Risk Factors For Multidrug-resistant Infection Research Articles

Risk Factors for Post-Operative Multi-Drug-Resistant Organism Bacterial Infection in Patients With Stanford Acute Type A Aortic Dissection.

Background: To explore the risk factors for multi-drug-resistant organism (MDRO) infection in patients with Stanford acute type A aortic dissection (ATAAD). We conducted a retrospective cohort study using the data of post-operative patients with ATAAD in our hospital. Patients and Methods: This study included 82 post-operative patients with ATAAD in the past decade. They were divided into a MDRO group (n = 31) and a non-MDRO group (n = 51) according to whether they had acquired multi-drug-resistant (MDR) bacterial infection. Multivariable logistic regression was used to analyze the risk factors for MDR infections in patients with ATAAD. Results: The incidence of multi-drug-resistant bacterial infection was 37.80%. Seventeen factors, including hospital stay (p = 0.007), utilization of third-generation cephalosporins (p = 0.0068), antibiotic species of exposure (p = 0.0002), leukocyte-depleted red blood cell suspension dosage (p < 0.0001), fresh frozen plasma dosage (p < 0.0001), application of blood purification (p = 0.0493), and the total antibiotic days of exposure (p = 0.0001) diverged between the two groups (all p < 0.05). The logistic regression analysis revealed that the utilization of third-generation cephalosporins (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.01-5.33; p = 0.0478), antibiotic species of exposure (OR, 5.76; 95% CI, 1.45-22.83; p = 0.0128), leukocyte-depleted red blood cell suspension dosage (OR, 12.43; 95% CI, 2.71-57.07; p = 0.0012), and fresh frozen plasma dosage (OR, 5.05; 95% CI, 1.18-21.56; p = 0.0286) were independent variables for MDRO infections. Among the 23 drug-resistant bacteria detected, Acinetobacter baumannii was the main pathogen. Conclusions: Our study shows that the utilization of third-generation cephalosporins, antibiotic species of exposure, leukocyte-depleted red blood cell suspension dosage, and fresh frozen plasma dosage were independent risk factors for post-operative multi-drug-resistant infection in patients with ATAAD. Acinetobacter baumannii occupied the largest share of resistant bacteria that induce infection in post-operative patients with ATAAD.

Risk Factors for Infection With Multidrug-Resistant Gram-Negative Bacteria in a Tertiary Care Hospital in Saudi Arabia: A Case-Control Study.

Background The increase in the incidence of multidrug-resistant (MDR) organisms especially Gram-negative bacteria (GNB) in healthcare facilities is a serious cause of concern. This study identified risk factors for the infection with these MDR GNB, such asAcinetobacterbaumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli to inform healthcare workers about strategies for their containment. Methods A case-control study was carried out at a tertiary care hospital where 100 patients with healthcare-associated infections (infections arising 48 hours after admission) caused by MDR GNB were compared with two control groups, i.e., 100 patients with healthcare-associated infections caused by non-MDR GNB (not meeting the criteria of MDR) and 100 patients without infection caused by GNB. MDR bacteria were defined as the ones that were non-susceptible to at least one antibiotic in three or more classes of antibiotics. The data were analyzed using descriptive statistics (frequency and percentage of categorical variables). Multivariate regression analysis was undertaken to identify significant predictors of MDR GNB. Odds ratios with 95% confidence intervals were calculated, and the level of significance was determined at p-value < 0.05. Results A total of 388 organisms were isolated during four months (January-April 2015) from 332 patients. Fifty-six (17%) of the patients were infected with more than one organism. Among the MDR bacteria, the most dominant MDR organism wasA. baumannii(38%), followed byK.pneumoniae(31%),P. aeruginosa(20%), andE. coli(11%). Among the non-MDR organisms, the most dominant wasP. aeruginosa(47%), followed byE. coli (32%),K.pneumoniae (18%), andA. baumannii(3%). Patients with MDR organisms compared with the first control group (patients with non-MDR organisms) showed that prior antibiotic use (p-value: 0.001), intensive care unit (ICU) admission (p-value: 0.001), and indwelling medical devices (p-value: 0.005) were significant risk factors for MDR infections. It was also found that the risk factors for MDR GNB infection were the same in the second control group (patients without infection): prior antibiotic use (p-value: 0.002), ICU admission (p-value: 0.001), and indwelling medical devices (p-value: 0.03). Based on the comparison of the two control groups, prolonged hospital stays of more than five days (p-value: 0.001), immunosuppressive therapy (p-value: 0.02), and over 60 years of age (p-value: 0.02) were significant risk factors for non-MDR infection. Conclusion The risk factors identified in our study provide guidance to healthcare workers for the prevention and containment of MDR GNB.

Outcomes of Granulocyte Transfusion in Haematology Patients with Febrile Neutropenia - a Single Centre Retrospective Cross Sectional Study

BACKGROUND: Febrile neutropenia (FN) and subsequent infection related mortality and morbidity remains a challenge during treatment of haematological malignancies and Hematopoietic Stem Cell Transplantation (HSCT). Opportunistic fungal infections and multi drug resistant(MDR) bacterial infections remain important causes of morbidity and mortality in neutropenic individuals. Historically from 1960 onwards granulocyte collection and transfusions for neutropenic patients have been used to treat febrile neutropenia. Previous studies to assess the role of granulocyte transfusion(GT) as bridging therapy before neutrophil engraftment have been inconclusive . Most of these studies had an absolute neutrophil coun(ANC)<0.5 X 10^9/l as inclusion criteria. Our hypothesis was that the benefit of GT may be in the subset of patients with ANC < 0.2 X 10^9/l. The objective was to analyse the outcomes of two retrospective cohorts, one with and another without GT . METHODS: Electronic medical records of patients more than 18 years of age and undergone Induction therapy for AML and Allogenic HSCT at the institution between 2015 to 2022 were screened. Patients who developed FN with ANC < 0.2 x 10^9/l were included and those with higher ANCs at the time of GT were excluded .Patients with age less than 18 years ,those with other haemato-oncologic malignancies and patients who underwent AML induction with regimen other than 7 days of cytarabine + 3 days of daunorubicin (7+3)were excluded. Apheresed GT was available during 2020-2022 period and was used as per treating physician's discretion. Those who developed FN but having lung infection were also excluded . Patients who met the same inclusion and exclusion criteria who developed FN but did not receive GT (2015-2019 period ) were analysed as control group. Granulocytes were collected after administration of 450mcg of Granulocyte Colony Stmulating Factor (GCSF) and oral Dexamethasone 8mg 12 hours prior to collection to ABO group matched donors. Apheresis was done using Spectra Optia Apheresis System. GT was continued till infection was controlled and there were robust signs of bone marrow recovery. Forty two day survival, total duration of neutropenia and hospital stay between the two groups were compared. Data was entered in Microsoft excel version 2019 and analysed using SPSS version 21. Data were compared between two cohorts using Chi-square test and t-test for equality of means. RESULTS:The demographic details of the the two cohorts is given in Table 1.Among 33 patients who received GT, 1 patient expired (3%). There were 5 patient deaths in the control cohort (n=37, 13.5%). Even though 10.5 % difference in the 42 day survival between the control and the study cohorts was noted, Chi-square analysis did not show a statistically significant difference (p =0.118). Mean duration of hospital stay for the study cohort was 34.30 days (±7.239) as compared to 30.62 days (± 5.663) for the control cohort (p = 0.020). Mean days of neutropenia for study cohort was 14.03 days (± 6.252) and 12.38 days (±4.152) for the control cohort (p=0.193).There were no grade III/IV adverse events attributable to the GT documented in the medical records of the subjects in the study cohort. CONCLUSIONS: Although patient deaths were lower in the study cohort (with a 10% difference from the control cohort), it did not achieve statistical significance. This might have been due to the limited number of patients in both the cohorts.The study is also limited by the retrospective design.Since the study cohort and the control cohort received treatment in two different time periods, there could have been a difference in the supportive care . Inspite of all these limitations our findings may point towards the need for conducting a prospective Randomised controlled trial in patients with very severe neutropenia (ANC<0.2x 10^9/L) and other potential risk factors for MDR infections. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Nomogram Model for Predicting the Risk of Multidrug-Resistant Bacteria Infection in Diabetic Foot Patients.

ObjectiveThis study established an individualized nomogram for predicting the risk of multidrug-resistant bacterial (MDRB) infection in patients with the diabetic foot (DF), and providing a reference for clinical prevention and treatment.MethodsA total of 199 DF patients admitted to the hospital from July 2015 to December 2018 were included in this study. The pathogenic bacteria at the site of infection were detected and the factors affecting the occurrence of MDRB infection in DF patients summarized. The R software was used to draw the nomogram, and the Bootstrap Method used to internally verify the model. The calibration curve and the Harrell’s Concordance Index (C-index) were used to evaluate the predictive effect of the nomogram model.ResultsLogistic regression analysis showed that age, course of diabetes, previous use of antibacterial drugs, types of antibacterial drugs, and osteoporosis were risk factors for multidrug-resistant infections in DF (P<0.05). The area under the receiver operating characteristic curve (AUC, Area Under Curve) of the nomogram model after internal verification was 0.773 (95% CI: 0.704–0.830). The mean absolute error between the predicted probability of infection in the nomogram and the actual occurrence of MDRB was 0.032, indicating that the nomogram model had good forecasting efficiency and stability.ConclusionThe risk factors for multidrug-resistant infections in DF are age, course of diabetes, previous use of antibacterial drugs, types of antibacterial drugs used, and osteoporosis. The nomogram model drawn on these risk factors has good predictive accuracy and can assist medical staff in formulating targeted infection prevention strategies for patients.

Clinical outcomes, molecular epidemiology and resistance mechanisms of multidrug-resistant Pseudomonas aeruginosa isolated from bloodstream infections from Qatar

Background Bloodstream infections (BSIs) caused by multidrug-resistant (MDR)-Pseudomonas aeruginosa are associated with poor clinical outcomes, at least partly due to delayed appropriate antimicrobial therapy. The characteristics of MDR-P. aeruginosa bloodstream isolates have not been evaluated in Qatar. Our study aimed to examine in vitro susceptibility, clinical and molecular characteristics, and mechanisms of resistance of MDR-P. aeruginosa bloodstream isolates from Qatar. Materials and methods We included all MDR-P. aeruginosa isolated from blood cultures taken between October 2014 and September 2017. Blood cultures were processed using BD BACTEC™ FX automated system. BD Phoenix™ was used for identification, Liofilchem® MIC Test Strips for MIC determination. Whole-genome sequencing was performed using the Illumina-HiSeq-2000. Results Out of 362 P. aeruginosa bloodstream isolates, 16 (4.4%) were MDR. The median patient age was 55 years (range 43–81) and all patients presented with septic shock. Most patients received meropenem (12/16) and/or colistin (10/16). Clinical response was achieved in eight patients, and five patients died within 30-days. MDR-P. aeruginosa isolates belonged to 13 different sequence types. All isolates were non-susceptible to cefepime and ciprofloxacin. The most active agents were colistin (16/16) and aztreonam (10/16). Seven isolates produced bla VIM, and four possessed genes encoding extended-spectrum β-lactamases. Aminoglycoside modifying enzymes were present in 15/16, transferable qnr-mediated quinolone resistance gene was detected in 3/16, and the novel ciprofloxacin modifying enzyme CrpP-encoding gene in one isolate. Conclusion MDR-P. aeruginosa BSIs are relatively uncommon in Qatar but are highly resistant, harbour multiple resistance genes, and are commonly associated with unfavourable clinical outcomes. Colistin was the only agent with consistent activity against the study isolates. Key messages MDR-P. aeruginosa constituted <5% of P. aeruginosa blood isolates over three years. Typical risk factors for MDR infections were highly prevalent in the study population and overall clinical outcomes are consistent with those previously reported. Colistin was the only agent with consistent antibacterial activity against the study isolates.

Multidrug-resistant bacteria in diabetic foot infections: Experience from a portuguese tertiary centre.

In recent years, the emergence of antibiotic resistant pathogens made increasingly difficult to establish appropriate empiric antimicrobial therapy protocols for acute diabetic foot infection (DFI) treatment. Early recognition of the population at‐risk for multidrug‐resistant (MDR) bacterial infection is of paramount importance in order to decrease large‐spectrum antibiotic overuse. This study used retrospective cohort study in a multidisciplinary tertiary diabetic foot unit. Patients with severe DFI were included and divided according to their infection resistance profile (susceptible vs MDR bacteria). Data regarding their comorbidities and length of hospital stay were collected. The primary endpoint was to determine the risk factors for MDR infections and to evaluate if these were associated with an increased length of stay (LOS). A total of 112 microbial isolates were included. Predominance of Gram‐positive bacteria was observed and 22.3% of isolated bacteria were MDR. Previous hospitalisation was associated with a higher likelihood of MDR infection. MDR bacterial infection was also associated with an increased LOS (P = .0296). Our study showed a high incidence of MDR bacteria in patients with a DFI, especially in those who had a recent hospitalisation. MDR infections were associated with a prolonged LOS and represent a global public health issue for which emergent measures are needed.

Multi-Drug-Resistant Bacterial Infection after Pancreatoduodenectomy: Risk Factors and Clinical Impact.

Background: Infection by multi-drug-resistant (MDR) bacteria is a high-risk factor for poor clinical results. Pancreatoduodenectomy (PD) has been associated with a high rate of complications, including intra-abdominal infections. However, there are few data available regarding MDR infection in patients undergoing PD. This study evaluated the present situation of risk factors for and clinical impact of MDR infection on patients who received PD. Methods: A total of 357 consecutive patients who underwent PD in our department from January 2016 to June 2018 were analyzed retrospectively. They were grouped into those with MDR infection (observation group) and those without MDR infection (control group). Univariable and multivariable analyses were used to identify risk factors for MDR infection in the two groups and the relations between MDR infection and clinical outcome. Results: Infections by MDR bacteria occurred in 38 patients (10.6%), and a total of 49 MDR bacterial strains were detected. Carbapenem-resistant Acinetobacter baumannii and MDR Pseudomonas aeruginosa were the most common strains. Multivariable analysis suggested that pancreatic fistula (p = 0.001) and post-operative use of quinolones (p = 0.000) were risk factors for MDR infection. At the same time, MDR infection was an independent risk factor for an increase in the 30-day in-hospital mortality rate (p = 0.005). Conclusions: Intensive intra-operative management to reduce the incidence of pancreatic fistula as well as curtailing empirical use of antibiotics, especially quinolones, may help to reduce the incidence of MDR infection and thus in-hospital deaths.

What we can do? The risk factors for multi-drug resistant infection in pediatric intensive care unit (PICU): a case-control study

BackgroundThe risk factors for multi-drug resistant infection (MDRI) in the pediatric intensive care unit (PICU) remain unclear. It’s necessary to evaluate the epidemiological characteristics and risk factors for MDRI in PICU, to provide insights into the prophylaxis of MDRI clinically.MethodsClinical data of 79 PICU children with MDRI were identified, and 80 children in PICU without MDRI in the same period were selected as control group. The related children’s characteristics, clinical care, microbiologic data, treatments provided, and outcomes of the patients with were reviewed and collected. Univariate and multivariate logistic regression analyses were performed to identify the potential risks of MDRI in PICU.ResultsOf the diagnosed 79 cases of MDRI, there were28 cases of CR-AB, 24 cases of MRSA, 22 cases of PDR-PA,3 cases of VRE and 2 cases of CRE respectively. Univariate analyses indicated that the length of PICU stay, the duration of mechanical ventilation > 5 days, parenteral nutrition, coma, urinary catheter indwelling, invasive operation, 2 or more antibiotics use were associated with MDRIs (all p < 0.05); The logistic multiple regression analyses indicated that coma, parenteral nutrition, 2 or more antibiotics use and the duration of mechanical ventilation > 5 days were independent risk factors associated with MDRI (all p < 0.05).ConclusionsThis present study has identified several potentially modifiable risk factors for MDRI in PICU, it’s conducive to take appropriate measures targeting risk factors of MDRI for health care providers to reduce MDRI.

Infections in elderly intensive care unit patients

The elderly population is increasing in the developed world, therefore elderlies account for a considerable proportion of intensive care unit (ICU) admissions. A precise threshold for “elderly” is a matter of debate. The process of ageing is associated with physiological and functional alterations of the human body and organs that render elderly people vulnerable to infections. As a result of dysfunction of specific parts of immune response called immunosenescence, elderly patients may be threatened by severe infections. Chronic low-grade inflammation, termed inflammaging, is another contributor. In addition to these, comorbidities associated with increasing age, such as diabetes mellitus and immunosuppressive conditions pose an additive risk for infections and in some studies they were associated with increased mortality. Epidemiology of ICU infections may differ in elderlies, compared to other adults. Infections tend to be less microbiologically confirmed and site of infection may be obscure on presentation. The identified pathogens are frequently Gram-negative and particularly Enterobacteriaceae exhibiting a multidrug-resistant (MDR) phenotype. Multiple antibiotic prescriptions in this age-group, specific comorbidities (such as bronchiectasis or chronic obstructive pulmonary disease), residence in long term care facilities and frequent hospitalisations, are among others recognized risk factors for MDR infections. Data from two large European databases show that intra-abdominal infections are predominant among ICU infections in the elderly and Candida spp infections rank second, after Enterobacteriaceae. Age may pose important implications in treatment decisions. Organ derangements, physiological changes caused by increasing age and multiple concomitant medications call clinicians for vigilance about adverse events and toxicity. Despite all the above, elderlies in the ICU did not exhibit worse outcomes compared to younger counterparts in a straightforward manner. Studies however are heterogenous and most of them are single centers. As age is a continuous process, only analysis performed in subgroups of 65–74 (young-old elderlies), 75–84 (old elderlies) and >85 (old-old or oldest old elderlies) provides a better depiction of ICU outcomes. Most studies have shown a worse ICU outcome for the group of oldest-old elderlies, compared with young adults and elderlies in the range of 65 to 84 years of age. These data indicate that age per se may not represent a barrier in decisions concerning ICU admission and triage has to be done on an individual basis. However, epidemiological particularities of this age group should be taken into account in the selection of early and appropriate antimicrobial treatment, which will optimize patients’ outcomes.

Antimicrobial resistance in clinical Escherichia coli isolated from companion animals in Australia

Multidrug-resistant (MDR) Escherichia coli have become a major public health concern to both humans and animal health. While the frequency of antimicrobial resistance (AMR) in clinical E. coli is monitored regularly in human medicine, current frequency of AMR in companion animals remains unknown in Australia. In this study we conducted antimicrobial susceptibility testing (AST) and where possible, determined potential risk factors for MDR infection among 883 clinical Escherichia coli isolated from dogs (n=514), cats (n=341) and horses (n=28). AST was undertaken for 15 antimicrobial agents according to the Clinical Laboratory Standards Institute (CLSI) guidelines and interpreted using epidemiological cut-off values (ECOFFs) as well as CLSI veterinary and human clinical breakpoints. The AST revealed complete absence of resistance to carbapenems while resistance to amikacin was observed at a low level in isolates from dogs (1.6%) and cats (1.5%) compared to horses (10.7%). Among dog isolates, resistance to fluoroquinolones ranged from 9.1%–9.3% whereas among cat isolates, it ranged from 3.2%–5%. Among dog isolates, the proportion showing a 3rd generation cephalosporin (3GC) non-wild type phenotype was significantly higher (P<0.05) in skin and soft tissue infection (SSTI, n=122) isolates (17.2%–20.5%) compared to urinary tract infection (UTI, n=392) isolates (9.9%–10.2%). The frequency of multidrug resistance was 18.1%, 11.7% and 42.9% in dog, cat and horse isolates, respectively. Risk factor analysis revealed that MDR E. coli isolated from UTI were positively associated with chronicity of infection and previous antimicrobial treatment. Dogs and cats with chronic UTI that had been previously treated with antimicrobials were eight times and six times more likely to be infected with MDR E. coli compared to dogs and cats with non-chronic UTI, and no history of antimicrobial treatment, respectively. This study revealed that pre-existing disease condition and prior antimicrobial use were the major risks associated with UTI with MDR E. coli in companion animals.

Specific Clinical Profile and Risk Factors for Mortality in General Surgery Patients with Infections by Multi-Drug-Resistant Gram-Negative Bacteria.

The incidence of gram-negative multi-drug-resistant (MDR) infections is increasing worldwide. This study sought to determine the incidence, clinical profiles, risk factors, and mortality of these infections in general surgery patients. All general surgery patients with a clinical infection by gram-negative MDR bacteria were studied prospectively for a period of five years (2007-2011). Clinical, surgical, and microbiologic parameters were recorded, with a focus on the identification of risk factors for MDR infection and mortality. Incidence of MDR infections increased (5.6% to 15.2%) during the study period; 106 patients were included, 69.8% presented nosocomial infections. Mean age was 65 ± 15 years, 61% male. Extended-spectrum β-lactamases (ESBL) Escherichia coli was the most frequent MDR bacteria. Surgical site infections and abscesses were the most common culture locations. The patients presented multiple pre-admission risk factors and invasive measures during hospitalization. Mortality was 15%, and related to older age (odds ratio [OR] 1.07), malnutrition (OR 13.5), chronic digestive conditions (OR 4.7), chronic obstructive pulmonary disease (OR 3.9), and surgical re-intervention (OR 9.2). Multi-drug resistant infections in the surgical population are increasing. The most common clinical profile is a 65-year-old male, with previous comorbidities, who has undergone a surgical intervention, intensive care unit (ICU) admission, and invasive procedures and who has acquired the MDR infection in the nosocomial setting.

Resistant Gram-negative infections in the outpatient setting in Latin America

Latin America has a high rate of community-associated infections caused by multidrug-resistant Enterobacteriaceae relative to other world regions. A review of the literature over the last 10 years indicates that urinary tract infections (UTIs) by Escherichia coli, and intra-abdominal infections (IAIs) by E. coli and Klebsiella pneumoniae, were characterized by high rates of resistance to trimethoprim/sulfamethoxazole, quinolones, and second-generation cephalosporins, and by low levels of resistance to aminoglycosides, nitrofurantoin, and fosfomycin. In addition, preliminary data indicate an increase in IAIs by Enterobacteriaceae producing extended-spectrum β-lactamases, with reduced susceptibilities to third- and fourth-generation cephalosporins. Primary-care physicians in Latin America should recognize the public health threat associated with UTIs and IAIs by resistant Gram-negative bacteria. As the number of therapeutic options become limited, we recommend that antimicrobial prescribing be guided by infection severity, established patient risk factors for multidrug-resistant infections, acquaintance with local antimicrobial susceptibility data, and culture collection.

One-year outcomes of community-acquired and healthcare-associated pneumonia in the Veterans Affairs Healthcare System

While studies have demonstrated higher medium-term mortality for community-acquired pneumonia (CAP), mortality and costs have not been characterized for healthcare-associated pneumonia (HCAP) over a 1-year period. We conducted a retrospective cohort study to evaluate mortality rates and health system costs for patients with CAP or HCAP during initial hospitalization and for 1 year after hospital discharge. We selected 50 758 patients admitted to the Veterans Affairs (VA) healthcare system between October 2003 and May 2007. Main outcome measures included hospital, post-discharge, and cumulative mortality rates and cost during initial hospitalization and at 12 months following discharge. Hospital and 1-year HCAP mortality were nearly twice that of CAP. HCAP was an independent predictor for hospital mortality (odds ratio (OR) 1.62, 95% confidence interval (CI) 1.49-1.76) and 1-year mortality (OR 1.99, 95% CI 1.87-2.11) when controlling for demographics, comorbidities, pneumonia severity, and factors associated with multidrug-resistant infection, including immune suppression, previous antibiotic treatment, and aspiration pneumonia. HCAP patients consistently had higher mortality in each stratum of the Charlson-Deyo-Quan comorbidity index. HCAP patients incurred significantly greater cost during the initial hospital stay and in the following 12 months. Demographics and comorbid conditions, particularly aspiration pneumonia, accounted for 19-33% of this difference. HCAP represents a distinct category of pneumonia with particularly poor survival up to 1 year after hospital discharge. While comorbidities, pneumonia severity, and risk factors for multidrug-resistant infection may interact to produce even higher mortality compared to CAP, they alone do not explain the observed differences.

Nursing home-acquired pneumonia: a 10 year single-centre experience

BackgroundPneumonia among nursing home (NH) residents has increased considerably in recent years, but it remains unclear whether it should be considered as community-acquired pneumonia (CAP) or a new category of...

Diagnostic Strategies for Healthcare-Associated Pneumonia

The first point of a good diagnostic strategy for healthcare-associated pneumonia (HCAP) is correct classification of patients with specific criteria, as suggested by the last American Thoracic Society/ Infectious Diseases Society of America (ATS/IDSA) guidelines. However, clinical practice and recent literature have suggested new risk factors for multidrug-resistant infection (MRI): the presence of permanent indwelling devices, prior antibiotic use in the last 3 months, chronic and advanced pulmonary diseases (chronic obstructive pulmonary disease, bronchiectasis, etc.), history of alcoholism, and immunosuppression. The clinical presentation in HCAP patients is often unusual (mild respiratory symptoms and frequent extrapulmonary manifestations) due to different factors: advanced age, neurological disorders, and multiple chronic comorbidities. Moreover, HCAP commonly presents a worse clinical course than community-acquired pneumonia, a prolonged length of stay, and a mortality rate close to hospital-acquired pneumonia. Chest radiography and routine laboratory markers (including C-reactive protein) are always needed for clinical evaluation and severity assessment. The clinical use of new biomarkers of infection and sepsis (procalcitonin, etc.) is currently being investigated. Extensive microbiological testing to overcome the high prevalence of MRI in HCAP, including urinary antigens for Legionella and Streptococcus pneumoniae; blood cultures; Gram staining and low respiratory tract secretions (sputum, tracheobronchial aspirate, fibrobronchial aspirate, protected specimen brush, bronchoalveolar lavage); and cultures for aerobic, anaerobic, mycobacterial, and fungal pathogens are recommended, whereas the indication for serology tests for respiratory viruses and atypical pathogens is low. By contrast, the new polymerase chain reaction-based techniques for the rapid identification (2 to 4 hours) of microbial pathogens in respiratory samples (nasopharyngeal swab, bronchoalveolar lavage) seem to be the most innovative future perspective in the diagnostics of HCAP.

Tackling Empirical Antibiotic Therapy for Ventilator-Associated Pneumonia in Your ICU: Guidance for Implementing the Guidelines

Guidelines published jointly by the American Thoracic Society and Infectious Diseases Society of America endorse the practice of appropriate empirical antibiotic therapy for ventilator-associated pneumonia (VAP) and even provide recommendations for specific antibiotics based on whether a patient has risk factors for multidrug-resistant infections. Unfortunately, the current guidelines provide little insight into how a specific institution can best develop a strategy for providing empirical antibiotic therapy. This review article focuses on important steps that should be taken in developing a hospital-specific pathway for the empirical antibiotic treatment of VAP. Consideration should be given to developing a multidisciplinary group to obtain intensive care unit (ICU)-specific antibiograms for the most common causative organisms, real-time minimum inhibitory concentration (MIC) data or MIC distributions from surveillance studies over a representable time frame, and implementing empirical dosage strategies aimed at achieving not only appropriate therapy but also optimal therapy based on pharmacodynamic targets. A proper deescalation strategy will also be vital to managing antibiotic choices and dosages, as well as providing useful recommendations for discontinuation of therapy. Finally, continued feedback of program results is critical to maintaining compliance as well as for reevaluating empirical antibiotic choices.