were Klebsiella pneumoniae 16.4%, Acinetobacter baumannii 14.4%, Staphylococcus aureus 11.8%, and Escherichia coli 11.4%.

CONCLUSIONS

A two-fold higher incidence rate of BSI was detected compared to the average incidence in European countries. BSI of unknown source (BSI-UNK) was predominant. K. pneumoniae and A. baumannii bacteria were the most often isolated microorganisms causing HAI. Infection control based on incidence rate for each type of infection is necessary in ICU to assess the epidemiological situation.

Effect of a Lower vs Higher Positive End-Expiratory Pressure Strategy on Ventilator-Free Days in ICU Patients Without ARDS: A Randomized Clinical Trial

IMPORTANCE

It is uncertain whether invasive ventilation can use lower positive end-expiratory pressure (PEEP) in critically ill patients without acute respiratory distress syndrome (ARDS).

OBJECTIVE

To determine whether a lower PEEP strategy is noninferior to a higher PEEP strategy regarding duration of mechanical ventilation at 28 days.

DESIGN, SETTING, AND PARTICIPANTS

Noninferiority randomized clinical trial conducted from October 26, 2017, through December 17, 2019, in 8 intensive care units (ICUs) in the Netherlands among 980 patients without ARDS expected not to be extubated within 24 hours after start of ventilation. Final follow-up was conducted in March 2020.

INTERVENTIONS

Participants were randomized to receive invasive ventilation using either lower PEEP, consisting of the lowest PEEP level between 0 and 5 cm H2O (n = 476), or higher PEEP, consisting of a PEEP level of 8 cm H2O (n = 493).

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for the difference in ventilator-free days at day 28 of -10%. Secondary outcomes included ICU and hospital lengths of stay; ICU, hospital, and 28- and 90-day mortality; development of ARDS, pneumonia, pneumothorax, severe atelectasis, severe hypoxemia, or need for rescue therapies for hypoxemia; and days with use of vasopressors or sedation.

RESULTS

Among 980 patients who were randomized, 969 (99%) completed the trial (median age, 66 [interquartile range {IQR}, 56-74] years; 246 [36%] women). At day 28, 476 patients in the lower PEEP group had a median of 18 ventilator-free days (IQR, 0-27 days) and 493 patients in the higher PEEP group had a median of 17 ventilator-free days (IQR, 0-27 days) (mean ratio, 1.04; 95% CI, 0.95-∞; P = .007 for noninferiority), and the lower boundary of the 95% CI was within the noninferiority margin. Occurrence of severe hypoxemia was 20.6% vs 17.6% (risk ratio, 1.17; 95% CI, 0.90-1.51; P = .99) and need for rescue strategy was 19.7% vs 14.6% (risk ratio, 1.35; 95% CI, 1.02-1.79; adjusted P = .54) in patients in the lower and higher PEEP groups, respectively. Mortality at 28 days was 38.4% vs 42.0% (hazard ratio, 0.89; 95% CI, 0.73-1.09; P = .99) in patients in the lower and higher PEEP groups, respectively. There were no statistically significant differences in other secondary outcomes.

CONCLUSIONS AND RELEVANCE

Among patients in the ICU without ARDS who were expected not to be extubated within 24 hours, a lower PEEP strategy was noninferior to a higher PEEP strategy with regard to the number of ventilator-free days at day 28. These findings support the use of lower PEEP in patients without ARDS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03167580.

Impact of Oral Care and Antisepsis on the Prevalence of Ventilator-Associated Pneumonia

PURPOSE

This study aimed to evaluate the impact of oral care and use of chlorhexidine gluconate on the prevention of ventilator-associated pneumonia (VAP) in patients admitted to an intensive care unit (ICU).

MATERIALS AND METHODS

An evaluation was performed on 229 patients admitted to ICU in 2012 (before implementation of oral care protocol) and 329 in 2013 (after the protocol). Oral care was based on the removal of secretions from the oral cavity with 0.12% chlorhexidine solution for brushing and sterile gauze for cleaning before a new aspiration. The cases of VAP were evaluated by observing respiratory signs, radiological changes, and culture and laboratory results. The following data were also analysed: gender, length hospital of stay, mechanical ventilation, use of antibiotics and aetiological agent of infection.

RESULTS

There was a tendency towards lower risk of development of VAP after application of oral care protocol (odds ratio = 0.64-95% CI: 0.39-1.04). There was also a reduction in the incidence of early pneumonia (up to 72 h of hospitalisation). With regard to the aetiological agent of infections, although Gram-negative bacteria predominated in the two periods studied, there was a decrease in the cases of Staphylococcus aureus infection.

CONCLUSION

Oral care protocol has statistically significantly reduced the risk of developing early VAP in ICU patients, thus demonstrating the importance of multidisciplinary teamwork for hospitalised patients.

[Practice of nosocomial infection management in burn department based on the American hospital evaluation standard of the Joint Commission International]

Objective: To explore the role of continuous quality improvement measures based on the American hospital evaluation standard of the Joint Commission International (JCI) in prevention and control of nosocomial infection in Burn Department of the Second Affiliated Hospital of Zhejiang University School of Medicine (hereinafter referred to as the author' s department). Methods: From 2013 to 2018, based on 11 JCI standards related to infection prevention and control and the current situation of the author' s department, more than 50 doctors, nurses, and nursing assistants from the author' s department participated in continuous improvement of the three-level management system of nosocomial infection in the author' s department, focusing on implementing of management of patient with multidrug resistant bacteria infection, optimizing the infection control management of instrument and cloth, and implementing target management on 5 indicators such as hand hygiene implementation rate, and carrying out inspection, quality management, and improvement on 11 items of prevention and control of nosocomial infection. The implementation rate of hand hygiene from 2013 to 2018 and the accuracy rate of hand hygiene from 2016 to 2018 of medical staff in the author' s department, and incidences of catheter-related bloodstream infection (CRBSI) of central venous, catheter-associated urinary tract infection (CAUTI), and ventilator associated pneumonia (VAP) of burn intensive care unit in the author's department from 2013 to 2018 were monitored.The following 7 indicators were monitored from 2013 to 2018, including false negative rate of nosocomial infection, incidence of hyperglycemia during intensive insulin treatment for severely burned patients, the implementation rate of CRBSI preventive measures, the specification rate of surface fixation of indwelling catheter, the implementation rate of VAP preventive measures, the accuracy rate of bed temperature during the use of suspended bed, and the implementation rate of hand hygiene of standardized training medical staff in the author' s department before and after improvement. Data were statistically analyzed with chi-square test. Results: The implementation rate of hand hygiene of medical staff in the author' s department was 88.0%-89.5% from 2013 to 2018, the correct rate of hand hygiene of medical staff in the author' s department was 95.10%-97.35%, and both reached the target values. The incidences of CRBSI in 2015, VAP in 2017, and CAUTI in 2013, 2014, and 2017 of burn intensive care unit failed to reach the respective target value and reached the respective target value after quality improvement, and the above-mentioned 3 indicators reached the respective target value in other years. From 2013 to 2018, the false negative rate of nosocomial infection and the incidence of hyperglycemia during intensive insulin treatment of severely burned patients in the author' s department after improvement were significantly lower than those before improvement (χ(2)=24.50, 4.74, P<0.05 or P<0.01), the implementation rate of CRBSI preventive measures, the specification rate of surface fixation of indwelling catheter, the implementation rate of VAP preventive measures, and the accuracy rate of bed temperature during the use of suspended bed after improvement in the author' s department were significantly higher than those before improvement (χ(2)=13.78, 6.50, 20.37, 13.92, P<0.05 or P<0.01), and the implementation rate of hand hygiene of standardized training medical staff in the author' s department after improvement was similar to that before improvement (χ(2)=1.71, P>0.05). Conclusions: The introduction of JCI standard can improve the implementation rate and accuracy rate of hand hygiene of medical staff in burn department, reduce the incidences of CRBSI, CAUTI, and VAP, and improve the effect of prevention and control of nosocomial infection in burn department.