non-VAP Group Research Articles

Changes in immune indicators and bacteriologic profile were associated with patients with ventilator-associated pneumonia.

The aim of this study is to explore and identify ventilator-associated pneumonia (VAP)-related prognostic immune factors and further detect the drug-resistant pathogens to establish the theoretical guidance for clinical prevention and treatment strategies of VAP. A total of 478 patients using ventilator who were hospitalized in July 2014 to November 2016 in our hospital were enrolled in this study. About 103 patients with VAP (21.5%, 103/478) among 478 cases of patients using ventilator. Among the 103 patients with VAP, the distribution of pathogenic bacteria and drug resistance in patients with VAP were detected and analyzed. In the VAP group, 35 patients died and 43 patients had simultaneous sepsis. Compared with those of non-VAP group, the proportion of CD3+ (P = .012), CD3+CD4+ (P = .024) and CD8+CD28+ ( P = .017) T cells in VAP group increased significantly, which indicated more severe immune response. Multivariate regression model analysis revealed that tracheotomy of mechanical ventilation (P = .013), mechanical ventilation time ≥7 days (P = .02) and aspiration and reflux (P = .011) were independent risk factors associated with VAP. According to the results of bacterial culture and drug sensitivity test, rational selection of antibiotics and monitoring of patients within intensive care unit can effectively control the incidence of VAP and improve the prognosis of patients.

C-Reactive Protein Kinetics in Prognosis of Ventilator Associated Pneumonia

Introduction: Prognosis of Ventilator Associated Pneumonia (VAP) is commonly predicted by on-site assessment of clinical, haematological and biochemical parameters. Sequential measurement of C-Reactive Protein (CRP) which is one of the low-cost biomarkers could be useful in the early identification of poor outcome of VAP. Aim: To assess the prognostic value of progressive CRP levels in patients with VAP and compare with non-VAP group of ventilated patients. Materials and Methods: This was a prospective observational cohort study at medico-surgical ICU between November 2017 and October 2018. The patients on mechanical ventilator for more than 48 hours were divided into VAP (n=27) and non-VAP group (n=38). VAP was considered based on modified Clinical Pulmonary Infection Score (CPIS) more than 6 along with microbiological evidence from Tracheal aspirate or Bronchoalveolar lavage fluid with consolidation in Chest X-ray. Study subjects were monitored for the development of VAP. CRP measurements were done daily for the first 7 days then on 14th day. The evolution of mean CRP concentration throughout the course of VAP and non-VAP were analysed and compared between survivors and non-survivors. Results: Mean CRP level of VAP patients on the day of diagnosis was almost similar to non-VAP cohort. The mean CRP of non-survivor groups of both VAP and non-VAP patients had shown a gradual increase after day 4. However, the mean CRP after day 4, in the survivor group of both VAP and non-VAP showed either decreasing or unchanged trends. Conclusion: It was evident that the dynamics of the CRP levels in patients with VAP can be used to assess the effects of the therapy for a better outcome.

A STUDY OF VENTILATOR-ASSOCIATED PNEUMONIA: INCIDENCE, OUTCOME, RISK FACTORS AND MEASURES TO BE TAKEN FOR PREVENTION

Background: Pneumonia is the second most common nosocomial infection among critically ill patients, affecting 27% of all critically ill patients.
 Methods: The study was conducted in an intensive care unit (ICU) of a tertiary care centre. A total of 100 patients who were kept on mechanical ventilator were randomly selected. Cases included were patients of both sexes who were kept on mechanical ventilator for more than 48 h, having the age of >15 years. Patients who died or developed pneumonia within 48 h or those who were admitted with pneumonia at the time of admission and patients of ARDS (Acute Respiratory Distress Syndrome) were excluded from the study.
 Results: The mean duration of mechanical ventilation was found to be 12.3±3.1 days for the non-VAP group and 19.1 ±4.2 days for the VAP group that those requiring prolonged ventilator support (>15 days) had a significantly higher incidence of VAP (P-value, 0.001). Supine position and stuporous, comatose patients were found to be risk factors, having a high incidence of VAP, and proved to be statistically significant.
 Conclusion: Incidence is directly proportional to duration of mechanical ventilation and re-intubation is a strong risk factor for development of VAP. Therefore, duration of ventilation has to be reduced to get rid of morbidity and mortality associated with mechanical ventilation, which can be achieved by administering a proper weaning protocol and titrating sedation regimens as per the need of the patients.
 Keywords: Incidence, Infection, ICU

Effect of post-pyloric feeding by spiral nasoenteric tubes on ventilator-associated pneumonia in neurocritical care patients: a retrospective analysis of three clinical randomized controlled trials

To explore the effect of post-pyloric feeding by spiral nasoenteric tubes on ventilator-associated pneumonia (VAP) in neurocritical care patients. A retrospective study was performed to analyze the clinical data of 175 neurocritical care adult patients with mechanical ventilation (MV) more than 48 hours, who were enrolled in three randomized controlled trials (RCT) conducted by Guangdong Provincial People's Hospital for post-pyloric tube placement between April 2012 to March 2019. The following patient clinical data were collected when patients were enrolled: gender, age, neurologic diagnosis, comorbidities, medication, endotracheal reintubation, bronchoscope treatment, the distal site of nasoenteric tubes, and acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, Glasgow coma scale (GCS) score, and acute gastrointestinal injury (AGI) grade assessed. Patients were divided into VAP group and non-VAP group according to the occurrence of VAP, and the differences of each index between the two groups were compared. Then the influencing factors of P < 0.1 were included in multivariate Logistic regression analysis to identify the potential risk factors affecting the incidence of VAP. Furthermore, patients were divided into gastric feeding group and post-pyloric feeding group according to the distal site of nasoenteric tubes, and subgroup analysis was performed to evaluate the variety of VAP in patients with different tube sites and status. (1) Forty-two patients occurred VAP in 175 MV patients, and the incidence of VAP was 24.0%. (2) Univariate analysis showed the P value of post-pyloric feeding, APACHE II score, GCS score and bronchoscope treatment were less than 0.1, and post-pyloric feeding and GCS score in VAP group were significantly lower than those in non-VAP group [post-pyloric feeding: 19.0% (8/42) vs. 36.8% (49/133), GCS: 5 (3, 7) vs. 6 (4, 9), both P < 0.05]. Multivariate Logistic regression analysis indicated that post-pyloric feeding was independent protective factor [odds ratio (OR) = 0.360, 95% confidence internal (95%CI) = 0.151-0.857, P = 0.021] and bronchoscope treatment was the independent risk factor (OR = 2.210, 95%CI = 1.051-4.647, P = 0.036) for VAP. (3) The incidence of VAP was 28.8% (34/118), 0% (0/4), 8.3% (1/12), 26.7% (4/15), 22.2% (2/9) and 5.9% (1/17) respectively when tube tip in stomach, D1, D2, D3, D4 and jejunum confirmed by abdominal radiography. Post-pyloric feeding in each proportion seemed to present lower VAP rate compared with gastric feeding, however, no significant difference was found (all P > 0.05). (4) The incidence of VAP in post-pyloric feeding group was significantly lower than that in gastric feeding group [14.0% (8/57) vs. 28.8% (34/118), OR = 0.403, 95%CI = 0.173-0.941, P = 0.032]. Lower VAP rate appeared on patients with SOFA < 12 (OR = 0.392, 95%CI = 0.154-0.995, P = 0.044) and AGI grade ≥ II (OR = 0.086, 95%CI = 0.011-0.705, P = 0.006) fed by post-pyloric route according to the result of subgroup analysis stratified by age, gender, APACHE II score, SOFA score and AGI grade. Post-pyloric feeding would decrease the incidence of VAP in neurocritical care patients on MV.

Analysis of high risk factors and prognosis of patients with ventilator associated pneumonia treated with mechanical ventilation in ICU

Objective To analyze the high risk factors and prognosis of patients with ventilator associated pneumonia(VAP) treated with mechanical ventilation(MV) in Intensive Care Unit(ICU), and to provide theoretical evidence for effective treatment and prevention. Methods From January 2015 to January 2017, 156 MV patients treated in ICU of Shaoxing Municipal Hospital were enrolled retrospectively.According to the occurrence of VAP, the patients were divided into VAP group(76 cases) and non-VAP group(80 cases). The data including sex, age, ICU time, MV time, cases of withdrawing machine failure, prognosis, serum albumin, blood glucose levels, APACHE Ⅱ score, types of antibiotics and days of continuous applying were recorded.Single factor χ2 test and multiple factor logistic regression analysis were used to analyze the high-risk factors and prognosis related to occurrence of VAP. Results Univariate analysis showed that the age, mortality, serum albumin and blood glucose levels, MV time, weaning failure rate, APACHE Ⅱ score, antibiotic combination type and days of continuous use, application of H2 receptor antagonists time between, the VAP group and non-VAP group had statistically significant differences (χ2=6.568, 16.558, 5.132, 5.896, 27.043, 15.018, 48.863, 46.752, 27.431, 3.981, P=0.010, 0.000, 0.023, 0.015, 0.000, 0.000, 0.000, 0.000, 0.000, 0.046). After age adjustment, logistic regression analysis showed that serum albumin 5 days, APACHE Ⅱ score>15 points, antibiotics continuous use>3 days, and antibiotic combination type>2 were independent risk factors for VAP(χ2=5.115, 5.984, 21.252, 18.043, 9.008, 14.545, P=0.030, 0.026, 0.000, 0.000, 0.007, 0.001). Compared with surviving patients with VAP, death patients lived longer in ICU and MV, and APACHE Ⅱ scores were higher(t=4.136, 6.382, 7.312, P=0.000, 0.000, 0.000). Conclusion There are multiple high-risk factors of VAP in patients treated with MV in ICU.The death demonstrated longer ICU time, MV time and higher APACHE Ⅱ score, need to be strengthened monitoring, early prevention and treatment. Key words: Pneumonia, ventilator-associated; Respiration, artificial; Risk factor; Prognosis; Intensive care units; Universal precautions; Glucocorticoids; Anti-bacterial agents; Albumin

Diagnostic value of HBP, PCT combined with APACHE Ⅱ score respectively in ventilator-associated pneumonia

Objective: To evaluate the diagnostic value of the heparin-binding protein (HBP), procalcitonin (PCT) and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score in ventilator-associated pneμmonia (VAP). Methods: A total of 160 patients who required tracheotomy or intubation and assisted breathing with invasive mechanical ventilator from the First Affiliated Hospital of Zhengzhou University from January 2015 to January 2017 was included in this prospective study,and divided into VAP group and no-VAP group based on if VAP happened or not; the VAP group was further divided into deterioration group and improvement group based on the curative effect after anti-infective treatment for 1 week. A total of 40 community acquired pneumonia (CAP) patients and 30 healthy volunteers were also included as control groups. The levels of HBP and PCT in blood of the subjects were tested with enzyme-linked immuno sorbent assay (ELISA) and chemiluminescence immunoassay (ECLIA) respectively, APACHE Ⅱ score was utilized to assess the severity of illness. The difference of HBP, PCT levels and APACHE Ⅱ score among the groups were analyzed. Receiver operating characteristic(ROC) curve was utilized to analyze the diagnostic value of HBP, PCT, APACHE Ⅱ score in VAP. Results: A total of 230 subjects participated in this study, including 68 VAP patients, 92 non-VAP patients, 40 CAP patients and 30 healthy volunteers. Before administration of mechanical ventilation, there were no statistically significant differences in HBP, PCT and APACHE Ⅱ score between VAP group and non-VAP group (all P>0.05). The levels of HBP,PCT and APACHE Ⅱ score were (41.4±21.3) μg/L,(0.355±0.254) μg/L,(13.4±2.5) respectively when the VAP was diagnosed,which were higher than those within the first 12 h of mechanical ventilation (7.3±2.7) μg/L, (0.080±0.038) μg/L, (8.4±2.0), all P<0.001). The HBP, PCT and APACHE Ⅱ score had no significant difference between within the first 12 h of mechanical ventilation and after mechanical ventilation in non-VAP group (all P>0.05). The levels of HBP was positively correlated with PCT and APACHE Ⅱ score (r=0.82, 0.68, all P<0.001). In deterioration group,the HBP,PCT and APACHE Ⅱ score after 1 week of anti-infective treatment were higher than those when the VAP was diagnosed (all P<0.001). No matter it is when the VAP was diagnosed or after anti-infective treatment for 1 week,the levels of HBP, PCT and APACHE Ⅱ score in deterioration group were higher than those in the improvement group (all P<0.001). The area under curve (AUC) of HBP+APACHE Ⅱ score, PCT+APACHE Ⅱ score for VAP diagnosis was 0.98, 0.95 respectively. The sensitivity of HBP+APACHE Ⅱ score in the diagnosis of VAP was lower than PCT+APACHE Ⅱ score (94.1% vs 95.6%),and the specificity was higher (92.4% vs 82.6%). Conclusion: The diagnostic value of HBP+APACHE Ⅱ score for early VAP is superior to PCT+APACHE Ⅱ score.

Lung Ultrasound Combined With Procalcitonin for a Diagnosis of Ventilator-Associated Pneumonia

Lung ultrasound is a valuable imaging tool in the diagnosis of community-acquired pneumonia. However, its diagnostic accuracy in ventilator-associated pneumonia (VAP) has not been fully investigated. The aim of this study was to evaluate the diagnostic performance of the combination of a lung ultrasound with procalcitonin (PCT) in mechanically ventilated subjects with symptoms suggestive of pneumonia. A prospective study of 124 subjects with suspected VAP in 2 multidisciplinary ICUs was conducted between December 2016 and October 2017. Lower respiratory tract specimens were collected from all the subjects at enrollment and on the following 3 d. PCT assays were performed within 1 h of enrollment. Lung ultrasound and then computed tomography of the chest were performed within 24 h to detect lung consolidations. The subjects were divided into VAP and non-VAP groups according to the results of a computed tomography of the chest and semi-quantitative culture of the lower respiratory tract sample. A total of 124 subjects were included (48 in the VAP group and 76 in the non-VAP group). A positive lung ultrasound result combined with PCT of ≥0.25 ng/mL diagnosed VAP, with a sensitivity and specificity of 81.3 and 85.5%, respectively. The area under the receiver operating characteristic curve was significantly higher for lung ultrasound combined with PCT than for a white blood cell count, PCT, C-reactive protein, or Clinical Pulmonary Infection Score alone. A combination of lung ultrasound and PCT was accurate in the diagnosis of VAP. Lung ultrasound is a useful lung-imaging tool to assist VAP diagnosis.

A novel biomarker of serum Histidine-Rich Glycoprotein (HRG) for diagnosing and predicting prognosis of ventilator-associated pneumonia (VAP): a pilot study.

Histidine-Rich Glycoprotein (HRG) has been reported to be associated with idiopathic pulmonary fibrosis, cancer, and sepsis as a novel biomarker. However, there is limited evidence regarding its value in diagnosing or prognosis evaluating of ventilator-associated pneumonia (VAP). A total of 186 patients intubated in ICU and 65 healthy volunteers were enrolled in this study. Patients were divided into VAP group (n = 116), non-VAP group (n = 70) and control group (n = 65). The HRG, C reactive protein (CRP) and procalcitonin (PCT) levels were measured 72 hours after intubation, while blood sample was acquired from healthy controls for the test. HRG of VAP group was significantly lower than non-VAP group and control group (p < 0.001), while CRP and PCT were significantly higher (p < 0.001). The ROC analysis showed that the AUC of HRG was 0.777 95% CI (0.708-0.847) with a cut-off value of 38.55 μg/mL, which was lower than CRP [AUC = 0.912, 95% CI (0.847-0.950)] and PCT [AUC = 0.818, 95% CI (0.759-0.876)]. No linear correlation was found between HRG and CRP, as well as PCT (p > 0.05). However, the survival analysis showed that patients with higher level of HRG had a significantly higher survival rate (p < 0.001). The multivariate Cox regression analysis also demonstrated that the higher level of HRG was associated with better survival [HR 0.290, 95% CI (0.131-0.641), p = 0.002]. Serum HRG decreases when the patient develops VAP, which might be used as a biomarker for the diagnosis of VAP, with relatively less accuracy than PCT and CRP. However, HRG is valuable in predicting the clinical outcomes of mechanical ventilation patients.

Soluble triggering receptor expressed on myeloid cells-1 as a useful biomarker for diagnosing ventilator-associated pneumonia after congenital cardiac surgery in children.

The present study aimed to assess the usefulness of soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) in the diagnosis of ventilator-associated pneumonia (VAP) in paediatric patients with congenital heart disease (CHD) following cardiac surgery. The current prospective study enrolled 48 patients with congenital heart diseases who were suspected of having VAP; these patients were undergoing cardiac surgery between August 2016 and October 2017 in the Cardiac Intensive Care Unit of Shanghai Children's Medical Center (Shanghai, China). A total of 31 patients were diagnosed with VAP using a polymerase chain reaction (PCR) assay, while 17 patients without VAP were designated as the Non-VAP group. A bronchoscopy was performed and samples were collected for measurement on the day that VAP was diagnosed. The sTREM-1 levels were measured in bronchoalveolar lavage fluid (BALF) and exhaled ventilator condensate (EVC). BALF specimens were also sent to the microbiology laboratory for PCR assays and quantitative culturing. The positive detection rate of bacteria using the PCR assay and traditional culture was 64.6% (31/48) and 39.6% (19/48). sTREM-1 was significantly higher in the BALF (146.21 pg/ml vs. 118.06 pg/ml) and EVC (125.29 pg/ml vs. 120.48 pg/ml) of patients with VAP demonstrated compared with the patients without VAP. The findings suggest that the detection of sTREM-1 in BALF and EVC samples may be useful for the diagnosis of VAP following heart surgery in children.

Risk factors and etiological analysis of ventilator-associated pneumonia: three year's cases analysis of intensive care unit in county hospital

To investigate the risk factors of ventilator-associated pneumonia (VAP) and the distribution and drug resistance of pathogens in intensive care unit (ICU) of county hospital. 234 patients on mechanical ventilation for more than 48 hours admitted to ICU of Shexian People's Hospital of Huangshan City from January 2016 to June 2018 were enrolled. The clinical data of all patients including gender, age, past medical history, exposure to antibiotics, medication, the duration of mechanical ventilation, the length of ICU stay, serum albumin, tracheotomy, re-intubation, prognosis, and pathogenic bacteria and drug sensitivity test of VAP patients were collected. The patients were divided into VAP group and non-VAP group according to the occurrence of VAP. The differences of each index between the two groups were compared. The risk factors of VAP were analyzed by multivariate Logistic regression. The distribution and drug resistance of pathogenic bacteria in sputum culture of lower respiratory tract of VAP patients were analyzed. Among the 234 patients on mechanical ventilation, 95 patients had VAP, and the incidence of VAP was 40.60%. (1) Risk factors of VAP: it was shown by univariate analysis that there were significant differences between VAP patients and non-VAP patients in past history, the duration of mechanical ventilation, the length of ICU stay, albumin < 28 g/L, antibiotic exposure and tracheotomy, but there were no significant differences in gender, age, glucocorticoid, sedative, gastric motility and coma between the two groups. It was shown by multivariate Logistic regression analysis that brain injury and cerebrovascular accident, the duration of mechanical ventilation > 7 days, albumin < 28 g/L and tracheotomy were independent risk factors for VAP occurrence [brain injury: odds ratio (OR) = 41.40, 95% confidence interval (95%CI) = 2.14-799.60, P = 0.014; cerebrovascular accident: OR = 36.07, 95%CI = 1.86-699.64, P = 0.018; the duration of mechanical ventilation > 7 days: OR = 1.23, 95%CI = 1.11-1.36, P < 0.001; albumin < 28 g/L: OR = 2.27, 95%CI = 1.03-5.01, P = 0.042; tracheotomy: OR = 3.33, 95%CI = 1.30-8.56, P = 0.012]. (2) Distribution and drug resistance of VAP pathogens: a total of 108 strains of pathogens were isolated from sputum samples of 95 patients with VAP. Gram-negative (G-) bacteria accounted for 86.11% (93/108). The isolation rate of Klebsiella pneumoniae was the highest, reaching 31.48% (34/108); the isolation rates of Pseudomonas aeruginosa, Stenotrophomonas maltophilia and Acinetobacter baumannii were 22.22% (24/108), 8.33% (9/108) and 9.26% (10/108), respectively. Gram-positive (G+) bacteria accounted for 6.48% (7/108), of which Staphylococcus aureus was 4.63% (5/108); and fungi was 7.41% (8/108). Drug resistance analysis showed that Klebsiella pneumoniae was 100% sensitive to amikacin (AMK), meropenem (MEM) and polymyxin (POL), and were suggested as the preferred drug. Pseudomonas aeruginosa was 100% sensitive to AMK, tobramycin (TOB) and POL, but 100% resistant to compound trimethoprim (PCST). Stenotrophomonas maltophilia was 100% sensitive to PCST and 100% resistant to AMK, piperacillin (PIP), piperacillin tazobactam (TZP) and TOB. Acinetobacter baumannii was 100% sensitive to cefoxitin (FOX), cefuroxime (CXM) and POT. Staphylococcus aureus was 100% sensitive to gentamicin (GEN), furantoin (NIT), rifampicin (RIF), vancomycin (VAN) and teicoplanin (TEC), while the drug resistance to clindamycin (CLI) and penicillin (PEN) was high (both 80.00%). Most pathogens were multidrug-resistant. The mortality of patients with multidrug resistant bacteria infection was significantly higher than that of non-multidrug resistant bacteria infection [51.85% (28/52) vs. 30.56% (11/36), χ 2 = 4.240, P = 0.046]. VAP was associated with brain injury and cerebrovascular accident, duration of mechanical ventilation < 7 days, albumin > 28 g/L and tracheotomy. VAP patients were infected mainly with G- bacteria and showed multiple drug resistance.

Predictive value of α-amylase in tracheal aspirates for ventilator-associated pneumonia in elderly patients.

This study aims to investigate the correlation between α-amylase in tracheal aspirates and risk factors of aspiration, as well as ventilator-associated pneumonia (VAP), in elderly patients undergoing mechanical ventilation and explore the clinical value of α-amylase for predicting VAP. Tracheal aspirates were collected from elderly patients within 2weeks after tracheal intubation in mechanical ventilation, and α-amylase was detected. Patients were grouped according to the presence of VAP. The correlation between α-amylase and risk factors of aspiration before intubation, as well as VAP, were analyzed. The sample of this study comprised 147 patients. The average age of these patients was 86.9years. The incidence of VAP was 21% during the study period. Tracheal aspirate α-amylase level increased with the increase in the number of risk factors for aspiration before intubation, α-amylase level was significantly higher in the VAP group than in the non-VAP group, the area under the receiver operating characteristic curve (ROC) of the diagnostic value of α-amylase for VAP was 0.813 (95% CI: 0.721-0.896), threshold value was 4,681.5U/L, sensitivity was 0.801 and specificity was 0.793. Logistic multivariate analysis revealed the following risk factors for VAP: a number of risk factors before intubation of ≥3, a Glasgow score of <8 points, the absence of continuous aspiration of subglottic secretion and a tracheal aspirate α-amylase level of >4681.5U/L. Tracheal aspirate α-amylase can serve as a biomarker for predicting VAP in elderly patients undergoing mechanical ventilation.

Diagnostic value of sputum smear and simplified clinical pulmonary infection score of ventilator associated pneumonia in the early stage

Objective To explore the diagnostic value of sputum smear coupled with simplified clinical pulmonary infection score (CPIS) of ventilator associated pneumonia (VAP) in the early stage. Methods A cohort of 59 consecutive patients with VAP admitted in Intensive Care Unit from June, 2014 to June, 2016 were enrolled for a prospective and observational study. Concurrently, another 59 patients without pulmonary infection undergone mechanical ventilation over 48 hrs, were assigned into the control group. The criteria of exclusion were patients with pulmonary malignancies, autoimmune diseases and immunodeficiency. APACHEⅡscores of all patients were recorded. All patients’ inferior airway sputum which met the criteria was taken to make a validated sputum smear(i.e. polymorphonuclear leukocyte >25 and squamous epithelial cell <10 per low-power field) for Gram stain and culture on the admission day. Meanwhile, simplified CPIS were calculated. Data were statistically processed by SPSS 15.0, enumeration data were statistically analyzed by Chi-Square test, and measurement data were represented as Mean±SD. The significant differences in characteristics between two groups were analyzed by independent t test, and P<0.05 was considered statistically significant. As positive sputum smear and simplified CPIS≥5 were set respectively as a positive screening criterion, sensitivity, specificity, positive predictive value and negative predictive value of each marker and combined markers were calculated. Results There were no significant differences in demographics and clinical features (including age, sex, APACHEⅡscores) of patients in VAP and non-VAP patients (P>0.05). The rates of bacteria detected were Gram-negative [44.1% (26/59)], Gram-positive [40.6% (24/59)], none [10.2% (6/59)] and both [5.1% (3/59)] bacteria in VAP group, while [39.0% (23/59)], [30.5% (18/59)], [27.1% (16/59)] and [3.4% (2/59)] were found in non-VAP group correspondingly. There were no significant differences in the percentages of different bacteria in sputum smear between two groups(P>0.05). The values of diagnostic sensitivity of sputum smear and sputum smear coupled with simplified CPIS were 89.8% and 84.7%; the specificity were 27.1% and 79.7%; the positive predictive values were 55.2% and 80.6%; and the negative predictive values were 72.7% and 83.9%, respectively. Conclusions No matter the ventilated patients suffered VAP or not, bacteria might be detected from their lower respiratory tracts. Sputum smear could not be taken as an exclusively diagnostic evidence. While sputum smear coupled with simplified CPIS might improve the diagnostic efficacy of VAP, and provide the guildlines of appropriate choice of antibiotics employed in the early stage. Key words: Sputum smear and gram stain; Clinical pulmonary infection score; Ventilator associated pneumonia

Comparision of risk factors and pathogens in patients with early- and late-onset ventilator-associated pneumonia in intensive care unit

Objective: To compare risk factors and bacterial etiology in patients with early-onset versus late-onset ventilator-associated pneumonia (VAP) in intensive care unit (ICU). Methods: This prospective cohort study enrolled mechanically ventilated patients hospitalized for more than 48 hours in the first affiliated hospital, China Medical University from Jan 2012 to Jun 2016. Subjects were classified by ventilator status: early-onset VAP (< 5 d ventilation, E-VAP) or late-onset VAP (≥ 5 d ventilation, L-VAP). Potential risk factors and pathogen were evaluated. Results: A total of 4 179 patients in adult ICU were screened, 3 989 (95.5%) of whom were mechanically ventilated, 962 patients with mechanical ventilation time ≥ 48 h. VAP developed in 142 patients. E-VAP and L-VAP had different potential risk factors based on statistical analysis.Independent risk factors for E-VAP included male (OR=1.825, 95%CI 1.006-3.310), chronic obstructive pulmonary disease (COPD; OR=3.746, 95%CI 1.795-7.818), emergency intubation (OR=1.932, 95%CI 1.139-3.276), aspiration (OR=3.324, 95%CI 1.359-8.130). Whereas independent risk factors for L-VAP were coma (OR=2.335, 95%CI 1.300-4.194), renal dysfunction (OR=0.524, 95%CI 0.290-0.947), emergency intubation (OR=2.184, 95%CI 1.334-3.574). Mortality in E-VAP and L-VAP group were both higher than the non-VAP group[30.2%(19/63)vs 19.8%(162/820), P=0.044; 29.1%(23/79) vs 19.8%(162/820), P=0.046]. The pathogens isolated from early-onset versus late-onset VAP were not significantly different between groups, which the most common ones were acinetobacter baumannii, pseudomonas aeruginosa and klebsiella pneumoniae. Conclusion: E-VAP and L-VAP have different risk factors, however related pathogens are similar. Different specific preventive strategies are suggested based on different onset of VAP.

Researching the Changes of Serum Procalcitonin Levels in Ventilator-Associated Pneumonia Patients

Background: Ventilator-Associated Pneumonia (VAP) is the most common hospital acquired infection in the intensive care unit with high mortality rate. The role of the clinical symptoms for the VAP diagnosis is limited. Procalcitonin (PCT), currently interested biomarkers, plays an important role in the diagnosis and the outcome of the ventilator-associated pneumonia patients. Objective: To evaluate the changes of serum procalcitonin level for the diagnosis and the prognosis of the ventilator-associated pneumonia patients. Materials and Methods: One hundred twenty two mechanical ventilated cases at Intensive Care Unit were divided into the VAP group (n=63) and the non-VAP group (n=59) depending on whether the patients developed VAP after 48 hour of endotracheal intubations and mechanical ventilation or not. The serum procalcitonin level, Clinical Pulmonary Infection Score (CPIS) described by Pugin et al. Or Schurink et al. were determined at the following times: The starting of mechanical ventilation, the VAP onset, at days 3, 5, 7 after VAP. Results: Serum procalcitonin level>0.5 ng/ ml had a role at quite good VAP diagnosis with the Sensitivity (Se) 68.25% and the Specificity (Sp) 89.83%. When both Pugin’s CPIS and procalcitonin were positive, the diagnostic efficiency were Se 59.58% and Sp 97.06%. When both Schurink’s CPIS and procalcitonin were positive, the diagnostic efficiency were Se 51.99% and Sp 92.07%. Mortality rate was 5% at serum procalcitonin level<0.5 ng/ ml but it was 75% at serum procalcitonin level>10 ng/ ml. Conclusions: Procalcitonin has both the diagnosis value in the ventilator- associated pneumonia patients and the prognostic value in their treatment outcome and the mortality rate. Serum procalcitonin concentration >0.5 ng/ml had a role at quite good VAP diagnosis with the sensitivity 68.25% and the specificity 89.83%. The higher serum procalcitonin level was associated with the higher mortality rate and the mortality rate was 75% at serum procalcitonin level>10 ng/ ml in ventilator-associated pneumonia.

Incidence and outcome of ventilator-associated pneumonia in Inkosi Albert Luthuli and King Edward VIII Hospital surgical intensive care units

Background. Ventilator-associated pneumonia (VAP) is one of the most common causes of hospital morbidity and mortality, but has been poorly studied in the South African context. Objective. To evaluate the incidence and outcome of VAP in the intensive care units (ICUs) of two major centres in the Durban metropolitan area. Methods. The study was conducted over a period of 6 months with all intubated and mechanically ventilated patients who were screened on admission to ICU. A questionnaire was prepared to note patients’ age, gender, date and time of intubation or reintubation. Patients were monitored from date of admission to the date of discharge from ICU or death. A diagnosis of VAP was made on a clinical pulmonary infection score (CPIS) of ≥6. Results. Of 32 patients evaluated, eight patients (25%) were diagnosed with VAP. Median duration of ventilation in the VAP group was 249 hours v. 65.5 hours in the non-VAP group ( p =0.0002). We found no statistically significant association between age or gender with the development of VAP ( p =0.28 and p =0.59, respectively). The most common organism isolated was Acinetobacter baumannii , followed by Pseudomonas aeruginosa . Three of the eight (37.5%) patients diagnosed with VAP died in the ICU. Conclusion. VAP is common in critically ill patients, possibly associated with poor outcome. These results highlight the need for strict adherence to evidence-based preventive measures.

Incidence and outcome of ventilator-associated pneumonia in Inkosi Albert Luthuli and King Edward VIII Hospital surgical intensive care units

Background. Ventilator-associated pneumonia (VAP) is one of the most common causes of hospital morbidity and mortality, but has been poorly studied in the South African context. Objective. To evaluate the incidence and outcome of VAP in the intensive care units (ICUs) of two major centres in the Durban metropolitan area. Methods. The study was conducted over a period of 6 months with all intubated and mechanically ventilated patients who were screened on admission to ICU. A questionnaire was prepared to note patients’ age, gender, date and time of intubation or reintubation. Patients were monitored from date of admission to the date of discharge from ICU or death. A diagnosis of VAP was made on a clinical pulmonary infection score (CPIS) of ≥6. Results. Of 32 patients evaluated, eight patients (25%) were diagnosed with VAP. Median duration of ventilation in the VAP group was 249 hours v. 65.5 hours in the non-VAP group ( p =0.0002). We found no statistically significant association between age or gender with the development of VAP ( p =0.28 and p =0.59, respectively). The most common organism isolated was Acinetobacter baumannii , followed by Pseudomonas aeruginosa . Three of the eight (37.5%) patients diagnosed with VAP died in the ICU. Conclusion. VAP is common in critically ill patients, possibly associated with poor outcome. These results highlight the need for strict adherence to evidence-based preventive measures.

Novel Method to Improve Radiologist Agreement in Interpretation of Serial Chest Radiographs in the ICU.

Objectives:To determine whether a novel method and device, called a variable attenuation plate (VAP), which equalizes chest radiographic appearance and allows for synchronization of manual image windowing with comparison studies, would improve consistency in interpretation.Materials and Methods:Research ethics board approved the prospective cohort pilot study, which included 50 patients in the intensive care unit (ICU) undergoing two serial chest radiographs with a VAP placed on each one of them. The VAP allowed for equalization of density and contrast between the patients’ serial chest radiographs. Three radiologists interpreted all the studies with and without the use of VAP. Kappa and percent agreement was used to calculate agreement between radiologists’ interpretations with and without the plate.Results:Radiologist agreement was substantially higher with the VAP method, as compared to that with the non-VAP method. Kappa values between Radiologists A and B, A and C, and B and C were 46%, 55%, and 51%, respectively, which improved to 73%, 81%, and 66%, respectively, with the use of VAP. Discrepant report impressions (i.e., one radiologist's impression of unchanged versus one or both of the other radiologists stating improved or worsened in their impression) ranged from 24 to 28.6% without the use of VAP and from 10 to 16% with the use of VAP (χ2 = 7.454, P < 0.01). Opposing views (i.e., one radiologist's impression of improved and one of the others stating disease progression or vice versa) were reported in 7 (12%) cases in the non-VAP group and 4 (7%) cases in the VAP group (χ2 = 0.85, P = 0.54).Conclusion:Numerous factors play a role in image acquisition and image quality, which can contribute to poor consistency and reliability of portable chest radiographic interpretations. Radiologists’ agreement of image interpretation can be improved by use of a novel method consisting of a VAP and associated software and has the potential to improve patient care.

Risk factors for ventilator-associated pneumonia in patients with severe traumatic brain injury in a Serbian trauma centre

The aims of this study were (1) to assess the incidence of ventilator-associated pneumonia (VAP) in patients with traumatic brain injury (TBI), (2) to identify risk factors for developing VAP, and (3) to assess the prevalence of the pathogens responsible. The following data were collected prospectively from patients admitted to a 24-bed intensive care unit (ICU) during 2013/14: the mechanism of injury, trauma distribution by system, the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the Abbreviated Injury Scale (AIS) score, the Injury Severity Score (ISS), underlying diseases, Glasgow Coma Scale (GCS) score, use of vasopressors, need for intubation or cardiopulmonary resuscitation upon admission, and presence of pulmonary contusions. All patients were managed with a standardized protocol if VAP was suspected. The Sequential Organ Failure Assessment (SOFA) score and the Clinical Pulmonary Infection Score (CPIS) were measured on the day of VAP diagnosis. Of the 144 patients with TBI who underwent mechanical ventilation for >48h, 49.3% did not develop VAP, 24.3% developed early-onset VAP, and 26.4% developed late-onset VAP. Factors independently associated with early-onset VAP included thoracic injury (odds ratio (OR) 8.56, 95% confidence interval (CI) 2.05-35.70; p=0.003), ISS (OR 1.09, 95% CI 1.03-1.15; p=0.002), and coma upon admission (OR 13.40, 95% CI 3.12-57.66; p<0.001). Age (OR 1.04, 95% CI 1.02-1.07; p=0.002), ISS (OR 1.09, 95% CI 1.04-1.13; p<0.001), and coma upon admission (OR 3.84, 95% CI 1.44-10.28; p=0.007) were independently associated with late-onset VAP (Nagelkerke r(2)=0.371, area under the curve (AUC) 0.815, 95% CI 0.733-0.897; p<0.001). The 28-day survival rate was 69% in the non-VAP group, 45.7% in the early-onset VAP group, and 31.6% in the late-onset VAP group. Acinetobacter spp was the most common pathogen in patients with early- and late-onset VAP. These results suggest that the extent of TBI and trauma of other organs influences the development of early VAP, while the extent of TBI and age influences the development of late VAP. Patients with early- and late-onset VAP harboured the same pathogens.

High-risk primary disease and medical factors of ventilator-associated pneumonia in neonates: A Meta-analysis

Objective To provide the evidences for the management strategies of ventilator-associated pneumonia (VAP) in neonates, we systematically reviewed all related studies and analyzed the high-risk primary disease and medical factors of VAP in neonates. Methods We retrieved all related studies in CNKI, Wan-fang, VIP, CBM, Pubmed and Embase and evaluated their quality by Newcastle-Ottawa Scale and analyzed all data by qualitative and Meta-analysis. Results There were 12 case-control studies with higher methodological quality and involving 1 994 neonates and with 708 VAP patients. Six studies involving 872 neonates were in-cluded, the odds ratio of respiratory distress syndrome(OR=2.81) and malnutrition(OR=5.18) had significant differences between VAP and non-VAP group. Seven studies involving 1 110 neonates were included and the odds ratio of patients with corticosteroids (OR=3.12), central inhibitors (OR=2.31), antacids (OR=4.35) and Gamma globulin with large doses (OR=2.35) had significant differences between VAP group and non VAP. Four studies involving 554 neonates were included and the odds ratio of patients with closed chest drainage (OR=1.81)and umbilical vein catheterization (OR=9.19) had significant differences between VAP group and non VAP. Six studies involving 1 139 neonates were included and the odds ratio of patients with parenteral nutrition (OR=1.82)and blood transfusions (OR=2.49) had significant differences between VAP group and non VAP. Conclusions Our study confirms that the respiratory distress syndrome and malnutrition corticosteroids, central inhibitors, antacids, Gamma globulin with large doses, closed chest drainage, umbilical vein catheteriza-tion, parenteral nutrition and blood transfusions are important risk and early-warning factors. Key words: Neonates; Ventilator-associated pneumonia; Primary disease; Medical factors; Meta-analysis

Procalcitonin as a diagnostic marker of ventilator-associated pneumonia in cardiac surgery patients.

The aim of the present study was to assess whether procalcitonin (PCT) can be used as a diagnostic marker for ventilator-associated pneumonia (VAP) in cardiac surgery patients. Between January 2012 and June 2013, a total of 92 patients were recruited and divided into non-VAP (59 patients) and VAP (33 patients) groups. The preoperative and postoperative characteristics of the patients were recorded. Serum levels of PCT, interleukin (IL)-6 and C-reactive protein (CRP) were measured using an electrochemiluminescence immunoassay. Subsequently, receiver operating characteristic curves of the PCT, IL-6 and CRP levels were constructed. In addition, associations between the sequential organ failure assessment (SOFA) scores and the serum levels of PCT, IL-6 and CRP in the VAP patients were analyzed. No statistically significant difference was observed between the non-VAP and VAP patients in the occurrence of postoperative complications. However, the SOFA scores (days 1 and 7), the duration of stay in the intensive care unit and the mechanical ventilation time were all significantly higher in the VAP group when compared with the non-VAP group (P<0.05). The optimum PCT cut-off value for VAP diagnosis on day 1 was 5.0 ng/ml, with a sensitivity of 91% and a specificity of 71%. The serum PCT levels on days 1 and 7 were found to correlate positively with the SOFA scores (r=0.54 and r=0.66 for days 1 and 7, respectively). Therefore, the results suggested that serum PCT may be used as diagnostic marker for VAP in patients following cardiac surgery.