Pneumonia In ICU Patients Research Articles

Visualizing and diagnosing spillover within randomized concurrent controlled trials through the application of diagnostic test assessment methods

BackgroundSpillover of effect, whether positive or negative, from intervention to control group patients invalidates the Stable Unit Treatment Variable Assumption (SUTVA). SUTVA is critical to valid causal inference from randomized concurrent controlled trials (RCCT). Spillover of infection prevention is an important population level effect mediating herd immunity. This herd effect, being additional to any individual level effect, is subsumed within the overall effect size (ES) estimate derived by contrast-based techniques from RCCT’s. This herd effect would manifest only as increased dispersion among the control group infection incidence rates above background.Methods and resultsThe objective here is to explore aspects of spillover and how this might be visualized and diagnosed. I use, for illustration, data from 190 RCCT’s abstracted in 13 Cochrane reviews of various antimicrobial versus non-antimicrobial based interventions to prevent pneumonia in ICU patients. Spillover has long been postulated in this context. Arm-based techniques enable three approaches to identify increased dispersion, not available from contrast-based techniques, which enable the diagnosis of spillover within antimicrobial versus non-antimicrobial based infection prevention RCCT’s. These three approaches are benchmarking the pneumonia incidence rates versus a clinically relevant range, comparing the dispersion in pneumonia incidence among the control versus the intervention groups and thirdly, visualizing the incidence dispersion within summary receiver operator characteristic (SROC) plots. By these criteria there is harmful spillover effects to concurrent control group patients.ConclusionsArm-based versus contrast-based techniques lead to contrary inferences from the aggregated RCCT’s of antimicrobial based interventions despite similar summary ES estimates. Moreover, the inferred relationship between underlying control group risk and ES is ‘flipped’.

Application of FOCUS-PDCA program to reduce the incidence of ventilator-associated pneumonia in ICU patients

Application of FOCUS-PDCA program to reduce the incidence of ventilator-associated pneumonia in ICU patients

Construction and validation of a predictive model of pneumonia for ICU patients with traumatic brain injury (TBI).

The incidence of pneumonia in ICU patients with TBI is very high, seriously affecting the prognosis. This study aims to construct a predictive model for pneumonia in ICU patients with TBI and provide help for the prevention of TBI-related pneumonia.Clinical data of ICU patients with TBI were collected from the Medical Information Mart for Intensive Care (MIMIC)-IV database and hospital data. Variables were screened by lasso and multivariate logistic regression to construct a predictive nomogram model, verified in internal validation cohort and external validation cohort by receiver operator characteristic (ROC) curve, calibration curve and decision curve analysis (DCA).A total of 1850 ICU patients with TBI were enrolled in the study from the MIMIC-IV database, including 1298 in the training cohort and 552 in internal validation cohort. The external validation cohort included 240 ICU patients with TBI from hospital data. Nine variables were selected from the training cohort by lasso regression and multivariate logistic regression, and a pneumonia prediction nomogram was constructed. This nomogram has a high discrimination in training, internal validation and external validation cohorts (AUC = 0.857, 0.877, 0.836). The calibration curve and DCA showed that this nomogram had a high calibration and better clinical decision-making efficiency.The nomogram showed excellent discrimination and clinical utility to predict pneumonia, and could identify pneumonia high-risk patients early, thus providing personalised treatment strategies for ICU patients with TBI.

Ventilator associated pneumonia in ICU patients: Systematic review

Ventilator associated pneumonia in ICU patients: Systematic review

Does chlorhexidine reduce the incidence of ventilator-associated pneumonia in ICU patients? A systematic review and meta-analysis

Does chlorhexidine reduce the incidence of ventilator-associated pneumonia in ICU patients? A systematic review and meta-analysis

Abstract P3080: S100A8/9 Is A Key Regulator For Normal Heart Function During Pseudomonas Aeruginosa Infection

Rationale: P. aeruginosa ( P.a ) infection can cause severe pneumonia in ICU patients that leads to cardiac inflammation and cardiac dysfunction. Growing evidence indicates that a large number of neutrophils are recruited to the site of P.a. infection and releases S100A8/9 into the microenvironment. S100A8/9 has been shown to activate both the immune system (TLR4/RAGE) and has bactericidal properties. Often, hyperactivation of the inflammatory responses by S100A8/9 causes cardiac inflammation and dysfunction. Thus, we hypothesize that excessive production of S100A8/9 restrict bacterial growth and enhances the host immune response in order to control the infection and preserve heart function. Objective: To identify the mechanism of S100A8/9 mediated cardiac inflammation and cardiac dysfunction during P. aeruginosa infection. Methods and Results: To investigate the role of S100A8/9 in cardiac inflammation and cardiac dysfunction, we infected wild type (WT) and S100A8/9KO mice with P.a. intranasally. We monitored bodyweight at 24h intervals and measured weight loss, survival, and bacterial burden in the lungs and heart. We performed multicolor flow cytometry on BAL cells and heart cells for immune cell phenotyping and ELISA for cytokine levels. Also, we measured cardiac electric activity (EKG) and heart function (echocardiography). We found that bacterial burden in the lungs and heart was higher in S100A8/9KO mice than in WT, which correlated with increased mortality. We found severe cardiac electrical abnormalities (second-degree AV block) in S100A8/9KO mice and left ventricular dysfunction. However, there was no significant difference in the BALF immune cell phenotypes of both S100A8/9KO and WT infected mice. Finally, the S100A8/9 inhibitor enhanced the survival of P.a. infected mice. Conclusion: Our data demonstrate that neutrophil recruitment and release of S100A8/9 is critical to control bacterial growth in the lungs, however, uncontrolled neutrophil accumulation leads to excessive production of S100A8/9. Hyperactivation of the immune system by excessive S100A8/9 leads to systemic inflammation and bacterial dissemination of the heart. Furthermore, our studies revealed that blocking S100A8/9 receptor binding enhances the survival of mice during P.a. infection.

A Review on The Causative Agents, Risk Factors and Management of Ventilator-Associated Pneumonia: South Asian Perspective

Ventilator-Associated Pneumonia (VAP) is common hospital-acquired pneumonia in ICU patients. Patients with pneumonia after 48 hours of mechanical ventilation are VAP affected. INICC found that VAP rates between 2012 to 2017 are 14.1 per 1000 episodes. The most common pathogens include Acinetobacter baumannii, Pseudomonas Aeruginosa and Klebsiella pneumoniae. Developing countries seem to have a higher mortality rate compared to developed countries. Treatment protocol involves antibiotic therapy. For the early onset of VAP, cephalosporin (cefotaxime or ceftriaxone), fluoroquinolone, or piperacillin-tazobactam are found to be effective while for late-onset, ceftazidime, ciprofloxacin, meropenem, and piperacillin-tazobactam seems to have positive Results. Apart from antibiotics, other options like bacteriophage therapy can offer a good alternative to fight the rapid emergence of MDR pathogens. J MEDICINE 2022; 23: 151-161

Frequency of Stroke Acquired Pneumonia in Patients Admitted in Intensive Care Unit with Stroke

Introduction: Stroke is a highly morbid entity, and it can be fatal directly due to neurological damage and affecting the respiratory system or can add to overall morbidity and mortality due to its associated complications like stroke-associated pneumonia (SAP). Objective: The objective of this study was to investigate the prevalence of stroke-associated pneumonia in ICU patients. Study Design: This Descriptive case series was conducted in Saddique Family Hospital Gujranwala from October 2020 to April 2021. In this study, the cases of either gender agaged0 to 70 years suffering from stroke within 12 hours were included. SAP was labels on fever, cough, and non-homogenous opacities on chest X-ray. Results: In the present study, 160 cases of stroke were included, and out of these 82 (51.25%) were males and 78 (48.75%) females. The mean age of the subjects was 54.24±7.15 years and the mean duration of stroke was 7.05±2.54 hours. There were 35 (21.88%) cases that had DM, 28 (17.50%) had HTN and 30 (18.75%) of cases had a history of smoking. In 20 (12.50%) of the patients, stroke-acquired pneumonia (SAP) was discovered. With a p= 0.34, SAP was found in 12 (15.38%) female patients compared to 8 (9.75%) male cases. With a p= 0.15, SAP was more common in instances with DM, where it was detected in 7 (20%) of the cases compared to 13 (10.4%) in cases without DM. SAP was found in 5 (17.85%) instances of HTN and 4 (13.33%) cases of smoking history, with p values of 0.35 and 1.0, respectively. SAP was found in 15 (14.42%) patients with a stroke length of 6-12 hours, compared to 5 (8.92%) instances with a stroke duration of shorter than this, with a p= 0.45. Conclusion: Stroke acquired pneumonia is not uncommon and is seen in more than 1 out of every 10 cases and it is more seen in females and those with history of DM, HTN and duration of stroke 6 to 12 hours, though none of this variable was found statistically significant. Keywords: SAP, DM, HTN, Smoking.

Frequency Of Stroke Acquired Pneumonia in Patients Admitted in Intensive Care Unit with Stroke

Stroke is a highly morbid entity, and it can be fatal directly due to neurological damage and affecting the respiratory system or can add to overall morbidity and mortality due to its associated complications like stroke-associated pneumonia (SAP). Objective: To investigate the prevalence of stroke-associated pneumonia in ICU patients. Methods: A descriptive case series was conducted at Faisalabad Medical University from October 2020 to April 2021. In this study, the cases of either gender suffering from stroke within 12 hours were included. SAP was labelled on the basis of fever, cough, and non-homogenous opacities on chest X-ray. Results: In the present study, 160 cases of stroke were included, and out of these 82 (51.25%) were males and 78 (48.75%) females. The mean age of the subjects was 54.24±7.15 years and the mean duration of stroke was 7.05±2.54 hours. There were 35 (21.88%) cases that had DM, 28 (17.50%) had HTN and 30 (18.75%) of cases had a history of smoking. In 20 (12.50%) of the patients, SAP was discovered. With a p= 0.34, SAP was found in 12 (15.38%) female patients compared to 8 (9.75%) male cases. With a p= 0.15, SAP was more common in instances with DM, where it was detected in 7 (20%) of the cases compared to 13 (10.4%) in cases without DM. SAP was found in 5 (17.85%) instances of HTN and 4 (13.33%) cases of smoking history, with p values of 0.35 and 1.0, respectively. SAP was found in 15 (14.42%) patients with a stroke length of 6-12 hours, compared to 5 (8.92%) instances with a stroke duration shorter than this, with a p= 0.45. Conclusions: Stroke acquired pneumonia is not uncommon and is seen in more than 1 out of every 10 cases and it is more seen in females and those with a history of DM, HTN, and duration of stroke is 6 to 12 hours, though none of these variables was found statistically significant.

Frequency of Stroke Acquired Pneumonia in Patients Admitted In Intensive Care Unit with Stroke

Stroke is a highly morbid entity and it can be fatal directly due to neurological damage and affecting the respiratory system or can add to over all morbidity and mortality due to its associated complications like stroke associated pneumonia (SAP). Objective: To determine the frequency of stroke acquired pneumonia in ICU patients. Study Design: Descriptive case series. Settings: Department of Medicine, THQ Hospital, Sargodha. Period: Six months from October, 2020 to April, 2021 Material & Methods: In this study, the cases of either gender and age 30 to 70 years suffering from stroke within 12 hours were included. SAP was labelled on the basis of fever, cough and non homogenous opacities on chest X-ray. Results: In the present study, 160 cases of stroke were included and out of these 82 (51.25%) were males and 78 (48.75%) females. The mean age of the subjects was 54.24±7.15 years and mean duration of stroke was 7.05±2.54 hours. There were 35 (21.88%) cases that had DM, 28 (17.50%) had HTN and 30 (18.75%) of cases had history of smoking. Stroke acquired pneumonia (SAP) was seen in 20 (12.50%) of the cases. SAP was seen in 12 (15.38%) female cases as compared to 8 (9.75%) males with p= 0.34. SAP was more seen in cases with DM where this was observed in 7 (20%) of the cases as compared to 13 (10.4%) with no DM with p= 0.15. SAP was seen in 5 (17.85%) cases with HTN and 4 (13.33%) cases with history of smoking with p values of 0.35 and 1.0 respectively. SAP was seen in 15 (14.42%) cases with duration of stroke 6-12 hours in contrast to 5 (8.92%) cases with duration less than this with p= 0.45. Conclusion: Stroke acquired pneumonia is not uncommon and is seen in more than 1 out of every 10 cases and it is more seen in females and those with history of DM, HTN and duration of stroke 6 to 12 hours; though none of this variable was found statistically significant.

Effect Of Cluster Intervention Strategy Combined with Targeted Nursing on Prevention of Ventilator-Associated Pneumonia in Icu Patients

Background VAP is a common complication of ventilator maintenance therapy. The occurrence of VAP is related to many factors such as long duration of breathing, invasive operation, pollution of respiratory tubes and instruments, and low immunity of patients. The prevention of VAP in critically ill patients I the primary problem for clinical medical staff. Avoiding exogenous bacteria invading the respiratory tract and endogenous bacterial infection is the main method. Objective To investigate the value of optimized cluster nursing intervention combined with targeted nursing measures in reducing the incidence of ventilator-associated pneumonia (VAP) in patients with mechanical ventilation in intensive care unit (ICU). Methods 200 patients with mechanical ventilation in ICU of our institute from January 2017 to June 2020 were selected and randomly divided into study group and control group, with 100 cases in each group. The study group was treated with cluster nursing intervention combined with targeted nursing measures optimized by muItL criteria decision analysis method, and the control group was treated with targeted nursing measures. The incidence of VAP, the detection rate of pathogenic bacteria in sputum specimens and the effect of nursing execution were compared between the two groups. 200 patients were divided into VAP group and non-VAP group according to whether VAP occurred. Multivariate Logistic regression model analysis was used to explore the risk factors of VAP in AECOPD patients. Results A total of 4 strains were detected in the study group and 18 strains were detected in the control group. The detection rate of pathogenic bacteria in the study group was higher than that in the control group (y2=10.010, P=0.002<0.05). The incidence of VAP in the study group was 4.00% lower than 17.00% in the control group, and the difference was statistically significant (P<0.05). Compared with VAP group and non-VAP group, the proportion of patients with serum albumin<30g/L, diabetes mellitus rate, APACHE II score>15 points, tracheotomy rate and mechanical ventilation time≥5 days in VAP group were significantly higher than those in non-VAP group, which had statistical significance (P<0.05). The results of logistic regression model snowed that serum albumin ≥30g/L and optimized cluster nursing could effectively reduce the risk of VAP in ICU patients with mechanical ventilation (P<0.05). The risk of VAP in ICU patients with mechanical ventilation was increased by the combination of diabetes rate. APACHE II score≥15 points, tracheotomy and mechanical ventilation time ≥ 5 days (P<0.05). Conclusion The risk of VAP in ICU patients with mechanical ventilation is high, and the optimized cluster nursing intervention combined with targeted nursing measures can effectively reduce the incidence of VAP.

Neutrophil Extracellular Traps in SARS-CoV2 Related Pneumonia in ICU Patients: The NETCOV2 Study.

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a poorly understood disease involving a high inflammatory status. Neutrophil extracellular traps (NETs) have been described as a new pathway to contain infectious diseases but can also participate in the imbalance of the inflammatory and the coagulation systems. NETs could be a therapeutic target in COVID-19 patients.Methods: Consecutive patients with SARS-CoV2 related pneumonia admitted to the intensive care unit were included in a prospective bicentric study. Neutrophil extracellular trap concentrations were quantified in whole blood samples at day-1 and day-3 by flow cytometry. The primary outcome was the association between the blood NET quantification at ICU admission and the number of days with refractory hypoxemia defined by a PaO2/FIO2 ratio ≤100 mmHg.Results: Among 181 patients admitted to the ICUs for acute respiratory failure related to SARS-CoV2 pneumonia, 58 were included in the analysis. Patients were 62 [54, 69] years old in median, mostly male (75.9%). The median number of days with severe hypoxemia was 4 [2, 6] days and day-28 mortality was 27.6% (n = 16). The blood level of NETs significantly decreased between day-1 and day-3 in patients who survived (59.5 [30.5, 116.6] to 47 [33.2, 62.4] p = 0.006; 8.6 [3.4, 18.0] to 4 [1.4, 10.7] p = 0.001 and 7.4 [4.0, 16.7] to 2.6 [1.0, 8.3] p = 0.001 for MPO+, Cit-H3+, and MPO+ Cit-H3+ NETs, respectively) while it remained stable in patients who died (38.4 [26.0, 54.8] to 44.5 [36.4, 77.7] p = 0.542; 4.9 [1.3, 13.0] to 5.5 [2.8, 6.9] p = 0.839 and 4 [1.3, 13.6] to 2.7 [1.4, 4.5] p = 0.421 for MPO+, Cit-H3+, and MPO+ Cit-H3+ NETs, respectively). In multivariable negative binomial regression, the blood level of MPO+ NETs was negatively associated with the number of days with severe hypoxemia within 7 days (0.84 [0.73, 0.97]), while neither Cit-H3+ NETs nor double-positive NETs were significantly associated with the primary outcome.Conclusion: The whole blood level of NETs at day-1 was negatively associated with the number of days with severe hypoxemia in patients admitted to the intensive care unit for SARS-CoV2 related pneumonia. The lack of decrease of the blood level of NETs between day-1 and day-3 discriminated patients who died within day-28.

Abstract 457: Outer Membrane Vesicle From Pseudomonas Aeruginosa Causes Inflammation and Cardiac Dysfunction

Rationale: P. aeruginosa ( P.a ) infection causes severe pneumonia in ICU patients that lead to cardiac inflammation, eventual tissue remodeling, fibrosis, and cardiac complication. Growing evidence indicates that cardiac resident CCR2 - , MHC-II low macrophages function as important regulators of cardiac inflammation and steady-state heart function. After tissue injury or infection, inflammatory monocytes are recruited to the heart and differentiate into inflammatory macrophages, which contribute to cardiac inflammation and dysfunction. Our preliminary result showed P.a. infection causes cardiac inflammation, fibrosis, and cardiac dysfunction without disseminating into the heart tissue. Also, the gram-negative bacteria can release toxins or outer membrane vesicles (OMVs) that target host cells and induces apoptosis. Thus we hypothesize that the cardiac damage caused by P.a infection is mainly due to the release of bacterial toxins and OMVs or inflammatory mediators released by immune cells. Understanding the molecular mechanism of cardiac inflammation and dysfunction is critical for the development of host-directed therapy. Objective: To identify the mechanism of P.a induced inflammation and cardiac dysfunction to develop therapies to prevent cardiac damage during infection. Methods and Results: To investigate the role of OMVs in cardiac inflammation and cardiac dysfunction, we have isolated OMVs from P. aeruginosa culture supernatant and purified using ultracentrifugation followed by gradient centrifugation. We quantified OMVs and used to stimulate the MDMs, BMDMs and hiPSC cardiomyocytes. Our in vitro study showed that OMVs activates Akt and MAPK signaling pathways and induces the production of inflammatory cytokines from macrophages. Additionally, we found that OMVs incubation significantly reduced the hiPSC myocyte contraction. Conclusion: These studies demonstrated that OMVs from P.a induced inflammatory cytokine production and subsequent myocyte contractile dysfunction. Studies are ongoing to determine the role of OMVs on the action potential of hiPSC-CMs. In future, we will determine the impact of OMVs in cardiac dysfunction in mouse model.

A study to assess the effectiveness of oral care intervention on the occurance of ventilator associated pneumonia in ICU patients

A study to assess the effectiveness of oral care intervention on the occurance of ventilator associated pneumonia in ICU patients

Lung ultrasound versus chest radiograph in the diagnosis of pneumonia in ICU patients

Lung ultrasound versus chest radiograph in the diagnosis of pneumonia in ICU patients

Pneumonia in severely injured patients with thoracic trauma: results of a retrospective observational multi-centre study

BackgroundWhile the incidence and aspects of pneumonia in ICU patients has been extensively discussed in the literature, studies on the occurrence of pneumonia in severely injured patients are rare. The aim of the present study is to elucidate factors associated with the occurrence of pneumonia in severely injured patients with thoracic trauma.SettingLevel-I University Trauma Centres associated with the TraumaRegister DGU®.MethodsA total of 1162 severely injured adult patients with thoracic trauma documented in the TraumaRegister DGU® (TR-DGU) were included in this study. Demographic data, injury severity, duration of mechanical ventilation (MV), duration of ICU stay, occurrence of pneumonia, bronchoalveolar lavage, aspiration, pathogen details, and incidences of mortality were evaluated. Statistical evaluation was performed using SPSS (Version 25.0, SPSS, Inc.) software.ResultsThe overall incidence of pneumonia was 27.5%. Compared to patients without pneumonia, patients with pneumonia had sustained more severe injuries (mean ISS: 32.6 vs. 25.4), were older (mean age: 51.3 vs. 47.5) and spent longer periods under MV (mean: 368.9 h vs. 114.9 h). Age, sex (male), aspiration, and duration of MV were all independent predictors for pneumonia occurrence in a multivariate analysis. The cut-off point for duration of MV that best discriminated between patients who would and would not develop pneumonia during their hospital stay was 102 h. The extent of thoracic trauma (AISthorax), ISS, and presence of pulmonary comorbidities did not show significant associations to pneumonia incidence in our multivariate analysis. No significant difference in mortality between patients with and without pneumonia was observed.ConclusionsLikelihood of pneumonia increases with age, aspiration, and duration of MV. These parameters were not found to be associated with differences in outcomes between patients with and without pneumonia. Future studies should focus on independent parameters to more clearly identify severely injured subgroups with a high risk of developing pneumonia.Level of evidenceLevel II - Retrospective medical record review.

To Determine the Bacteriological Profile and Antibiotic Sensitivity Pattern of the Isolates Causing Ventilator Associated Pneumonia in ICU Patients

Background: Ventilator associated pneumonia (VAP) is a type of nosocomial pneumonia occurring in patients who are mechanically ventilated for more than 48 hours. VAP is the most common nosocomial infection occurring in the intensive care units and its incidence varies from 8% to 28%. AIMS & OBJECTIVES- This study was done to determine the bacteriological profile and antibiotic sensitivity pattern of the isolates obtained from the endotracheal aspirates of the clinically suspected patients of VAP in ICU. Materials & Methods: Ventilator associated pneumonia (VAP) is a type of nosocomial pneumonia occurring in patients who are mechanically ventilated for more than 48 hours. VAP is the most common nosocomial infection occurring in the intensive care units and its incidence varies from 8% to 28%. AIMS & OBJECTIVES- This study was done to determine the bacteriological profile and antibiotic sensitivity pattern of the isolates obtained from the endotracheal aspirates of the clinically suspected patients of VAP in ICU. Results: Out of 110 patients included in the study, only 85 patients were diagnosed as VAP patients based on clinical and microbiological criteria. Pseudomonas aeruginosa (35.55%) was the most common gram-negative isolate obtained in VAP cases followed by Escherichia coli (27.77%) and Acinetobacter baumanni (16.66%). Among Gram positive bacteria, Staphylococcus aureus 40 (80%) was the most common isolate. The most active antibiotic against the gram-negative isolates was imipenem (82.2%), followed by piperacillin-tazobactum (77.7%) and amikacin (63.3%). All the Gram-positive isolates were susceptible to vancomycin and linezolid. Conclusion: Due to the increasing incidence of multi drug resistant pathogens in ICU, early and correct diagnosis of VAP is an important challenge for critical care physicians. Hence, knowing the bacteriological profile causing VAP and their routine antibiotic susceptibility pattern can improve the patient’s clinical outcome.

Year in review 2011: Critical Care - infection

There is an ever-growing importance for critical assessment of benefits and harms of various strategies with regards to antibiotic stewardship, infection control, molecular detection of pathogens and adequate treatment of multidrug-resistant organisms in ICUs. Ongoing financial constraints globally, changing demographics with an increasing and aging population and the slow introduction of new antibiotics make the utilisation of the best available evidence and goal-directed strategies essential in the ICU setting. This review will summarise findings from some of the recent major publications in the area of infectious diseases with emphasis on the role of behaviour change strategies for infection control purposes, the role of biomarkers such as C-reactive protein and procalcitonin, and the impact of molecular diagnostics in clinical decision-making. Furthermore, we will update readers on some recent findings in relation to invasive fungal infections, community-acquired pneumonia and ventilator-associated pneumonia in ICU patients.

Epidemiology of ventilator-associated pneumonia in ICU patients

Ventilator-associated pneumonia (VAP) is the most frequent ICU-acquired infection among patients receiving mechanical ventilation. The aim of our study was to test the incidence, the rate of mortality and the impact of VAP to prolong the duration of ICU stay, in our both medical and surgical ICU.

Effect of an oral care protocol in preventing ventilator-associated pneumonia in ICU patients

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