Early Ventilator-associated Pneumonia Research Articles

Outcomes of High-Dose Versus Low-Dose Vitamin D on Prognosis of Sepsis Requiring Mechanical Ventilation: A Randomized Controlled Trial.

Background: Critically ill patients with sepsis have a high incidence of vitamin D deficiency. Vitamin D promotes the synthesis of human cathelicidin antimicrobial peptide, a precursor of LL-37, which is a part of the innate immune system. This study investigated the effectiveness and safety of the early administration of high-dose enteral vitamin D3 in comparison with low-dose vitamin D3 in patients with sepsis requiring mechanical ventilation (MV). Methods: Eighty adult patients with sepsis requiring MV with known vitamin D deficiency were randomly assigned to receive either an enteral 50 000 IU (Group I) or 5000 IU (Group II) vitamin D supplementation. Clinical and laboratory parameters were evaluated at baseline and on days 4 and 7 between the study groups. The change in serum procalcitonin (PCT) levels on day 7 was the primary outcome, while the change in serum LL-37 levels on day 7, changes in sequential organ failure assessment (SOFA) score, and clinical pulmonary infection score on day 7, MV duration, and hospital length of stay (LOS) were the secondary outcomes. Results: The (day 7-day 0) change in serum PCT and LL-37 levels and SOFA score were significantly different in Group I (P = .010, P < .001, and P < .001, respectively). The SOFA score was significantly different on days 4 and 7 in Group I (P < .001 and P < .001, respectively). The incidence of early ventilator-associated pneumonia was significantly different between both treatment groups (P = .025). The hospital LOS was shorter in Group I (P < .001). No 25-hydroxyvitamin-D toxicity was observed in either group. Conclusions: Early enteral administration of high-dose vitamin D3 in critically ill patients with sepsis requiring MV along with standard treatment for sepsis decreased serum procalcitonin levels, increased serum LL-37 levels, and ameliorated illness severity scores.

Evolution of Tracheobronchial Colonization Following Tracheal Intubation in Patients With Neurologic Injury Who Are Ventilated: The INSPIRE Study

BackgroundCharacteristics and course of endotracheal secretions have scarcely been studied in patients under mechanical ventilation (MV) at risk of developing ventilator-associated pneumonia (VAP). Research questionExhaustive description of endotracheal secretions and determination of their predictive value for the diagnosis of VAP during MV. Study design and methodsSingle-center prospective study in neuro-injured patients requiring MV for at least 7 days. Patients with pulmonary and infectious diseases were ineligible. All endotracheal aspirates (ETA) collected between tracheal intubation and Day7 were analyzed. Macroscopic characteristics and microbiology were assessed. CPIS was calculated daily. A blinded adjudication committee validated all VAP events. ResultsForty-eight patients and 1544 ETAs were analyzed. Overall, 81% of the ETA were purulent and 50% were thick. Culture results showed high inter- and intra-individual variability. Ten patients (21%) developed an early VAP. Eight patients (80%) with VAP and 14 (37%) without had a CPIS>6. The day before VAP diagnosis, a 20-mL increase in ETA volume detected a VAP with a sensitivity of 67% and a specificity of 93%. InterpretationOur study provides new information on the course of respiratory colonization in mechanically ventilated patients and suggests that ETA color and aspect, and pathogens kinetics cannot predict VAP. Traditional VAP criteria (CPIS and bacterial load) had also a low diagnostic specificity. Contrariwise, an increase in secretion volume should alert for VAP development.

Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial

Patients with acute brain injury are at high risk of ventilator-associated pneumonia (VAP). The benefit of short-term antibiotic prophylaxis remains debated. We aimed to establish the effect of an early, single dose of the antibiotic ceftriaxone on the incidence of early VAP in patients with severe brain injury who required mechanical ventilation. PROPHY-VAP was a multicentre, randomised, double-blind, placebo-controlled, assessor-masked, superiority trial conducted in nine intensive care units in eight French university hospitals. We randomly assigned comatose (Glasgow Coma Scale score [GCS] ≤12) adult patients (age ≥18 years) who required mechanical ventilation for at least 48 h after acute brain injury to receive intravenous ceftriaxone 2 g or placebo once within the 12 h following tracheal intubation. Participants did not receive selective oropharyngeal and digestive tract decontamination. The primary outcome was the proportion of patients developing early VAP from the 2nd to the 7th day of mechanical ventilation, confirmed by masked assessors. The analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew or did not give consent to continue and those who did not receive the allocated treatment because they met a criterion for non-eligibility. The trial is registered with ClinicalTrials.gov, NCT02265406. From Oct 14, 2015, to May 27, 2020, 345 patients were randomly assigned (1:1) to receive ceftriaxone (n=171) or placebo (n=174); 330 received the allocated intervention and 319 were included in the analysis (162 in the ceftriaxone group and 157 in the placebo group). 166 (52%) participants in the analysis were men and 153 (48%) were women. 15 patients did not receive the allocated intervention after randomisation and 11 withdrew their consent. Adjudication confirmed 93 cases of VAP, including 74 early infections. The incidence of early VAP was lower in the ceftriaxone group than in the placebo group (23 [14%] vs 51 [32%]; hazard ratio 0·60 [95% CI 0·38-0·95], p=0·030), with no microbiological impact and no adverse effects attributable to ceftriaxone. In patients with acute brain injury, a single ceftriaxone dose decreased the risk of early VAP. On the basis of our findings, we recommend that an early, single dose of ceftriaxone be included in all bundles for the prevention of VAP in patients with brain injury who require mechanical ventilation. French Ministry of Social Affairs and Health.

CLINICAL CHARACTERISTICS AND OUTCOME OF VENTILATOR ASSOCIATED PNEUMONIA IN PATIENTS WITH RENAL FAILURE

Background: Ventilator associated pneumonia (VAP) causes significant morbidity and mortality. Data from patients with preexisting renal failure is limited. Our aim was to evaluate the clinical characteristics and outcome of VAP in patients with renal failure and/or on maintenance hemodialysis. Material and Methods: A prospective observational study was conducted from February 2022 to February 2023. Patients &gt;18 years, on mechanical ventilation (MV) for &gt;48 hours, having underlying deranged renal function and who developed VAP were included. Demographics, cause of intubation, day of onset of VAP, clinical features, laboratory parameters and tracheal cultures were noted. Patients were followed till day 14 of VAP for mortality. Results: Out of 165 MV patients, 67 (40.60%) developed VAP, 33 (49.25%) in ≤ 4 days. The cause of intubation was respiratory distress in 58(86.8%) patients. In 61(91%) patients tracheal cultures were positive with Acinetobacter species (64%) as the most common organism and 93% of which were carbapenem resistant. Carbapenem resistant organisms were more frequently in case of late onset VAP (91.2% versus 72.7% p=0.049). A total of 42 patients (62%) died, 76 % within 7 days of VAP and 13 patients (19.40%) recovered with successful extubation. There was no significant difference in 14 days mortality between early or late VAP. Conclusion: VAP rates in patients with preexisting renal failure were 40%. Half of them developed in &lt;4 days. Acinetobacter spp. was the predominant causative agent. Attributed mortality was high at 63% where two thirds of patients died within 14 days. Keywords: Outcome, Renal failure, Ventilator associated pneumonia, Mechanical ventilator

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

Background &#x0D; 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.&#x0D; Objectives &#x0D; 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. &#x0D; Patients and Methods&#x0D; 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.&#x0D; Results&#x0D; 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%). &#x0D; Conclusion&#x0D; ETA can be a reliable, non-invasive alternative to BAL in VAP diagnosis associated with rapid and relatively accurate results.

Epidemiology, risk factors and prognosis of ventilator-associated pneumonia during severe COVID-19: Multicenter observational study across 149 European Intensive Care Units

BackgroundCOVID-19 patients requiring mechanical ventilation are particularly at risk of developing ventilator-associated pneumonia (VAP). Risk factors and the prognostic impact of developing VAP during critical COVID-19 have not been fully documented. MethodsPatients invasively ventilated for at least 48 h from the prospective multicentre COVID-ICU database were included in the analyses. Cause-specific Cox regression models were used to determine factors associated with the occurrence of VAP. Cox-regression multivariable models were used to determine VAP prognosis. Risk factors and the prognostic impact of early vs. late VAP, and Pseudomonas-related vs. non-Pseudomonas-related VAP were also determined. Main findings3388 patients were analysed (63 [55–70] years, 75.8% males). VAP occurred in 1523/3388 (45.5%) patients after 7 [5–9] days of ventilation. Identified bacteria were mainly Enterobacteriaceae followed by Staphylococcus aureus and Pseudomonas aeruginosa. VAP risk factors were male gender (Hazard Ratio (HR) 1.26, 95% Confidence Interval [1.09–1.46]), concomitant bacterial pneumonia at ICU admission (HR 1.36 [1.10–1.67]), PaO2/FiO2 ratio at intubation (HR 0.99 [0.98–0.99] per 10 mmHg increase), neuromuscular-blocking agents (HR 0.89 [0.76–0.998]), and corticosteroids (HR 1.27 [1.09–1.47]). VAP was associated with 90-mortality (HR 1.34 [1.16–1.55]), predominantly due to late VAP (HR 1.51 [1.26–1.81]). The impact of Pseudomonas-related and non-Pseudomonas-related VAP on mortality was similar. ConclusionVAP affected almost half of mechanically ventilated COVID-19 patients. Several risk factors have been identified, among which modifiable risk factors deserve further investigation. VAP had a specific negative impact on 90-day mortality, particularly when it occurred between the end of the first week and the third week of ventilation.

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.

Effects of systemic antibiotics in early onset ventilator-associated pneumonia in trauma patients: A single-centre retrospective cohort study

Background: Ventilator-associated pneumonia is one of the commonest complications encountered in intubated patients: its incidence ranges from 20% to 60%, with higher incidences seen in patients with polytrauma. Ventilator-associated pneumonia can result in poor neurological outcomes upon discharge, longer duration of mechanical ventilation and prolonged intensive care unit stays. The use of systemic antibiotics has been proposed as one method to reduce this complication. However, its effectiveness remains to be determined, and concerns about bacterial resistance hinder its use. This study aims to evaluate the effects of systemic antibiotics on early ventilator-associated pneumonia prevention. Methods: This is a single-centred retrospective cohort study, using data in the local trauma registry from 2015 to 2020. Patients aged ⩾18 years who suffered from injury to the head or trunk and were intubated within 12 h of hospitalization were evaluated for early ventilator-associated pneumonia to determine the effectiveness of systemic antibiotics on the incidence of ventilator-associated pneumonia and to identify other risk factors for ventilator-associated pneumonia in patients suffering from trauma. Result: A total of 250 patients were recruited; 59 of them met the criteria for early onset ventilator-associated pneumonia. Early use of broad-spectrum antibiotics with potent anaerobic coverage was found to be protective for early onset ventilator-associated pneumonia (adjusted odds ratio = 0.228, p = 0.044). Increasing age and severe thoracic or abdominal injury were also found to be strong non-modifiable predictors for the development of early onset ventilator-associated pneumonia. Conclusion: Use of systemic antibiotics with potent anaerobic coverage within 3 h of injury was found to prevent early onset ventilator-associated pneumonia in those intubated within 12 h of injury. However, a large-scale randomized control trial may be needed to further evaluate its benefit and its potential side effects, most notably the risk of antibiotic resistance.

Incidence and Risk Factors Association for Ventilator Associated Pneumonia in Neontal Intensive Care Unit

Introduction: Ventilator Associated Pneumonia (VAP), the nosocomial pneumonia developing in mechanically ventilated patients after 48 hours of mechanical ventilation, is the second commonest nosocomial infection in the neonatal intensive care unit (NICU). VAP occurring within 96 hours of initiation of mechanical ventilation is termed as early VAP and later than that is known as late VAP. The aim of this study was to determine the incidence rate and risk factors of early and late ventilator associated pneumonia in NICU. Methods: The study was conducted from December 2015 to November 2017 in which 40 neonates were ventilated for more than 48 hours of which those who developed VAP as per CDC criteria were enrolled in the study. Birth weight, gestation age, reintubation if needed and number of days of ventilation were noted. Statistical associations were further evaluated between various parameters of VAP and time of development of VAP. Results: Incidence of Early VAP was 12.5% and that of Late VAP was 87.5%. 93.95% neonates who were reintubated developed VAP. Duration of mechanical ventilation and re-intubation were significantly associated with the time of development of VAP. Birth weight and gestation age were statistically insignificant factors in determining VAP. Conclusions: Re-intubation and duration of mechanical ventilation are a significant risk factor for development of late VAP. Gestation age and birth weight have been identified as additional risk factors. Early diagnosis is necessary for appropriate treatment and decreased hospital stay.

Efficacy of High-Dose Vitamin C Infusion on Outcomes in Sepsis Requiring Mechanical Ventilation: A Double-Blind Randomized Controlled Trial.

Background Critically ill patients have an increased requirement for vitamin C in sepsis and these patients have low levels of vitamin C. The researchers validated the efficacy of high-dose vitamin C intravenous infusion (IVI) in patients with sepsis requiring mechanical ventilation. Methods Forty patients were randomly assigned to 2 groups (20 each) in a 1 : 1 ratio in accordance with the vitamin C treatment regimen: Group I (GI): patients received 1.5 g/6 h vitamin C in 50 ml of dextrose 5% in water (D5W) IVI over 30 minutes for 4 consecutive days; Group II (GII): patients received 100 mg vitamin C/day as a first single dose in 50 ml of D5W IVI over 30 minutes and the other three subsequent doses were 50 ml of plain D5W IVI over 30 minutes for 4 consecutive days. Primary outcomes were the change in sequential organ failure assessment (SOFA) score at day 7, the incidence of ventilator-associated pneumonia (VAP), and the plasma vitamin C level. The glutathione peroxidase (GPX) activity, C-reactive protein (CRP) level, duration of vasopressor therapy, and 28-day mortality were secondary outcomes. Results The change in SOFA score at day 7 showed a significant difference between GI and GII (p < 0.001). The incidence of early VAP was significantly lower in GI (p=0.044). Vitamin C levels showed a significant rise in GI at day 1 and day 4 (p < 0.001 and p < 0.001, respectively). GPX activity of day 4 and day 7 was significantly higher in GI (p=0.005 and p=0.014, respectively). CRP levels of day 4 and day 7 were significantly higher in GII (p < 0.001 and p < 0.001, respectively). There was a significant difference in 28-day mortality (p=0.038) and duration of vasopressor therapy (p=0.033) in GI compared to GII. Conclusion The early use of high-dose vitamin C intravenous infusion in patients with sepsis requiring mechanical ventilation in combination with the standard treatment for sepsis lowered the incidence of VAP, increased the antioxidant status, and improved the illness severity. Trial Registration. This trial is registered with ClinicalTrials.gov Identifier (NCT04029675).

To study the ventilator associated pneumonia in the ICU patients in a tertiary care hospital: Incidence, risk factors and etiological agents

Ventilator Associated Pneumonia (VAP) is the second most common nosocomial infection in the United States, with high mortality and morbidity. Duration of hospital stay increased in average of 7 to 9 days with increase in treatment cost of $40,000 per patient. However, clinical evidence on the incidence of this infection is poor, especially from ICUs in India. : To study the incidence, risk factors and etiological agents in ICU patients developing VAP in a tertiary care hospital in India.In this study, patients who were kept on ventilator for more than 48 hours in ICU were enrolled. To clinically diagnose VAP, the modified clinical pulmonary infection score (CPIS) and clinical criteria were used as a screening tool. A full clinical history of the patients was documented, as well as the date of admission to the ICU, the date of initiation of mechanical ventilation, and the method of access to the patients' airway. A standard PROFORMA was used and the collected data was observed and analysed further. : In the present study out of 45 patients enrolled for the study, only 6 patients (13.3%) showed VAP. The presence of early VAP was observed in 3 patients whereas late VAP was also observed in 3 patients. The male and female patients exhibited similar incidences of VAP. The patients with an age group more than 70 years showed a maximum (37.5%) prevalence of VAP. Clinical features like fever and increased amount of secretions were found to be associated with the occurrence of VAP. Smoking and diseases like hypertension, kidney disease, malignancy and chronic lung disease were non-significantly associated with VAP. Whereas disease states like coma and enteral nutrition were found to be significantly associated with VAP. Acinetobacter and Klebsiella were the most common organisms isolated in our institution.: VAP remains a significant concern to patients admitted to an ICU for mechanical ventilation, highlighting the critical need for preventive measures.

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.

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.

Ventilator-associated pneumonia: Outcome in pediatric intensive care unit of a tertiary care center

Background: The profile and pattern of ventilator-associated pneumonia (VAP) varies among different settings, depending on the definition, the type of hospital or intensive care unit (ICU), the population studied, and the level of antibiotic exposure. Aim: We aimed to study the profile and pattern of VAP among mechanically ventilated children admitted to a pediatric ICU. Methods: Critically ill children aged 1 month to 12 years of age, who received mechanical ventilation and developed VAP, were included in the study. The VAP was diagnosed using the Clinical Pulmonary Infection Score. The Pediatric Index of Mortality 3 (PIM-3) was also calculated. Categorization of diagnosis was done based on PIM-3 guidelines. The mean length of stay duration of mechanical ventilation was also noted down. Results: The incidence of VAP in the present study was 37.78%. PIM-3 was 2.24. The mean length of stay in cases of early VAP was 8.14 days, whereas it was 20.3 days in late VAP. Two important conditions that led to the development of VAP were respiratory conditions (33.33%) and neurological conditions (27.45%). Liver injury and renal injury were noted in 14 (27.5%) and 10 (19.6%) patients. Significant differences were observed in the mean length of stay and in cases of reintubation. The three most common organisms seen were methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter, and Klebsiella along with Pseudomonas, whereas among nonsurvivors, they were Candida, Citrobacter, Enterococcus spp., methicillin-resistant coagulase-negative staphylococci, and Streptococcus. Conclusion: VAP is a common entity among ventilated children. Cases of late VAP face a longer length of stay on mechanical ventilation. Parenteral nutrition and the presence of nasogastric tubing were significantly associated with late-onset VAP as compared to early VAP. Three most common organisms seen were MRSA, Acinetobacter, and Klebsiella along with Pseudomonas.

Role of colonizers and value of routine surveillance culture of endotracheal aspirate of patients in the diagnosis of ventilator associated pneumonia

Background: Ventilator associated pneumonia (VAP) is considered to be second most common nosocomial infection patients requiring critical care.&#x0D; Aims and Objective: The present study was conducted to study the role of colonizers and importance of surveillance cultures of endotracheal aspirate (ETA) in the diagnosis of ventilator associated pneumonia in a tertiary care hospital in Lucknow.&#x0D; Materials and Methods: An observational longitudinal study was conducted over a period of 2 years, on a total of 210 critically ill patients on mechanical ventilation for &gt;48hrs, to identify the common isolates from ETA culture. Follow up of such patients was done to know the role of these isolates in causation of Ventilator Associated Pneumonia (VAP). Patients fulfilling both clinical Pulmonary infection score (CPIS&gt;6) and microbiological criteria were diagnosed as VAP. Those microorganisms with a colony count of less&lt;105 cfu/ml in both the patients with VAP and those without VAP were considered as colonizers.&#x0D; Results: Klebseilla pneumonia (46.2%), Pseudomonas aeruginosa (16.2%) and E.coli (13.8%) were found be the commonest colonisers followed by Acinetobacterbaumanii (8.6%), Citrobacterkoseri (3.8%), Coagulase Negative Staphylococci (2.9%), Staphylococcus aureus (2.4%) and Proteus vulgaris (1%). Of the total patients 28 developed VAP out of which 21 had late onset VAP and 7 had early onset VAP. Among the VAP positive patients the causative organism was Klebsiella pneumonia (53.6%) for majority of cases followed by Pseudomonas aeruginosa (21.4%) and Acinetobacter baumanii (17.9%).&#x0D; Conclusion: Prolonged duration of mechanical ventilation increased the chances of colonization by MDR microorganisms leading to nosocomial or Hospital acquired infections (HAI) such as VAP which in turn lead to increased rate of morbidity and mortality. VAP considered to be a leading cause of HAI, routine quantitative surveillance culture of ETA(endotracheal aspirate) will allow prospectively to determine prevalence and progression of colonization in lower respiratory tract, so that strict and prompt preventive measures can be taken rather than cure.

Lung ultrasound score to monitor COVID-19 pneumonia progression in patients with ARDS.

COVID-19 pneumonia typically begins with subpleural ground glass opacities with progressive extension on computerized tomography studies. Lung ultrasound is well suited to this interstitial, subpleural involvement, and it is now broadly used in intensive care units (ICUs). The extension and severity of lung infiltrates can be described numerically with a reproducible and validated lung ultrasound score (LUSS). We hypothesized that LUSS might be useful as a tool to non-invasively monitor the evolution of COVID-19 pneumonia at the bedside. LUSS monitoring was rapidly implemented in the management of our COVID-19 patients with RT-PCR-documented COVID-19. The LUSS was evaluated repeatedly at the bedside. We present a graphic description of the course of LUSS during COVID-19 in 10 consecutive patients admitted in our intensive care unit with moderate to severe ARDS between March 15 and 30th. LUSS appeared to be closely related to the disease progression. In successfully extubated patients, LUSS decreased and was lower than at the time of intubation. LUSS increased inexorably in a patient who died from refractory hypoxemia. LUSS helped with the diagnosis of ventilator-associated pneumonia (VAP), showing an increased score and the presence of new lung consolidations in all 5 patients with VAPs. There was also a good agreement between CT-scans and LUSS as for the presence of lung consolidations. In conclusion, our early experience suggests that LUSS monitoring accurately reflect disease progression and indicates potential usefulness for the management of COVID-19 patients with ARDS. It might help with early VAP diagnosis, mechanical ventilation weaning management, and potentially reduce the need for X-ray and CT exams. LUSS evaluation is easy to use and readily available in ICUs throughout the world, and might be a safe, cheap and simple tool to optimize critically ill COVID-19 patients care during the pandemic.

Impact of Oral Care and Antisepsis on the Prevalence of Ventilator-Associated Pneumonia.

This study aimed to evaluate the impact of oral care and use of chlorhexidine gluconate on the prevention of ventilator-associated pneumonia (VAP) in patients admitted to an intensive care unit (ICU). An evaluation was performed on 229 patients admitted to ICU in 2012 (before implementation of oral care protocol) and 329 in 2013 (after the protocol). Oral care was based on the removal of secretions from the oral cavity with 0.12% chlorhexidine solution for brushing and sterile gauze for cleaning before a new aspiration. The cases of VAP were evaluated by observing respiratory signs, radiological changes, and culture and laboratory results. The following data were also analysed: gender, length hospital of stay, mechanical ventilation, use of antibiotics and aetiological agent of infection. There was a tendency towards lower risk of development of VAP after application of oral care protocol (odds ratio = 0.64-95% CI: 0.39-1.04). There was also a reduction in the incidence of early pneumonia (up to 72 h of hospitalisation). With regard to the aetiological agent of infections, although Gram-negative bacteria predominated in the two periods studied, there was a decrease in the cases of Staphylococcus aureus infection. Oral care protocol has statistically significantly reduced the risk of developing early VAP in ICU patients, thus demonstrating the importance of multidisciplinary teamwork for hospitalised patients.

Does a 2-Day Course of Antibiotics Lower the Incidence of Ventilator-associated Pneumonia in Patients Undergoing Targeted Temperature Management Following Cardiac Arrest?

Synopsis: This double-blind, randomized control trial evaluated the efficacy of a 2-day course of amoxicillin-clavulanate in reducing the incidence of early ventilator-associated pneumonia in patients undergoing targeted temperature management following an out-of-hospital cardiac arrest with initial shockable rhythm. There was a significant reduction in the incidence of early ventilator-associated pneumonia in the treatment group when compared with placebo, but no reduction in ventilator-free days or mortality at day 28. Source: Francois B, Cariou A, Clere-Jehl R, et al. Prevention of early ventilator-associated pneumonia after cardiac arrest. N Engl J Med. 2019;381:1831–1842.

Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest

BackgroundPatients who are treated with targeted temperature management after out-of-hospital cardiac arrest with shockable rhythm are at increased risk for ventilator-associated pneumonia. The benefit of preventive short-term antibiotic therapy has not been shown.MethodsWe conducted a multicenter, double-blind, randomized, placebo-controlled trial involving adult patients (>18 years of age) in intensive care units (ICUs) who were being mechanically ventilated after out-of-hospital cardiac arrest related to initial shockable rhythm and treated with targeted temperature management at 32 to 34°C. Patients with ongoing antibiotic therapy, chronic colonization with multidrug-resistant bacteria, or moribund status were excluded. Either intravenous amoxicillin–clavulanate (at doses of 1 g and 200 mg, respectively) or placebo was administered three times a day for 2 days, starting less than 6 hours after the cardiac arrest. The primary outcome was early ventilator-associated pneumonia (during the first 7 days of hospitalization). An independent adjudication committee determined diagnoses of ventilator-associated pneumonia.ResultsA total of 198 patients underwent randomization, and 194 were included in the analysis. After adjudication, 60 cases of ventilator-associated pneumonia were confirmed, including 51 of early ventilator-associated pneumonia. The incidence of early ventilator-associated pneumonia was lower with antibiotic prophylaxis than with placebo (19 patients [19%] vs. 32 [34%]; hazard ratio, 0.53; 95% confidence interval, 0.31 to 0.92; P=0.03). No significant differences between the antibiotic group and the control group were observed with respect to the incidence of late ventilator-associated pneumonia (4% and 5%, respectively), the number of ventilator-free days (21 days and 19 days), ICU length of stay (5 days and 8 days if patients were discharged and 7 days and 7 days if patients had died), and mortality at day 28 (41% and 37%). At day 7, no increase in resistant bacteria was identified. Serious adverse events did not differ significantly between the two groups.ConclusionsA 2-day course of antibiotic therapy with amoxicillin–clavulanate in patients receiving a 32-to-34°C targeted temperature management strategy after out-of-hospital cardiac arrest with initial shockable rhythm resulted in a lower incidence of early ventilator-associated pneumonia than placebo. No significant between-group differences were observed for other key clinical variables, such as ventilator-free days and mortality at day 28. (Funded by the French Ministry of Health; ANTHARTIC ClinicalTrials.gov number, NCT02186951.)

Ventilator-associated pneumonia in Coronary Care Unit of a tertiary level hospital in Bangladesh: causative organisms and pattern of antibiotic sensitivity

Background: Ventilator-Associated Pneumonia (VAP) is a frequent nosocomial infection. The etiology of VAP varieswith different patient populations and types of critical care settings.&#x0D; Materials &amp; methods: This prospective observational study was conducted at the Coronary Care Unit (CCU) ofIbrahim Cardiac Hospital &amp; Research Institute from April 2016 to November 2016. Demographic details andincidence of VAP was recorded and analysed by appropriate statistical tests.&#x0D; Results: 52 patients required mechanical ventilation, of whom 19 (36.5%) developed VAP. 15 (78.9%) had early VAP,while 4 (21.2%) had late VAP. CPIS, Modified CPIS and APACHE II Score- all were significantly higher among thosewho developed VAP (p&lt;0.01). The most frequent indication for intubation among those who developed VAP was type Irespiratory failure (57.9%), type II respiratory failure (15.8%) and post-cardiac arrest (26.3%). Acinetobacter (31.6%)was the commonest organism isolated on tracheal aspirate, followed by Pseudomonas (21.05%), Candida (21.05%)and Klebsiella (10.5%). Acinetobacter, Klebsiella and MRSA were the organisms isolated from tracheal aspirates ofthose with late onset VAP. Acinetobacter was mostly sensitive to Colistin, 80% of Pseudomonas is also sensitive tosame. A number of organisms were resistant to Amikacin and Imipenem.&#x0D; Conclusion: The commonest organism responsible for VAP in our CCU was Acinetobacter, which was largely sensitiveto Colistin. The emergence of antibiotic resistance of microorganisms causing VAP is a matter of serious concern inthis study. Regular surveillance of antibiotic susceptibility pattern is very important to prevent multi-resistant bacterialinfections.&#x0D; Bangladesh Crit Care J September 2019; 7(2): 73-76