Early-onset Hospital-acquired Pneumonia Research Articles

THE ROLE OF INFRARED RADIATION WITH TERAHERTZ MODULATION IN POST-CARDIOSURGERY PULMONARY COMPLICATIONS

Background. Early pulmonary complications after cardiosurgery worsen general state of the patients, require additional therapeutic and diagnostic measures, increase the pharmacological load, extend the length of stay in the hospital and in some cases leads to the lethal outcome. Objective. The purpose of this study was to evaluate the effectiveness of the infrared radiation with terahertz modulation in the early-onset hospital-acquired pneumonia and ventilator-associated pneumonia in patients after cardiosurgery. Design and methods. This is an observational retrospective open comparative study with pseudo-control (“case-control study”). We included patients with pulmonary complications (infi ltrative and focal changes in the lungs diagnosed as nosocomial pneumonia and ventilator-associated pneumonia) in the early post-cardiosurgery period (after coronary bypass surgery and / or prosthetic heart valves). They were divided into 2 groups: we applied infrared Terahertz radiation at the acupuncture point Da-bao (RР 21) (“IK-Dipole”, Russia) in addition to the standard therapy in the 1st group. The patients of the 2nd group received only standard therapy. Results. Early (the fi rst day) application of infrared radiation with terahertz modulation allowed to reduce terms of stay of the patient in the intensive care unit (by 4-8 days); to reduce radiological and pharmacological stress; to reduce the intubation and ventilation time (by 4-8 days); to improve prognosis; to start earlier (by 4-8 days) the rehabilitation activities. Conclusion. Therefore, the infrared radiation with terahertz modulation helps to improve the quality and effectiveness of treatment in patients with pulmonary complications after cardiosurgery.

Management of mechanical ventilation in patients with hospital-acquired pneumonia: A retrospective, observational study.

Hospital-acquired pneumonia (HAP) in intensive care patients is a frequent reason for mechanical ventilation (MV). The management of MV and ventilator weaning vary, depending on the type of lung inflammation. This retrospective, observational study screened the data from all patients admitted to the intensive care unit (ICU) of the Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc between 2011 and 2016. The aims were to determine the parameters of pressure-controlled ventilation, the frequencies of tracheostomy, bronchoscopy, reconnection to MV, the length of ICU and hospital stay and the mortality in subgroups with early-/late-onset HAP compared to a subgroup with community-acquired pneumonia (CAP) and patients with MV without pneumonia. The primary outcome of this study was MV length. Over the study period, a total of 2672 patients were hospitalised. Excluded were 137 organ donors, 66 patient without MV and 20 patients placed on volume-controlled ventilation. The cohort comprised 2.447 patients requiring MV. A total of 1.927 patients (78.7%) were indicated for MV without signs of pneumonia. CAP was diagnosed in 131 patients (5.4%). The criteria for HAP were met by 389 patients (16.0%). Early-onset and late-onset HAP was diagnosed in 63 (2.6%) and 326 (13.3%) patients, respectively. In the subgroups without pneumonia, with CAP, early- and late-onset HAP, the median MV times were 3, 6, 6 and 12 days, respectively, and the median peak inspiratory pressure (Pinsp) of MV was 20, 25, 25 and 27 cm H2O, respectively. The median positive end-expiratory pressure (PEEP) was 5, 8, 8 and 11 cm H2O, respectively. The median inspired oxygen concentrations (FiO2) were 0.45, 0.7, 0.7 and 0.8, respectively. The median length of hospital stays was 8, 15, 15 and 17 days. The mortality rates were 11.4%, 3.8%, 9.5% and 31.3%, respectively. During MV, the late-onset HAP subgroup was shown to have the highest Pinsp, PEEP and FiO2, the longest MV time, ICU and hospital stay, the highest frequency of tracheostomy, reconnection to MV, pulmonary hygiene bronchoscopy and the highest mortality compared to the early-onset HAP and CAP subgroups. The lowest values were found in the mechanically ventilated patients without pneumonia. The differences were due to the severity of lung damage that is graduated from CAP over early-onset HAP after late-onset HAP.

HOSPITAL-ACQUIRED PNEUMONIA IN ICU PATIENTS

This prospective study aimed at assessing the effect of initial antibiotic therapy on the mortality of patients with hospital-acquired pneumonia (HAP) by analyzing bacterial pathogens and their resistance to antimicrobial agents. Included were patients hospitalized in the Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and Dentistry, Palacký University Olomouc and University Hospital Olomouc in 2009 who developed HAP. Bacterial pathogens and their resistance to antibiotics were identified using standard microbiological methods. The patient's mortality with respect to their initial antibiotic therapy was statistically analyzed. The group comprised 51 patients with HAP. Early-onset HAP was identified in 7 (14%) patients and late-onset HAP in 44 (86%) patients. The most frequent bacterial pathogens were strains of Klebsiella pneumoniae, Pseudomonas aeruginosa, Burkholderia cepacia complex and Escherichia coli, together accounting for 72%. Eighteen patients died directly due to HAP, an overall mortality rate of 35%. If initial therapy effective against the bacterial pathogen was selected, 21 patients survived and 9 died. If the bacterial pathogens were resistant to the selected initial antibiotic therapy, 9 patients died and 12 survived. The mortality rates were 30% and 43% for adequate and inadequate antibiotic therapy, respectively. Given the small group of patients, the difference has low statistical significance. However, it does document the clinical impact of bacterial resistance on the survival or death of patients with HAP.

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Early-onset hospital-acquired pneumonia (E-HAP) is one of the leading causes of sepsis and mortality after liver transplantation (LT). The appropriate antimicrobial therapy is crucially important for surviving sepsis in this context. The aim of this study was to analyze microbiological findings, associated factors, and optimal antibiotic regimens for E-HAP after LT. Patients demonstrating E-HAP in a single-center cohort of 148 LT recipients were prospectively detected. The diagnosis of pneumonia relied on a combination of supportive clinical findings and a positive culture of a lower respiratory tract sample. E-HAP was considered present if pneumonia occurred within 6 days of intensive care unit (ICU) admission after LT. Twenty-three patients (15.5%) developed E-HAP, which were caused by 36 pathogens (61.1% were gram-negative bacilli, and 33.3% were classified as hospital-acquired). For patients who developed E-HAP, the duration of mechanical ventilation and the ICU stay were significantly longer. Despite a trend toward higher mortality at any time in the E-HAP group, there was no significant difference in mortality between patients with E-HAP and patients without E-HAP. Lactatemia, vasopressor requirements, Simplified Acute Physiology Score II (SAPS II) score on ICU admission, and mechanical ventilation lasting more than 48 hours after LT were associated with E-HAP. Combinations of broad-spectrum β-lactams and aminoglycosides were active against more than 91% of the encountered pathogens. However, antibiotic de-escalation was possible in more than one-third of cases after identification of the pathogens. In conclusion, E-HAP after LT is a severe condition that appears to be influenced by physiological derangements induced by the surgery, such as lactatemia, vasopressor requirements, and mechanical ventilation requirements, as well as the postoperative SAPS II score. At the time of treatment initiation, an antimicrobial regimen usually proposed for late-onset pneumonia should be followed.

Antimicrobial treatment of lower respiratory tract infections in the hospital setting

Respiratory tract infections (RTIs) that may require hospitalization include acute exacerbations of chronic bronchitis (AECB), community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP), which includes ventilator-associated pneumonia (VAP). Healthcare-associated pneumonia (HCAP) is treated similar to HAP and may be considered with HAP. For CAP requiring hospitalization, the current guidelines for the treatments of RTIs generally recommend either a beta-lactam and macrolide combination or a fluoroquinolone. The respiratory fluoroquinolones (levofloxacin, gatifloxacin, moxifloxacin, and gemifloxacin) are excellent antibiotics due to high levels of susceptibility among gram-negative, gram-positive, and atypical pathogens. The fluoroquinolones are active against > 98% of Streptococcus pneumoniae, including penicillin-resistant strains. Fluoroquinolones are also recommended for AECB requiring hospitalization. Evidence from clinical trials suggests that levofloxacin monotherapy is as efficacious as combination ceftriaxone-erythromycin therapy in the treatment of patients hospitalized with CAP. For early-onset HAP, VAP, and HCAP without the risk of multidrug resistance, ceftriaxone, ampicillin-sulbactam, ertapenem, or one of the fluoroquinolones is recommended. High-dose, short-course therapy regimens may offer improved treatment due to higher drug concentrations, more rapid killing, increased adherence, and the potential to reduce development of resistance. Recent studies have shown that short-course therapy with levofloxacin, azithromycin, or telithromycin in patients with CAP was effective, safe, and tolerable and may control the rate of resistance.

Hospital acquired pneumonia

Hospital acquired pneumonia (HAP) is defined as pneumonia that occurs 48 hours or longer after hospital admission and excludes any infection that is incubating at the time of admission1. It is also commonly termed nosocomial pneumonia. Ventilator-associated pneumonia is widely recognised as pneumonia developing after at least 48 hours of mechanical ventilation (MV), and can be considered a subgroup of HAP with distinct differences in terms of pathogenesis, histology, aetiology and prognosis. The concept of ‘early-’ and ‘late-onset’ HAP is also useful: • Early-onset HAP is commonly defined as occurring within four days of hospitalisation, with Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus the most frequently isolated organisms2,3. • Late-onset HAP, occurring five or more days after hospitalisation, is caused by pathogens such as enteric Gram-negative bacilli that have replaced the ‘community’ pathogens in the oropharynx. Patients readmitted to hospital with pneumonia following recent hospital discharge may have features more consistent with HAP than with community acquired pneumonia (CAP).