Prognosis Of Ventilator-associated Pneumonia Research Articles

Epidemiology, risk factors and prognosis of ventilator-associated pneumonia during severe COVID-19: Multicenter observational study across 149 European Intensive Care Units

BackgroundCOVID-19 patients requiring mechanical ventilation are particularly at risk of developing ventilator-associated pneumonia (VAP). Risk factors and the prognostic impact of developing VAP during critical COVID-19 have not been fully documented. MethodsPatients invasively ventilated for at least 48 h from the prospective multicentre COVID-ICU database were included in the analyses. Cause-specific Cox regression models were used to determine factors associated with the occurrence of VAP. Cox-regression multivariable models were used to determine VAP prognosis. Risk factors and the prognostic impact of early vs. late VAP, and Pseudomonas-related vs. non-Pseudomonas-related VAP were also determined. Main findings3388 patients were analysed (63 [55–70] years, 75.8% males). VAP occurred in 1523/3388 (45.5%) patients after 7 [5–9] days of ventilation. Identified bacteria were mainly Enterobacteriaceae followed by Staphylococcus aureus and Pseudomonas aeruginosa. VAP risk factors were male gender (Hazard Ratio (HR) 1.26, 95% Confidence Interval [1.09–1.46]), concomitant bacterial pneumonia at ICU admission (HR 1.36 [1.10–1.67]), PaO2/FiO2 ratio at intubation (HR 0.99 [0.98–0.99] per 10 mmHg increase), neuromuscular-blocking agents (HR 0.89 [0.76–0.998]), and corticosteroids (HR 1.27 [1.09–1.47]). VAP was associated with 90-mortality (HR 1.34 [1.16–1.55]), predominantly due to late VAP (HR 1.51 [1.26–1.81]). The impact of Pseudomonas-related and non-Pseudomonas-related VAP on mortality was similar. ConclusionVAP affected almost half of mechanically ventilated COVID-19 patients. Several risk factors have been identified, among which modifiable risk factors deserve further investigation. VAP had a specific negative impact on 90-day mortality, particularly when it occurred between the end of the first week and the third week of ventilation.

Using Restricted Cubic Splines to Study the Duration of Antibiotic Use in the Prognosis of Ventilator-Associated Pneumonia.

Background: Ventilator-associated pneumonia (VAP) is the most widespread and life-threatening nosocomial infection in intensive care units (ICUs). The duration of antibiotic use is a good predictor of prognosis in patients with VAP, but the ideal duration of antibiotic therapy for VAP in critically ill patients has not been confirmed. Research is therefore needed into the optimal duration of antibiotic use and its impact on VAP. Methods: The Medical Information Mart for Intensive Care database included 1,609 patients with VAP. Chi-square or Student’s t-tests were used to compare groups, and Cox regression analysis was used to investigate the factors influencing the prognoses of patients with VAP. Nonlinear tests were performed on antibiotic use lasting <7, 7–10, and >10 days. Significant factors were included in the model for sensitivity analysis. For the subgroup analyses, the body mass indexes (BMIs) of patients were separated into BMI <30 kg/m2 and BMI ≥30 kg/m2, with the criterion of statistical significance set at p < 0.05. Restricted cubic splines were used to analyze the relationship between antibiotic use duration and mortality risk in patients with VAP. Results: In patients with VAP, the effects of antibiotic use duration on the outcomes were nonlinear. Antibiotic use for 7–10 days in models 1–3 increased the risk of antibiotic use by 2.6020-, 2.1642-, and 2.3263-fold relative to for >10 days, respectively. The risks in models 1–3 for <7 days were 2.6510-, 1.9933-, and 2.5151-fold higher than those in models with >10 days of antibiotic use, respectively. These results were robust across the analyses. Conclusions: The duration of antibiotic treatment had a nonlinear effect on the prognosis of patients with VAP. Antibiotic use durations of <7 days and 7–10 days both presented risks, and the appropriate duration of antibiotic use can ensure the good prognosis of patients with VAP.

The relationship between the expression of serum IL-18 mRNA, CC16, and sTREM-1 and the severity and prognosis of ventilator-associated pneumonia in elderly patients.

This study aimed to explore the relationship between the severity and prognosis of elderly patients with ventilator-associated pneumonia (VAP) and the expression of serum interleukin-18 mRNA (IL-18 mRNA), Clara cell secretory protein 16 (CC16) and the soluble triggering receptor expressed on myeloid cells 1 (sTREM-1). The patients were divided into a VAP group (n=75) and a non-VAP group (n=110). According to the Acute Physiology and Chronic Health Evaluation II (APACHEII) score, the patients with VAP were divided into a low-risk group, an intermediate-risk group and a high-risk group. According to the 28-day outcome, the patients were divided into a survival group and a death group. Serum levels of IL-18, CC16 and sTREM-1 were detected, and their value in the prediction and prognosis of VAP was analyzed using a receiver operating characteristic (ROC) curve. Serum levels of IL-18 and sTREM-1 in the VAP group were higher than those in the non-VAP group, while CC16 levels were lower in the VAP group than those in the non-VAP group (P<0.05). Serum levels of IL-18 and sTREM-1 decreased in order from the high-risk group to the intermediate-risk group to the low-risk group, while CC16 levels increased in order (P<0.05). ROC curve analysis showed that the Youden index and AUC of combined diagnosis of VAP with serum IL-18 mRNA, CC16 and sTREM-1 were 0.710 and 0.930, which were higher than those of single diagnosis (P<0.05). Serum levels of IL-18 mRNA and sTREM-1 in the survival group were lower than those in the death group, and the CC16 level was higher than that in the death group (P<0.05). ROC curve analysis showed that the Youden index and AUC of combined diagnosis with serum IL-18 mRNA, CC16 and sTREM-1 were 0.506 and 0.731, which were higher than those of single diagnosis (P<0.05). The combination of these 3 factors is of high value in predicting the severity and prognosis of VAP and can provide reference for clinical treatment.

Effect of antibiotic therapy on the prognosis of ventilator-associated pneumonia caused by Stenotrophomonas maltophilia

BackgroundVentilator-associated pneumonia (VAP) caused by Stenotrophomonas maltophilia is poorly described in the literature. However, it has been shown to be associated with increased morbidity and mortality. Probabilistic antibiotic therapy against S. maltophilia is often ineffective as this pathogen is resistant to many antibiotics. There is no consensus at present on the best therapeutic strategy to adopt (class of antibiotics, antibiotic combination, dosage, treatment duration). The aim of this study was to evaluate the effect of antibiotic therapy strategy on the prognosis of patients with VAP caused by S. maltophilia.ResultsThis retrospective study evaluated all consecutive patients who developed VAP caused by S. maltophilia between 2010 and 2018 while hospitalized in the intensive care unit (ICU) of a French university hospital in Reunion Island, in the Indian Ocean region. A total of 130 patients with a median Simplified Acute Physiology Score II of 58 [43–73] had VAP caused by S. maltophilia after a median duration of mechanical ventilation of 12 [5–18] days. Ventilator-associated pneumonia was polymicrobial in 44.6% of cases, and ICU mortality was 50.0%. After multivariate Cox regression analysis, the factors associated with increased ICU mortality were older age (hazard ratio (HR): 1.03; 95% CI 1.01–1.04, p = 0.001) and high Sequential Organ Failure Assessment score on the day of VAP onset (HR: 1.08; 95% CI 1.03–1.14, p = 0.002).Appropriate antibiotic therapy, and in particular trimethoprim–sulfamethoxazole, was associated with decreased ICU mortality (HR: 0.42; 95% CI 0.24–0.74, p = 0.003) and decreased hospital mortality (HR: 0.47; 95% CI 0.28–0.79, p = 0.04).Time to start of appropriate antibiotic therapy, combination therapy, and duration of appropriate antibiotic therapy had no effect on ICU mortality (p > 0.5).ConclusionIn our study, appropriate antibiotic therapy, and in particular trimethoprim–sulfamethoxazole, was associated with decreased ICU and hospital mortality in patients with VAP caused by S. maltophilia.

Incidence and Prognosis of Ventilator-Associated Pneumonia in Critically Ill Patients with COVID-19: A Multicenter Study.

The primary objective of this multicenter, observational, retrospective study was to assess the incidence rate of ventilator-associated pneumonia (VAP) in coronavirus disease 2019 (COVID-19) patients in intensive care units (ICU). The secondary objective was to assess predictors of 30-day case-fatality of VAP. From 15 February to 15 May 2020, 586 COVID-19 patients were admitted to the participating ICU. Of them, 171 developed VAP (29%) and were included in the study. The incidence rate of VAP was of 18 events per 1000 ventilator days (95% confidence intervals [CI] 16–21). Deep respiratory cultures were available and positive in 77/171 patients (45%). The most frequent organisms were Pseudomonas aeruginosa (27/77, 35%) and Staphylococcus aureus (18/77, 23%). The 30-day case-fatality of VAP was 46% (78/171). In multivariable analysis, septic shock at VAP onset (odds ratio [OR] 3.30, 95% CI 1.43–7.61, p = 0.005) and acute respiratory distress syndrome at VAP onset (OR 13.21, 95% CI 3.05–57.26, p < 0.001) were associated with fatality. In conclusion, VAP is frequent in critically ill COVID-19 patients. The related high fatality is likely the sum of the unfavorable prognostic impacts of the underlying viral and the superimposed bacterial diseases.

Impact of KPC Production and High-Level Meropenem Resistance on All-Cause Mortality of Ventilator-Associated Pneumonia in Association with Klebsiella pneumoniae.

Carbapenemase-producing Enterobacterales and specifically Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp) are rapidly spreading worldwide. The prognosis of ventilator-associated pneumonia (VAP) caused by KPC-Kp is not well known. Our study tries to assess whether ventilator-associated pneumonia caused by a KPC-Kp strain is associated with higher all-cause mortality than that caused by carbapenem-susceptible isolates. This is a retrospective cohort study of patients with VAP due to K. pneumoniae from a 35-bed polyvalent intensive care unit in a university hospital (>40,000 annual admissions) between January 2012 and December 2016. Adjusted multivariate analysis was used to study the association of KPC-Kp with 30-day all-cause mortality (Cox regression). We analyze 69 cases of K. pneumoniae VAP, of which 39 were produced by a KPC-Kp strain with high-level resistance to meropenem (MIC > 16 mg/ml). All-cause mortality at 30 days was 41% in the KPC-Kp group (16/39) and 33.3% in the carbapenem-susceptible cases (10/30). KPC-Kp etiology was not associated with higher mortality when controlled for confounders (adjusted hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.46 to 3.41). Adequate targeted therapy (HR, 0.03; 95% CI, <0.01 to 0.23) was associated with all-cause mortality. Assuming the limitations due to the available sample size, the prognosis of VAP caused by KPC-Kp is similar to VAPs caused by carbapenem-susceptible K. pneumoniae when appropriate treatment is used.

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.

Can the ARDS Diagnosis at Intensive Care Admission Effect on Prognosis of Ventilator Associated Pneumonia

Can the ARDS Diagnosis at Intensive Care Admission Effect on Prognosis of Ventilator Associated Pneumonia

Visualization studies on research status of the ventilator-associated pneumonia based on SinoMed database

To survey the distribution pattern and subject domain knowledge of the literatures about ventilator-associated pneumonia (VAP). Literatures about VAP published until December 2017 were identified in SinoMed database for statistics and analysis. The information of author, organization and province was extracted by BICOMS software for generating co-occurrence matrix, at the same time, the topic words were cluster analyzed by Gcluto software to generate topical visual surface maps and visualization matrices, and the current research hotspots were analyzed. NetDraw from Ucinet 6.0 software was used to arrange the relationship among topic words according to the centrality, and the social network diagrams of authors, authors' provinces and institutions were draw to analyze the current status of VAP research cooperation. 4 851 VAP-related literatures were retrieved preliminarily, and 43 were excluded from abstracts, news reports, information and missing literatures. Finally, a total of 4 808 articles were enrolled in the visual analysis. From 2001 to 2004, the number of VAP-related literatures published was less than 10. Since 2009, the number of VAP documents had increased steadily, from 2010 to 2017, the peak period of publications reached 91.7% (4 411/4 808). According to the analysis of the amount of publications, the top three of 34 provincial administrative regions that published VAP-related literature in China were Guangdong Province (n = 628), Jiangsu Province (n = 478) and Zhejiang Province (n = 404), the number of hospitals issued by the First Affiliated Hospital of Chongqing Medical University was the largest (n = 20); there was only one journal with more than 100 articles, and there were 154 journals with only one article, accounting for 34.8% of the total number of journals. A total of 9 921 authors participated in the VAP-related literature writing, the number of high-yielding authors was not large, and the institution could not establish an effective social network diagram, suggesting that communication and cooperation should be strengthened in hospitals and outside hospitals. The results of the topic words social network analysis showed that the VAP research field was centered around the core of "mechanical ventilation", "intensive care unit (ICU)", "risk factor analysis", "nursing", "etiological analysis", "preventive measures" and "pathogens". The current research hotspots were at the edge of the network map, such as "drug sensitivity analysis", "Acinetobacter baumannii", "bronohoalveolar lavage (BAL)" and "acute exacerbation of chronic obstructive pulmonary disease (AECOPD)". By clustering 80 high-frequency topic words, at present, VAP research hotspots were mainly focus on five topics: obstructive pulmonary disease, especially in acute exacerbation, was prone to VAP; concerned about newborns and children's VAP; types, drug resistance and selection of antimicrobial agents for VAP pathogens in ICU; clinical efficacy and prognosis of VAP through preventive measures, pulmonary supportive care and comprehensive care interventions; oral care and airway management during mechanical ventilation was also the key aspect of the treatment of VAP. In recent years, the academics had attached great importance to the study of VAP, the number of publications had reached a historical peak, and the research direction was diverse. However, it was necessary to strengthen cooperation among research institutes, collect and count epidemiological data, improve and expand the research quality and scale of clinical diagnosis, nurse, prevention, pathogen distribution and drug resistance analysis.

Pathogenic features and prognosis of ventilator-associated pneumonia in patients with liver failure

Pathogenic features and prognosis of ventilator-associated pneumonia in patients with liver failure

High-throughput sequencing of 16S rDNA amplicons characterizes bacterial composition in bronchoalveolar lavage fluid in patients with ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is a life-threatening disease that is associated with high rates of morbidity and likely mortality, placing a heavy burden on an individual and society. Currently available diagnostic and therapeutic approaches for VAP treatment are limited, and the prognosis of VAP is poor. The present study aimed to reveal and discriminate the identification of the full spectrum of the pathogens in patients with VAP using high-throughput sequencing approach and analyze the species richness and complexity via alpha and beta diversity analysis. The bronchoalveolar lavage fluid samples were collected from 27 patients with VAP in intensive care unit. The polymerase chain reaction products of the hypervariable regions of 16S rDNA gene in these 27 samples of VAP were sequenced using the 454 GS FLX system. A total of 103,856 pyrosequencing reads and 638 operational taxonomic units were obtained from these 27 samples. There were four dominant phyla, including Proteobacteria, Firmicutes, Actinobacteria, and Bacteroidetes. There were 90 different genera, of which 12 genera occurred in over ten different samples. The top five dominant genera were Streptococcus, Acinetobacter, Limnohabitans, Neisseria, and Corynebacterium, and the most widely distributed genera were Streptococcus, Limnohabitans, and Acinetobacter in these 27 samples. Of note, the mixed profile of causative pathogens was observed. Taken together, the results show that the high-throughput sequencing approach facilitates the characterization of the pathogens in bronchoalveolar lavage fluid samples and the determination of the profile for bacteria in the bronchoalveolar lavage fluid samples of the patients with VAP. This study can provide useful information of pathogens in VAP and assist clinicians to make rational and effective therapeutic decisions.

Prognosis of ventilator-associated pneumonia: what lies beneath

Ventilator-associated pneumonia (VAP) continues to be a major problem in the care of intensive care unit (ICU) patients. The incidence of VAP in mechanically ventilated patients is high, ranging from 10 to 30%. The clinical symptoms of VAP are ambiguous and there is no generally accepted gold standard for the diagnosis of VAP. The associated mortality is still high at 30–40% 1, 2. Established clinical scores and biomarkers are only of limited value in terms of diagnosis and prognosis. Since VAP is an infectious disease we traditionally use biomarkers of infection for diagnostic and prognostic purposes. Inflammatory markers such as leukocyte count and C-reactive protein (CRP) are still widely used in the diagnosis of VAP, although it is well known that sensitivity in the ICU setting is highly limited. Until recently, only procalcitonin as a more accurate marker of bacterial infection turned out to be of clinical value. Procalcitonin is useful for the guidance of antibiotic therapy in community-acquired pneumonia (CAP), which has been shown by several studies of the Basel group in recent years 3, 4. Nobre et al. 5 were the first to demonstrate a median reduction of antibiotic treatment of 4 days (six versus 10) following a procalcitonin-guided strategy as opposed to a clinical strategy in patients with VAP. The ProVAP trial demonstrated that procalcitonin guidance can reduce the duration of antibiotic therapy in patients with VAP. In the ProVAP trial Stolz et al. 6 performed a multicentre, randomised, controlled trial with 101 patients with VAP. Patients were either assigned to an antibiotic discontinuation strategy according to American Thoracic Society/Infectious Diseases Society of America guidelines (control group) or to a strategy using serial serum procalcitonin measurements (procalcitonin group). The number of antibiotic-free days patients were alive 28 days after VAP onset was significantly …

A binational cohort study of ventilator-associated pneumonia in Denmark and Australia

The objective was to determine the incidence and prognosis of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) in Melbourne (29-bed ICU), Australia and Aarhus and Aalborg (22-bed unit and 8-bed ICU, respectively), Denmark and to characterize participating ICUs with regard to prevalence of nosocomial type bacterial pathogens, antibiotic resistance and antibiotic consumption. In this prospective cohort study 25 patients in Melbourne and 32 patients in Aarhus + Aalborg had a first episode of VAP. The incidence of VAP per 1000 ventilator d was 6.2 in Melbourne and 9.5 in Aarhus + Aalborg. Case fatality during hospital admission was 28% and 59%, respectively (unadjusted odds ratio (OR) 0.3, 95% confidence interval (CI) 0.1-0.8). OR adjusted for age and APACHE II score was 0.2 (95% CI 0.1-1.0). Nosocomial type pathogens including methicillin resistant Staphylococcus aureus were more prevalent in Melbourne, and antibiotic consumption per VAP patient was 35% higher in Melbourne than in Aarhus + Aalborg. To judge from the present data, there seems to be a complicated interrelationship between prognosis on the 1 hand and antibiotic consumption and resistance on the other. A more favourable prognosis was found in Melbourne, where levels of antibiotic consumption and antimicrobial resistance were higher than in Aarhus + Aalborg.

Ceftazidime administered by continuous perfusion can improve the prognosis of ventilator-associated pneumonia

Ceftazidime administered by continuous perfusion can improve the prognosis of ventilator-associated pneumonia