Late Ventilator-associated Pneumonia Research Articles

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 >18 years, on mechanical ventilation (MV) for >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 <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 
 Ventilator-associated pneumonia (VAP) is a common nosocomial lung infection. Quick and accurate identification of the causative pathogen is crucial to improve prognosis. To date, the literature is controversial regarding whether endotracheal aspirate (ETA) can be used as an alternative to bronchoalveolar lavage (BAL) in VAP diagnosis.
 Objectives 
 To evaluate the consistency between the results of BAL and ETA in the diagnosis of early- and late VAP and to determine the microbial profiles of the involved microorganisms and their antimicrobial susceptibility. 
 Patients and Methods
 This is a single-centre prospective study that included 50 VAP-suspected patients conducted at Shar Hospital, Sulaimani, Iraq, from July 2021 to February 2022. The patients were categorised into early VAP and late VAP. For each patient, both ETA and BAL techniques were used to obtain samples for microbiological analysis and antimicrobial susceptibility testing.
 Results
 Ten (20%) patients developed early VAP, and 40 (80%) developed late VAP. The culture results of samples obtained by BAL showed microbial growth in 45 (90%) of the cases. Meanwhile, ETA resulted in microbial growth in 40 (80%) patients. In 45 (90%) of the samples, both techniques yielded the same results regarding microbial growth in the cultures. Among the 45 samples with the same growth results, 35 (70%) showed the same type of microbes, and 5 (10%) showed no microbial growth, indicating substantial agreement. In both BAL and ETA, Pseudomonas aeruginosa, Staphylococcus aureus, and Acinetobacter baumannii were the most frequently isolated pathogens. Both early- and late-VAP were associated with a high frequency of multidrug-resistant microorganisms, 6 (75%) and 25 (56.8%), respectively. However, extensively drug-resistant/pan-drug-resistant isolates were much more common in late-VAP patients (12, 27.3%). 
 Conclusion
 ETA can be a reliable, non-invasive alternative to BAL in VAP diagnosis associated with rapid and relatively accurate results.

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: A Narrative Review

The difficulty of early diagnosis, the proper anti-microbial chosen, and the relatively high morbidity and mortality; make us collect the related subjects to deal with the most critical complication (ventilator-associated pneumonia) showing the major points needed for every intensivist. Ventilator-associated pneumonia is considered the most common respiratory complication (infection) in intensive care unit patients. Ventilator-associated pneumonia can be defined as a hospital-acquired infection of the lung parenchyma that occurs after 2 days of mechanical ventilation. Its incidence is about 9-25% in intubated patients for more than 2 days. We could classify ventilator-associated pneumonia as early and late; the first one happened within four days of receiving mechanical ventilation, otherwise, the late onset occurred after day four. Some patients with hospital stays before intensive care unit admission and intubation are considered to have late ventilator-associated pneumonia regardless of the period of mechanical ventilation because those patients might have had pathogens previously (nosocomial). Severe ill patients, prolonged mechanical ventilation, and failed extubation trials (recurrent intubation) lead to the development of ventilator-associated pneumonia rapidly and aggressively. Furthermore,ventilator-associated pneumonia is attributed to prolonged hospitality as well as high morbidity and mortality. We aimed in this narrative review to discuss ventilator-associated pneumonia regarding the etiology, causative agents, risk factors, strategies for early diagnosis, accurate treatment, and optimal prevention protocols.

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.

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.

Nutritional Status Disorders and Selected Risk Factors of Ventilator-Associated Pneumonia (VAP) in Patients Treated in the Intensive Care Ward-A Retrospective Study.

Introduction: The development of pneumonia in patients treated in intensive care wards is influenced by numerous factors resulting from the primary health condition and co-morbidities. The aim of this study is the determination of the correlation between nutritional status disorders and selected risk factors (type of injury, epidemiological factors, mortality risk, inflammation parameters, age, and gender) and the time of pneumonia occurrence in patients mechanically ventilated in intensive care wards. Material and method: The study included 121 patients with injuries treated in the intensive care ward who had been diagnosed with pneumonia related to mechanical ventilation. The data were collected using the method of retrospective analysis of patients’ medical records available in the electronic system. Results: Ventilator-associated pneumonia (VAP) occurred more frequently in patients over 61 years of age (40.4%), men (67.8%), after multiple-organ injury (45.5%), and those with a lower albumin level (86%), higher CRP values (83.5%), and leukocytes (68.6%). The risk of under-nutrition assessed with the NRS-2002 system was confirmed in the whole study group. The statistical analysis demonstrated a correlation between the leukocytes level (p = 0.012) and epidemiological factors (p = 0.035) and the VAP contraction time. Patients infected with Staphylococcus aureus had 4% of odds for the development of late VAP in comparison to Acinetobacter baumannii (p < 0.001), whereas patients infected by any other bacteria or fungi had about four times lower odds of the development of late VAP in comparison to Acinetobacter baumannii (p = 0.02). Patients with results in APACHE from 20 to 24 and from 25 to 29 had 13% and 21%, respectively, odds of the development of late VAP in comparison to patients with APACHE II scores ranging from 10 to 19 (respectively, p = 0.006; p = 0.028). Conclusions: The development of VAP is impacted by many factors, the monitoring of which has to be included in prophylactics and treatment.

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.

Colistin versus meropenem in the empirical treatment of ventilator-associated pneumonia (Magic Bullet study): an investigator-driven, open-label, randomized, noninferiority controlled trial

BackgroundColistin is recommended in the empirical treatment of ventilator-associated pneumonia (VAP) with a high prevalence of carbapenem-resistant gram-negative bacilli (CR-GNB). However, the efficacy and safety of colistin are not well defined.MethodsA multicenter prospective randomized trial conducted in 32 European centers compared the efficacy and safety of colistin (4.5 million unit loading dose followed by a maintenance dose of 3 million units every 8 h) versus meropenem (2 g every 8 h), both in combination with levofloxacin (500 mg every 12 h) for 7–14 days in patients with late VAP. Between May 2012 and October 2015, 232 patients were randomly assigned to the 2 treatment groups. The primary endpoint was mortality at 28 days after randomization in the microbiologically modified intention-to-treat (mMITT) population. Secondary outcomes included clinical and microbiological cure, renal function at the end of the treatment, and serious adverse events. The study was interrupted after the interim analysis due to excessive nephrotoxicity in the colistin group; therefore, the sample size was not achieved.ResultsA total of 157 (67.7%) patients were included in the mMITT population, 36 of whom (22.9%) had VAP caused by CR-GNB. In the mMITT population, no significant difference in mortality between the colistin group (19/82, 23.2%) and the meropenem group (19/75, 25.3%) was observed, with a risk difference of − 2.16 (− 15.59 to 11.26, p = 0.377); the noninferiority of colistin was not demonstrated due to early termination and limited number of patients infected by carbapenem-resistant pathogens. Colistin plus levofloxacin increased the incidence of renal failure (40/120, 33.3%, versus 21/112, 18.8%; p = 0.012) and renal replacement therapy (11/120, 9.1%, versus 2/112, 1.8%; p = 0.015).ConclusionsThis study did not demonstrate the noninferiority of colistin compared with meropenem, both combined with levofloxacin, in terms of efficacy in the empirical treatment of late VAP but demonstrated the greater nephrotoxicity of colistin. These findings do not support the empirical use of colistin for the treatment of late VAP due to early termination.Trial registrationClinicalTrials.gov, NCT01292031. Registered 9 February 2011.

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

Is prehospital endobronchial intubation a risk factor for subsequent ventilator associated pneumonia? A retrospective analysis.

More than half of patients under mechanical ventilation in the intensive care unit (ICU) are field-intubated, which is a known risk factor for ventilator associated pneumonia (VAP). We assessed whether field endobronchial intubation (EBI) is associated with the development of subsequent VAP during the ICU stay. This retrospective, nested case-control study was conducted in a cohort of field-intubated patients admitted to an ICU of a teaching hospital during a three-year period. Cases were defined as field-intubated patients with EBI and controls corresponded to field-intubated patients with proper position of the tracheal tube on admission chest X-ray. Primary endpoint was the development of early VAP. Secondary endpoints included the development of early ventilator associated tracheo-bronchitis, late VAP, duration of mechanical ventilation, length of stay and mortality in the ICU. A total of 145 patients were studied (mean age: 54 ± 19 years; men: 74%). Reasons for field intubation were predominantly multiple trauma (49%) and cardiorespiratory arrest (38%). EBI was identified in 33 patients (23%). Fifty-three patients (37%) developed early or late VAP. EBI after field intubation was associated with a nearly two-fold increase of early VAP, though not statistically significant (30% vs. 17%: p = 0.09). No statistically significant difference was found regarding secondary outcomes. The present study suggests that inadvertent prehospital EBI could be associated with a higher incidence of early-onset VAP. Larger studies are required to confirm this hypothesis. Whether strategies aimed at decreasing the incidence and duration of EBI could reduce the incidence of subsequent VAP remains to be determined.

Effects of antibiotic prophylaxis on ventilator-associated pneumonia in severe traumatic brain injury. A post hoc analysis of two trials

PurposeTo investigate the role of antibiotic prophylaxis (AP) in the incidence of ventilator-associated pneumonia (VAP) in patients suffering from traumatic brain injury (TBI). Materials and methodsThis post hoc analysis was conducted based on data from 2 multicentre double-blind studies that aimed to prevent VAP using hydrocortisone or povidone iodine. Data from TBI patients were extracted and pooled. Patients were classified into 2 groups: those who received an AP (AP group) and those who did not (control group). Results295 patients were included (AP group, n = 146; control group, n = 149). The incidence of VAP was 145 (49%). VAP incidence was lower in the AP group (39% vs 59%, Relative Risk = 0.33, 95%CI, 0.19–0.56, p = 0.001). Time to VAP occurrence was delayed (Hazard Ratio = 0.50, 95%CI 0.36–0.69, p < 0.001). The incidence of early VAP (>2 and ≤ 5 days) was lower in the AP group (10% vs 32%; p < 0.001), whereas that of late VAP (>5 days) did not differ (AP group 29% vs control group 28%; p = 0.811). Length of stay and mortality did not differ between the 2 groups. ConclusionsEarly use of AP delayed and may prevent the occurrence of VAP in severe TBI patients but did not change length of stay or mortality.

Ventilator associated pneumonia: incidence, profile and outcome in pediatric intensive care unit of tertiary care centre

Background: Ventilator-Associated Pneumonia (VAP) refers to nosocomial pneumonia occurring 48 hours or more after initiation of mechanical ventilation (MV), with frequencies ranging from 15-45%. The incidence rates of VAP are higher in developing countries with limited resources. Early and late VAP differ in their pathogenesis, micro-organisms responsible, antibiotic sensitivity, outcome and treatment.Methods: Retrospective cohort study of all critically ill children between 1 month to 12 years who were admitted and mechanically ventilated in our 8-bedded PICU between January 2015 to June 2016 and developed Ventilator associated pneumonia. PIM3 (Paediatric Index of Mortality 3) was calculated. We compared early and late VAP for risk factors, length of stay on mechanical ventilation (LOS MV) and outcome. The data collected were compiled and tabulated.Results: The incidence of VAP in this study was 40%. We found significant correlation between early and late VAP with parenteral nutrition (p = 0.001), presence of nasogastric tube (p = 0.012) and mortality (p = 0.027). The LOS MV was Mean 7.25 days in early VAP, while 22.75 days in late VAP; which demonstrated significant correlation (p = 0.003). There was no significant correlation of PIM3 with VAP, reintubation and mortality. Most frequent organisms found in Early VAP were Acinetobacter baumannii and MRSA, whereas in late VAP Pseudomonas aeruginosa was commonest isolated organism.Conclusions: VAP is a major cause of mortality in PICU. Late VAP was associated with longer length of stay on mechanical ventilation (LOS MV), higher mortality. This study thus emphasizes the need for prospective multicentric case-control studies for formulating and applying early preventive strategies in PICU to reduce VAP-related mortality.

Comparative study of incidence, risk factors, etiological agents and outcome of early and late ventilator associated pneumonia in paediatric intensive care unit at a tertiary care centre

Background: Ventilator Associated Pneumonia (VAP), the nosocomial pneumonia developing in mechanically ventilated patients after 48 hours of mechanical ventilation, is the second most common nosocomial infection in the paediatric intensive care unit (PICU). 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, risk factors and bacteriological profile and outcome of early and late ventilator associated pneumonia in PICU.Methods: The study was conducted from December 2015 to November 2017 in which 89 children beyond 1 year of age were ventilated for more than 48 hours of which those who developed VAP as per CDC criteria were enrolled in the study. The endotracheal secretions were collected, processed and recorded as per standard microbiological methods. Statistical associations were further evaluated between various parameters of VAP and time of development of VAP.Results: Of all the mechanically ventilated patients, 33.7% developed VAP. Incidence of Early VAP was 23.3% and that of Late VAP was 76.67%. Duration of mechanical ventilation and re-intubation were significantly associated with the time of development of VAP. Micro-organisms identified by culture, involved in the aetiology of VAP were: gram-negative bacteria in 74.9% and gram-positive bacteria in 25.1%. The overall mortality rate was 43.33%.Conclusions: Re-intubation and duration of mechanical ventilation are a significant risk factor for development of late VAP. Overall the most common Gram-negative bacteria associated with VAP was Acinetobacter baumanii. The most common isolate in early VAP was Acinetobacter baumanii whereas infections by Pseudomonas and E. coli are common in late VAP. population.

Pattern and incidence of ventilator associated pneumonia among mechanically ventilated patients

Background: Initial empirical therapy of ventilator-associated pneumonia (VAP), which is based on organisms recovered, can be modified based on the knowledge of local microbiological data, patient characteristics, and sensitivity pattern of expected pathogens at the institution. Aim of this study was conducted to observe the regional the incidence of VAP among mechanically ventilated patients.Methods: All the patients who conformed to the inclusion criteria of the study, and who were in the ICU settings and put on ventilatory support, underwent vigorous aseptic precautions and later on developed VAP were taken into the study.Results: Total 374 admitted patients were needed mechanically ventilation. Among 31 developed LRTI. The Overall incidence rate of VAP was computed to be 8.2% with highest rate among patients of age group 31-50 years. The incidence rates of VAP were found highest for Acinetobacter (54.8%) with second highest mortality (47%) whereas maximum mortality (66.66%) was caused by Klebsiella, the second most common incidence of VAP. Twenty-one patients developed early VAP whereas remaining 10 subjects developed late VAP. Mortality was higher between early VAP (57.14%) compared to the late VAP cases (30%). Majority of organisms were sensitive to Cefoperazone + Sulbactum (29), Imipenem (24) and Meropenem (22).Conclusions: Despite advances in diagnostic and treatment modalities of VAP, its management still continues to be a challenge for clinicians. The findings emerging out of this investigation will help in initial selection of antibiotics for the empiric treatment of VAP. Later on, therapy can be modified based on the knowledge of pattern and profile of VAP patients along with sensitivity pattern of expected pathogens.

Nebulized Versus IV Amikacin as Adjunctive Antibiotic for Hospital and Ventilator-Acquired Pneumonia Postcardiac Surgeries: A Randomized Controlled Trial*

Nebulized antibiotics offer high efficacy due to significant local concentrations and safety with minimal blood levels. This study evaluates the efficacy and nephrotoxicity of nebulized versus IV amikacin in postcardiothoracic surgical patients with nosocomial pneumonia caused by multidrug-resistant Gram- negative bacilli. Prospective, randomized, controlled study on surgical patients divided into two groups. Postcardiac surgery ICU. The first gtroup was administered IV amikacin 20 mg/kg once daily. The second group was prescribed amikacin nebulizer 400 mg twice daily. Both groups were co-administered IV piperacillin/tazobactam empirically. Recruited patients were diagnosed by either hospital-acquired pneumonia or ventilator-associated pneumonia where 56 (42.1%) patients were diagnosed with hospital-acquired pneumonia, 51 (38.34%) patients were diagnosed with early ventilator-associated pneumonia, and 26 (19.54%) patients with late ventilator-associated pneumonia. Clinical cure in both groups assessed on day 7 of treatment was the primary outcome. Efficacy was additionally evaluated through assessing the length of hospital stay, ICU stay, days on amikacin, days on mechanical ventilator, mechanical ventilator-free days, days to reach clinical cure, and mortality rate. Lower nephrotoxicity in the nebulized group was observed through significant preservation of kidney function (p < 0.001). Although both groups were comparable regarding length of hospital stay, nebulizer group showed shorter ICU stay (p = 0.010), lower number of days to reach complete clinical cure (p = 0.001), fewer days on mechanical ventilator (p = 0.035), and fewer days on amikacin treatment (p = 0.022). Nebulized amikacin showed better clinical cure rates, less ICU stay, and fewer days to reach complete recovery compared to IV amikacin for surgical patients with nosocomial pneumonia. It is also a less nephrotoxic option associated with less deterioration in kidney function.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis.

We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Effects of subglottic secretion drainage at different intervals on ventilator-associated pneumonia

Objective To investigate the effects of subglottic secretion drainage at different intervals on ventilator-associated pneumonia(VAP). Methods A total of 150 patients receiving tracheostomy during January 2015 to December 2016 were divided into A, B, C group according to the order of intubation time. The subglottic secretion drainage was attracted at intervals of 2, 4, and 6 h respectively. The differences in balloon secretion on occult blood test(after intubation, intubation time, 3 d, 5 d,7 d), the content of airborne bacteria in the air sac, the number of VAP and the time of VAP occurrence between the 3 groups were analyzed. Results The 3 groups that group A had 78 positive cases, group B had 46 cases and group C had 38 cases had statistical significance differences compared with balloon retentate occult blood test (χ2=28.23, P=0.00); there were statistical significance differences between the 3 groups of bacteria (Z=11.91, P=0.00), there were statistically significant differences between group A and group C (Z=-3.01, P=0.00), between group B and group C (Z=-2.19, P=0.01). There were statistical significance differences between the 3 groups of the number of VAP cases (χ2=7.50, P=0.00) that there were 12 cases happening in group A, 13 cases in group B and 23 cases in group C. There were statistical significance differences between group A and group C (χ2=5.32, P=0.02), between group B and group C (χ2=4.34, P=0.04). The occurrence time of VAP which was (169.25±20.80) h in group A, (168.35±18.04) h in group B and (129.47±18.13) h in group C,there was significantly different between the 3 groups (F=2 788.19, P=0.00), the differences between group A and group C (t=3.19, P=0.00), group B and group C (t=68.40, P=0.00) were statistically significant. Conclusions The subglottic secretion drainage at intervals of 4 hours will not only reduce the damage to the airway mucosa, but also reduce the incidence of airway bacteria and the incidence of VAP and delay the occurrence of late VAP. Key words: Mechanical, mechanical; Pneumonia, ventilator-associated; Subglottic secretion

Efficacy of a bundle approach in preventing the incidence of ventilator associated pneumonia (VAP).

Ventilator-associated pneumonia (VAP) is a potentially preventable iatrogenic illness that may develop following mechanical ventilation. A bundle for the prevention of VAP consists of different measures which may vary between institutions, and may include: elevation of the head of the bed, oral care with chlorhexidine, subglottic suctioning, daily assessment for extubation and the need for proton-pump inhibitors, use of closed suction systems, and maintaining endotracheal cuff pressure at 25 cmH2O. Our aim was to determine the efficacy of a VAP prevention bundle, consisting of the above-mentioned measures, by evaluating the incidence of VAP before (no-VAP-B group) and after (VAP-B group) the introduction of the bundle. We retrospectively evaluated the data for patients who were mechanically ventilated with an endotracheal tube, in the period between 1 September and 31 December 2014 (no-VAP-B group, n = 55, 54.5% males, mean age 67.8 ± 14.5 years) and between 1 January to 30 April 2015 (VAP-B group, n = 74, 62.1% males, mean age 64.8 ± 13.7 years). There were no statistically significant differences between no-VAP-B and VAP-B groups in demographic data, intensive care unit (ICU) mortality, hospital mortality, duration of ICU treatment, and duration of mechanical ventilation. No significant differences in the rates of VAP and early VAP (onset ≤7 days after intubation) were found between no-VAP-B and VAP-B groups (41.8% versus 25.7%, p = 0.06 and 10.9% versus 12.2%, p > 0.99, respectively). However, a significant decrease in the late VAP (onset >8 days after intubation) was found in VAP-B group compared to no-VAP-B group (13.5% versus 30.9%, p = 0.027). Overall, our results support the use of VAP prevention bundle in clinical practice.