Mortality in Ventilator‐Associated Tracheobronchitis and Pneumonia in Oncology Patients: The Impact of Microbiological Aspects

: Mechanical ventilation epitomizes intensive care medicine. Ventilator‑associated complications are mainly Ventilator associated respiratory infections (VARI); These are a major cause of concern in the intensive care units (ICUs) worldwide, especially in developing countries. VARI includes patients with ventilator‑associated tracheobronchitis (VAT) and ventilator‑associated pneumonia (VAP).The clinical profile, severity, microbiology, and outcomes of such infections is not well described in Eastern India. The primary objective of the study was to study the risk factors, severity scoring, microbiological profile and 28 days outcome of patients admitted in intensive care unit of our hospital.Secondary objective of our study was to find out any correlation between risk factors, severity scoring, microbiological profile, and outcome of patients with VAT and VAP admitted in intensive care unit of our hospital.: This was a prospective observational study done in the ICU of a tertiary care centre in eastern India. A total 50 patients of clinically, microbiologically and/or radiologically diagnosed case of VAP and VAT were included in the study. A structured data collection proforma was prepared and data collection was done. Raw data was tabulated and analysed: 66% of our patients were male, Smoking was the commonest addiction(24%), VARI developed early with 17% on Day 3, 72% developed VARI within 5 days of ventilation. 16% had history of recent admission, Diabetes and hypertension were the commonest comorbidities. 58% of the patients developed VAP, the median SOFA score in VAP was 6 also similar in VAT. Patients with neurological diseases had the maximum number of VAT and VAP. Klebsiella pneumoniae was the commonest organism causing VAT (42%) while Acinetobacter Baumanii was commonest to cause VAP (44%). 51% of VAP patients were on volume control mode, while it was 52% of VAT patients. Most isolates are MDR pathogens with intermediate sensitivity to Polymyxin being most common (66%) 1 isolate was pan resistant. Mortality was 58% for VAP and 19% in VAT. Both Klebsiella and Acinetobacter accounts for 41% death in VAP group, in VAT group Klebsiella was commonest however no statistical significance with other organism.: Gram negative bacteria were the predominant cause of VAT and VAP, Acinetobacter and Klebsiella are the commonest organisms. Most Isolates are MDR with intermediate sensitivity to Polymyxins. Median SOFA scores were the same in both. Mortality was high in VAP group. Volume control mode was predominant mode of ventilation, Neurological causes was predominant cause that leads to ventilation and subsequent VARI.

Ventilator-Associated Tracheobronchitis in a Mixed Surgical and Medical ICU Population

Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries

Ventilator-Associated Tracheobronchitis

Outcomes associated with ventilator-associated events (VAE), respiratory infections (VARI), pneumonia (VAP) and tracheobronchitis (VAT) in ventilated pediatric ICU patients: A multicentre prospective cohort study

Comparison study between bacteriological aetiology and outcome of VAT & VAP

Colonization of lower airways by Staphylococcus aureus is a risk factor for the development of ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP). However, little is known about the virulence factors of methicillin-sensitive and -resistant S. aureus (MSSA and MRSA) that may influence host colonization and progression to VAT and VAP. We evaluated MRSA and MSSA endotracheal aspirates (ETA) for genotype and α-hemolysin activity in relation to the development of VAT and VAP. Serial S. aureus ETA isolates from ventilated patients were analyzed for methicillin resistance, molecular type by Multi-Locus Sequence Typing and spa-typing, and α-hemolysin activity by semiquantitative analysis of hemolysis on sheep blood agar and quantitative measurement of cytolysis of human lung epithelial cells. The virulence of selected strains was assessed in mice by intranasal challenge. We detected S. aureus from ETA samples in a quarter of the 231 ventilated patients analyzed; one-third of them developed VAP. VAP patients (n = 15) were mainly infected by MSSA strains (87%), whereas colonized individuals (n = 18) not progressing to disease mainly carried MRSA strains (68%). MSSA isolates from colonized or VAT patients exhibited significantly lower α-hemolysin activity than those from VAP cases; however, no such relationship was found with MRSA strains. α-Hemolysin activity of S. aureus isolates was predictive for virulence in mouse pneumonia model. MSSA strains with strong blood agar hemolysis and high α-hemolysin activity are markers for VAP, but not VAT, and might be considered in differential diagnosis and initiation of therapy.

IntroductionTwo small randomized controlled trials have suggested beneficial effects of antibiotic treatment in patients with ventilator-associated tracheobronchitis (VAT). The primary aim of this study is to determine the impact of appropriate antibiotic treatment on transition from VAT to ventilator-associated pneumonia (VAP) in critically ill patients. The secondary objective was to determine the incidence of VAP in patients with VAT.MethodsThis was a prospective observational multicenter study. All patients with a first episode of VAT were eligible. Patients with tracheostomy at intensive care unit (ICU) admission, and those with VAP prior to VAT were excluded. VAT was defined using all the following criteria: fever > 38°C with no other cause, purulent tracheal secretions, positive tracheal aspirate (≥105 cfu/mL), and absence of new infiltrate on chest X ray. Only VAP episodes diagnosed during the 96 h following VAT, and caused by the same bacteria, were taken into account. Antibiotic treatment was at the discretion of attending physicians. Risk factors for transition from VAT to VAP were determined using univariate and multivariate analysis. All variables from univariate analysis with P values <0.1 were incorporated in the multivariate logistic regression analysis.ResultsOne thousand seven hundred and ten patients were screened for this study. Eighty-six, and 123 patients were excluded for tracheostomy at ICU admission, and VAP prior to VAT; respectively. One hundred and twenty two (7.1%) patients were included. 17 (13.9%) patients developed a subsequent VAP. The most common microorganisms in VAT patients were Pseudomonas aeruginosa (30%), Staphylococcus aureus (18%), and Acinetobacter baumannii (10%). Seventy-four (60%) patients received antimicrobial treatment, including 58 (47.5%) patients who received appropriate antimicrobial treatment. Appropriate antibiotic treatment was the only factor independently associated with reduced risk for transition from VAT to VAP (OR [95% CI] 0.12[0.02-0.59], P = 0.009). The number of patients with VAT needed to treat to prevent one episode of VAP, or one episode of VAP related to P. aeruginosa was 5, and 34; respectively.ConclusionsAppropriate antibiotic treatment is independently associated with reduced risk for transition from VAT to VAP.

The aim is to discuss the clinical, microbiologic, and radiological criteria used in the diagnosis of ventilator-associated pneumonia (VAP), distinguish between ventilator-associated tracheobronchitis (VAT) and VAP, and reconcile the proposed Centers for Disease Control surveillance criteria with clinical practice. Numerous ventilator-associated complications (VACs), including VAP and VAT, may occur in critically ill, intubated patients. A variety of definitions for identifying VAP have been proposed, but there is no diagnostic gold standard. The proposed surveillance definition will identify infectious and noninfectious VAC, including VAP and VAT, but this definition may be inadequate for clinical practice. The clinical characteristics of VAP and VAT are similar and include fever, leukocytosis, and purulent sputum. An infiltrate on chest radiograph is consistent with VAP but lacks diagnostic precision, so it is not a criterion in the proposed surveillance definition and should be interpreted cautiously by clinicians. Microbiologically, quantitative and semiquantitative endotracheal aspirate cultures may be employed to diagnose VAP and VAT. Positive bronchoalveolar lavage and protected specimen brush cultures are useful only for the diagnosis of VAP. Experts should collaborate to develop consensus definitions for VAP and VAT that can be applied in practice.

Introduction Ventilator Associated Pneumonia (VAP) is associated with significant cost, morbidity, and mortality. There is limited data on the incidence of VAP, appropriate antibiotic timing, and the impact of multidrug resistant VAP in intubated Coronavirus disease-19 (COVID-19) patients. Methods A retrospective study was conducted at 2 tertiary urban academic centers involving 132 COVID-19 patients requiring invasive mechanical ventilation (IMV). The epidemiology of VAP, the impact of prior empiric antibiotic administration on the development of Multidrug Resistant Organism (MDRO) infections, and the impact of VAP on patient outcomes were studied. Results The average age of the patients was 60.58% were males, 70% were African-Americans and two-thirds of patients had diabetes, hypertension, or heart disease. The average Body Mass Index (BMI) was 32.9. Forty-one patients (27%) developed VAP. Patients with VAP had a significantly higher Sequential Organ Failure Assessment (SOFA) score prior to Intensive Care Unit (ICU) admission. Sixty percent received empiric antibiotics before initiation of IMV, mostly on hospital admission, and 81% received empiric antibiotics at the time of intubation. The administration of empiric antibiotics was not associated with a higher prevalence of VAP. The prevalence of VAP was 22 per 1000 days on ventilation. No difference in mortality was seen between VAP and non-VAP groups at 49% and 57% respectively (p = 0.4). VAP was associated with increased ICU length of stay (LOS), 30 vs. 16 days (p < 0.001), and longer hospital LOS 35 vs. 17 days (p < 0.001). 40% of VAPs were caused by MDROs. The most common organism was Staphylococcus aureus (28%), with almost half (48%) being methicillin resistant Staphylococcus aureus (MRSA). Conclusion VAP was a common complication of patients intubated for COVID-19 pneumonia. Most patients received empiric antibiotics upon the hospital and/or ICU admission. There was a 40% incidence of multidrug resistant pneumonia. Patients who developed VAP had almost twice as long hospital and ICU LOS.

Background: Ventilator associated pneumonia (VAP) remains to be the commonest cause of hospital morbidity and mortality in spite of advances in diagnostic techniques and management. VAP refers to bacterial pneumonia developing in patients who have been receiving mechanical ventilation for at least 48 hours. It is the commonest complication associated with mechanical ventilation. The objectives were to know the incidence and outcome of VAP in a tertiary care centre at Indira Gandhi Institute of child health (IGICH) and to identify the probable risk factors for ventilator associated pneumonia (VAP) and to identify the most common pathogenic bacteria causing VAP. Methods: This is a prospective study of children mechanically ventilated in the pediatric intensive care unit of Indira Gandhi Institute of Child Health. Children between the age group of >1month to <18 years were included in the study. Ventilator associated pneumonia is defined as per the clinical pulmonary infection score given by Pugin et al, patients were monitored with various clinical and laboratory parameters like fever, purulent endotracheal aspirates, pulmonary radiological changes, leukocytosis, arterial blood gas analysis, blood culture and endotracheal tube aspirate grams stain and culture and sensitivity pattern and other relevant investigations. Results: Out of the seventy five children requiring mechanical ventilation 17 developed VAP giving the incidence of 22.66%. Early onset VAP constituted 41.1% of the cases and the rest is late onset VAP (58.9%). Reintubation of more than 2 times, central venous lines, tracheostomy and prolonged ventilation are the risk factors for VAP. Pseudomonas (6), Klebsiella (8) were the most frequent and significant etiological agents causing VAP. Pseudomonas and Klebsiella are the common organisms in late onset VAP and Staphylococcus aureus (MRSA) (2) and E coli (1) are isolated in early onset VAP. There is no statistically significant difference in mortality between the VAP and Non-VAP cases. VAP prolongs the duration of mechanical ventilation, length of intensive care and the duration of hospital stay compared to the Non VAP cases. The average duration of ventilation in VAP cases is 6.68±4.12 days. The mean duration of PICU care (16.65days) and hospital stay in VAP children is also prolonged (20.53 days) and it is statistically significant. Conclusions: VAP is an important nosocomial infection in PICU with the incidence of 22.66%. Prolonged ventilation and repeated intubations are the major risk factors. Central venous lines and tracheostomy are the added risk factors for VAP. Judicious use of ventilator support and early weaning will reduce the incidence of VAP. Gram negative organisms are the most common organisms causing VAP. VAP did not influence the mortality but it did prolong the duration of ventilation, intensive care and hospital stay in turn increasing the morbidity.

Background:Ventilator-associated pneumonia (VAP) remains a critical challenge in intensive care units (ICUs), particularly in settings with limited infection control infrastructure. While global data exist, there is a striking lack of contemporary evidence from northern regions of Saudi Arabia, where healthcare delivery and microbial resistance patterns may differ significantly from metropolitan centers. Objective:To assess the incidence, microbiological profile, and outcome predictors of VAP in a resource-limited ICU in Al Jouf, Saudi Arabia—an underreported region in current literature. Methods:This retrospective observational study included adult ICU patients diagnosed with VAP between January 2021 and December 2023 at Prince Mutaib Bin Abdulaziz Hospital. Demographic, clinical, and microbiological data were collected. Multivariable logistic regression was used to identify independent predictors of ICU mortality. Results:Of 270 ICU patients, 70 (26%) developed VAP. The most common pathogens were Acinetobacter baumannii (37.1%) and Klebsiella pneumoniae (21.4%). ICU mortality was 74.3%, with age ≥65 years (OR 3.47) and female sex (OR 8.00) independently associated with death. MDR organisms were identified even in early-onset VAP, challenging traditional classifications. Conclusion:This study highlights the high burden of VAP and associated mortality in a northern Saudi ICU, where antimicrobial resistance patterns and resource constraints amplify the clinical risk. The findings call for region-specific infection control strategies and stewardship programs tailored to non-tertiary healthcare settings.

Background: Ventilator-associated pneumonia (VAP) is the most monitored form of respiratory tract infections (RTIs). A small number of epidemiological studies have monitored community-acquired pneumonia (CAP), non-ventilator hospital-acquired pneumonia (NV-HAP) and ventilator-associated tracheobronchitis (VAT) in intensive care units (ICUs). The objective of this study was to assess the frequency, etiology, mortality, and additional costs of RTIs. Methods: One-year prospective RTI surveillance at a 30-bed ICU. The study assessed the rates and microbiological profiles of CAP, VAP, NV-HAP, VAT, and VAP prevention factors, the impact of VAP and NV-HAP on the length of ICU stays, and the additional costs of RTI treatment and mortality. Results: Among 578 patients, RTIs were found in 30%. The CAP, NV-HAP, VAP, and VAT rates/100 admissions were 5.9, 9.0, 8.65, and 6.05, respectively. The VAP incidence density/1000 MV-days was 10.8. The most common pathogen of RTI was Acinetobacter baumannii MDR. ICU stays were extended by VAP and NV-HAP for 17.8 and 3.7 days, respectively, and these RTIs increased the cost of therapy by 13,029 and 2708 EUR per patient, respectively. The mortality rate was higher by 11.55% in patients with VAP than those without device-associated and healthcare-associated infections (p = 0.0861). Conclusions: RTIs are a serious epidemiological problem in patients who are admitted and treated in ICU, as they may affect one-third of patients. Hospital-acquired RTIs extend hospitalization time, increase the cost of treatment, and worsen outcomes.

Impact of Ventilator-Associated Pneumonia on Outcome in Patients With COPD

Early distinguishing ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP) remains difficult in the daily practice. However, this question appears clinically relevant, as treatments of VAT and VAP currently differ. In this study, we assessed the accuracy of sepsis criteria according to the Sepsis-3 definition in the early distinction between VAT and VAP. Retrospective single-center cohort, including all consecutive patients with a diagnosis of VAT (n = 70) or VAP (n = 136), during a 2-year period. Accuracy of sepsis criteria according to Sepsis-3, total SOFA and respiratory SOFA, calculated at time of microbiological sampling were assessed in differentiating VAT from VAP, and in predicting mortality on ICU discharge. Sensitivity and specificity of sepsis criteria were found respectively at 0.4 and 0.91 to distinguish VAT from VAP, and at 0.38 and 0.75 for the prediction of mortality in VA-LRTI. A total SOFA ≥ 6 and a respiratory SOFA ≥ 3 were identified as the best cut-offs for these criteria in differentiating VAT from VAP, with sensitivity and specificity respectively found at 0.63 and 0.69 for total SOFA, and at 0.49 and 0.7 for respiratory SOFA. Additionally, for prediction of mortality, a total SOFA ≥ 7 and a respiratory SOFA = 4 were identified as the best-cut-offs, respectively yielding sensitivity and specificity at 0.56 and 0.61 for total SOFA, and at 0.22 and 0.95 for respiratory SOFA. Sepsis criteria according to the Sepsis-3 definition show a high specificity but a low sensitivity for the diagnosis of VAP. Our results do not support the use of these criteria for the early diagnosis of VAP in patients with VA-LRTI.