Risk Factors of Ventilator-Associated Pneumonia in Critically III Patients

Phage-based therapy against biofilm producers in gram-negative ESKAPE pathogens

Persistent antibiotic use results in the rise of antimicrobial resistance with limited or no choice for multidrug-resistant (MDR) and extensively drug resistant (XDR) bacteria. This necessitates a need for alternative therapy to effectively combat clinical pathogens that are resistant to last resort antibiotics. The study investigates hospital sewage as a potential source of bacteriophages to control resistant bacterial pathogens. Eighty-one samples were screened for phages against selected clinical pathogens. Totally, 10 phages were isolated against A. baumannii, 5 phages against K. pneumoniae, and 16 phages were obtained against P. aeruginosa. The novel phages were observed to be strain-specific with complete bacterial growth inhibition of up to 6 h as monotherapy without antibiotics. Phage plus colistin combinations reduced the minimum-biofilm eradication concentration of colistin up to 16 folds. Notably, a cocktail of phages exhibited maximum efficacy with complete killing at 0.5-1 μg/ml colistin concentrations. Thus, phages specific to clinical strains have a higher edge in treating nosocomial pathogens with their proven anti-biofilm efficacy. In addition, analysis of phage genomes revealed close phylogenetic relations with phages reported from Europe, China, and other neighbouring countries. This study serves as a reference and can be extended to other antibiotics and phage types to assess optimum synergistic combinations to combat various drug resistant pathogens in the ongoing AMR crisis.

Antimicrobial materials for endotracheal tubes: A review on the last two decades of technological progress

Ventilator-associated pneumonia (VAP) is an unresolved problem in nosocomial settings, remaining consistently associated with a lack of treatment, high mortality, and prolonged hospital stay. The endotracheal tube (ETT) is the major culprit for VAP development owing to its early surface microbial colonization and biofilm formation by multiple pathogens, both critical events for VAP pathogenesis and relapses. To combat this matter, gradual research on antimicrobial ETT surface coating/modification approaches has been made. This review provides an overview of the relevance and implications of the ETT bioburden for VAP pathogenesis and how technological research on antimicrobial materials for ETTs has evolved. Firstly, certain main VAP attributes (definition/categorization; outcomes; economic impact) were outlined, highlighting the issues in defining/diagnosing VAP that often difficult VAP early- and late-onset differentiation, and that generate misinterpretations in VAP surveillance and discrepant outcomes. The central role of the ETT microbial colonization and subsequent biofilm formation as fundamental contributors to VAP pathogenesis was then underscored, in parallel with the uncovering of the polymicrobial ecosystem of VAP-related infections. Secondly, the latest technological developments (reported since 2002) on materials able to endow the ETT surface with active antimicrobial and/or passive antifouling properties were annotated, being further subject to critical scrutiny concerning their potentialities and/or constraints in reducing ETT bioburden and the risk of VAP while retaining/improving the safety of use. Taking those gaps/challenges into consideration, we discussed potential avenues that may assist upcoming advances in the field to tackle VAP rampant rates and improve patient care. STATEMENT OF SIGNIFICANCE: The use of the endotracheal tube (ETT) in patients requiring mechanical ventilation is associated with the development of ventilator-associated pneumonia (VAP). Its rapid surface colonization and biofilm formation are critical events for VAP pathogenesis and relapses. This review provides a comprehensive overview on the relevance/implications of the ETT biofilm in VAP, and on how research on antimicrobial ETT surface coating/modification technology has evolved over the last two decades. Despite significant technological advances, the limited number of gathered reports (46), highlights difficulty in overcoming certain hurdles associated with VAP (e.g., persistent colonization/biofilm formation; mechanical ventilation duration; hospital length of stay; VAP occurrence), which makes this an evolving, complex, and challenging matter. Challenges and opportunities in the field are discussed.

Evaluation of a bundle approach for the prophylaxis of ventilator-associated pneumonia: A retrospective single-center Study

Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring after the first 48 hours of intubation and mechanical ventilation and is the most frequent hospital-acquired infection associated with intensive care unit (ICU) admissions. Herein, we defined a novel VAP bundle including 10 preventive items. We analyzed compliance rates and clinical effectiveness associated with this bundle in patients undergoing intubation at our medical center. A total of 684 consecutive patients who underwent mechanical ventilation were admitted to the ICU between June 2018 and December 2020. VAP was diagnosed by at least two physicians based on the relevant United States Centers for Disease Control and Prevention criteria. We retrospectively evaluated associations between compliance and VAP incidence. The overall compliance rate was 77%, and compliance generally remained steady during the observation period. Moreover, although the number of ventilatory days remained unchanged, the incidence of VAP improved statistically significantly over time. Low compliance was identified in four categories: head-of-bed elevation of 30- 45º, avoidance of oversedation, daily assessment for extubation, and early ambulation and rehabilitation. The incidence of VAP was lower in those with an overall compliance rate of ≥ 75% than its incidence in the lower compliance group (15.8 vs. 24.1%, p = 0.018). When comparing low-compliance items between these groups, we found a statistically significant difference only for daily assessment for extubation (8.3 vs. 25.9%, p = 0.011). In conclusion, the evaluated bundle approach is effective for the prophylaxis of VAP and is thus eligible for inclusion in the Sustainable Development Goals.

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

BACKGROUND

COVID-19 patients requiring mechanical ventilation are particularly at risk of developing ventilator-associated pneumonia (VAP). Risk factors and the prognostic impact of developing VAP during critical COVID-19 have not been fully documented.

METHODS

Patients invasively ventilated for at least 48 h from the prospective multicentre COVID-ICU database were included in the analyses. Cause-specific Cox regression models were used to determine factors associated with the occurrence of VAP. Cox-regression multivariable models were used to determine VAP prognosis. Risk factors and the prognostic impact of early vs. late VAP, and Pseudomonas-related vs. non-Pseudomonas-related VAP were also determined.

MAIN FINDINGS

3388 patients were analysed (63 [55-70] years, 75.8% males). VAP occurred in 1523/3388 (45.5%) patients after 7 [5-9] days of ventilation. Identified bacteria were mainly Enterobacteriaceae followed by Staphylococcus aureus and Pseudomonas aeruginosa. VAP risk factors were male gender (Hazard Ratio (HR) 1.26, 95% Confidence Interval [1.09-1.46]), concomitant bacterial pneumonia at ICU admission (HR 1.36 [1.10-1.67]), PaO₂/FiO₂ ratio at intubation (HR 0.99 [0.98-0.99] per 10 mmHg increase), neuromuscular-blocking agents (HR 0.89 [0.76-0.998]), and corticosteroids (HR 1.27 [1.09-1.47]). VAP was associated with 90-mortality (HR 1.34 [1.16-1.55]), predominantly due to late VAP (HR 1.51 [1.26-1.81]). The impact of Pseudomonas-related and non-Pseudomonas-related VAP on mortality was similar.

CONCLUSION

VAP affected almost half of mechanically ventilated COVID-19 patients. Several risk factors have been identified, among which modifiable risk factors deserve further investigation. VAP had a specific negative impact on 90-day mortality, particularly when it occurred between the end of the first week and the third week of ventilation.

Efficacy of Intermittent and Continuous Subglottic Secretion Drainage in Preventing the Risk of Ventilator-Associated Pneumonia: A Meta-Analysis of Randomized Control Trials

Ventilator-associated pneumonia (VAP) is hospital-acquired pneumonia that develops 48 h or longer following mechanical ventilation. However, cuff pressure fluctuates significantly due to patient or tube movement, which might result in microaspiration. Subglottic secretion drainage (SSD) has been suggested as a method for VAP prevention bundles. This systematic review and meta-analysis aims to investigate the efficacy and safety of subglottic SSD in preventing VAP. The secondary outcomes of this study are to investigate the intensive care unit (ICU) stay length and mortality rate regarding VAP. This study followed the Preferred Reporting Item for Systematic Review and Meta-Analysis guidelines. A thorough search of PubMed, Embase, and the Web of Science was conducted between June and August 2022. The study analysis used the Mantel-Haenszel method, and the quality of the included study was assessed using the Cochrane Risk of Bias 2. Eighteen randomized controlled trials with a total of 2537 intubated patients were included. It was found that SSD was associated with a lower risk of VAP (RR 1.44; 95% CI; 1.20-1.73; p < 0.0001). The subgroup analysis (utilizing intermittent and continuous methods) found no statistically significant difference between the two groups (p = 0.28). The secondary endpoints showed that there was no significant difference in mortality (RR 1.02; 95% CI; 0.87-1.20; p = 0.83), but there were substantial differences in ICU stays (mean difference, 3.42 days; 95% CI; 2.07-4.76; p < 0.00001) in favor of the SSD group. This was based on a very low certainty of evidence due to concerns linked to the risk of bias and inconsistency. The use of SSD was associated with a reduction in VAP incidence and ICU stay length, but there was no significant difference in the mortality rate.

Impact of antimicrobial stewardship interventions on days of therapy and guideline adherence: A comparative point-prevalence survey assessment

Background

Antimicrobial stewardship (AMS) is a crucial tool for rationalizing the use of antimicrobial agents and reducing the burden of antimicrobial resistance. We aimed to assess the impact of AMS interventions on antimicrobial utilization and adherence to antimicrobial guidelines.

Methods

We conducted a prospective quasi-experimental study at a major tertiary hospital in the United Arab Emirates. Using standardized World Health Organization’s methodology, point-prevalence surveys (PPS) were performed in November 2019 and January 2022. Core AMS interventions consisted of proactive bloodstream infection service, proactive and reactive infectious diseases consult service, prospective audit and feedback by clinical pharmacists, development of antimicrobial guidelines based on cumulative antibiograms, and implementation of induction programs for new clinical staff. Days of therapy (DOT) per 1000 patient days present and rate of compliance with antimicrobial guidelines were compared before and after the core interventions. Multiple logistic regression analysis was carried out to adjust for the potential confounding effects of age, gender, hospitalization within 90 days, central or peripheral line insertion, urinary catheterization, and mechanical ventilation. P-value&lt;0.05 was considered statistically significant.

Results

Pre- and post-intervention PPSs included 292 and 370 patients, respectively. Both had similar age and gender distribution. Patients receiving antimicrobials were 51% (149/292) in 2019 and 45% (166/370) in 2022 (p 0.12). Univariate analysis showed a reduced post-intervention DOT per 1000 patients present (6.1 +/- 16.2 vs 2.4 +/-5.1, p&lt;0.01) and an improved post-intervention guideline compliance (59% vs 67%, p 0.23). Following multiple logistic regression, the reduction in post-intervention DOT remained statistically significant (co-efficient -0.17 (95% CI -8.58 to -1.94, p&lt;0.01), and the improvement in guideline adherence became statistically significant (adjusted odds ratio 1.91 (95% CI 1.05 to 3.45, p 0.03).

Conclusion

Coordinated and sustained AMS interventions have a significant impact on improving antimicrobial utilisation and adherence to guidelines.

Ventilator Acquired Pneumonia in COVID-19 ICU Patients: A Retrospective Cohort Study during Pandemia in France

Describe the characteristics of ventilation-acquired pneumonia (VAP) and potential risk factors in critically ill SARS-CoV-2 patients admitted in three French public hospitals during the first year of the COVID-19 pandemic. We conducted a monocentric retrospective study in seven Marseille intensive care units (ICUs) aiming to describe VAP characteristics and identify their risk factors. VAP patients were compared to a non-VAP control group. From March to November 2020, 161 patients admitted for viral-induced acute respiratory failure (ARF) requiring invasive mechanical ventilation (IMV) were included. This cohort was categorized in two groups according to the development or not of a VAP during their stay in ICU. 82 patients (51%) developed ventilation-acquired pneumonia. Most of them were men (77%) and 55% had hypertension. In the VAP population, 31 out of 82 patients (38%) had received dexamethasone and 47% were administered antibiotic course prior to ICU admission. An amount of 88% of respiratory infections were late VAPs with a median delay of 10 days from the onset of IMV. Gram negative bacteria were responsible for 62% of VAPs with Pseudomonas spp. being the most documented bacteria. Less than a third of the ICU-acquired infections were due to multidrug resistant (MDR) bacteria mainly displaying AmpC cephalosporin hyper production resistance phenotype. Multivariate analysis revealed that early Dexamethasone administration in ICU, male sex, older age and ROX score were risk factors for VAP whereas pre-ICU antimicrobial treatment and higher IGS 2 were protective factors. VAP is a frequent ICU-related complication affecting half of patients infected with SARS-CoV-2 and requiring IMV. It was responsible for increased morbidity due to a longer ICU and hospital stay. VAP risk factors included demographic factors such as age and sex. Dexamethasone was associated with a threefold greater risk of developing VAP during ICU stay. These results need to be comforted by large multi-centric studies before questioning the only available and effective treatment against SARS-CoV-2 in ICU patients.

Management of Bacterial and Fungal Infections in the ICU: Diagnosis, Treatment, and Prevention Recommendations

Bacterial and fungal infections are common issues for patients in the intensive care unit (ICU). Large, multinational point prevalence surveys have identified that up to 50% of ICU patients have a diagnosis of bacterial or fungal infection at any one time. Infection in the ICU is associated with its own challenges. Causative organisms often harbour intrinsic and acquired mechanisms of drug-resistance, making empiric and targeted antimicrobial selection challenging. Infection in the ICU is associated with worse clinical outcomes for patients. We review the epidemiology of bacterial and fungal infection in the ICU. We discuss risk factors for acquisition, approaches to diagnosis and management, and common strategies for the prevention of infection.

Risk Factors of Hospital-Acquired Pneumonia Among Hospitalized Patients With Cardiac Diseases

Background To our knowledge, no studies have been done in Saudi Arabia to determine the risk factors of hospital-acquired pneumonia (HAP) among hospitalized cardiac patients. This study aimed to assess these risk factors. Methods A retrospective study was done at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Five hundred hospitalized patients diagnosed with pre-existing cardiovascular disease (CVD) were included. A checklist was used to collect data about patients' demographic characteristics; BMI; smoking and alcohol abuse; type of cardiac disease; other chronic diseases; exposure to immunosuppressives; chemotherapy and radiotherapy in the last six months; glucocorticoid use; application of ventilator; initial, follow-up chest X-ray results; pneumonia vaccination status; nasogastric tube use; general anesthesia received; use of loop diuretics; presence of pulmonary diseases; levels of WBC, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); results of blood and respiratory cultures; number of hospitalizations and intensive care unit (ICU) admissions in the last six months; and Richmond Agitation and Sedation Scale (RASS) score. Results The prevalence of pneumonia was 7%. Females; patients with autoimmune diseases who were exposed to immunosuppressives or glucocorticoids; those with an initial or second abnormal chest X-ray; patients who used nasogastric tube, had pulmonary disease, and had high levels of WBC, ESR, or CRP; and patients hospitalized for more than two times had a significantly higher percentage of having pneumonia. Abnormal second chest X-ray, high ESR, and more than two times of hospitalization within the last six months were the risk factors of pneumonia on multivariate logistic regression analysis. Conclusion Better prevention and intervention programs are needed to assess the risk factors of pneumonia among admitted cardiac patients.

The effectiveness of colistin/levofloxacin compared to colistin/meropenem in the treatment of ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii: a randomized controlled clinical trial

Background and purpose

The treatment of ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii (CRAB) is still a great challenge. This study evaluated the effectiveness of the colistin/levofloxacin regimen compared to the usual colistin/meropenem regimen in the treatment of patients with VAP caused by CRAB.

Experimental approach

The patients with VAP were randomly assigned to experimental (n = 26) and control (n = 29) groups. The first group received IV colistin 4.5 MIU every 12 h + levofloxacin 750 mg IV daily, and the second group received IV colistin with the same dose + meropenem 1 g IV every 8 h for 10 days. The clinical (complete response, partial response, or treatment failure) and microbiological responses at the end of the intervention were recorded and compared between the two groups.

Findings/Results

The complete response rate was higher (n = 7; 35%) and the failure rate was lower (n = 4; 20%) in the experimental group than in the control group (n = 2; 8%, and n = 11; 44%, respectively), but the differences were not statistically significant. Even though the microbiological response rate was higher in the experimental group (n = 14; 70%) than in the control group (n = 12; 48%), the difference was not statistically significant. The mortality rate was 6 (23.10%) and 4 patients (13.8%) in the experimental and control groups, respectively (P = 0.490).

Conclusion and implication

The levofloxacin/colistin combination can be considered an alternative regimen to meropenem/colistin in the treatment of VAP caused by CRAB.

Bacteriophage Cocktails in the Post-COVID Rehabilitation

Increasing evidence suggests that gut dysbiosis is associated with coronavirus disease 2019 (COVID-19) infection and may persist long after disease resolution. The excessive use of antimicrobials in patients with COVID-19 can lead to additional destruction of the microbiota, as well as to the growth and spread of antimicrobial resistance. The problem of bacterial resistance to antibiotics encourages the search for alternative methods of limiting bacterial growth and restoring the normal balance of the microbiota in the human body. Bacteriophages are promising candidates as potential regulators of the microbiota. In the present study, two complex phage cocktails targeting multiple bacterial species were used in the rehabilitation of thirty patients after COVID-19, and the effectiveness of the bacteriophages against the clinical strain of Klebsiella pneumoniae was evaluated for the first time using real-time visualization on a 3D Cell Explorer microscope. Application of phage cocktails for two weeks showed safety and the absence of adverse effects. An almost threefold statistically significant decrease in the anaerobic imbalance ratio, together with an erythrocyte sedimentation rate (ESR), was detected. This work will serve as a starting point for a broader and more detailed study of the use of phages and their effects on the microbiome.

Insights from Transcriptomics: CD163+ Profibrotic Lung Macrophages in COVID-19

Coronavirus disease (COVID-19) begins with upper airway symptoms but proceeds in a significant proportion of patients to life-threatening infection of the lower respiratory tract, where an exuberant inflammatory response, edema, and adverse parenchymal remodeling impair gas exchange. Respiratory failure is caused initially by flooding of the airspaces with plasma exudate, sloughed epithelium, and inflammatory cells. For many patients with COVID-19, this acute phase has been observed to give way to a prolonged course of acute respiratory distress syndrome, and a significant proportion of patients go on to develop fibroproliferative remodeling of the lung parenchyma, which lengthens the duration of respiratory impairment and mechanical ventilation. Monocyte-derived macrophages have previously been implicated in the fibrotic phase of lung injury in multiple models. From several recent studies that used single-cell genomic techniques, a profile of the transcriptomic state of COVID-19 lung macrophages has emerged. Linkages have been made between these macrophages, which are monocyte-derived and CD163+, and profibrotic macrophages found in other contexts, including animal models of fibrosis and idiopathic pulmonary fibrosis. Here, emerging concepts of macrophage profibrotic function in COVID-19 are highlighted with a focus on gaps in knowledge to be addressed by future research.

Host and microbiome features of secondary infections in lethal covid-19

Secondary infections contribute significantly to covid-19 mortality but driving factors remain poorly understood. Autopsies of 20 covid-19 cases and 14 controls from the first pandemic wave complemented with microbial cultivation and RNA-seq from lung tissues enabled description of major organ pathologies and specification of secondary infections. Lethal covid-19 segregated into two main death causes with either dominant diffuse alveolar damage (DAD) or secondary pneumonias. The lung microbiome in covid-19 showed a reduced biodiversity and increased prototypical bacterial and fungal pathogens in cases of secondary pneumonias. RNA-seq distinctly mirrored death causes and stratified DAD cases into subgroups with differing cellular compositions identifying myeloid cells, macrophages and complement C1q as strong separating factors suggesting a pathophysiological link. Together with a prominent induction of inhibitory immune-checkpoints our study highlights profound alterations of the lung immunity in covid-19 wherein a reduced antimicrobial defense likely drives development of secondary infections on top of SARS-CoV-2 infection.

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Covid-19 autopsy cohort complemented with microbial cultivation and deep sequencing

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Major death causes stratify into DAD and secondary pneumonias

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Prototypical bacterial and fungal agents are found in secondary pneumonias

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Macrophages and C1q stratify DAD subgroups and indicate immune impairment in lungs

Interventions to promote oral care regimen adherence in the critical care setting: A systematic review

BACKGROUND

Oral care is a fundamental nurse-led intervention in the critical care setting that provides patient comfort and prevents adverse outcomes in critically ill patients. To date, there has been minimal focus on nurse-focused interventions to improve adherence to oral care regimens in the adult intensive care unit setting.

OBJECTIVES

The objectives of this study were to (i) identify types and characteristics of interventions to improve oral care adherence amongst critical care nurses and intervention core components, (ii) evaluate the effectiveness of interventions to improve adherence of oral care regimens, and (iii) identify the types of outcome measures used to assess oral care regimen adherence.

DESIGN

This is a systematic review in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

Key bibliographic databases and platforms, including Scopus, Cochrane, MEDLINE, CINAHL, Embase, PsycINFO, ProQuest, and Web of Science, were searched for studies published before July 2020. The Joanna Briggs Institute's quality appraisal tool was used to assess risk of bias in included studies.

RESULTS

A total of 21 original research studies were identified, of which 18 studies used multifaceted interventions. In accordance with the Joanna Briggs Institute's quality appraisal tools, four of the 20 quasi-experimental studies were rated as high quality. The one randomised control trial was of moderate quality. Outcome measures included oral care adherence behaviours, oral care knowledge, self-reported adherence, and documentation. Improved effectiveness in oral care adherence was reported in 20 studies.

CONCLUSIONS

Review findings confirm interventions to change behaviours improve oral care adherence. The most effective interventional approach could not be determined owing to heterogeneity in intervention design and outcome measures. Oral care in the intensive care unit is a vital, nurse-led activity that reduces the risk of hospital-acquired infection. It is recommended that future research adopt implementation science methods to ensure stakeholder engagement and feasibility.

SYSTEMATIC REVIEW REGISTRATION NUMBER

This review was submitted and subsequently registered on PROSPERO, the International Perspective Register of Systematic Reviews PROSPERO 2019 CRD42019123142.

Ventilator-Associated Pneumonia, Multidrug-Resistant Bacteremia and Infection Control Interventions in an Intensive Care Unit: Analysis of Six-Year Time-Series Data

Ventilator-associated pneumonia (VAP) occurs more than 48h after mechanical ventilation and is associated with a high mortality rate. The current hospital-based study aims to investigate the association between VAP rate, incidence of bacteremia from multidrug-resistant (MDR) pathogens, and infection control interventions in a single case mix ICU from 2013 to 2018. Methods: The following monthly indices were analyzed: (1) VAP rate; (2) use of hand hygiene disinfectants; (3) isolation rate of patients with MDR bacteria; and (4) incidence of bacteremia/1000 patient-days (total cases, total carbapenem-resistant cases, and carbapenem-resistant Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae cases separately). Results: Time trends of infection control interventions showed increased rates in isolation of patients with MDR pathogens (p <0.001) and consumption of hand disinfectant solutions (p =0.001). The last four years of the study an annual decrease of VAP rate by 35.12% (95% CI: −53.52 to −9.41; p =0.01) was recorded, which significantly correlated not only with reduced trauma and cardiothoracic surgery patients (IRR:2.49; 95% CI: 2.09−2.96; p <0.001), but also with increased isolation rate of patients with MDR pathogens (IRR: 0.52; 95% CI: 0.27−0.99; p = 0.048), and hand disinfectants use (IRR: 0.40; 95% CI: 0.18−0.89; p =0.024). Conclusions: Infection control interventions significantly contributed to the decrease of VAP rate. Constant infection control stewardship has a stable time-effect and guides evidence-based decisions.

Prognostic Role of Serum Adrenomedullin in Patients with Ventilator Associated Pneumonia

Objective: Ventilator associated pneumonia is a common type of sepsis that occurs to about 9–27% of all mechanically ventilated patients and 20–50% of them develop septic shock. Several clinical, laboratory, and radiological methods have been used for diagnosing VAP. Adrenomedullin (ADM) has been found to be elevated in the plasma of septic patients. The study aim was to explore the prognostic role of ADM in the VAP patients. Design: A prospective observational study. Setting: Intensive Care Department of Alexandria University Hospitals. Patients: A total of 140 patients with proven VAP after medical ICU admission were consecutively enrolled. Methods: APACHE II score, SOFA score, CRP, lactate, and serum ADM were measured at day 0 of VAP diagnosis and 5 days later. The results were correlated with the outcomes of patients. Results: APACHE II, lactate, and serum ADM on day 0 could predict an unfavorable outcome. ADM prediction power was significantly higher than APACHE II and lactate. Day 5 readings of all tested parameters could predict occurrence of the unfavorable outcome. ADM on day 0 showed the highest sensitivity (96.25%). Conclusions: Serum adrenomedullin when measured at days 0 and 5 of VAP diagnosis may serve as an early predictor of unfavorable outcome.

Relationship between ventilator bundle compliance and the occurrence of ventilator-associated events: a prospective cohort study

Background

Instead of ventilator-associated pneumonia (VAP), the modern definition of ventilator-associated events (VAEs) has been introduced to identify infectious and noninfectious respiratory complications. Some studies revealed that compliance to the ventilator bundle is associated with decreased occurrence of VAP, but little is known about its association with the decrease of VAEs occurrence.

Methods

A prospective cohort research design was used. Data were collected over eight months from May 2019 to February 2020 in five general intensive care units. The researchers assessed the compliance to ventilator care bundle using the Institute for Healthcare Improvement ventilation bundle checklist. Mechanically ventilated patients were prospectively assessed for the occurrence of VAEs using a pre-validated calculator from the Centers for Disease Control and Prevention. All are non-invasive tools and no intervention was done by the authors.

Results

A total of 141 mechanically ventilated patients completed the study. The odds ratio of having VAEs in patients who received ventilator bundle was -1.19 (95% CI, -2.01 to -0.38), a statistically significant effect, Wald χ2(1) = 8.18, p = 0.004.

Conclusion/ implications for practice

Ventilator bundle compliance was associated with a reduced risk for VAEs occurrence. Nurses should comply with the ventilator bundle because it is associated with decreased VAEs occurrence.

Development of a Tool for Measuring Ventilator-Associated Pneumonia Prevention Behaviors of Intensive Care Unit Nurses

Introduction: Ventilator-associated pneumonia (VAP) lengthens intensive care unit (ICU) stays and increases medical expenses and mortality risk. Aim: We aimed to develop and validate a tool for measuring VAP prevention behaviors among ICU nurses. Method: This is a methodological study that included a tool development step, based on the procedure suggested by DeVellis, and a tool verification step. Results: Through a literature review and focus interviews, 35 preliminary items were selected. After a content validity examination by experts and a pre-test, 30 items were chosen for this study. In the testing phase of the main survey, the final version tool was used on 452 ICU nurses to assess validity and reliability. From factor analysis, 7 factors and 17 items were selected. The factors included aspiration prevention, ventilator management, oral care, suction system management, subglottic suction, spontaneous awakening trials and spontaneous breathing trials, and standard precautions. The total determination coefficient was 71.6%. These factors were verified using convergent, discriminant, and concurrent validity tests. Internal consistency reliability was acceptable (Cronbach’s α = 0.80); thus, the VAP prevention behavior measurement tool was proven valid and reliable. Conclusions: This tool can be used with ICU nurses to measure behaviors associated with VAP prevention and, in turn, VAP prevention measures can be improved.

Early detection of gram‑negative bacteria using metagenomic next‑generation sequencing in acute respiratory distress syndrome: A case report

Metagenomic next-generation sequencing (mNGS) is an effective method that can be used for the identification of early pathogens in patients with suspected severe pneumonia. However, the potential of mNGS for evaluating the prognosis of acute respiratory distress syndrome (ARDS) in patients with severe pneumonia remains unclear. In the present report, hospital-acquired gram-negative bacteria infections were detected in a case using metagenomic next-generation sequencing (mNGS) in a sample of bronchoalveolar fluid. This was obtained from a 58-year-old male patient with traumatic wet lung after a neurosurgery. According to the results, of which the profiles of the resistance genes were detected by mNGS, drugs designed to control infection were adjusted, namely to polymyxin B (500,000 U/12 h), azithromycin (0.5 g/24 h) and ganciclovir (0.25 g/12 h). Following adjusting treatment for 8 days, the symptoms of lung infection and hypoxemia were markedly improved, resulting in the patient being transferred out of the intensive care unit 15 days after treatment. To conclude, observations from the present report suggest that mNGS is a useful method for the early identification of pathogens in patients with pneumonia caused by ARDS. However, further studies are required to identify the complementary role of mNGS in supporting conventional microbiological methods in routine clinical practice.

Colistin conditioning surfaces combined with antimicrobial treatment to prevent ventilator-associated infections

Biofilm formation on endotracheal tubes (ETT) is an important factor in the development of ventilator-associated pneumonia (VAP). This work aimed to investigate the effectiveness of colistin (COL) against the early stages of biofilm formation by Pseudomonas aeruginosa. Two strategies were used: pre-conditioning the adhesion surfaces with COL before biofilm formation and growing biofilms in its presence. The combined effect of treating P. aeruginosa 24-hours old biofilms with Ciprofloxacin (CIP) or colistin (COL) on clean and COL-conditioned surfaces was also assessed. Random deposition of COL residues altered the physico-chemical properties of the adhesion surfaces and impaired biofilm formation. Moreover, as a consequence of the reduced amount of biofilms attached to COL conditioned surfaces, adhered cells became more exposed to the subsequent action of CIP or COL, suggesting a combined outcome of prophylactic and therapeutic COL-based strategies. Results highlighted the promising use of COL to prevent the establishment of biofilms on ETT.

RISK score for developing ventilator-associated pneumonia in children: The RISVAP study

OBJECTIVES

Ventilator-associated pneumonia (VAP) is the second most common healthcare-associated infection in children. The aim of this study was to determine the risk factors for VAP in children and to create a risk score for developing VAP (RISVAP score).

STUDY DESIGN

It was a prospective observational study, including children who required mechanical ventilation (MV), registered in the multicentre ENVIN-HELICS database from 2014 to 2019. The regression coefficients of each independent risk factor for VAP were used to create the RISVAP score. Each factor scored 0 if it was absent, or, if it was present, an assigned value from 1 to 7, according to the regression coefficient.

RESULTS

A total of 3798 patients were included, 97(2.5%) developing VAP. The independent risk factors for VAP were: female (odds ratio [OR]: 1.642, p = 0.024), MV > 4 days (OR: 26.79, p < 0.001), length in pediatric intensive care unit > 7 days (OR: 11.74, p < 0.001), and previous colonisation (OR: 4.18, p < 0.001). The RISVAP was calculated for each patient as the sum of all the independent risk factors. Three risk groups were obtained: low (0-5 points), intermediate (6-12 points), and high risk for VAP (13-16 points). The area under the curve for the final score was 0.905 (95%confidence interval: 0.888-0.923, p < 0.001).

CONCLUSIONS

The RISVAP is the first risk score for VAP in pediatric populations. Using this predictive score, might be helpful to detect vulnerable patients and therefore implement preventative strategies.

The emergent neurosurgical outcome of spontaneous intracranial hemorrhage in patients with chronic liver disease

Objectives

The influence of chronic liver disease (CLD) on emergent neurosurgical outcomes in patients with spontaneous intracerebral hemorrhage (ICH) remains unclear. CLD is usually associated with coagulopathy and thrombocytopenia, which contribute to a high rebleeding rate and poor prognosis after surgery. This study aimed to confirm the outcomes of spontaneous intracranial hemorrhage in patients with CLD after emergent neurosurgery.

Materials and Methods

We reviewed the medical records of all patients with spontaneous ICH from February 2017 to February 2018 at the Buddhist Tzu Chi Hospital, Hualien, Taiwan. This study was approved by the Review Ethical Committee/Institutional Board Review of Hualien Buddhist Tzu Chi Hospital (IRB111-051-B). Patients with aneurysmal subarachnoid hemorrhage, tumors, arteriovenous malformations, and those younger than 18 years were excluded. Duplicate electrode medical records were also removed.

Results

Among the 117 enrolled patients, 29 had CLD and 88 did not. There were no significant differences in essential characteristics, comorbidities, biochemical profile, Glasgow coma scale (GCS) score at admission, or ICH sites. The length of hospital stay (LOS) and length of intensive care unit stay (LOICUS) are significantly longer in the CLD group (LOS: 20.8 vs. 13.5 days, P = 0.012; LOICUS: 11 vs. 5 days, P = 0.007). There was no significant difference in the mortality rate between the groups (31.8% vs. 28.4%, P = 0.655). The Wilcoxon rank-sum test for liver and coagulation profiles between survivors and the deceased revealed significant differences in the international normalized ratio (P = 0.02), including low platelet counts (P = 0.03) between survivors and the deceased. A multivariate analysis of mortality found that every 1 mL increase in ICH at admission increased the mortality rate by 3.9%, and every reduction in GCS at admission increased the mortality rate by 30.7%. In our subgroup analysis, we found that the length of ICU stay and LOS are significantly longer in patients with CLD who underwent emergent neurosurgery: 17.7 ± 9.9 days versus 7.59 ± 6.68 days, P = 0.002, and 27.1 ± 7.3 days versus 16.36 ± 9.08 days, P = 0.003, respectively.

Conclusions

From our study's perspective, emergent neurosurgery is encouraged. However, there were more prolonged ICU and hospital stays. The mortality rate of patients with CLD who underwent emergent neurosurgery was not higher than that of patients without CLD.

A retrospective evaluation of multiple definitions for ventilator associated pneumonia (VAP) diagnosis in an Australian regional intensive care unit

BACKGROUND

Ventilator Associated Pneumonia is a common complication of invasively ventilated patients with significant and underestimated morbidity and mortality. Defining VAP cases is greatly varied as many definitions are used with varying success and sensitivity. This study evaluates VAP detection using four definitions in a regional Australian Intensive Care Unit (ICU).

METHODS

A cohort of patients admitted to ICU at the Mackay Base Hospital from April 1st 2020 to March 31st 2021, who had endo-tracheal intubation and mechanical ventilation for longer than 48 h were identified. Each patient was examined across four common definitions of VAP. Head-to-head analysis of definitions was pursued to determine the most suitable definition. The four definitions used included: An Australian VAP definition, the CDC VAP definition, the Mackay Base Hospital Local Protocol and a Physician Decision Arm.

RESULTS

66 unique patients and 2 re-intubations were identified during the data collection window. The local protocol identified 8 cases of VAP. The Australian VAP definition identified 6 additional cases and 0 missed cases compared to the local protocol. The CDC definition missed 4 cases and identified 4 additional cases compared to the local protocol. Finally, the physician arm identified 10 cases including 8 additional cases and missed 6 cases.

CONCLUSIONS

VAP is an extremely difficult clinical condition to define and detect. Definitions have varied accuracy and suffer logistically for application to the individual patient. Refined criteria for diagnosis of VAP is greatly needed and its prevalence in intensive care units likely remains uncertain.

Causative Agents of Ventilator-Associated Pneumonia and Resistance to Antibiotics in COVID-19 Patients: A Systematic Review

Patients with coronavirus disease 2019 (COVID-19) have an increased risk of ventilator-associated pneumonia (VAP). This systematic review updates information on the causative agents of VAP and resistance to antibiotics in COVID-19 patients. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed/MEDLINE, and LILACS databases from December 2019 to December 2021. Studies that described the frequency of causative pathogens associated with VAP and their antibiotic resistance patterns in critically ill COVID-19 adult patients were included. The Newcastle-Ottawa Quality Assessment Scale was used for critical appraisal. The data are presented according to the number or proportions reported in the studies. A total of 25 articles were included, involving 2766 VAP cases in COVID-19 patients (range 5–550 VAP cases). Most of the studies included were carried out in France (32%), Italy (20%), Spain (12%) and the United States (8%). Gram-negative bacteria were the most frequent causative pathogens of VAP (range of incidences in studies: P. aeruginosa 7.5–72.5%, K. pneumoniae 6.9–43.7%, E. cloacae 1.6–20% and A. baumannii 1.2–20%). S. aureus was the most frequent Gram-positive pathogen, with a range of incidence of 3.3–57.9%. The median incidence of Aspergillus spp. was 6.4%. Few studies have recorded susceptibility patterns among Gram-negative causative pathogens and have mainly reported extended-spectrum beta-lactamase (ESBL), AmpC, and carbapenem resistance. The median frequency of methicillin resistance among S. aureus isolates was 44.4%. Our study provides the first comprehensive description of the causative agents and antibiotic resistance in COVID-19 patients with VAP. Gram-negative bacteria were the most common pathogens causing VAP. Data on antibiotic resistance patterns in the published medical literature are limited, as well as information about VAP from low- and middle-income countries.

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

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

COVID-19 Autopsies Reveal Underreporting of SARS-CoV-2 Infection and Scarcity of Co-infections

Coronavirus disease 2019 (COVID-19) mortality can be estimated based on reliable mortality data. Variable testing procedures and heterogeneous disease course suggest that a substantial number of COVID-19 deaths is undetected. To address this question, we screened an unselected autopsy cohort for the presence of SARS-CoV-2 and a panel of common respiratory pathogens. Lung tissues from 62 consecutive autopsies, conducted during the first and second COVID-19 pandemic waves in Switzerland, were analyzed for bacterial, viral and fungal respiratory pathogens including SARS-CoV-2. SARS-CoV-2 was detected in 28 lungs of 62 deceased patients (45%), although only 18 patients (29%) were reported to have COVID-19 at the time of death. In 23 patients (37% of all), the clinical cause of death and/or autopsy findings together with the presence of SARS-CoV-2 suggested death due to COVID-19. Our autopsy results reveal a 16% higher SARS-CoV-2 infection rate and an 8% higher SARS-CoV-2 related mortality rate than reported by clinicians before death. The majority of SARS-CoV-2 infected patients (75%) did not suffer from respiratory co-infections, as long as they were treated with antibiotics. In the lungs of 5 patients (8% of all), SARS-CoV-2 was found, yet without typical clinical and/or autopsy findings. Our findings suggest that underreporting of COVID-19 contributes substantially to excess mortality. The small percentage of co-infections in SARS-CoV-2 positive patients who died with typical COVID-19 symptoms strongly suggests that the majority of SARS-CoV-2 infected patients died from and not with the virus.

Risk Factors and Protective Factors against Ventilator-Associated Pneumonia-A Single-Center Mixed Prospective and Retrospective Cohort Study

Introduction: Understanding the factors associated with the development of ventilator-associated pneumonia (VAP) in critically ill patients in the intensive care unit (ICU) will allow for better prevention and control of VAP. The aim of the study was to evaluate the incidence of VAP, as well as to determine risk factors and protective factors against VAP. Design: Mixed prospective and retrospective cohort study. Methods: The cohort involved 371 critically ill patients who received standard interventions to prevent VAP. Additionally, patients in the prospective cohort were provided with continuous automatic pressure control in tapered cuffs of endotracheal or tracheostomy tubes and continuous automatic subglottic secretion suction. Logistic regression was used to assess factors affecting VAP. Results: 52 (14%) patients developed VAP, and the incidence density of VAP per 1000 ventilator days was 9.7. The median days to onset of VAP was 7 [4; 13]. Early and late onset VAP was 6.2% and 7.8%, respectively. According to multivariable logistic regression analysis, tracheotomy (OR = 1.6; CI 95%: 1.1 to 2.31), multidrug-resistant bacteria isolated in the culture of lower respiratory secretions (OR = 2.73; Cl 95%: 1.83 to 4.07) and ICU length of stay >5 days (OR = 3.32; Cl 95%: 1.53 to 7.19) were positively correlated with VAP, while continuous control of cuff pressure and subglottic secretion suction used together were negatively correlated with VAP (OR = 0.61; Cl 95%: 0.43 to 0.87). Conclusions: Tracheotomy, multidrug-resistant bacteria, and ICU length of stay >5 days were independent risk factors of VAP, whereas continuous control of cuff pressure and subglottic secretion suction used together were protective factors against VAP.

Performance Assessment of Medical Professionals in Prevention of Ventilator Associated Pneumonia in Intensive Care Units

PURPOSE

Ventilator-associated pneumonia (VAP) is one of the most common infections in intensive care units (ICU) with a 6-52% incidence. The VAP mortality rate is 50% to 70%. Medical professionals (MPs) working in the ICU are expected to follow the guidelines to prevent VAP. The study aimed to assess the performance of MPs in preventing VAP and to associate the performance with the baseline information.

METHODS

An observational cross-sectional study was conducted in the ICUs of selected hospitals in eastern Saudi Arabia. A total of 152 MPs were selected by random sampling. A structured questionnaire including baseline information, knowledge and performance-related questions was used to collect the data. Frequency, mean, and chi-square tests were used for analysis.

RESULTS

Out of 152 MPs, 40.8% had adequate and 7.9% had inadequate knowledge. A high mean score of 12.9 ± 2.2 was obtained by physicians, followed by 11.3 ± 1.6 by nurses, 9.8 ± 2.2 by RTs, and 8.6 ± 2.1 by interns. Overall, 52.6% had satisfactory performance. Approximately 57.9% and 67.8% of MPs cleaned their hands before touching the patient and the ventilator, respectively. Many (79.6%) MPs used personal protective equipment in the ICU. Some (47.4%) of the MPs changed the patient's position regularly. About 77.6% of MPs followed the sterile technique when suctioning the airway. There was a significant association found between the performance of MPs on the prevention of VAP with age (p < 0.001), designation (p < 0.05), professional experience (p < 0.05), managing chronic obstructive pulmonary disease conditions (p < 0.05) and training attended (p < 0.001).

CONCLUSION

Although some of the MPs had satisfactory performance regarding VAP prevention in the ICU, more attention should be paid to training them on clinical guidelines to improve health care quality and reduce the rate of VAP.

Trends and Factors Associated With Ventilator-Associated Pneumonia: A National Perspective

Background: Ventilator-associated pneumonia (VAP) is a hospital-acquired pneumonia that occurs more than 48 hours after mechanical ventilation. Studies showing temporal trends, predictors, and outcomes of VAP are very limited.

Objective: We used the National database to delineate the trends and predictors of VAP from 2009 to 2017.

Methods: We analyzed data from the Nationwide Inpatient Sample (NIS) for adult hospitalizations who received mechanical ventilation (MV) by using ICD-9/10-CM procedures codes. We excluded hospitalizations with length of stay (LOS) less than two days. VAP and other diagnoses of interest were identified by ICD-9/10-CM diagnosis codes. We then utilized the Cochran Armitage trend test and multivariate survey logistic regression models to analyze the data.

Results: Out of a total of 5,155,068 hospitalizations who received mechanical ventilation, 93,432 (1.81%) developed VAP. Incidence of VAP decreased from 20/1000 in 2008 to 17/1000 in 2017 with a 5% decrease. Patients who developed VAP had lower mean age (59 vs 61; p<0.001) and higher LOS (25 days vs. 12 days; p<0.001). In multivariable regression analysis, we identified that males, African Americans, teaching hospitals and co-morbidities like neurological disorders, pulmonary circulation disorders and electrolyte disorders are associated with the increased odds of developing VAP. VAP was also associated with higher rates of discharge to facilities and increased LOS.

Conclusion: Our study identified the trends along with the risk predictors of VAP in MV patients. Our goal is to lay the foundation for further in-depth analysis of this trend for better risk stratification and development of preventive strategies to reduce the incidence of VAP among MV patients.

Increased Use of Antibiotics in the Intensive Care Unit During Coronavirus Disease (COVID-19) Pandemic in a Brazilian Hospital

Background: Microbial drug resistance is one of the biggest public health problems. Antibiotic consumption is an essential factor for the emergence and spread of multiresistant bacteria. Therefore, we aimed to analyze the antibiotics consumption in the Intensive Care Unit (ICU), identifying trends in the antibiotics use profile and microbiological isolates throughout the COVID-19 pandemic. Methods: We performed this retrospective observational study in intensive care units of a Brazilian tertiary hospital from January 2019 to December 2020. The primary outcome was antimicrobial consumption in the ICU, measured by defined daily doses (DDDs) per 100 bed-days. As a secondary outcome, bacterial infections (microbiological isolates) were calculated in the same fashion. Outcomes trends were analyzed using Joinpoint regression models, considering constant variance (homoscedasticity) and first-order autocorrelation assumptions. A monthly percent change (MPC) was estimated for each analyzed segment. Results: Seven thousand and nine hundred fifty-three patients had data available on prescribed and received medications and were included in the analyses. Overall, the use of antibiotics increased over time in the ICU. The reserve group (World Health Organization Classification) had an increasing trend (MPC = 7.24) from February to April 2020. The azithromycin consumption (J01FA) increased rapidly, with a MPC of 5.21 from January to April 2020. Polymyxin B showed a relevant increase from March to June 2020 (MPC = 6.93). The peak of the antibiotic consumption of Reserve group did not overlap with the peak of the pathogenic agents they are intended to treat. Conclusion: Overall antimicrobial consumption in ICU has increased in the context of the COVID-19 pandemic. The peaks in the antimicrobial's use were not associated with the rise of the pathogenic agents they intended to treat, indicating an empirical use, which is especially concerning in the context of treating multidrug-resistant (MDR) infections. This fact may contribute to the depletion of the therapeutic arsenal for MDR treatment.

Prognostic biomarkers in predicting mortality in respiratory patients with ventilator-associated pneumonia

Background

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection. Red cell distribution width (RDW) and neutrophil-lymphocyte ratio (NLR) are prognostic factors to mortality in different diseases. The aim of this study is to evaluate prognostic efficiency RDW, NLR, and the Sequential Organ Failure Assessment (SOFA) score for mortality prediction in respiratory patients with VAP.

Results

One hundred thirty-six patients mechanically ventilated and developed VAP were included. Clinical characteristics and SOFA score on the day of admission and at diagnosis of VAP, RDW, and NLR were assessed and correlated to mortality. The average age of patients was 58.80 ± 10.53. These variables had a good diagnostic performance for mortality prediction AUC 0.811 for SOFA at diagnosis of VAP, 0.777 for RDW, 0.728 for NLR, and 0.840 for combined of NLR and RDW. The combination of the three parameters demonstrated excellent diagnostic performance (AUC 0.889). A positive correlation was found between SOFA at diagnosis of VAP and RDW (r = 0.446, P < 0.000) and with NLR (r = 0.220, P < 0.010).

Conclusions

NLR and RDW are non-specific inflammatory markers that could be calculated quickly and easily via routine hemogram examination. These markers have comparable prognostic accuracy to severity scores. Consequently, RDW and NLR are simple, yet promising markers for ICU physicians in monitoring the clinical course, assessment of organ dysfunction, and predicting mortality in mechanically ventilated patients. Therefore, this study recommends the use of blood biomarkers with the one of the simplest ICU score (SOFA score) in the rapid diagnosis of critical patients as a daily works in ICU.

Assessing the Impact of Gender and COPD on the Incidence and Mortality of Hospital-Acquired Pneumonia. A Retrospective Cohort Study Using the Spanish National Discharge Database (2016-2019)

BACKGROUND

We aim to analyze incidence and outcomes of patients hospitalized with hospital-acquired pneumonia (HAP) according to chronic obstructive pulmonary disease (COPD) status and sex in Spain (2016-2019).

METHODS

We conducted a retrospective cohort study using national hospital discharge data of patients ≥40 years with a primary diagnosis of HAP, using the specific diagnostics of non-ventilator (NV)-HAP and ventilator-associated pneumonia (VAP).

RESULTS

We identified 37,029 patients with HAP ((NV)-HAP 87.28%, VAP 12.72%), 13.40% with COPD. HAP incidence increased over time, but only in subjects without COPD (p < 0.001). In women, incidence of HAP and (NV)-HAP was similar regardless of COPD status, but VAP incidence was lower in COPD women (p = 0.007). In men, the incidence of (NV)-HAP was significantly higher in those with COPD, while VAP incidence was lower in COPD men (p < 0.001). The in-hospital mortality (IHM) was similar in men and women with and without COPD. The risk of dying in hospital increased with age, congestive heart failure, cancer, and dialysis among men and women with COPD. Men that underwent surgery had a lower risk of IHM. VAP increased 2.58-times the probability of dying in men and women. Finally, sex was not associated with IHM among COPD patients.

CONCLUSIONS

Incidence of HAP was significantly higher in COPD patients than in those without COPD, at the expense of (NV)-HAP but not of VAP. When stratifying by sex, we found that the difference was caused by men. IHM was similar in COPD and non-COPD patients, with no significant change overtime. In addition, sex was not associated with IHM.

Pulmonary Infections, Including Ventilator-Associated Pneumonia

Pneumonia is a leading cause of morbidity and mortality and a primary cause of hospitalizations. Guidelines have been established through the American Thoracic Society and Infectious Diseases Society of America in 2016 focusing on the causative pathogen for antibiotic selection. In 2017 an International European task force provided guidelines of specific antibiotic selections based on drug resistance and mortality risk. Improving patient outcomes is based not only on the appropriate treatment, which should not be delayed, but also on implementation and adherence to evidence-based strategies to reduce the increased risk of mortality.

Assessment of knowledge and compliance to evidence-based guidelines for VAP prevention among ICU nurses in Tanzania

BACKGROUND

Implementation of evidence-based guidelines (EBGs) related to VAP is an effective measure for the prevention of ventilator-associated pneumonia (VAP). While low knowledge regarding the EBGs related to VAP prevention among ICU nurses is still a major concern among nurses in ICUs globally, the situation in Tanzania is scarcely known. This study aimed to assess the ICU nurses' knowledge, compliance, and barriers toward evidence-based guidelines for the prevention of VAP in Tanzania.

METHODS

A cross-sectional study, involving ICU nurses of major hospitals in Tanzania, was conducted. A structured questionnaire was administered among 116 ICU nurses. Data analysis included descriptive statistics and the independent sample t-test.

RESULTS

The mean knowledge score was 3.86(SD = 1.56), based on ten questions (equivalent to 38.6%). Nurses with a degree or higher level of nursing education performed significantly better than the nurses with a diploma or lower level of nursing education (p = 0.004). The mean self-reported compliance score for EBGs for the prevention of VAP was 15.20 (SD = 0.93) which is equivalent to 60.8% based on 25 questions. The main barriers to the implementation of EBGs for VAP prevention were lack of skills (96.6%), lack of adequate staff (95.5%), and lack of knowledge (79.3%).

CONCLUSION

Considering the severity and impact of VAP, and the higher risks of HAIs in resource-limited countries like Tanzania, the lower level of knowledge and compliance implies the need for ongoing educational interventions and evaluation of the implementation of the EBGs for VAP prevention by considering the local context.

Secondary pneumonias in critically ill patients with COVID-19: risk factors and outcomes

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the current evidence of secondary pneumonias in COVID-19 patients, its incidence, risk factors and impact outcomes.

RECENT FINDINGS

Early studies reported low incidence of hospital-acquired infections in COVID-19 patients. More recent large studies clearly showed that the incidence of secondary pneumonias was markedly high in patients under mechanical ventilation. Duration of mechanical ventilation, acute respiratory distress syndrome, prone position and male sex were identified as risk factors. The adjunctive therapy with steroids and immunomodulators were associated with a higher risk of pneumonia and invasive pulmonary Aspergillosis. Although secondary pneumonias seemed to be associated with poor outcomes, namely mortality, in comparison with influenza, no difference was found in heterogeneity of outcomes. Immunosuppressive therapy has been studied in several observational and randomized trials with conflicting results and the true impact on superinfections, namely secondary pneumonias, has not been properly assessed.

SUMMARY

According to the current evidence, COVID-19 patients are at an increased risk of secondary pneumonias. The impact of immunosuppressive therapies on superinfections is yet to be determined. Further studies are needed to assess the true risk of secondary infections associated with immunosuppressive therapies and to identify preventive strategies.

Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Cohort Study

INTRODUCTION

Aim of this study is to analyse the characteristics of ventilator-associated pneumonia (VAP) inpatients infected by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2).

MATERIALS AND METHODS

A retrospective study was conducted, including coronavirus infectious disease 2019 (COVID-19) patients who developed VAP from March to May 2020 (VAP COVID-19). They were compared to non-COVID-19 patients who developed VAP from January 2011 to December 2019 (VAP NO COVID-19) and COVID-19 patients who did not develop VAP (NO VAP COVID-19).

RESULTS

Overall, 42 patients were included in the VAP COVID-19group, 37 in the NO VAP COVID-19 group, and 188 in the VAP NO COVID-19 group. VAP COVID-19 had significantly higher rates of shock (71% vs. 48%, p = 0.009), death in ICU (52% vs. 30%, p = 0.011), VAP recurrence (28% vs. 4%, p < 0.0001), positive blood culture (26% vs. 13%, p = 0.038), and polymicrobial culture (28% vs. 13%, p = 0.011) than VAP NO COVID-19. At the multivariate analysis, death in patients with VAP was associated with shock (p = 0.032) and SARS-CoV-2 (p = 0.008) infection.

CONCLUSIONS

VAP in COVID-19 patients is associated with shock, bloodstream, and polymicrobial infections.

Machine Learning Model to Predict Ventilator Associated Pneumonia in patients with Traumatic Brain Injury: The C.5 Decision Tree Approach

BACKGROUND

There is paucity in the literature to predict the occurrence of Ventilator Associated Pneumonia (VAP) in patients with Traumatic Brain Injury (TBI). We aimed to build a C.5. Decision Tree (C.5 DT) machine learning model to predict VAP in patients with moderate to severe TBI.

METHODS

This was a retrospective study including all adult patients who were hospitalized with TBI plus head abbreviated injury scale (AIS) ≥ 3 and were mechanically ventilated in a level 1 trauma center between 2014 and 2019.

RESULTS

A total of 772 eligible patients were enrolled, of them 169 had VAP (22%). The C.5 DT model achieved moderate performance with 83.5% accuracy, 80.5% area under the curve, 71% precision, 86% negative predictive value, 43% sensitivity, 95% specificity and 54% F-score. Out of 24 predictors, C.5 DT identified 5 variables predicting occurrence of VAP post-moderate to severe TBI (Time from injury to emergency department arrival, blood transfusion during resuscitation, comorbidities, Injury Severity Score and pneumothorax).

CONCLUSIONS

This study could serve as baseline for the quest of predicting VAP in patients with TBI through the utilization of C.5. DT machine learning approach. This model helps provide timely decision support to caregivers to improve patient's outcomes.

Ventilator-associated pneumonia among ICU patients in WHO Southeast Asian region: A systematic review

Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections and a leading cause of death among patients in Intensive Care Unit (ICU). The South East Asian Region is a part of the world with limited health resources where infectious diseases are still underestimated. We aimed to review the literature in this part of the world to describe incidence, mortality and microbiological evidence of VAP and explore preventive and control strategies. We selected 24 peer-reviewed articles published from January 1, 2000 to September 1, 2020 from electronic databases and manual searching for observational studies among adult patients diagnosed with VAP expressed per thousand days admitted in ICU. The VAP rates ranged from 2.13 to 116 per thousand days, varying among different countries of this region. A significant rate of mortality was observed in 13 studies ranging from 16.2% to 74.1%. Gram negative organisms like Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella pneumoniae and Gram-positive organisms like Staphylococcus aureus and Enterococcus species were frequently found. Our findings suggest an alarming situation of VAP among patients of most of the countries of this region with increasing incidence, mortality and antibiotic resistance. Thus, there is an urgent need for cost effective control and preventive measures like interventional studies and educational programs on staff training, hand hygiene, awareness on antibiotic resistance, implementation of antibiotic stewardship programs and appropriate use of ventilator bundle approach.

Evaluation of pneumonia due to mechanical ventilation and its association with the severity of disease in patients admitted to intensive care unit

Among the hospital-acquired infections, ventilator-associated pneumonia (VAP) has the highest mortality and morbidity rates. The aim of this study was to identify VAP in the intensive care unit (ICU) and its association with the severity of the disease. This descriptive-analytic study was conducted in Golestan University of Medical Sciences (Northern Iran). In the present study, 239 patients undergoing mechanical ventilation hospitalized in ICU were selected through non-random sampling. Data were recorded by using APACHE II criteria and diagnosis of VAP was made based on clinical criterion and physician confirmation. Data were analyzed by independent t-test, Chi-square test, Mann-Whitney test, and single-variable logistic test. The incidence of VAP was 19.2% and it was significantly related to mean arterial pressure (P = 0.035) and male sex (P = 0.122). There was a significant and direct correlation between the incidence of VAP and the increase in the value of gastric residual volume > 200 ml (P = 0.001). The findings of this study showed that male sex, increased arterial pressure, and gastric residual volume were the risk factors for the development of of VAP.

Microbial diversity and colonization patterns of two step-down care units from a tertiary care hospital

Nosocomial surfaces are potential pathogen reservoirs. Our aim was to describe the microbial diversity and analyze microbial patterns of healthcare-associated pathogens in two step-down-care-units at a tertiary care hospital. We monitored infected patients over 45 days to describe microbial diversity and colonization patterns. A total of 2762 isolates were recovered from the sampled sites, coagulase-negative staphylococci represented 44.64% (1233/2762) of the isolates. The most frequently recovered ESKAPE species (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter cloacae) were A. baumannii (7.53%; 208/2762 isolates) and E. faecium/Enterococcus faecalis (5.18%; 143/2762). We recovered a high diversity of species, including potential pathogens. A. baumannii was detected more frequently on diverse surfaces and persisted in patients’ nostrils during the hospital stay.

Combination of toothbrushing and chlorhexidine compared with exclusive use of chlorhexidine to reduce the risk of ventilator-associated pneumonia: A systematic review with meta-analysis

This study aimed to compare the effectiveness of 0.12% chlorhexidine alone and 0.12% chlorhexidine in combination with toothbrushing to prevent ventilator-associated pneumonia (VAP) in mechanically ventilated patients. The Embase, Latin American and Caribbean Health Science Literature, PubMed, Scientific Electronic Library Online, Scopus, LIVIVO, Web of Science, Cochrane Library, OpenThesis, and Open Access Thesis and Dissertations databases were used. Only randomized controlled trials without restrictions on the year or language of publication were included. Two reviewers assessed the risk of bias using the Joanna Briggs Institute Critical Appraisal Tool. A meta-analysis using a random-effects model estimated the combined relative risk (RR). The Grading of Recommendations, Assessment, Development and Evaluations approach was used to assess the certainty of the evidence. Initially, 2,337 studies were identified, of which 4 were considered in the systematic review and 3 in the meta-analysis (total sample: 796 patients). The studies were published between 2009 and 2017. All eligible studies had a low risk of bias. The meta-analysis revealed that the risk of VAP was 24% lower in patients receiving chlorhexidine combined with toothbrushing than in those receiving chlorhexidine alone (RR: 0.76; 95% confidence interval: 0.55-1.06), with moderate certainty of evidence and without statistical significance. In conclusion, considering the limitations of this study, a standard protocol for the prevention of VAP is not yet recommended. More studies with larger sample sizes are needed to draw strong conclusions. However, considering that toothbrushing is a simple intervention, it should be a common practice in mechanically ventilated patients, especially among patients with coronavirus disease.

Effect of chronic obstructive pulmonary disease combined with ventilator-associated pneumonia on patient outcomes: A systematic review and meta-analysis

The purpose of the present systematic review and meta-analysis was to uncover whether chronic obstructive pulmonary disease (COPD) as a co-morbidity influences outcomes of patients with ventilator-associated pneumonia (VAP) compared to VAP alone and whether the development of VAP in patients with COPD is associated with poor outcome in comparison to COPD alone. An electronic search of the PubMed, Embase, Scopus, BioMed Central, CENTRAL and Google scholar databases for all types of studies assessing the influence of COPD on outcomes of patients with VAP and vice versa was performed. A total of 7 studies were included. Of these, 3 studies assessed the impact of COPD on outcomes of patients with VAP. Meta-analysis indicated that the presence of COPD significantly increased the mortality of patients with VAP [risk ratio (RR): 1.37, 95% CI: 1.14-1.65, I²=3%, P=0.007]. The analysis failed to demonstrate any significant effect of COPD on the duration of mechanical ventilation in patients with VAP [mean difference (MD): 2.37, 95% CI: -5.77 to 10.50, I²=38%, P=0.57]. However, the duration of the intensive care unit (ICU) stay was significantly longer in patients with COPD and VAP as compared with that of patients with VAP without COPD (MD: 5.53, 95% CI: 0.73-10.33, I²=0%, P=0.02). A total of 4 studies assessed the impact of VAP on outcomes of patients with COPD. Meta-analysis indicated that the presence of VAP significantly increased mortality of patients with COPD (RR: 1.52, 95% CI: 1.08-2.12, I²=71%, P=0.02). Pooled analysis indicated that the presence of VAP in patients with COPD significantly increased the duration of mechanical ventilation (MD: 13.73, 95% CI: 7.86-19.61, I²=92%, P<0.00001) and the duration of the ICU stay as compared to patients with COPD but without VAP (MD: 17.36, 95% CI: 9.55-25.17, I²=90%, P<0.0001). To conclude, within the limitations of the study, the present results indicated that the combination of COPD and VAP significantly increased patient mortality and the duration of ICU stay. The development of VAP in patients with COPD also significantly increased the duration of mechanical ventilation. Further case-matched studies are required to assess the influence of the severity of COPD in combination with VAP on patient outcomes.

Predictive Factors for Failure of Noninvasive Ventilation in Adult Intensive Care Unit: A Retrospective Clinical Study

Background

Noninvasive ventilation (NIV) has been reported to be beneficial for patients with acute respiratory failure in intensive care unit (ICU); however, factors that influence the clinical outcome of NIV were unclarified. We aim to determine the factors that predict the failure of NIV in critically ill patients with acute respiratory failure (ARF). Setting. Adult mixed ICU in a medical university affiliated hospital. Patients and Methods. A retrospective clinical study using data from critical adult patients with initial NIV admitted to ICU in the period August 2016 to November 2017. Failure of NIV was regarded as patients needing invasive ventilation. Logistic regression was employed to determine the risk factor(s) for NIV, and a predictive model for NIV outcome was set up using risk factors.

Results

Of 101 included patients, 50 were unsuccessful. Although more than 20 variables were associated with NIV failure, multivariate logistic regression demonstrated that only ideal body weight (IBW) (OR 1.110 (95%1.027-1.201), P=0.009), the maximal heart rate during NIV period (HR-MAX) (OR 1.024 (1.004-1.046), P=0.021), the minimal respiratory rate during NIV period (RR-MIN) (OR 1.198(1.051-1.365), P=0.007), and the highest body temperature during NIV period (T-MAX) (OR 1.838(1.038-3.252), P=0.037) were independent risk factors for NIV failure. We set up a predictive model based on these independent risk factors, whose area under the receiver operating characteristic curve (AUROC) was 0.783 (95% CI: 0.676-0.899, P < 0.001), and the sensitivity and specificity of model were 68.75% and 71.43%, respectively, with the optimal cut-off value of 0.4863.

Conclusion

IBW, HR-MAX, RR-MIN, and T-MAX were associated with NIV failure in patients with ARF. A predictive model based on the risk factors could help to discriminate patients who are vulnerable to NIV failure.

Detection of Carbapenemase and CTX-M Encoding Genes Directly from Bronchoalveolar Lavage Using the CRE and ESBL ELITe MGB Assays: Toward Early and Optimal Antibiotic Therapy Management of Critically Ill Patients with Pneumonia

The detection of carbapenemase extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (EB) has become a major issue among critically ill patients, especially due to their impact on appropriate antimicrobial therapy. This study aimed at evaluating the potential contribution of molecular assays to early optimization of empirical antibiotic therapy among critically ill patients with carbapenemase- and/or CTX-M-producing EB pneumonia. The CRE and ESBL ELITe MGB^® assays were evaluated directly on 197 bronchoalveolar lavage (BAL) samples obtained from 120 patients. Molecular results were then compared to routine culture-based diagnostic results, and a retrospective analysis of the therapeutic antimicrobial management was performed. Among the 197 clinical specimens, bla_KPC-like and bla_CTX-M-like were detected in 20 (10.2%) and 12 (6.1%) specimens belonging to 15 and 11 patients, respectively. Positive predictive value (PPV) and negative predictive value (NPV) of the CRE ELITe MGB Kit were 85% [95% confidence interval [CI]: 64.9-94.6] and 100%, respectively. PPV and NPV of the ESBL ELITe MGB Kit were 75% [95% CI: 49.4-90.2] and 100%, respectively. Retrospective analysis of the therapeutic antimicrobial management at the time of BAL collection showed that in ∼50% of patients with carbapenemase- and CTX-M-producing EB pneumonia empirical antibiotic therapy could have been optimized at least 48-72 hr earlier if positive molecular data had been used. The CRE and ESBL ELITe MGB assays might be an interesting tool for expediting optimization of empirical antibiotic therapy in critically ill patients with pneumonia, depending on local epidemiology of antibiotic resistance, patient risk stratification for EB infection, and availability of an antimicrobial stewardship team.

The impact of Candida spp airway colonization on clinical outcomes in patients with ventilator-associated pneumonia: A systematic review and meta-analysis

BACKGROUND

Previous studies have drawn different conclusions about the impact of Candida airway colonization on clinical outcomes in patients with ventilator-associated pneumonia (VAP).

METHODS

We searched PubMed, the Cochrane Library, Embase (via OVID), and Web of Science database. We included both retrospective and prospective observational studies. The mean difference (MD) or risk ratio (RR) with 95% confidence intervals (CI) were applied to assess the association between Candida colonization and clinical outcomes.

RESULTS

A total of 8 studies with 1,661 patients were pooled in our final studies. Compared with patients with VAP without Candida colonization, patients with Candida colonization had significantly longer durations of mechanical ventilation (MD, 1.93; 95% CI, 0.53-3.33). The intensive care unit (ICU) length of stay seems to be longer among Candida colonized patients than noncolonized patients, although the results were not so significant (MD, 1.15; 95% CI, -1.04 to 3.34). Patients with colonization had higher 28-day mortality and ICU mortality than those without colonization (28-day mortality: RR, 1.64; 95% CI, 1.27-2.12; ICU mortality: RR, 1.57; 95% CI, 1.26-1.94).

CONCLUSIONS

The presence of Candida spp airway colonization is associated with longer durations of mechanical ventilation, higher 28-day mortality, higher ICU mortality, and probably longer ICU length of stay compared with the absence of colonization in patients with VAP.

The Impact of an Attending Intensivist on the Clinical Outcomes of Patients Admitted to the Cardiac Surgical Intensive Care Unit after Coronary Artery Bypass Grafting

Background

We aimed to investigate the associations of critical care provided in a cardiac surgical intensive care unit (CSICU) staffed by an attending intensivist with improvements in intensive care unit (ICU) quality and reductions in postoperative complications.

Methods

Patients who underwent elective isolated coronary artery bypass grafting (CABG) between January 2007 and December 2012 (the control group) were propensity-matched (1:1) to CABG patients between January 2013 and June 2018 (the intensivist group).

Results

Using propensity score matching, 302 patients were extracted from each group. The proportion of patients with at least 1 postoperative complication was significantly lower in the intensivist group than in the control group (17.2% vs. 28.5%, p=0.001). In the intensivist group, the duration of mechanical ventilation (6.4±13.7 hours vs. 13.7±49.3 hours, p=0.013) and length of ICU stay (28.7±33.9 hours vs. 41.7±90.4 hours, p=0.018) were significantly shorter than in the control group. The proportions of patients with prolonged mechanical ventilation (2.3% vs. 7.6%, p=0.006), delirium (1.3% vs. 6.3%, p=0.003) and acute kidney injury (1.3% vs. 5.3%, p=0.012) were significantly lower in the intensivist group than in the control group.

Conclusion

A transition from an open ICU model with trainee coverage to a closed ICU model with attending intensivist coverage can be expected to yield improvements in CSICU quality and reductions in postoperative complications.