Cases Of Ventilator-associated Pneumonia Research Articles

The most frequent and important events that threaten patient safety in intensive care units from the perspective of health-care professionals'.

Background:Patient safety is a priority in all health-care centers across the world. This study aimed to determine the frequency of events that threaten patient safety and the grade threating of events from the perspective of the health-care professionals in the intensive care units (ICUs).Materials and Methods:This cross-sectional study was conducted in 2016. The participants were 306 members of health-care professionals (physicians and nurses) with at least 1 year of work experience in ICUs of educational hospitals affiliated to Isfahan University of Medical Sciences. Data were collected using a three-section self-made questionnaire. Data analysis was done using descriptive statistics (frequency distribution and percentage) and version 16 of SPSS software.Results:A total of 306 questionnaires were completed out of 320 questionnaires handed out among participants. During the last month, 91.2% of the participants had reported at least a case of medication error, 75.6% had reported at least a case of ventilator-associated pneumonia, and 74.2% had reported at least a case of catheter-induced urinary infection in ICUs.Conclusion:The occurrence of events threatening the patient safety in ICUs warrants proper planning by administrators of health-care centers. Medication error was the most frequent and important event of threat to patient safety and falling was the least frequent event of threat to patient safety in ICUs. Considering the frequency and magnitude of medication error in ICUs, a well-adjusted preventive plan should be designed and implemented to improve the patient safety.

Utility of chest ultrasonography and pulmonary infection score in early diagnosis of ventilator-associated pneumonia

Background Ventilator-associated pneumonia (VAP) remains a morbid and prevalent problem throughout the world. Lung ultrasound (LUS) is increasingly being used at the bedside for assessing alveolar-interstitial syndrome, lung consolidation, pneumothorax, and pleural effusion. Purpose The aim was to focus on the use of bedside LUS alone and in association with the clinical pulmonary infection score (CPIS) in early diagnosis of VAP, to describe the sonographic features, to compare between LUS and portable chest radiography (CXR) in early diagnosis of ventilator-associated pneumonia (VAP), and weather LUS affects the prognostic outcomes of VAP. Patients and methods A total of 40 patients with suspected VAP were enrolled. Portable CXR, LUS, and computed tomography scan (gold standard) were performed. The CPIS was calculated for early and reliable diagnosis of VAP. The prognostic outcomes were highlighted. Results Among forty VAP-suspected cases, 30 (75%) were confirmed using computed tomography (gold standard). LUS imaging of VAP cases diagnosed 28 (70%) with consolidation, 89.3% of them with air bronchogram, and 32.5% of them with pleural effusion. Validity for early VAP diagnosis using portable CXR demonstrated 86.7, 100, 100, 71.4, and 90%; ultrasound 93.3, 100, 100, 83.3, and 95%; whereas CPI score 50, 90, 93.8, 62.5, and 60% regarding sensitivity, specificity, positive predictive value, negative predictive value, and accuracy, respectively. CPIS combined with LUS revealed higher sensitivity (96.7%) and accuracy (97.5%). Low CPIS less than or equal to 6, modes of mechanical ventilation (continuous positive airway pressure and biphasic positive airway pressure), shorter duration of respiratory support, LUS imaging of air bronchogram and simple pleural effusion were significantly associated with improved outcomes of VAP cases. The duration of mechanical ventilation and early detection of air bronchogram by LUS were the independent mortality predictors with odds ratio of 2.4 and 3.11 and 95% CI of 1.56–4.55 and 1.8–17.66, respectively. Conclusion LUS was a reliable tool for early VAP diagnosis at the bedside. Combination approach increases the prognostic and diagnostic accuracy of LUS in VAP.

Cost assessment of a new oral care program in the intensive care unit to prevent ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is the most frequent hospital-acquired infections in intensive care units (ICU). In the bundle of care to prevent the VAP, the oral care is very important strategies, to decrease the oropharyngeal bacterial colonization and presence of causative bacteria of VAP. In view of the paucity of medical economics studies, our objective was to determine the cost of implementing this oral care program for preventing VAP. In five ICUs, during period 1, caregivers used a foam stick for oral care and, during period 2, a stick and tooth brushing with aspiration. Budgetary effect of the new program from the hospital's point of view was analyzed for both periods. The costs avoided were calculated from the incidence density of VAP (cases per 1000days of intubation). The cost study included device cost, benefit lost, and ICU cost (medication, employer and employee contributions, blood sample analysis…). A total of 2030 intubated patients admitted to the ICUs benefited from oral care. The cost of implementing the study protocol was estimated to be €11,500 per year. VAP rates decreased significantly between the two periods (p1 = 12.8% and p2 = 8.5%, p = 0.002). The VAP revenue was ranged from €28,000 to €45,000 and the average cost from €39,906 to €42,332. The total cost assessment calculated was thus around €1.9 million in favor of the new oral care program. Our study showed that the implementation of a simple strategy improved the quality of patient care is economically viable. NCT02400294.

Effects of subglottic secretion drainage at different intervals on ventilator-associated pneumonia

Objective To investigate the effects of subglottic secretion drainage at different intervals on ventilator-associated pneumonia(VAP). Methods A total of 150 patients receiving tracheostomy during January 2015 to December 2016 were divided into A, B, C group according to the order of intubation time. The subglottic secretion drainage was attracted at intervals of 2, 4, and 6 h respectively. The differences in balloon secretion on occult blood test(after intubation, intubation time, 3 d, 5 d,7 d), the content of airborne bacteria in the air sac, the number of VAP and the time of VAP occurrence between the 3 groups were analyzed. Results The 3 groups that group A had 78 positive cases, group B had 46 cases and group C had 38 cases had statistical significance differences compared with balloon retentate occult blood test (χ2=28.23, P=0.00); there were statistical significance differences between the 3 groups of bacteria (Z=11.91, P=0.00), there were statistically significant differences between group A and group C (Z=-3.01, P=0.00), between group B and group C (Z=-2.19, P=0.01). There were statistical significance differences between the 3 groups of the number of VAP cases (χ2=7.50, P=0.00) that there were 12 cases happening in group A, 13 cases in group B and 23 cases in group C. There were statistical significance differences between group A and group C (χ2=5.32, P=0.02), between group B and group C (χ2=4.34, P=0.04). The occurrence time of VAP which was (169.25±20.80) h in group A, (168.35±18.04) h in group B and (129.47±18.13) h in group C,there was significantly different between the 3 groups (F=2 788.19, P=0.00), the differences between group A and group C (t=3.19, P=0.00), group B and group C (t=68.40, P=0.00) were statistically significant. Conclusions The subglottic secretion drainage at intervals of 4 hours will not only reduce the damage to the airway mucosa, but also reduce the incidence of airway bacteria and the incidence of VAP and delay the occurrence of late VAP. Key words: Mechanical, mechanical; Pneumonia, ventilator-associated; Subglottic secretion

Incidence of Ventilator-Associated Pneumonia in Critically Ill Children Undergoing Mechanical Ventilation in Pediatric Intensive Care Unit.

Background: Among hospital-acquired infections (HAIs) in children, ventilator-associated pneumonia (VAP) is the most common after blood stream infection (BSI). VAP can prolong length of ventilation and hospitalization, increase mortality rate, and directly change a patient’s outcome in Pediatric Intensive Care Units (PICU). Objectives: The research on VAP in children is limited, especially in Iran; therefore, the identification of VAP incidence and mortality rate will be important for both clinical and epidemiological implications. Materials and Methods: Mechanically ventilated pediatric patients were assessed for development of VAP during hospital course on the basis of clinical, laboratory and imaging criteria. We matched VAP group with control group for assessment of VAP related mortality in the critically ill ventilated children. Results: VAP developed in 22.9% of critically ill children undergoing mechanical ventilation. Early VAP and late VAP were found in 19.3% and 8.4% of VAP cases, respectively. Among the known VAP risk factors that were investigated, immunodeficiency was significantly greater in the VAP group (p = 0.014). No significant differences were found between the two groups regarding use of corticosteroids, antibiotics, PH (potential of hydrogen) modifying agents (such as ranitidine or pantoprazole), presence of nasogastric tube and total or partial parenteral nutrition administration. A substantial number of patients in the VAP group had more than four risk factors for development of VAP, compared to those without VAP (p = 0.087). Mortality rate was not statistically different between the VAP and control groups (p = 0.477). Conclusion: VAP is still one of the major causes of mortality in PICUs. It is found that altered immune status is a significant risk factor for acquiring VAP. Also, occurrence of VAP was high in the first week after admission in PICU.

Ventilator bundle guided by context of JCI settings can effectively reduce the morbidity of ventilator-associated pneumonia

To observe the impact of improving the compliance of ventilator bundle on morbidity of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients undergoing mechanical ventilation (MV) guided by context of Joint Commission International (JCI) settings, and to study the oral care efficacy of suction tube sponge brush. A prospective study was conducted. The patients who needed MV admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Xiamen University from January 2013 to December 2016 were enrolled. In the context of JCI settings, necessary measurements were taken to enhance the compliance of ventilator bundle each year. In 2013, the preventive measures were set up and the education was strengthened. In 2014, the compliance of hand hygiene and bedside elevation was strengthened. In 2015, a control study was conducted to evaluate the effect between the traditional cotton dipped in chlorhexidine and the suction tube sponge brush rinsed with chlorhexidine on oral health impact parameters. The suction tube sponge brush rinsed with chlorhexidine oral care was introduced to improve compliance. In 2016, electronic bundle checklist for daily self-audits was conducted. The annually morbidity of VAP through the software of hospital and ICU was collected and calculated. The annual incidence of VAP was indicated by the VAP cases per 1 000 MV days. Based on the VAP incidence rate in 2013 as 1, the VAP incidence-rate ratio (IRR) of each year was calculated. During the study period, a total of 2 733 patients admitted to the ICU, including 1 403 patients undergoing MV. Ninety-four of the 1 403 patients with community-acquired pneumonia (CAP), aspiration pneumonia, back elevation ban, incomplete information, and withdrew from the study were excluded. 1 399 patients undergoing MV were enrolled in the final analysis, with total MV days of 11 012 days, and 94 patients occurred VAP. The annual incidence of VAP was progressively declined from 2013 to 2016, and the VAP cases per 1 000 MV days were 17.0, 10.0, 5.9, 3.5 cases, respectively. Based on the VAP incidence rate in 2013, the IRR of VAP from 2014 to 2016 was also progressively declined, which was 0.59 [95% confidence interval (95%CI) = 0.35-0.98], 0.35 (95%CI = 0.18-0.64), and 0.21 (95%CI = 0.09-0.41), with statistical significance (all P < 0.05). In 2013, ICU patients had the lowest rates of bedside elevation and hand hygiene compliance, which were 28.57% and 54.29%, respectively. Compared with 2013, by the implementation of two quality control circle (QCC) projects for bedside elevation and hand hygiene, the rates of bedside elevation and hand hygiene compliance were improved significantly in 2014, which were 82.35%, 91.18%, respectively (both P < 0.05). In 2015, the compliance of chlorhexidine oral care which was the worst performed in 2014 had been improved by the method of QCC, and the rate of the compliance was significantly higher than that in 2013 (87.10% vs. 62.86%, P < 0.05). Compared with 2013, bundle compliance was significantly increased in 2016, except for the sterile operation of the suction tube [daily wake and weaning: 95.00% vs. 71.43%, bedside elevation for over 30degree angle: 92.50% vs. 28.57%, hand hygiene: 97.50% vs. 54.29%, chlorhexidine mouth care once per 6-8 hours: 95.00% vs. 62.86%, turned back and posture drainage: 97.50% vs. 80.00%], the differences were statistically significant (all P < 0.05). The incidences of bad breath, dirt residue and plaque were significantly lower in the group of oral care by using suction tube sponge brush with chlorhexidine (30 cases) compared with the group of traditional cotton pad with chlorhexidine (30 cases; bad breath: 10.0% vs. 40.0% %, dirt residue: 16.7% vs. 70.0%, plaque: 3.3% vs. 30.0%, all P < 0.05). There was no significant difference in the incidence of oral ulcers between the oral brush group and the traditional group (10.0% vs. 30.0%, P > 0.05). Ventilator bundle can effectively reduce the morbidity of VAP in the context of JCI settings, and the oral care by using suction tube sponge brush and chlorhexidine can effectively improve oral hygiene.

From VAP to VAE: Implications of the New CDC Definitions on a Burn Intensive Care Unit Population.

Ventilator-associated pneumonia (VAP) is a frequent complication of severe burn injury. Comparing the current ventilator-associated event-possible VAP definition to the pre-2013 VAP definition, we identified considerably fewer VAP cases in our burn ICU. The new definition does not capture many VAP cases that would have been reported using the pre-2013 definition. Infect Control Hosp Epidemiol 2017;38:867-869.

Suspicious outbreak of ventilator-associated pneumonia caused by Burkholderia cepacia in a surgical intensive care unit

We reviewed Burkholderia cepacia infections in a hospital from 2013-2016 to report a suspicious outbreak that occurred in a surgical intensive care unit in 2015, and to outline the infection control measures adopted thereafter. Review of the health care-associated infection data regarding B cepacia via the surveillance system, hospital information system, electronic medical records, and laboratory information system together with the outbreak investigation was managed by the health care-associated infection control team. During June 1-14, 2015, 4 cases of ventilator-associated pneumonia (VAP) were identified; B cepacia was isolated from endotracheal aspirate samples. On June 16, 120 environmental samples were collected and analyzed for microbiologic differentiation. Thirteen strains of B cepacia were prominently found in the expiratory blocks of ventilators, revealing the biocontamination source. After chemical disinfection without damaging ventilator components, repeat microbiologic testing of random ventilator samples yielded negative results until July 30, 2015. Retrospective data showed that isolation rates of B cepacia strains had increased since 2014. Although the resistance phenotype of these strains varied slightly, they exhibited similar patterns of antibiotic susceptibility. Routine cleaning and disinfection of ventilators, in addition to an intervention bundle, should form part of an integrated VAP prevention and management approach.

Mechanical ventilator as a major cause of infection and drug resistance in intensive care unit.

Ventilator-associated pneumonia (VAP) is the most frequent infection in intensive care units (ICU). It is associated with high rates of long morbidity and mortality. Management of a case of VAP is often said to add $40,000 to hospital costs USA. All these data directed our interest to study the etiology, risk factors, and antibiotic susceptibility patterns of VAP in ICU of Tanta University Hospital. This study included 36 cases of VAP. Endotracheal aspirates were obtained from all cases and microbiologically analyzed. Samples were collected over 1year. Forty-two strains were isolated from 28 cases, while eight cases showed no bacterial growth. The most frequent organism was Staphylococcus aureus (30.95%), followed by Acinetobacter baumannii and Pseudomonas aeruginosa (21.43% for each), and the least common was Staphylococcus epidermidis (2.38%). Multi-drug resistance was detected in (50%) of the isolated bacteria in this study. Imipenem, amikacin, linezolid, vancomycin, and levofloxacin are recommended to be the most effective drugs in management of VAP. VAP is a serious problem in ICU carrying many risks for the patient live. Regimens of empirical treatment should take in consideration the update in the bacterial etiology and antibiotic susceptibility patterns of VAP.

내과계중환자실에서 인공호흡기관련 폐렴 번들 적용의 효과

Purpose: The purpose of this study was to confirm the compliance of the application of a ventilator-associated pneumonia bundle and understand its effects on the decrease in the incidence of ventilator-associated pneumonia. Methods: This was a retrospective observational study with history control group design. Subjects were selected from January to June 2014, prior to the intervention using the ventilator-associated pneumonia bundle. Subjects were also selected from October 2014 to March 2015, 3 months after the intervention. The number of subjects was 112 before the intervention, and 107 after the intervention. Results: The number of nurses who followed the bundles increased from 8 out of 29 (27.6%) before the intervention to 19 out of 29 (65.5%) after the intervention (odd ratio=4.99, confidence interval=1.63-15.25, p=.004). There were 3 cases of ventilator-associated pneumonia before the intervention and 1 case after the intervention. The ventilator days were 2,143 days before the intervention and 2,232 days after the intervention. The ventilator-associated pneumonia rate of the 1,000 ventilator days was 1.40 before the intervention and decreased to 0.45 after the intervention. Conclusion: This study is meaningful, as there has been little research conducted regarding the application of the ventilator-associated pneumonia bundle in South Korea. Key Words: Ventilator-associated pneumonia; Ventilator bundle; Infection control; Intensive care units Key Words: ì¸ê³µí˜¸í¡ê¸°ê´€ë ¨ íë ´; ì¸ê³µí˜¸í¡ê¸°ê´€ë ¨ íë ´ 번들; 감염관리; 중환자실

Current Epidemiology of Ventilator-associated Pneumonia in an Intensive Care Unit in Vietnam

BackgroundThe increase of multi-drug-resistant Gram-negative bacteria as a cause of ventilator-associated pneumonia (VAP) is a global concern. The epidemiology of VAP in Southeast Asia remains largely unknown.MethodsThis prospective cohort study was conducted at the Intensive Care Unit (ICU) of Bach Mai Hospital in Hanoi. Patients who received mechanical ventilation for >48 hours, and were diagnosed with VAP, in November 2015–May 2016 were included. Patients with no positive respiratory culture for a causative organism were excluded. Those with multiple VAP episodes >7 days apart with a different causative organism were counted separately.ResultsFifty-six patients (67 episodes) with VAP in 992 admissions were identified. Ten had ≥2 episodes. In 11 episodes, ≥2 isolates were found from a respiratory sample; 78 isolates were identified in total. The cohort median age was 61 (interquartile range [IQR]: 48–70) years, with 43 (76.8%) males. Fourteen (24.6%) patients had diabetes, 10 (17.5%) had chronic kidney diseases, 17 (29.8%) had congestive heart disease, 9 (15.8%) had COPD, and 5 (8.8%) had malignancy. Among isolated bacteria, Acinetobacter baumannii (ACB) was highly resistant to meropenem, levofloxacin, and amikacin (Table). The 7-day mortality was 13% (n = 7) and 31-day mortality was 43.8% (n = 21). ACB cases had higher 31-day mortality (18 [56.2%] vs. 4 [25%]; P = 0.041) and longer ICU stay (16 days [IQR: 10–27] vs. 9 [3–15]; P = 0.024; deceased excluded) than non-ACB. Colistin was used in 23 (41.1%) cases as empiric therapy and 25 (44.6%) as definitive therapy.ConclusionHigh resistance rates and worse clinical outcomes were found in VAP cases due to ACB in ICU in Vietnam. Further study is warranted for appropriate treatment and infection control measures.TableAntimicrobial resistance of bacterial isolates* in ventilator-associated pneumonia, n (%) Acinetobacter baumannii (n = 37) Klebsiella pneumoniae (n = 11) Pseudomonas aeruginosa (n = 15)Meropenem37 (100)7 (63.6)11 (73.3)Ceftazidime37 (100)11 (100)10 (66.7)Levofloxacin37 (100)11 (100)11 (73.3)Amikacin35 (94.6)3 (27.3)10 (66.7)Colistin000*Include Stenotrophomonas maltophilia (n = 6), Serratia marcescens (n = 3), Enterobacter cloacae (n = 2), Elizabethkingia meningoseptica (n = 2).Disclosures All authors: No reported disclosures.

Impact of colistin-initiation delay on mortality of ventilator-associated pneumonia caused by A. baumannii.

There has been increased incidence and high mortality in cases with ventilator-associated pneumonia (VAP) caused by colistin-only-susceptible Acinetobacter baumannii (COS-AB). Colistin has emerged as a therapeutic option for VAP caused by multidrug-resistant Gram-negative organisms including COS-AB. A retrospective study was conducted to examine the impact of early versus late initiation of colistin on 30-day mortality of critically ill patients with VAP caused by COS-AB. Critically ill patients with VAP caused by COS-AB who received colistin were enrolled. The receiver operating characteristic (ROC) curve was used to identify the temporal breakpoint that maximized the difference in 30-day mortality. A total of 56 patients (34 men and 22 women) were included in the study. About 86% of all cases were late-onset VAP. The 30-day mortality was 46.4%. The rate was higher among patients with admission Acute Physiology and Chronic Health Evaluation II (APACHE II) score > 18 and patients with a delay of more than four days in initiating colistin treatment. The mortality rate was 26.9% among patients with treatment delay of four or fewer days and 63.3% for patients with a treatment delay of more than four days. A delay of four days or more in initiating colistin in patients with VAP caused by COS-AB significantly increases mortality. Colistin should be considered in the empirical protocols in late-onset VAP cases when COS-AB is highly suspected.

Does ventilator-associated event surveillance detect ventilator-associated pneumonia in intensive care units? A systematic review and meta-analysis.

BackgroundVentilator-associated event (VAE) is a new surveillance paradigm for monitoring complications in mechanically ventilated patients in intensive care units (ICUs). The National Healthcare Safety Network replaced traditional ventilator-associated pneumonia (VAP) surveillance with VAE surveillance in 2013. The objective of this study was to assess the consistency between VAE surveillance and traditional VAP surveillance.MethodsWe systematically searched electronic reference databases for articles describing VAE and VAP in ICUs. Pooled VAE prevalence, pooled estimates (sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV)) of VAE for the detection of VAP, and pooled estimates (weighted mean difference (WMD) and odds ratio ([OR)) of risk factors for VAE compared to VAP were calculated.ResultsFrom 2191 screened titles, 18 articles met our inclusion criteria, representing 61,489 patients receiving mechanical ventilation at ICUs in eight countries. The pooled prevalence rates of ventilator-associated conditions (VAC), infection-related VAC (IVAC), possible VAP, probable VAP, and traditional VAP were 13.8 %, 6.4 %, 1.1 %, 0.9 %, and 11.9 %, respectively. Pooled sensitivity and PPV of each VAE type for VAP detection did not exceed 50 %, while pooled specificity and NPV exceeded 80 %. Compared with VAP, pooled ORs of in-hospital death were 1.49 for VAC and 1.76 for IVAC; pooled WMDs of hospital length of stay were −4.27 days for VAC and −5.86 days for IVAC; and pooled WMDs of ventilation duration were −2.79 days for VAC and −2.89 days for IVAC.ConclusionsVAE surveillance missed many cases of VAP, and the population characteristics identified by the two surveillance paradigms differed. VAE surveillance does not accurately detect cases of traditional VAP in ICUs.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1506-z) contains supplementary material, which is available to authorized users.

Staff education aimed at reducing ventilator-associated pneumonia.

Mechanical ventilation is a life-saving invasive procedure performed in intensive care units (ICUs) where critical patients are given advanced support. The purpose of this study was to assess the effect of personnel training on the incidence of ventilator-associated pneumonia (VAP). The study, performed prospectively in the ICU, was planned in two periods. In both periods, patient characteristics were recorded on patient data forms. In the second period, ICU physicians and assistant health personnel were given regular theoretical and practical training. Twenty-two cases of VAP developed in the pre-training period, an incidence of 31.2. Nineteen cases of VAP developed in the post-training period, an incidence of 21.0 (P<0.001). Training reduced development of VAP by 31.7 %. Crude VAP mortality was 69 % in the first period and 26 % in the second (P<0.001). Statistically significant risk factors for VAP in both periods were prolonged hospitalization, increased number of days on mechanical ventilation, and enteral nutrition; risk factors determined in the first period were re-intubation, central venous catheter use and heart failure and, in the second period, erythrocyte transfusion >5 units (P<0.05). Prior to training, compliance with hand washing (before and after procedure), appropriate aseptic endotracheal aspiration and adequate oral hygiene in particular were very low. An improvement was observed after training (P<0.001). The training of personnel who will apply infection control procedures for the prevention of healthcare-associated infections is highly important. Hand hygiene and other infection control measures must be emphasized in training programmes, and standard procedures in patient interventions must be revised.

Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate.

Ventilator-associated pneumonia (VAP) in neonates can be reduced by implementing preventive care practices. Implementation of a group, or bundle, of evidence-based practices that improve processes of care has been shown to be cost-effective and to have better outcomes than implementation of individual single practices. The purpose of this article is to describe a safe, effective, and efficient neonatal VAP prevention protocol developed for caregivers in the neonatal intensive care unit (NICU). Improved understanding of VAP causes, effects of care practices, and rationale for interventions can help reduce VAP risk to neonatal patients. In order to improve care practices to affect VAP rates, initial and annual education occurred on improved protocol components after surveying staff practices and auditing documentation compliance. In 2009, a tertiary care level III NICU in the Midwestern United States had 14 VAP cases. Lacking evidence-based VAP prevention practices for neonates, effective adult strategies were modified to meet the complex needs of the ventilated neonate. A protocol was developed over time and resulted in an annual decrease in VAP until rates were zero for 20 consecutive months from October 2012 to May 2014. This article describes a VAP prevention protocol developed to address care practices surrounding hand hygiene, intubation, feeding, suctioning, positioning, oral care, and respiratory equipment in the NICU. Implementation of this VAP prevention protocol in other facilities with appropriate monitoring and tracking would provide broader support for standardization of care. Individual components of this VAP protocol could be studied to strengthen the inclusion of each; however, bundled interventions are often considered stronger when implemented as a whole.

Molecular detection of atypical microorganisms in patients with ventilator associated pneumonia

Ventilator-associated pneumonia (VAP) is one of the major causes of morbidity and mortality among the critically ill patients of intensive care units (ICU). The present cross sectional study was conducted to isolate and identify bacterial causes of VAP among the patients admitted in intensive care unit (ICU) of Dhaka Medical College Hospital. The study was conducted between July, 2013 to June 2014. A total of 65 endotracheal aspirate (ETA) and blood samples were collected from patients with clinically suspected ventilator associated peumonia(VAP). Samples were collected from patients on mechanical ventilation for more than 48 hours. ETA and blood samples were cultured aerobically. Multiplex PCR was performed with ETA to detect Mycoplasma pneumoniae, Legionella pneumophila and Chlamydia pneumoniae. Among the atypical bacteria, M. pneumoniae were detected in 5 (7.69%), L. pneumophila in 4 (6.15%) cases by multiplex PCR in ETA from VAP cases. No C. pneumoniae was detected. The study revealed that in VAP cases atypical bacteria should be considered as a possible bacterial agents.Ibrahim Med. Coll. J. 2015; 9(1): 22-25

Central Nervous System Depressants Poisoning and Ventilator Associated Pneumonia: An Underrated Risk Factor at the Toxicological Intensive Care Unit.

Background:Ventilator-Associated Pneumonia (VAP) is the main cause of nosocomial infection at intensive care units (ICUs), which causes high mortality and morbidity.Objectives:The objective of the present survey was to identify the VAP risk and prognostic factors among poisoned patients, who were admitted to the toxicological ICU (TICU), especially central nervous system (CNS) depressants due to their prevalence and importance.Patients and Methods:A case-control study was conducted at the Loghman Hakim hospital between March 2013 and March 2014. Among 300 poisoned patients with mechanical ventilator ≥ 48 hours, 150 patients, who had developed microbiologically-confirmed VAP were considered as the VAP group and 150 without VAP were defined as the control group. The following data were collected; age, gender, type of poisoning, glasgow coma score, Acute physiology and chronic health evaluation (APACHE) II score, length of hospital stay, previous antibiotic use, microbial culture of the trachea, body temperature, leukocyte count, and patients’ outcome. Based on the type of poisoning, patients were divided into three groups including: opioid, CNS depressants and others. All data were expressed as means (SD) for continuous variables and frequencies for categorical variables. Logistic regression was used to determine the relationship between risk factors and VAP.Results:The mean age of the patients was 33.9 ± 14.3 years. The probable VAP incidence and mortality were 22% and 18.6%, respectively. The rate of CNS depressant versus opioid use (odds ratio, 3.74; P < 0.027), APACHE II (odds ratio, 1.28; P < 0.000) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent risk factors for VAP. While, the APACHE II score (odds ratio, 1.12; P < 0.044) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent predictors of VAP mortality among these patients. The most common microorganisms in VAP cases were Methicillin-Resistant Staphylococcus aureus (MRSA) and Acinetobacter sp. (56.7% and 12.7%, respectively).Conclusions:Central nervous system depressant was an important risk factor for VAP among poisoned patients. Hypoventilation due to CNS depression can lead to VAP. The APACHE II and length of hospital stay were shown as independent predictors of VAP and mortality among these patients.

Clinical study of ventilator associated pneumonia in a tertiary care centre

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.

Antibiotic Utilization Patterns in Patients with Ventilator-Associated Pneumonia: A Canadian Context.

This retrospective cohort study describes the patterns of antibiotic use for the treatment of ventilator-associated pneumonia (VAP) in the Calgary Zone of Alberta Health Services. Timing, appropriateness, and duration of antibiotics were evaluated in two hundred consecutive cases of VAP derived from 4 adult intensive care units (ICU). Antibiotic therapy was initiated in less than 24 hours from VAP diagnosis in 83% of cases. Although most patients (89%) received empiric therapy that demonstrated in vitro sensitivity to the identified pathogens, only 24% of cases were congruent with the 2008 Association of Medical Microbiology and Infectious Disease (AMMI) guidelines. Both ICU (p = 0.001) and hospital (p = 0.015) mortality were significantly lower and there was a trend for shorter ICU length of stay (p = 0.051) in patients who received appropriate versus inappropriate initial antibiotics. There were no outcome differences related to compliance with AMMI guidelines. This exploratory study provides insight into the use of antimicrobials for the treatment of VAP in a large Canadian health region. The discordance between the assessments of appropriateness of empiric therapy based on recovered pathogens versus AMMI guidelines is notable, emphasizing the importance of using as much as possible local microbiologic and antimicrobial resistance data.

Antibiotic resistance & pathogen profile in ventilator-associated pneumonia in a tertiary care hospital in India.

Background & objectives:Ventilator-associated pneumonia (VAP) is an important hospital-acquired infection with substantial mortality. Only a few studies are available from India addressing the microbiological aspects of VAP, which have been done with small study populations. This study was carried out in the intensive care units (ICUs) of a tertiary care hospital to assess the profile of pathogens and to determine the pattern of antimicrobial resistance.Methods:This was a retrospective study of clinically suspected cases of VAP. Over a three year period, a total of 247 cases in 2011, 297 in 2012 and 303 in 2013 admitted in ICUs on mechanical ventilation with clinical evidence of VAP were included in our study. The endotracheal aspirate samples from these suspected cases were subjected to quantitative culture technique, and colony count of ≥105 colony forming units/ml was considered significant. Antimicrobial susceptibility test for the isolates was done.Results:VAP rates of 44.1, 43.8 and 26.3 were seen in 2011, 2012 and 2013, respectively. In all the three years, non-fermentative Gram-negative bacilli were the predominant organisms, followed by Pseudomonas spp. and Klebsiella spp. Staphylococcus aureus exhibited a downwards trend in prevalence from 50.0 per cent in 2011 to 34.9 per cent in 2013. An increase in vancomycin-resistant enterococci was seen from 4.3 per cent in 2012 to 8.3 per cent in 2013, while methicillin resistance amongst the S. aureus crossed the 50 per cent mark in 2013. An increasing trend in resistance was shown by Pseudomonas spp. for piperacillin-tazobactam (PTZ), amikacin and imipenem (IPM). For the non-fermenters, resistance frequency remained very high except for IPM (33.1%) and polymyxin-B (2.4%).Interpretation & conclusions:Our findings show VAP as an important problem in the ICU setting. The incidence of multidrug-resistant pathogens was on the rise. The resistance pattern of these pathogens can help an institution to formulate effective antimicrobial policy. To have a comprehensive pan-India picture, multicentric studies are needed.