Prevalence, risk factors, and mortality for ventilator-associated pneumonia in middle-aged, old, and very old critically ill patients*

COVID-19 severe pneumonia: Prospective multicentre study on demands on intensive care capacities

OBJECTIVES

The aim of the study was to obtain data on demands on the intensive care capacities to treat COVID-19 patients, and to identify predictors for in-hospital mortality.

METHODS

The prospective observational multicentre study carried out from 1 March till 30 June 2020 included adult patients with confirmed SARS-CoV-2 infection with respiratory failure requiring ventilatory support or high-flow nasal oxygen therapy (HFNO).

RESULTS

Seventy-four patients, 46 males and 28 females, median age 67.5 (Q1-Q3: 56-75) years, were included. Sixty-four patients (86.5%) had comorbidity. Sixty-six patients (89.2%) were mechanically ventilated, four of them received extracorporeal membrane oxygenation therapy. Eight patients (10.8%) were treated with non-invasive ventilation and HFNO only. The median of intensive care unit (ICU) stay was 22.5 days. Eighteen patients (24.3%) needed continuous renal replacement therapy. Thirty patients (40.5%) died. Age and acute kidney injury were identified as independent predictors of in-hospital death, and chronic kidney disease showed trend towards statistical significance for poor outcome.

CONCLUSIONS

Sufficient number of intensive care beds, organ support equipment and well-trained staff is a decisive factor in managing the COVID-19 epidemic. The study focused on the needs of intensive care in the COVID-19 patients. Advanced age and acute kidney injury were identified as independent predictors for in-hospital mortality. When compared to clinical course and ICU management of patients with severe community-acquired pneumonia caused by other pathogens, we observed prolonged need for ventilatory support, high rate of progression to acute respiratory distress syndrome and significant mortality in studied population.

Nosocomial Pneumonia in the Era of Multidrug-Resistance: Updates in Diagnosis and Management

Nosocomial pneumonia (NP), including hospital-acquired pneumonia in non-intubated patients and ventilator-associated pneumonia, is one of the most frequent hospital-acquired infections, especially in the intensive care unit. NP has a significant impact on morbidity, mortality and health care costs, especially when the implicated pathogens are multidrug-resistant ones. This narrative review aims to critically review what is new in the field of NP, specifically, diagnosis and antibiotic treatment. Regarding novel imaging modalities, the current role of lung ultrasound and low radiation computed tomography are discussed, while regarding etiological diagnosis, recent developments in rapid microbiological confirmation, such as syndromic rapid multiplex Polymerase Chain Reaction panels are presented and compared with conventional cultures. Additionally, the volatile compounds/electronic nose, a promising diagnostic tool for the future is briefly presented. With respect to NP management, antibiotics approved for the indication of NP during the last decade are discussed, namely, ceftobiprole medocaril, telavancin, ceftolozane/tazobactam, ceftazidime/avibactam, and meropenem/vaborbactam.

Protocol for an international, multicentre, prospective, observational study of nosocomial pneumonia in intensive care units: the PneumoINSPIRE study

Background: Nosocomial pneumonia in the critical care setting is associated with increased morbidity, significant crude mortality rates and high health care costs. Ventilator-associated pneumonia represents about 80% of nosocomial pneumonia cases in intensive care units (ICUs). Wide variance in incidence of nosocomial pneumonia and diagnostic techniques used has been reported, while successful treatment remains complex and a matter of debate. Objective: To describe the epidemiology, diagnostic strategies and treatment modalities for nosocomial pneumonia in contemporary ICU settings across multiple countries around the world. Design, setting and patients: PneumoINSPIRE is a large, multinational, prospective cohort study of adult ICU patients diagnosed with nosocomial pneumonia. Participating ICUs from at least 20 countries will collect data on 10 or more consecutive ICU patients with nosocomial pneumonia. Site-specific information, including hospital policies on antibiotic therapy, will be recorded along with patient-specific data. Variables that will be explored include: aetiology and antimicrobial resistance patterns, treatment-related parameters (including time to initiation of antibiotic therapy, and empirical antibiotic choice, dose and escalation or de-escalation), pneumonia resolution, ICU and hospital mortality, and risk factors for unfavourable outcomes. The concordance of ventilator-associated pneumonia diagnosis with accepted definitions will also be assessed. Results and conclusions: PneumoINSPIRE will provide valuable information on current diagnostic and management practices relating to ICU nosocomial pneumonia, and identify research priorities in the field. Trial registration:ClinicalTrials.gov identifier NCT02793141.

Emergence of Nosocomial Pneumonia Caused by Colistin-Resistant Escherichia coli in Patients Admitted to Chest Intensive Care Unit

(1) Background: Colistin is a last-resort antibiotic used in treating multidrug-resistant Gram-negative infections. The growing emergence of colistin resistance in Escherichia coli (E. coli) represents a serious health threat, particularly to intensive care unit (ICU) patients. (2) Methods: In this work, we investigated the emergence of colistin resistance in 140 nosocomial E. coli isolated from patients with pneumonia and admitted to the chest ICU over 36 months. Virulence and resistance-related genes and E. coli pathotypes in colistin-resistant and colistin-sensitive isolates were determined. (3) Results: Colistin resistance was observed in 21/140 (15%) of the nosocomial E. coli isolates. The MIC₅₀ of the resistant strains was 4 mg/L, while MIC₉₀ was 16 mg/L. Colistin-resistant isolates were also co-resistant to amoxicillin, amoxicillin/clavulanic, aztreonam, ciprofloxacin, and chloramphenicol. The mechanism of colistin resistance was represented by the presence of mcr-1 in all resistant strains. Respectively, 42.9% and 36.1% of colistin-resistant and colistin-sensitive groups were extended-spectrum β-lactamase (ESBL) producers, while 23.8% and 21% were metallo β-lactamase (MBL) producers. bla_TEM-type was the most frequently detected ESBL gene, while bla_IMP-type was the most common MBL in both groups. Importantly, most resistant strains showed a significantly high prevalence of astA (76.2%), aggR (76.2%), and pic (52.4%) virulence-related genes. Enteroaggregative E. coli (76%) was the most frequently detected genotype among the colistin-resistant strains. (4) Conclusion: The high colistin resistance rate observed in E. coli strains isolated from patients with nosocomial pneumonia in our university hospital is worrisome. These isolates carry different drug resistance and virulence-related genes. Our results indicate the need for careful monitoring of colistin resistance in our university hospital. Furthermore, infection control policies restricting the unnecessary use of extended-spectrum cephalosporins and carbapenems are necessary.

Risks of ventilator-associated pneumonia and invasive pulmonary aspergillosis in patients with viral acute respiratory distress syndrome related or not to Coronavirus 19 disease

Background

Data on incidence of ventilator-associated pneumonia (VAP) and invasive pulmonary aspergillosis in patients with severe SARS-CoV-2 infection are limited.

Methods

We conducted a monocenter retrospective study comparing the incidence of VAP and invasive aspergillosis between patients with COVID-19-related acute respiratory distress syndrome (C-ARDS) and those with non-SARS-CoV-2 viral ARDS (NC-ARDS).

Results

We assessed 90 C-ARDS and 82 NC-ARDS patients, who were mechanically ventilated for more than 48 h. At ICU admission, there were significantly fewer bacterial coinfections documented in C-ARDS than in NC-ARDS: 14 (16%) vs 38 (48%), p < 0.01. Conversely, significantly more patients developed at least one VAP episode in C-ARDS as compared with NC-ARDS: 58 (64%) vs. 36 (44%), p = 0.007. The probability of VAP was significantly higher in C-ARDS after adjusting on death and ventilator weaning [sub-hazard ratio = 1.72 (1.14–2.52), p < 0.01]. The incidence of multi-drug-resistant bacteria (MDR)-related VAP was significantly higher in C-ARDS than in NC-ARDS: 21 (23%) vs. 9 (11%), p = 0.03. Carbapenem was more used in C-ARDS than in NC-ARDS: 48 (53%), vs 21 (26%), p < 0.01. According to AspICU algorithm, there were fewer cases of putative aspergillosis in C-ARDS than in NC-ARDS [2 (2%) vs. 12 (15%), p = 0.003], but there was no difference in Aspergillus colonization.

Conclusions

In our experience, we evidenced a higher incidence of VAP and MDR-VAP in C-ARDS than in NC-ARDS and a lower risk for invasive aspergillosis in the former group.

Identification of Factors Affecting Mortality in Late-Onset Ventilator-Associated Pneumonia

Objective

Pneumonia that develops 48 hours after intubation has been defined as ventilator-associated pneumonia (VAP) in patients hospitalized in the intensive care unit (ICU). Late-onset VAP (LO-VAP) is described as pneumonia that occurs within or after the 5th day of mechanical ventilation. We aimed to determine the factors that affect the mortality and survival in patients with LO-VAP.

Materials and Methods

We retrospectively reviewed the hospital records of adult patients (>18 years) who developed LO-VAP in the training and research hospital between January 2014 and June 2018. We compared the demographic findings and laboratory characteristics of the survivors and deaths on the 28-day mortality.

Results

The mean age of 231 (90 female and 141 male) patients with LO-VAP was 73.43±14.06 years. As a result of multivariate logistic regression analysis, we determined that advanced age (p=0.023; 95% confidence interval [CI]: 1.003-1.047) and unconsciousness (p=0.001; 95% CI: 1.674-6.547) were the independent factors affecting mortality. However, parenteral nutrition (PN) (p=0.027; 95% CI: 0.263-0.923) and tracheostomy (p=0.001; 95% CI: 0.112-0.545) were the independent factors supporting survival. We found that acute physiology and chronic health evaluation II score, presence of bacteremia, and enteral nutrition did not have a significant effect on mortality.

Conclusion

Use of tracheostomy and PN in patients with LO-VAP has a positive effect on survival. Our study also points out that mortality can be high in patients with advanced age and unconsciousness.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

A Comparison of Outcomes of Trauma Patients With Ventilator-Associated Events by Diagnostic Criteria Set

BACKGROUND

The Centers for Disease Control and Prevention replaced the definition for ventilator-associated pneumonia with an algorithm comprised of three categories: ventilator-associated condition (VAC), infection-related ventilator associated complication (IVAC), and possible ventilator-associated pneumonia (PVAP). We sought to compare the outcome of trauma patients with VAEs to those with no VAEs.

METHODS

Patients admitted from 2013 to 2017 were identified from trauma registry. Logistic regression was performed for the association between VAEs and mortality.

RESULTS

Two thousand six hundred eighty patients were admitted to our trauma center, 2,290 had no VAE, 100 had VACs, 85 had IVACs, and 205 had PVAPs. Adjusted for race, sex, blunt injury mechanisms, and Injury Severity Score, all VAEs had a longer hospital length of stay, intensive care unit stay, and days of ventilator support when compared with those with no VAE (all P < 0.0001). Nosocomial complication rates were not different by VAE group. Compared with patients with no VAE, an over 2-fold increased mortality odds was observed for VAC (OR 2.39, 95% CI 1.50-3.80) and IVAC patients (OR 2.07, 95% CI 1.23-3.47), and a 50% mortality increased was observed for PVAP patients (OR 1.46, 95% CI 1.00-2.12). These associations became similar with an approximate 2.5-fold increased mortality odds among patients with at least 1 week on ventilator support.

CONCLUSION

VAEs increase the odds of mortality, particularly for patients with VACs and IVACs. Among patients on ventilator support for at least a week, the associations are similar among VAE types, suggesting no single VAE type is more severe than others.

Changes in immune indicators and bacteriologic profile were associated with patients with ventilator-associated pneumonia

The aim of this study is to explore and identify ventilator-associated pneumonia (VAP)-related prognostic immune factors and further detect the drug-resistant pathogens to establish the theoretical guidance for clinical prevention and treatment strategies of VAP. A total of 478 patients using ventilator who were hospitalized in July 2014 to November 2016 in our hospital were enrolled in this study. About 103 patients with VAP (21.5%, 103/478) among 478 cases of patients using ventilator. Among the 103 patients with VAP, the distribution of pathogenic bacteria and drug resistance in patients with VAP were detected and analyzed. In the VAP group, 35 patients died and 43 patients had simultaneous sepsis. Compared with those of non-VAP group, the proportion of CD3 (P = .012), CD3CD4 (P = .024) and CD8CD28 ( P = .017) T cells in VAP group increased significantly, which indicated more severe immune response. Multivariate regression model analysis revealed that tracheotomy of mechanical ventilation (P = .013), mechanical ventilation time ≥7 days (P = .02) and aspiration and reflux (P = .011) were independent risk factors associated with VAP. According to the results of bacterial culture and drug sensitivity test, rational selection of antibiotics and monitoring of patients within intensive care unit can effectively control the incidence of VAP and improve the prognosis of patients.

Ventilator-associated pneumonia in adults: a narrative review

Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative.

Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation

BACKGROUND

Ventilator-associated pneumonia is the most common intensive care unit (ICU)-acquired infection, yet accurate diagnosis remains difficult, leading to overuse of antibiotics. Low concentrations of IL-1β and IL-8 in bronchoalveolar lavage fluid have been validated as effective markers for exclusion of ventilator-associated pneumonia. The VAPrapid2 trial aimed to determine whether measurement of bronchoalveolar lavage fluid IL-1β and IL-8 could effectively and safely improve antibiotic stewardship in patients with clinically suspected ventilator-associated pneumonia.

METHODS

VAPrapid2 was a multicentre, randomised controlled trial in patients admitted to 24 ICUs from 17 National Health Service hospital trusts across England, Scotland, and Northern Ireland. Patients were screened for eligibility and included if they were 18 years or older, intubated and mechanically ventilated for at least 48 h, and had suspected ventilator-associated pneumonia. Patients were randomly assigned (1:1) to biomarker-guided recommendation on antibiotics (intervention group) or routine use of antibiotics (control group) using a web-based randomisation service hosted by Newcastle Clinical Trials Unit. Patients were randomised using randomly permuted blocks of size four and six and stratified by site, with allocation concealment. Clinicians were masked to patient assignment for an initial period until biomarker results were reported. Bronchoalveolar lavage was done in all patients, with concentrations of IL-1β and IL-8 rapidly determined in bronchoalveolar lavage fluid from patients randomised to the biomarker-based antibiotic recommendation group. If concentrations were below a previously validated cutoff, clinicians were advised that ventilator-associated pneumonia was unlikely and to consider discontinuing antibiotics. Patients in the routine use of antibiotics group received antibiotics according to usual practice at sites. Microbiology was done on bronchoalveolar lavage fluid from all patients and ventilator-associated pneumonia was confirmed by at least 104 colony forming units per mL of bronchoalveolar lavage fluid. The primary outcome was the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage. Data were analysed on an intention-to-treat basis, with an additional per-protocol analysis that excluded patients randomly assigned to the intervention group who defaulted to routine use of antibiotics because of failure to return an adequate biomarker result. An embedded process evaluation assessed factors influencing trial adoption, recruitment, and decision making. This study is registered with ISRCTN, ISRCTN65937227, and ClinicalTrials.gov, NCT01972425.

FINDINGS

Between Nov 6, 2013, and Sept 13, 2016, 360 patients were screened for inclusion in the study. 146 patients were ineligible, leaving 214 who were recruited to the study. Four patients were excluded before randomisation, meaning that 210 patients were randomly assigned to biomarker-guided recommendation on antibiotics (n=104) or routine use of antibiotics (n=106). One patient in the biomarker-guided recommendation group was withdrawn by the clinical team before bronchoscopy and so was excluded from the intention-to-treat analysis. We found no significant difference in the primary outcome of the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage in the intention-to-treat analysis (p=0·58). Bronchoalveolar lavage was associated with a small and transient increase in oxygen requirements. Established prescribing practices, reluctance for bronchoalveolar lavage, and dependence on a chain of trial-related procedures emerged as factors that impaired trial processes.

INTERPRETATION

Antibiotic use remains high in patients with suspected ventilator-associated pneumonia. Antibiotic stewardship was not improved by a rapid, highly sensitive rule-out test. Prescribing culture, rather than poor test performance, might explain this absence of effect.

FUNDING

UK Department of Health and the Wellcome Trust.

A population-based cohort study of mortality of intensive care unit patients with liver cirrhosis

BACKGROUND

The impact of liver cirrhosis on the outcomes of admission to intensive care unit (ICU) is not completely understood. Our purpose is to identify risk factors for mortality in ICU patients with liver cirrhosis.

METHODS

Using reimbursement claims from Taiwan's National Health Insurance Research Database from in 2006-2012, 1,250,300 patients were identified as having ICU stays of more than 1 day, and 37,197 of these had liver cirrhosis. With propensity score-matching for socioeconomic status, pre-existing medical conditions, and cirrhosis-related morbidities, 37,197 ICU patients without liver cirrhosis were selected for comparison. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of cirrhosis associated with 30-day, ICU, and one-year mortality were calculated.

RESULTS

Compared with control, cirrhotic patients had higher 30-day mortality (aOR 1.60, 95% CI 1.53 to 1.68), particularly those with jaundice (aOR 2.23, 95% CI 2.03 to 2.45), ascites (aOR 2.32, 95% CI 2.19 to 2.46) or hepatic coma (aOR 2.21, 95% CI 2.07 to 2.36). Among ICU patients, liver cirrhosis was also associated with ICU mortality (aOR 144, 95% CI 1.38 to 1.51) and one-year mortality (aOR 1.40, 95% CI 1.35 to 1.46). Associations between cirrhosis of liver and increased 30-day mortality were significant in both sexes and every age group.

CONCLUSIONS

Liver cirrhosis was associated with 30-day mortality in ICU patients. Jaundice, ascites, hepatic coma, more than 4 admissions due to cirrhosis, and more than 30 days of hospital stay due to cirrhosis were exacerbated factors in cirrhotic ICU patients.

A clinical trial of silver-coated and tapered cuff plus supraglottic suctioning endotracheal tubes in preventing ventilator-associated pneumonia

PURPOSE

Novel designs of the endotracheal tube (ETT) are emerged to reduce the risk of ventilator-associated pneumonia (VAP). We evaluated the effect of two different types, namely silver-coated (Bactiguard) and subglottic suctioning (Taperguard) ETTs, on the incidence of VAP in critically-ill patients.

METHODS

A total of 90 patients, mechanically ventilated for >72 h, were randomly assigned to Bactiguard and Taperguard groups. They otherwise received routine care, including VAP prevention measures during their intensive care unit (ICU) stay. Subglottic suctioning was performed in Taperguard group. Statistical analyses were performed using SPSS 25 for iMacs.

RESULTS

Both groups had similar demographics and did not differ in the prevalence of comorbidities and the severity of underlying illness. There was no difference in the frequency of reintubation (P = .565), the duration of ventilation, ICU and total hospital length of stay. VAP developed in 31% of the Bactiguard group and 20% of the Taperguard group (P = .227). Nearly twice the number of patients died in the Bactiguard group compared to the Taperguard group. This difference was not significant either (P = .352).

CONCLUSIONS

The use of Bactiguard or Taperguard ETTs was not associated with any difference in the incidence of VAP or ICU mortality.

Implementation of new standard operating procedures for geriatric trauma patients with multiple injuries: a single level I trauma centre study

BACKGROUND

The demographic changes towards ageing of the populations in developed countries impose a challenge to trauma centres, as geriatric trauma patients require specific diagnostic and therapeutic procedures. This study investigated whether the integration of new standard operating procedures (SOPs) for the resuscitation room (ER) has an impact on the clinical course in geriatric patients. The new SOPs were designed for severely injured adult trauma patients, based on the Advanced Trauma Life Support (ATLS) and imply early whole-body computed tomography (CT), damage control surgery, and the use of goal-directed coagulation management.

METHODS

Single-centre cohort study. We included all patients ≥65 years of age with an Injury Severity Score (ISS) ≥ 9 who were admitted to our hospital primarily via ER. A historic cohort was compared to a cohort after the implementation of the new SOPs.

RESULTS

We enrolled 311 patients who met the inclusion criteria between 2000 and 2006 (group PreSOP) and 2010-2012 (group SOP). There was a significant reduction in the mortality rate after the implementation of the new SOPs (P = .001). This benefit was seen only for severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9-15). There were no differences with regard to infection rates or rate of palliative care.

CONCLUSIONS

We found an association between implementation of new ER SOPs, and a lower mortality rate in severely injured geriatric trauma patients, whereas moderately injured patients did not obtain the same benefit.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03319381, retrospectively registered 24 October 2017.

Prognostic factors associated with mortality in mechanically ventilated patients in the intensive care unit: A single-center, retrospective cohort study of 905 patients

Data on outcomes of patients receiving mechanical ventilation (MV) in China are scarce.To investigate factors associated with the prognosis of patients given MV in the intensive care unit (ICU).A 12-year (January 1, 2006-December 31, 2017) retrospective cohort study.ICU of Beijing Geriatric Hospital, China.A total of 905 patients aged ≥16 years given MV during the study period.None.Among 905 patients included (610 men; median age, 78 years; Acute Physiology and Chronic Health Evaluation [APACHE]-II score, 27.3 ± 8.9), 585 survived (388 men; median age, 77 years; average APACHE-II score, 25.6 ± 8.4), and 320 died in the ICU (222 men; median age, 78 years; APACHE-II score, 30.6 ± 8.9). All-cause ICU mortality was 35.4%. In patients aged <65 years, factors associated with ICU mortality were APACHE-II score (odds ratio [OR], 1.108; 95% confidence interval [95% CI], 1.021-1.202; P = .014), nosocomial infection (OR, 6.618; 95% CI, 1.065-41.113; P = .043), acute kidney injury (OR, 17.302; 95% CI, 2.728-109.735; P = .002), invasive hemodynamic monitoring (OR, 10.051; 95% CI, 1.362-74.191; P = .024), MV for cardiopulmonary resuscitation (OR, 0.122; 95% CI, 0.016-0.924; P = .042), duration of MV (OR, 0.993; 95% CI, 0.988-0.998; P = .008), successful weaning from MV (OR, 0.012; 95% CI, 0.002-0.066; P < .001), and renal replacement therapy (OR, 0.039; 95% CI, 0.005-0.324; P = .003). In patients aged ≥65 years, factors associated with mortality were APACHE-II score (OR, 1.062; 95% CI, 1.030-1.096; P < .001), nosocomial infection (OR, 2.427; 95% CI, 1.359-4.334; P = .003), septic shock (OR, 2.017; 95% CI, 1.153-3.529; P = .014), blood transfusion (OR, 1.939; 95% CI, 1.174-3.202; P = .010), duration of MV (OR, 0.999; 95% CI, 0.999-1.000; P = .043), and successful weaning from MV (OR, 0.027; 95% CI, 0.015-0.047; P < .001).APACHE-II score, successful weaning, and nosocomial infection in the ICU are independently associated with the prognosis of patients given MV in the ICU.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

Epidemiology of ICU-acquired pneumonia

PURPOSE OF REVIEW

Review of the epidemiology of ICU-acquired pneumonia, including both ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP) in nonventilated ICU patients, with critical review of the most recent literature in this setting.

RECENT FINDINGS

The incidence of ICU-acquired pneumonia, mainly VAP has decrease significantly in recent years possibly due to the generalized implementation of preventive bundles. However, the exact incidence of VAP is difficult to establish due to the diagnostic limitations and the methods employed to report rates. Incidence rates greatly vary based on the studied populations. Data in the literature strongly support the relevance of intubation, not ventilatory support, in the development of HAP in ICU patients, but also that the incidence of HAP in nonintubated patients is not negligible. Despite the fact of a high crude mortality associated with the development of VAP, the overall attributable mortality of this complication was estimated in 13%, with higher mortality rates in surgical patients and those with mid-range severity scores at admission. Mortality is consistently greatest in patients with HAP who require intubation, slightly less in VAP, and least for nonventilated HAP. The economic burden of ICU acquired pneumonia, particularly VAP, is important. The increased costs are mainly related to the longer periods of ventilatory assistance and ICU and hospital stays required by these patients. However, the different impact of VAP on economic burden among countries is largely dependent on the different costs associated with heath care.

SUMMARY

VAP has significant impact on mortality mainly in surgical patients and those with mid-range severity scores at admission. The economic burden on ICU-acquired pneumonia depends mainly on the increased length of stay of these patients.

An interactive nomogram to predict healthcare-associated infections in ICU patients: A multicenter study in GuiZhou Province, China

Objective

To develop and validate an interactive nomogram to predict healthcare-associated infections (HCAIs) in the intensive care unit (ICU).

Methods

A multicenter retrospective study was conducted to review 2017 data from six hospitals in Guizhou Province, China. A total of 1,782 ICU inpatients were divided into either a training set (n = 1,189) or a validation set (n = 593). The patients’ demographic characteristics, basic clinical features from the previous admission, and their need for bacterial culture during the current admission were extracted from electronic medical records of the hospitals to predict HCAI. Univariate and multivariable analyses were used to identify independent risk factors of HCAI in the training set. The multivariable model’s performance was evaluated in both the training set and the validation set, and an interactive nomogram was constructed according to multivariable regression model. Moreover, the interactive nomogram was used to predict the possibility of a patient developing an HCAI based on their prior admission data. Finally, the clinical usefulness of the interactive nomogram was estimated by decision analysis using the entire dataset.

Results

The nomogram model included factor development (local economic development levels), length of stay (LOS; days of hospital stay), fever (days of persistent fever), diabetes (history of diabetes), cancer (history of cancer) and culture (the need for bacterial culture). The model showed good calibration and discrimination in the training set [area under the curve (AUC), 0.871; 95% confidence interval (CI), 0.848–0.894] and in the validation set (AUC, 0.862; 95% CI, 0.829–0.895). The decision curve demonstrated the clinical usefulness of our interactive nomogram.

Conclusions

The developed interactive nomogram is a simple and practical instrument for quantifying the individual risk of HCAI and promptly identifying high-risk patients.

Prevention of Ventilator-Associated and Early Postoperative Pneumonia Through Tapered Endotracheal Tube Cuffs: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Microaspiration of subglottic secretions is considered a major pathogenic mechanism of hospital-acquired pneumonia, either early postoperative or ventilator-associated pneumonia. Tapered endotracheal tube cuffs have been proposed to provide a better seal of the extraluminal airway, thereby preventing microaspiration and possibly hospital-acquired pneumonia. We performed a systematic review and meta-analysis to assess the value of endotracheal tubes with tapered cuffs in the prevention of hospital-acquired pneumonia.

DATA SOURCES

A systematic search of MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, and ICTRP was conducted up to March 2017.

STUDY SELECTION

Eligible trials were randomized controlled clinical trials comparing the impact of tapered cuffs versus standard cuffs on hospital-acquired pneumonia.

DATA EXTRACTION

Random-effects meta-analysis calculated odds ratio and 95% CI for hospital-acquired pneumonia occurrence rate between groups. Secondary outcome measures included mortality, duration of mechanical ventilation, length of hospital and ICU stay, and cuff underinflation.

DATA SYNTHESIS

Six randomized controlled clinical trials with 1,324 patients from intensive care and postoperative wards were included. Only two studies concomitantly applied subglottic secretion drainage, and no trial performed continuous cuff pressure monitoring. No significant difference in hospital-acquired pneumonia incidence per patient was found when tapered cuffs were compared with standard cuffs (odds ratio, 0.97; 95% CI, [0.73-1.28]; p = 0.81). There were likewise no differences in secondary outcomes.

CONCLUSIONS

Application of tapered endotracheal tube cuffs did not reduce hospital-acquired pneumonia incidence among ICU and postoperative patients. Further research should examine the impact of concomitant use of tapered cuffs with continuous cuff pressure monitoring and subglottic secretion drainage.

Risk factors of ventilator-associated pneumonia in elderly patients receiving mechanical ventilation

Purpose: The aim of this study was to verify the potential risk factors of ventilator-associated pneumonia (VAP) in elderly Chinese patients receiving mechanical ventilation (MV). The secondary aim of this study was to present logistical regression prediction models of VAP occurrence in elderly Chinese patients receiving MV. Methods: Patients (aged 80 years or above) receiving MV for ≥48 h were enrolled from the Chinese People's Liberation Army (PLA) General Hospital from January 2011 to December 2015. A chi-squared test and Mann-Whitney U-test were used to compare the data between participants with VAP and without VAP. Univariate logistic regression models were performed to explore the relationship between risk factors and VAP. Results: A total of 901 patients were included in the study, of which 156 were diagnosed as VAP (17.3%). The incidence density of VAP was 4.25/1,000 ventilator days. Logistic regression analysis showed that the independent risk factors for elderly patients with VAP were COPD (OR =1.526, P < 0.05), intensive care unit (ICU) admission (OR=1.947, P < 0.01), the MV methods (P < 0.023), the number of antibiotics administered (OR=4.947, P < 0.01), the number of central venous catheters (OR=1.809, P < 0.05), the duration of indwelling urinary catheter (OR=1.805, P < 0.01) and the use of corticosteroids prior to MV (OR=1.618, P < 0.05). Logistic regression prediction model of VAP occurrence in the Chinese elderly patients with mechanical ventilation:L o g i t   P = - 6 . 468 + 0 . 423 X 1 + 0 . 666 X 2 + 0 . 871 X 3 + - 0 . 501 X 5 + 0 . 122 X 6 + 0 . 593 X 7 + 0 . 590 X 8 + 1 . 599 X 9 . Conclusion: VAP occurrence is associated with a variety of controllable factors including the MV methods and the number of antibiotics administered. A model was established to predict VAP occurrence so that high-risk patients could be identified as early as possible.

Infections in the Elderly Critically-Ill Patients

Infections are leading causes of morbidity and mortality in the advanced aged. Various factors including immunosenescens, comorbid chronic diseases, and alterations in normal physiological organ functions may modify the frequency and severity of infections in elderly patients. Normal body reactions to ensuing infection, such as increased body temperature, may be blunted in those patients causing difficulties in differential diagnosis between infection and other diseases. In severe infections the respiratory and urinary tracts are the most frequently involved systems which may be accompanied by severe sepsis. Bacteremia and sepsis are also associated with indwelling vascular catheters in the elderly who are admitted to the intensive care unit (ICU). Older patients are more vulnerable to the Clostridioides difficile infection, as well. Although the general management of infections in severely ill elderly patients is not different than in younger patients, meticulous care in fluid management and careful individualized optimization in antibiotic therapy, along with the other principals of antimicrobial stewardship are warranted in order to prevent increased mortality caused by infection. Organized team management when treating critically ill elderly patients in the ICU is essential and will reduce the morbidity and mortality due to infection in such patients.

Risk Factors of Ventilator-Associated Pneumonia in Critically III Patients

Ventilator-associated pneumonia (VAP), a hospital acquired pneumonia that occurs more than 48 h after mechanical ventilation, is a common complication of mechanical ventilation with a high mortality rate. VAP can cause patients to have difficulty weaning off the ventilator and to stay in the hospital longer, which results in a huge financial burden to patients and a huge demand for medical resources. Several strategies, such as drugs including chlorhexidine, β-lactam antibiotics and probiotics, have been used to prevent VAP in clinic. The incidence and the mortality rate of VAP have been decreased with the development of preventative strategies in the past decades, but VAP remains one of the most common causes of nosocomial infections and death in the intensive care unit. Current challenges in the management of VAP involved the lack of a gold standard for diagnosis, the absence of effective preventative strategies, and the rise in antibiotic resistance. Therefore, in order to reduce the incidence of VAP and improve the outcome of patients with mechanical ventilation, it is necessary to clarify the risk factors of VAP for clinical prevention and control of VAP. This paper reviews the international risk factors of VAP occurrence reported in recent years, including patient characteristics, increased mechanical ventilation time and prolonged length of hospital stay, disorders of consciousness, burns, comorbidities, prior antibiotic therapy, invasive operations, gene polymorphisms, and mentions the corresponding preventive measures. Each factor is not only an independent risk factor of VAP, but also has an influence on each other. A better understanding of risk factors for VAP is helpful for predicting the occurrence of VAP, improving the prevention and control of VAP, and reducing the morbidity and mortality rates of patients with VAP.

The Effects of Oral Care Protocol on the Incidence of Ventilation-Associated Pneumonia in Selected Intensive Care Units in Jordan

PURPOSE

This study aims to evaluate the effects of oral care protocol on the incidence of ventilator-associated pneumonia (VAP) at selected intensive care units (ICUs) in Jordan using clinical pulmonary infection score.

METHODS

A quasi-experimental design was used, and 1 large teaching hospital from the Jordanian capital, along with 2 hospitals from the southern region, was selected. A total of 218 patients participated, among which VAP risk in 2 independent groups was evaluated through the Clinical Pulmonary Infection Score sheet.

RESULTS

The VAP incidence rate was significantly lower in the intervention group (n = 102) as compared with control group (n = 116) (21.6 vs 35.3, respectively; P = .018); in addition, ICU stay and intubation period were significantly shorter among the intervention group. A higher risk of VAP was independently predicted by previous lung diseases (odds ratio [OR], 1.441; 95% confidence interval [CI], 1.185-1.88), open suctioning system (OR, 2.536; 95% CI, 1.261-5.101), and duration of intubation (OR, 1.770; 95% CI, 0.845-2.220). The oral care protocol has effectively improved ventilated patients' oral health, which has statistically reduced the incidence of VAP. It occurred more frequently among patients who have lung disease and those who were intubated for more than 7 days and have an open suctioning system.

CONCLUSION

Health care teams should ensure that effective care protocol is implemented among patients.

Trainee colonoscopy quality is influenced by the independent and unobserved performance characteristics of supervising physicians

Background  Endoscopy training remains an apprenticeship, and the characteristics that facilitate transfer of high quality procedural skills from role models to trainees are unknown. We sought to determine whether unobserved supervisor performance influences the quality of colonoscopy performed by trainees, by studying how supervisors perform alone and how trainees perform while under those same supervisors. Methods  This was a retrospective cross-sectional study conducted among ambulatory adults ≥ 50 years old who underwent colonoscopy for cancer screening or polyp surveillance from 2006 to 2015 at one academic medical center. The primary exposures were the colonoscopy withdrawal time (WT) and adenoma detection rate (ADR) of supervisors while performing colonoscopies alone. The primary outcomes were the WT and ADR of trainees performing colonoscopies under supervision. Results  Data were included from 22 attending gastroenterologist supervisors, 56 gastroenterology fellow trainees, and 2777 adults undergoing 3094 colonoscopy procedures. Among all supervised colonoscopies, mean trainee WT was 12.7 minutes (SD 4.9) and trainee ADR was 33.5 %. The trainee WT was 0.42 minutes longer (standard error = 0.16, P  = 0.01) per minute increase in supervisor WT. Similarly, trainee ADR was higher under a high ADR supervisor, and the odds ratio of high compared to low supervisor ADR category was 1.28 (95 %CI 1.01 - 1.62, P  = 0.04) after adjusting for other factors. Conclusions  The unobserved performance characteristics of supervising endoscopists may influence the quality of colonoscopy performed by trainees.

Aluminum (oxy) Hydroxide Nanorods Activate an Early Immune Response in Pseudomonas aeruginosa Vaccine

Bacterial vaccines have been widely used to prevent infectious diseases, especially in veterinary medicine. Although there are many reports on bacterin adjuvants, only a few contain innovations in bacterin adjuvants. Taking this into consideration, in this study we designed and synthesized a new aluminum (oxy) hydroxide (AlOOH) nanorod (Al-NR) with a diameter of 200 ± 80 nm and a length of 1.1 ± 0.6 μm. Using whole- Pseudomonas aeruginosa PAO1 as antigens, we showed that the bacterial antigens of P. aeruginosa PAO1 adsorbed on the Al-NRs induced a quick and stronger antigen-specific antibody response than those of the other control groups, especially in the early stage of immunization. Furthermore, the level of antigen-specific IgG was approximately 4-fold higher than that of the no adjuvant group and 2.5-fold higher than those of other adjuvant groups in the first week after the initial immunization. The potent adjuvant activity of the Al-NRs was attributed to the rapid presentation of antigen adsorbed on them by APCs. Additionally, Al-NRs induced a milder local inflammation than the other adjuvants. In short, we confirmed that Al-NRs, enhancing both humoral and cellular immune responses, are a potentially promising vaccine adjuvant delivery system for inhibiting the whole- Pseudomonas aeruginosa infection.

Elderly versus nonelderly patients with invasive aspergillosis in the ICU: a comparison and risk factor analysis for mortality from the AspICU cohort

Data regarding the epidemiology and diagnosis of invasive aspergillosis in the critically ill population are limited, with data regarding elderly patients (≥75 years old) even scarcer. We aimed to further compare the epidemiology, characteristics and outcome of elderly versus nonelderly critically ill patients with invasive aspergillosis (IA) Prospective, international, multicenter observational study (AspICU) including adult intensive care unit (ICU) patients, with a culture and/or direct examination and/or histopathological sample positive for Aspergillus spp. at any site. We compared clinical characteristics and outcome of IA in ICU patients using two different diagnostic algorithms. Elderly and nonelderly ICU patients with IA differed in a number of characteristics, including comorbidities, clinical features of the disease, mycology testing, and radiological findings. No difference regarding mortality was found. According to the clinical algorithm, elderly patients were more likely to be diagnosed with putative IA. Elderly patients had less diagnostic radiological findings and when these findings were present they were detected late in the disease course. The comparison between elderly survivors and nonsurvivors demonstrated differences in clinical characteristics of the disease, affected sites and supportive therapy needed. All patients who were diagnosed with proven IA died. Increased vigilance combined with active search for mycological laboratory evidence and radiological confirmation are necessary for the timely diagnosis of IA in the elderly patient subset. Although elderly state per se is not a particular risk factor for mortality, a high SOFA score and the decision not to administer antifungal therapy may have an impact on survival of elderly patients.

High rates of methicillin-resistant Staphylococcus aureus colonisation in a Brazilian Intensive Care Unit

OBJECTIVE

To evaluate the colonisation rate of Staphylococcus aureus in the oropharynx and the insertion site of central venous catheters in intensive care unit patients.

DESIGN

Cross-sectional study.

SETTING

Brazilian intensive care unit.

MEASUREMENTS

Samples were collected from October to December 2015 from the oropharyngeal cavity and central venous catheter insertion site of 110 patients. Samples that presented growth of Staphylococcus aureus were isolated and their sensitivity profiles were tested for several antimicrobials.

FINDINGS

The study participants (110) were mostly females older than 60 years (53.6%). The mean length of hospitalisation was 15.5 days (±31.3). A total of 188 biological samples were collected: 110 collected from the oropharynx and 78 from the central venous catheter insertion site. A 35% (n = 38/110) S. aureus colonisation rate of the patients was observed in at least one collection site. In the oropharynx alone, a 31% rate (n = 34/110) was found, and a 12.8% rate (n = 10/78) at central venous catheter insertion sites only. MRSA colonisation in the oropharynx or at the central venous catheter occurred in 29 (26.4%) patients and vancomycin resistant Staphylococcus aureus was present in 24 (22.4%) of the patients studied. Patients hospitalised for seven days or more were 4.8 times more likely to be colonised compared to patients hospitalised less than seven days (95% CI = 1.2-28.5).

CONCLUSION

The oropharynx and the central venous catheter are important reservoirs of this bacterium that in critical conditions may become pathogenic. The data showed a high degree of resistance of the bacterial populations isolated to different drugs, which may hinder the control of these organisms.

A Comparison of Clinical Characteristics and Outcomes of Ventilator-Associated Pneumonias Among Burn Patients by Diagnostic Criteria Set

OBJECTIVES

The National Healthcare Safety Network (NHSN) replaced its old definition for ventilator-associated pneumonia (VAP) with ventilator-associated events (VAEs) in 2013. Little data is available comparing the two definitions in burn patients.

METHODS

Data from 2011 to 2014 were collected on burn patients mechanically ventilated for at least 2 days. VAP was determined using two methods: (1) pneumonia as defined by the previous more clinical CDC (NHSN) definition captured in the burn registry; (2) pneumonia as defined by the recent CDC (NHSN) standard of VAEs where patients meeting the criteria for possible VAP were considered having a pneumonia. Cohen kappa statistic was measured to compare both definitions, and chi-square and ANOVA to compare admission and clinical outcomes.

RESULTS

There were 266 burn patients who were mechanically ventilated for at least 2 days between 2011 and 2014. One hundred patients (37.5%) met the criteria by the old definition and 35 (13.1%) met the criteria for both. The kappa statistic was 0.34 (95% confidence interval 0.23-0.45), suggesting weak agreement. Those who met both definitions were mechanically ventilated for a longer period of time (P = 0.0003), and had a longer intensive care unit (ICU) length of stay (LOS) (P = 0.0004) and hospital LOS (P = 0.0014).

CONCLUSIONS

There is weak agreement between the two definitions of VAP in severely burn patients. However, patients who met both VAP definitions had longer ventilator days, ICU, and hospital stays.

Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide, observational cohort study

Purpose

Chlorhexidine oral care is widely used in critically and non-critically ill hospitalized patients to maintain oral health. We investigated the effect of chlorhexidine oral care on mortality in a general hospitalized population.

Methods

In this single-center, retrospective, hospital-wide, observational cohort study we included adult hospitalized patients (2012–2014). Mortality associated with chlorhexidine oral care was assessed by logistic regression analysis. A threshold cumulative dose of 300 mg served as a dichotomic proxy for chlorhexidine exposure. We adjusted for demographics, diagnostic category, and risk of mortality expressed in four categories (minor, moderate, major, and extreme).

Results

The study cohort included 82,274 patients of which 11,133 (14%) received chlorhexidine oral care. Low-level exposure to chlorhexidine oral care (≤ 300 mg) was associated with increased risk of death [odds ratio (OR) 2.61; 95% confidence interval (CI) 2.32–2.92]. This association was stronger among patients with a lower risk of death: OR 5.50 (95% CI 4.51–6.71) with minor/moderate risk, OR 2.33 (95% CI 1.96–2.78) with a major risk, and a not significant OR 1.13 (95% CI 0.90–1.41) with an extreme risk of mortality. Similar observations were made for high-level exposure (> 300 mg). No harmful effect was observed in ventilated and non-ventilated ICU patients. Increased risk of death was observed in patients who did not receive mechanical ventilation and were not admitted to ICUs. The adjusted number of patients needed to be exposed to result in one additional fatality case was 47.1 (95% CI 45.2–49.1).

Conclusions

These data argue against the indiscriminate widespread use of chlorhexidine oral care in hospitalized patients, in the absence of proven benefit in specific populations.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5171-3) contains supplementary material, which is available to authorized users.

Safety and efficacy of N-acetyl-cysteine for prophylaxis of ventilator-associated pneumonia: a randomized, double blind, placebo-controlled clinical trial

Ventilator-associated-pneumonia (VAP) is characterized by morbidity, mortality, and prolonged length of stay in intensive care unit (ICU). The present study aimed to examine the effect of N-acetyl-cysteine (NAC) in preventing VAP in patients hospitalized in ICU. We performed a prospective, randomized, double-blind, placebo-controlled trial of 60 mechanically ventilated patients at high risk of developing VAP. NAC (600 mg/twice daily) and placebo (twice daily) were administered to NAC group (n = 30) and control group (n = 30), respectively, through the nasogastric tube in addition to routine care. The clinical response was considered as primary (incidence of VAP) and secondary outcomes. Twenty-two (36.6%) patients developed VAP. Patients treated with NAC were significantly less likely to develop clinically confirmed VAP compared with patients treated with placebo (26.6% vs. 46.6%; P = 0.032). Patients treated with NAC had significantly less ICU length of stay (14.36 ± 4.69 days vs. 17.81 ± 6.37 days, P = 0.028) and less hospital stay (19.23 ± 5.54 days vs. 24.61 ± 6.81 days; P = 0.03) than patients treated with placebo. Time to VAP was significantly longer in the NAC group (9.42 ± 1.9 days vs. 6.46 ± 2.53 days; P = 0.002). The incidence of complete recovery was significantly higher in the NAC group (56.6% vs. 30%; P = 0.006). No adverse events related to NAC were identified. NAC is safe and effective to prevent and delay VAP, and improve its complete recovery rate in a selected, high-risk ICU population.

A Systematic Review of the Burden of Multidrug-Resistant Healthcare-Associated Infections Among Intensive Care Unit Patients in Southeast Asia: The Rise of Multidrug-Resistant Acinetobacter baumannii

OBJECTIVETo summarize the clinical burden (cumulative incidence, prevalence, case fatality rate and length of stay) and economic burden (healthcare cost) of healthcare-associated infections (HAIs) due to multidrug-resistant organisms (MDROs) among patients in intensive care units (ICUs) in Southeast Asia.DESIGNSystematic review.METHODSWe conducted a comprehensive literature search in PubMed, EMBASE, CINAHL, EconLit, and the Cochrane Library databases from their inception through September 30, 2016. Clinical and economic burdens and study quality were assessed for each included study.RESULTSIn total, 41 studies met our inclusion criteria; together, 22,876 ICU patients from 7 Southeast Asian countries were included. The cumulative incidence of HAI caused by A. baumannii (AB) in Southeast Asia is substantially higher than has been reported in other regions, especially carbapenem-resistant AB (CRAB; 64.91%) and multidrug-resistant AB (MDR-AB) (58.51%). Evidence of a dose-response relationship between different degrees of drug resistance and excess mortality due to AB infections was observed. Adjusted odds ratios were 1.23 (95% confidence interval [CI], 0.51-3.00) for MDR-AB, 1.72 (95% CI, 0.77-3.80) for extensively drug-resistant AB (XDR-AB), and 1.82 (95% CI, 0.55-6.00) for pandrug-resistant AB (PDR-AB). There is, however, a paucity of published data on additional length of stay and costs attributable to MDROs.CONCLUSIONSThis review highlights the challenges in addressing MDROs in Southeast Asia, where HAIs caused by MDR gram-negative bacteria are abundant and have a strong impact on society. With our findings, we hope to draw the attention of clinicians and policy makers to the problem of antibiotic resistance and to issue a call for action in the management of MDROs.Infect Control Hosp Epidemiol 2018;39:525-533.

Efficacy of continuous versus intermittent subglottic secretion drainage in preventing ventilator-associated pneumonia in patients requiring mechanical ventilation: A single-center randomized controlled trial

Objective

Aspiration of subglottic secretion is a widely used intervention to prevent ventilator-associated pneumonia (VAP). This study aimed to compare the efficacy of continuous and intermittent subglottic secretion drainage (SSD) in preventing VAP.

Methods

A single-center randomized controlled trial was conducted on adult postoperative patients who were expected to undergo mechanical ventilation for more than 48 hours. Primary outcome measure was incidence of VAP and secondary outcome measures were length of mechanical ventilation and intensive-care unit (ICU) stay.

Results

Fifty-nine patients received continuous SSD, while 60 patients received intermittent SSD. Of these 119 patients, 88 (74%) were excluded and 15 and 16 patients were allocated to receive continuous and intermittent SSD, respectively. VAP was detected in 4 (26.7%) and 7 (43.8%) patients in the continuous and intermittent groups, respectively, (p=0.320). The length of mechanical ventilation was significantly shorter (p=0.034) in the continuous group (99.5±47.1 h) than in the intermittent group (159.9±94.5 h). The length of ICU stay was also shorter (p=0.0097) in the continuous group (6.3±2.1 days) than the intermittent group (9.8±4.8 days).

Conclusions

Although continuous SSD did not reduce the incidence of VAP, it reduced the length of mechanical ventilation and ICU stay when compared to intermittent SSD.

Effect of an acrylic terpolymer barrier film beneath transparent catheter dressings on skin integrity, risk of dressing disruption, catheter colonisation and infection

OBJECTIVES

We assessed the effect of a skin-protective terpolymer barrier film around the catheter insertion site on frequency of dressing disruptions and skin integrity issues (hyperaemia, skin irritation, residues of adhesives and moisture under the dressing). Secondary outcomes included colonisation of the central venous catheter (CVC) and rates of central line-associated bloodstream infection.

RESEARCH METHODOLOGY

A monocentric, open-label, randomised controlled trial was performed comparing a control group receiving standard transparent catheter dressings without the skin-protecting barrier film and an intervention group receiving a transparent chlorhexidine-impregnated dressing with use of the skin-protective acrylic terpolymer barrier film (3M™ Cavilon™ No - Sting Barrier Film, 3 M Health Care, St. Paul, MN, USA).

RESULTS

Sixty patients were enrolled and randomised in the study accounting for 60 central venous catheters and a total of 533 catheter days. Dressing disruptions occurred more frequently and at sooner time point in the control group. Skin integrity issues were significantly less observed in the intervention group. No differences in CVC colonisation or central line-associated bloodstream infection were observed.

CONCLUSIONS

The application of a barrier film creating a skin-protective polymer layer beneath transparent catheter dressings is associated with less dressing disruptions and skin integrity issues without altering the risk of infectious complications if used in combination with a chlorhexidine-impregnated catheter dressing.

World-Wide Variation in Incidence of Staphylococcus aureus Associated Ventilator-Associated Pneumonia: A Meta-Regression

Staphylococcus aureus (S. aureus) is a common Ventilator-Associated Pneumonia (VAP) isolate. The objective here is to define the extent and possible reasons for geographic variation in the incidences of S. aureus-associated VAP, MRSA-VAP and overall VAP. A meta-regression model of S. aureus-associated VAP incidence per 1000 Mechanical Ventilation Days (MVD) was undertaken using random effects methods among publications obtained from a search of the English language literature. This model incorporated group level factors such as admission to a trauma ICU, year of publication and use of bronchoscopic sampling towards VAP diagnosis. The search identified 133 publications from seven worldwide regions published over three decades. The summary S. aureus-associated VAP incidence was 4.5 (3.9–5.3) per 1000 MVD. The highest S. aureus-associated VAP incidence is amongst reports from the Mediterranean (mean; 95% confidence interval; 6.1; 4.1–8.5) versus that from Asian ICUs (2.1; 1.5–3.0). The incidence of S. aureus-associated VAP varies by up to three-fold (for the lowest versus highest incidence) among seven geographic regions worldwide, whereas the incidence of VAP varies by less than two-fold. Admission to a trauma unit is the most important group level correlate for S. aureus-associated VAP.

Characteristics and factors associated with nosocomial pneumonia among patients undergoing continuous renal replacement therapy (CRRT): A case-control study

OBJECTIVES

Continuous renal replacement therapy (CRRT) is a specialized type of dialysis. However, the characteristics and factors associated with nosocomial pneumonia in patients undergoing CRRT have received little attention to date. Therefore, this study investigated the characteristics of and factors contributing to nosocomial pneumonia in patients receiving CRRT.

METHODS

The clinical data of 1160 patients undergoing CRRT during the period January 2008 to December 2015 were analyzed retrospectively. Of these 1160 cases, 145 (12.5%) were included in the nosocomial pneumonia group, while 1015 were included in the control group.

RESULTS

The primary pathogen in the 145 cases of nosocomial pneumonia in the CRRT patients was Staphylococcus aureus (58.57%); the morbidity rate was 12.5%. Multivariate logistic regression analysis revealed that age (odds ratio (OR) 2.209), initial curative time (OR 1.960), underlying diseases (OR 1.820), consciousness disorder (OR 1.616), organ failure (OR 2.154), the Acute Physiology and Chronic Health Evaluation II score (APACHE II) (OR 1.186), and the Charlson Comorbidity Index score (CCI) (OR 1.278) were risk factors for nosocomial pneumonia (all p<0.05). Conversely, the serum white blood cell count (OR 0.585), albumin (OR 0.673), and hemoglobin (OR 0.712) levels were protective factors (all p<0.05).

CONCLUSIONS

Results from this study indicate that by modifying risk factors, such as providing adequate nutrition, earlier treatment of underlying diseases, and controlling organ failure, the risks associated with nosocomial pneumonia may be reduced.

Ventilator-associated respiratory infection in a resource-restricted setting: impact and etiology

Background

Ventilator-associated respiratory infection (VARI) is a significant problem in resource-restricted intensive care units (ICUs), but differences in casemix and etiology means VARI in resource-restricted ICUs may be different from that found in resource-rich units. Data from these settings are vital to plan preventative interventions and assess their cost-effectiveness, but few are available.

Methods

We conducted a prospective observational study in four Vietnamese ICUs to assess the incidence and impact of VARI. Patients ≥ 16 years old and expected to be mechanically ventilated > 48 h were enrolled in the study and followed daily for 28 days following ICU admission.

Results

Four hundred fifty eligible patients were enrolled over 24 months, and after exclusions, 374 patients’ data were analyzed. A total of 92/374 cases of VARI (21.7/1000 ventilator days) were diagnosed; 37 (9.9%) of these met ventilator-associated pneumonia (VAP) criteria (8.7/1000 ventilator days). Patients with any VARI, VAP, or VARI without VAP experienced increased hospital and ICU stay, ICU cost, and antibiotic use (p < 0.01 for all). This was also true for all VARI (p < 0.01 for all) with/without tetanus. There was no increased risk of in-hospital death in patients with VARI compared to those without (VAP HR 1.58, 95% CI 0.75–3.33, p = 0.23; VARI without VAP HR 0.40, 95% CI 0.14–1.17, p = 0.09). In patients with positive endotracheal aspirate cultures, most VARI was caused by Gram-negative organisms; the most frequent were Acinetobacter baumannii (32/73, 43.8%) Klebsiella pneumoniae (26/73, 35.6%), and Pseudomonas aeruginosa (24/73, 32.9%). 40/68 (58.8%) patients with positive cultures for these had carbapenem-resistant isolates. Patients with carbapenem-resistant VARI had significantly greater ICU costs than patients with carbapenem-susceptible isolates (6053 USD (IQR 3806–7824) vs 3131 USD (IQR 2108–7551), p = 0.04) and after correction for adequacy of initial antibiotics and APACHE II score, showed a trend towards increased risk of in-hospital death (HR 2.82, 95% CI 0.75–6.75, p = 0.15).

Conclusions

VARI in a resource-restricted setting has limited impact on mortality, but shows significant association with increased patient costs, length of stay, and antibiotic use, particularly when caused by carbapenem-resistant bacteria. Evidence-based interventions to reduce VARI in these settings are urgently needed.

Electronic supplementary material

The online version of this article (10.1186/s40560-017-0266-4) contains supplementary material, which is available to authorized users.

Aging increases the expression of lung CINCs and MCP-1 in senile patients with pneumonia

Objective

To explore the relationship between aging and the expression of monocyte chemoattractant protein (MCP) and cytokine-induced neutrophil chemoattractant (CINCs) in patients with pneumonia.

Results

Bacteria counts in senile group were significantly higher than non-senile group, and while white blood cell and neutrophil counts in senile group were observably lower than non-senile group. The concentration of MCP-1 was significantly higher in senile group compared with the non-senile group, and the expression of CINC-1 and CINC-2α was also higher in senile group. In all patients with different pathogens, expression of all the factors was significantly higher in senile group compared with the non-senile group. What’s more, expression of MCP-1, CINC-1 and CINC-2α showed significant difference in some patients with different pathogens. CINC-2β and CINC-3 expression was not detected in both groups.

Materials and methods

The present study included 800 patients with pneumonia who were hospitalized to the Department of Respiratory Medicine in Tongji Hospital during the period from December of 2014 to June of 2016. All patients were divided into two groups: senile pneumonia and non-senile pneumonia group. Bacteria, white blood cell and neutrophil counts were determined by automatic blood cell analyzer. The expression of MCP-1, CINC-1, CINC-2α, CINC-2β and CINC-3 was determined by ELISA assay.

Conclusions

Aging can increase the expression of MCP-1,CINC-1 and CINC-2α in patients with pneumonia, which may lead to increased risk of pneumonia in the elderly.

Risk factors for health care-associated infection in hospitalized adults: Systematic review and meta-analysis

BACKGROUND

Health care-associated infections (HAIs) are a public health problem that increase health care costs. This article aimed to systematically review the literature and meta-analyze studies investigating risk factors (RFs) independently associated with HAIs in hospitalized adults.

METHODS

Electronic databases (MEDLINE, Embase, and LILACS) were searched to identify studies from 2009-2016. Pooled risk ratios (RRs) or odds ratios (ORs) or mean differences (MDs) and 95% confidence intervals (CIs) were calculated and compared across the groups. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Of 867 studies, 65 met the criteria for review, and the data of 18 were summarized in the meta-analysis. The major RFs independently associated with HAIs were diabetes mellitus (RR, 1.76; 95% CI, 1.27-2.44), immunosuppression (RR, 1.24; 95% CI, 1.04-1.47), body temperature (MD, 0.62; 95% CI, 0.41-0.83), surgery time in minutes (MD, 34.53; 95% CI, 22.17-46.89), reoperation (RR, 7.94; 95% CI, 5.49-11.48), cephalosporin exposure (RR, 1.77; 95% CI, 1.30-2.42), days of exposure to central venous catheter (MD, 5.20; 95% CI, 4.91-5.48), intensive care unit (ICU) admission (RR, 3.76; 95% CI, 1.79-7.92), ICU stay in days (MD, 21.30; 95% CI, 19.81-22.79), and mechanical ventilation (OR, 12.95; 95% CI, 6.28-26.73).

CONCLUSIONS

Identifying RFs that contribute to develop HAIs may support the implementation of strategies for their prevention, therefore maximizing patient safety.

Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study

We report on intensive care nosocomial pneumonia (NP) in Europe through a review of EU-VAP/CAP manuscripts: a prospective observational study, enrolling patients from 27 ICUs in nine European countries. From 2,436 eligible ICU patients, 827 cases presented NP, with 18.3 episodes of VAP per 1000 ventilator-days. Most common findings were worsening oxygenation, purulent respiratory secretions and temperature increase. At least three criteria from Clinical Pulmonary Infection score (CPIS) were present in 77.9 % of episodes, but only 0.2 % met six CPIS criteria. Diagnosis was confirmed mainly noninvasively (74.8 %), with half qualitative and quantitative cultures. The dominant isolate was S. aureus in Spain, France, Belgium and Ireland, P. aeruginosa in Italy and Portugal, Acinetobacter in Greece and Turkey, but Escherichia coli in Germany. NP resulted in 6 % higher mortality, longer ICU stay and duration of mechanical ventilation (12 and 10 days). COPD and age ≥45 years were not associated with higher VAP incidence but did correlate with increased mortality. Trauma had higher VAP incidence but lower mortality. Bacteremia (led by MRSA and Acinetobacter baumannii) was documented in 14.6 %, being associated with extra ICU stay and mortality. Vasopressors and ICUs with above 25 % prevalence of Potential Resistant Organisms (PRM) were independently associated with PRM, being documented in 50.7 % of patients with early-onset VAP without known risk factors. Most patients initially received combination therapy. Delay in appropriate antimicrobial choice significantly increased mortality, and LOS in survivors was six days longer (p < 0.05). In conclusion, NP management in Europe presents local differences and major shifts when compared to reports from North America, outcomes of randomized trials and general guidelines.

Vaccination with a recombinant OprL fragment induces a Th17 response and confers serotype-independent protection against Pseudomonas aeruginosa infection in mice

Pseudomonas aeruginosa (PA) is the major causative agent of nosocomial infection. Despite of adequate use of antibiotics, it still represents a major challenge in controlling PA infection. The local pulmonary Th17 response plays an important protective role against PA infection. And the Th17-mediated protection is antibody independent, so we hypothesized that it would be an optimal strategy of a vaccine for PA control to induce an effective Th17 response. Herein we report the successful production of a recombinant fragment of the OprL (reOprL) of PA. Purified reOprL forms homogeneous monomers in solution and vaccination with reOprL elicited a remarkable Th17 response. In addition, reOprL vaccination conferred effective serotype-independent protection against PA infection, which relied on the Th17 response. Our data suggest that reOprL is a good candidate for the future development of Th17 immunity based PA vaccines.

Incidence, temporal trend and factors associated with ventilator-associated pneumonia in mainland China: a systematic review and meta-analysis

Background

Data to date is far from sufficient to describe the recent epidemiology of ventilator-associated pneumonia (VAP) in mainland China. This study aimed to estimate the overall incidence of VAP, with a special focus on its temporal trend and associated factors.

Methods

Meta-analyses of 195 studies published from 2010 to 2015 were conducted, followed by subgroup analyses by methodological quality, pre-defined setting characteristics and attributes of populations.

Results

The overall cumulative VAP incidence in mainland China was 23.8% (95% confidence interval (CI) 20.6–27.2%), with the results showing high heterogeneity. The pooled incidence densities were 24.14 (95% CI 21.19–27.51) episodes and 22.83 (95% CI 19.88–26.23) patients per 1000 ventilator-days. A decline in the cumulative incidence was observed from 2006 (49.5%, 95% CI 40.0–59.0%) to 2014 (19.6%, 95% CI 10.4–31.0%); differences in the incidence rates were also documented according to Chinese provinces and diagnostic criteria (p < 0.001). Older age (≥60 years), coma, re-intubation, tracheotomy and prolonged ventilation were the factors significantly associated with the occurrence of VAP.

Conclusions

The incidence of VAP remains high in mainland China but has decreased since 2006. The reported rates vary considerably across individual studies, probably due to variations in diagnosis and geographical region. More studies using standard definitions and cut-off points are needed to better clarify the epidemiology of VAP across the country.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2566-7) contains supplementary material, which is available to authorized users.