Onset Of Ventilator-associated Pneumonia Research Articles

Distributions of Mechanically Ventilated Patients in Relation to Time and Incidences of VAE, VAC, IVAC, and VAP

SESSION TITLE: Mechanical Ventilation & Respiratory Failure II SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: Ventilator-associated events (VAE) are surveillance paradigms established by the CDC, and they denote three categories of increasing progression from a ventilator-associated condition (VAC), to an infection-related ventilator-associated condition (IVAC), and finally to ventilator-associated pneumonia (VAP). Moreover, the first criteria for VAC can only be met after 2 days of stable daily values (PEEP or FiO2). Following a period of two days of more of instability, additional specific criteria, such as WBCs, temperature, antimicrobial therapy, and a positive culture, would need to be met to move through the remaining categories. Considering VAEs are rather new in critical care, there has been a growing interest in quantifying these definitions for practical application. While a distinction exists between an early onset (the first 4 days) and a late onset (after the 4th day) of VAP, very little information exists on the duration of intubation before a VAE. Furthermore, some studies have looked at the incidence of early onset VAP in the ICU, found that the highest observed number of cases occurred in day 3 and 4 after admission and that the incidence increases with the duration of mechanical ventilation and the median time from ICU admission to the onset of the first episodes was 6 days. METHODS: We retrospectively examined patients’ data admitted to intensive care units (ICUs) at our institution from May 2013 through December 2015 with an emphasis on the numbers of days from intubation to the onset of any of the three categories of VAE. Total of 858 patients were included. Our final dataset consisted of 152 patients that met CDC-defined criteria as part of the hospital’s daily VAE surveillance routine. RESULTS: We found the following: Days to VAC: number of patients 82, median time to first episode 5.50, IQR 7.0. The days to IVAC: number of patients 38, median time to first episode 5.50, IQR 4.0. And the days to VAP: number of patients 32, median time to first episode 5.00, IQR 4.5 CONCLUSIONS: Although we used the time from intubation rather than the time from admission to the ICU as a starting point, the median values are very similar. Between 3-5 days from intubation, 50% of patients developed VAC and IVAC, while 60% developed VAP. Fewer cases occurred after 12 days in all three categories. Conversely, the majority of VAEs (61.8%) did occur after the 4th day. Our data highlights the need for prevention and control methods between day 3 and 9 of mechanical intubation to prevent most of these conditions. CLINICAL IMPLICATIONS: This study suggests to clinicians the peak time of developing VAP. Infection control measures need to be maximized throughout ICU stay and especially around the peak of incidence which was found to be around the 4th day of intubation. DISCLOSURE: The following authors have nothing to disclose: Hermann Simo, Aahd Kubbara, William Barnett, Reyna Altook, Wail Alamoudi, Rasha Nakity, Faisal Khateeb, Talia Tarazi, Nawaf Almeshal, Fadi Safi, Ragheb Assaly No Product/Research Disclosure Information

Management for Preventing Ventilator-Associated Pneumonia at ICU Panti Rapih Hospital: A Clinical Case Study

Background : Ventilator-Associated Pneumonia (VAP) is one kind of nosocomial infection that happens to patients who use mechanical ventilator and tracheostomy. Patients who are hospitalized in Intensive Care Unit (ICU) would have high risk onsuffering from Pneumonia. Objective : This paper aims to describe the interventions of nurses and to give recommendations for managing the VAP prevention using case study method. Methods : The data were collected from a patient who used mechanical ventilator and continued by observing and interviewing the nurses who took care of the patient. Results : The development of late onset of VAP was noticed after 96 hours. The observation result showed that there were fungi appeared after conducting a sputum culture from the patient. There was an increase of White Blood Cells on 72 hours after the intubation and the temperature increased until 37o C while the patient was using ventilator. Unfortunately, the nurses were not aware of the tendency of late onset VAP development in the patient. Discussion : Fungi are microorganism which causes VAP. The fungi were not proliferating because the patient had received early antibiotics for treatment. Early administration of antibiotics will prevent the development of VAP, but late VAP is associated with antibiotic-resistant organism. The significant increase of WBC count and the tendency of temperature while the patient was using ventilator were signs for developing infection. VAP can be prevented by conducting good oral hygiene every 2 hours using chlorhexidine 0.12% and using orogastric tube and ETT with sub glotticport to patients who use mechanical ventilator. Furthermore, positioning the patient’s head with 35o - 45o bed elevation is intended to prevent aspiration as well as checkingadequate endotracheal tube cuff of at least 20 cm H2. Conclusion : Awareness, responsibility, knowledge, skills of nurses are basis forinfection control especially for preventing VAP incidents.

Management for Preventing Ventilator-Associated Pneumonia at ICU Panti Rapih Hospital: A Clinical Case Study

Background : Ventilator-Associated Pneumonia (VAP) is one kind of nosocomial infection that happens to patients who use mechanical ventilator and tracheostomy. Patients who are hospitalized in Intensive Care Unit (ICU) would have high risk onsuffering from Pneumonia. Objective : This paper aims to describe the interventions of nurses and to give recommendations for managing the VAP prevention using case study method. Methods : The data were collected from a patient who used mechanical ventilator and continued by observing and interviewing the nurses who took care of the patient. Results : The development of late onset of VAP was noticed after 96 hours. The observation result showed that there were fungi appeared after conducting a sputum culture from the patient. There was an increase of White Blood Cells on 72 hours after the intubation and the temperature increased until 37o C while the patient was using ventilator. Unfortunately, the nurses were not aware of the tendency of late onset VAP development in the patient. Discussion : Fungi are microorganism which causes VAP. The fungi were not proliferating because the patient had received early antibiotics for treatment. Early administration of antibiotics will prevent the development of VAP, but late VAP is associated with antibiotic-resistant organism. The significant increase of WBC count and the tendency of temperature while the patient was using ventilator were signs for developing infection. VAP can be prevented by conducting good oral hygiene every 2 hours using chlorhexidine 0.12% and using orogastric tube and ETT with sub glotticport to patients who use mechanical ventilator. Furthermore, positioning the patient’s head with 35o - 45o bed elevation is intended to prevent aspiration as well as checkingadequate endotracheal tube cuff of at least 20 cm H2. Conclusion : Awareness, responsibility, knowledge, skills of nurses are basis forinfection control especially for preventing VAP incidents.

Clinical predictors and microbiology of ventilator-associated pneumonia in the intensive care unit: a retrospective analysis in six Italian hospitals.

The purpose of this study was to assess the main clinical predictors and microbiological features of ventilator-associated pneumonia (VAP) in the Intensive Care Unit (ICU) environment. This work is a retrospective analysis over one year from September 2010 to September 2011. Patients' risk factors, causes of admission, comorbidities and respiratory specimens collected in six Italian ICUs were reviewed. Incidence and case fatality rate of VAP were evaluated. After stratification for VAP development, univariate and multivariate analyses were performed to assess the impact of patients' conditions on the onset of this infection. A total of 1,647 ICU patients (pts) were considered. Overall, 115 patients (6.9%) experienced at least one episode of VAP. The incidence rate for VAP was 5.82/1,000 pts-days, with a case fatality rate of 44.3%. Multivariate analysis showed that admission for neurological disorders (aIRR 4.12, CI 1.24-13.68, p = 0.02) and emergency referral to ICU from other hospitals (aIRR 2.11, CI 1.03-4.31, p = 0.04) were associated with higher risk of VAP, whereas a tendency to a higher risk of infection was detected for admission due to respiratory disease, cardiac disease, trauma and for having obesity or renal failure. A total of 372 microbiological isolates from respiratory specimens were collected in VAP patients. The most common species were Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa, showing high resistance rates to carbapenems. Neurological disorders and emergency referral at the admission into the ICU are significantly associated with the onset of VAP. A high incidence of multi-drug resistant Gram-species was detected in the respiratory specimens.

Ventilator-Associated Pneumonia in Low Birth Weight Neonates at a Neonatal Intensive Care Unit: A Retrospective Observational Study

Ventilator-associated pneumonia (VAP) is one of the most common healthcare-associated infections among ventilated patients. The aim of this study was to determine the clinical characteristics and risk factors for the development of VAP in intubated low birth weight (LBW) neonates in a neonatal intensive care unit. LBW infants (<2.5kg) admitted to the neonatal intensive care unit of Kaohsiung Medical University Hospital from January 2005 to December 2009 were enrolled. We retrospectively analyzed perinatal and neonatal data of the enrolled intubated LBW infants by chart review. Six hundred and five LBW infants were analyzed. One hundred and fourteen of the infants were intubated for >48hours, 15 (13.2%) of whom had VAP. Of these 15 patients, the average age at onset of VAP was 24.0±11.2days, the average postmenstrual age was 30.6±1.8weeks, and the mean gestational age was 27.1±2.3weeks, which was significantly lower than the mean gestational age in the group without VAP (30.2±3.5weeks). The mean birth body weight was 944.4±268.4g in the VAP group and 1340.1±455.4g in the group without VAP (p<0.001). Longer duration of intubation (odds ratio: 1.35, 95% confidence interval: 1.12-1.62) and parenteral nutrition (odds ratio: 1.32, 95% confidence interval: 1.14-1.51) were found in the VAP group after adjusting for gestational age and birth weight. VAP was a problem for the LBW infants with intubation for >48hours in ourneonatal intensive care unit. VAP most frequently occurred at a postmenstrual age of 30-32weeks in this study. Longer duration of tube placement and parenteral nutrition were found in the VAP group. Early removal of the endotracheal tube and adequate enteral nutrition may decrease the occurrence of VAP in LBW infants.

Impact of ventilator-associated pneumonia on mortality and epidemiological features of patients with secondary peritonitis.

BackgroundDespite the significant impact of nosocomial infections on the morbidity and mortality of patients staying in the intensive care unit (ICU), no study over the past 20 years has focused specifically on VAP following secondary peritonitis. The objective of the present study was to determine in-hospital mortality and epidemiological features attributed to ventilator-associated pneumonia (VAP) following secondary peritonitis.MethodsProspective observational study involved 418 consecutive patients admitted in the ICU. Univariate and multivariate analyses were performed to identify risk factors associated with mortality and development of VAP.ResultsThe incidence of VAP following secondary peritonitis was 9.6 %. Risk factors associated with the development of VAP were hospital-acquired peritonitis, requiring >48 h of mechanical ventilation, and SOFA score. The onset of VAP was late in majority of patients. VAP was developed about 16.8 days after the initiation of the peritonitis. Etiological microorganisms responsible for the peritonitis were different than for VAP. The 90-day in-hospital mortality rate was 47.5 % of VAP patients. Independent factors associated with 30- to 90-day in-hospital mortality were VAP and SOFA.ConclusionsIn light of the impact on morbidity and mortality in the ICU, more attention should be given to the concurrent features among VAP and secondary peritonitis.

Empiric antimicrobial therapy for ventilator-associated pneumonia after brain injury.

Issues regarding recommendations on empiric antimicrobial therapy for ventilator-associated pneumonia (VAP) have emerged in specific populations.To develop and validate a score to guide empiric therapy in brain-injured patients with VAP, we prospectively followed a cohort of 379 brain-injured patients in five intensive care units. The score was externally validated in an independent cohort of 252 brain-injured patients and its extrapolation was tested in 221 burn patients.The multivariate analysis for predicting resistance (incidence 16.4%) showed two independent factors: preceding antimicrobial therapy ≥48 h (p<0.001) and VAP onset ≥10 days (p<0.001); the area under the receiver operating characteristic curve (AUC) was 0.822 (95% CI 0.770-0.883) in the learning cohort and 0.805 (95% CI 0.732-0.877) in the validation cohort. The score built from the factors selected in multivariate analysis predicted resistance with a sensitivity of 83%, a specificity of 71%, a positive predictive value of 37% and a negative predictive value of 96% in the validation cohort. The AUC of the multivariate analysis was poor in burn patients (0.671, 95% CI 0.596-0.751).Limited-spectrum empirical antimicrobial therapy has low risk of failure in brain-injured patients presenting with VAP before day 10 and when prior antimicrobial therapy lasts <48 h.

THE IMPACT OF TRACHEOTOMY ON THE CLINICALCOURSE OF VENTILATOR-ASSOCIATED PNEUMONIA

Ventilator-associated pneumonia (VAP) is the most common infection among intensive care unit (ICU) patients. The aim of the present study was to evaluate the impact of tracheotomy on VAP clinical course. The study was conducted in a 15-bed Surgical and Neurosurgical ICU, Department of Anesthesiology and Intensive Care, Sestre milosrdnice University Hospital Center in Zagreb, Croatia. All patients developing VAP during ICU stay were eligible for the study. In VAP patients not tracheotomized during ICU stay, the mortality rate was approximately two times higher as compared with patients tracheotomized either before or after VAP onset (crude risk ratio 1.83, 95% confidence interval (95% CI) 1.15-2.91, p = 0.01; crude odds ratio 3.47, 95% CI 1.52-7.94; p = 0.003). In the surviving VAP patients, the duration of mechanical ventilation before VAP onset was higher in the "T before VAP" group as compared with the "no T before VAP" group (8, 6-10 vs. 3, 2-5; p < 0.001), but the number of post-VAP days on mechanical ventilation was shorter in "T before VAP" patients than in "no T before VAP" patients (0, 0-1 vs. 4, 3-9; p < 0.001). The duration of mechanical ventilation after VAP onset in the "T after VAP" group was longer as compared with the "T before VAP" group (4, 3-12 vs. 0, 0-1; p < 0.001). The present study indicated tracheotomy to be associated with a reduced duration of mechanical ventilation after VAP onset, but only if patients were tracheotomized at the moment of VAP onset.

Efficacy of intermittent sub-glottic suctioning in prevention of ventilator-associated pneumonia- A preliminary study of 100 patients.

Background and Aims:Oropharyngeal colonisation followed by aspiration of contaminated secretions is the major cause for ventilator-associated pneumonia (VAP). Pooled secretions present in the sub-glottic area above inflated endotracheal tube cuff may be aspirated into the lower airways. It was hypothesised that intermittent suctioning of sub-glottic secretions would prevent VAP.Methods:Group I (n = 50) patients were intubated with HiLo Evac™ endotracheal (ET) tube with facility for sub-glottic suctioning, and Group II (n = 50) patients were intubated with HiLo Contour™ ET tube without such facility. In the Group I, sub-glottic suctioning was performed every 2 h. Incidence of VAP, mean ventilator days, Intensive Care Unit (ICU) stay and mortality were compared. Qualitative variables were reported as percentages and were compared by Chi-square test or unpaired two-tailed, Fisher's exact test, as appropriate, to analyse the significance of difference between the two groups.Results:The two groups were similar with respect to demographic characteristics. VAP was seen in 6% of patients in Group I and 22% of patients in Group II (P = 0.021). Both early- and late-onset VAPs were significantly reduced in Group I. Both ventilator days (8.0 vs. 6.45; P = 0.001) and ICU stay (8.33 vs. 6.33; P = 0.001) on the day of onset of VAP were significantly more in the Group I. Total ventilator days were significantly less (6.52 vs. 8.32; P = 0.006) with lower incidence of mortality (36% vs. 48%; P = 0.224) in the Group I.Conclusion:Intermittent sub-glottic suctioning reduces the incidence of VAP including late-onset VAP.

Ventilator-associated pneumonia in intensive care units of a tertiary care hospital in Punjab

IntroductionHealth care associated infections from invasive medical devices in intensive care pose the highest risk prolonging the hospital stay and cost for the patients. Ventilator-associated pneumonia (VAP) is an important infection in mechanically ventilated patients. Due to increasing incidence of multidrug-resistant organisms in intensive care units (ICUs), early and correct diagnosis of VAP is an urgent challenge for an optimal antibiotic treatment. ObjectivesThe aim of this study was to assess the incidence, commonest pathogens, and resistance pattern of isolates of VAP in ICUs of a tertiary care hospital. Material and methodsA prospective study was performed over a period of six months, enrolling patients undergoing mechanical ventilation for >48h. Endotracheal aspirates and bronchoalveolar lavage samples were collected from patients suspected of VAP and semi-quantitative cultures were performed on all samples. VAP was diagnosed by m-CPIS score (≥6). ResultsA total of 2369 patients were admitted in ICUs, of which 979 patients were on ventilator assistance (4165 ventilator days). Out of these, 47 (4.8%) patients developed VAP and early onset VAP was seen in 66% cases. The VAP rate was 11.03/1000 ventilator days. The commonest pathogen was Acinetobacter spp. followed by Pseudomonas spp. and Klebsiella spp. Most of the Acinetobacter spp. were resistant to cephalosporins, ciprofloxacin, and showed maximum susceptibility to tigecycline and polymyxin B. ConclusionsThe early onset VAP was more and incidence was high in males. This study highlights the predominance of resistant Gram-negative pathogens in VAP cases.

Silver-coated endotracheal tubes for prevention of ventilator-associated pneumonia in critically ill patients.

Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in intubated and mechanically ventilated patients. Endotracheal tubes (ETTs) appear to be an independent risk factor for VAP. Silver-coated ETTs slowly release silver cations. It is these silver ions that appear to have a strong antimicrobial effect. Because of this antimicrobial effect of silver, silver-coated ETTs could be an effective intervention to prevent VAP in people who require mechanical ventilation for 24 hours or longer. Our primary objective was to investigate whether silver-coated ETTs are effective in reducing the risk of VAP and hospital mortality in comparison with standard non-coated ETTs in people who require mechanical ventilation for 24 hours or longer. Our secondary objective was to ascertain whether silver-coated ETTs are effective in reducing the following clinical outcomes: device-related adverse events, duration of intubation, length of hospital and intensive care unit (ICU) stay, costs, and time to VAP onset. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10, MEDLINE, EMBASE, EBSCO CINAHL, and reference lists of trials. We contacted corresponding authors for additional information and unpublished studies. We did not impose any restrictions on the basis of date of publication or language. The date of the last search was October 2014. We included all randomized controlled trials (RCTs) and quasi-randomized trials that evaluated the effects of silver-coated ETTs or a combination of silver with any antimicrobial-coated ETTs with standard non-coated ETTs or with other antimicrobial-coated ETTs in critically ill people who required mechanical ventilation for 24 hours or longer. We also included studies that evaluated the cost-effectiveness of silver-coated ETTs or a combination of silver with any antimicrobial-coated ETTs. Two review authors (GT, HV) independently extracted the data and summarized study details from all included studies using the specially designed data extraction form. We used standard methodological procedures expected by The Cochrane Collaboration. We performed meta-analysis for outcomes when possible. We found three eligible randomized controlled trials, with a total of 2081 participants. One of the three included studies did not mention the amount of participants and presented no outcome data. The 'Risk of bias' assessment indicated that there was a high risk of detection bias owing to lack of blinding of outcomes assessors, but we assessed all other domains to be at low risk of bias. Trial design and conduct were generally adequate, with the most common areas of weakness in blinding. The majority of participants were included in centres across North America. The mean age of participants ranged from 61 to 64 years, and the mean duration of intubation was between 3.2 and 7.7 days. One trial comparing silver-coated ETTs versus non-coated ETTs showed a statistically significant decrease in VAP in favour of the silver-coated ETT (1 RCT, 1509 participants; 4.8% versus 7.5%, risk ratio (RR) 0.64, 95% confidence interval (CI) 0.43 to 0.96; number needed to treat for an additional beneficial outcome (NNTB) = 37; low-quality evidence). The risk of VAP within 10 days of intubation was significantly lower with the silver-coated ETTs compared with non-coated ETTs (1 RCT, 1509 participants; 3.5% versus 6.7%, RR 0.51, 95% CI 0.31 to 0.82; NNTB = 32; low-quality evidence). Silver-coated ETT was associated with delayed time to VAP occurrence compared with non-coated ETT (1 RCT, 1509 participants; hazard ratio 0.55, 95% CI 0.37 to 0.84). The confidence intervals for the results of the following outcomes did not exclude potentially important differences with either treatment. There were no statistically significant differences between groups in hospital mortality (1 RCT, 1509 participants; 30.4% versus 26.6%, RR 1.09, 95% CI 0.93 to 1.29; low-quality evidence); device-related adverse events (2 RCTs, 2081 participants; RR 0.65, 95% CI 0.37 to 1.16; low-quality evidence); duration of intubation; and length of hospital and ICU stay. We found no clinical studies evaluating the cost-effectiveness of silver-coated ETTs. This review provides limited evidence that silver-coated ETT reduces the risk of VAP, especially during the first 10 days of mechanical ventilation.

The role of PCT and CPIS score in the diagnosis of active pulmonary tuberculosis complicated with ventilator associated pneumonia

Objective To explore the value of the variation of clinical pulmonary infection score (CPIS) and serum procalcitonin (PCT) in diagnosis and treatment evaluation in patients suffering from active pulmonary tuberculosis with complication of ventilator-associated pneumonia (VAP). Methods A retrospective analysis was carried out in 58 VAP patients from June 1, 2009 to December 30, 2014 in the respiratory intensive care unit. According to the patient suffering from tuberculosis or not, patients were divided into two groups. The PCT and CPIS score changes were observed in the two groups of patients with intra-tracheal intubation 1, 3 and 7 days after VAP onset. Comparisons of CPIS and PCT scores were carried out between two groups at different intervals after VAP onset. Data were statistically processed by SPSS 19.0. Count data were tested by χ2, and measurement data were expressed by mean±standard deviation (±s). The comparison within the groups was made by t test, whereas the comparison between the groups was by means of repeated measure analysis of variance and Bonferroni test; Pearson linear correlation analysis was used, and P<0.05 was considered statistically significant. Results At the same observation interval in two groups of patients with VAP, there was no significant difference in the serum levels of PCT and CPIS score (P>0.05) ; there were significant differences in PCT and CPIS scores between VAP occurred at the first day, the third day and at time of intra-tracheal intubation in two groups (P 0.05). In addition, at the 7 days the correlation coefficient between PCT and survival patients'mechanical ventilation, days in ICU and total length of hospital stay were 0.92, 0.83, and 0.71, respectively, yet the 7-day CPIS score correlation coefficients were 0.83, 0.74 and 0.70, (both P<0.05) . Conclusions Early monitoring of serum PCT and CIPS score of pulmonary tuberculosis patients can judge the incidence of VAP, and the variations of PCT and CIPS score can predict the severity and prognosis of the disease as well. Key words: Ventilator associated pneumonia; Pulmonary tuberculosis; Procalcitonin; Clinical pulmonary infection score

Spectrum of Early Onset and Late Onset Ventilator Associated Pneumonia (VAP) in a Tertiary Care Hospital of Bangladesh: A Prospective Cohort Study

Objective : To compare the outcome of critically ill patients developing early onset Ventilator-associated pneumonia (VAP) occurring within 96 h of ICU admission and late onset VAP occurring after 96 h of ICU admission in critically ill patients admitted in the ICU of BIRDEM General Hospital of Bangladesh.Study Design: Prospective cohort study.Material and Methods: Study data obtained over a period of 24 months (July 2012 - June 2014) in the ICU of a tertiary care hospital was prospectively analyzed. Subjects were classified by ventilator status: early onset VAP (&lt; 96 hrs of mechanical ventilation) or late-onset VAP (?96 hrs of mechanical ventilation). Baseline demographics and bacterial etiology were analyzed according to the spectrum of status of VAP.Results: The incidence of VAP was 35.73 per 1,000 ventilator days. In our study 52% of the cases were early-onset VAP, while 48% were late-onset VAP. Acinetobacter was the commonest organism isolated from late-onset VAP (p = 0.029) while Pseudomonas was the commonest isolates obtained from early-onset VAP (p = 0.046). Klebsiella, MRSA and E. coli were almost identically distributed between groups (p &gt; 0.05). There is significant difference of sensitivity pattern of Acinetobacter baumannii and pseudomonas aeruginosa in both early and late-onset VAP (p=0.01). The overall mortality rate in our study was 44%. The mortality was significantly higher in the late-onset VAP (62.5%) than that in the early-onset VAP (26.9%) (p=0.011).Conclusion: From this study we conclude that late-onset VAP had poor prognosis in terms of mortality as compared to the early-onset type. The higher mortality in the late-onset VAP could be attributed to older age, higher co-morbidities like diabetes mellitus, COPD and CKD. The findings are similar to findings of other international studiesBangladesh Crit Care J March 2015; 3 (1): 9-13

Antifungal therapy in patients with pulmonary Candida spp. colonization may have no beneficial effects.

BackgroundIn critically ill patients, Candida spp. can often be identified in pulmonary samples. The impact of prompt antifungal therapy in these patients is unknown.MethodsIn this retrospective study, 500 adult patients with pulmonary Candida spp. colonization admitted to the intensive care unit (ICU) between 2010 and 2012 were included. The patients were analyzed according to whether or not they received antifungal therapy, which was administered at the discretion of the attending physician. Logistic regression analysis was performed to investigate the impact of antifungal therapy on hospital mortality and new onset of ventilator-associated pneumonia. In a stepwise backward elimination, the impact of age, cancer as an underlying disease, Simplified Acute Physiology Score (SAPS) II, and Sequential Organ Failure Assessment (SOFA) score were considered.ResultsAfter excluding 178 patients with multifocal Candida spp., isolated pulmonary Candida spp. colonization was found in 322 patients (cohort 1). Pre-existing pneumonia was found in 147/322 patients. Out of the remaining 175 patients (cohort 2), 44 patients received any antifungal therapy, and 131 were defined as the control group. Patients who received antifungal therapy had higher hospital mortality (50 vs. 30 %, p = 0.02) and pneumonia rates (47.7 vs. 16.8 %; p < 0.001) than those who did not. In Cox regression analysis, antifungal therapy was not independently associated with favorable outcome (mortality: odds ratio 0.854 (95 % CI 0.467–1.561); new pneumonia: 1.048 (0.536–2.046)), but SAPS II and SOFA score were significantly (p < 0.05) independent covariates for worse outcome.ConclusionsIn critically ill patients with pulmonary Candida spp. colonization, antifungal therapy may not have an impact on the incidence of new pneumonia or in-hospital mortality after adjustment for confounders.Electronic supplementary materialThe online version of this article (doi:10.1186/s40560-015-0097-0) contains supplementary material, which is available to authorized users.

Does Low-Dose Hydrocortisone Therapy Prevent Ventilator-Associated Pneumonia in Trauma Patients?

The incidence of ventilator-associated pneumonia (VAP) is particularly high in trauma patients. Immediate acute inflammation response is one of the hallmarks of multiple trauma. This phenomenon is associated with an immunosuppression state and may increase the risk of VAP. In our study, we aimed to evaluate whether low-dose steroids prevent VAP onset in multiple trauma patients. All adult patients admitted in our intensive care unit (ICU) for multiple trauma with predicted duration of mechanical ventilation over 48 hours were included. We compared 2 different periods: a retrospective cohort of patients who did not receive low-dose steroids for VAP prevention and a prospective cohort of patients who received hydrocortisone with a dose of 100 mg/8 hours for a scheduled period of 7 days. We included 175 patients: 92 in the steroids (-) group and 83 in the steroids (+) group. The incidence of VAP was not different between the 2 studied groups (29.3% and 26.5%; P = 0.676). When predictive factors of VAP onset were studied in multivariate analysis, steroids had no preventive effect on VAP [OR = 1.6; 95% confidence interval, 0.73-3.6; P = 0.234]. We did not find any difference between the 2 groups, neither in terms of ICU length of stay (respectively, 11 ± 9.7 days vs. 12.3 ± 10.7 days; P = 0.372) nor in terms of ICU mortality (29.3% vs 24.1%; P = 0.434).

Does Selective Digestive Decontamination Prevent Ventilator-Associated Pneumonia in Trauma Patients?

The incidence of ventilator-associated pneumonia (VAP) is particularly high in patients with trauma. The efficacy and safety of selective digestive decontamination (SDD) was not studied extensively. We aimed in our randomized double-blind, placebo-controlled study to evaluate whether SDD prevents VAP onset in multiple trauma patients. All adult patients admitted in our intensive care unit for multiple trauma with a predicted duration of mechanical ventilation (MV) over 48 hours were included. We included 44 patients who were divided into 4 groups: group A receiving subglottic and gastric treatment suspension (polymyxin E 100 mg, vancomycin 1 g, and amphotericin B 500 mg), group B receiving placebo, group C receiving subglottic placebo and gastric treatment suspension, and group D receiving subglottic treatment suspension and gastric placebo. The suspension was given 4 times a day during 7 consecutive days. To this topical treatment, we associated an intravenous administration of cefotaxime (1 g 3 times a day during 4 consecutive days). The incidence of VAP in the 4 groups was, respectively, 45.5%, 46.2%, 22.2%, and 27.3% (P=0.236). In multivariate analysis, none of the 3 tested regimens was identified as a protective factor against VAP. However, prolonged duration of MV was the only independent factor predicting VAP onset (odds ratio=1.1; 95% confidence interval [1.1-1.4]; P=0.049).

Microbial composition and antibiotic resistance of biofilms recovered from endotracheal tubes of mechanically ventilated patients.

In critically ill patients, breathing is impaired and mechanical ventilation, using an endotracheal tube (ET) connected to a ventilator, is necessary. Although mechanical ventilation is a life-saving procedure, it is not without risk. Because of several reasons, a biofilm often forms at the distal end of the ET and this biofilm is a persistent source of bacteria which can infect the lungs, causing ventilator-associated pneumonia (VAP). There is a link between the microbial flora of ET biofilms and the microorganisms involved in the onset of VAP. Culture dependent and independent techniques were already used to identify the microbial flora of ET biofilms and also, the antibiotic resistance of microorganisms obtained from ET biofilms was determined. The ESKAPE pathogens play a dominant role in the onset of VAP and these organisms were frequently identified in ET biofilms. Also, antibiotic resistant microorganisms were frequently present in ET biofilms. Members of the normal oral flora were also identified in ET biofilms but it is thought that these organisms initiate ET biofilm formation and are not directly involved in the development of VAP.

Microbiology, resistance patterns, and risk factors of mortality in ventilator-associated bacterial pneumonia in a Northern Thai tertiary-care university based general surgical intensive care unit.

BackgroundVentilator-associated pneumonia (VAP) occurrence, causative pathogens, and resistance patterns in surgical intensive care units (SICU) are different between Western and developing Asian countries. In Thailand, resistant organisms have progressively increased in the last decade. However, the evidence describing causes of VAP and its outcomes, especially secondary to resistant pathogens, in Asian developing countries’ SICUs is very limited. Therefore, the objective of this study was to describe the incidence, pathogen characteristics, and risk factors that impact mortality and patient survival following VAP in a tertiary Northern Thai SICU.MethodsBetween 2008 and 2012, VAP occurred in a total of 150 patients in Chiang Mai University’s general SICUs (6.3±2.8 cases per 1,000 mechanical ventilator days). The following clinical data were collected from 46 patients who died and 104 patients who survived: microbiologic results, susceptible patterns, and survival status at hospital discharge. Antimicrobial susceptibility patterns were classified as susceptible, multidrug resistant (MDR), extensively drug resistant (XDR), and pan-drug resistant (PDR). The hazard ratio (HR) was calculated for risk factor analysis.ResultsRegarding the microbiology, gram negative organisms were the major pathogens (n=142, 94.7%). The first three most common organisms were Acinetobacter baumannii (38.7% of all organisms, mortality 41.4%), Klebsiella pneumoniae (17.3%, mortality 30.8%), and Pseudomonas aeruginosa (16.7%, mortality 16%) respectively. The most common gram positive organism was Staphylococcus aureus (4.0%, mortality 50%). The median day of VAP occurrence were significantly different between the three groups (P<0.01): susceptible (day 4), MDR (day 5), and XDR (day 6.5). Only half of all VAP cases were caused by susceptible organisms. Antibiotic resistance was demonstrated by 49.3% of the gram negative organisms and 62.5% of the gram positive organisms. Extensive drug resistance was evident only in Acinetobacter baumannii (30.6%) and Pseudomonas aeruginosa (1.3%). No pan-drug resistance was found during surveillance. The significant HR risk factors were age (P=0.03), resistant organisms (P=0.04), XDR (P=0.02), and acute physiology and chronic health evaluation II score (<0.01). Acinetobacter baumannii (P=0.06) and intubation due to severe sepsis (P=0.08) demonstrated a trend toward a significant increase in the HR. On the other hand, there were significantly decreased HRs in trauma patients (P=0.01). Initial administration of appropriate antibiotic therapy had a tendency toward a significant decrease in the HR (P=0.08).ConclusionGram negative organisms were the primary cause of bacterial VAP in Chiang Mai University’s general SICU. Resistant strains were present in half of all VAP cases and were associated with the day of VAP onset. Regarding risk factors, age, acute physiology, chronic health evaluation II score, resistant organisms (especially XDR), and being a non-trauma patient increased the risk of mortality.

Azithromycin inhibits MUC5AC induction via multidrug-resistant Acinetobacter baumannii in human airway epithelial cells

Acinetobacter baumannii is one of the main pathogens that cause ventilator-associated pneumonia (VAP). Hypersecretion of mucin in the airway is associated with the onset of VAP. Furthermore, macrolides are known to accelerate the resolution of VAP. However, this mechanism has not been elucidated. We examined whether macrolides inhibit MUC5AC production that is induced by multidrug-resistant A. baumannii (MDRAB). MUC5AC production in bronchial cells after MDRAB stimulation was analyzed by enzyme-linked immunosorbent assay and quantitative reverse transcription-polymerase chain reaction. For the inhibition study, cells were treated with azithromycin (AZM) or clarithromycin (CAM) simultaneously along with MDRAB stimulation. Western blotting was performed was performed to determine potential rules for signal modules. MDRAB induced MUC5AC production and gene expression. The EGFR-ERK/JNK-NF-κB pathway was involved in MDRAB-induced MUC5AC production. AZM but not CAM inhibited MUC5AC production. AZM suppressed the phosphorylation of ERK/JNK and the nuclear translocation of NF-κB. Our results suggest that the efficacy of macrolides against VAP may be due to the inhibition of mucin production.

Effect of two methods of subglottic secretion drainage on the incidence of ventilator-associated pneumonia

To observe the effect of two different ways of subglottic secretion drainage on the incidence of ventilator-associated pneumonia. A total of 149 patients receiving mechanical ventilation from October 2007 to February 2010 in our hospital were enrolled in our study. According to the random number table, they were divided into 3 groups: a control group (47), a intermittent drainage group (54), and a continuous drainage group (48). There was no significant difference in APACHE II score before intubation in the patients of the 3 groups. Conventional treatment and care was performed in the control group, while subglottic rinse was performed every 4 h in the intermittent drainage group and continuous aspiration in the continuous drainage group. The incidence and mortality of ventilator-associated pneumonia were compared among groups within 30 days after intubation. The tolerance and complications were observed. The incidence rate of early onset ventilator-associated pneumonia in the intermittent drainage group (13.0%) and the continuous drainage group (14.6%) was significantly lower than that in the control group (40.4%), and the difference was statistically significant (χ(2) = 9.914, 7.978;P = 0.002,0.005), but there was no difference between the former 2 groups (χ(2) = 0.056; P = 0.812). There was no significant difference in the incidence of late-onset ventilator-associated pneumonia or mortality among groups (P > 0.05). Good tolerance of the 2 methods was observed. Subglottic secretion drainage by both the intermittent and the continuous methods can efficiently prevent early onset ventilator-associated pneumonia.