Episodes Of Ventilator-associated Pneumonia Research Articles

Ventilator-associated pneumonia risk factors in patients with severe COVID-19 in southern Brazil: A retrospective observational study

BackgoundDuring the SARS-CoV-2 pandemic, a significant number of critical patients required ventilatory assistance in health institutions. In this context, Ventilator-Associated Pneumonia (VAP) was the most prevalent nosocomial infection among critically ill patients. We aimed to analyze the occurrence of VAP in critically ill patients with SARS-CoV-2 and the risk factors associated with the outcome. MethodThis is a multicenter, retrospective cohort study which included patients ≥18 years old, diagnosed with COVID-19, admitted to intensive care units (ICU) and who received invasive mechanical ventilation (MV) for >2 consecutive days. The associations between the variables were initially tested, and those that showed potential associations (p<0.05) were included in the multivariate logistic regression model. ResultsOne third of patients had an episode of VAP, with an incidence density of 34.97 cases per 1000 MV days. In addition, 42.37% (50) of the microorganisms causing VAP were multidrug-resistant, predominantly gram-negative bacteria (61.32%). More than 50% of participants developed healthcare-associated infections and 243 (73.64%) died. The factors associated with greater chances of VAP were: prone position (OR= 3.77), BMI 25-29.9 kg/m2 (OR= 4.76), pressure injury (OR= 4.41), length of stay in the ICU (OR= 1.06), positive tracheal aspirate before VAP (OR= 5.41) and dyspnea (OR= 3.80). ConclusionsPatients with COVID-19 are at high risk of VAP, which leads to an increased risk of death (OR = 2.18). Multiple factors increase the chances of VAP in this population, namely: work overload in health institutions, prone position, prolonged ICU time, infusion of multiple drugs, invasive devices, and in particular, immobility in bed.

Recurrent ventilator-associated pneumonia in severe Covid-19 ARDS patients requiring ECMO support

ObjectiveTo describe ventilator-associated pneumonia (VAP) recurrence in COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support, and to evaluate the impact of antimicrobial treatment duration of the first VAP episode on VAP recurrence.MethodsAdult patients with COVID-19 severe pneumonia on ECMO admitted between March 2020 and January 2022 were retrospectively included. Primary outcome was incidence of VAP recurrence, and secondary outcome was the impact of duration of antimicrobial treatment on VAP recurrence.ResultsAmong the 252 included patients, 226 (90%) developed a first VAP. Sixteen had lung abscess and were excluded, leaving 210 patients. VAP recurrence occurred in 172 patients (82%), with a median (IQR) time from first VAP to recurrence of 10 (7–13) days. Pseudomonas aeruginosa and Enterobacteriaceae were respectively responsible for 28% and 52% of first VAP, and 51% and 62% of first recurrence episodes. Among the 210 patients with a first VAP, 158 (75%) received a short course of antibiotics [< 8 days, median (IQR) duration 6 (5–7) days] and 52 (25%) received a prolonged course of antibiotics [≥ 8 days, median (IQR) duration 9 (8–10) days]. Estimated cumulative incidence of VAP recurrence, taking into account death and extubation as competing risks, was not different in patients with short– and prolonged–antimicrobial treatment.ConclusionsIn patients with severe Covid-19–ARDS requiring ECMO support, VAP recurrence occurs frequently, with Enterobacteriaceae and Pseudomonas aeruginosa as predominant causative microorganisms. An antimicrobial treatment of ≥ 8 days for the treatment of first VAP episode did not reduce the risk of VAP recurrence, as compared to shorter duration.

Ventilator-associated pneumonia related to extended-spectrum beta-lactamase producing Enterobacterales during severe acute respiratory syndrome coronavirus 2 infection: risk factors and prognosis

BackgroundPatients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) and requiring mechanical ventilation suffer from a high incidence of ventilator associated pneumonia (VAP), mainly related to Enterobacterales. Data regarding extended-spectrum beta-lactamase producing Enterobacterales (ESBL-E) VAP are scarce. We aimed to investigate risk factors and outcomes of ESBL-E related VAP among critically ill coronavirus infectious disease-19 (COVID-19) patients who developed Enterobacterales related VAP.Patients and methodsWe performed an ancillary analysis of a multicenter prospective international cohort study (COVID-ICU) that included 4929 COVID-19 critically ill patients. For the present analysis, only patients with complete data regarding resistance status of the first episode of Enterobacterales related VAP (ESBL-E and/or carbapenem-resistant Enterobacterales, CRE) and outcome were included.ResultsWe included 591 patients with Enterobacterales related VAP. The main causative species were Enterobacter sp (n = 224), E. coli (n = 111) and K. pneumoniae (n = 104). One hundred and fifteen patients (19%), developed a first ESBL-E related VAP, mostly related to Enterobacter sp (n = 40), K. pneumoniae (n = 36), and E. coli (n = 31). Eight patients (1%) developed CRE related VAP. In a multivariable analysis, African origin (North Africa or Sub-Saharan Africa) (OR 1.7 [1.07–2.71], p = 0.02), time between intubation and VAP (OR 1.06 [1.02–1.09], p = 0.002), PaO2/FiO2 ratio on the day of VAP (OR 0.997 [0.994–0.999], p = 0.04) and trimethoprim-sulfamethoxazole exposure (OR 3.77 [1.15–12.4], p = 0.03) were associated with ESBL-E related VAP. Weaning from mechanical ventilation and mortality did not significantly differ between ESBL-E and non ESBL-E VAP.ConclusionESBL-related VAP in COVID-19 critically-ill patients was not infrequent. Several risk factors were identified, among which some are modifiable and deserve further investigation. There was no impact of resistance of the first Enterobacterales related episode of VAP on outcome.

Estimation of Additional Costs in Patients with Ventilator-Associated Pneumonia.

Healthcare-associated infections (HAIs) present a global public health challenge, contributing to high morbidity and mortality and substantial economic burdens. Ventilator-associated pneumonia (VAP) ranks as the second most prevalent HAI in intensive care units (ICUs), emphasizing the need for economic analyses in this context. This retrospective cohort study, conducted at the General Hospital of Alicante from 2012 to 2019, aimed to assess additional costs related to VAP by comparing the extended length of stay for infected and non-infected ICU patients undergoing mechanical ventilation (MV) for more than 48 h. Employing propensity score association, 434 VAP patients were compared to an equal number without VAP. The findings indicate a significantly longer mechanical ventilation period for VAP patients (17.40 vs. 8.93 days, p < 0.001), resulting in an extra 13.56 days of stay and an additional cost of EUR 20,965.28 per VAP episode. The study estimated a total cost of EUR 12,348,965.28 for VAP during the study period, underscoring the economic impact of VAP. These findings underscore the urgent need for rigorous infection surveillance, prevention, and control measures to enhance healthcare quality and reduce overall expenditures.

Clinical and microbiological evaluation of ventilator-associated pneumonia in an intensive care unit in Vietnam

The increasing incidence of multidrug-resistant Gram-negative bacteria causing ventilator-associated pneumonia (VAP) is a global concern. A better understanding of the epidemiology of VAP in Southeast Asia is essential to optimise treatments and patient outcomes. VAP epidemiology in an intensive care unit in Vietnam was investigated. A prospective cohort study was conducted. Patients who were ventilated for >48 hours, diagnosed with VAP, and had a positive respiratory culture between October 2015 and March 2017 were included. Whole-genome sequencing (WGS) was performed on Acinetobacter baumannii isolates. We identified 125 patients (137 episodes) with VAP from 1,699 admissions. Twelve patients had 2 VAP episodes. The median age was 60 years (interquartile range: 48-70), and 68.8% of patients were male. Diabetes mellitus was the most frequent comorbidity (N=35, 28%). Acinetobacter baumannii was most frequently isolated in the first VAP episode (N=84, 67.2%) and was multiply resistant to meropenem, levofloxacin, and amikacin. The 30-day mortality rate was 55.2% (N=69) and higher in patients infected with A.baumannii (N=52, 65%). WGS results suggested a complex spread of multiple clones. In an intensive care unit in Vietnam, VAP due to A.baumannii had a high mortality rate, and A.baumannii and K.pneumoniae were multidrug resistant, with carbapenem resistance of 97% and 70%, respectively.

Lung abscess following ventilator-associated pneumonia during COVID-19: a retrospective multicenter cohort study

BackgroundPatients undergoing mechanical ventilation (MV) for COVID-19 exhibit an increased risk of ventilator-associated pneumonia (VAP). The occurrence of lung abscesses following VAP in these patients has been poorly studied. We aimed to describe the incidence, characteristics, risk factors and prognosis of lung abscesses complicating VAP after COVID-19.MethodsWe conducted an observational, retrospective study in three French intensive care units. Patients admitted for acute respiratory failure with a confirmed SARS-CoV-2 PCR and requiring MV for more than 48 h were included.ResultsAmong the 507 patients included, 326 (64%) had a documented VAP. Of these, 23 (7%) developed a lung abscess. Enterobacterales (15/23, 65%) were the main documentation, followed by non-fermenting Gram-negative bacilli (10/23, 43%) and Gram-positive cocci (8/23, 35%). Lung abscesses were mainly plurimicrobial (15/23, 65%). In multivariate analysis, a plurimicrobial 1st VAP episode (OR (95% CI) 2.93 (1.16–7.51); p = 0.02) and the use of hydrocortisone (OR (95% CI) 4.86 (1.95–12.1); p = 0.001) were associated with lung abscess development. Intensive care unit (ICU) mortality of patients with lung abscesses reached 52%, but was not significantly higher than for patients with VAP but no lung abscess. Patients with lung abscesses had reduced ventilator-free days at day 60, a longer duration of MV and ICU stay than patients with VAP but no lung abscess (respectively, 0 (0–3) vs. 16 (0–42) days; p < 0.001, 49 (32–73) vs. 25 (11–41) days; p < 0.001, 52 (36–77) vs. 28 (16–47) days; p < 0.001).ConclusionsLung abscessing pneumonia is not uncommon among COVID-19 patients developing VAP. A plurimicrobial first VAP episode and the use of hydrocortisone are independently associated with this complication. In COVID-19 patients with persistent VAP, a chest CT scan investigating the evolution toward lung abscess should be considered.

Ventilator-Associated Pneumonia in COVID-19 Patients Admitted in Intensive Care Units: Relapse, Therapeutic Failure and Attributable Mortality—A Multicentric Observational Study from the OutcomeRea Network

Introduction: Ventilator-associated pneumonia (VAP) incidence is high among critically ill COVID-19 patients. Its attributable mortality remains underestimated, especially for unresolved episodes. Indeed, the impact of therapeutic failures and the determinants that potentially affect mortality are poorly evaluated. We assessed the prognosis of VAP in severe COVID-19 cases and the impact of relapse, superinfection, and treatment failure on 60-day mortality. Methods: We evaluated the incidence of VAP in a multicenter prospective cohort that included adult patients with severe COVID-19, who required mechanical ventilation for ≥48 h between March 2020 and June 2021. We investigated the risk factors for 30-day and 60-day mortality, and the factors associated with relapse, superinfection, and treatment failure. Results: Among 1424 patients admitted to eleven centers, 540 were invasively ventilated for 48 h or more, and 231 had VAP episodes, which were caused by Enterobacterales (49.8%), P. aeruginosa (24.8%), and S. aureus (22%). The VAP incidence rate was 45.6/1000 ventilator days, and the cumulative incidence at Day 30 was 60%. VAP increased the duration of mechanical ventilation without modifying the crude 60-day death rate (47.6% vs. 44.7% without VAP) and resulted in a 36% increase in death hazard. Late-onset pneumonia represented 179 episodes (78.2%) and was responsible for a 56% increase in death hazard. The cumulative incidence rates of relapse and superinfection were 45% and 39.5%, respectively, but did not impact death hazard. Superinfection was more frequently related to ECMO and first episode of VAP caused by non-fermenting bacteria. The risk factors for treatment failure were an absence of highly susceptible microorganisms and vasopressor need at VAP onset. Conclusions: The incidence of VAP, mainly late-onset episodes, is high in COVID-19 patients and associated with an increased risk of death, similar to that observed in other mechanically ventilated patients. The high rate of VAP due to difficult-to-treat microorganisms, pharmacokinetic alterations induced by renal replacement therapy, shock, and ECMO likely explains the high cumulative risk of relapse, superinfection, and treatment failure.

Unintended impact of COVID-19 pandemic on the rate of catheter related nosocomial infections and incidence of multiple drug resistance pathogens in three intensive care units not allocated to COVID-19 patients in a large teaching hospital

BackgroundThe prevalence of resistant hospital infections in the intensive care unit (ICU) increases mortality and antibiotic resistance. COVID-19 pandemic may have unintended impact on nosocomial infections (NI) and the prevalence of resistant microorganism.MethodologyThe present non-interventional study was performed by a pre and a post survey each lasting 8 months before (March–October 2019) and after (March–October 2020) the onset of COVID-19 pandemic in three ICU’s, not allocated to COVID-19 patients, in Nemazee Hospital, Shiraz, Iran. The rates of the following nosocomial infections were compared at pre- and post-pandemic period: ventilator associated pneumonia (VAP), central line associated blood stream infection (CLABSI), catheter-associated urinary tract infections (CAUTI) and incidence of multiple drug resistance (MDR) pathogens.ResultsPre-pandemic and pandemic incidence of VAP was 23.5 and 17.2 cases per 1000 device-days, respectively; an absolute decrease of 27%. The main reason for the decrease in the rate of VAP during the pandemic was a significant decrease in the rate of VAP caused by Acinetobacter baumannii; from 39 to 17% in total VAP episodes. The rate of VAP associated with other microorganisms remained relatively unchanged from 14.2 cases in pre-pandemic period to 14.3 cases per 1000 MV-days during the pandemic (P = 0.801). Pre-pandemic incidence of CLABSI was 7.3 cases and, in pandemic period, was 6.5 cases per 1000 device-days (IRR = 0.88, 95% CI 0.43–1.73, P = 0.703). Pre-pandemic incidence of CAUTI was 2 and in pandemic period, was 1.4 cases per 1000 device-days (IRR = 0.70, 95% CI 0.22–1.98, P = 0.469).ConclusionThe results of the present study showed a decrease in the incidence of VAP in critically ill non-COVID-19 patients during the pandemic compared to before the pandemic, especially regarding Acinetobacter baumannii.

Impact of coronavirus disease 2019 (COVID-19) pandemic in hospital-acquired infections and bacterial resistance at an oncology hospital.

Hospital-acquired infection (HAI) rates were negatively affected by the the coronavirus disease 2019 (COVID-19) pandemic. We describe the incidence of HAIs, main pathogens, and multidrug-resistant organisms (MDROs) isolated in cancer patients before and during the pandemic. This retrospective, comparative study included patients with HAIs. We compared 2 periods: the prepandemic period (2018, 2019, and the first 3 months of 2020) with the pandemic period (April-December 2020 and all of 2021). Instituto Nacional de Cancerología, a tertiary-care oncology public hospital in Mexico City, Mexico. Patients with the following HAIs were included: nosocomial pneumonia, ventilator-associated pneumonia (VAP), secondary bloodstream infection (BSI), central-line-associated bloodstream infection (CLBSI), and Clostridioides difficile infection (CDI). Demographic data, clinical characteristics, pathogens isolated, and MDRO data were included. We identified 639 HAIs: 381 (7.95 per 100 hospital discharges) in the prepandemic period and 258 (7.17 per 100 hospital discharges) in the pandemic period. Hematologic malignancy was documented in 263 (44.3%) patients; 251 (39.2%) were in cancer progression or relapse. Nosocomial pneumonia was more frequent during the pandemic period (40.3% vs 32.3%; P = .04). Total episodes of VAP were not different between the 2 periods (28.1% vs 22.1%; P = .08), but during the pandemic period, the VAP rate was higher among COVID-19 patients than non-COVID-19 patients (72.2% vs 8.8%; P < .001). Escherichia coli, Stenotrophomonas maltophilia, and Staphylococcus aureus bacteremia cases were more frequent in the pandemic period. Extended-spectrum β-lactamases (ESBL)-E. coli was the only MDRO that occurred more frequently during the pandemic period. In cancer patients, nosocomial pneumonia was more frequent during the pandemic period. We did not observe a significant impact on other HAIs. MDROs did not significantly increase during the pandemic.

Incidence of iatrogenic withdrawal syndrome and associated factors in surgical pediatric intensive care

BackgroundIatrogenic withdrawal syndrome (IWS) is a complication of prolonged sedation/analgesia in pediatric intensive care unit (PICU) patients. The epidemiology of IWS is poorly understood, as validated diagnostic tools are rarely used. The main objective of our study was to use the WAT-1 score to assess the incidence of IWS in our unit. The secondary objectives were to evaluate the consequences of IWS, associated factors, and management modalities. Material and methodsFrom July 2018 to January 2019, 48 children receiving endotracheal ventilation and sedation/analgesia by continuous infusion (>48 h) of benzodiazepines and/or opioids were included. As soon as sedation/analgesia was decreased and until 72 h after its complete discontinuation, the WAT-1 score was determined every 12 h. Substitution therapy was used for 98% of patients upon opioid and/or benzodiazepine withdrawal. IWS was defined as a WAT-1 score ≥3. Factors associated with IWS were assessed by univariate analysis. ResultsIWS occurred in 25 (52%) patients. IWS was associated with a higher number of ventilator-associated pneumonia episodes (17 [68%] vs. one [4%]) and a longer PICU stay (13 [7; 25] vs. 9.0 [5.0; 10.5]) (p<0.001). Overall, 11 patients developed IWS after less than 5 days of sedation/analgesia. Severe head injury was associated with IWS (p = 0.03). Neither sedation discontinuation nor IWS prevention was standardized. ConclusionThe high incidence and adverse consequences of IWS require improved prevention. Risk groups should be defined and a standardized withdrawal protocol established. The occurrence of IWS should be monitored routinely using a validated score.

Incidence, Outcomes and Risk Factors of Recurrent Ventilator Associated Pneumonia in COVID-19 Patients: A Retrospective Multicenter Study.

Background: High incidence of ventilator associated pneumonia (VAP) has been reported in critically ill patients with COVID-19. Among these patients, we aimed to assess the incidence, outcomes and risk factors of VAP recurrences. Methods: We conducted an observational retrospective study in three French intensive care units (ICUs). Patients admitted for a documented COVID-19 from March 2020 to May 2021 and requiring mechanical ventilation (MV) for ≥48 h were included. The study main outcome was the incidence of VAP recurrences. Secondary outcomes were the duration of MV, ICU and hospital length of stay and mortality according to VAP and recurrences. We also assessed the factors associated with VAP recurrences. Results: During the study period, 398 patients met the inclusion criteria. A total of 236 (59%) of them had at least one VAP episode during their ICU stay and 109 (46%) of these patients developed at least one recurrence. The incidence of VAP recurrence considering death and extubation as competing events was 29.6% (IC = [0.250−0.343]). Seventy-eight percent of recurrences were due to the same bacteria (relapses). Patients with a VAP recurrence had a longer duration of MV as compared with one VAP and no VAP patients (41 (25−56) vs. 16 (8−30) and 10 (5−18) days; p < 0.001) and a longer ICU length of stay (46 (29−66) vs. 22 (12−36) and 14 (9−25) days; p < 0.001). The 90-day mortality was higher in the recurrence group as compared with the no VAP group only (31.2 vs. 21.0% (p = 0.021)). In a multivariate analysis including bacterial co-infection at admission, the use of immunosuppressive therapies and the bacteria responsible for the first VAP episode, the duration of MV was the only factor independently associated with VAP recurrence. Conclusion: In COVID-19 associated respiratory failure, recurrences affected 46% of patients with a first episode of VAP. VAP recurrences were mainly relapses and were associated with a prolonged duration of MV and ICU length of stay but not with a higher mortality. MV duration was the only factor associated with recurrences.

Impact of colonization with multidrug-resistant bacteria on the risk of ventilator-associated pneumonia in septic shock

The objective is to identify the risk markers of multi-drug resistant bacteria (MDRB) related ventilator-associated pneumonia (VAP) in septic shock patients with previous MDRB carriage. This retrospective study was conducted in a medical ICU from 2010 to 2020. Consecutive patients with septic shock and still in the ICU after 48 h, were eligible. The following microorganisms were defined as MDRB: extended-spectrum beta-lactamase producing enterobacteriaceae, methicillin-resistant Staphylococcus aureus, multi-drug resistant Pseudomonas aeruginosa, imipenem-resistant Acinetobacter baumanii and Stenotrophomonas maltophilia. Screening for MDRB colonization was performed at ICU admission and during ICU stay. The determinants of MDRB-related VAP were assessed using a time-dependent cause-specific Cox model. 643 patients were analyzed and 122 (18.9%) had at least one episode of VAP. The overall ICU mortality was 32.5%. The incidence of MDRB carriage was 31%, distributed into MDRB carriage at admission (14.3%) and MDRB acquired during ICU stay (16.7%). In multivariate analysis, MDRB colonization in ICU was independently associated with an increased risk of VAP (CSH: 1.85; 95% CI: 1.05-3.23; p = 0.03) whereas carriage prior to admission was not. Imported and acquired MDRB carriage harbor different risks of subsequent MDRB-related VAP in patients with septic shock.

Co-Infection and Ventilator-Associated Pneumonia in Critically Ill COVID-19 Patients Requiring Mechanical Ventilation: A Retrospective Cohort Study.

Considering virus-related and drug-induced immunocompromised status of critically ill COVID-19 patients, we hypothesize that these patients would more frequently develop ventilator-associated pneumonia (VAP) than patients with ARDS from other viral causes. We conducted a retrospective observational study in two intensive care units (ICUs) from France, between 2017 and 2020. We compared bacterial co-infection at ICU admission and throughout the disease course of two retrospective longitudinally sampled groups of critically ill patients, who were admitted to ICU for either H1N1 or SARS-CoV-2 respiratory infection and depicted moderate-to-severe ARDS criteria upon admission. Sixty patients in the H1N1 group and 65 in the COVID-19 group were included in the study. Bacterial co-infection at the endotracheal intubation time was diagnosed in 33% of H1N1 and 16% COVID-19 patients (p = 0.08). The VAP incidence per 100 days of mechanical ventilation was 3.4 (2.2–5.2) in the H1N1 group and 7.2 (5.3–9.6) in the COVID-19 group (p < 0.004). The HR to develop VAP was of 2.33 (1.34–4.04) higher in the COVID-19 group (p = 0.002). Ten percent of H1N1 patients and 30% of the COVID-19 patients had a second episode of VAP (p = 0.013). COVID-19 patients have fewer bacterial co-infections upon admission, but the incidence of secondary infections increased faster in this group compared to H1N1 patients.

Clinical Features and Outcomes of Monobacterial and Polybacterial Episodes of Ventilator-Associated Pneumonia Due to Multidrug-Resistant Acinetobacter baumannii.

Multidrug-resistant A. baumannii (MDRAB) VAP has high morbidity and mortality, and the rates are constantly increasing globally. Mono- and polybacterial MDRAB VAP might differ, including outcomes. We conducted a single-center, retrospective (January 2014–December 2016) study in the four ICUs (12–18–24 beds each) of a reference Lithuanian university hospital, aiming to compare the clinical features and the 30-day mortality of monobacterial and polybacterial MDRAB VAP episodes. A total of 156 MDRAB VAP episodes were analyzed: 105 (67.5%) were monomicrobial. The 30-day mortality was higher (p < 0.05) in monobacterial episodes: overall (57.1 vs. 37.3%), subgroup with appropriate antibiotic therapy (50.7 vs. 23.5%), and subgroup of XDR A. baumannii (57.3 vs. 36.4%). Monobacterial MDRAB VAP was associated (p < 0.05) with Charlson comorbidity index ≥3 (67.6 vs. 47.1%), respiratory comorbidities (19.0 vs. 5.9%), obesity (27.6 vs. 9.8%), prior hospitalization (58.1 vs. 31.4%), prior antibiotic therapy (99.0 vs. 92.2%), sepsis (88.6 vs. 76.5%), septic shock (51.9 vs. 34.6%), severe hypoxemia (23.8 vs. 7.8%), higher leukocyte count on VAP onset (median [IQR] 11.6 [8.4–16.6] vs. 10.9 [7.3–13.4]), and RRT need during ICU stay (37.1 vs. 17.6%). Patients with polybacterial VAP had a higher frequency of decreased level of consciousness (p < 0.05) on ICU admission (29.4 vs. 14.3%) and on VAP onset (29.4 vs. 11.4%). We concluded that monobacterial MDRAB VAP had different demographic/clinical characteristics compared to polybacterial and carried worse outcomes. These important findings need to be validated in a larger, prospective study, and the management implications to be further investigated.

Role of Multidrug-resistant Pathogens in Ventilator-Associated Pneumonia in a Tertiary Care Hospital in India

Aim: Ventilator-associated pneumonia (VAP) is the second most common infection acquired in the intensive care unit (ICU). Bacteriological profiles cause VAP and their susceptibility patterns vary in different institutions. Methods: A prospective study was conducted from June 2017 to May 2018 in a tertiary care hospital as per the recent NHSN guidelines in finding the incidence of VAP and further determining the etiological agents by both conventional and automated methods. The combination disk method (Phenotypic confirmatory test), ampicillin C (AmpC) disk test, modified carbapenem inactivation method, imipenem/ethylenediamine tetraacetic acid combined disc test, and cefoxitin disk test were performed for the detection of extended-spectrum beta-lactamases (ESBL), AmpC β-lactamases, carbapenemases, metallo-beta-lactamases (MBL), and methicillin-resistant Staphylococcus aureus, respectively. Results: Among 104 patients, 31 cases developed PVAP (possible VAP) during their ICU stay; of these cases, two patients had two episodes of VAP each, and the incidence of VAP was 32%. The most common isolate was Acinetobacter baumannii (38%), followed by Pseudomonas aeruginosa (22%), Klebsiella pneumoniae (16%), and Escherichia coli (13.51%). Twenty (54%) of the 37 VAP pathogens were multidrug resistant. ESBL was produced by 40% and 67% of E. coli and K. pneumoniae, respectively. MBL was produced by 25% of P. aeruginosa. In addition, AmpC beta-lactamases were produced by 18% each of the Enterobacteriaceae and non-fermenters, respectively. One of the two S. aureus isolates was methicillin-resistant. Conclusion: The majority of VAP cases in our setting were caused by highly resistant strains. The frequency of specific multidrug resistance pathogens causing VAP may vary due to hospital, patient population, exposure to antibiotics, type of ICU patients, and changes over time, emphasizing the need for timely local surveillance data.

Ventilator-associated pneumonia prevention in the Intensive care unit using Postpyloric tube feeding in China (VIP study): study protocol for a randomized controlled trial

BackgroundVentilator-associated pneumonia is a challenge in critical care and is associated with high mortality and morbidity. Although some consensuses on preventing ventilator-associated pneumonia are reached, it is still somewhat controversial. Meta-analysis has shown that postpyloric tube feeding may reduce the incidences of ventilator-associated pneumonia, which still desires high-quality evidence. This trial aims to evaluate the efficacy and safety profiles of postpyloric tube feeding versus gastric tube feeding.Methods/designIn this multicenter, open-label, randomized controlled trial, we will recruit 924 subjects expected to receive mechanical ventilation for no less than 48 h. Subjects on mechanical ventilation will be randomized (1:1) to receive postpyloric or gastric tube feeding and routine preventive measures simultaneously. The primary outcome is the proportion of patients with at least one ventilator-associated pneumonia episode. Adverse events and serious adverse events will be observed closely.DiscussionThe VIP study is a large-sample-sized, multicenter, open-label, randomized, parallel-group, controlled trial of postpyloric tube feeding in China and is well-designed based on previous studies. The results of this trial may help to provide evidence-based recommendations for the prevention of ventilator-associated pneumonia.Trial registrationChictr.org.cn ChiCTR2100051593. Registered on 28 September 2021

Effectiveness of Educational Intervention in Preventing Ventilator Associated Pneumonia in Neonatal Intensive Care Unit: A Cohort Study

Background: Despite improvement in overall survival, neonatal period is not free of complications. Ventilator associated Pneumonia (VAP) is a serious complication and account for 6.8 - 32.2 % of healthcare associated infections among neonates. Objective: The objective of the study was to document the effectiveness of an educational programme for neonatal intensive care (NICU) service provider in preventing occurrence of ventilator associated pneumonia in NICU. Methods: It was a prospective cohort study compared with historical control taken from the hospital records. All neonates admitted to the NICU during 12 months period from May 2019 to April 2020 were enrolled. Prospective enrollment of ventilated baby after educational interventions was subjected to the VAP educational care bundle. Eligible neonates who spent more than 48 h on MV were followed up and monitored closely for the development of VAP. Detail history, thorough clinical examination, relevant investigation including chest radiography were carried out on all enrolled infants. Results: A total of 54 neonates ventilated newborn, 41 met the inclusion criteria and were enrolled in the current study; 22 cases in pre-intervention phase and 19 cases in the post- intervention phase. Among enrolled mechanically ventilated newborn, 18 patients (18/41, 44%) developed at least single episode of VAP during the ventilated period. Baseline characteristics were comparable in both the groups. The primary indication of mechanical ventilation was sepsis related complications during both the phases (9/22, 41% and 8/19, 42.1%). Next to sepsis, perinatal asphyxia (5/22, 22.7%) was the indication of MV in pre-intervention period whereas respiratory distress syndrome (7/19, 36.8%) was the second leading causes of MV during post-intervention period. Significant reduction in VAP incidence rate was observed after implementation of VAP interventions, as 13/22, 59 % episodes of VAP were diagnosed in pre-intervention period compared to 5/19, 26.3% were diagnosed during implementation period. (p = 0.035). Non-significant reduction in mean duration of MV days was observed in the post-intervention period when compared to pre-intervention counterpart (7.23±4.48 days versus 5.16±2.77 days, p = 0.089). There was no significant reduction in NICU length of stay (13.05±8.16 versus 11.58±7.75 days in pre and post intervention period respectively, p = 0.56). The difference in overall mortality rates between the two phases were 15/22, 68.18% and 10/19, 52.63% respectively and found to be non- significant. Gram negative bacteria were the most commonly isolated micro-organisms, Acinetobacter was the leading causative pathogen. Conclusion: It demonstrates that an educational program including bundle of infection control practice can reduce the occurrence of VAP during ventilation period. These educational programs for NICU care providers can be expanded to other NICU s of the country to prevent ventilator associated pneumonia. Bangladesh Med Res Counc Bull 2021; 47(2): 143-150

Poor Sensorium at the Time of Intubation Predicts Polymicrobial Ventilator Associated Pneumonia.

BackgroundVentilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with a high mortality rate.AimThe study was conducted to estimate the frequency, outcomes, and predictors of polymicrobial VAP.MethodsA prospective observational study was conducted in mechanically ventilated adult patients in the medical intensive care unit in a tertiary care hospital in India from July 2016 to July 2018 with a 30-day follow-up period. The patients were grouped into monomicrobial and polymicrobial VAP. We compared the 30-day outcome parameters such as discharge from hospital, in-hospital stay, death, and complications such as catheter associated urinary tract infection (CAUTI), central line associated blood stream infection (CRBSI), bacteremia and collapse of lung. The predictors of polymicrobial VAP were identified by multiple logistic regression.ResultsOut of 301 patients clinically diagnosed with VAP, 151 patients were excluded, and the remaining 150 developed 186 episodes of VAP during the study period. The incidence of polymicrobial VAP was 62.9%. Out of 150 patients, 51 patients had monomicrobial VAP, and 99 had polymicrobial VAP. On univariate analysis, diabetes mellitus and poor sensorium (Glasgow Coma Scale [GCS] score <8) during endotracheal intubation; 30-day outcome, mean days of mechanical ventilation after VAP diagnosis and days in ICU; and CAUTI were significantly associated with polymicrobial VAP. On multivariable logistic regression, poor sensorium (GCS score <8) at the time of endotracheal intubation was an independent predictor of polymicrobial VAP.ConclusionThe incidence of polymicrobial VAP is high in the medical ICU and is associated with increased duration of mechanical ventilation, hospital stay, and incidence of CAUTI. Poor GCS score was the single independent predictor of polymicrobial VAP.

How common is ventilator-associated pneumonia after coronavirus disease 2019?

Purpose of reviewThe first studies on COVID-19 patients with acute respiratory distress syndrome (ARDS) described a high rate of secondary bacterial ventilator-associated pneumonia (VAP). The specificity of VAP diagnoses in these patients are reviewed, including their actual rate.Recent findingsPublished studies described high rates of bacterial VAP among COVID-19 patients with ARDS, and these VAP episodes are usually severe and of specifically poor prognosis with high mortality. Indeed, Severe acute respiratory syndrome - coronavirus disease 19 (SARS-CoV2) infection elicits alterations that may explain a high risk of VAP. In addition, breaches in the aseptic management of patients might have occurred when the burden of care was heavy. In addition, VAP in these patients is more frequently suspected, and more often investigated with diagnostic tools based on molecular techniques.SummaryVAP is frequented and of particularly poor prognosis in COVID-19 patients with ARDS. It can be explained by SARS-CoV-2 pathophysiology, and also breaches in the aseptic procedures. In addition, tools based on molecular techniques allow an early diagnosis and unmask VAP usually underdiagnosed by traditional culture-based methods. The impact of molecular technique-based diagnostics in improving antibacterial therapy and COVID-19 prognosis remain to be evaluated.

Epidemiology of ventilator-associated pneumonia in ICU COVID-19 patients: an alarming high rate of multidrug-resistant bacteria

BackgroundCOVID‑19 is a novel cause of acute respiratory distress syndrome (ARDS) that leads patients to intensive care unit (ICU) admission requiring invasive ventilation, who consequently are at risk of developing of ventilator‑associated pneumonia (VAP). The aim of this study was to assess the incidence, antimicrobial resistance, risk factors, and outcome of VAP in ICU COVID-19 patients in invasive mechanical ventilation (MV).MethodsObservational prospective study including adult ICU admissions between January 1, 2021, and June 31, 2021, with confirmed COVID-19 diagnosis were recorded daily, including demographics, medical history, ICU clinical data, etiology of VAPs, and the outcome. The diagnosis of VAP was based on multi-criteria decision analysis which included a combination of radiological, clinical, and microbiological criteria in ICU patients in MV for at least 48 h.ResultsTwo hundred eighty-four COVID-19 patients in MV were admitted in ICU. Ninety-four patients (33%) had VAP during the ICU stay, of which 85 had a single episode of VAP and 9 multiple episodes. The median time of onset of VAP from intubation were 8 days (IQR, 5–13). The overall incidence of VAP was of 13.48 episodes per 1000 days in MV. The main etiological agent was Pseudomonas aeruginosa (39.8% of all VAPs) followed by Klebsiella spp. (16.5%); of them, 41.4% and 17.6% were carbapenem resistant, respectively. Patients during the mechanical ventilation in orotracheal intubation (OTI) had a higher incidence than those in tracheostomy, 16.46 and 9.8 episodes per 1000-MV day, respectively. An increased risk of VAP was reported in patients receiving blood transfusion (OR 2.13, 95% CI 1.26–3.59, p = 0.005) or therapy with Tocilizumab/Sarilumab (OR 2.08, 95% CI 1.12–3.84, p = 0.02). The pronation and PaO2/FiO2 ratio at ICU admission were not significantly associated with the development of VAPs. Furthermore, VAP episodes did not increase the risk of death in ICU COVID-19 patients.ConclusionsCOVID-19 patients have a higher incidence of VAP compared to the general ICU population, but it is similar to that of ICU ARDS patients in the pre-COVID-19 period. Interleukin-6 inhibitors and blood transfusions may increase the risk of VAP. The widespread use of empirical antibiotics in these patients should be avoided to reduce the selecting pressure on the growth of multidrug-resistant bacteria by implementing infection control measures and antimicrobial stewardship programs even before ICU admission.