Tracheal Cultures Research Articles

Prevalence of Gram-negative Bacteria Isolated from Patients with Ventilator-Associated Pneumonia in Intensive Care Units of Imam Khomeini Hospital, Ahwaz, Iran

Background: Ventilator-associated pneumonia (VAP) is a common nosocomial infection among hospitalized patients who have undergone intubation and mechanical ventilation for more than 48 hours. Patients admitted to the intensive care unit (ICU) are at risk of developing life-threatening VAP due to specific conditions, especially with Gram-negative pathogens with advanced drug resistance. Hereby, the control of these agents and its monitoring is of particular importance. In this study, the pattern of antibiotic resistance of Gram-negative bacteria isolated from tracheal culture of patients with VAP investigated in ICU of Imam Khomeini Hospital of Ahwaz. M aterials and Methods: In this cross-sectional study, tracheal samples were collected during April 2016 to April 2017 from patients who were on mechanical ventilation in ICU of Imam Khomeini Hospital in Ahwaz, Khuzestan province, southwest of Iran. After isolation, bacterial strains were identified using biochemical tests. Then, antimicrobial resistance pattern of these isolates investigated using standard disc diffusion according to clinical and laboratory standards institute 2016 (CLSI 2016) guidelines. R es ults: A total of 111 bacterial isolates were identified which were as following; Acinetobacter baumannii , Pseudomonas aeruginosa , Klebsiella pneumoniae , Escherichia coli , Stenotrophomonas maltophilia , and Serratia marcescens , with prevalence of 54%, 19.8%, 14.4%, 6.4%, 4.5%, and 0.9%, respectively. Antibiotic susceptibility test of isolates showed that almost all isolates had high resistance to treatment antibiotics and were multi-drug resistance (MDR). The A . baumannii isolates were resistant to ciprofloxacin and piperacillin-tazobactam, but ampicillin-tazobactam had a good effect. C onclusion: The results of this study showed that patients admitted to ICU due to their conditions of treatment are more likely to develop VAP by Gram-negative pathogens. The empirical treatment of VAP due to predominant bacterial causes and emerging drug resistance has become more challenging. It requires to use of multidrug regimens for routine clinical practice. It should be noted that in order to appropriate antimicrobial therapy, precise and correct diagnosis is very important.

An evaluation of the infection agents and the demographic characteristics of patients followed up on a mechanical ventilator in neurology intensive care: A retrospective, single center, observational study

Aim: The incidence of nosocomial infections is higher than other sites of the hospitals at intensive care units (ICU) because of high frequency of invasive interventions and multidrug resistant microorganism’s prevalence. Ventilator-related pneumonia cases have the highest mortality risk among the nosocomial infections. The aim of this study was to evaluate the endotracheal aspirate cultures and the demographic characteristics of patients followed up on mechanical ventilation in Neurology Intensive Care.Methods: Our study was designed as a retrospective, cross-sectional and descriptive. Retrospective evaluation was made of 51 patients who were attached to a mechanical ventilator in the last 6 months and from whom a tracheal aspirate culture was taken. The endotracheal aspirate samples were taken under sterile conditions using a specifically designed catheter with the method of administering saline into the intubation tube and then aspiration. Blood culture results sent for analysis at the same time as the tracheal aspirate samples were also retrospectively evaluated in patients determined with positive production. A record was made of the demographic characteristics of the patients, diagnosis on admittance to ICU, risk factors, and microbial production in the tracheal aspirate culture.Results: In the first culture, there was no production in 22 (43.1%) cases, and Acinetobacter baumanii was determined in 14 (27.5%) patients, Pseudomonas aeruginosa in 3 (5.9%), Klebsiella pneumonia in 3 (5.9%), Staphylococcus aureus in 2 (3.9%), Corynebacterium striatum in 2 (3.9%), Acinetobacter baumanii + Pseudomonas aeruginosa in 2 (3.9%), Acinetobacter baumanii + Klebsiella pneumonia in 2 (3.9%), and Acinetobacter baumanii + Escherichia coli in 1 (2.0%). The second culture was taken from patients on the mean 11th day. In 3 (10.7%) patients there was no production in the second culture and in the other patients, Acinetobacter baumanii was determined in 15 (53.6%) patients, Pseudomonas aeruginosa in 3 (10.7%), Klebsiella pneumonia in 2 (7.1%), Escherichia coli in 1 (3.6%), Corynebacterium striatum in 1 (3.6%), and Acinetobacter baumanii + Pseudomonas aeruginosa in 3 (10.7%).Conclusion: The culture results in this study of patients admitted for neurological reasons were observed to be consistent with findings in literature. The high mortality rate of 64.7% in these ICU patients is due to the majority being ischemic stroke patients. This suggests that both the severe table associated with neurological findings and agents such as Acinetobacter baumanii and Pseudomonas aeruginosa contribute to Neurology ICU patients.

Microbiological Etiologies of Pneumonia Complicating Stroke: A Systematic Review.

Identifying the causal pathogens of pneumonia complicating stroke is challenging, and antibiotics used are often broad spectrum, without recourse to the microbiological cause. We aimed to review existing literature to identify organisms responsible for pneumonia complicating stroke, before developing a consensus-based approach to antibiotic treatment. A systematic literature review of multiple electronic databases using predefined search criteria was undertaken, in accordance with Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. Published studies of hospitalized adults with ischemic stroke, intracerebral hemorrhage, or both, which identified microbiological etiologies for pneumonia complicating stroke up to January 1, 2017, were considered. Analysis included summary statistics and random-effects meta-analysis where appropriate. Fifteen studies (40% ischemic stroke, 60% ischemic stroke and intracerebral hemorrhage) involving 7968 patients were included. Reported occurrence of pneumonia varied considerably between studies (2%-63%) with a pooled frequency of 23% (95% confidence interval, 14%-34%; I2=99%). Where reported (60%), the majority of pneumonia occurred within 1 week of stroke (78%). Reported frequency of positive culture data (15%-88%) varied widely. When isolated, aerobic Gram-negative bacilli (38%) and Gram-positive cocci (16%) were most frequently cultured; commonly isolated organisms included Enterobacteriaceae (21.8%: Klebsiella pneumoniae, 12.8% and Escherichia coli, 9%), Staphylococcus aureus (10.1%), Pseudomonas aeruginosa (6%), Acinetobacter baumanii (4.6%), and Streptococcus pneumoniae (3.5%). Sputum was most commonly used to identify pathogens, in isolation (40%) or in conjunction with tracheal aspirate (15%) or blood culture (20%). Although the analysis was limited by small and heterogeneous study populations, limiting determination of microbiological causality, this review suggests aerobic Gram-negative bacilli and Gram-positive cocci are frequently associated with pneumonia complicating stroke. This supports the need for appropriately designed studies to determine microbial cause and a consensus-based approach in antibiotic usage and further targeted antibiotic treatment trials for enhanced antibiotic stewardship.

Abstract P-191: A MAJOR CLINICAL CHALLENGE IN PEDIATRIC INTENSIVE CARE UNIT WITH PANDRUG-RESISTANT OXA-48 KLEBSIELLA PNEUMONIAE OUTBREAK

Aims & Objectives: Background: Carbapenem-resistant Klebsiella pneumoniae (CRKP) has been reported to cause serious outbreaks. In our knowledge it is the first study about pandrug-resistant (PDR) OXA-48 positive CRKP infection in pediatric intensive care unit (PICU). Aim: To share our experience with PDR-CRKP outbreak with survival rate of 14% mortality in our clinic. Methods Between September 2016 and January 2017, PDR Klebsiella pneumoniae outbreak in a 20-bed tertiary PICU was evaluated prospectively. Demographic characteristics, underlying diseases, invasive procedures, previous infection and antibiotics usage, infection center, applying therapies and measures are recorded. Results 7 patients (6 male, 1 female) were followed for PDR OXA-48 positive CRKP. The mean age of the patients was 6 years, the mean time of appearance of infection in PICU was 45 days. Infection was detected in tracheal aspirate culture in 2 patients, catheter-related blood culture in 2, wound culture in 2, and urine culture in 1 patient. Combination therapy with high dose meropenem and imipenem infusion, amikacin, colistin and tigecycline was used in treatment. The mean duration of antibiotic treatment and isolation was 15.7 and 65.4 days, respectively. Skin and digestive tract colonization occurred in all patients. Only one patient lost becouse of her own illness, while there was no active infection. Conclusions PDR-CRKP infection is the most serious form of nasocomial outbreaks for intensive care units due to high mortality rate. We wanted to share our experience, which was for the first time in the PICU with very low mortality.

Outcome Difference in Neurosurgical Patients Based on Timing of Tracheostomy and Ventilator Associated Pneumonia

Background and Objective: Tracheostomy in neurosurgical patients has been shown in various studies to lower the length of ICU stay and the length of hospital stay by decreasing the incidence of ventilator associated pneumonia. In this regard, we wanted to evaluate the outcome of neurosurgical ICU patients based on timing of tracheostomy and ventilator associated pneumonia.Methods: This is a retrospective single centre study performed over a period of two and a half years. Early tracheostomy was defi ned as those done three days of intubation or earlier and late as those done then after. Statistical analysis was done using SPSS.Results: There were 56 patients over the study period of which 18 patients underwent early tracheostomy and 38 patients underwent late tracheostomy. There was no statistically significant difference between the two groups with regards to the length of ICU stay, the length of hospital stay or the length of tracheostomy tube in situ. But based on tracheal aspirate culture positivity, length of tracheostomy tube in situ was signifi cantly longer in those with positive bacterial cultures.Early tracheostomy does not improve neurosurgical outcome while documented pneumonia prolongs the length of tracheostomy tube in situ.Nepal Journal of Neuroscience 15:19-22, 2018

Incidence and Diagnostic Evaluation of Postoperative Fever in Pediatric Patients With Neuromuscular Disorders

Children with neuromuscular disorders have a significant chance of developing scoliosis and/or hip dislocation during childhood and adolescence and often undergo surgical reconstruction. Because of their high rate of medical comorbidities, these patients are at higher risk of postoperative complications and are therefore often comanaged, along with orthopaedics, by pediatric medicine and critical care teams. Fever during the postoperative stay is a frequent occurrence and often prompts extensive diagnostic workup which increases the cost and burden on the health system but have unclear effects on the care of the patient. The objective of our study was to evaluate the frequency of postoperative fever in pediatric patients with neuromuscular disorders after spine and hip deformity correction surgery and evaluate the utility of the diagnostic tests performed for the assessment of postoperative fever. We performed an IRB-approved retrospective study on patients who underwent corrective surgery for neuromuscular scoliosis or hip dislocation at a single institution. The occurrence of postoperative fever was characterized by maximum temperature, postoperative day (POD) of occurrence, and frequency as defined by either single or multiple temperature spikes. Diagnostic tests performed for the workup of postoperative fever were reviewed. The cost per health effect was estimated by dividing the total costs of diagnostic tests by the number of tests that changed patient care. In total, 108 patients (62 females and 46 males) were identified. A total of 42 patients (38.9%) underwent posterior spinal fusion and 66 (61.1%) patients underwent hip surgery (pelvic osteotomy in 8 patients, femoral osteotomy in 31 patients, and both pelvic and femoral osteotomy in 27 patients). The mean age at the time of surgery was 11.1 years (range, 3 to 18 y). In total, 66 patients (61.1%) developed postoperative fever (mean temperature, 38.6°C). The frequency of fever was in the form of multiple temperature spikes in 37 patients (56%) and in the form of a single spike in 29 patients (44%). Of the 149 diagnostic tests performed for postoperative fever, there were a total of 16 positive tests (10.7% of total tests ordered; n=16/149) including 5/27 urine analysis, 4/26 urine culture, 4/28 chest x-ray, 1/1 wound culture, 0/1 sputum culture, urine Gram stain 0/1, tracheal aspirate culture 0/1, throat culture 1/1, adenovirus polymerase chain reaction (PCR) 0/5, human metapneumovirus PCR 0/5, parainfluenza PCR 0/5, rhinovirus PCR 0/1, 1/3 bronchoalveolar culture, and 0/7 respiratory virus panel. A total of 37 blood cultures were drawn and all were negative. There was a significant difference (P=0.04) in frequency of negative diagnostic workup performed at the first, second, and third POD as compared with positive diagnostic workup. Total cost of the diagnostic tests was $65,284 and the cost per health effect was $6582 ($65,284/10). Diagnostic tests in patients with postoperative fever were associated with prolonged length of hospital stay in comparison with patients who did not perform any diagnostic workup using the Spearman ρ test (P=0.02). In total, 61% of pediatric patients developed postoperative fever after surgical correction of neuromuscular deformity. An infectious source of postoperative fever was identified in 32.4% of patients with postoperative fever who underwent diagnostic workup. Urinary tract infection was the most common finding in patients with postoperative fever. Poor association between the development of postoperative fever and wound infection was found. Only 10.7% of fever diagnostic workup tests were positive in our population. The diagnostic workup tests might be less valuable if performed early on the first, second, and third PODs than those performed late after the third POD with exceptions based on clinical assessment. No patients with postoperative fever had positive blood cultures, therefore the routine use of blood cultures in the evaluation of postoperative fever in such population is not recommended. Level IV-retrospective.

Infectious Laryngotracheitis Virus Viral Chemokine-Binding Protein Glycoprotein G Alters Transcription of Key Inflammatory Mediators In Vitro and In Vivo.

Infectious laryngotracheitis virus (ILTV) is an alphaherpesvirus that infects chickens, causing upper respiratory tract disease and significant losses to poultry industries worldwide. Glycoprotein G (gG) is a broad-range viral chemokine-binding protein conserved among most alphaherpesviruses, including ILTV. A number of studies comparing the immunological parameters between infection with gG-expressing and gG-deficient ILTV strains have demonstrated that expression of gG is associated with increased virulence, modification of the amount and the composition of the inflammatory response, and modulation of the immune responses toward antibody production and away from cell-mediated immune responses. The aims of the current study were to examine the establishment of infection and inflammation by ILTV and determine how gG influences that response to infection. In vitro infection studies using tracheal organ tissue specimen cultures and blood-derived monocytes and in vivo infection studies in specific-pathogen-free chickens showed that leukocyte recruitment to the site of infection is an important component of the induced pathology and that this is influenced by the expression of ILTV gG and changes in the transcription of the chicken orthologues of mammalian CXC chemokine ligand 8 (CXCL8), chicken CXCLi1 and chicken CXCLi2, among other cytokines and chemokines. The results from this study demonstrate that ILTV gG interferes with chemokine and cytokine transcription at different steps of the inflammatory cascade, thus altering inflammation, virulence, and the balance of the immune response to infection.IMPORTANCE Infectious laryngotracheitis virus is an alphaherpesvirus that expresses gG, a conserved broad-range viral chemokine-binding protein known to interfere with host immune responses. However, little is known about how gG modifies virulence and influences the inflammatory signaling cascade associated with infection. Here, data from in vitro and in vivo infection studies are presented. These data show that gG has a direct impact on the transcription of cytokines and chemokine ligands in vitro (such as chicken CXCL8 orthologues, among others), which explains the altered balance of the inflammatory response that is associated with gG during ILTV infection of the upper respiratory tract of chickens. This is the first report to associate gG with the dysregulation of cytokine transcription at different stages of the inflammatory cascade triggered by ILTV infection of the natural host.

An Unusual Case of Horner Syndrome

SESSION TITLE: Critical Care 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Horner's syndrome manifests in varying degrees of ptosis, miosis, and anhidrosis. Etiology can vary from central lesions, intracranial tumors and strokes, to peripheral causes, such as carotid artery dissections, pancoast tumors, blunt trauma or iatrogenic injuries. Tracheobronchial injury secondary to intubation is a rare complication, occurring in 0.005% of intubations1. We report a case of Horner's syndrome in an intubated patient due to a tracheal tear. CASE PRESENTATION: A 34 year old woman presented to the emergency department with dyspnea. She was febrile, tachycardic, tachypnic and became hypotensive requiring intubation and vasopressors with a diagnosis of septic shock due to pneumonia. On volume assist control ventilation with a positive end expiratory pressure of 10 cm H2O, her PaO2 to FiO2 ratio was 135. Chest x-ray showed bilateral alveolar infiltrates consistent with acute respiratory distress syndrome; treatment included lung protective ventilation and paralysis. She was positive for influenza A and her urine antigen was positive for Streptococcus pneumoniae, however, tracheal cultures from the day of admission grew only Staphylococcus aureus. She received appropriate antibiotics and oseltamivir. On hospital day 9, she was found to have a pneumothorax and a chest tube was placed. That evening, new onset, unilateral right pupil dilation prompted a CT scan of both the head and neck. The CT revealed a linear laceration of the trachea and air extending into the posterior mediastinum (Figures 1 and 2) and superiorly along the carotids. Bronchoscopy revealed a small anterior tracheal tear. The endotracheal tube was advanced beyond the tear and ventilator settings were changed to minimize ventilator pressures. A subsequent bronchoscopy revealed resolution of the tracheal tear. DISCUSSION: We believe that the increased intrathoracic pressure from free air compressed neurons in the sympathetic chain resulting in Horner’s syndrome. Several reported cases demonstrate Horner's syndrome as a complication of pneumomediastinum. Chipman et al, reported an alcoholic patient who presented with right sided ptosis and miosis and was subsequently found to have significant pneumomediastinum stemming from alveolar rupture in the setting of severe retching2. CONCLUSIONS: The development of Horner's syndrome due to tracheal rupture in an intubated patient is a rare finding. In critically ill patients, as here, it may be possible to treat the laceration with conservative, non-procedural management. Reference #1: Management of iatrogenic tracheobronchial injuries: a retrospective analysis of 29 cases. Schneider et al. Ann Thorac Surg. 2007 Jun;83(6):1960-4. Reference #2: Unilateral ptosis and miosis caused by pneumomediastinum Chipman et al. Neurology 2007;68;1155 DISCLOSURE: The following authors have nothing to disclose: Shivdeep Deo, Michael Vest, David Manoff, Michael Sneider, Alberto Iaia, Timothy Roedder No Product/Research Disclosure Information

Stimulatory Secretions of Airway Epithelial Cells Accelerate Early Repair of Tracheal Epithelium

Airway stem/progenitor epithelial cells (AECs) are notable for their differentiation capacities in response to lung injury. Our previous finding highlighted the regenerative capacity of AECs following transplantation in repairing tracheal injury and reducing the severity of alveolar damage associated acute lung injury in a rabbit model. The goal of this study is to further investigate the potential of AECs to re-populate the tracheal epithelium and to study their stimulatory effect on inhibiting pro-inflammatory cytokines, epithelial cell migration and proliferation, and epithelial-to-mesenchymal transition (EMT) process following tracheal injury. Two in vitro culture assays were applied in this study; the direct co-culture assay that involved a culture of decellularised tracheal epithelium explants and AECs in a rotating tube, and indirect co-culture assay that utilized microporous membrane-well chamber system to separate the partially decellularised tracheal epithelium explants and AEC culture. The co-culture assays provided evidence of the stimulatory behaviour of AECs to enhance tracheal epithelial cell proliferation and migration during early wound repair. Factors that were secreted by AECs also markedly suppressed the production of IL-1β and IL-6 and initiated the EMT process during tracheal remodelling.

Microbiology of Tracheal Secretions: What to Expect with Children and Adolescents with Tracheostomies.

Introduction People with tracheostomies exhibit a higher risk of colonization of the lower respiratory tract, acute tracheitis and pneumonia. Despite this, the culture of tracheal secretions is not a routine in most hospitals, and sometimes empiric therapy is based on personal experience, which is not an ideal situation. Objective To recognize the pathogens present in the tracheal secretions collected from people up to 18 years old with tracheostomies. Methods Prospective evaluation of patients under the age of 18 of a tertiary care hospital. A standardized questionnaire was completed, and tracheal secretion aspirates were sent for microbiological cultures and antibiograms. Results Twenty patients under 18 years of age were evaluated, 65% of whom were male. The microbiological culture was positive in 90% of the patients, and the most common microorganisms found were Pseudomonas aeruginosa (55.5%) and Staphylococcus aureus (27.7%). Discussion Tracheostomized children and adolescents have respiratory tracts colonized by pathogens, the most common of which is Pseudomonas aeruginosa . These patients must undergo tracheal secretion cultures, whether they present symptoms or not, to determine if there is a correlation between the colonization and the infections. This finding could guide the adequate treatment, avoiding the inappropriate use of antibiotics and indicating the better therapy in cases of laryngeal reconstruction. Conclusion In this sample, the culture of tracheal secretions was mainly positive, and the most common agent was P. aeruginosa . We suggest the routine access to Brazilian children and adolescents tracheal secretion cultures, which could help to make a profile of these children and guide the use of antibiotics.

Systemic Fungal Infections in Donors for Corneal Transplantation.

To determine the prevalence of postkeratoplasty fungal infection when corneal tissue from donors with a recent medical history of oral thrush or respiratory, urine, wound, sputum, bronchial, tracheal, or throat culture positive for fungus is identified before recovery and after decontamination of the corneal tissue with 5% povidone-iodine flush to the donors' eyes during recovery. This is a prospective analysis of corneas from 42 donors with a documented medical history of fungus or positive fungal culture, which were recovered between January 2010 and November 2010. Standard aseptic swab of the donors' corneas before and after application of 5% povidone-iodine solution was performed. Culture results were analyzed in relationship to the donors' medical history and potential posttransplantation infections. Eighty-four eyes from 42 patients were swabbed for cultures during the study period. Seven eyes (8.3%) were positive for fungal growth before treatment with 5% povidone-iodine, whereas there were no positive fungal cultures after treatment (P = 0.007). Fifty-four corneas from this study group were used for corneal transplantation. There were no cases of fungal infection in any postkeratoplasty eyes transplanted from this study group. In this small study, the overall prevalence of fungal infections after corneal transplantation using corneal donor tissue from donors with a fungal-positive medical history is low. Corneal fungal contamination in donors with a history of fungal infection or a positive fungal culture can be significantly reduced with a 5% povidone-iodine flush.

Cartilage rings contribute to the proper embryonic tracheal epithelial differentiation, metabolism, and expression of inflammatory genes.

The signaling cross talk between the tracheal mesenchyme and epithelium has not been researched extensively, leaving a substantial gap of knowledge in the mechanisms dictating embryonic development of the proximal airways by the adjacent mesenchyme. Recently, we reported that embryos lacking mesenchymal expression of Sox9 did not develop tracheal cartilage rings and showed aberrant differentiation of the tracheal epithelium. Here, we propose that tracheal cartilage provides local inductive signals responsible for the proper differentiation, metabolism, and inflammatory status regulation of the tracheal epithelium. The tracheal epithelium of mesenchyme-specific Sox9Δ/Δ mutant embryos showed altered mRNA expression of various epithelial markers such as Pb1fa1, surfactant protein B (Sftpb), secretoglobulin, family 1A, member 1 (Scgb1a1), and trefoil factor 1 (Tff1). In vitro tracheal epithelial cell cultures confirmed that tracheal chondrocytes secrete factors that inhibit club cell differentiation. Whole gene expression profiling and ingenuity pathway analysis showed that the tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ), and transforming growth factor-β (TGF-β) signaling pathways were significantly altered in the Sox9 mutant trachea. TNF-α and IFN-γ interfered with the differentiation of tracheal epithelial progenitor cells into mature epithelial cell types in vitro. Mesenchymal knockout of Tgf-β1 in vivo resulted in altered differentiation of the tracheal epithelium. Finally, mitochondrial enzymes involved in fat and glycogen metabolism, cytochrome c oxidase subunit VIIIb (Cox8b) and cytochrome c oxidase subunit VIIa polypeptide 1 (Cox7a1), were strongly upregulated in the Sox9 mutant trachea, resulting in increases in the number and size of glycogen storage vacuoles. Our results support a role for tracheal cartilage in modulation of the differentiation and metabolism and the expression of inflammatory-related genes in the tracheal epithelium by feeding into the TNF-α, IFN-γ, and TGF-β signaling pathways.

A Randomized Trial of the Amikacin Fosfomycin Inhalation System for the Adjunctive Therapy of Gram-Negative Ventilator-Associated Pneumonia: IASIS Trial

Clinical failures in ventilator-associated pneumonia (VAP) caused by gram-negative bacteria are common and associated with substantial morbidity, mortality, and resource utilization. We assessed the safety and efficacy of the amikacin fosfomycin inhalation system (AFIS) for the treatment of gram-negative bacterial VAP in a randomized double-blind, placebo-controlled, parallel group, phase 2 study between May 2013 and March 2016. We compared standard of care in each arm plus 300mg amikacin/120mg fosfomycin or placebo (saline), delivered by aerosol twice daily for 10days (or to extubation if< 10days) via the investigational eFlow Inline System (PARI GmbH). The primary efficacy end point waschange from baseline in the Clinical Pulmonary Infection Score (CPIS) during the randomized course of AFIS/placebo, using the subset of patients with microbiologically proven baseline infections with gram-negative bacteria. There were 143 patients randomized: 71 to the AFIS group, and 72 to the placebo group. Comparison of CPIS change from baseline between treatment groups was not different (P= .70). The secondary hierarchical end point of no mortality and clinical cure at day 14 or earlier was also not significant (P= .68) nor was the hierarchical end point of no mortality and ventilator-free days (P= .06). The number of deaths in the AFIS group was 17(24%) and 12 (17%) in the placebo group (P= .32). The AFIS group had significantly fewer positive tracheal cultures on days 3 and 7 than placebo. In this trial of adjunctive aerosol therapy compared with standard of care IV antibiotics in patients with gram-negative VAP, the AFIS was ineffective in improving clinical outcomes despite reducing bacterial burden. ClinicalTrials.gov; No.: NCT01969799; URL: www.clinicaltrials.gov.

Infant position in neonates receiving mechanical ventilation.

In patients of various ages undergoing mechanical ventilation (MV), it has been observed that positions other than the standard supine position, such as the prone position, may improve respiratory parameters. The benefits of these positions have not been clearly defined for critically ill newborns receiving MV.This is an update of a review first published in 2005 and last updated in 2013. Primary objectiveTo assess the effects of different positioning of newborn infants receiving MV (supine vs prone, lateral decubitus or quarter turn from prone) in improving short-term respiratory outcomes. Secondary objectiveTo assess the effects of different positioning of newborn infants receiving MV on mortality and neuromotor and developmental outcomes over the long term, and on other complications of prematurity. We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8), MEDLINE via PubMed (1966 to 22 August 2016), Embase (1980 to 22 August 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 22 August 2016). We also searched clinical trials databases, conference proceedings and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised and quasi-randomised clinical trials comparing different positions in newborns receiving mechanical ventilation. Three unblinded review authors independently assessed trials for inclusion in the review and extracted study data. We used standard methodological procedures as expected by The Cochrane Collaboration and assessed the quality of the evidence using the GRADE approach. If the meta-analysis was not appropriate owing to substantial clinical heterogeneity between trials, we presented review findings in narrative format. We included in this review 19 trials involving 516 participants. Seven of the included studies (N = 222) had not been evaluated in the previous review. Investigators compared several positions: prone versus supine, prone alternant versus supine, prone versus lateral right, lateral right versus supine, lateral left versus supine, lateral alternant versus supine, lateral right versus lateral left, quarter turn from prone versus supine, quarter turn from prone versus prone and good lung dependent versus good lung uppermost.Apart from two studies that compared lateral alternant versus supine, one comparing lateral right versus supine and two comparing prone or prone alternant versus the supine position, all included studies had a cross-over design. In five studies, infants were ventilated with continuous positive airway pressure (CPAP); in the other studies, infants were treated with conventional ventilation (CV).Risks of bias did not differ substantially for different comparisons and outcomes. This update detects a moderate to high grade of inconsistency, similar to previous versions. However, for the analysed outcomes, the direction of effect was the same in all studies. Therefore, we consider that this inconsistency had little effect on the conclusions of the meta-analysis. When comparing prone versus supine position, we observed an increase in arterial oxygen tension (PO2) in the prone position (mean difference (MD) 5.49 mmHg, 95% confidence interval (CI) 2.92 to 8.05 mmHg; three trials; 116 participants; I2= 0). When percent haemoglobin oxygen saturation was measured with pulse oximetry (SpO2), improvement in the prone position was between 1.13% and 3.24% (typical effect based on nine trials with 154 participants; I2= 89%). The subgroup ventilated with CPAP (three trials; 59 participants) showed a trend towards improving SpO2 in the prone position compared with the supine position, although the mean difference (1.91%) was not significant (95% CI -1.14 to 4.97) and heterogeneity was extreme (I2= 95%).Sensitivity analyses restricted to studies with low risk of selection bias showed homogeneous results and verified a small but significant effect (MD 0.64, 95% CI 0.26 to 1.02; four trials; 92 participants; I2= 0).We also noted a slight improvement in the number of episodes of desaturation; it was not possible to establish whether this effect continued once the intervention was stopped. Investigators studied few adverse effects from the interventions in sufficient detail. Two studies analysed tracheal cultures of neonates after five days on MV, reporting lower bacterial colonisation in the alternating lateral position than in the supine posture. Other effects - positive or negative - cannot be excluded in light of the relatively small numbers of neonates studied. This update of our last review in 2013 supports previous conclusions. Evidence of low to moderate quality favours the prone position for slightly improved oxygenation in neonates undergoing mechanical ventilation. However, we found no evidence to suggest that particular body positions during mechanical ventilation of the neonate are effective in producing sustained and clinically relevant improvement.

A Fatal Case of Community Acquired Cupriavidus Pauculus Pneumonia.

Cupriavidus pauculus is a rarely isolated non-fermentative, aerobic bacillus, which occasionally causes severe human infections, especially in immunocompromised patients. Strains have been isolated from various clinical and environmental sources. A 67-year-old man was admitted to the Intensive Care Unit with acute respiratory failure. The patient was diagnosed with bilateral pneumonia, pulmonary sepsis and underwent invasive mechanical ventilation. Examination revealed diminished bilateral vesicular breath sounds, fever, intense yellow tracheal secretions, a respiratory rate of 24/minute, a heart rate of 123/minute, and blood pressure of 75/55 mmHg. Vasoactive treatment was initiated. Investigations revealed elevated lactate and C-reactive protein levels. A chest X-ray showed bilateral infiltration. Parenteral ciprofloxacin and ceftriaxone were administered. Tracheal aspirate culture and blood culture showed bacterial growth of Cupriavidus pauculus. Colistin was added to the treatment. There was a poor clinical response despite repeated blood culture showing negative results. The diagnosis of multiple organ dysfunction syndrome (MODS) caused by C. pauculus was made. The patient died eleven days after admission. Clinical improvement cannot always be expected in spite of targeted antibiotic therapy. This pathogen should be considered responsible for infections that usually develop in immunocompromised patients.

Microbial investigation of biofilms recovered from endotracheal tubes using sonication in intensive care unit pediatric patients

ObjectivesTo compare cultured microorganisms identified on endotracheal tubes biofilms through sonication technique with traditional tracheal aspirate collected at extubation of pediatric intensive care unit patients. MethodsDemographic and epidemiological data were analyzed to identify factors possibly related with the microbiological profile of the two collection methods. Associations between categorical and continuous variables were analyzed using the chi-square or Fisher's exact test, or Student's t test. p-Value <0.05 were considered significant. ResultsThirty endotracheal tubes and tracheal aspirates samples from 27 subjects were analyzed. Only one patient presented the clinical diagnosis of ventilator-associated pneumonia. Overall, 50% of bacteria were Gram-negative bacilli, followed by Gram-positive bacteria in 37%, and fungi in 10%. No statistically significant difference on the distribution of Gram-positive or Gram-negative bacteria (p=0.996), and fungi (p=0.985) were observed between the collection methods. Pseudomonas spp. was the most frequent microorganism identified (23.8%), followed by Streptococcus spp. (18.5%), Acinetobacter spp. (15.9%), coagulase-negative staphylococci (11.2%), and Klebsiella spp. (8.6%). Concordant results between methods amounted to 83.3%. Pseudomonas aeruginosa and Acinetobacter baumannii showed carbapenem resistance in 50% and 43.7% of the isolates, respectively. In general, cultures after endotracheal tubes sonication (non-centrifuged sonication fluid and centrifuged sonication fluid) yielded bacteria with higher rates of antimicrobial resistance compared to tracheal aspirates cultures. Additionally, in 12 subjects (40%), we observed discrepancies regarding microbiologic profiles of cultures performed using the collection methods. ConclusionsOur study demonstrated that sonication technique can be applied to ET biofilms to identify microorganisms attached to their surface with a great variety of species identified. However, we did not find significant differences in comparison with the traditional tracheal aspirate culture approach.

The Association between Positive Tracheal Aspirate Cultures and Adverse Pulmonary Outcomes in Preterm Infants with Severe Bronchopulmonary Dysplasia.

Objective Bacterial colonization of the airway may contribute to the development of bronchopulmonary dysplasia. Whether airway colonization increases risk for later adverse respiratory outcomes is less clear. We described tracheal aspirate culture results obtained from preterm infants receiving mechanical ventilation at 36 weeks postmenstrual age (PMA) and evaluated the association between bacteria type and the risk for prolonged supplemental oxygen use. Study Design We conducted a retrospective, single-center cohort study comparing infants (1) with and without a tracheal aspirate culture that grew a Gram-negative rod (GNR) and (2) with and without a culture that grew a Gram-positive cocci (GPC). Results Among 121 infants, 65 (53.7%) and 51 (42.2%) had a tracheal aspirate culture that grew a potentially pathogenic GNR and GPC prior to 36 weeks PMA, respectively. GNR were associated with increased risk for death or use of supplemental oxygen at discharge (adjusted odds ratio [aOR], 6.2; 95% confidence interval [CI], 1.8-21.1), and use of supplemental oxygen at discharge among survivors (aOR, 5.5; 95% CI, 1.6-19.0). GPC did not affect the risk for any study outcomes. Conclusion GNR but not GPC in the airways of preterm infants receiving mechanical ventilation at 36 weeks PMA is associated with increased risk for prolonged supplemental oxygen use.

Use of Tracheal Aspirate Culture in Newly Intubated Patients with Community-Onset Pneumonia

Successful treatment of life-threatening community-acquired pneumonia requires appropriate empiric antibiotic coverage. But using conventional diagnostic techniques, a microbiological diagnosis is often not achieved. The diagnostic usefulness of tracheal aspirate at the time of intubation in patients with severe pneumonia has not been well studied. The purpose of this study was to evaluate the use of tracheal aspirate culture in identifying pneumonia pathogens. We identified all patients older than 18 years of age with International Classification of Disease, Ninth Revision codes and radiographic evidence of pneumonia seen in the emergency departments at 2 university-affiliated Utah hospitals from December 2009 to November 2010 and from December 2011 to November 2012. Patients intubated within 24 hours of arrival were then identified electronically. Postintubation orders instructed respiratory therapists to obtain tracheal aspirate for culture. All culture results were reviewed individually and defined as positive if a pneumonia pathogen was identified. Results of other microbiology studies were obtained from the electronic medical record. Of 2,011 patients with pneumonia, 94 were intubated and 84 had a tracheal aspirate obtained. Of these 84 patients, 47 (56%) had a pulmonary pathogen identified by tracheal aspirate culture, 80 also had blood cultures, and 71 underwent Pneumococcal and Legionella urinary antigen testing. A microbiological diagnosis was made in 55 patients (65.5%) by any diagnostic method. In 39% of patients (32 of 82), the tracheal aspirate culture was the only positive test, resulting in a unique microbiological diagnosis in patients who would have otherwise been classified as "culture negative." Tracheal aspirate cultures obtained as part of routine care identified a plausible pneumonia pathogen in more than one-half of emergency department adult patients with severe pneumonia requiring intubation. Tracheal aspirate culture offers important additive diagnostic value to other routine tests.

Factors associated with nosocomial infection in the elderly in the Intensive Care Unit

Background: The elderly have increased vulnerability to disease and exposure to hospital infections. Aims: The study aims to evaluate the clinical and epidemiological factors associated with nosocomial infection in the elderly. Methods: A retrospective study with a population of 625 elderly patients admitted to intensive care units and a sample of 308 elderly who developed nosocomial infection from January 2012 to June 2015. Results: A total of 49.7% of the elderly presented a growth of micro-organisms in tracheal aspirates. The diseases classified as increased likelihood of tracheal infection (3.61, 95% - CI 1.84 to 7.10; p = 0.005) and the probability of growth of micro-organism in the culture performed elsewhere - general (8.96, 95% - CI 3.03 to 26.49; p = 0.005). Surgical procedures increased the chance of growth of micro-organisms in tracheal secretion culture (OR 1.96, 95% CI 1.11 to 3.48) and surgical site culture (OR 5.06, 95% CI 1, from 76 to 14.55). The neurological disease increased the chance of growth of micro-organisms in the cultures of tracheal secretions, blood and general (OR 3.80, 95% CI 1.22 to 11.83; OR 3.27, 95% CI 1.24 - 8.66; OR 15.61, 95% CI 4.78 to 50.98). The pneumothorax increases by four times the probability of growth of micro-organisms in the catheter tip (OR 4.17, 95% CI 1.24 to 13.97). Chronic and acute renal failure and other diagnoses increased by eighteen times the chance of growth of micro-organisms in general culture (OR 18.06, 95% CI 3.63 to 89.86). Conclusion: The main risk factors for nosocomial infection of elderly in the Intensive Care Unit are chronic and acute renal failure, neurological diseases and surgical procedures and must be adopted a policy of prevention and control of nosocomial infection in the treatment of the elderly. Keywords: Elderly, Cross infection, Intensive care.

Impact of tracheal cuff shape on microaspiration of gastric contents in intubated critically ill patients: study protocol for a randomized controlled trial.

BackgroundVentilator-associated pneumonia (VAP) is the most common infection in intubated critically ill patients. Microaspiration of the contaminated gastric and oropharyngeal secretions is the main mechanism involved in the pathophysiology of VAP. Tracheal cuff plays an important role in stopping the progression of contaminated secretions into the lower respiratory tract. Previous in vitro studies suggested that conical cuff shape might be helpful in improving tracheal sealing. However, clinical studies found conflicting results. The aim of this study is to determine the impact of conical tracheal cuff shape on the microaspiration of gastric contents in critically ill patients.Methods/DesignThis prospective cluster randomized controlled crossover open-label trial is currently being conducted in ten French intensive care units (ICUs). Patients are allocated to intubation with a polyvinyl chloride (PVC) standard (barrel)-shaped or a PVC conical-shaped tracheal tube. The primary objective is to determine the impact of the conical shaped tracheal cuff on abundant microaspiration of gastric contents. Secondary outcomes include the incidence of microaspiration of oropharyngeal secretions, tracheobronchial colonization, VAP and ventilator-associated events. Abundant microaspiration is defined as the presence of pepsin at significant level (>200 ng/ml) in at least 30 % of the tracheal aspirates. Pepsin and amylase are quantitatively measured in all tracheal aspirates during the 48 h following inclusion. Quantitative tracheal aspirate culture is performed at inclusion and twice weekly. We plan to recruit 312 patients in the participating ICUs.DiscussionBEST Cuff is the first randomized controlled study evaluating the impact of PVC tracheal-cuff shape on gastric microaspirations in patients receiving invasive mechanical ventilation. Enrollment began in June 2014 and is expected to end in October 2015.Trial registrationClinicalTrials.gov Identifier: NCT01948635 (registered 31 August 2013).