Early-onset Ventilator-associated Pneumonia Research Articles

Suction circuit flushing with chlorhexidine decreases ventilator-associated pneumonia: a quasi-experimental study.

Endotracheal suctioning of mechanically ventilated patients differs across the world. In many low and middle-income countries, endotracheal suctioning is often performed with a sterile suctioning catheter that is used for 12 h or during the length of one nursing shift. The effect of flushing multiple used endotracheal suction system with chlorhexidine after suctioning to reduce ventilator associated pneumonia (VAP) remains unclear. The aim of the study is to assess the effectiveness of flushing multiple-used open endotracheal suction catheters and suctioning system with chlorhexidine gluconate 0.2% to reduce VAP in mechanically ventilated patients in a resource-limited Intensive Care Unit (ICU). Due to the difficulty of blinding the intervention for nurses who perform endo-tracheal suction procedures, we adopted a quasi-experimental method with a randomized controlled trial design. A sample of 136 ICU patients were allocated to the intervention (n = 68) or control group (n = 68) between May and November 2020. The intervention was flushing the multiple-used suction catheter and suction system with 40ml chlorhexidine gluconate 0.2% and in the control group we used normal saline to flush the catheter and suction system. The primary outcome was incidence of VAP and the cost of the flushing solutions was the secondary outcome measure. Patients in the intervention group had a lower incidence of VAP compared to patients in the control group; 15 (22.1%) vs 29 (42.6%), p = 0.01. The incidence of late-onset VAP was 26.2% in the intervention group and 49% in the control group (p = 0.026) and the early-onset VAP was 13.2% in the intervention group and 25% in the control group (p = 0.081). Chlorhexidine gluconate 0.2% reduced the cost of suction system flushing (median: 78.4 vs 300 EGP, p < 0.001). Using chlorhexidine gluconate 0.2% to flush multiple-used suctioning catheters after every endo-tracheal suction procedure might reduce the incidence of VAP in mechanically ventilated patients. Chlorhexidine gluconate 0.2% can be a cost-effective solution for flushing the suction circuit. Nurses working in resource-limited ICUs and using suctioning catheters multiple times might consider using chlorhexidine gluconate 0.2% instead of normal saline or distilled water when flushing the suction system. ClinicalTrials.gov, identifier NCT05206721.

Pathogenic and Non-Pathogenic Microbial Presence in Ventilator Associated Pneumonia Patients in Intensive Care Unit and Safety Protocols Under Surveillance of Healthcare Provider: A Research Study

Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection that is associated with longer stays in intensive care units (ICUs) and under mechanical ventilation for more than 48 hours. This article explores the prevalence and impact of VAP on mortality and morbidity, emphasizing the microbial associations involved in hospital-acquired infections. Various infections, including Lung infections, surgical site infections, sepsis, and urinary tract infections, are discussed, along with their associated microorganisms. Diagnostic criteria for VAP and related infections are outlined, highlighting the importance of microbiological testing for accurate diagnosis. The underlying factors for VAP acquisition in ICU patients are identified, and prompt antibiotic initiation is emphasized as a critical first-line defense against VAP. In this study, we have populated data from 100 ICU patients, among which 45 were suffering from VAP. It was found that female patients (57.40%) were more affected than male patients (30.43%). The decreasing PaO2 level was seen to be the early sign of infection. It was found that the time of ventilation was the major factor influencing the VAP. The most common organism causing infection in our study was found to be Staphylococcus Aureus (45.1%). The prognosis of early-onset VAP was 35.55% while compared to Late-onset VAP 64.44%. When compared to VAP and Non-VAP patients there was not very huge difference with 55% and 45% respectively. The other factor was age and position. Implementation of Prevention strategies, such as protective environments and HEPA filtration systems, is proposed to reduce VAP incidence. Proper diagnosis, treatment, and prevention are crucial to combatting VAP and enhancing patient outcomes in hospital settings.

Ventilator-associated pneumonia in an academic intensive care unit in Johannesburg, South Africa

Background. Ventilator-associated pneumonia (VAP) has an estimated incidence of 10 - 41.5 events per 1 000 ventilator days in developing countries, and carries high mortality. Little is known about the incidence and outcomes of VAP in Johannesburg, South Africa. Objectives. To describe VAP in a tertiary public hospital in Johannesburg, assess the microbiological pathogens associated with VAP (both early and late), and outline the outcomes of these patients. Methods. The study was a retrospective record review of patients admitted to the Helen Joseph Hospital intensive care unit (ICU) between March 2013 and January 2016. Results. VAP developed in 24/842 ventilated patients (2.9%; 95% confidence interval (CI) 1.8 - 4.2), with an incidence of 23 events per 1 000 ventilator days, during the study period. Of these patients, one-third (29.2%) died and 70.8% were discharged from the ICU. Late-onset VAP (onset ≥5 days after intubation, incidence 45.8%) was associated with higher mortality (54.6%) than early-onset VAP (onset within 4 days after intubation, incidence 54.2% and mortality 7.7%). Commonly isolated organisms were Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa. There was a trend towards an increased risk of multidrug-resistant organisms with late-onset VAP (adjusted relative risk 2.26; 95% CI 0.92 - 5.57; p=0.077) and airway access through a tracheostomy (relative risk 1.68; 95% CI 0.78 - 3.57). Conclusion. The study showed a low to moderate incidence of VAP of 23 events per 1 000 ventilator days. A tracheostomy and late-onset VAP were associated with infection by drug-resistant organisms. The mortality rate was 29.2% in this setting, with a seven-fold increase in mortality with late-onset 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.

A Clinical Study of Ventilator Associated Pneumonia

Background: Ventilator Associated Pneumonia is a significant cause of mortality and morbidity in the critical care setting. Ventilator Associated Pneumonias are highly preventable owing to identification of risk factors, causes and best practices in the ICU.Aims and Objectives :The present study is aimed at determining the incidence of Ventilator Associated Pneumonia and their associated risk factors.Materials and Methods: The present hospital based observational study included 50 cases on ventilator support from the ICU of Apna Hospital, Hyderabad. All the cases were included after consent and underwent detailed history taking, relevant clinical examinations and necessary laboratory investigations. The incidence of VAP’s was determined and the data was analysed to find the related factors. Data was collected in MS Excel, presented in as numbers and percentages in the form of tables and charts.Results: The incidence of Ventilator Associated Pneumonia was found to be 38%. Early Onset VAP was estimated to be 47.3%, Late Onset VAP to be 52.7%. There was male predominance(64%) in our study group. Age groups 40-60 years contributed the most of the study population. Diabetes, Hypertension, CVD, alcoholism and tobacco use were associated in VAP cases.Conclusion :There is a high incidence of Ventilator Associated Pneumonia in the critical care setting. Further research should be conducted to evaluate the causes and detailed risk factors as Ventilator Associated Pneumonia are a major cause of mortality, morbidity and increase the financial burden of the patient and the hospital.

Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile.

Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections, which develops in mechanically ventilated patients after 48 hours of mechanical ventilation. The purpose of this study was to determine the incidence rate, various risk factors, microbiological profile, and outcome of early- vs late-onset ventilator-associated pneumonia (VAP) in medical intensive care unit (MICU). This prospective study was conducted on 273 patients admitted to the MICU in JIPMER, Puducherry, from October 2018 to September 2019. The incidence of VAP was 39.59 per 1000 ventilation days of MICU patients (93/273). Of these, 53 (56.9%) patients had early-onset VAP and 40 (43.1%) had late-onset VAP. Multiple logistic regression analysis showed that steroid therapy, supine head position, coma or impaired unconsciousness, tracheostomy, and re-intubation were found to be independent predictors of early- and late-onset VAP, respectively. Most cases of VAP were caused by Gram-negative bacteria (90.6%), with nonfermenters contributing to 61.8%. The most frequent pathogens causing early-onset VAP were Acinetobacter baumannii (28.9%) and Pseudomonas aeruginosa (20.6%), while in late-onset VAP, A. baumannii (32.9%) and Klebsiella pneumoniae (21.9%) were the most common. Maximum death rate was seen in patients infected with Escherichia coli (50%) and Stenotrophomonas maltophilia (38.5%). There was no significant association between the presence of VAP and mortality among the studied population. The incidence of VAP in our study was high. There were no significant differences in the prevalence of pathogens associated with early-onset or late-onset VAP. Our study shows that early-onset and late-onset VAP have different risk factors, highlighting the need for developing different preventive and therapeutic strategies. Gunalan A, Sastry AS, Ramanathan V, Sistla S. Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile. Indian J Crit Care Med 2023;27(6):411-415.

Detection of Pathogens and Antimicrobial Resistance Genes in Ventilator-Associated Pneumonia by Metagenomic Next-Generation Sequencing Approach.

The early identification of pathogens and their antibiotic resistance are essential for the management and treatment of patients affected by ventilator-associated pneumonia (VAP). However, microbiological culture may be time-consuming and has a limited culturability of many potential pathogens. In this study, we developed a rapid nanopore-based metagenomic next-generation sequencing (mNGS) diagnostic assay for detection of VAP pathogens and antimicrobial resistance genes (ARGs). Endotracheal aspirate (ETA) samples from 63 patients with suspected VAP were collected between November 2021 and July 2022. Receiver operating characteristic (ROC) curves were established to compare the pathogen identification performance of the target pathogen reads, reads percent of microbes (RPM) and relative abundance (RA). The evaluation of the accuracy of mNGS was performed comparing with the gold standard and the composite standard, respectively. Then, the ARGs were analyzed by mNGS. ROC curves showed that RA has the highest diagnostic value and the corresponding threshold was 9.93%. The sensitivity and specificity of mNGS test were 91.3% and 78.3%, respectively, based on the gold standard, while the sensitivity and specificity of mNGS test were 97.4% and 100%, respectively, based on the composite standard. A total of 13 patients were virus-positive based on mNGS results, while the coinfection rate increased from 27% to 46% compared to the rate obtained based on clinical findings. The mNGS test also performed well at predicting antimicrobial resistance phenotypes. Patients with a late-onset VAP had a significantly greater proportion of ARGs in their respiratory microbiome compared to those with early-onset VAP (P = 0.041). Moreover, the median turnaround time of mNGS was 4.43 h, while routine culture was 72.00 h. In this study, we developed a workflow that can accurately detect VAP pathogens and enable prediction of antimicrobial resistance phenotypes within 5 h of sample receipt by mNGS.

Early-Onset Ventilator-Associated Pneumonia in Pediatric Severe Traumatic Brain Injury.

Early-onset ventilator-associated pneumonia (VAP) is associated with poor outcomes in patients with severe traumatic brain injury (TBI). The primary aim of this study was to describe VAP, including the microbiology of VAP and differences in frequency of VAP when various definitions are applied. The secondary aim was to determine the clinical variables associated with the development of VAP in children with severe TBI. This is a retrospective cohort study at a quaternary referral children's hospital with a level I trauma center designation. Inclusion criteria were patients aged 0-18years admitted to the pediatric intensive care unit between 2015 and 2020 with severe TBI requiring at least 2days of invasive ventilation. VAP was defined by using Center of Disease Control (CDC) definition or clinical VAP, based on physician diagnosis. We compared general demographics, reviewed trauma and injury data, and outcomes to assess any differences between patients with VAP and non-VAP patients. Associations were tested with regression models. After applying all inclusion and exclusion criteria, 90 patients were included in the analysis. Patients with VAP were older (8.5 vs. 5.6years, P = 0.03). Patients with VAP were less likely to have suffered from abusive head trauma (P = 0.01). Patients who received continuous neuromuscular blockade or targeted temperature management did not have different frequencies of VAP. CDC-defined VAP was diagnosed in 27% of patients. Number of patients with VAP increased to 41% for physician-diagnosed or clinical VAP. Methicillin-sensitive Staphylococcus aureus was the most common isolate grown, followed by Hemophilus influenza, with most VAP occurring on days 2-5 of intubation. VAP was not associated with mortality but was associated with worse functional status scale in patients who survived to discharge (8 vs. 7.5, P = 0.048). Over a cumulative period of days, nebulized 3% and albuterol were associated with decreased incidence of VAP. Ventilator-associated pneumonia occurs commonly in children with severe TBI, with rates of 27-41%, depending on CDC-defined VAP or clinical VAP. The discrepancy between clinical VAP and CDC-defined VAP further illustrates the need for a standardized definition for VAP. Although most interventions were not associated with VAP, nebulized 3% saline and albuterol were associated with reduced incidence of VAP; future investigation is needed to determine whether mucolytic agents can decrease the rate of VAP in children with severe TBI.

Ventilator-associated pneumonia: Study of clinical outcome

Introduction: Ventilator-associated pneumonia (VAP) is a nosocomial pneumonia that develops within 48 hours or more of mechanical ventilation. It is also associated with significant morbidity including increased ventilatory days, intensive care unit (ICU) stay and higher medical cost that leads to high mortality rate in ICU. Aim: To evaluate the clinical outcome of the patients diagnosed with VAP and also to identify the risk factors for VAP. Methodology: This retrospective study included 27 patients admitted in Medical and casualty ICU's from August 2013 to April 2014 who were diagnosed with various diseases and later developed VAP. The patient's demographic data and diagnosis based on Centres for Disease Control and prevention (CDC) criteria were collected. Results: Among 27 patients, 20 were male patients and 7 were female patients. The order of organism according to the frequency in the current study was found to be Acinectobacter, Klebsiella, Pseudomonas aeruginosa, methicillin resistant Staphylococcus aureus, Streptococcus pneumonia, Hemophilus influenza, Enterobacter sp. Twenty two patients had late onset VAP and five patients had early onset VAP. Overall the survival was 52%. Conclusion: The incidence and the mortality of VAP are high in the current ICU setup. The mortality rate in the current study was 48% and the patients who survived had a longer ICU stay due to ventilator dependence.

Microbial Pattern and their Sensitivity of Ventilator Associated Pneumonia in an Intensive Care Unit of a Ter-tiary Care Hospital in Dhaka

Background: ICU admission imposes great risk of nosocomial infections on the patients due to various invasive interventions. Patients treated in these units receive invasive procedures such as endotracheal intubation and mechanical ventilation which predispose to a nosocomial pneumonia of a special entity named as ‘Ventilator Associated Pneumonia’. Almost half of all the cases of hospital acquired pneumonia are due to VAP and about half of all antibiotics administration in ICU are for treatment of Ventilator Associated Pneumonia. Objectives: objective of the current study was to study the local microbiological profile of ventilator associated pneumonia and their sensitivity pattern in the Critical Care department of BIRDEM general hospital. Design: Cross-sectional study. Setting: ICU of an academic tertiary care hospital in the period of July 2017 to June 2018. Methods: All consecutive patients who were intubated and mechanically ventilated for a period of at least 48 hours within the study period were evaluated for the selection criteria of the study. The included study participants were followed up daily for signs of development of VAP. Once VAP was suspected pertinent investigations were sent to confirm the diagnosis. Tracheal aspirate was collected using conventional specimen trap and aseptic endotracheal suctioning technique and sent for Gram staining and culture and sensitivity testing. Results: In this study total 92 patients out of 625 intubated patients during the study period after fulfilling the inclusion criteria were selected as study participants. 35 participants out of 92developed VAP. Only 1 (2.9 %) patient did not yield any microbial growth in the tracheal aspirate sample and 34 (97.2 %) participants had growth of organisms in their tracheal aspirate samples. Total growths of 45 organisms were found in respiratory secretions of 34 VAP patients. The commonest organism was Acinetobacter which was grown in 21 (46.7%) samples followed by Pseudomonas in 10 (22.2%) samples; Klebsiella in 8 (17.8%) samples; Staphylococcus aureus in 3 (6.7%) samples; Candida in 2 (4.4%) and Enterococcus in 1 sample (2.2%). Most of the bacteria grown in the tracheal aspirates of VAP positive participants were sensitive to less than three antibiotic classes. Conclusion: Multidrug resistant organisms are mostly responsible for both early and late onset VAP in ICU. Bangladesh Crit Care J September 2022; 10(2): 122-126

Microbiological and Antibiotic Profile of Broncho-Alveolar Lavage Aspirate in Mechanically Ventilated Patients in a Tertiary Care Hospital

Introduction: VAP increases the patient stay in the ICU and indirectly increases the cost of patient management. Based on the time of onset of VAP, it can be divided into two types. Early-onset VAP occurs during the first four days of mechanical ventilation and is usually caused by antibiotic sensitive bacteria. Late-onset VAP develops five or more days after initiation of MV and is caused by multidrug-resistant (MDR) pathogens.5 Early diagnosis of VAP with appropriate antibiotic therapy can reduce the emergence of resistant organisms. Methods: This cross-sectional study was done in College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan after taking clearance from the institutional review committee. Study included all the patients who required mechanical ventilation for more than 72 hoursAll the included patients had their endotracheal tube aspirated using an ambu bronchoscope and sent to microbiology department for culture and sensitivity. The reports were collected after 72. Results: The most common organism grown during culture and gram staining were Acinetobacter Baumannii (81), followed by Klebsiella Peumoniae (44) than Pseudomonas Aeroginosa (32).. We observed a higher rate of culture positivity from the samples of male patients than those obtained from the female patients. Similar findings were observed by Morehead et al13and debjita debnath et al12 . In our study, gram-negative bacilli were the most commonly isolated pathogen from BAL which is similar to studies done by, debjita debnath, Fagon et al14 and Şimşek et al15. In our study, Acinetobacter Baumannii (81) was the most common followed by Klebsiella Peumoniae (44) than Pseudomonas Aeroginosa (32),first line of antibiotics in patients who were mechanically ventilated were piperacillin plus tazobactam, meropenem,cotrimoxazole, amikacin and gentamicin. The second line drugs were polymyxin B, colistimethate and tigecycline. Conclusions: Acinetobactor Baumanni is the most common causative organism of ventilator associated pneumonia. In most of the cases first line antibiotics ( meropenem, amikacin and clotrimoxazole) are sensitive. Among the second line antibiotics, Polymyxin B was found to be most effective.

Frequency and Outcome of Ventilator Associated Pneumonia in an Intensive Care Unit of a Tertiary Care Hospital in Dhaka

Background: Intubation and mechanical ventilation are integral parts of critical care management. Though a lifesaving intervention, invasive mechanical ventilation imposes a great risk of nosocomial pneumonia to the patient. Ventilator associated pneumonia rates in an ICU is a predictor of successful infection control strategy. Objectives: objective of the current study was to study the frequency of ventilator associated pneumonia and its outcome in the critical care setting. Methods: This prospective observational cross-sectional study was done in department of critical care medicine of BIRDEM General Hospital for the period of 1st July, 2017 to 30th June, 2018. All consecutive patients who were intubated and mechanically ventilated for a period of at least 48 hours within the study period were evaluated for the selection criteria of the study. The included study participants were followed up daily for signs of development of VAP. Once VAP was suspected pertinent investigations were sent to confirm the diagnosis. Study participants were observed regularly to identify signs of pulmonary infection. The microbiological tests were done in the Department of Microbiology of BIRDEM. Quantitative culture was done (expressed as CFU/ml) and antibiotic sensitivity was done by standard disc diffusion method. A cutoff value of 105 CFU/ml was taken as a positive culture. CPIS score was calculated to diagnose VAP .The study participants were followed up to transfer to step down unit/ward or death to see the outcome. Data were collected in preformed data collection sheet and analyzed by the statistical packages for social sciences (SPSS) software version 22. Results: In this study total 92 patients out of 625 intubated patients during the study period after fulfilling the inclusion criteria were selected as study participants. The mean age of the the participants who developed VAP was 65.05±14.79 years with a range of 27 to 101 years. 62.9% (n=22) were female and 37.1% (n=13) were male. In this study DM, HTN &amp; Renal disease were the most common co-morbidities. Among the 35 VAP positive participants 51.4% (n=18) developed early onset VAP and 48.6% (n=17) developed late onset VAP. Among the VAP positive participants 31.4% were survivors and 68.6% were non-survivors and among the VAP negative participants 68.4% were survivors and 31.6% were non survivors (p=0.001). Conclusion: Frequency of VAP was 5.6% in the study. It was associated with significantly prolonged length of mechanical ventilation and length of ICU stay and high mortality. Bangladesh Crit Care J March 2022; 10 (1): 43-47

Risk Factors and Protective Factors against Ventilator-Associated Pneumonia-A Single-Center Mixed Prospective and Retrospective Cohort Study.

Introduction: Understanding the factors associated with the development of ventilator-associated pneumonia (VAP) in critically ill patients in the intensive care unit (ICU) will allow for better prevention and control of VAP. The aim of the study was to evaluate the incidence of VAP, as well as to determine risk factors and protective factors against VAP. Design: Mixed prospective and retrospective cohort study. Methods: The cohort involved 371 critically ill patients who received standard interventions to prevent VAP. Additionally, patients in the prospective cohort were provided with continuous automatic pressure control in tapered cuffs of endotracheal or tracheostomy tubes and continuous automatic subglottic secretion suction. Logistic regression was used to assess factors affecting VAP. Results: 52 (14%) patients developed VAP, and the incidence density of VAP per 1000 ventilator days was 9.7. The median days to onset of VAP was 7 [4; 13]. Early and late onset VAP was 6.2% and 7.8%, respectively. According to multivariable logistic regression analysis, tracheotomy (OR = 1.6; CI 95%: 1.1 to 2.31), multidrug-resistant bacteria isolated in the culture of lower respiratory secretions (OR = 2.73; Cl 95%: 1.83 to 4.07) and ICU length of stay >5 days (OR = 3.32; Cl 95%: 1.53 to 7.19) were positively correlated with VAP, while continuous control of cuff pressure and subglottic secretion suction used together were negatively correlated with VAP (OR = 0.61; Cl 95%: 0.43 to 0.87). Conclusions: Tracheotomy, multidrug-resistant bacteria, and ICU length of stay >5 days were independent risk factors of VAP, whereas continuous control of cuff pressure and subglottic secretion suction used together were protective factors against VAP.

Analysis of risk factors for early-onset ventilator-associated pneumonia in a neurosurgical intensive care unit

BackgroundVentilator-associated pneumonia (VAP) is a severe infection among patients in the neurosurgery intensive care unit (NICU).MethodsWe retrospectively evaluated risk factors for early-onset ventilator-associated pneumonia (EOVAP) from January 2019 to December 2019 at a NICU. A total of 89 NICU patients who were intubated within 48 h of onset and whose mechanical ventilation time was at least 7 days were enrolled. We evaluated EOVAP that occurred within the first 7 days after the onset of mechanical ventilation. The enrolled patients had no history of chronic lung disease and no clinical manifestations of infection before intubation. Clinical data of patients were recorded, and the incidence of and risk factors for EOVAP were analyzed. Patients were also grouped by age (≥ 65 vs. < 65 years) and whether they had received hypothermia treatment or not.ResultsAmong 89 mechanically ventilated patients (49 men and 40 women; the mean age ± SD was 60.1 ± 14.3 years), 40 patients (44.9%) developed EOVAP within 7 days and 14 patients (15.7%) had a multidrug resistant bacterial infection. Binary logistic regression analysis indicated that older age (≥ 65 years) (odds ratio [OR]:3.53, 95% confidence interval [CI]:1.27–9.79, P = 0.015) and therapeutic hypothermia (OR:3.68, CI:1.10–12.31, p = 0.034) were independent predictors of EOVAP. Levels of peripheral blood leukocytes, neutrophils and platelets were lower in the therapeutic hypothermia group than those who did not receive hypothermia treatment.ConclusionsThis study found that older age (≥ 65 years) and therapeutic hypothermia were independently associated with the risk of EOVAP in NICU patients.

Automatic Continuous Control of Cuff Pressure and Subglottic Secretion Suction Used Together to Prevent Pneumonia in Ventilated Patients-A Retrospective and Prospective Cohort Study.

The ventilator bundle consists of multiple methods to reduce ventilator-associated pneumonia (VAP) rates in Intensive Care Units (ICU). The aim of the study was to evaluate how the continuous automatic pressure control in tapered cuffs of endotracheal/tracheostomy tubes applied along with continuous automatic subglottic secretion suction affect the incidence of VAP. In the prospective cohort (n = 198), the standard VAP bundle was modified by continuous automatic pressure control in taper-shaped cuff of endotracheal/tracheostomy tubes and subglottic secretion suction. VAP incidence, time to VAP onset, invasive mechanical ventilation days/free days, length of ICU stay, ICU mortality, and multidrug-resistant bacteria were assessed and compared to the retrospective cohort (n = 173) with the standard bundle (intermittent cuff pressure of standard cuff, lack of subglottic secretion suction). A smaller incidence of VAP (9.6% vs. 19.1%) and early onset VAP (1.5% vs. 8.1%) was found in the prospective compared to the retrospective cohort (p < 0.01). Patients in the prospective cohort were less likely to develop VAP (RR = 0.50; 95% CI: 0.29 to 0.85) and early-onset VAP (RR = 0.19; 95% CI: 0.05 to 0.64) and had longer time to onset VAP (median 9 vs. 5 days; p = 0.03). There was no significant difference (p > 0.05) between both cohorts in terms of invasive mechanical ventilation days/free days, length of ICU stay, ICU mortality and multidrug-resistant bacteria. Modification of the bundle for prevention of VAP can reduce early-onset VAP and total incidence of VAP and delay the time of VAP occurrence.

Emergence of blaNDM-1 and blaVIM producing Gram-negative bacilliin ventilator-associated pneumonia at AMR Surveillance Regional Reference Laboratory in India.

IntroductionVentilator-associated pneumonia (VAP) may be a life threatening nosocomial infection encountered in intensive care units. Currently the emergence of carbapenem-resistant Gram-negative pathogens has become worrisome threat worldwide.Material and methodsEndotracheal aspirates samples were collected from patients who were under mechanical ventilation for > 48 h. The bacterial isolates were identified by MALDI-TOF-MS and antibiotic susceptibility testing performed. All carbapenem resistant isolates were tested by Modified Hodge test (MHT), modified carbapenem inactivation method (mCIM), and EDTA-CIM (eCIM) and PCR were performed to detect blaIMP, blaVIM and blaNDM producing MBL genes.ResultsVAP occurred in 172/353(48.7%), 23.3% had early-onset VAP and 76.7% had late-onset VAP. Males (69.2%) were found to suffer more from VAP. Prior antibiotic therapy, CPI>6, prior surgery and tracheostomy were associated with VAP. The mortality in VAP (58.1%) contrasted with non-VAP (40%). 99/169 (58.6%) Gram-negative isolates were resistant to carbapenems. Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae were common pathogens found in late onset VAP, whereas K. pneumoniae, A. baumannii and Staphylococcus aureus were common in early onset VAP. The PCR results detected blaNDM in 37/172(21.5%) and blaVIM in 30/172(17.4%); 15/172(8.7%) isolates carried both genes.ConclusionThe blaNDM-1 and blaVIM genes are the main antibiotic-resistance genes that induce resistance patterns to carbapenems in VAP, highlighting CRE strains of potential public health concern and therapeutic challenge. Diagnostic laboratories in India must get on high caution for early MBL detection as it may limit the wide dispersal of MBL genes.

A STUDY OF VENTILATOR-ASSOCIATED PNEUMONIA, SURGICAL SITE INFECTION AND CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION: INCIDENCE, OUTCOME, RISK FACTORS AND MEASURES TO BE TAKEN FOR PREVENTION IN A TERTIARY CARE TEACHING HOSPITAL

Objective: Hospital-associated infections (HAIs) contribute to increased morbidity and mortality, excess healthcare cost, and prolonged hospital stay. This study aims to determine the incidence, risk factors of ventilator associated pneumonia (VAP), surgical site infection (SSI), and central line associated blood stream infection (CLABSI). Together it also assesses the knowledge and practice of nursing staff, physician in understanding HAIs and prevention, also to improve the core knowledge of administration procedures. Methods: A prospective study was conducted among patients, nurses, and doctors of Shamanur Shivashankarapa Institute of Medical Sciences and Research Center hospital for a period of about 6 months. The data were collected, analyzed in terms of both inferential and descriptive statistics. Results: The incidence rate of VAP was found to be 23.61%. VAP was more prominent in males and occurred more in patients who received prolonged ventilation, supine position, and altered mental status, and these risk factors was found to be statistically significant (p&lt;0.05). Acinetobacter was the commonly found causative organism for VAP. The mortality rate in our study was found to be 1 and was reported in early-onset VAP. SSI was more common in females and occurred mostly in elective surgeries with more comorbid conditions and American Society of Anesthesiologists score and these were found to be statistically significant (p&lt;0.05). MRCONS and Escherichia coli were the most common pathogen identified. Mortality rate in our study was zero and 15 patients were clinically well. The incidence rate of CLABSI was found to be 31.25%. Out of 32 centralized patients, only 10 developed CLABSI and is more prominent in males. Staphylococcus aureus was the common organism followed by E. coli. Mortality rate in our study was zero and all the patients became clinically well. From the questionnaire survey, all the doctors and nurses were aware of HAIs and the most common susceptible population according to them were inpatients and the most effective method to prevent HAIs is to wash hand properly, use gloves while doing procedures. Conclusion: VAP was more prominent followed by SSI and CLABSI. Study clearly indicates that educational interventions should be implemented to address the gaps regarding knowledge and practice of nurse and physicians.

Effect of oral care in reducing the incidence of early-onset ventilator-associated pneumonia in preterm infants.

Oral care using chlorhexidine has been considered useful in reducing the incidence of ventilator-associated pneumonia (VAP) in adult patients. However, no study has proved the effect of oral care in reducing the incidence of VAP in preterm infants. To investigate the efficacy of oral care using a sponge brush moistened with sterile water in reducing the bacterial load in the oral cavity and the incidence of early-onset VAP in preterm infants METHODS: The bacterial number in the oral cavity was evaluated on-site with the dielectrophoretic impedance measurement system. Bacterial numbers before and after oral care were investigated prospectively. Then, the incidence of early-onset VAP was compared retrospectively between infants who received oral care before re-intubation and those who did not. The mean bacterial number (cfu/ml) in the oral cavity in infants managed with endotracheal intubation (n = 23), continuous positive airway pressure (n = 38), and high-flow nasal cannula (n = 22) significantly reduced (p < .01) after versus before oral care (4.46 × 107 vs. 1.25 × 106 ; 1.32 × 107 vs. 6.82 × 105 ; and 1.68 × 107 vs. 6.50 × 105 ). The incidence rate of early-onset VAP after re-intubation was 51% (20/39) in patients who did not receive oral care. Then, it significantly decreased to 21% (7/33; p = .009) after receiving oral care. Oral care with sterile water may be effective in reducing the bacterial load in the oral cavity and the incidence of early-onset VAP in preterm infants.

Antimicrobial Susceptibility among Pathogens Isolated in Early- versus Late-Onset Ventilator-Associated Pneumonia.

Ventilator-associated pneumonia (VAP) is associated with increased hospital stay and high morbidity and mortality in critically ill patients. The aims of this study were to (i) determine the incidence of multidrug-resistant (MDR) pathogens in the first episodes of VAP and to assess potential differences in bacterial profiles of subjects with early- versus late-onset VAP. This was a retrospective cohort study over a period of 18 months including all patients who had a first episode of VAP confirmed by positive bacterial culture. Subjects were distributed into two groups according to the number of intubation days: early-onset VAP (<5 days) or late-onset VAP (≥5 days). The primary endpoint was the nature of causative pathogens and their resistance profiles. Sixty patients were included, 29 men and 31 women, with an average age of 38 ± 16 years. The IGS 2 at admission was 40.5 [32–44] and APACHE was 19 [15–22]. Monomicrobial infections were diagnosed in 77% of patients (n = 46). The most frequently isolated bacteria were A. baumannii, 53% (n = 32); P. aeruginosa in 37% (n = 22); Enterobacterales in 28% (n = 17) and S. aureus in 5% (n = 3). Ninety-seven percent of the bacteria were MDR. The VAP group comprised 36 (60%) episodes of early-onset VAP and 24 (40%) episodes of late-onset VAP. There was no significant difference in the distribution of the bacterial isolates, nor in terms of antibacterial resistances between early- and late-onset VAPs. Our data support recent observations that there is no microbiological difference in the prevalence of potential MDR pathogens or in their resistance profiles associated with early- versus late-onset VAPs, especially in countries with high rates of MDR bacteria.

Evaluation of Bacteria Causing Ventilator-Associated Pneumonia in Patients Admitted to Internal ICUs and Internal Wards at Shiraz Teaching Hospitals, 2017 - 2018

Background: Ventilator-associated pneumonia (VAP), a subset of hospital infections, occurs in patients who have been mechanically ventilated for at least 48 hours. Objectives: Our study aimed at determining the frequency and antibiotic susceptibility patterns of bacteria causing VAP in teaching hospitals of Shiraz. Methods: This was a descriptive cross-sectional study conducted in Shiraz for eight months (November 2017 to June 2018). Samples were detected according to diagnostic bacteriologic tests, and antibiotic susceptibility tests were performed by the disk diffusion (Kirby-Bauer) method based on the Clinical and Laboratory Standards Institute (CLSI). Results: A total of 51 patients with VAP were examined, of whom 10 and eight patients had a chronic obstructive pulmonary disease and acute respiratory distress syndrome, respectively. The late-onset VAP rate (61.7%) was higher than the early-onset VAP rate (38.3%). In our study, 45.2% of patients with VAP received antibiotics before the incidence of pneumonia, of whom 31.6% died. Of the remaining 54.8%, only 8.7% died. In other words, patients who received antibiotics before the incidence of pneumonia had higher mortality. The most frequently used antibiotics were meropenem (76.6%) and vancomycin (78.7%). Among 59 bacteria isolated, Acinetobacter and Pseudomonas were the most prevalent organisms. Conclusions: Our results showed that most of the isolates (40%) belonged to multi-drug resistant (MDR) pathogens. Probably, antimicrobial treatment before the onset of VAP led to the selection of these MDR pathogens.