Diagnosis Of Ventilator-associated Pneumonia Research Articles

Ventilator Associated Pneunomia in Neonatal Intensive Care Unit: Occurrence and Risk Factors

Objectives: To examine the occurrence of pneumonia linked with a ventilator in the neonatal intensive care unit and to determine the related risk factors. Purpose of study: To better identify the associated morbidity and mortality, pathophysiology, and recommended measures to avoid this disease, paediatric VAP diagnosis methods must become more standardized and exact. Study design: A cross-sectional study Place and Duration: This study was conducted at Aga Khan University hospital from May 2021 to May 2022 Methodology: This study includes a total of 70 participants admitted in neonatal intensive care unit. All the patients were put under the ventilator for more than 2 days. At the time of admission, the X-ray of the chest was performed, and it was also performed every day. When certain organisms were present on the tracheal aspirate, ventilator-associated pneumonia (VAP) was diagnosed. After 2 days of ventilation, microbial analysis and gram staining were done for tracheal aspirates. They were later examined to determine the occurrence of nosocomial pneumonia and what are the risk factors linked with it. A Chi-square test and t-test were conducted to examine all the data. A confidence level of 0.05 was set. Results: Pneumonia associated with the ventilator occurred in 31.4% of the participants where a large number had developed it between 4-14 days after intubation. There were certain risk factors that were determined in our research. They include the use of H2 blockers, invasive lines, low PaO2/FiO2, and re-intubation. There were two things (use of steroids and enteral feeding through nasogastric) that were not linked with the occurrence of this pneumonia. The patients who were in the group of ventilator-associated pneumonia were having a longer time period of stay and mechanical ventilation. Practical implication: In newborn and paediatric intensive care units, VAP continues to be a significant and unresolved problem. The results of this study will highlight the numerous elements that significantly contribute to ventilator-associated pneumonia. Conclusion: The occurrence of pneumonia associated with ventilators is high. Those patients who were having above mentioned risk factors should require pay special attention towards prevention. Keywords: pneumonia, ventilators, ventilator associated pneumonia, neonatal intensive care unit

CONSISTENCY BETWEEN BRONCHOALVEOLAR LAVAGE AND ENDOTRACHEAL ASPIRATE IN THE DIAGNOSIS OF VENTILATOR-ASSOCIATED PNEUMONIA

Background 
 Ventilator-associated pneumonia (VAP) is a common nosocomial lung infection. Quick and accurate identification of the causative pathogen is crucial to improve prognosis. To date, the literature is controversial regarding whether endotracheal aspirate (ETA) can be used as an alternative to bronchoalveolar lavage (BAL) in VAP diagnosis.
 Objectives 
 To evaluate the consistency between the results of BAL and ETA in the diagnosis of early- and late VAP and to determine the microbial profiles of the involved microorganisms and their antimicrobial susceptibility. 
 Patients and Methods
 This is a single-centre prospective study that included 50 VAP-suspected patients conducted at Shar Hospital, Sulaimani, Iraq, from July 2021 to February 2022. The patients were categorised into early VAP and late VAP. For each patient, both ETA and BAL techniques were used to obtain samples for microbiological analysis and antimicrobial susceptibility testing.
 Results
 Ten (20%) patients developed early VAP, and 40 (80%) developed late VAP. The culture results of samples obtained by BAL showed microbial growth in 45 (90%) of the cases. Meanwhile, ETA resulted in microbial growth in 40 (80%) patients. In 45 (90%) of the samples, both techniques yielded the same results regarding microbial growth in the cultures. Among the 45 samples with the same growth results, 35 (70%) showed the same type of microbes, and 5 (10%) showed no microbial growth, indicating substantial agreement. In both BAL and ETA, Pseudomonas aeruginosa, Staphylococcus aureus, and Acinetobacter baumannii were the most frequently isolated pathogens. Both early- and late-VAP were associated with a high frequency of multidrug-resistant microorganisms, 6 (75%) and 25 (56.8%), respectively. However, extensively drug-resistant/pan-drug-resistant isolates were much more common in late-VAP patients (12, 27.3%). 
 Conclusion
 ETA can be a reliable, non-invasive alternative to BAL in VAP diagnosis associated with rapid and relatively accurate results.

173. Evaluating Respiratory Tract Culturing in Mechanically Ventilated Patients: Opportunity for Diagnostic Stewardship

Abstract Background Overdiagnosis of ventilator associated pneumonia (VAP) is common and may be due, in part, to excessive culturing of the respiratory tract in ventilated patients. We sought to evaluate the appropriateness of these cultures based on clinical characteristics leading to culture acquisition, and the relationship with antibiotic use. Methods We included mechanically ventilated adult patients in the Neuroscience and Cardiac Surgery Intensive Care Units at an academic medical center in Baltimore, MD, who had respiratory tract cultures obtained from March 1 to June 30, 2021. The appropriateness of respiratory cultures was evaluated by chart review in a standardized manner using a published algorithm (Figure 1). Clinical characteristics of patients with appropriate vs. inappropriate cultures were compared using Fisher’s exact test. Results 98 respiratory tract cultures (58 endotracheal aspirates, 25 mini bronchoalveolar lavages (BAL), 13 BALs, and 2 bronchial washings) were evaluated. Of these, 19 (19%) were deemed appropriate and 79 (81%) were inappropriate. Compared to patients with inappropriate cultures, those with appropriate cultures were more likely to demonstrate worsening oxygenation, new or increasing infiltrate on chest x-ray, or hemodynamic instability. The groups did not significantly differ with respect to fever or changes in WBC count (Figure 2). Of 79 inappropriate cultures, 31 (39%) received a clinical diagnosis of VAP from their provider. In 23 (29%) instances, antibiotics were started or changed based on culture results, and 9 (11%) were on empiric therapy for VAP that was continued unchanged. An additional 24 (30%) continued antibiotics not directed toward VAP. Excluding those on antibiotics not directed towards index respiratory culture results, patients received a median of 6 (IQR 2.5, 7) days of therapy. Conclusion A large majority of lower respiratory tract cultures in mechanically ventilated patients are potentially inappropriate and associated with overdiagnosis of VAP and unnecessary antibiotic exposure. Incorporating respiratory tract specific attributes into clinical decision making rather than “pan-culturing” for fever or leukocytosis may be an opportunity for diagnostic stewardship in this setting. Disclosures Kimberly C. Claeys, PharmD, BioFire Diagnostics: Honoraria.

Relationship Between Intra-Abdominal pressure and microaspiration of gastric contents in critically ill mechanically ventilated patients

The relationship between increased intra-abdominal pressure (IAP) and microaspiration of oro-gastric content in mechanically-ventilated patients has not yet been established. Microaspiration is proposed as one of the causes of ventilator-associated pneumonia (VAP). We aimed to investigate whether mechanically-ventilated patients with increased IAP present evidence of lung microaspiration by assessing pepsin levels in bronchial secretions and evaluated the relationship between pepsin and VAP.68 mechanically-ventilated patients and 10 control subjects were recruited from an academic ICU in Greece. IAP, pH, pepsin and total protein levels, in bronchial secretions, were assessed within 14 days. Patients underwent assessment for timely VAP diagnosis based on clinical, radiological and laboratory criteria.Pepsin and total protein levels were significantly elevated in patients compared to controls. Pepsin values correlated significantly with IAP (r = 0.61, ***p < 0.001). Multivariate regression analysis showed that IAP was an independent risk factor for increased pepsin values in bronchial secretions [OR95%CI 1.463(1.061–1.620), *p = 0.014]. Pepsin values were higher in patients with VAP, while IAP was independently associated with VAP. There was an indication towards increased VAP in patients with increased pepsin.In conclusion, our results show that pepsin in bronchial secretions may be elevated when IAP is increased, indicating microaspiration and potentially VAP.

A retrospective evaluation of multiple definitions for ventilator associated pneumonia (VAP) diagnosis in an Australian regional intensive care unit.

Ventilator Associated Pneumonia is a common complication of invasively ventilated patients with significant and underestimated morbidity and mortality. Defining VAP cases is greatly varied as many definitions are used with varying success and sensitivity. This study evaluates VAP detection using four definitions in a regional Australian Intensive Care Unit (ICU). A cohort of patients admitted to ICU at the Mackay Base Hospital from April 1st 2020 to March 31st 2021, who had endo-tracheal intubation and mechanical ventilation for longer than 48h were identified. Each patient was examined across four common definitions of VAP. Head-to-head analysis of definitions was pursued to determine the most suitable definition. The four definitions used included: An Australian VAP definition, the CDC VAP definition, the Mackay Base Hospital Local Protocol and a Physician Decision Arm. 66 unique patients and 2 re-intubations were identified during the data collection window. The local protocol identified 8 cases of VAP. The Australian VAP definition identified 6 additional cases and 0 missed cases compared to the local protocol. The CDC definition missed 4 cases and identified 4 additional cases compared to the local protocol. Finally, the physician arm identified 10 cases including 8 additional cases and missed 6 cases. VAP is an extremely difficult clinical condition to define and detect. Definitions have varied accuracy and suffer logistically for application to the individual patient. Refined criteria for diagnosis of VAP is greatly needed and its prevalence in intensive care units likely remains uncertain.

Prevention and treatment of ventilator-associated pneumonia in COVID-19.

Ventilator-associated pneumonia (VAP) is the most common acquired infection in the intensive care unit. Recent studies showed that the critical COVID-19 patients with invasive mechanical ventilation have a high risk of developing VAP, which result in a worse outcome and an increasing economic burden. With the development of critical care medicine, the morbidity and mortality of VAP remains high. Especially since the outbreak of COVID-19, the healthcare system is facing unprecedented challenges. Therefore, many efforts have been made in effective prevention, early diagnosis, and early treatment of VAP. This review focuses on the treatment and prevention drugs of VAP in COVID-19 patients. In general, prevention is more important than treatment for VAP. Prevention of VAP is based on minimizing exposure to mechanical ventilation and encouraging early release. There is little difference in drug prophylaxis from non-COVID-19. In term of treatment of VAP, empirical antibiotics is the main treatment, special attention should be paid to the antimicrobial spectrum and duration of antibiotics because of the existence of drug-resistant bacteria. Further studies with well-designed and large sample size were needed to demonstrate the prevention and treatment of ventilator-associated pneumonia in COVID-19 based on the specificity of COVID-19.

Ventilator-Associated Pneumonia Prevention in Pediatric Patients: Narrative Review.

Ventilator-associated pneumonia (VAP), one of the most common healthcare-associated infections in intensive care settings, is associated with significant morbidity and mortality. VAP is diagnosed in >10% of patients on mechanical ventilation, incidence rising with number of ventilator days. In recent decades, the pathophysiology of VAP, VAP risk factors and treatment have been extensively studied. In critically ill pediatric patients, mechanical issues such as insufficient tightness of the ventilator circuit (mainly due to historically based preference of uncuffed tubes) and excessive humidity in the circuit are both significant risk factors of VAP development. Protocol-based approaches to critically ill patients on mechanical ventilation, closed suctioning, upper body position, enteral feeding and selective gastric acid suppression medication have a beneficial effect on VAP incidence. In recent decades, cuffed tubes applied to the whole spectrum of critically ill pediatric patients (except neonates <2700 g of weight), together with cuff-oriented nursing care including proper cuff-pressure (<20 cm H2O) management and the use of specialized tracheal tubes with subglottic suction ports combined with close infraglottic tracheal suctioning, have been implemented. The aim of this review was to summarize the current evidence-based knowledge about the pathophysiology, risk factors, diagnosis, treatment and prevention of VAP in clinically oriented settings.

Bronchoscopy for diagnosis of ventilator-associated pneumonia.

Bronchoscopy for diagnosis of ventilator-associated pneumonia.

Clinicoradiological correlation of Endotracheal secretion culture in each case of suspected VAP: a need of the present to combat drug-resistance

Background: Ventilator-associated pneumonia (VAP) in intensive care unit (ICU)-admitted patients is a life-threatening event, caused by a diverse range of microbes having varied susceptibility to different classes of antibiotics. Materials and Methods: We enrolled patients admitted in trauma ICU on mechanical ventilation for &gt;48 h. Modified clinical pulmonary infection score (≥6) having a significant bacterial count (≥105 cfu/ml) in endotracheal (ET) secretions was used to diagnose VAP. Subsequently, we did antibiotic susceptibility testing by the modified Kirby–Bauer method, and the results were interpreted per Clinical and Laboratory Standards Institute guidelines. Results: We enrolled 389 patients in this study. Amongst these, we noted VAP events in 87 patients with an incidence of 15.62/1000 days of ventilators. Gram-negative rods were the predominant microbes causing VAP. Acinetobacter baumannii-calcoaceticus complex (n = 30) followed by Klebsiella pneumoniae (n = 27) and Pseudomonas aeruginosa (n = 19) was the predominant isolate. All nine isolated Staphylococcus aureus strains were methicillin-resistant S. aureus (MRSA). About 48.72% (38/78) of the Gram-negative microbes were meropenem sensitive. All strains of A. baumanii and P. aeruginosa were sensitive to polymyxin B, whereas all isolated MRSA strains were sensitive to vancomycin and linezolid. In addition, drug-resistant epidemiological important bacterial pathogens were also isolated from ET secretions. Conclusion: VAP is caused by a diverse group of multidrug-resistant microorganisms; however, drug-resistant microbes also colonise the in situ ET tubes. Therefore, accurate diagnosis of VAP and its differentiation from ET tube colonisation is a need of present times as appropriate treatment of actual VAP cases will reduce the burden of drug-resistant microbes in ICU settings.

Time to Look for Another Infectious Source? White Blood Cell Trends during Ventilator-Associated Pneumonia

Background: Ventilator-associated pneumonia (VAP) continues to plague patients in intensive care units (ICUs) throughout the world. Persistent leukocytosis despite antibiotic treatment for VAP can have many etiologies including normal inflammatory response, inadequate VAP antimicrobial therapy, and the presence of additional infectious diagnoses. Hypothesis: Surgical patients with VAP and a second infectious source have a different white blood cell count (WBC) trend than patients with VAP alone. Patients and Methods: Retrospective, single-center study of surgical ICU patients diagnosed with VAP (>104 CFU/mL on semi-quantitative culture) between January 2019 and June 2020. Chart review identified additional infections diagnosed during VAP treatment. White blood cell count values were compared between patients treated for VAP alone (VAP-alone) and those with additional infections (VAP-plus) using a Wilcoxon test. Univariable analysis compared admission type, surgeries, and steroid use between cohorts. Results: Eighty-eight VAPs were included for analysis; 61 (69%) were VAP-alone and 27 (31%) VAP-plus. Average age was 47.1 ± 16.7 years, 78% were male, and 93% were trauma admissions. Median hospital day of VAP diagnosis was six (interquartile range [IQR], 4-10). Nearly all patients (99%) were started on initial antibiotic agents to which the VAP organism was sensitive. Daily WBC was higher for VAP-plus compared with VAP-alone on days five, six, and seven of treatment. The maximum WBC was higher for VAP-plus (21.6 k/mcL vs. 16.1 k/mcL; p = 0.02). There were no differences in admission types, number of surgeries, or steroid use between groups. Conclusions: Providers should have increased suspicion for additional sources of infection when ICU patients with a VAP continue to have elevated WBC despite appropriate antibiotic therapy.

Efficacy of Modified Ventilator-Associated Pneumonia Prevention Bundles on Ventilator-Associated Pneumonia Incidence Rate in the Intensive Care Unit

Ventilator-associated pneumonia (VAP) is defined as pneumonia that develops in an intubated patient after 48 h of mechanical ventilation. In India, there is a paucity of literature in terms of compliance to VAP prevention bundles and their benefits. The aim of this study was to compare the reduction of VAP incidence rates amongst patients who received existing VAP prevention bundles and modified VAP prevention bundles. This pilot study was conducted in the adult intensive care unit of a tertiary care hospital. There were 60 patients in all, 30 patients in each group. The diagnosis of VAP was based on the clinical presentation and correlation with Clinical Pulmonary Infection Score. The incidence of VAP was 3/435 ventilator days (6.80%) in the patients receiving a modified VAP prevention bundle. In the conventional VAP prevention bundle group, the incidence of VAP was six episodes per 439 ventilator days (13.60%). Our study concluded that the modified VAP prevention bundle is effective in reducing the incidence of VAP amongst intubated patients.

Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit

See Bonus NeoBriefs videos and downloadable teaching slides Intubated infants in the NICU are at risk of developing ventilator-associated pneumonia (VAP), a common type of health care-associated infection. The Centers for Disease Control and Prevention developed guidelines for diagnosing VAP in patients younger than 1 year, which include worsening gas exchange, radiographic findings, and at least 3 defined clinical signs of pneumonia. VAP in infants is treated with empiric antibiotics selected based on local resistance patterns and individualized patient data. Many NICUs have implemented prevention bundles in an effort to decrease VAP by ensuring the cleanest environment for intubated neonates (hand hygiene, sterile handling of equipment), positioning of infants to prevent gastric reflux, and constantly reevaluating for extubation readiness. Although these prevention bundle elements are intuitive and generally low risk, none are based on strong research support. This article reviews the epidemiology, pathogenesis, diagnosis, treatment, and prevention of VAP in NICU patients, focusing on recent evidence, highlighting areas of emerging research, and identifying persistent knowledge gaps.

Endotracheal tube microbiome in hospitalized patients defined largely by hospital environment

BackgroundStudies of the respiratory tract microbiome primarily focus on airway and lung microbial diversity, but it is still unclear how these microbial communities may be affected by intubation and long periods in intensive care units (ICU), an aspect that today could aid in the understanding of COVID19 progression and disease severity. This study aimed to explore and characterize the endotracheal tube (ETT) microbiome by analyzing ETT-associated microbial communities.MethodsThis descriptive study was carried out on adult patients subjected to invasive mechanical ventilation from 2 to 21 days. ETT samples were obtained from 115 patients from ICU units in two hospitals. Bacteria isolated from endotracheal tubes belonging to the ESKAPE group were analyzed for biofilm formation using crystal violet quantification. Microbial profiles were obtained using Illumina sequencing of 16S rRNA gene.ResultsThe ETT microbiome was mainly composed by the phyla Proteobacteria, Firmicutes and Bacteroidetes. Microbiome composition correlated with the ICU in which patients were hospitalized, while intubation time and diagnosis of ventilator-associated pneumonia (VAP) did not show any significant association.ConclusionThese results suggest that the ICU environment, or medical practices, could be a key to microbial colonization and have a direct influence on the ETT microbiomes of patients that require mechanical ventilation.

The Role of Lung Ultrasound Monitoring in Early Detection of Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Observational Study.

Specific lung ultrasound signs combined with clinical parameters allow for early diagnosis of ventilator-associated pneumonia in the general ICU population. This retrospective cohort study aimed to determine the accuracy of lung ultrasound monitoring for ventilator-associated pneumonia diagnosis in COVID-19 patients. Clinical (i.e., clinical pulmonary infection score) and ultrasound (i.e., presence of consolidation and a dynamic linear–arborescent air bronchogram, lung ultrasound score, ventilator-associated lung ultrasound score) data were collected on the day of the microbiological sample (pneumonia-day) and 48 h before (baseline) on 55 bronchoalveolar lavages of 33 mechanically-ventilated COVID-19 patients who were monitored daily with lung ultrasounds. A total of 26 samples in 23 patients were positive for ventilator-associated pneumonia (pneumonia cases). The onset of a dynamic linear–arborescent air bronchogram was 100% specific for ventilator-associated pneumonia. The ventilator-associated lung ultrasound score was higher in pneumonia-cases (2.5 (IQR 1.0 to 4.0) vs. 1.0 (IQR 1.0 to 1.0); p < 0.001); the lung ultrasound score increased from baseline in pneumonia-cases only (3.5 (IQR 2.0 to 6.0) vs. −1.0 (IQR −2.0 to 1.0); p = 0.0001). The area under the curve for clinical parameters, ventilator-associated pneumonia lung ultrasound score, and lung ultrasound score variations were 0.472, 0.716, and 0.800, respectively. A newly appeared dynamic linear–arborescent air bronchogram is highly specific for ventilator-associated pneumonia in COVID-19 patients. A high ventilator-associated pneumonia lung ultrasound score (or an increase in the lung ultrasound score) orients to ventilator-associated pneumonia.

Increased risk of ventilator‐associated pneumonia in patients after cardiac arrest treated with mild therapeutic hypothermia

BackgroundWe aimed at investigating the incidence, characteristics and outcome of ventilator‐associated pneumonia (VAP) in patients after cardiac arrest (CA) and its potential association with mild therapeutic hypothermia (MTH). We hypothesized, that MTH might increase the risk of VAP.MethodsProspective observational study including comatose adult patients after successful resuscitation from out‐of‐hospital or in‐hospital CA with presumed cardiac cause admitted to ICU and treated with MTH at 33°C for 24 h or normothermia (NT) with treatment of fever ≥38°C by pharmacological means. The primary outcome measure was the development of VAP. VAP diagnosis included mechanical ventilation >48 h combined with clinical and radiologic criteria. For a microbiologically confirmed VAP (mcVAP), a positive respiratory culture was required.ResultsAbout 23% of 171 patients developed VAP, 6% presented with mcVAP. VAP was associated with increased ICU‐LOS (9 (IQR 5–14) vs. 6 (IQR 3–9) days; p < .01), ventilator‐dependent days (6 (IQR 4–9) vs. 4 (IQR 2–7) days; p < .01) and duration of antibiotic treatment (9 (IQR 5–13) vs. 5 (IQR 2–9) days; p < .01), but not with mortality (OR 0.88 (95% CI: 0.43–1.81); p = .74). Patients treated with MTH (47%) presented higher VAP (30% vs. 17%; p = .04) and mcVAP rates (11% vs. 2%; p = .03). MTH was associated with VAP in multivariable logistic regression analysis with an OR of 2.67 (95% CI: 1.22–5.86); p = .01.ConclusionsVAP appears to be a common complication in patients after CA, accompanied by more ventilator‐dependent days, prolonged antibiotic treatment, and ICU‐LOS. Treatment with MTH is significantly associated with development of VAP.

Effect of Gram Stain–Guided Initial Antibiotic Therapy on Clinical Response in Patients With Ventilator-Associated Pneumonia

Gram staining should provide immediate information for detecting causative pathogens. However, the effect of Gram staining on restricting the initial antibiotic choice has not been investigated in intensive care units (ICUs). To compare the clinical response to Gram stain-guided restrictive antibiotic therapy vs guideline-based broad-spectrum antibiotic treatment in patients with ventilator-associated pneumonia (VAP). This multicenter, open-label, noninferiority randomized clinical trial (Gram Stain-Guided Antibiotics Choice for VAP) was conducted in the ICUs of 12 tertiary referral hospitals in Japan from April 1, 2018, through May 31, 2020. Patients aged 15 years or older with a VAP diagnosis and a modified Clinical Pulmonary Infection Score of 5 or higher were included. The primary analysis was based on the per-protocol analysis population. Patients were randomized to Gram stain-guided antibiotic therapy or guideline-based antibiotic therapy (based on the 2016 Infectious Disease Society of America and American Thoracic Society clinical practice guidelines for VAP). The primary outcome was the clinical response rate; clinical response was defined as completion of antibiotic therapy within 14 days, improvement or lack of progression of baseline radiographic findings, resolution of signs and symptoms of pneumonia, and lack of antibiotic agent readministration, with a noninferiority margin of 20%. Secondary outcomes were the proportions of antipseudomonal agents and anti-methicillin-resistant Staphylococcus aureus (MRSA) agents as initial antibiotic therapies; 28-day mortality, ICU-free days, ventilator-free days; and adverse events. In total, 206 patients (median [IQR] age, 69 [54-78] years; 141 men [68.4%]) were randomized to the Gram stain-guided group (n = 103) or guideline-based group (n = 103). Clinical response occurred in 79 patients (76.7%) in the Gram stain-guided group and 74 patients (71.8%) in the guideline-based group (risk difference, 0.05; 95% CI, -0.07 to 0.17; P < .001 for noninferiority). Reduced use of antipseudomonal agents (30.1%; 95% CI, 21.5%-39.9%; P < .001) and anti-MRSA agents (38.8%; 95% CI, 29.4%-48.9%; P < .001) was observed in the Gram stain-guided group vs guideline-based group. The 28-day cumulative incidence of mortality was 13.6% (n = 14) in the Gram stain-guided group vs 17.5% (n = 18) in the guideline-based group (P = .39). Escalation of antibiotics according to culture results was performed in 7 patients (6.8%) in the Gram stain-guided group and 1 patient (1.0%) in the guideline-based group (P = .03). There were no significant differences between the groups in ICU-free days, ventilator-free days, and adverse events. Results of this trial showed that Gram stain-guided treatment was noninferior to guideline-based treatment and significantly reduced the use of broad-spectrum antibiotics in patients with VAP. Gram staining can potentially ameliorate the multidrug-resistant organisms in the critical care setting. ClinicalTrials.gov Identifier: NCT03506113.

Assessment of different diagnostic modalities for the detection of ventilator-associated pneumonia

Background Ventilator-associated pneumonia (VAP) is one of the common causes of nosocomial infection. The diagnosis of VAP is subject to marked interobserver variability. The clinical pulmonary infection score (CPIS) is simple, easily applicable and affordable, but may lead to overestimation and unnecessary use of antibiotics and hence microbiological resistance. However, at least 48 h are needed for definitive diagnosis using the microbiological methods, which may lead to delay in starting treatment. The best diagnostic method for the diagnosis of VAP remains unclear. Therefore, there is a great need for a definitive and simple method for the early detection of VAP. Aim This study aimed to assess the accuracy of different diagnostic tests for the early detection of VAP. Results In terms of the microbiological diagnosis of VAP, we isolated the same organism by protected endotracheal aspirate (EA) and bronchoalveolar lavage in about 76% of patients. The diagnostic performance of CPIS combined with EA gram stain was better than use of CPIS alone, with an area under the curve (AUC) of 0.81. The VAP lung ultrasound score (VPLUS) had a sensitivity and specificity of 70% at cutoff point more than 2, with an AUC of 0.71. Combining CPIS with VPLUS yielded the best diagnostic performance, with the sensitivity and specificity being nearly 85% at CPIS more than or equal to 8+VPLUS more than or equal to 2, AUC 0.92. Conclusions LUS is a very promising tool that aids in the diagnosis of VAP based on identification of specific sonographic features. However, it cannot replace microbiological sampling. The combination of clinical or ultrasound findings with gram stain yielded the best diagnostic performance.

Isolated Pattern of Microorganism among Pediatric Patients with Ventilator-associated Pneumonia (VAP) in a Tertiary Care Hospital Karachi

Background: The Ventilator associated pneumonia (VAP) is a common condition with inflammation of lungs. The patients on mechanical ventilation or artificial breathings for 48 to 72 hours tend to developed this condition., which is a type of Nosocomial Pneumonia.&#x0D; Objective: To assess the causative agent and treatment pattern among the patients suffering from ventilator associated pneumonia.&#x0D; Methodology: A cross sectional study was conducted for the period of 8 months at a tertiary health care setup of the Karachi Pakistan among the patient’s with VAP. Total of 72 patients with confirmed diagnosis of VAP were included in the study. Data was collected from the children intensive care units on a structed questionnaire. The required variables were obtained from the patients files/Records after the ethical approval was obtained before the collection of data Results were evaluated using the SPSS version 20.0.&#x0D; Results: The study found out that the VAP is most type of hospital acquired pneumonia form the health care system., showed 59.8% (n=61) males and 34.3% (n=35) females’ patients with VAP diagnosis. The age group revealed majority of the patients 46.1% (n=47) were 0–1-year-old, 11.8% (n=12) patients were above 2- 3 years old. 18.6% patients (n=19) were &gt;3 years-4years old. The study also assesses ventilators support &gt;48 hours have around 20-30% (Mean 6.9 days CI: 1.16-3.65) chance to develop the VAP. The subsequent effects of VAP shows the two-fold rates of mortality hence requiring the more length of stay at hospital and extra charges.&#x0D; Conclusion: The VAP occurs among the considerable numbers of patients on the ventilator supports, the findings suggests that an appropriate management, prevention strategies and effective treatment is needed to reduces the mortality and complications of VAP.

A nationwide retrospective analysis of ventilator-associated pneumonia in the US

Ventilator-associated pneumonia (VAP) is a major cause of healthcare-associated mortality and morbidity in critically ill patients who are mechanically ventilated. The purpose of this study was to describe the various primary discharge diagnoses of hospitalizations with VAP, to identify their demographic characteristics, and to identify risk factors for mortality in hospitalizations with VAP. Hospitalizations with a diagnosis of VAP with mechanical ventilation for over 24 hours were selected from the National Inpatient Sample in 2016 and 2017. In total, 33,140 hospitalizations with VAP were analyzed. The leading principal discharge diagnoses for hospitalizations leading to VAP were sepsis due to an unspecified organism (16.92%), respiratory failure (8.09%), and VAP (6.38%). Mortality among hospitalizations with VAP was 20.9%. Independent risk factors for mortality in hospitalizations with VAP were uninsured status (adjusted odds ratio [aOR] 2.13, 95% confidence interval [CI] 1.49–3.06, P < 0.001), acute renal failure (aOR 2.00, 95% CI 1.75–2.30, P < 0.001), and liver disease (aOR 1.82, 95% CI 1.52–2.18, P < 0.001). In conclusion, VAP is associated with significant mortality. Infective, traumatic, cardiovascular, and respiratory conditions accounted for over 85% of hospitalizations with VAP. Acute renal failure, the presence of liver disease, and lack of insurance are associated with higher mortality in hospitalizations with VAP.

Comparative Respiratory Tract Microbiome Between Carbapenem-Resistant Acinetobacter baumannii Colonization and Ventilator Associated Pneumonia.

BackgroundCarbapenem-resistant Acinetobacter baumannii (CRAB) is a common cause of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, but its infection and colonization state are difficult to distinguish. If the judgment is wrong, it may aggravate the abuse of antibiotics and further accelerate the evolution of drug resistance. We sought to provide new clues for the diagnosis, pathogenesis and treatment of CRAB VAP based on lower respiratory tract (LRT) microbiota.MethodsA prospective study was conducted on patients with mechanical ventilation from July 2018 to December 2019 in a tertiary hospital. Multi-genomics studies (16S rRNA amplicon, metagenomics, and whole-genome sequencing [WGS]) of endotracheal deep aspirate (ETA) were performed.ResultsFifty-two ICU patients were enrolled, including 24 with CRAB VAP (CRAB-I), 22 with CRAB colonization (CRAB-C), and six CRAB-negative patients (infection-free) (CRAB-N). Diversity of pulmonary microbiota was significantly lower in CRAB-I than in CRAB-C or CRAB-N (mean Shannon index, 1.79 vs. 2.73 vs. 4.81, P < 0.05). Abundances of 11 key genera differed between the groups. Acinetobacter was most abundant in CRAB-I (76.19%), moderately abundant in CRAB-C (59.14%), and least abundant in CRAB-N (11.25%), but its interactions with other genera increased in turn. Metagenomics and WGS analysis showed that virulence genes were more abundant in CRAB-I than in CRAB-C. Multi-locus sequence typing (MLST) of 46 CRAB isolates revealed that the main types were ST208 (30.43%) and ST938 (15.22%), with no difference between CRAB-I and CRAB-C.ConclusionLower respiratory tract microbiota dysbiosis including elevated relative abundance of Acinetobacter and reduced bacterial interactions, and virulence enrichment may lead to CRAB VAP.