Etiology Of Ventilator-associated Pneumonia Research Articles

639. A Decade-Long Analysis of Ventilator-Associated Pneumonia in the Intensive Care Unit of a Public Hospital in a Major Brazilian City: An Exploration of Trends, Challenges, and Opportunities

Abstract Background Ventilator-associated pneumonia (VAP) remains a critical issue in ICUs. This study investigates VAP dynamics over the past decade by examining trends in its incidence, shifts in etiological agents and their antimicrobial sensitivities, and factors affecting patient mortality.Figure 1Ten-Year Trend of Ventilator-Associated Pneumonia Incidence in the ICU of a Major Brazilian Public Hospital: Initial Reduction Reversed in 2020 Due to the COVID-19 Pandemic; Current Levels (2021-2023) Show a 23% Decrease Compared to the Start of the Series (2014-2016). Ten-Year Trend of Ventilator-Associated Pneumonia Incidence in the ICU of a Major Brazilian Public Hospital: Initial Reduction Reversed in 2020 Due to the COVID-19 Pandemic; Current Levels (2021-2023) Show a 23% Decrease Compared to the Start of the Series (2014-2016). Methods Surveillance of ICU patients on mechanical ventilation in a 300-bed public hospital in Belo Horizonte, Brazil (Jan/2014-Dec/2023) followed the National Healthcare Safety Network protocol. Logistic regression analyzed VAP mortality risks. Microorganism clusters were identified using dynamic programming to determine edit distances between pseudoDNA strings, which were formed from concatenated antimicrobial sensitivity results (S, R, I) for each strain.Figure 2Ten-Year Trends in VAP Etiology in the ICU of a Major Brazilian Public Hospital: Despite Variations in Predominant Agents, the Same Bacteria (e.g., Acinetobacter, Staphylococcus aureus, Pseudomonas, Klebsiella, Serratia) Have Consistently Caused VAP Throughout the Decade. Ten-Year Trends in VAP Etiology in the ICU of a Major Brazilian Public Hospital: Despite Variations in Predominant Agents, the Same Bacteria (e.g., Acinetobacter, Staphylococcus aureus, Pseudomonas, Klebsiella, Serratia) Have Consistently Caused VAP Throughout the Decade. Results From 2014 to 2023, there were 1,166 VAP cases (20.9 cases per 1,000 ventilator-days). Initially, the incidence of VAP decreased significantly until 2019, but a rising trend began in 2020 and persisted through 2022 (Fig. 1). The predominant etiological agents, Acinetobacter, Staphylococcus aureus, Pseudomonas, and Klebsiella, accounted for 70%-80% of cases (Fig. 2). Antimicrobial sensitivity remained relatively stable over the decade, with a notable decline only in 2023 (Fig. 3). PseudoDNA analysis for Acinetobacter baumannii revealed two clusters: a small multisensible cluster (4% of strains) and a larger multiresistant cluster present throughout the decade (Fig. 4). The same pattern was observed for the other predominant microorganisms. A logistic regression model predicting mortality in VAP patients identified four significant predictors (area under the ROC curve = 0.68): patient age, time from hospitalization to pneumonia diagnosis, secondary sepsis (Odds Ratio = 2.6), and number of prior hospitalizations at the same hospital.Figure 3Ten-Year Trends in Antimicrobial Sensitivity of Acinetobacter, Pseudomonas, Klebsiella and Staphylococcus aureus Causing VAP in the ICU of a Major Brazilian Public Hospital: Increased Resistance Observed in 2023. Ten-Year Trends in Antimicrobial Sensitivity of Acinetobacter, Pseudomonas, Klebsiella and Staphylococcus aureus Causing VAP in the ICU of a Major Brazilian Public Hospital: Increased Resistance Observed in 2023. Conclusion We addressed three key questions on VAP: 1) Despite a temporary increase in 2020, we achieved a 23% overall reduction in VAP incidence, though it remains above benchmark levels. 2) The etiology of VAP has been consistent over the decade, but antimicrobial sensitivity has deteriorated. 3) Age, time from hospitalization to pneumonia diagnosis, prior admissions, and notably, secondary sepsis, are significant risk factors for VAP mortality.Figure 4PseudoDNA Cluster Analysis of Acinetobacter baumannii Showing Two Distinct Groups: A Small Multisensible Cluster (4% of Strains) and a Predominant Multiresistant Cluster Persistent Over the Decade PseudoDNA Cluster Analysis of Acinetobacter baumannii Showing Two Distinct Groups: A Small Multisensible Cluster (4% of Strains) and a Predominant Multiresistant Cluster Persistent Over the Decade Disclosures All Authors: No reported disclosures

Analysis of Bacterial Metabolites in Breath Gas of Critically Ill Patients for Diagnosis of Ventilator-Associated Pneumonia-A Proof of Concept Study.

Bacterial infection of the lower respiratory tract frequently occurs in mechanically ventilated patients and may develop into life-threatening conditions. Yet, existing diagnostic methods have moderate sensitivity and specificity, which results in the overuse of broad-spectrum antibiotics administered prophylactically. This study aims to evaluate the suitability of volatile bacterial metabolites for the breath-based test, which is used for diagnosing Ventilator-Associated Pneumonia (VAP). The in vitro experiments with pathogenic bacteria most prevalent in VAP etiology (i.e., Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa) were performed to identify bacteria-derived metabolites using a specially designed cultivation system enabling headspace sampling for GC-MS analysis. Thirty-nine compounds were found to be significantly metabolized by tested species and, therefore, selected for monitoring in the exhaled breath of critically ill, mechanically ventilated (MV) patients. The emission of volatiles from medical respiratory devices was investigated to estimate the risk of spoiling breath results with exogenous pollutants. Bacterial metabolites were then evaluated to differentiate VAP patients from non-infected MV controls using Receiver Operating Characteristic (ROC) analysis, with AUC, sensitivity, and specificity calculated. Nine bacterial metabolites that passed verification through a non-parametric ANOVA test for significance and LASSO penalization were identified as key discriminators between VAP and non-VAP patients. The diagnostic model achieved an AUC of 0.893, with sensitivity and specificity values of 87% and 82.4%, respectively, being competitive with traditional methods. Further validation could solidify its clinical utility in critical care settings.

Prevalence and etiology of ventilator-associated pneumonia during the COVID-19 pandemic in Denmark: Wave-dependent lessons learned from a mixed-ICU.

Ventilator-associated pneumonia (VAP) may be a particular concern in patients with severe coronavirus disease 2019 (COVID-19). We aimed to determine the prevalence and etiology of VAP in critically ill COVID-19 patients in a Danish intensive care unit (ICU) during the first three waves of the COVID-19 pandemic and to study associations between dexamethasone (DXM) use and development of VAP. In an observational single-center study patients were retrospectively screened for VAP including causative pathogens, use of DXM and commonly used antibiotics. Diagnosis of VAP required invasive mechanical ventilation (IMV) >48 h with presence of a new bacterial agent and clinical signs of infection. For analysis, common descriptive statistics were applied. Cox proportional hazards models were used to analyze the association between DXM use and VAP. VAP was detected in 53/119 (44.5%) mechanically ventilated patients across all three COVID-19 waves. Median length of IMV for VAP patients was 24 [15-41] days, and 3 out of 4 were males. VAP was most prevalent (47.0%) during the second wave. Common pathogens included Klebsiella pneumoniae (24.5%), Enterobacter aerogenes (17.0%) and Pseudomonas aeruginosa (13.2%), Staphylococcus aureus (13.2%), and Escherichia coli (13.2%). A change from Gram-negative bacteria only to a combination of Gram-positive and Gram-negative bacteria was observed in the second wave compared to first. Use of DXM was not associated with VAP (adjusted hazard ratio 1.63 95% CI: 0.84-3.17). The prevalence of VAP was high across all three COVID-19 waves and showed a different distribution of pathogens between the first and second wave. Use of DXM was not associated with VAP development. Further and larger studies are needed to understand the risk factors associated with VAP in patients with COVID-19.

Untargeted Blood Lipidomics Analysis in Critically Ill Pediatric Patients with Ventilator-Associated Pneumonia: A Pilot Study.

This study aims to explore the diagnostic potential of blood lipid profiles in suspected ventilator-associated pneumonia (VAP). Early detection of VAP remains challenging for clinicians due to subjective clinical criteria and the limited effectiveness of current diagnostic tests. Blood samples from 20 patients, with ages between 6 months and 15 years, were collected at days 1, 3, 6, and 12, and an untargeted lipidomics analysis was performed using a Ultra high Pressure Liquid Chromatography hyphenated with High Resolution Mass Spectrometry UPLC-HRMS (TIMS-TOF/MS) platform. Patients were stratified based on modified pediatric clinical pulmonary index score (mCPIS) into high (mCPIS ≥ 6, n = 12) and low (mCPIS < 6, n = 8) VAP suspicion groups. With the untargeted lipid profiling, we were able to identify 144 lipid species from different lipid groups such as glycerophospholipids, glycerolipids, and sphingolipids, in the blood of children with VAP. Multivariate and univariate statistical analyses revealed a distinct distribution of blood lipid profiles between the studied groups, indicating the potential utility of lipid biomarkers in discriminating VAP presence. Additionally, specific lipids were associated with pharyngeal culture results, notably the presence of Klebsiella pneumoniae and Staphylococcus aureus, underscoring the importance of lipid profiling in identifying the microbial etiology of VAP.

The ongoing challenge of ventilator-associated pneumonia: epidemiology, prevention, and risk factors for mortality in a secondary care hospital intensive care unit

Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality among intensive care unit infections. Despite various preventive measures, the incidence of VAP remains high. This study aimed to explore the epidemiology and risk factors for VAP associated mortality in a secondary care hospital, comparing outcomes before and after implementing a VAP prevention bundle. This retrospective study was conducted from July 1, 2021, to June 30, 2023, at a secondary care hospital. Patients over 18 years old who underwent mechanical ventilation for more than 48 hours were included. The study compared the incidence, microbiological etiology, and outcomes of VAP before and after implementing the VAP prevention bundle and analyzed risk factors for mortality from VAP. A total of 83 patients diagnosed with VAP were included. Despite concerted efforts to implement the VAP prevention bundle, there was no significant decrease in the VAP rate per 1000 ventilator days, early-onset VAP, secondary bloodstream infections, acute respiratory distress syndrome, and 30-day mortality. The microbiological etiology of VAP remained consistent between the two periods. A decrease in lymphocyte count and albumin level were identified as independent risk factors for 30-day mortality. Concerted efforts to implement a VAP prevention bundle did not significantly reduce the incidence or improve outcomes of VAP in this secondary care hospital setting. The microbiological etiology remained unchanged. Monitoring lymphocyte count and albumin level may help identify patients at high mortality risk. Further research is needed to develop more effective VAP prevention and management strategies.

Frequency and Etiology of Ventilator-Associated Pneumonia in COVID-19 Patients Presenting to Tertiary Care Hospital

Objective: To establish the frequency and aetiology of the pathogens causing Ventilator-Associated Pneumonia in COVIDpatients admitted to a tertiary care hospital. Study Design: Cross-sectional study. Place and Duration of Study: Department of Medicine and Intensive Care, Pak Emirates Military Hospital, RawalpindiPakistan, from July 2021 to Feb 2022. Methodology: Patients between 25 to 70 years of age of either gender with severe COVID pneumonia with positive RT-PCR, clinical and radiological evidence of critical disease, and needing ventilatory support due to respiratory failure were included in this study. Ventilator-associated pneumonia (VAP) was identified and confirmed by positive culture taken 48 hours after intubation, and Cultures noted organisms. Results: Of 300, 238(79.3%) patients developed Ventilator-Associated Pneumonia (VAP) 48 hours after intubation. VAP was diagnosed by positive cultures taken from bronchial secretions and blood samples. Culture report analyses were assessed for pathogens, which revealed Klebsiella pneumonia (KP) being the most common pathogen 64(26.9%), followed by Acinetobacter baumannii 49(20.6%) and Pseudomonas aeruginosa 26(10.9%). Polymicrobial culture results were also seen,which revealed Acinetobacter+Klebsiella in 29(12.2%) subjects, Pseudomonas with KP in 33(13.9%), and Acinetobacter with Pseudomonas aeruginosa in 13(5.5%). Conclusion: Klebsiella pneumonia is the most common pathogen found to cause VAP in COVID-19 patients. Around 30% of polymicrobial cultures were noted.

Detection of Extended-spectrum Beta-lactamases (ESBLs), Carbapenemase, Metallo-β-lactamase Production Bacteria and Antibiotic Susceptibility Pattern in Hospitalized Patients with Ventilator-associated Pneumonia

Background: Due to the increase in microbial resistance, nosocomial multidrug resistance infections, including ventilator-associated pneumonia (VAP), are presently one of the main causes of death in hospitals since they are difficult to treat. Objectives: This study aimed to investigate the bacterial etiology of VAP and their microbial resistance pattern in Dezful Hospital, southwest of Iran. Methods: In this cross-sectional study, 131 bacterial isolates were isolated from the respiratory secretions of the patients with VAP in ICU wards. Antibiotic susceptibility testing (AST) of all isolates was carried out after the identification. Then the extended-spectrum beta-lactamases (ESBLs), carbapenemase, and metallobetalactamase were identified by phenotyping and genotyping. Results: The most frequent isolates were Staphylococcus aureus (30.5%), Acinetobacter baumannii (25.2%), and Klebsiella pneumoniae (24.4%). All strains of S. aureus were sensitive to vancomycin, ticoplanin, quinupristin-dalfopristin, and linezolid. Escherichia coli and Klebsiella showed high resistance to cephalosporins. More than 93% of Acinetobacter isolates were resistant to carbapenem and quinolones. The overall prevalence of ESBLs and carbapenemase producing bacteria were 80.43% and 73.6%, respectively. The most frequent ESBLs gene was blaCTX-M gene (78.3%) followed by blaAMP-C gene (67.5%), blaSHV gene (64.8%), and blaTEM gene (54%). Conclusions: In sum, there was a possibility that the treatment of nosocomial multidrug resistant infections such as VAP would become a major challenge. Therefore, it was recommended that AST results should always be considered when selecting the appropriate treatment regimen. Furthermore, it was found important to emphasize the principles of antibiotic stewardship and to constantly monitor the pattern of microbial susceptibility.

Ventilator-Associated Pneumonia in Neonates Admitted to a Tertiary Care NICU in Bulgaria.

Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection (HAI) among neonatal patients in the intensive care units (ICUs) and is a serious challenge for neonatologists because it affects critically ill patients who need prolonged mechanical ventilation. In Bulgaria, there is no detailed data at regional and national levels on the characteristics of VAP in newborns, which imposes a necessity for specific studies of risk factors and etiology of VAP. The aim of the study was to analyze the frequency, characteristics and risk factors for the occurrence of VAP in newborns hospitalized in intensive care unit. This was a prospective study, conducted between January 2017 and June 2018 in the NICU of University Hospital “St. George” Plovdiv, Bulgaria. The sample consisted of 507 neonates, followed up prospectively, 107 of whom were placed on mechanical ventilation for ≥48 h. VAP was diagnosed in 33 out of 107 neonates (31%). The VAP incidence rate was 35.06/1.000 ventilator days. We confirmed differences between the median birth weight (1,310 vs. 1,690 g, p = 0.045) and average gestational age (31.08 g.w. vs. 33.08 g.w, p = 0.04) of the patients with and without VAP. The average stay of patients with VAP in the NICU was statistically significantly longer than the hospital stay of non-VAP patients (35.70 ± 21.84 days vs. 21.77 ± 17.27 days (t = 3.241, p = 0.002). In neonates with VAP, the duration of mechanical ventilation was statistically significantly longer compared with non-VAP patients (16.88 ± 11.99 vs. 5.42 ± 4.48; t = 5.249, p = 0.000). A statistically significant prevalence of Gram-negative bacteria among VAP patients was demonstrated (91%) compared to the Gram-positive (9%), p < 0.05. The leading causative agent of VAP was Klebsiella pneumoniae ESBLs + (27%), followed by Acinetobacter baumannii (14%), Pseudomonas aeruginosa (12%) and Escherichia coli (12%). In multivariate logistic regression, mechanical ventilation >7 days was established as an independent risk factor for VAP (OR 3.6; 95% CI: 1.7–6.5, p = 0.003). VAP remains a serious and outstanding issue in pediatric and neonatal intensive care units. The findings of the current study emphasize that the birth weight, gestational age, and duration of hospital stay have a significant association with ventilator-associated pneumonia.

Bacterial Ventilator-Associated Pneumonia in COVID-19 Patients: Data from the Second and Third Waves of the Pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic, many patients requiring invasive mechanical ventilation were admitted to intensive care units (ICU) for COVID-19-related severe respiratory failure. As a matter of fact, ICU admission and invasive ventilation increased the risk of ventilator-associated pneumonia (VAP), which is associated with high mortality rate and a considerable burden on length of ICU stay and healthcare costs. The objective of this review was to evaluate data about VAP in COVID-19 patients admitted to ICU that developed VAP, including their etiology (limiting to bacteria), clinical characteristics, and outcomes. The analysis was limited to the most recent waves of the epidemic. The main conclusions of this review are the following: (i) P. aeruginosa, Enterobacterales, and S. aureus are more frequently involved as etiology of VAP; (ii) obesity is an important risk factor for the development of VAP; and (iii) data are still scarce and increasing efforts should be put in place to optimize the clinical management and preventative strategies for this complex and life-threatening disease.

Epidemiology of ventilator-associated pneumonia in ICU COVID-19 patients: an alarming high rate of multidrug-resistant bacteria

BackgroundCOVID‑19 is a novel cause of acute respiratory distress syndrome (ARDS) that leads patients to intensive care unit (ICU) admission requiring invasive ventilation, who consequently are at risk of developing of ventilator‑associated pneumonia (VAP). The aim of this study was to assess the incidence, antimicrobial resistance, risk factors, and outcome of VAP in ICU COVID-19 patients in invasive mechanical ventilation (MV).MethodsObservational prospective study including adult ICU admissions between January 1, 2021, and June 31, 2021, with confirmed COVID-19 diagnosis were recorded daily, including demographics, medical history, ICU clinical data, etiology of VAPs, and the outcome. The diagnosis of VAP was based on multi-criteria decision analysis which included a combination of radiological, clinical, and microbiological criteria in ICU patients in MV for at least 48 h.ResultsTwo hundred eighty-four COVID-19 patients in MV were admitted in ICU. Ninety-four patients (33%) had VAP during the ICU stay, of which 85 had a single episode of VAP and 9 multiple episodes. The median time of onset of VAP from intubation were 8 days (IQR, 5–13). The overall incidence of VAP was of 13.48 episodes per 1000 days in MV. The main etiological agent was Pseudomonas aeruginosa (39.8% of all VAPs) followed by Klebsiella spp. (16.5%); of them, 41.4% and 17.6% were carbapenem resistant, respectively. Patients during the mechanical ventilation in orotracheal intubation (OTI) had a higher incidence than those in tracheostomy, 16.46 and 9.8 episodes per 1000-MV day, respectively. An increased risk of VAP was reported in patients receiving blood transfusion (OR 2.13, 95% CI 1.26–3.59, p = 0.005) or therapy with Tocilizumab/Sarilumab (OR 2.08, 95% CI 1.12–3.84, p = 0.02). The pronation and PaO2/FiO2 ratio at ICU admission were not significantly associated with the development of VAPs. Furthermore, VAP episodes did not increase the risk of death in ICU COVID-19 patients.ConclusionsCOVID-19 patients have a higher incidence of VAP compared to the general ICU population, but it is similar to that of ICU ARDS patients in the pre-COVID-19 period. Interleukin-6 inhibitors and blood transfusions may increase the risk of VAP. The widespread use of empirical antibiotics in these patients should be avoided to reduce the selecting pressure on the growth of multidrug-resistant bacteria by implementing infection control measures and antimicrobial stewardship programs even before ICU admission.

Clonal Diversity of Klebsiella spp. and Escherichia spp. Strains Isolated from Patients with Ventilator-Associated Pneumonia.

Ventilator-associated pneumonia (VAP) is one of the most severe complications affecting mechanically ventilated patients. The condition is caused by microaspiration of potentially pathogenic bacteria from the upper respiratory tract into the lower respiratory tract or by bacterial pathogens from exogenous sources such as healthcare personnel, devices, aids, fluids and air. The aim of our prospective, observational study was to confirm the hypothesis that in the etiology of VAP, an important role is played by etiological agents from the upper airway bacterial microflora. At the same time, we studied the hypothesis that the vertical spread of bacterial pathogens is more frequent than their horizontal spread among patients. A total of 697 patients required mechanical ventilation for more than 48 h. The criteria for VAP were met by 47 patients. Clonality of bacterial isolates from 20 patients was determined by comparing their macrorestriction profiles obtained by pulsed-field gel electrophoresis (PFGE). Among these 20 patients, a total of 29 PFGE pulsotypes of Klebsiella spp. and Escherichia spp. strains were observed. The high variability of clones proves that there was no circulation of bacterial pathogens among hospitalized patients. Our finding confirms the development of VAP as a result of bacterial microaspiration and therefore the endogenous origin of VAP.

CLINICAL, LABORATORY CHARACTERISTICS AND TREATMENT RESULTS OF VENTILATOR-ASSOCIATED PNEUMONIA AT HUE UNIVERSITY OF MEDICINE AND PHARMACY HOSPITAL

Background: Ventilator-associated pneumonia (VAP) are frequently nosocomial infections at intensive care units (ICU). VAP result in increasing ICU stay, cost and mortality rate. Microorganisms which caused VAP were variety, change of state continously with high rate antibiotic-resistance. For the high quality of treatment therapy, physians must be care about etiology, clinical and laboratory characteristics of VAP for prevention and target treatment. Objectives: To describe the clinical and laboratory characteristics of VAP and comment the result of VAP treatment. Materials and method: Cross-section study of 30 patients who were diagnosed VAP from 04/01/2017 to 04/01/2018 at Anesthesia and Critical Care Department of Hue University of Medicine and Pharmacy Hospital. Results: Mean age of patients was 72.3 ± 14.3. Early VAP was 30%, lately VAP was 70%. Fever and increase mucus sputum were main clinical characteristics of VAP. Microorganisms which caused disease were A. baumannii, S. aureus, P. aeruginosa and Enterobacter spp with high rate antibiotic resistance. Mean mechanical ventilation was 16.8 ± 9.3 days. Mean ICU treatment was 23.7 ± 11.7 days. The mortality of VAP was 46.6%. Conclusion: VAP caused increase ICU stay and mortality rate of patients. It’s essential in a bundle care for VAP prevention and early treatment based on VAP etiology. Key words: Ventilator-associated pneumonia (VAP)

The relationship between ventilator-associated pneumonia and chronic obstructive pulmonary disease: what is the current evidence?

Chronic obstructive pulmonary disease (COPD) affects approximately 65 million people from which > 25% will require intensive care unit (ICU) admission. Ventilator-associated pneumonia (VAP) is the commonest ICU infection and results in increased morbidity/mortality and costs. The literature on the interaction between COPD and VAP is scarce and controversial. The project aimed to search the literature in order to address the following: (i) Is COPD a risk factor for VAP development? (ii) Does COPD impact the outcome of patients with VAP? (iii) Does VAP development impact the outcome of COPD patients? (iv) Does COPD impact the aetiology of VAP? Current evidence on the topic is controversial. Regarding the impact of VAP on COPD patients, the majority of the existing limited number of studies suggests that VAP development results in higher mortality and longer duration of mechanical ventilation and ICU stay. Also, the majority of the studies exploring the impact of COPD on VAP outcomes suggest that COPD is independently associated with a decrease in survival, although the number of such studies is limited. Regarding the aetiology, Pseudomonas aeruginosa is the most frequent pathogen in VAP patients with COPD. Noteworthy, one study suggests that P. aeruginosa is higher in COPD patients even in the early-onset VAP subgroup. This manuscript provides a comprehensive overview of the available literature on the interaction between COPD and VAP, highlighting the differences and limitations that may have led to controversial results, and it may act as a platform for further research with important clinical implications.

Diagnostic and Prognostic Value of Serum Procalcitonin in Pneumonia - A Prospective Observational Study

Objectives: Community-acquired and nosocomial respiratory tract infections are public health problems of major concern and a leading cause of mortality. In the current prospective observational study, we intend to study the utility of procalcitonin (PCT) estimation in the diagnosis and prognosis of Community-acquired Pneumonia (CAP) and Ventilator-associated Pneumonia (VAP). Materials and Methods: The study was conducted over a period of two years. 40 patients with diagnosis of CAP and 40 patients of VAP were included in the study. Serum Procalcitonin levels were estimated using BRAHMS PCT Kryptor Immunofluorescent Assay (Biomerieux, France). Other routine investigations including sputum culture and endotracheal secretions cultures were done. Chi-square analysis was done to assess its prognostic and diagnostic significance. Results: PCT was positive (> 0.05ng/ml) in 68% patients with CAP and 80% patients with VAP. Higher absolute values of PCT were seen in patients with VAP compared to CAP. In VAP PCT was positive in more patients with bronchopneumonia than lobar pneumonia. Streptococcus pneumoniae was the most common bacterial etiology of CAP, and was associated with a positive PCT in 75% cases. Acinetobacter was the most common bacterial etiology of VAP, and was associated with a positive PCT in 80% cases. Mortality was more in PCT positive patients in both CAP and VAP. Maximum mortality in VAP was with PCT >10 ng/ml. Conclusion: PCT is a useful adjuvant in the diagnosis of both CAP and VAP. Positive PCT levels indicate a bacterial etiology for pneumonia. A high PCT level is a poor prognostic indicator and is associated with a higher mortality.

A Study on Bacterial Etiology of Ventilator Associated Pneumonia and its Antimicrobial Pattern

A Study on Bacterial Etiology of Ventilator Associated Pneumonia and its Antimicrobial Pattern

Comparative study of incidence, risk factors, etiological agents and outcome of early and late ventilator associated pneumonia in paediatric intensive care unit at a tertiary care centre

Background: Ventilator Associated Pneumonia (VAP), the nosocomial pneumonia developing in mechanically ventilated patients after 48 hours of mechanical ventilation, is the second most common nosocomial infection in the paediatric intensive care unit (PICU). VAP occurring within 96 hours of initiation of mechanical ventilation is termed as early VAP and later than that is known as late VAP. The aim of this study was to determine the incidence rate, risk factors and bacteriological profile and outcome of early and late ventilator associated pneumonia in PICU.Methods: The study was conducted from December 2015 to November 2017 in which 89 children beyond 1 year of age were ventilated for more than 48 hours of which those who developed VAP as per CDC criteria were enrolled in the study. The endotracheal secretions were collected, processed and recorded as per standard microbiological methods. Statistical associations were further evaluated between various parameters of VAP and time of development of VAP.Results: Of all the mechanically ventilated patients, 33.7% developed VAP. Incidence of Early VAP was 23.3% and that of Late VAP was 76.67%. Duration of mechanical ventilation and re-intubation were significantly associated with the time of development of VAP. Micro-organisms identified by culture, involved in the aetiology of VAP were: gram-negative bacteria in 74.9% and gram-positive bacteria in 25.1%. The overall mortality rate was 43.33%.Conclusions: Re-intubation and duration of mechanical ventilation are a significant risk factor for development of late VAP. Overall the most common Gram-negative bacteria associated with VAP was Acinetobacter baumanii. The most common isolate in early VAP was Acinetobacter baumanii whereas infections by Pseudomonas and E. coli are common in late VAP. population.

Сучасні принципи діагностики та лікування пневмонії, асоційованої з медичним доглядом, лікарняної і вентилятор-асоційованої пневмоній у дітей: Review Up To Date 2017

Hospital-acquired and ventilator-associated pneumonia are common causes of morbidity and mortality in children of different age groups, despite improved modern respiratory care, a wide range of antibiotic therapy, and the possibility of disease prevention. Pneumonia associated with medical care has a course similar to the hospital-acquired pneumonia and includes the episode of pneumonia in patients who were hospitalized for >2 days during the last 90 days; or live in health care facilities and need permanent care; received intravenous and / or chemotherapy for the last 30 days; visited the hemodialysis department.The purpose of this publication is to reduce the complications and mortality rate of children with pneumonia associated with medical care, hospital-acquired and ventilator-associated pneumonia by familiarizing pediatric pulmonologists, intensive care physicians, surgeons with current diagnostic and treatment recommendations. We have attempted to explore and analyze the data available from current sources on the principles of treatment for pneumonia associated with medical care, hospital-acquired and ventilator-associated pneumonia, and to synthesize current concepts for childhood patients. The article is based on the evidence base, strength and degree of evidence defined in each recommendation on patient management. Modern diagnostics of hospital-acquired pneumonia takes into account the timing of onset of the disease. In children with the late-onset of hospital-acquired pneumonia there is a high frequency of multidrug-resistant flora, therefore, more frequent combination therapy is chosen. Children with the early onset of hospital-acquired pneumonia are prescribed monotherapy of antibiotics. Most of the antibiotic therapy principles, which applied to the treatment of hospital-acquired pneumonia, can be also applied to the management of pneumonia associated with medical care. The etiology of ventilator-associated pneumonia is associated with aspiration of pathogens from the oropharynx and from the sites around the endotracheal cuff, determines the advantage of non-invasive ventilation techniques over mechanical ones. The review provides a detailed algorithm for the diagnosis of pneumonia associated with medical care, hospital-acquired and ventilator-associated pneumonia, as well as a differentiated approach to the antibiotic treatment of the patient.

Bacteriological profile of ventilator-associated pneumonia in a tertiary care hospital

Ventilator-associated pneumonia (VAP) is the most frequent intensive care unit (ICU)-acquired infection. The etiology of VAP and their antimicrobial susceptibility pattern varies with different patient populations and types of ICUs. An observational cross-sectional study was performed over a period of 2 years in a tertiary care hospital to determine the various etiological agents causing VAP and to detect the presence of multidrug-resistant (MDR) pathogens in these VAP patients. Combination disk method, Modified Hodge test, ethylenediaminetetraacetic acid disk synergy test, and AmpC disk test were performed for the detection of extended-spectrum beta-lactamase (ESBL), carbapenemases, metallo-beta-lactamases (MBL), and AmpC beta-lactamases, respectively. The prevalence of VAP was 35%. Enterobacteriaceae (66.66%) and Staphylococcus aureus (20%) were common in early-onset VAP, while nonfermenters (50%) and Enterobacteriaceae (40.61%) were predominant from late-onset VAP. Nearly 60.87% of the bacterial pathogens were MDR. ESBL was produced by 21.74% of Enterobacteriaceae. AmpC β-lactamase was positive in 35.29% nonfermenters and 26.08% Enterobacteriaceae. MBL was positive in 17.64% nonfermenters and 17.39% Enterobacteriaceae. Among the S. aureus isolates, 75% were cefoxitin resistant. Prior antibiotic therapy (P = 0.001) and hospitalization of 5 days or more (P = 0.001) were independent risk factors for VAP by MDR pathogens. polymyxin B, tigecycline, and vancomycin were the most sensitive drugs for Gram-negative and positive isolates respectively from VAP. SPSS for Windows Version SPSS 17.0 (SPSS Inc., Chicago, IL, USA) and Chi-square with Yates correction. Late-onset VAP is increasingly associated with MDR pathogens. Treatment with polymyxin B, tigecycline, and vancomycin should be kept as last-line reserve drugs against most of the MDR pathogens.

An antibiotic stewardship exercise in the ICU: building a treatment algorithm for the management of ventilator-associated pneumonia based on local epidemiology and the 2016 Infectious Diseases Society of America/American Thoracic Society guidelines.

IntroductionManagement of ventilator-associated pneumonia (VAP), the most common infection in patients on mechanical ventilation, should be tailored to local microbiological data. The aim of this study was to determine susceptibility patterns of organisms causing VAP to develop a treatment algorithm based on these findings and evidence from the literature.Materials and methodsThis is a retrospective analysis of the microbiological etiology of VAP in the intensive care unit (ICU) of a Lebanese tertiary care hospital from July 2015 to July 2016. We reviewed the latest clinical practice guidelines on VAP and tried to adapt these recommendations to our setting.ResultsIn all, 43 patients with 61 VAP episodes were identified, and 75 bacterial isolates caused VAP. Extensively drug-resistant (XDR) Acinetobacter baumannii was the most common organism (37%), and it had occurred endemically throughout the year. Pseudomonas aeruginosa was the next most common organism (31%), and 13% were XDR. Enterobacteriaceae (15%) and Stenotrophomonas maltophilia (12%) shared similar incidences. Our algorithm was based on guidelines, in addition to trials, systematic reviews, and meta-analyses that studied the effectiveness of available antibiotics in treating VAP.ConclusionKnowing that resistance can rapidly develop within a practice environment, more research is needed to identify the best strategy for the management of VAP.

Ventilator Associated Pneumonia a challenge in intensive care unit acquired infection

Background: Ventilator-Associated Pneumonia (VAP) is one of the frequent intensive-care-unit (ICU)-acquired infection. The aetiology of VAP varies with patients’ profiles and ICU settings. Due to the increasing incidence of multidrug-resistant organisms in ICUs, early and correct diagnosis of VAP is an urgent challenge for an optimal antibiotic treatment. The aim of the study was to assess the incidence of VAP in different patients by various organisms to create a database of the causative agents of VAP, their drug resistance profile in that area.Methodology: A prospective study was done over a period of 12 months in a rural tertiary care hospital enrolling patients undergoing mechanical ventilation (MV) for &gt;48 h. Samples were collected from patients with suspected VAP, cultures were performed on all samples. VAP was diagnosed by the growth of significant pathogens. Combination disk method, EDTA disk synergy (EDS) test and cefoxitin double disc synergy test were performed for the detection of different patterns of drug resistance.Results: Culture positive cases were 52.29% of total. Acinetobacter spp, Klebsiella pneumoniae and Staphylococcus aureus were most frequent pathogen in early-onset VAP, while Pseudomonas spp. and Acinetobacter spp. dominated the list of pathogens responsible for lateonset VAP. Prior antibiotic therapy and hospitalization of five days or more were independent risk factors for VAP by MDR pathogens.Conclusions: This study highlighted high incidence of VAP in our setup. Production of ESBL, AmpC beta-lactamases and metallo beta-lactamases were responsible for the multi-drug resistance of the pathogens causing VAP, implicating the injudicious use of antimicrobial therapy. Combined approaches of rotational antibiotic therapy and education programs might be beneficial to fight against these MDR pathogens to decrease the incidence of VAP.Bangladesh Journal of Medical Science Vol.15(4) 2016 p.588-595