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Guillamet CV, Kollef MH. Is Zero Ventilator-Associated Pneumonia Achievable? Updated Practical Approaches to Ventilator-Associated Pneumonia Prevention. Infect Dis Clin North Am 2024; 38:65-86. [PMID: 38040518 DOI: 10.1016/j.idc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions took pride in implementing effective VAP prevention bundles that combined at least head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. Spontaneous breathing and awakening trials have also consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP.
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Affiliation(s)
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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Hurley J. Indirect (herd) effects of topical antibiotic prophylaxis and oral care versus non-antimicrobial methods increase mortality among ICU patients: realigning Cochrane review data to emulate a three-tier cluster randomised trial. BMJ Open 2023; 13:e064256. [PMID: 38035749 PMCID: PMC10689355 DOI: 10.1136/bmjopen-2022-064256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/19/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVE This study aimed to estimate the direct effects to recipients and indirect (herd) effects to non-recipients of each of topical antibiotic prophylaxis (TAP) and oral care methods on patient mortality within randomised concurrent controlled trials (RCCT) using Cochrane review data. DESIGN Control and intervention groups from 209 RCCTs of TAP (tier 3), oral care (tier 2) each versus non-antimicrobial (tier 1) ventilator-associated pneumonia (VAP) prevention interventions arranged to emulate a three-tiered cluster randomised trial (CRT). Eligible RCCTs were those including ICU patients with >50% of patients receiving >24 hours of mechanical ventilation (MV) with mortality data available as abstracted in 13 Cochrane reviews. EXPOSURES Direct and indirect exposures to either TAP or oral care within RCCTs versus non-antimicrobial VAP prevention interventions. MAIN OUTCOMES AND MEASURES The ICU mortality within control and intervention groups, respectively, within RCCTs of either TAP or oral care versus that within non-antimicrobial VAP prevention RCCTs serving as benchmark. RESULTS The ICU mortality was 23.9%, 23.0% and 20.3% for intervention groups and 28.7%, 25.5% and 19.5% for control groups of RCCTs of TAP (tier 1), oral care (tier 2) and non-antimicrobial (tier 3) methods of VAP prevention, respectively. In a random effects meta-regression including late mortality data and adjusting for group mean age, year of study publication and MV proportion, the direct effect of TAP and oral care versus non-antimicrobial methods were 1.04 (95% CI 0.78 to 1.30) and 1.1 (95% CI 0.77 to 1.43) whereas the indirect effects were 1.39 (95% CI 1.03 to 1.74) and 1.26 (95% CI 0.89 to 1.62), respectively. CONCLUSIONS Indirect (herd) effects from TAP and oral care methods on mortality are stronger than the direct effects as made apparent by the three-tiered CRT. These indirect effects, being harmful to concurrent control groups by increasing mortality, perversely inflate the appearance of benefit within RCCTs.
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Affiliation(s)
- James Hurley
- Melbourne Medical School, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
- Internal Medicine Service, Ballarat Health Services, Grampians Health, Ballarat, Victoria, Australia
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Tejerina-Álvarez EE, de la Cal López MÁ. Selective decontamination of the digestive tract: concept and application. Med Intensiva 2023; 47:603-615. [PMID: 37858367 DOI: 10.1016/j.medine.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/20/2023] [Indexed: 10/21/2023]
Abstract
Selective digestive decontamination (SDD) is a prophylactic strategy aimed at preventing or eradicating bacterial overgrowth in the intestinal flora that precedes the development of most infections in the Intensive Care Unit. SDD prevents serious infections, reduces mortality, is cost-effective, has no adverse effects, and its short- or long-term use is not associated with any significant increase in antimicrobial resistance. SDD is one of the most widely evaluated interventions in critically ill patients, yet its use is not widespread. The present article offers a narrative review of the most relevant evidence and an update of the pathophysiological concepts of infection control supporting the use of SDD.
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Affiliation(s)
- Eva Esther Tejerina-Álvarez
- Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain.
| | - Miguel Ángel de la Cal López
- Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo, Getafe, Madrid, Spain.
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Hurley JC. Staphylococcus aureus hitchhiking from colonization to bacteremia via Candida within ICU infection prevention studies: a proof of concept modelling. Eur J Clin Microbiol Infect Dis 2023; 42:543-554. [PMID: 36877261 PMCID: PMC10105687 DOI: 10.1007/s10096-023-04573-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/13/2023] [Indexed: 03/07/2023]
Abstract
Whether Candida within the patient microbiome drives the pathogenesis of Staphylococcus aureus bacteremia, described as microbial hitchhiking, cannot be directly studied. Group-level observations from studies of various decontamination and non-decontamination-based ICU infection prevention interventions and studies without study interventions (observational groups) collectively enable tests of this interaction within causal models. Candidate models of the propensity for Staphylococcus aureus bacteremia to arise with versus without various antibiotic, anti-septic, and antifungal exposures, each identified as singleton exposures, were tested using generalized structural equation modelling (GSEM) techniques with Candida and Staphylococcus aureus colonization appearing as latent variables within the models. Each model was tested by confrontation against blood and respiratory isolate data, obtained from 467 groups within 284 infection prevention studies. Introducing an interaction term between Candida colonization and Staphylococcus aureus colonization substantially improved GSEM model fit. Model-derived coefficients for singular exposure to anti-septic agents (- 1.28; 95% confidence interval; - 2.05 to - 0.5), amphotericin (- 1.49; - 2.3 to - 0.67), and topical antibiotic prophylaxis (TAP; + 0.93; + 0.15 to + 1.71) as direct effects versus Candida colonization were similar in magnitude but contrary in direction. By contrast, the coefficients for singleton exposure to TAP, as with anti-septic agents, versus Staphylococcus colonization were weaker or non-significant. Topical amphotericin would be predicted to halve both candidemia and Staphylococcus aureus bacteremia incidences versus literature derived benchmarks for absolute differences of < 1 percentage point. Using ICU infection prevention data, GSEM modelling validates the postulated interaction between Candida and Staphylococcus colonization facilitating bacteremia.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia. .,Division of Internal Medicine, Grampians Health Ballarat, PO Box 577, Ballarat, VIC, 3353, Australia.
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Ecological effects of selective oral decontamination on multidrug-resistance bacteria acquired in the intensive care unit: a case-control study over 5 years. Intensive Care Med 2022; 48:1165-1175. [PMID: 35953676 PMCID: PMC9463265 DOI: 10.1007/s00134-022-06826-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022]
Abstract
Purpose This case–control study investigated the long-term evolution of multidrug-resistant bacteria (MDRB) over a 5-year period associated with the use of selective oropharyngeal decontamination (SOD) in the intensive care unit (ICU). In addition, effects on health care-associated infections and ICU mortality were analysed. Methods We investigated patients undergoing mechanical ventilation > 48 h in 11 adult ICUs located at 3 campuses of a university hospital. Administrative, clinical, and microbiological data which were routinely recorded electronically served as the basis. We analysed differences in the rates and incidence densities (ID, cases per 1000 patient-days) of MDRB associated with SOD use in all patients and stratified by patient origin (outpatient or inpatient). After propensity score matching, health-care infections and ICU mortality were compared. Results 5034 patients were eligible for the study. 1694 patients were not given SOD. There were no differences in the incidence density of MDRB when SOD was used, except for more vancomycin-resistant Enterococcus faecium (0.72/1000 days vs. 0.31/1000 days, p < 0.01), and fewer ESBL-producing Klebsiella pneumoniae (0.22/1000 days vs. 0.56/1000 days, p < 0.01). After propensity score matching, SOD was associated with lower incidence rates of ventilator-associated pneumonia and death in the ICU but not with ICU-acquired bacteremia or urinary tract infection. Conclusions Comparisons of the ICU-acquired MDRB over a 5-year period revealed no differences in incidence density, except for lower rate of ESBL-producing Klebsiella pneumoniae and higher rate of vancomycin-resistant Enterococcus faecium with SOD. Incidence rates of ventilator-associated pneumonia and death in the ICU were lower in patients receiving SOD. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06826-7.
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COVID-19 Secondary Infections in ICU Patients and Prevention Control Measures: A Preliminary Prospective Multicenter Study. Antibiotics (Basel) 2022; 11:antibiotics11081016. [PMID: 36009884 PMCID: PMC9405068 DOI: 10.3390/antibiotics11081016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022] Open
Abstract
The incidence of secondary infections in critically ill coronavirus disease 2019 (COVID-19) patients is worrisome. We investigated whether selective digestive decontamination (SDD) added to infection control measures during an intensive care unit (ICU) stay modified these infection rates. Methods: A retrospective observational cohort study was carried out in four ICUs in Spain. All consecutive ventilated patients with a SARS-CoV-2 infection engaged in national infection control programs between 1 March and 10 December 2020 were investigated. Patients were grouped into two cohorts according to the site of ICU admission. Secondary relevant infections were included. Infection densities corresponding to ventilator-associated pneumonia (VAP), catheter bacteremia, secondary bacteremia, and multi-resistant germs were obtained as the number of events per 1000 days of exposure and were compared between SDD and non-SDD groups using Poisson regression. Factors that had an independent association with mortality were identified using multidimensional logistic analysis. Results: There were 108 patients in the SDD cohort and 157 in the non-SDD cohort. Patients in the SDD cohort showed significantly lower rates (p < 0.001) of VAP (1.9 vs. 9.3 events per 1000 ventilation days) and MDR infections (0.57 vs. 2.28 events per 1000 ICU days) and a non-significant reduction in secondary bacteremia (0.6 vs. 1.41 events per 1000 ICU days) compared with those in the non-SDD cohort. Infections caused by MDR pathogens occurred in 5 patients in the SDD cohort and 21 patients in the non-SDD cohort (p = 0.006). Differences in mortality according to SDD were not found. Conclusion: The implementation of SDD in infection control programs significantly reduced the incidence of VAP and MDR infections in critically ill SARS-CoV-2 infected patients.
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Szychowiak P, Villageois-Tran K, Patrier J, Timsit JF, Ruppé É. The role of the microbiota in the management of intensive care patients. Ann Intensive Care 2022; 12:3. [PMID: 34985651 PMCID: PMC8728486 DOI: 10.1186/s13613-021-00976-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/15/2021] [Indexed: 12/13/2022] Open
Abstract
The composition of the gut microbiota is highly dynamic and changes according to various conditions. The gut microbiota mainly includes difficult-to-cultivate anaerobic bacteria, hence knowledge about its composition has significantly arisen from culture-independent methods based on next-generation sequencing (NGS) such as 16S profiling and shotgun metagenomics. The gut microbiota of patients hospitalized in intensive care units (ICU) undergoes many alterations because of critical illness, antibiotics, and other ICU-specific medications. It is then characterized by lower richness and diversity, and dominated by opportunistic pathogens such as Clostridioides difficile and multidrug-resistant bacteria. These alterations are associated with an increased risk of infectious complications or death. Specifically, at the time of writing, it appears possible to identify distinct microbiota patterns associated with severity or infectivity in COVID-19 patients, paving the way for the potential use of dysbiosis markers to predict patient outcomes. Correcting the microbiota disturbances to avoid their consequences is now possible. Fecal microbiota transplantation is recommended in recurrent C. difficile infections and microbiota-protecting treatments such as antibiotic inactivators are currently being developed. The growing interest in the microbiota and microbiota-associated therapies suggests that the control of the dysbiosis could be a key factor in the management of critically ill patients. The present narrative review aims to provide a synthetic overview of microbiota, from healthy individuals to critically ill patients. After an introduction to the different techniques used for studying the microbiota, we review the determinants involved in the alteration of the microbiota in ICU patients and the latter's consequences. Last, we assess the means to prevent or correct microbiota alteration.
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Affiliation(s)
- Piotr Szychowiak
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional Universitaire de Tours, 37000, Tours, France
| | - Khanh Villageois-Tran
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Laboratoire de Bactériologie, AP-HP, Hôpital Beaujon, 92110, Paris, France
| | - Juliette Patrier
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Jean-François Timsit
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Étienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.
- Laboratoire de Bactériologie, AP-HP, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018, Paris, France.
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Elderman JH, Ong DSY, van der Voort PHJ, Wils EJ. Anti-infectious decontamination strategies in Dutch intensive care units: A survey study on contemporary practice and heterogeneity. J Crit Care 2021; 64:262-269. [PMID: 34052572 DOI: 10.1016/j.jcrc.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Despite increasing evidence and updated national guidelines, practice of anti-infectious strategies appears to vary in the Netherlands. This study aimed to determine the variation of current practices of anti-infectious strategies in Dutch ICUs. MATERIALS AND METHODS In 2018 and 2019 an online survey of all Dutch ICUs was conducted with detailed questions on their anti-infectious strategies. RESULTS 89% (63 of 71) of the Dutch ICUs responded to the online survey. The remaining ICUs were contacted by telephone. 47 (66%) of the Dutch ICUs used SDD, 14 (20%) used SOD and 10 (14%) used neither SDD nor SOD. Within these strategies considerable heterogeneity was observed in the start criteria of SDD/SOD, the regimen adjustments based on microbiological surveillance and the monitoring of the interventions. CONCLUSIONS The proportion of Dutch ICUs applying SDD or SOD increased over time. Considerable heterogeneity in the regimens was reported. The impact of the observed differences within SDD and SOD practices on clinical outcome remains to be explored.
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Affiliation(s)
- J H Elderman
- Department of Intensive Care, IJsselland Hospital, Capelle aan den IJssel, the Netherlands; Department of Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - D S Y Ong
- Department of Medical Microbiology and Infection Control, Franciscus Gasthuis & Vlietland Hospital, Rotterdam, the Netherlands; Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P H J van der Voort
- Department of Critical Care, University Medical Center Groningen, Groningen, the Netherlands
| | - E-J Wils
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Intensive Care, Franciscus Gasthuis & Vlietland Hospital, Rotterdam, the Netherlands
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Wittekamp BH, Plantinga NL. Less daily oral hygiene is more in the ICU: no. Intensive Care Med 2021; 47:331-333. [PMID: 33558968 PMCID: PMC7870028 DOI: 10.1007/s00134-021-06359-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Bastiaan H Wittekamp
- Intensive Care, Ziekenhuisgroep Twente (Hospital Group Twente), Almelo, The Netherlands.
| | - Nienke L Plantinga
- Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Hurley JC. How the Cluster-randomized Trial "Works". Clin Infect Dis 2021; 70:341-346. [PMID: 31260511 DOI: 10.1093/cid/ciz554] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/29/2019] [Indexed: 11/13/2022] Open
Abstract
Cluster-randomized trials (CRTs) are able to address research questions that randomized controlled trials (RCTs) of individual patients cannot answer. Of great interest for infectious disease physicians and infection control practitioners are research questions relating to the impact of interventions on infectious disease dynamics at the whole-of-population level. However, there are important conceptual differences between CRTs and RCTs relating to design, analysis, and inference. These differences can be illustrated by the adage "peas in a pod." Does the question of interest relate to the "peas" (the individual patients) or the "pods" (the clusters)? Several examples of recent CRTs of community and intensive care unit infection prevention interventions are used to illustrate these key concepts. Examples of differences between the results of RCTs and CRTs on the same topic are given.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Australia.,Division of Internal Medicine, Ballarat Health Services, Australia
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Abstract
Supplemental Digital Content is available in the text. Objectives: To compare methods to adjust for confounding by disease severity during multicenter intervention studies in ICU, when different disease severity measures are collected across centers. Design: In silico simulation study using national registry data. Setting: Twenty mixed ICUs in The Netherlands. Subjects: Fifty-five–thousand six-hundred fifty-five ICU admissions between January 1, 2011, and January 1, 2016. Interventions: None. Measurements and Main Results: To mimic an intervention study with confounding, a fictitious treatment variable was simulated whose effect on the outcome was confounded by Acute Physiology and Chronic Health Evaluation IV predicted mortality (a common measure for disease severity). Diverse, realistic scenarios were investigated where the availability of disease severity measures (i.e., Acute Physiology and Chronic Health Evaluation IV, Acute Physiology and Chronic Health Evaluation II, and Simplified Acute Physiology Score II scores) varied across centers. For each scenario, eight different methods to adjust for confounding were used to obtain an estimate of the (fictitious) treatment effect. These were compared in terms of relative (%) and absolute (odds ratio) bias to a reference scenario where the treatment effect was estimated following correction for the Acute Physiology and Chronic Health Evaluation IV scores from all centers. Complete neglect of differences in disease severity measures across centers resulted in bias ranging from 10.2% to 173.6% across scenarios, and no commonly used methodology—such as two-stage modeling or score standardization—was able to effectively eliminate bias. In scenarios where some of the included centers had (only) Acute Physiology and Chronic Health Evaluation II or Simplified Acute Physiology Score II available (and not Acute Physiology and Chronic Health Evaluation IV), either restriction of the analysis to Acute Physiology and Chronic Health Evaluation IV centers alone or multiple imputation of Acute Physiology and Chronic Health Evaluation IV scores resulted in the least amount of relative bias (0.0% and 5.1% for Acute Physiology and Chronic Health Evaluation II, respectively, and 0.0% and 4.6% for Simplified Acute Physiology Score II, respectively). In scenarios where some centers used Acute Physiology and Chronic Health Evaluation II, regression calibration yielded low relative bias too (relative bias, 12.4%); this was not true if these same centers only had Simplified Acute Physiology Score II available (relative bias, 54.8%). Conclusions: When different disease severity measures are available across centers, the performance of various methods to control for confounding by disease severity may show important differences. When planning multicenter studies, researchers should make contingency plans to limit the use of or properly incorporate different disease measures across centers in the statistical analysis.
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Abstract
PURPOSE OF REVIEW In the last 2 years, two major guidelines for the management of nosocomial pneumonia have been published: The International European Respiratory Society/European Society of Intensive Care Medicine/European Society of Clinical Microbiology and Infectious Diseases/Asociación Latinoamericana de Toráx guidelines for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) and the American guidelines for management of adults with HAP and VAP; both the guidelines made important clinical recommendations for the management of patients. RECENT FINDINGS With the increasing emergence of multidrug resistant (MDR) organisms, paired with a relative reduction in new antibiotic development, nosocomial infections have become one of the most significant issues affecting global healthcare today. Despite several stark differences between the European and American guidelines, they are in agreement about many aspects of nosocomial pneumonia management. SUMMARY American and European guidelines promote prompt and appropriate empiric treatment which is immediately guided by local microbiological data, followed by an adequate de-escalation protocol based on culture results with a 1-week course of treatment. Both also questioned the use of biomarkers in HAP/VAP, whether as part of the diagnosis or daily assessment of patients. On the contrary, they have conflicting views in regards to the optimum method of diagnosis, the risk factors used to stratify patients, the use of clinical scoring systems and the various antibiotic classes used. All were presented with varying levels of evidence to support these differences in opinion, indicating that further research into these areas is required before a consensus can be agreed upon.
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Frencken JF, Wittekamp BHJ, Plantinga NL, Spitoni C, van de Groep K, Cremer OL, Bonten MJM. Associations Between Enteral Colonization With Gram-Negative Bacteria and Intensive Care Unit-Acquired Infections and Colonization of the Respiratory Tract. Clin Infect Dis 2019; 66:497-503. [PMID: 29186403 DOI: 10.1093/cid/cix824] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/14/2017] [Indexed: 01/25/2023] Open
Abstract
Background Enteral and respiratory tract colonization with gram-negative bacteria may lead to subsequent infections in critically ill patients. We aimed to clarify the interdependence between gut and respiratory tract colonization and their associations with intensive care unit (ICU)-acquired infections in patients receiving selective digestive tract decontamination (SDD). Methods Colonization status of the rectum and respiratory tract was determined using twice-weekly microbiological surveillance in mechanically ventilated subjects receiving SDD between May 2011 and June 2015 in a tertiary medical-surgical ICU in the Netherlands. Acquisition of infections was monitored daily by dedicated observers. Marginal structural models were used to determine the associations between gram-negative rectal colonization and respiratory tract colonization, ICU-acquired gram-negative infection, and ICU-acquired gram-negative bacteremia. Results Among 2066 ICU admissions, 1157 (56.0%) ever had documented gram-negative carriage in the rectum during ICU stay. Cumulative incidences of ICU-acquired gram-negative infection and bacteremia were 6.0% (n = 124) and 2.1% (n = 44), respectively. Rectal colonization was an independent risk factor for both respiratory tract colonization (cause-specific hazard ratio [CSHR], 2.93 [95% confidence interval {CI}, 2.02-4.23]) and new gram-negative infection in the ICU (CSHR, 3.04 [95% CI, 1.99-4.65]). Both rectal and respiratory tract colonization were associated with bacteremia (CSHR, 7.37 [95% CI, 3.25-16.68] and 2.56 [95% CI, 1.09-6.03], respectively). Similar associations were observed when Enterobacteriaceae and glucose nonfermenting gram-negative bacteria were analyzed separately. Conclusions Gram-negative rectal colonization tends to be stronger associated with subsequent ICU-acquired gram-negative infections than gram-negative respiratory tract colonization. Gram-negative rectal colonization seems hardly associated with subsequent ICU-acquired gram-negative respiratory tract colonization.
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Affiliation(s)
- Jos F Frencken
- Julius Center for Health Sciences and Primary Care
- Department of Intensive Care Medicine, University Medical Center Utrecht
| | | | | | | | - Kirsten van de Groep
- Julius Center for Health Sciences and Primary Care
- Department of Intensive Care Medicine, University Medical Center Utrecht
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care
- Department of Medical Microbiology, University Medical Center Utrecht, The Netherlands
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van Hout D, Plantinga NL, Bruijning-Verhagen PC, Oostdijk EAN, de Smet AMGA, de Wit GA, Bonten MJM, van Werkhoven CH. Cost-effectiveness of selective digestive decontamination (SDD) versus selective oropharyngeal decontamination (SOD) in intensive care units with low levels of antimicrobial resistance: an individual patient data meta-analysis. BMJ Open 2019; 9:e028876. [PMID: 31494605 PMCID: PMC6731916 DOI: 10.1136/bmjopen-2018-028876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To determine the cost-effectiveness of selective digestive decontamination (SDD) as compared to selective oropharyngeal decontamination (SOD) in intensive care units (ICUs) with low levels of antimicrobial resistance. DESIGN Post-hoc analysis of a previously performed individual patient data meta-analysis of two cluster-randomised cross-over trials. SETTING 24 ICUs in the Netherlands. PARTICIPANTS 12 952 ICU patients who were treated with ≥1 dose of SDD (n=6720) or SOD (n=6232). INTERVENTIONS SDD versus SOD. PRIMARY AND SECONDARY OUTCOME MEASURES The incremental cost-effectiveness ratio (ICER; ie, costs to prevent one in-hospital death) was calculated by comparing differences in direct healthcare costs and in-hospital mortality of patients treated with SDD versus SOD. A willingness-to-pay curve was plotted to reflect the probability of cost-effectiveness of SDD for a range of different values of maximum costs per prevented in-hospital death. RESULTS The ICER resulting from the fixed-effect meta-analysis, adjusted for clustering and differences in baseline characteristics, showed that SDD significantly reduced in-hospital mortality (adjusted absolute risk reduction 0.0195, 95% CI 0.0050 to 0.0338) with no difference in costs (adjusted cost difference €62 in favour of SDD, 95% CI -€1079 to €935). Thus, SDD yielded significantly lower in-hospital mortality and comparable costs as compared with SOD. At a willingness-to-pay value of €33 633 per one prevented in-hospital death, SDD had a probability of 90.0% to be cost-effective as compared with SOD. CONCLUSION In Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD. These data support the implementation of SDD in settings with low levels of antimicrobial resistance.
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Affiliation(s)
- Denise van Hout
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
| | - Nienke L Plantinga
- University Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Patricia C Bruijning-Verhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
- Center for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Evelien A N Oostdijk
- University Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Marie G A de Smet
- University Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Marc J M Bonten
- University Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Cornelis H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
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15
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Vazquez Guillamet C, Kollef MH. Is Zero Ventilator-Associated Pneumonia Achievable?: Practical Approaches to Ventilator-Associated Pneumonia Prevention. Clin Chest Med 2019; 39:809-822. [PMID: 30390751 DOI: 10.1016/j.ccm.2018.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions implemented effective VAP prevention bundles that combined head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. More recently, spontaneous breathing and awakening trials have consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP. More recent data question the overall positive impact of prevention bundles, including some of their core component interventions.
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Affiliation(s)
- Cristina Vazquez Guillamet
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, 2425 Camino de Salud, Albuquerque, NM 87106, USA; Division of Infectious Diseases, University of New Mexico School of Medicine, 2425 Camino de Salud, Albuquerque, NM 87106, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St Louis, MO 63110, USA.
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16
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Vandenbroucke-Grauls CMJE, van der Meer JWM. Decontamination of Oral or Digestive Tract for Patients in the Intensive Care Unit. JAMA 2018; 320:2081-2083. [PMID: 30347049 DOI: 10.1001/jama.2018.13764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christina M J E Vandenbroucke-Grauls
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medical Microbiology and Infection Control, Amsterdam Infection & Immunity Institute, Amsterdam, the Netherlands
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17
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Wittekamp BH, Plantinga NL, Cooper BS, Lopez-Contreras J, Coll P, Mancebo J, Wise MP, Morgan MPG, Depuydt P, Boelens J, Dugernier T, Verbelen V, Jorens PG, Verbrugghe W, Malhotra-Kumar S, Damas P, Meex C, Leleu K, van den Abeele AM, Gomes Pimenta de Matos AF, Fernández Méndez S, Vergara Gomez A, Tomic V, Sifrer F, Villarreal Tello E, Ruiz Ramos J, Aragao I, Santos C, Sperning RHM, Coppadoro P, Nardi G, Brun-Buisson C, Bonten MJM. Decontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients: A Randomized Clinical Trial. JAMA 2018; 320:2087-2098. [PMID: 30347072 PMCID: PMC6583563 DOI: 10.1001/jama.2018.13765] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/02/2018] [Indexed: 12/24/2022]
Abstract
Importance The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown. Objective To determine associations between CHX 2%, SOD, and SDD and the occurrence of ICU-acquired bloodstream infections with multidrug-resistant gram-negative bacteria (MDRGNB) and 28-day mortality in ICUs with moderate to high levels of antibiotic resistance. Design, Setting, and Participants Randomized trial conducted from December 1, 2013, to May 31, 2017, in 13 European ICUs where at least 5% of bloodstream infections are caused by extended-spectrum β-lactamase-producing Enterobacteriaceae. Patients with anticipated mechanical ventilation of more than 24 hours were eligible. The final date of follow-up was September 20, 2017. Interventions Standard care was daily CHX 2% body washings and a hand hygiene improvement program. Following a baseline period from 6 to 14 months, each ICU was assigned in random order to 3 separate 6-month intervention periods with either CHX 2% mouthwash, SOD (mouthpaste with colistin, tobramycin, and nystatin), or SDD (the same mouthpaste and gastrointestinal suspension with the same antibiotics), all applied 4 times daily. Main Outcomes and Measures The occurrence of ICU-acquired bloodstream infection with MDRGNB (primary outcome) and 28-day mortality (secondary outcome) during each intervention period compared with the baseline period. Results A total of 8665 patients (median age, 64.1 years; 5561 men [64.2%]) were included in the study (2251, 2108, 2224, and 2082 in the baseline, CHX, SOD, and SDD periods, respectively). ICU-acquired bloodstream infection with MDRGNB occurred among 144 patients (154 episodes) in 2.1%, 1.8%, 1.5%, and 1.2% of included patients during the baseline, CHX, SOD, and SDD periods, respectively. Absolute risk reductions were 0.3% (95% CI, -0.6% to 1.1%), 0.6% (95% CI, -0.2% to 1.4%), and 0.8% (95% CI, 0.1% to 1.6%) for CHX, SOD, and SDD, respectively, compared with baseline. Adjusted hazard ratios were 1.13 (95% CI, 0.68-1.88), 0.89 (95% CI, 0.55-1.45), and 0.70 (95% CI, 0.43-1.14) during the CHX, SOD, and SDD periods, respectively, vs baseline. Crude mortality risks on day 28 were 31.9%, 32.9%, 32.4%, and 34.1% during the baseline, CHX, SOD, and SDD periods, respectively. Adjusted odds ratios for 28-day mortality were 1.07 (95% CI, 0.86-1.32), 1.05 (95% CI, 0.85-1.29), and 1.03 (95% CI, 0.80-1.32) for CHX, SOD, and SDD, respectively, vs baseline. Conclusions and Relevance Among patients receiving mechanical ventilation in ICUs with moderate to high antibiotic resistance prevalence, use of CHX mouthwash, SOD, or SDD was not associated with reductions in ICU-acquired bloodstream infections caused by MDRGNB compared with standard care. Trial Registration ClinicalTrials.gov Identifier: NCT02208154.
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Affiliation(s)
- Bastiaan H. Wittekamp
- Intensive Care Center and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Nienke L. Plantinga
- Medical Microbiology and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ben S. Cooper
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, England
| | - Joaquin Lopez-Contreras
- Infectious Diseases–Internal Medicine, Hospital de Sant Pau-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pere Coll
- Department of Microbiology, Hospital de Sant Pau-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Mancebo
- Department of Intensive Care, Hospital de Sant Pau-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matt P. Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, Wales
| | | | - Pieter Depuydt
- Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Jerina Boelens
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Thierry Dugernier
- Department of Intensive Care Medicine, Clinique Saint Pierre, Ottignies-Louvain-la-Neuve, Belgium
| | - Valérie Verbelen
- Microbiology Department, Clinique Saint Pierre, Ottignies-Louvain-la-Neuve, Belgium
| | - Philippe G. Jorens
- IntensiveCare Medicine, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Walter Verbrugghe
- IntensiveCare Medicine, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine, & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Pierre Damas
- Department of Intensive Care Medicine, CHU Liège, Liege, Belgium
| | - Cécile Meex
- Clinical Microbiology, CHU Liège, Liege, Belgium
| | - Kris Leleu
- Anesthesiology and Critical Care, AZ Sint Jan Bruges, Bruges, Belgium
| | | | | | | | | | - Viktorija Tomic
- Laboratory for Respiratory Microbiology, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Franc Sifrer
- Intensive Care Unit, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | | | - Jesus Ruiz Ramos
- Intensive Care Unit, Hospital Universitario La Fe, Valencia, Spain
| | - Irene Aragao
- Intensive Care (UCIP), Hospital Santo Antonio–Centro Hospitalar do Porto (CHP), Porto, Portugal
| | - Claudia Santos
- Microbiology Laboratory, Hospital Santo Antonio–Centro Hospitalar do Porto (CHP), Porto, Portugal
| | | | - Patrizia Coppadoro
- Intensive Care Unit, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Giuseppe Nardi
- Department of Anesthesia and Intensive Care, Ospedale Infermi RIMINI–AUSL della Romagna, Rimini, Italy
| | - Christian Brun-Buisson
- Medical Intensive Care and Infection Control Unit, CHU Henri Mondor & University Paris Est Créteil, Paris, France
| | - Marc J. M. Bonten
- Medical Microbiology and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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18
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Wittekamp BH, Plantinga NL, Cooper BS, Lopez-Contreras J, Coll P, Mancebo J, Wise MP, Morgan MPG, Depuydt P, Boelens J, Dugernier T, Verbelen V, Jorens PG, Verbrugghe W, Malhotra-Kumar S, Damas P, Meex C, Leleu K, van den Abeele AM, Gomes Pimenta de Matos AF, Fernández Méndez S, Vergara Gomez A, Tomic V, Sifrer F, Villarreal Tello E, Ruiz Ramos J, Aragao I, Santos C, Sperning RHM, Coppadoro P, Nardi G, Brun-Buisson C, Bonten MJM. Decontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients: A Randomized Clinical Trial. JAMA 2018. [PMID: 30347072 DOI: 10.1001/jama.2018.13765sanchezramirezcc2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
IMPORTANCE The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown. OBJECTIVE To determine associations between CHX 2%, SOD, and SDD and the occurrence of ICU-acquired bloodstream infections with multidrug-resistant gram-negative bacteria (MDRGNB) and 28-day mortality in ICUs with moderate to high levels of antibiotic resistance. DESIGN, SETTING, AND PARTICIPANTS Randomized trial conducted from December 1, 2013, to May 31, 2017, in 13 European ICUs where at least 5% of bloodstream infections are caused by extended-spectrum β-lactamase-producing Enterobacteriaceae. Patients with anticipated mechanical ventilation of more than 24 hours were eligible. The final date of follow-up was September 20, 2017. INTERVENTIONS Standard care was daily CHX 2% body washings and a hand hygiene improvement program. Following a baseline period from 6 to 14 months, each ICU was assigned in random order to 3 separate 6-month intervention periods with either CHX 2% mouthwash, SOD (mouthpaste with colistin, tobramycin, and nystatin), or SDD (the same mouthpaste and gastrointestinal suspension with the same antibiotics), all applied 4 times daily. MAIN OUTCOMES AND MEASURES The occurrence of ICU-acquired bloodstream infection with MDRGNB (primary outcome) and 28-day mortality (secondary outcome) during each intervention period compared with the baseline period. RESULTS A total of 8665 patients (median age, 64.1 years; 5561 men [64.2%]) were included in the study (2251, 2108, 2224, and 2082 in the baseline, CHX, SOD, and SDD periods, respectively). ICU-acquired bloodstream infection with MDRGNB occurred among 144 patients (154 episodes) in 2.1%, 1.8%, 1.5%, and 1.2% of included patients during the baseline, CHX, SOD, and SDD periods, respectively. Absolute risk reductions were 0.3% (95% CI, -0.6% to 1.1%), 0.6% (95% CI, -0.2% to 1.4%), and 0.8% (95% CI, 0.1% to 1.6%) for CHX, SOD, and SDD, respectively, compared with baseline. Adjusted hazard ratios were 1.13 (95% CI, 0.68-1.88), 0.89 (95% CI, 0.55-1.45), and 0.70 (95% CI, 0.43-1.14) during the CHX, SOD, and SDD periods, respectively, vs baseline. Crude mortality risks on day 28 were 31.9%, 32.9%, 32.4%, and 34.1% during the baseline, CHX, SOD, and SDD periods, respectively. Adjusted odds ratios for 28-day mortality were 1.07 (95% CI, 0.86-1.32), 1.05 (95% CI, 0.85-1.29), and 1.03 (95% CI, 0.80-1.32) for CHX, SOD, and SDD, respectively, vs baseline. CONCLUSIONS AND RELEVANCE Among patients receiving mechanical ventilation in ICUs with moderate to high antibiotic resistance prevalence, use of CHX mouthwash, SOD, or SDD was not associated with reductions in ICU-acquired bloodstream infections caused by MDRGNB compared with standard care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02208154.
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Affiliation(s)
- Bastiaan H Wittekamp
- Intensive Care Center and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Nienke L Plantinga
- Medical Microbiology and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ben S Cooper
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, England
| | - Joaquin Lopez-Contreras
- Infectious Diseases-Internal Medicine, Hospital de Sant Pau-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pere Coll
- Department of Microbiology, Hospital de Sant Pau-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Mancebo
- Department of Intensive Care, Hospital de Sant Pau-Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, Wales
| | - Matt P G Morgan
- Adult Critical Care, University Hospital of Wales, Cardiff, Wales
| | - Pieter Depuydt
- Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Jerina Boelens
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Thierry Dugernier
- Department of Intensive Care Medicine, Clinique Saint Pierre, Ottignies-Louvain-la-Neuve, Belgium
| | - Valérie Verbelen
- Microbiology Department, Clinique Saint Pierre, Ottignies-Louvain-la-Neuve, Belgium
| | - Philippe G Jorens
- IntensiveCare Medicine, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Walter Verbrugghe
- IntensiveCare Medicine, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine, & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Pierre Damas
- Department of Intensive Care Medicine, CHU Liège, Liege, Belgium
| | - Cécile Meex
- Clinical Microbiology, CHU Liège, Liege, Belgium
| | - Kris Leleu
- Anesthesiology and Critical Care, AZ Sint Jan Bruges, Bruges, Belgium
| | | | | | | | | | - Viktorija Tomic
- Laboratory for Respiratory Microbiology, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Franc Sifrer
- Intensive Care Unit, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | | | - Jesus Ruiz Ramos
- Intensive Care Unit, Hospital Universitario La Fe, Valencia, Spain
| | - Irene Aragao
- Intensive Care (UCIP), Hospital Santo Antonio-Centro Hospitalar do Porto (CHP), Porto, Portugal
| | - Claudia Santos
- Microbiology Laboratory, Hospital Santo Antonio-Centro Hospitalar do Porto (CHP), Porto, Portugal
| | - Roberta H M Sperning
- Department of Microbiology, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Patrizia Coppadoro
- Intensive Care Unit, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Giuseppe Nardi
- Department of Anesthesia and Intensive Care, Ospedale Infermi RIMINI-AUSL della Romagna, Rimini, Italy
| | - Christian Brun-Buisson
- Medical Intensive Care and Infection Control Unit, CHU Henri Mondor & University Paris Est Créteil, Paris, France
| | - Marc J M Bonten
- Medical Microbiology and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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19
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Antipathy against SDD is justified: We are not sure. Intensive Care Med 2018; 44:1174-1176. [DOI: 10.1007/s00134-018-5198-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/25/2018] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW To summarize and contextualize recent evidence on preventing ventilator-associated pneumonia (VAP). RECENT FINDINGS Many centers continue to report dramatic decreases in VAP rates after implementing ventilator bundles. Interpreting these reports is complicated, however, by the subjectivity and lack of specificity of VAP definitions. More objective data suggest VAP rates may not have meaningfully changed over the past decade. If so, this compels us to re-examine and revise the prevention bundles we have been using to prevent VAP. New analyses suggest that most hospitals' ventilator bundles include a mix of helpful and potentially harmful elements. Spontaneous awakening trials, spontaneous breathing trials, head-of-bed elevation, and thromboprophylaxis appear beneficial. Oral chlorhexidine and stress ulcer prophylaxis may be harmful. Subglottic secretion drainage, probiotics, and novel endotracheal cuff designs do not clearly improve objective outcomes. Selective digestive decontamination by contrast appears to lower VAP and mortality rates. Effective implementation is as important as choosing the right bundle components. Best practices include engaging and educating staff, creating structures that facilitate bundle adherence, and providing regular feedback on process measure performance and outcome rates. SUMMARY VAP rates may still be elevated despite multiple reports to the contrary. Recent evidence suggests new ways to optimize the selection of ventilator bundle components and their implementation.
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van Meenen DMP, van der Hoeven SM, Binnekade JM, de Borgie CAJM, Merkus MP, Bosch FH, Endeman H, Haringman JJ, van der Meer NJM, Moeniralam HS, Slabbekoorn M, Muller MCA, Stilma W, van Silfhout B, Neto AS, ter Haar HFM, Van Vliet J, Wijnhoven JW, Horn J, Juffermans NP, Pelosi P, Gama de Abreu M, Schultz MJ, Paulus F. Effect of On-Demand vs Routine Nebulization of Acetylcysteine With Salbutamol on Ventilator-Free Days in Intensive Care Unit Patients Receiving Invasive Ventilation: A Randomized Clinical Trial. JAMA 2018; 319:993-1001. [PMID: 29486489 PMCID: PMC5885882 DOI: 10.1001/jama.2018.0949] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE It remains uncertain whether nebulization of mucolytics with bronchodilators should be applied for clinical indication or preventively in intensive care unit (ICU) patients receiving invasive ventilation. OBJECTIVE To determine if a strategy that uses nebulization for clinical indication (on-demand) is noninferior to one that uses preventive (routine) nebulization. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial enrolling adult patients expected to need invasive ventilation for more than 24 hours at 7 ICUs in the Netherlands. INTERVENTIONS On-demand nebulization of acetylcysteine or salbutamol (based on strict clinical indications, n = 471) or routine nebulization of acetylcysteine with salbutamol (every 6 hours until end of invasive ventilation, n = 473). MAIN OUTCOMES AND MEASURES The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for a difference between groups of -0.5 days. Secondary outcomes included length of stay, mortality rates, occurrence of pulmonary complications, and adverse events. RESULTS Nine hundred twenty-two patients (34% women; median age, 66 (interquartile range [IQR], 54-75 years) were enrolled and completed follow-up. At 28 days, patients in the on-demand group had a median 21 (IQR, 0-26) ventilator-free days, and patients in the routine group had a median 20 (IQR, 0-26) ventilator-free days (1-sided 95% CI, -0.00003 to ∞). There was no significant difference in length of stay or mortality, or in the proportion of patients developing pulmonary complications, between the 2 groups. Adverse events (13.8% vs 29.3%; difference, -15.5% [95% CI, -20.7% to -10.3%]; P < .001) were more frequent with routine nebulization and mainly related to tachyarrhythmia (12.5% vs 25.9%; difference, -13.4% [95% CI, -18.4% to -8.4%]; P < .001) and agitation (0.2% vs 4.3%; difference, -4.1% [95% CI, -5.9% to -2.2%]; P < .001). CONCLUSIONS AND RELEVANCE Among ICU patients receiving invasive ventilation who were expected to not be extubated within 24 hours, on-demand compared with routine nebulization of acetylcysteine with salbutamol did not result in an inferior number of ventilator-free days. On-demand nebulization may be a reasonable alternative to routine nebulization. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02159196.
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Affiliation(s)
- David M. P. van Meenen
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
| | | | - Jan M. Binnekade
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
| | | | - Maruschka P. Merkus
- Clinical Research Unit, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Frank H. Bosch
- Department of Intensive Care, Rijnstate, Arnhem, the Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | | | - Hazra S. Moeniralam
- Department of Intensive Care, Antonius Hospital, Nieuwegein, the Netherlands
| | - Mathilde Slabbekoorn
- Department of Intensive Care, Haaglanden Medical Center, The Hague, the Netherlands
| | | | - Willemke Stilma
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Bart van Silfhout
- Department of Intensive Care, Antonius Hospital, Nieuwegein, the Netherlands
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Jan Van Vliet
- Department of Intensive Care, Rijnstate, Arnhem, the Netherlands
| | | | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus; Technische Universität Dresden, Dresden, Germany
| | - Marcus J. Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, the Netherlands
- Mahidol Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
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Plantinga NL, Bonten MJM. Selective digestive and oropharyngeal decontamination in medical and surgical ICU patients: authors' reply. Clin Microbiol Infect 2017; 24:552-553. [PMID: 28993168 DOI: 10.1016/j.cmi.2017.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 11/15/2022]
Affiliation(s)
- N L Plantinga
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - M J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
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23
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Baskin PK, Mink JW, Gross RA. Correcting honest pervasive errors in the scientific literature. Neurology 2017; 89:11-13. [DOI: 10.1212/wnl.0000000000004106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Bos LD, Stips C, Schouten LR, van Vught LA, Wiewel MA, Wieske L, van Hooijdonk RT, Straat M, de Beer FM, Glas GJ, Visser CE, de Jonge E, Juffermans NP, Horn J, Schultz MJ. Selective decontamination of the digestive tract halves the prevalence of ventilator-associated pneumonia compared to selective oral decontamination. Intensive Care Med 2017; 43:1535-1537. [PMID: 28497272 DOI: 10.1007/s00134-017-4838-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Lieuwe D Bos
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory for Experimental Intensive Care & Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands. .,Department of Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands.
| | - Cheryl Stips
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Laura R Schouten
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Maryse A Wiewel
- Department of Medical Microbiology, Academic Medical Center, Amsterdam, The Netherlands.,Center for Experimental and Molecular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Luuk Wieske
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Roosmarijn T van Hooijdonk
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marleen Straat
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Friso M de Beer
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory for Experimental Intensive Care & Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
| | - Gerie J Glas
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Caroline E Visser
- Department of Medical Microbiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory for Experimental Intensive Care & Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Mailstop at M0-127, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory for Experimental Intensive Care & Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
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