Ventilator-associated pneumonia and its prevention

Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Early-onset pneumonia after out-of-hospital cardiac arrest

Early-onset pneumonia (EOP) is a common complication after successful cardiopulmonary resuscitation. Currently, EOP diagnosis is difficult because usual diagnostic tools are blunted by the features of post-cardiac arrest syndrome and therapeutic hypothermia itself. When the diagnosis of EOP is suspected, empiric antimicrobial therapy should be considered following bronchopulmonary sampling. The onset of EOP increases the length of mechanical ventilation duration and intensive care unit stay, but its influence on survival and neurological outcome seems marginal. Therapeutic hypothermia has been recognized as an independent risk factor for this infectious complication. All together, these observations underline the need for future prospective clinical trials to better delineate pathogens and risk factors associated with EOP. In addition, there is a need for diagnostic approaches serving the accurate diagnosis of EOP.

Aspiration and evaluation of gastric residuals in the neonatal intensive care unit: state of the science

The routine aspiration of gastric residuals (GR) is considered standard care for critically ill infants in the neonatal intensive care unit (NICU). Unfortunately, scant information exists regarding the risks and benefits associated with this common procedure. This article provides the state of the science regarding what is known about the routine aspiration and evaluation of GRs in the NICU focusing on the following issues: (1) the use of GRs for verification of feeding tube placement, (2) GRs as an indicator of gastric contents, (3) GRs as an indicator of feeding intolerance or necrotizing enterocolitis, (4) the association between GR volume and ventilator-associated pneumonia, (5) whether GRs should be discarded or refed, (6) the definition of an abnormal GR, and (7) the potential risks associated with aspiration and evaluation of GRs. Recommendations for further research and practice guidelines are also provided.

Ventilator-associated pneumonia: present understanding and ongoing debates

INTRODUCTION

Ventilator-associated pneumonia (VAP) is a common cause of nosocomial infection, and is related to significant utilization of health-care resources. In the past decade, new data have emerged about VAP epidemiology, diagnosis, treatment and prevention.

RESULTS

Classifying VAP strictly based on time since hospitalization (early- and late-onset VAP) can potentially result in undertreatment of drug-resistant organisms in ICUs with a high rate of drug resistance, and overtreatment for patients not infected with resistant pathogens. A combined strategy incorporating diagnostic scoring systems, such as the Clinical Pulmonary Infection Score (CPIS), and either a quantitative or qualitative microbiological specimen, plus serial measurement of biomarkers, leads to responsible antimicrobial stewardship. The newly proposed ventilator-associated events (VAE) surveillance definition, endorsed by the Centers for Disease Control and Prevention, has low sensitivity and specificity for diagnosing VAP and the ability to prevent VAE is uncertain, making it a questionable surrogate for the quality of ICU care. The use of adjunctive aerosolized antibiotic treatment can provide high pulmonary concentrations of the drug and may facilitate shorter durations of therapy for multi-drug-resistant pathogens. A group of preventive strategies grouped as a 'ventilator bundle' can decrease VAP rates, but not to zero, and several recent studies show that there are potential barriers to implementation of these prevention strategies.

CONCLUSION

The morbidity and mortality related to VAP remain high and, in the absence of a gold standard test for diagnosis, suspected VAP patients should be started on antibiotics based on recommendations per the 2005 ATS guidelines and knowledge of local antibiotic susceptibility patterns. Using a combination of clinical severity scores, biomarkers, and cultures might help with reducing the duration of therapy and achieving antibiotic de-escalation.

Population pharmacokinetics of single-dose amikacin in critically ill patients with suspected ventilator-associated pneumonia

AIMS

Modifications of antimicrobials' pharmacokinetic parameters have been reported in critically ill patients, resulting in a risk of treatment failure. We characterized amikacin pharmacokinetic variability in critically ill patients with ventilator-associated pneumonia (VAP) and evaluated several dosing regimens.

METHODS

We conducted a prospective multicenter study in critically ill patients with presumptive diagnosis of Gram-negative bacilli (GNB) VAP. Patients empirically received imipenem and a single-dose of amikacin, which was administered as a 30-min infusion (20 mg/kg). Concentrations were measured 0.5, 1, 8, 16, and 24 h after beginning of infusion. Pharmacokinetic parameters were estimated using a population approach. Main pharmacodynamic target was a ratio ≥ 10 between the concentration achieved 1 h after beginning of infusion (C 1h) and the minimal inhibitory concentration of the liable bacteria (MIC). We simulated individual C 1h for several dosing regimens by Monte Carlo method and computed C 1h/MIC ratios for MICs from 0.5 to 64 mg/L.

RESULTS

Sixty patients (47 males), median (range) age, and body weight, 61.5 years (28-84) and 78 kg (45-126), respectively, were included. Amikacin median C 1h was 45 mg/L (22-87). Mean value (between-patients variability) for CL, V1, Q, and V2 were 4.3 L/h (31 %), 15.9 L (22 %), 12.1 L/h (27 %), and 21.4 L (47 %), respectively. CL increased with CrCL (p<0.001) and V1 with body weight (p<0.001) and PaO2/FIO2 ratio (p<0.001). With a 25 mg/kg regimen, the pharmacodynamic target was achieved in 20 and 96 % for a MICs of 8 and 4 mg/L, respectively.

CONCLUSION

Amikacin clearance was decreased and its volume of distribution was increased as previously reported. A ≥ 25 mg/kg single-dose is needed for empirical treatment of GNB-VAP.

Gastric residual volume in critically ill patients: a dead marker or still alive?

Early enteral nutrition (EN) is consistently recommended as first-line nutrition therapy in critically ill patients since it favorably alters outcome, providing both nutrition and nonnutrition benefits. However, critically ill patients receiving mechanical ventilation are at risk for regurgitation, pulmonary aspiration, and eventually ventilator-associated pneumonia (VAP). EN may increase these risks when gastrointestinal (GI) dysfunction is present. Gastric residual volume (GRV) is considered a surrogate parameter of GI dysfunction during the progression of enteral feeding in the early phase of critical illness and beyond. By monitoring GRV, clinicians may detect patients with delayed gastric emptying earlier and intervene with strategies that minimize or prevent VAP as one of the major risks of EN. The value of periodic GRV measurements with regard to risk reduction of VAP incidence has frequently been questioned in the past years. Increasing the GRV threshold before interrupting gastric feeding results in marginal increases in EN delivery. More recently, a large randomized clinical trial revealed that abandoning GRV monitoring did not negatively affect clinical outcomes (including VAP) in mechanically ventilated patients. The results have revived the discussion on the role of GRV monitoring in critically ill, mechanically ventilated patients receiving early EN. This review summarizes the most recent clinical evidence on the use of GRV monitoring in critically ill patients. Based on the clinical evidence, it discusses the pros and cons and further addresses whether GRV is a dead marker or still alive for the nutrition management of critically ill patients.

International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care

There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.

Prevalence and test characteristics of national health safety network ventilator-associated events

OBJECTIVES

The primary aim of the study was to measure the test characteristics of the National Health Safety Network ventilator-associated event/ventilator-associated condition constructs for detecting ventilator-associated pneumonia. Its secondary aims were to report the clinical features of patients with National Health Safety Network ventilator-associated event/ventilator-associated condition, measure costs of surveillance, and its susceptibility to manipulation.

DESIGN

Prospective cohort study.

SETTING

Two inpatient campuses of an academic medical center.

PATIENTS

Eight thousand four hundred eight mechanically ventilated adults discharged from an ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The National Health Safety Network ventilator-associated event/ventilator-associated condition constructs detected less than a third of ventilator-associated pneumonia cases with a sensitivity of 0.325 and a positive predictive value of 0.07. Most National Health Safety Network ventilator-associated event/ventilator-associated condition cases (93%) did not have ventilator-associated pneumonia or other hospital-acquired complications; 71% met the definition for acute respiratory distress syndrome. Similarly, most patients with National Health Safety Network probable ventilator-associated pneumonia did not have ventilator-associated pneumonia because radiographic criteria were not met. National Health Safety Network ventilator-associated event/ventilator-associated condition rates were reduced 93% by an unsophisticated manipulation of ventilator management protocols.

CONCLUSIONS

The National Health Safety Network ventilator-associated event/ventilator-associated condition constructs failed to detect many patients who had ventilator-associated pneumonia, detected many cases that did not have a hospital complication, and were susceptible to manipulation. National Health Safety Network ventilator-associated event/ventilator-associated condition surveillance did not perform as well as ventilator-associated pneumonia surveillance and had several undesirable characteristics.

Association of compliance of ventilator bundle with incidence of ventilator-associated pneumonia and ventilator utilization among critical patients over 4 years

BACKGROUND:

Several studies showed that the implementation of the Institute for Healthcare Improvement (IHI) ventilator bundle alone or with other preventive measures are associated with reducing Ventilator-Associated Pneumonia (VAP) rates. However, the association with ventilator utilization was rarely examined and the findings were conflicting. The objectives were to validate the bundle association with VAP rate in a traditionally high VAP environment and to examine its association with ventilator utilization.

MATERIALS AND METHODS:

The study was conducted at the adult medical-surgical intensive care unit (ICU) at King Abdulaziz Medical City, Saudi Arabia, between 2010 and 2013. VAP data were collected by a prospective targeted surveillance as per Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) methodology while bundle data were collected by a cross-sectional design as per IHI methodology.

RESULTS:

Ventilator bundle compliance significantly increased from 90% in 2010 to 97% in 2013 (P for trend < 0.001). On the other hand, VAP rate decreased from 3.6 (per 1000 ventilator days) in 2010 to 1.0 in 2013 (P for trend = 0.054) and ventilator utilization ratio decreased from 0.73 in 2010 to 0.59 in 2013 (P for trend < 0.001). There were negative significant correlations between the trends of ventilator bundle compliance and VAP rate (cross-correlation coefficients −0.63 to 0.07) and ventilator utilization (cross-correlation coefficients −0.18 to −0.63).

CONCLUSION:

More than 70% improvement of VAP rates and approximately 20% improvement of ventilator utilization were observed during IHI ventilator bundle implementation among adult critical patients in a tertiary care center in Saudi Arabia. Replicating the current finding in multicenter randomized trials is required before establishing any causal link.

Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management

BACKGROUND

Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may, therefore, influence ventilator-associated pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation.

METHODS

We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization, using specific competing-risk methods (the Fine and Gray model).

RESULTS

Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual-care group vs 14 (9.2%) in the interventional group (P = .03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event (subhazard ratios [25th-75th percentiles], 0.44 [0.22-0.87], P = .02 and 0.50 [0.25-0.96], P = .03, respectively).

CONCLUSIONS

Using proper competing risk analyses, we found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP risk in patients who are mechanically ventilated.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov.

Risk factors for ventilator-associated events: a case-control multivariable analysis

OBJECTIVES

The Centers for Disease Control and Prevention recently released new surveillance definitions for ventilator-associated events, including the new entities of ventilator-associated conditions and infection-related ventilator-associated complications. Both ventilator-associated conditions and infection-related ventilator-associated complications are associated with prolonged mechanical ventilation and hospital death, but little is known about their risk factors and how best to prevent them. We sought to identify risk factors for ventilator-associated conditions and infection-related ventilator-associated complications.

DESIGN

Retrospective case-control study.

SETTING

Medical, surgical, cardiac, and neuroscience units of a tertiary care teaching hospital.

PATIENTS

Hundred ten patients with ventilator-associated conditions matched to 110 controls without ventilator-associated conditions on the basis of age, sex, ICU type, comorbidities, and duration of mechanical ventilation prior to ventilator-associated conditions.

INTERVENTIONS

None.

MEASUREMENTS

We compared cases with controls with regard to demographics, comorbidities, ventilator bundle adherence rates, sedative exposures, routes of nutrition, blood products, fluid balance, and modes of ventilatory support. We repeated the analysis for the subset of patients with infection-related ventilator-associated complications and their controls.

MAIN RESULTS

Case and control patients were well matched on baseline characteristics. On multivariable logistic regression, significant risk factors for ventilator-associated conditions were mandatory modes of ventilation (odds ratio, 3.4; 95% CI, 1.6-8.0) and positive fluid balances (odds ratio, 1.2 per L positive; 95% CI, 1.0-1.4). Possible risk factors for infection-related ventilator-associated complications were starting benzodiazepines prior to intubation (odds ratio, 5.0; 95% CI, 1.3-29), total opioid exposures (odds ratio, 3.3 per 100 μg fentanyl equivalent/kg; 95% CI, 0.90-16), and paralytic medications (odds ratio, 2.3; 95% CI, 0.79-80). Traditional ventilator bundle elements, including semirecumbent positioning, oral care with chlorhexidine, venous thromboembolism prophylaxis, stress ulcer prophylaxis, daily spontaneous breathing trials, and sedative interruptions, were not associated with ventilator-associated conditions or infection-related ventilator-associated complications.

CONCLUSIONS

Mandatory modes of ventilation and positive fluid balance are risk factors for ventilator-associated conditions. Benzodiazepines, opioids, and paralytic medications are possible risk factors for infection-related ventilator-associated complications. Prospective studies are needed to determine if targeting these risk factors can lower ventilator-associated condition and infection-related ventilator-associated complication rates.

The effect of a nurse-led multidisciplinary team on ventilator-associated pneumonia rates

Background. Ventilator-associated pneumonia (VAP) is a worrisome, yet potentially preventable threat in critically ill patients. Evidence-based clinical practices targeting the prevention of VAP have proven effective, but the most optimal methods to ensure consistent implementation and compliance remain unknown. Methods. A retrospective study of the trend in VAP rates in a community-hospital's open medical intensive care unit (MICU) after the enactment of a nurse-led VAP prevention team. The period of the study was between April 1, 2009, and September 30, 2012. The team rounded on mechanically ventilated patients every Tuesday and Thursday. They ensured adherence to the evidence-based VAP prevention. A separate and independent infection control team monitored VAP rates. Results. Across the study period, mean VAP rate was 3.20/1000 ventilator days ±5.71 SD. Throughout the study time frame, there was an average monthly reduction in VAP rate of 0.27/1000 ventilator days, P < 0.001 (CI: −0.40–−0.13). Conclusion. A nurse-led interdisciplinary team dedicated to VAP prevention rounding twice a week to ensure adherence with a VAP prevention bundle lowered VAP rates in a community-hospital open MICU. The team had interdepartmental and administrative support and addressed any deficiencies in the VAP prevention bundle components actively.

Blood stream infection in patients undergoing systematic off-pump coronary artery bypass: incidence, risk factors, outcome, and associated pathogens

BACKGROUND

Blood stream infection (BSI) is a major cause of mortality and morbidity for patients undergoing cardiac surgery. However, information is lacking about patients undergoing off-pump coronary artery bypass (OPCAB). The purpose of this study was to assess the incidence, risk factors, outcome and associated pathogens of BSI after OPCAB.

METHODS

One thousand ten consecutive patients undergoing OPCAB between 2001 and 2012 were included in a retrospective case-control study. A propensity-matched control was used for risk factor analysis.

RESULTS

Of the 1,010 patients, 26 patients (2.6%) had 32 episodes of BSI after surgery, which occurred at a median of 14 d after surgery. Gram-negative bacilli and gram-positive cocci were distributed equally. Methicillin-resistant Staphylococcus aureus was the pathogen identified most frequently, and the most common source of infection was a surgical site. The hospital mortality rate was 54%. By univariable analysis, diabetes mellitus, pre-operative renal impairment, pre-operative low hemoglobin, pre-operative endotracheal intubation, dialysis before or after surgery, cardiogenic shock, left ventricular ejection fraction of less than 40%, non-elective surgery, low number of distal anastomoses, atrial fibrillation after surgery, and re-operation for bleeding were significant risk factors. By multivariable analysis, the independent risk factors were left ventricular ejection fraction of less than 40%, low number of distal anastomoses, atrial fibrillation after surgery, and dialysis after surgery.

CONCLUSIONS

Blood stream infections remained a common complication after OPCAB, and the mortality was high. Gram-negative bacilli and gram-positive cocci were distributed equally. Methicillin-resistant S. aureus was the pathogen identified most frequently. Preventive tactics should target likely pathogens and high-risk patients undergoing OPCAB.

Perioperative nutrition: what is the current landscape?

Poor nutrition status has long been linked to increases in postoperative complications and adverse outcomes for the patient undergoing elective surgery. While optimal planning for nutrition therapy should be comprehensive spanning throughout the perioperative period, recent advances have focused on the concept of "prehabilitation" to best prepare the patient prior to the insult of surgery. Adding immune/metabolic modulating formulas the week of surgery with carbohydrate drinks to optimize glycogen deposition immediately prior to surgery, enhances patient recovery and return to baseline function. Such nutrition strategies should now be combined with a host of other practices (such as smoking cessation, weight loss, glucose control, and specialized exercise program) as part of a structured protocol to maximize patients' chances for a full and rapid recovery from their elective surgical procedure.

Independent risk factors for ventilator-associated pneumonia after cardiac surgery

OBJECTIVE

To investigate the related factors and pathogens of ventilator-associated pneumonia (VAP) after heart surgery so as to provide evidences for clinical prevention and therapy.

METHODS

In total 1,688 cases were collected from January 2004 to January 2011. Overall 105 patients developed VAP. Retrospectively analyzed these patients after heart surgery to determine the clinical data, pathogens and treatment measures.

RESULTS

The frequency of ventilator-associated pneumonia was 6.2% (105/1 688), and mortality was 25.7% (27/105), 198 pathogen strains were isolated by bacterial culture, in which Gram negative bacteria accounted for 69.2% (137/198), Gram positive bacteria 27.8% (55/198), and fungi 3.0% (6/198). The independent risk factors for VAP after cardiac surgery were: age >70 (p < .01), emergent surgery (p < .01), perioperative blood transfusions (p < 0.01), reintubation (p < .01) and days of mechanical ventilation (MV) (p < .01). Median length of stay in the ICU for patients who developed VAP or not was, respectively, (24.7 ± 4.5) days versus (3.2 ± 1.5) days (p < .05), and mortality was, respectively, 25.7% versus 2.9% in both populations (p < .05).

CONCLUSION

Age >70, emergent surgery, perioperative blood transfusions, reintubation and days of MV are the risk factors for VAP in patients following cardiac surgery. P. aeruginosa, P. klebsiella, S. aureus, and Acinetobacter baumannii were the main pathogens of VAP. According to the cause of VAP, active prevention and treatment measures should be developed and applied to shorten the time of MV and improve chances of survival.

Efficiency of a pneumatic device in controlling cuff pressure of polyurethane-cuffed tracheal tubes: a randomized controlled study

Background

The primary objective of this study was to determine the efficiency of a pneumatic device in controlling cuff pressure (P_cuff) in patients intubated with polyurethane-cuffed tracheal tubes. Secondary objectives were to determine the impact of continuous control of P_cuff, and cuff shape on microaspiration of gastric contents.

Methods

Prospective randomized controlled study. All patients requiring intubation and mechanical ventilation ≥48 h were eligible. The first 32 patients were intubated with tapered polyurethane-cuffed, and the 32 following patients were intubated with cylindrical polyurethane-cuffed tracheal tubes. Patients randomly received 24 h of continuous control of P_cuff using a pneumatic device (Nosten®), and 24 h of routine care of P_cuff using a manometer. Target P_cuff was 25 cmH₂O. P_cuff was continuously recorded, and pepsin was quantitatively measured in all tracheal aspirates during these periods.

Results

The pneumatic device was efficient in controlling P_cuff (med [IQ] 26 [24, 28] vs 22 [20, 28] cmH₂O, during continuous control of P_cuff and routine care, respectively; p = 0.017). In addition, percentage of patients with underinflation (31% vs 68%) or overinflation (53% vs 100%) of tracheal cuff, and percentage of time spent with underinflation (0.9 [0, 17] vs 14% [4, 30]) or overinflation (0 [0, 2] vs 32% [9, 54]) were significantly (p < 0.001) reduced during continuous control of P_cuff compared with routine care.

No significant difference was found in microaspiration of gastric content between continuous control of P_cuff compared with routine care, or between patients intubated with tapered compared with cylindrical polyurethane-cuffed tracheal tubes.

Conclusion

The pneumatic device was efficient in controlling P_cuff in critically ill patients intubated with polyurethane-cuffed tracheal tubes.

Trial registration

The Australian New Zealand Clinical Trials Registry (NCT01351259)

[Multicenter survey on ventilator-associated pneumonia prevention in intensive care]

OBJECTIVE

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in intensive care unit (ICU). The aim of the study was to evaluate the follow-up of the guidelines for VAP prevention.

STUDY DESIGN

Retrospective, observational and multicenter study.

PATIENTS AND METHODS

During one year, all patients with mechanical ventilation over 48 hours were included in the CCLIN-Ouest Network. The demographic characteristics of the patients, the use of specific protocol for VAP prevention and the density of incidence of VAP were recorded. The use of a protocol for preventing VAP (absence, incomplete, complete and care bundle (i.e. complete prevention of VAP with weaning mechanical protocol and sedation protocol)) was collected.

RESULTS

26 ICU with 5742 patients were included. Ten ICU (38%; 2595 patients) had no protocol for VAP prevention, eight ICU (31%; 1821 patients) had an incomplete protocol, five ICU (19%; 561 patients) had a complete protocol and three ICU (12%; 765 patients) had a care bundle. The density of incidence of VAP was 14.8‰ (Interquartile range [IQR]: 10.2-0.1) for no protocol group, 15.6‰ [IQR: 12.6-6.2] for incomplete protocol group, 11.0‰ [IQR: 9.1-14.0] for complete protocol group and 12.9‰ [5-7,7-9,9-12] for care bundle group (P=0.742).

CONCLUSIONS

The compliance to prevention of VAP was poor. Proposals for improving practice are discussed.

Worldwide challenges of multidrug-resistant bacteria in patients with hematologic malignancies

SUMMARY The emergence of infections due to multidrug-resistant (MDR) bacteria poses a major public health threat to all patients, but patients with hematologic malignancies are especially at risk. A common thread across all classes of bacteria is that increased reliance on and usage of broad-spectrum antibacterial agents, combined with the intrinsic ability of bacteria to develop and transmit resistance-conferring mutations, has led to the widespread dissemination of MDR organisms. In this article, we summarize the most worrisome MDR bacteria, assess their clinical impact on patients with hematologic malignancies and outline measures that are required to mitigate this impact.

The Severity of ICU-Acquired Pneumonia

Much controversy exists about pneumonia in intensive care-especially, ventilator-associated pneumonia (VAP)-about its diagnosis and its attributable mortality. A better consensus exists about its prevention and its treatment. VAP occurs in already critically ill patients, and the relationship between preexisting organ dysfunction or failures and the severity of VAP has been recently highlighted. The role of the underlying disease should be considered as dominant, and this fact explains the paradox that exists between the high mortality of VAP and the relative minor effect of prevention measures on mortality.

Use of gastric residual volume to guide enteral nutrition in critically ill patients: a brief systematic review of clinical studies

OBJECTIVE

In critically ill patients, the optimal procedure to monitor upper gastrointestinal function is controversial. Several authors have proposed gastric residual volume (GRV) as a tool to guide enteral nutrition. The aim of this contribution is to briefly discuss corresponding studies.

METHODS

We electronically searched MEDLINE, EMBASE, and CINAHL for studies relevant to the subject.

RESULTS

Six randomized controlled trials (RCTs) and six prospective observational studies were identified. Each analyzed different thresholds of GRV to guide enteral nutrition and to avoid complications (e.g., vomiting, aspiration, nosocomial pneumonia) in artificially ventilated patients. Due to heterogeneity in outcome measures, patient populations, type and diameter of feeding tubes, and randomization procedures, combination of the results of the six RCTs into a meta-analysis was not appropriate. High-quality RCTs studying medical patients could not demonstrate an association between complication rate and the magnitude of GRV. The only observational study that adjusted results to potential confounders and that studied surgical patients found, however, that the frequency of aspiration increased significantly if a GRV > 200 mL was registered more than once.

CONCLUSION

For mechanically ventilated patients with a medical diagnosis at admission to the intensive care unit, monitoring of GRV appears unnecessary to guide nutrition. Surgical patients might profit, however, from a low GRV threshold (200 mL).

Mobile elements, zoonotic pathogens and commensal bacteria: conduits for the delivery of resistance genes into humans, production animals and soil microbiota

Multiple antibiotic resistant pathogens represent a major clinical challenge in both human and veterinary context. It is now well-understood that the genes that encode resistance are context independent. That is, the same gene is commonly present in otherwise very disparate pathogens in both humans and production and companion animals, and among bacteria that proliferate in an agricultural context. This can be true even for pathogenic species or clonal types that are otherwise confined to a single host or ecological niche. It therefore follows that mechanisms of gene flow must exist to move genes from one part of the microbial biosphere to another. It is widely accepted that lateral (or horizontal) gene transfer (L(H)GT) drives this gene flow. LGT is relatively well-understood mechanistically but much of this knowledge is derived from a reductionist perspective. We believe that this is impeding our ability to deal with the medical ramifications of LGT. Resistance genes and the genetic scaffolds that mobilize them in multiply drug resistant bacteria of clinical significance are likely to have their origins in completely unrelated parts of the microbial biosphere. Resistance genes are increasingly polluting the microbial biosphere by contaminating environmental niches where previously they were not detected. More attention needs to be paid to the way that humans have, through the widespread application of antibiotics, selected for combinations of mobile elements that enhance the flow of resistance genes between remotely linked parts of the microbial biosphere. Attention also needs to be paid to those bacteria that link human and animal ecosystems. We argue that multiply antibiotic resistant commensal bacteria are especially important in this regard. More generally, the post genomics era offers the opportunity for understanding how resistance genes are mobilized from a one health perspective. In the long term, this holistic approach offers the best opportunity to better manage what is an enormous problem to humans both in terms of health and food security.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

PURPOSE

To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 11 intensive care units (ICUs), from 10 hospitals, members of the INICC, in 10 cities of Turkey.

METHODS

A prospective active before-after surveillance study was conducted to determine the effect of the INICC multidimensional approach in the VAP rate. The study was divided into two phases. In phase 1, active prospective surveillance of VAP was conducted using the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the INICC methods. In phase 2, we implemented the multidimensional approach for VAP. The INICC multidimensional approach included the following measures: (1) bundle of infection control interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of VAP rates, and (6) performance feedback of infection control practices. We compared the rates of VAP obtained in each phase. A time series analysis was performed to assess the impact of our approach.

RESULTS

In phase 1, we recorded 2,376 mechanical ventilator (MV)-days, and in phase 2, after implementing the multidimensional approach, we recorded 28,181 MV-days. The rate of VAP was 31.14 per 1,000 MV-days during phase 1, and 16.82 per 1,000 MV-days during phase 2, amounting to a 46 % VAP rate reduction (RR, 0.54; 95 % CI, 0.42-0.7; P value, 0.0001.)

CONCLUSIONS

The INICC multidimensional approach was associated with a significant reduction in the VAP rate in these adult ICUs of Turkey.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC)

We report on the effect of the International Nosocomial Infection Control Consortium's (INICC) multidimensional approach for the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 21 intensive-care units (ICUs), from 14 hospitals in 10 Indian cities. A quasi-experimental study was conducted, which was divided into baseline and intervention periods. During baseline, prospective surveillance of VAP was performed applying the Centers for Disease Control and Prevention/National Healthcare Safety Network definitions and INICC methods. During intervention, our approach in each ICU included a bundle of interventions, education, outcome and process surveillance, and feedback of VAP rates and performance. Crude stratified rates were calculated, and by using random-effects Poisson regression to allow for clustering by ICU, the incidence rate ratio for each time period compared with the 3-month baseline was determined. The VAP rate was 17.43/1000 mechanical ventilator days during baseline, and 10.81 for intervention, showing a 38% VAP rate reduction (relative risk 0.62, 95% confidence interval 0.5-0.78, P = 0.0001).

Effectiveness of a multidimensional approach for the prevention of ventilator-associated pneumonia in an adult intensive care unit in Cuba: findings of the International Nosocomial Infection Control Consortium (INICC)

OBJECTIVE

This study sought to assess the effect of the multidimensional approach developed by the International Nosocomial Infection Control Consortium (INICC) on the reduction of ventilator-associated pneumonia (VAP) rates in patients hospitalized in an adult intensive care unit (AICU) in an INICC member hospital in Havana, Cuba.

METHODS

We conducted a prospective surveillance pre-post study in AICU patients. The study was divided into two periods:baseline and intervention. During the baseline period, we conducted active prospective surveillance of VAP using the Centers for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) definition and INICC methods. During the intervention period, we implemented the INICC multidimensional approach for VAP, in addition to performing active surveillance. This multidimensional approach included the following measures: a bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback of VAP rates and performance feedback of infection control practices. The baseline rates of VAP were compared to the rates obtained after intervention, and we analyzed the impact of our interventions by Poisson regression.

RESULTS

During the baseline period, we recorded 114 mechanical ventilator (MV) days, whereas we recorded 2350MV days during the intervention period. The baseline rate of VAP was 52.63 per 1000MV days and 15.32 per 1000MV days during the intervention. At the end of the study period, we achieved a 70% reduction in the rate of VAP (RR, 0.3; 95% CI, 0.12-0.7; P value, 0.003.).

CONCLUSIONS

The implementation the INICC multidimensional approach for VAP was associated with a significant reduction in the VAP rate in the participating AICU of Cuba.