Mean Clinical Pulmonary Infection Score Research Articles

Comparison of Inhaled Colistin with Inhaled Amikacin-Fosfomycin in the Treatment of Ventilator-Associated Pneumonia Caused by Extensively Drug-Resistant (XDR) Acinetobacter: A Clinical Trial

Background: This study aimed to compare the effects of inhaled colistin and inhaled amikacin-fosfomycin combination in the treatment of ventilator-associated pneumonia (VAP) caused by extensively drug-resistant (XDR) Acinetobacter. This clinical trial is the first study to evaluate the effect of inhaled fosfomycin on VAP in Iran. Methods: In this clinical trial, 60 patients with Acinetobacter VAP were divided into two groups of 30 patients. The empirical regimen changed to meropenem plus intravenous colistin in both groups. Inhaled colistin in the first group and inhaled amikacin-fosfomycin in the second group were added to the intravenous therapy. Next, the mortality rate, if any, duration of treatment success, and patient withdrawal from VAP were evaluated in the two groups. Results: Although the mean clinical pulmonary infection score (CPIS) before treatment was not significantly different between the two groups, the mean score of the amikacin-fosfomycin group was significantly lower at 72 hours and seven days after the onset of treatment and at the end of treatment. Based on the intra-group assessments, the CPIS in both groups was significantly reduced (P < 0.001). Also, in the inter-group assessments, the mean CPIS changes were significantly different between the two groups, and in the amikacin-fosfomycin group, a greater reduction in the CPIS was observed (P = 0.007). Conclusions: The findings of the present study showed that the use of amikacin-fosfomycin nebulization could lead to increased recovery and reduced treatment duration in patients with VAP, caused by drug-resistant Acinetobacter baumannii.

Serum and alveolar procalcitonin had a weak diagnostic value for ventilator-associated pneumonia in patients with pulmonary infection score ≥ 6

Measuring the serum and alveolar procalcitonin level as inflammatory marker in the diagnosis of ventilator-associated pneumonia (VAP) has been taken into account. In this study, serum and alveolar procalcitonin levels in patients with suspected VAP and patients with confirmed VAP were compared. This cross-sectional study was conducted using 50 intubated intensive care unit (ICU) patients, connected to ventilator, from October 2014 to April 2015. 50 patients with clinical pulmonary infection score ≥6 were divided into two groups. Patients whose bronchoalveolar lavage (BAL) has shown the growth of more than 104 CFU/mL were included in confirmed VAP group and other patients were included in suspected VAP group. Serum and alveolar procalcitonin levels were measured and compared between both groups. Mean age of patients was 69.10 ± 42.13 with a range of 16-90 years, out of which 23 patients were male (46%) and 27 patients were female (54%). Moreover, patients' mean clinical pulmonary infection score was reported to be 7.02 ± 1.07. There was a significant relationship between serum and alveolar procalcitonin in suspected patients and patients with an approved form of pneumonia (p = 0.001 and 0.027). Area under the curve for alveolar procalcitonin was 0.683 (sensitivity = 57%; specificity = 80%) and for serum procalcitonin 0.751 (sensitivity = 71%; specificity = 73%) for the diagnosis of VAP. According to the results of the present study, we can diagnose ventilator-associated pneumonia earlier and more accurately by measuring procalcitonin level (particularly alveolar type) in intensive care unit patients.

Effects of oral care with glutamine in preventing ventilator-associated pneumonia in neurosurgical intensive care unit patients

PurposeThe study was designed as a randomized, controlled, experimental study aiming to determine the effects of oral care with glutamine in preventing ventilator-associated pneumonia in patients admitted to neurosurgical intensive care unit. MethodsThe universe consisted of patients who are admitted to neurosurgical intensive care unit between January 2014 and August 2015, while the sample consisted of 88 patients who fulfilled the inclusion criteria and were randomly selected. The study group received oral care with 5% glutamine, whereas the control group received oral care with 2% chlorhexidine gluconate solution. Data collecting toolsAll date was acquired using Patient Information Form, Acute Physiological and Chronic Health Evaluation scale (APACHE II), Beck Oral Assessment Scale (BOAS), Mucosal Plaque Score (MPS) and Clinical Pulmonary Infection Score (CPIS). One-way ANOVA test was used for comparing parameters with normal distribution between groups along with descriptive statistical methods. Kruskal-Wallis Test was used for comparing parameters without normal distribution between groups. ResultsIn the control group, mean BOAS score was 9.33±1.8 mean MPS score was 3.68±0.87 and mean CPIS score was 4.07±1.78. In the study group, mean BOAS score was 10.16±2.78, mean MPS score was 3.93±1.04 and mean CPIS score was 3.78±2.25. There was no statistically significant difference in mean scores at 1st day, 3rd day, 5th day and discharge (p>0.05). However, BOAS, MPS, CPIS and APACHE II scores was significantly lower at discharge than 1st day in both groups. ConclusionThere was no significant difference in using 5% glutamine or 2% chlorhexidine gluconate solution for oral care for the prevention of ventilator-associated pneumonia. Similar studies with bigger sample size and longer term should be conducted for better results.

Preintubation Application of Oral Chlorhexidine Does Not Provide Additional Benefit in Prevention of Early-Onset Ventilator-Associated Pneumonia

Daily application of oral chlorhexidine gluconate (CHX) following intubation to reduce the risk of ventilator-associated pneumonia (VAP) is now the standard of care in many ICUs. This randomized clinical trial evaluated the benefit of adding a preintubation CHX dose to the known benefit of postintubation CHX to reduce the risk of early-onset VAP. A secondary aim was to test the effect of a preintubation oral application of CHX on early endotracheal tube (ETT) colonization. Subjects (N = 314) were recruited from two teaching hospitals and were randomly assigned to oral application of 5 mL CHX 0.12% solution before intubation (intervention group, n = 157), or to a control group (n = 157) who received no CHX before intubation. All subjects received CHX bid after intubation. Groups were compared using a repeated-measures model with Clinical Pulmonary Infection Score (CPIS) as the response variable. In a planned subset of subjects, ETTs were cultured at extubation. Application of a preintubation dose of CHX did not provide benefit over the intervention period beyond that afforded by daily oral CHX following intubation. ETT colonization at extubation was < 20% in both groups (no statistically significant difference). Mean CPIS remained below 6 (VAP threshold score) in both groups. Although it is feasible to deliver CHX prior to intubation (including emergent or urgent intubation), the results suggest that preintubation CHX may be inconsequential when the ventilator bundle, including daily oral CHX, is in place. During the preintubation period, providers should focus their attention on other critical activities. ClinicalTrials.gov; No.: NCT00893763; URL: www.clinicaltrials.gov.

C-Reactive Protein, Procalcitonin, Clinical Pulmonary Infection Score, and Pneumonia Severity Scores in Nursing Home Acquired Pneumonia

Patients with nursing home acquired pneumonia (NHAP) present a distinct group of lower respiratory track infections with different risk factors, clinical presentation, and mortality rates. To evaluate the diagnostic value of clinical pulmonary infection score (CPIS), C-reactive protein, and procalcitonin and to compare the accuracy of pneumonia severity scores (confusion, urea nitrogen, breathing frequency, blood pressure, ≥ 65 y of age [CURB-65]; pneumonia severity index; NHAP index; systolic blood pressure, multilobar involvement, albumin, breathing frequency, tachycardia, confusion, oxygen, arterial pH [SMART-COP]; and systolic blood pressure, oxygen, age > 65 y, breathing frequency [SOAR]) in predicting in-patient mortality from NHAP. Nursing home residents admitted to the hospital with acute respiratory illness were enrolled in the study. Subjects were classified as having NHAP (Group A) or other pulmonary disorders (Group B). Clinical, imaging, and laboratory data were assessed to compute CPIS and severity scores. C-reactive protein and procalcitonin were measured by immunonephelometry and immunoassay, respectively. Fifty-eight subjects were diagnosed with NHAP (Group A) and 29 with other pulmonary disorders (Group B). The mean C-reactive protein ± SD was 16.38 ± 8.6 mg/dL in Group A and 5.2 ± 5.6 mg/dL in Group B (P < .001). The mean procalcitonin ± SD was 1.52 ± 2.75 ng/mL in Group A and 0.24 ± 0.21 ng/mL in Group B (P = .001). The mean CPIS ± SD was 5.4 ± 1.2 in Group A and 2.3 ± 1.5 in Group B (P < .001). At a cutoff value of 0.475 ng/mL, procalcitonin had a sensitivity of 83% and a specificity of 72%. At a cutoff value of 8.05 mg/dL, C-reactive protein had a sensitivity of 81% and a specificity of 79%. Procalcitonin and C-reactive protein levels were significantly higher in Gram-positive NHAP. The in-patient mortality was 17.2% in Group A. Procalcitonin levels were 4.67 ± 5.4 ng/mL in non-survivors and 0.86 ± 0.9 ng/mL in survivors (P < .001). The area under the curve for procalcitonin in predicting in-patient mortality was 0.84 (95% CI 0.70-0.98, P = .001). A procalcitonin level upon admission > 1.1 ng/mL was an independent predictor of in-patient mortality. Of the pneumonia severity scores, CURB-65 showed greater accuracy in predicting in-patient mortality (area under the curve of 0.68, 95% CI 0.53-0.84, P = .06). CPIS, procalcitonin, and C-reactive protein are reliable for the diagnosis of NHAP. Procalcitonin and CURB-65 are accurate in predicting in-patient mortality in NHAP.

Use of the clinical pulmonary infection score to guide therapy for ventilator-associated pneumonia risks antibiotic overexposure in patients with trauma

The clinical pulmonary infection score (CPIS) has been advocated to guide both the diagnosis and duration of therapy in ventilator-associated pneumonia (VAP). However, the clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury and inflammation, unnecessarily prolonging VAP therapy. This study evaluates the use of CPIS in determining the appropriate duration of antimicrobial therapy for VAP in patients with critical illness and trauma. Patients with VAP (≥10 CFU/mL in bronchoalveolar lavage [BAL] effluent) over 6 years were evaluated. Duration of antimicrobial therapy was determined by microbiologic resolution (≤10 CFU/mL) on repeated BAL. Recurrence was defined as >10 CFU/mL on BAL performed within 2 weeks of appropriate therapy. A CPIS of less than 6 was used as a threshold for VAP resolution. Of the patients with VAP, 1,028 were identified: 523 had community-acquired pathogens (mean CPIS, 6.9), and 505 had hospital-acquired (HA) pathogens (mean CPIS, 6.3). Using a CPIS of less than 6 yielded a sensitivity and specificity of 69% and 51% for community-acquired pathogens and 72% and 53% for HA pathogens, respectively. Antimicrobial therapy would have continued inappropriately in 59% of patients. Overall recurrence was 1%, occurring only with HA pathogens (mean CPIS, 5.9). CPIS should not be used to determine VAP resolution in patients with critical injury and trauma. It cannot reliably differentiate VAP from the systemic inflammatory response syndrome in the face of confounding clinical factors. Using CPIS to determine appropriate duration of antimicrobial therapy for patients with trauma is costly and could be harmful by unnecessarily prolonging exposure to antibiotics. Therapeutic study, level III.

Colistin as a first choice antibiotic for the initial empiric antimicrobial therapy of ventilator-associated pneumonia

To the Editors: We read with great interest the article recently published in the European Respiratory Journal ( ERJ ) by Rios et al. 1 regarding ventilator-associated pneumonia (VAP) due to colistin susceptible-only microorganisms. The authors concluded that colistin could be a suitable antibiotic for the initial empiric antimicrobial therapy in their intensive care unit (ICU) since they identified 30 carbapenem-sensitive (Carb-S) and 31 colistin-sensitive (Col-S) isolates. In our seven-bed general ICU 184 patients were admitted during a period of 18 months with the following characteristics: 125 (67.9%) males; age (mean±sd) 57.8±22.7 yrs; Simplified Acute Physiology Score II 48.2±11.8; Acute Physiology and Chronic Health Evaluation II 19.1±5.7; mean ICU stay 36.7±36.9 days; mean mechanical ventilation duration 29.2±15.9 days; and a total of 3,262 ventilator days. A total of 52 (28.3%) VAP episodes (15.9 episodes per 1,000 ventilator days, with a mean clinical pulmonary infection score at VAP onset of 7.4±1.6) …

The Clinical Pulmonary Infection Score Poorly Predicts Pneumonia in Patients With Burns

The Clinical Pulmonary Infection Score (CPIS) has been reported to be a useful tool in the diagnosis of ventilator-associated pneumonia (VAP) in the critical care setting. However, the systemic inflammation associated with injury may limit the utility of CPIS in patients with burns. The purpose of this study was to determine the potential utility of CPIS in the management of burn patients. A retrospective review was performed on all burn patients who underwent quantitative culture to diagnose VAP from 2003 to 2005. CPIS was retrospectively calculated for each patient on the day of the procedure. The sensitivity, specificity, and predictive values of a CPIS greater than 6 for VAP diagnosis were calculated. In addition, CPIS scores of patients with and without pneumonia were compared using the Mann-Whitney U test. A total of 46 quantitative cultures were obtained in 28 patients during the study period. Average patient age was 45 +/- 19 years, average TBSA was 33 +/- 18%, and the average APACHE II score on admission was 16 +/- 6. Sixty-eight percent of patients had inhalation injury. Twenty-six quantitative cultures were positive, and 20 were negative. Mean CPIS was 5.7 for patients with negative quantitative cultures and 5.5 for patients with positive cultures (P = .41). The sensitivity of CPIS scoring was 0.3, and its specificity was 0.8. CPIS had a positive predictive value of 0.7 and negative predictive value of 0.5. CPIS--a reported reliable indicator of VAP in critically ill patients--did not accurately predict the presence of pneumonia in burn patients. VAP diagnosis in burn patients should still rely on clinical suspicion verified by quantitative culture.

Effect of Backrest Elevation on the Development of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia is a common complication of mechanical ventilation. Backrest position and time spent supine are critical risk factors for aspiration, increasing the risk for pneumonia. Empirical evidence of the effect of backrest positions on the incidence of ventilator-associated pneumonia, especially during mechanical ventilation over time, is limited. To describe the relationship between backrest elevation and development of ventilator-associated pneumonia. A nonexperimental, longitudinal, descriptive design was used. The Clinical Pulmonary Infection Score was used to determine ventilator-associated pneumonia. Backrest elevation was measured continuously with a transducer system. Data were obtained from laboratory results and medical records from the start of mechanical ventilation up to 7 days. Sixty-six subjects were monitored (276 patient days). Mean backrest elevation for the entire study period was 21.7 degrees . Backrest elevations were less than 30 degrees 72% of the time and less than 10 degrees 39% of the time. The mean Clinical Pulmonary Infection Score increased but not significantly, and backrest elevation had no direct effect on mean scores. A model for predicting the Clinical Pulmonary Infection Score at day 4 included baseline score, percentage of time spent at less than 30 degrees on study day 1, and score on the Acute Physiology and Chronic Health Evaluation II, explaining 81% of the variability (F=7.31, P=.003). Subjects spent the majority of the time at backrest elevations less than 30 degrees . Only the combination of early, low backrest elevation and severity of illness affected the incidence of ventilator-associated pneumonia.

Duration of action of a single, early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: a pilot study

Objective The purpose of this study was to describe the effect of an early post-intubation oral application of chlorhexidine gluconate on oral microbial flora and ventilator-associated pneumonia. Methods Thirty-four intubated patients were randomly assigned to chlorhexidine gluconate by spray or swab or to control group. Oral cultures were done at study admission, 12, 24, 48, and 72 hours, whereas the Clinical Pulmonary Infection Score (CPIS) was documented at study admission, 48, and 72 hours. Results Reductions in oral culture scores (less growth) were only found in the treatment groups (swab and spray); no reduction was found in the control group. There was a trend for fewer positive cultures in the combined treatment groups. The mean CPIS for the control group increased to a level indicating pneumonia (4.7 to 6.6), whereas the CPIS for the treatment group increased only slightly (5.17 to 5.57). Conclusions Trends in the data suggest that use of chlorhexidine gluconate in the early post-intubation period may mitigate or delay the development of ventilator-associated pneumonia.

Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited.

The clinical pulmonary infection score-original or modified-has been proposed for the diagnosis and management of ventilator-associated pneumonia. In 79 episodes of suspected pneumonia, we prospectively assessed the diagnostic accuracy of the physicians' clinical assessment of probability and of the modified clinical pulmonary infection score, both measured before (pretest) and after (post-test) incorporating gram stains results, using bronchoalveolar lavage fluid culture as the reference test. The pretest clinical estimate was inaccurate (sensitivity 50%, specificity 58%); the mean clinical pulmonary infection score at baseline was 6.5 +/- 1.3 (range, 3-9) and 5.9 +/- 1.7 (range, 3-9), respectively, for the 40 confirmed and the 39 nonconfirmed episodes (p = 0.07), and only slightly more accurate (sensitivity 60%, specificity 59%) than the clinical prediction. Incorporating the gram stain results of either directed or blind protected sampling increased the diagnostic accuracy (sensitivity and specificity of 85% and 49% and 78% and 56%, respectively) of the clinical score and increased the likelihood ratio for pneumonia of a score of more than six from 1.46 to 1.67 and 1.77. The clinical pulmonary infection score has low diagnostic accuracy; however, incorporating gram stains results into the score may help clinical decision making in patients with clinically suspected pneumonia.

The diagnosis of ventilator-associated pneumonia using non-bronchoscopic, non-directed lung lavages.

(1)To assess the diagnostic utility of quantitative cultures of non-bronchoscopic lung lavage (NBL) in ventilator-associated pneumonia and evaluate the role of the Bacterial Index; (2) To assess the predictive value of NBL surveillance quantitative cultures in ventilated patients; (3) To evaluate the Clinical Pulmonary Infection Score (CPIS) system in ventilated patients. A prospective comparison of NBL with bronchoscopic bronchoalveolar lavage and protected specimen brush. Three intensive care units in academic tertiary care centres. 145 adults ventilated for 72 h, with and without clinical signs of pneumonia. Sampling of lower airway secretions by NBL, bronchoalveolar lavage and protected specimen brush. Diagnostic reliability of quantitative cultures, Bacterial Index and CPIS. 34 episodes of clinical ventilator-associated pneumonia were documented in 32 patients. 9 episodes were confirmed by concordant blood/pleural culture or post-mortem lung examination. Qualitative concordance of the predominant pathogen between sequential NBL: bronchoalveolar lavage and protected specimen brush was 83 %. Sensitivity and specificity of non-directed bronchial lavage at a threshold of 10(4) CFU/ml were 68 % and 70 % respectively (p = 0. 003) and were comparable with the bronchoscopic methods. However, the low positive predictive value of NBL indicates that quantitation in the absence of clinical signs is unlikely to be useful. Bacterial Index did not improve discriminatory power of quantitation compared with bacterial load of predominant organism. Mean CPIS for confirmed pneumonia cases was 8.4 +/- 1.01, significantly higher than for non-pneumonia observations (p = < 0.0001). NBL is a simple, safe, cheap, readily-available method of diagnosing ventilator-associated pneumonia with comparable diagnostic accuracy to bronchoscopic techniques. Quantitation of respiratory tract cultures can exclude pneumonia in patients with equivocal clinical signs. The diagnostic threshold should vary depending on the length of ventilation, likelihood of pneumonia and antibiotic administration. The Bacterial Index is a flawed mathematical device that has no contributory role in pneumonia diagnosis. The CPIS has some diagnostic role in selected cohorts of ventilated patients.