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Lethongkam S, Sunghan J, Wangdee C, Durongphongtorn S, Siri R, Wunnoo S, Paosen S, Voravuthikunchai SP, Dejyong K, Daengngam C. Biogenic nanosilver-fabricated endotracheal tube to prevent microbial colonization in a veterinary hospital. Appl Microbiol Biotechnol 2023; 107:623-638. [PMID: 36562803 PMCID: PMC9780629 DOI: 10.1007/s00253-022-12327-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/29/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
COVID-19 patients have often required prolonged endotracheal intubation, increasing the risk of developing ventilator-associated pneumonia (VAP). A preventive strategy is proposed based on an endotracheal tube (ETT) modified by the in situ deposition of eucalyptus-mediated synthesized silver nanoparticles (AgNPs). The surfaces of the modified ETT were embedded with AgNPs of approximately 28 nm and presented a nanoscale roughness. Energy dispersive X-ray spectroscopy confirmed the presence of silver on and inside the coated ETT, which exhibited excellent antimicrobial activity against Gram-positive and Gram-negative bacteria, and fungi, including multidrug-resistant clinical isolates. Inhibition of planktonic growth and microbial adhesion ranged from 99 to 99.999% without cytotoxic effects on mammalian cells. Kinetic studies showed that microbial adhesion to the coated surface was inhibited within 2 h. Cell viability in biofilms supplemented with human tracheal mucus was reduced by up to 95%. In a porcine VAP model, the AgNPs-coated ETT prevented adhesion of Pseudomonas aeruginosa and completely inhibited bacterial invasion of lung tissue. The potential antimicrobial efficacy and safety of the coated ETT were established in a randomized control trial involving 47 veterinary patients. The microbial burden was significantly lower on the surface of the AgNPs-coated ETT than on the uncoated ETT (p < 0.05). KEY POINTS: • Endotracheal tube surfaces were modified by coating with green-synthesized AgNPs • P. aeruginosa burden of endotracheal tube and lung was reduced in a porcine model • Effective antimicrobial activity and safety was demonstrated in a clinical trial.
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Affiliation(s)
- Sakkarin Lethongkam
- Division of Biological Science, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
- Natural Product Research Center of Excellence, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
- Center of Antimicrobial Biomaterial Innovation-Southeast Asia, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Jutapoln Sunghan
- Faculty of Veterinary Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Chalika Wangdee
- Department of Veterinary Surgery, Faculty of Veterinary Science, Chulalongkorn University, Henri-dunant, Bangkok, 10330, Thailand
| | - Sumit Durongphongtorn
- Department of Veterinary Surgery, Faculty of Veterinary Science, Chulalongkorn University, Henri-dunant, Bangkok, 10330, Thailand
| | - Ratchaneewan Siri
- Division of Physical Science, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Suttiwan Wunnoo
- Center of Antimicrobial Biomaterial Innovation-Southeast Asia, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Supakit Paosen
- Division of Biological Science, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
- Natural Product Research Center of Excellence, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
- Center of Antimicrobial Biomaterial Innovation-Southeast Asia, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Supayang P Voravuthikunchai
- Division of Biological Science, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
- Natural Product Research Center of Excellence, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
- Center of Antimicrobial Biomaterial Innovation-Southeast Asia, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Krittee Dejyong
- Faculty of Veterinary Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Chalongrat Daengngam
- Division of Physical Science, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
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Horng YT, Wang CJ, Chung WT, Chao HJ, Chen YY, Soo PC. Phosphoenolpyruvate phosphotransferase system components positively regulate Klebsiella biofilm formation. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 51:174-183. [DOI: 10.1016/j.jmii.2017.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/07/2017] [Accepted: 01/24/2017] [Indexed: 02/02/2023]
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Pérez-Granda MJ, Latorre MC, Alonso B, Hortal J, Samaniego R, Bouza E, Guembe M. Eradication of P. aeruginosa biofilm in endotracheal tubes based on lock therapy: results from an in vitro study. BMC Infect Dis 2017; 17:746. [PMID: 29202722 PMCID: PMC5715999 DOI: 10.1186/s12879-017-2856-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/26/2017] [Indexed: 02/08/2023] Open
Abstract
Background Despite the several strategies available for the management of biofilm-associated ventilator-associated pneumonia, data regarding the efficacy of applying antibiotics to the subglottic space (SS) are scarce. We created an in vitro model to assess the efficacy of antibiotic lock therapy (ALT) applied in the SS for eradication of Pseudomonas aeruginosa biofilm in endotracheal tubes (ETTs). Methods We applied 2 h of ALT to a P. aeruginosa biofilm in ETTs using a single dose (SD) and a 5-day therapy model (5D). We used sterile saline lock therapy (SLT) as the positive control. We compared colony count and the percentage of live cells between both models. Results The median (IQR) cfu counts/ml and percentage of live cells in the SD-ALT and SD-SLT groups were, respectively, 3.12 × 105 (9.7 × 104-0) vs. 8.16 × 107 (7.0 × 107-0) (p = 0.05) and 53.2% (50.9%-57.2%) vs. 91.5% (87.3%-93.9%) (p < 0.001). The median (IQR) cfu counts/ml and percentage of live cells in the 5D-ALT and 5D-SLT groups were, respectively, 0 (0-0) vs. 3.2 × 107 (2.32 × 107-0) (p = 0.03) and 40.6% (36.6%-60.0%) vs. 90.3% (84.8%-93.9%) (p < 0.001). Conclusion We demonstrated a statistically significant decrease in the viability of P. aeruginosa biofilm after application of 5D-ALT in the SS. Future clinical studies to assess ALT in patients under mechanical ventilation are needed.
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Affiliation(s)
- María Jesús Pérez-Granda
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | | | - Beatriz Alonso
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Hortal
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Rafael Samaniego
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Confocal Laser Scanning Microscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emilio Bouza
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Guembe
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain. .,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario "Gregorio Marañón", C/. Dr. Esquerdo, 46, 28007, Madrid, Spain.
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Senanayake E, Giri R, Gopal S, Nevill A, Luckraz H. Incidence of endotracheal tube colonization with the use of PneuX endotracheal tubes in patients following cardiac surgery. J Hosp Infect 2017; 95:81-86. [DOI: 10.1016/j.jhin.2016.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/08/2016] [Indexed: 12/01/2022]
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Lebeaux D, Lucet JC, Barbier FS. Nouvelles recommandations pour les infections associées au biofilm : implications en réanimation. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1182-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Høiby N, Bjarnsholt T, Moser C, Bassi G, Coenye T, Donelli G, Hall-Stoodley L, Holá V, Imbert C, Kirketerp-Møller K, Lebeaux D, Oliver A, Ullmann A, Williams C. ESCMID∗ guideline for the diagnosis and treatment of biofilm infections 2014. Clin Microbiol Infect 2015; 21 Suppl 1:S1-25. [DOI: 10.1016/j.cmi.2014.10.024] [Citation(s) in RCA: 451] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 01/22/2023]
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Zolfaghari PS, Wyncoll DLA. The tracheal tube: gateway to ventilator-associated pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:310. [PMID: 21996487 PMCID: PMC3334734 DOI: 10.1186/cc10352] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a major healthcare-associated complication with considerable attributable morbidity, mortality and cost. Inherent design flaws in the standard high-volume low-pressure cuffed tracheal tubes form a major part of the pathogenic mechanism causing VAP. The formation of folds in the inflated cuff leads to microaspiration of pooled oropharyngeal secretions into the trachea, and biofilm formation on the inner surface of the tracheal tube helps to maintain bacterial colonization of the lower airways. Improved design of tracheal tubes with new cuff material and shape have reduced the size and number of these folds, which together with the addition of suction ports above the cuff to drain pooled subglottic secretions leads to reduced aspiration of oropharyngeal secretions. Furthermore, coating tracheal tubes with antibacterial agents reduces biofilm formation and the incidence of VAP. In this Viewpoint article we explore the published data supporting the new tracheal tubes and their potential contribution to VAP prevention strategies. We also propose that it may now be against good medical practice to continue to use a 'standard cuffed tube' given what is already known, and the weight of evidence supporting the use of newer tube designs.
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Affiliation(s)
- Parjam S Zolfaghari
- London Deanery, Guy's and St Thomas' NHS Trust, Lambeth Palace Road, London SE1 7EH, UK.
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9
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Palomar M, Rodríguez P, Nieto M, Sancho S. [Prevention of nosocomial infection in critical patients]. Med Intensiva 2010; 34:523-33. [PMID: 20510481 DOI: 10.1016/j.medin.2010.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 03/10/2010] [Accepted: 03/12/2010] [Indexed: 01/12/2023]
Affiliation(s)
- M Palomar
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebrón, Barcelona, España.
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Activity of a silver-coated endotracheal tube in preclinical models of ventilator-associated pneumonia and a study after extubation*. Crit Care Med 2010; 38:1135-40. [DOI: 10.1097/ccm.0b013e3181cd12b8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ramirez P, Ferrer M, Torres A. Prevention measures for ventilator-associated pneumonia: a new focus on the endotracheal tube. Curr Opin Infect Dis 2007; 20:190-7. [PMID: 17496579 DOI: 10.1097/qco.0b013e328014daac] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to analyze the aspects related to the endotracheal tube which may influence the development of ventilator-associated pneumonia and to review the possible measures of prevention. RECENT FINDINGS The endotracheal tube participates in the pathogenesis of ventilator-associated pneumonia by the elimination of natural defense mechanisms, thereby allowing the entry of bacteria by the aspiration of subglottic secretions or the formation of biofilm on the endotracheal tube. The preventive measures of ventilator-associated pneumonia related to the endotracheal tube include these two mechanisms. It has been suggested that substitution of the endotracheal tube by early tracheostomy may reduce the risk of ventilator-associated pneumonia. SUMMARY Aspiration of the subglottic secretions seems to be an effective measure with little risk; decontamination or exhaustive control of the sealing of the cuff has not demonstrated a positive risk/benefit balance. The causal relationship between biofilm and ventilator-associated pneumonia has not been clearly established. Treatment of the biofilm with antibiotics, changes in the composition of the endotracheal tube or mechanical cleansing have achieved a reduction or elimination of the biofilm but their effect on the incidence of ventilator-associated pneumonia has not been studied. The benefit of early tracheostomy in reducing ventilator-associated pneumonia is still controversial.
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Affiliation(s)
- Paula Ramirez
- Intensive Care Unit, Hospital Universitario La Fe, Valencia, Spain
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Oosterhof JJ, Elving GJ, Stokroos I, van Nieuw Amerongen A, van der Mei HC, Busscher HJ, van Weissenbruch R, Albers FW. The influence of antimicrobial peptides and mucolytics on the integrity of biofilms consisting of bacteria and yeasts as affecting voice prosthetic air flow resistances. BIOFOULING 2003; 19:347-353. [PMID: 14768463 DOI: 10.1080/08927010310001612054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The integrity of biofilms on voice prostheses used to rehabilitate speech in laryngectomized patients causes unwanted increases in airflow resistance, impeding speech. Biofilm integrity is ensured by extracellular polymeric substances (EPS). This study aimed to determine whether synthetic salivary peptides or mucolytics, including N-acetylcysteine and ascorbic acid, influence the integrity of voice prosthetic biofilms. Biofilms were grown on voice prostheses in an artificial throat model and exposed to synthetic salivary peptides, mucolytics and two different antiseptics (chlorhexidine and Triclosan). Synthetic salivary peptides did not reduce the air flow resistance of voice prostheses afterm biofilm formation. Although both chlorhexidine and Triclosan reduced microbial numbers on the prostheses, only the Triclosan-containing positive control reduced the air flow resistance. Unlike ascorbic acid, the mucolytic N-acetylcysteine removed most EPS from the biofilms and induced a decrease in air flow resistance.
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Affiliation(s)
- Janine J Oosterhof
- Department of Biomedical Engineering, University of Groningen, Department of Otorhinolaryngology, University Hospital of Groningen, Groningen, The Netherlands
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Leone M, Albanese J, Antonini F, Nguyen-Michel A, Martin C. Long-term (6-year) effect of selective digestive decontamination on antimicrobial resistance in intensive care, multiple-trauma patients. Crit Care Med 2003; 31:2090-5. [PMID: 12973164 DOI: 10.1097/01.ccm.0000079606.16776.c5] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine whether selective digestive decontamination (SDD) had some negative impact on the bacterial resistance observed in strains isolated from samples from patients receiving nonabsorbable antibiotics and cefazolin. DESIGN Case-control study. SETTING Intensive care unit of a university tertiary-care hospital. PATIENTS Over a 6-yr period, 360 multiple trauma patients (case patients) submitted to SDD were compared with 360 patients not receiving SDD (controls). INTERVENTIONS SDD consisted of polymyxin E, gentamicin, and amphotericin B and was applied on the buccal mucosa and provided in the nares and the stomach. For the first 3 days, systemic cefazolin (1 g three times a day) was provided. Resistance analysis was performed in case patients and controls on samples collected at predetermined intervals. MEASUREMENTS AND MAIN RESULTS SDD was used in a small subset of patients admitted to the intensive care unit (360 of 5987 over the 6-yr study period). A relative overgrowth of gram-positive cocci was observed. Methicillin resistance of Staphylococcus epidermidis was increased (SDD 76%, controls 63%, p <.05) but not that of Staphylococcus aureus (SDD 20%, controls 18%). Resistance of Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter to beta-lactamines and aminoglycosides was the same in SDD patients and controls. CONCLUSIONS When used in a small subset of patients who have been shown to derive benefit from it (patients who have experienced multiple trauma), SDD has a moderate impact on microbial ecology. However, surveillance cultures are indispensable because the absence of resistance to SDD antibiotics determines the long-term safety of the SDD prophylaxis.
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Affiliation(s)
- Marc Leone
- Intensive Care Unit and Trsuma Center, Hospital Nord, Marseilles University Hospital System, Marseilles School of Medicine, France
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McCrory R, Jones DS, Adair CG, Gorman SP. Pharmaceutical strategies to prevent ventilator-associated pneumonia. J Pharm Pharmacol 2003; 55:411-28. [PMID: 12803762 DOI: 10.1211/0022357021035] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The increasing incidence of hospital-acquired (nosocomial) infection is a disturbing phenomenon resulting in significant patient mortality and putting considerable strain on healthcare budgets and personnel. One particularly serious aspect of nosocomial infection is that of ventilator-associated pneumonia (VAP). This arises in patients who receive mechanical ventilation within the intensive care unit. The quoted incidence of VAP varies widely (5-67%) and the reported mortality of patients with VAP is in the range of 24-71%. This review will examine the many factors that account for these wide ranges reported, including the patient population under investigation, the causative organism, the method of diagnosis, interventions employed and preventative strategies. The use of bioactive and drug-impregnated biomaterials for endotracheal tube construction is discussed as novel approaches to the prevention of VAP.
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Affiliation(s)
- Roisin McCrory
- Medical Devices Group, School of Pharmacy, The Queen's University of Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland, UK
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Leone M, Bourgoin A, Giuly E, Antonini F, Dubuc M, Viviand X, Albanèse J, Martin C. Influence on outcome of ventilator-associated pneumonia in multiple trauma patients with head trauma treated with selected digestive decontamination. Crit Care Med 2002; 30:1741-6. [PMID: 12163786 DOI: 10.1097/00003246-200208000-00011] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Ventilator-associated pneumonia is said to be associated with an increased mortality or a prolonged intensive care unit stay. In multiple trauma, the use of selective digestive decontamination has been reported to decrease morbidity and mortality associated with pneumonia. We performed a study to evaluate the attributable morbidity and mortality of ventilator-associated pneumonia in multiple trauma patients with head trauma treated with selective digestive decontamination. DESIGN Prospective, matched-paired, case-control study. SETTING Intensive care unit at a tertiary university hospital. PATIENTS During a 6-yr period, 324 consecutive multiple trauma patients with head trauma requiring mechanical ventilation for >48 hrs were prospectively followed for the development of VAP. Case-control matching criteria were as follows: 1) age difference within 5 yrs, 2) Glasgow coma scale within five categories, 3) injury severity score within 5 points, 4) APACHE II score within 5 points, 5) ventilation of control patients for at least as long as the cases. The selective digestive decontamination regimen was used in all patients (cases and controls): polymixin E, gentamicin, and amphotericin B. Systemic cefazolin (1 g three times a day) was given for the first 3 days of intensive care unit stay. MEASUREMENTS AND MAIN RESULTS Analysis was performed on 58 pairs that were matched with 100% of success The most common isolates recovered were Staphylococcus aureus (39%) and Haemophilus influenzae (22%). High-risk pathogens were rarely isolated: Pseudomonas aeruginosa (5.1%), Acinetobacter species (8.6%), and methicillin-resistant S. aureus (6.7%). The duration of mechanical ventilation and intensive care unit stay were increased in case patients (11.6 +/- 1.7 and 22.7 +/- 2.9 days, respectively) compared with control patients (9.4 +/- 1.3 and 16.8 +/- 2.9 days, respectively; p <.0006). Mortality was similar in both case (17%) and control (24%) patients. CONCLUSION Ventilator-associated pneumonia did not seem to increase mortality of multiple trauma patients with head trauma who received selective digestive decontamination. Whether or not this conclusion applied to trauma patients not receiving selective digestive decontamination should be evaluated in further studies.
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Affiliation(s)
- Marc Leone
- Intensive Care Unit and Trauma Center, Nord Hospital, Marseilles University Hospital System, Marseilles School of Medicine, Marseilles, France.
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Jones DS, McGovern JG, Woolfson AD, Adair CG, Gorman SP. Physicochemical characterization of hexetidine-impregnated endotracheal tube poly(vinyl chloride) and resistance to adherence of respiratory bacterial pathogens. Pharm Res 2002; 19:818-24. [PMID: 12134952 DOI: 10.1023/a:1016104516034] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE Ventilator-associated pneumonia is a frequent cause of mortality in intensive care patients. This study describes the physicochemical properties of hexetidine-impregnated poly(vinyl chloride) (PVC) endotracheal tube (ET) biomaterials and their resistance to microbial adherence (Staphylococcus aureus and Pseudomonas aeruginosa). METHODS PVC emulsion was cured in the presence of hexetidine (0-20% w/w) and was characterized in terms of drug release, surface properties (i.e., microrugosity/contact angle), mechanical (tensile) properties, and resistance to microbial adherence. RESULTS Under sink conditions, hexetidine release from PVC was diffusion-controlled. Increasing the concentration of hexetidine from 1% to 10% (w/w) (but not from 10% to 20% w/w) increased the subsequent rate of drug release. In general, increasing the concentration of hexetidine decreased both the tensile properties and hydrophobicity, yet increased PVC microrugosity. Following hexetidine release (21 days), the surface properties were similar to those of native PVC. The resistance of hexetidine-containing PVC (1% or 5%) to microbial adherence (following defined periods of drug release) was greater than that of native PVC and was constant over the examined period of hexetidine release. CONCLUSIONS ET PVC containing 1% (w/w) hexetidine offered an appropriate balance between suitable physicochemical properties and resistance to microbial adherence. This may offer an approach with which to reduce the incidence of ventilator-associated pneumonia.
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Affiliation(s)
- David S Jones
- Medical Devices Unit, School of Pharmacy, The Queen's University of Belfast, Medical Biology Centre, Northern Ireland, United Kingdom.
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Gorman SP, McGovern JG, Woolfson AD, Adair CG, Jones DS. The concomitant development of poly(vinyl chloride)-related biofilm and antimicrobial resistance in relation to ventilator-associated pneumonia. Biomaterials 2001; 22:2741-7. [PMID: 11545308 DOI: 10.1016/s0142-9612(01)00017-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Ventilator-associated pneumonia is a major cause of death in intensive care patients and the endotracheal tube, commonly fabricated from poly(vinyl chloride) (PVC), is acknowledged as a significant factor in this. Bacteria colonise the biomaterial, thereby adopting a sessile mode of growth that progresses to the establishment of an antibiotic-resistant biofilm by the accretion of a protective glycocalyx. This study examined the sequential steps involved in the formation of biofilm on PVC by atomic force microscopy and the concomitant development of resistance to an antibiotic (ceftazidime) and to a non-antibiotic antimicrobial agent (hexetidine). Staphylococcus aureus and Pseudomonas aeruginosa isolated from ET tube biofilm were employed. The surface microrugosity of bacteria growing in sessile mode on PVC decreased significantly (p < 0.05) over the period 4, 24, 48 h and 5 d. The progressive accretion of bacterial glycocalyx was readily visualised in micrographs leading to a smoother surface topography with time. The minimum inhibitory concentrations (MIC) and minimum bactericidal concentrations (MBC) for ceftazidime and hexetidine against planktonic (suspension) S. aureus were lower than for Ps. aeruginosa. Furthermore, sessile populations of S. aureus and Ps. aeruginosa on PVC exhibited greater resistance to both ceftazidime and hexetidine when compared to planktonic bacterial growth. The efficacy of the agents, determined by kill kinetics, against sessile bacteria was dependent on age, with established biofilms (> or = 24 h) significantly more resistant (p < 0.05) than early sessile populations (< or = 4 h). Importantly, for practice, even newly colonised bacteria (1 h) were significantly more resistant to antibiotic than planktonic bacteria. Hexetidine was significantly more active (p < 0.05) than ceftazidime on biofilms of both isolates, irrespective of age, with total kill within 24 h treatment. Hexetidine may offer promise in the resolution of infection associated with PVC endotracheal tubes.
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Affiliation(s)
- S P Gorman
- Medical Devices Group, School of Pharmacy, Medical Biology Centre, The Queen's University of Belfast, UK.
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Abstract
UNLABELLED VAP is a complex nosocomial infection, the disease expression and resulting patient outcome of which is dependent on host factors, the causative organism, the timing and adequacy of treatment, and the presence of intrinsic or inducible antibiotic resistance. Significant improvements have been achieved in our ability to reduce the occurrence of VAP in the hospital setting. Clinicians caring for mechanically ventilated patients should strive to develop focused programs for the prevention of VAP, other nosocomial infections, and the occurrence of antibiotic-resistant infections at their institutions. The benefits of such programs are well demonstrated. The components of a PDSA (Plan-Do-STUDY-Act) model that can be simply employed to develop a VAP prevention program are as follows: Stages Plan: 1. Identify potentially modifiable risk factors for VAP at the institutional level. 2. Develop a strategy to modify or prevent the occurrence of these risk factors. [figure: see text] Do: 1. Carry out the planned intervention strategy. 2. Identify problems in the implementation of the designed intervention. 3. Update the intervention with solutions for the identified problems. 4. Collect basic data (e.g., VAP rates, severity of illness). STUDY 1. Analyze data. 2. Summarize the results. Act: 1. Determine the overall success or failure of the intervention. 2. Identify potential modifications to improve the intervention strategy. 3. Prepare for next PDSA cycle. Inherent in the development and application of such programs is the concept that they are continuous processes striving to improve clinical performance over time (Fig. 3). At any given institution, the most likely approach to the prevention of NP and VAP will be a multifaceted one, employing interventions aimed at reducing the occurrence of aerodigestive tract colonization with pathogenic bacteria and aspiration. To be successful, such quality improvement programs must be embraced at the institutional level. Only in this way can hospitals hope to successfully reduce their rates of VAP and sustain or improve upon those efforts over time.
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Affiliation(s)
- M H Kollef
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
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van Saene HK, Damjanovic V, Williets T, Mostafa SM, Fox MA, Petros AJ. Pathogenesis of ventilator-associated pneumonia: is the contribution of biofilm clinically significant? J Hosp Infect 1998; 38:231-5. [PMID: 9561475 DOI: 10.1016/s0195-6701(98)90279-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Millsap KW, van der Mei HC, Bos R, Busscher HJ. Adhesive interactions between medically important yeasts and bacteria. FEMS Microbiol Rev 1998; 21:321-36. [PMID: 9532746 DOI: 10.1111/j.1574-6976.1998.tb00356.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Yeasts are being increasingly identified as important organisms in human infections. Adhesive interactions between yeasts and bacteria may contribute to yeast retention at body sites. Methods for studying adhesive interactions between bacterial strains are well known, and range from simple macroscopic methods to flow chamber systems with complex image analysis capabilities. The adhesive interactions between bacteria and yeasts have been studied employing several of the methods originally developed for studying adhesive interactions between bacteria. However, in many of the methods employed the larger size of the yeasts as compared with bacteria results in strong sedimentation of the yeasts, often invalidating the method adapted. In addition, most methods are semi-quantitative and do not properly control mass transport. Consequently, adhesive interaction mechanisms between yeasts and bacteria identified hitherto, including lectin binding and protein-protein interactions, must be regarded with caution. Extensive physico-chemical characteristics of yeast cell surfaces are not available and a physico-chemical mechanism has not yet been put forth. A new method for quantifying adhesive interactions between yeasts and bacteria is proposed, based on the use of a parallel plate flow chamber, in which the influence of adhering bacteria upon the kinetics of yeast adhesion and aggregation of the adhering yeasts is quantitatively evaluated, under carefully controlled mass transport.
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Affiliation(s)
- K W Millsap
- Laboratory for Materia Technica, University of Groningen, The Netherlands.
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McGovern J, Garvin C, Jones D, Woolfson A, Gorman S. Modification of biomaterial surface characteristics by body fluids in vitro. Int J Pharm 1997. [DOI: 10.1016/s0378-5173(97)04883-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jones DS, McGovern JG, Woolfson AD, Gorman SP. Role of physiological conditions in the oropharynx on the adherence of respiratory bacterial isolates to endotracheal tube poly(vinyl chloride). Biomaterials 1997; 18:503-10. [PMID: 9111955 DOI: 10.1016/s0142-9612(96)00170-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pneumonia is a major problem in intensive care patients and can be induced by pathogenic bacteria adhering to poly(vinyl chloride) (PVC) endotracheal (ET) tubes. This study examines the influence of surface properties on the adherence of the respiratory isolates Staphylococcus aureus and Pseudomonas aeruginosa to PVC. In particular, the influence of respiratory tract physiological conditions, 5% CO2 and saliva, on adherence was investigated. In general, decreased adherence to PVC was observed when bacteria were grown in CO2. When these CO2-grown bacteria were treated with saliva their adherence to PVC significantly increased; however, their adherence was significantly reduced to saliva-treated PVC. Treatment of both bacterial isolates with saliva decreased their negative zeta potential, a factor which may directly contribute to the observed increased microbial (saliva pretreated) adherence to PVC. Cell surface hydrophobicity (CSH) was evaluated by measuring the initial rates of microbial removal from a buffered aqueous phase, to ensure the absence of electrostatic interactions, to an organic phase (xylene). Under physiological conditions, CSH did not appear to be a dominant factor in biomaterial adherence as the CSH of S. aureus was decreased by saliva treatment but was unchanged for Ps. aeruginosa. Additionally, CSH also differed for the two isolates when grown in CO2, significantly decreasing with S. aureus but remaining unaltered with Ps. aeruginosa. Saliva treatment of PVC also decreased the advancing and receding contact angles of the biomaterial and its surface roughness, which may be a factor in the decreased adherence of saliva-treated bacteria to this surface. Alternative biomaterials or surface modifications appear necessary for the desired improvements in ET tube effectiveness. This study highlights the influence of physiological conditions on biomaterial and bacterial surface characteristics and subsequent interactions. It is imperative that the physiological conditions predominating in the clinical area of biomaterial use be considered when investigating device biocompatibility.
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Affiliation(s)
- D S Jones
- Pharmaceutical Devices Research Group, School of Pharmacy, Queen's University of Belfast, Northern Ireland, UK
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Gorman SP, Adair CG, Mawhinney WM. Incidence and nature of peritoneal catheter biofilm determined by electron and confocal laser scanning microscopy. Epidemiol Infect 1994; 112:551-9. [PMID: 8005221 PMCID: PMC2271507 DOI: 10.1017/s0950268800051256] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Thirty-two Tenckhoff catheters retrieved from continuous ambulatory peritoneal dialysis patients with a history of peritonitis were examined for microbial biofilm. Confocal laser scanning microscopy was successfully employed to visualize bacteria in biofilm occluded from view by scanning electron microscopy. Occluded but viable microbial biofilm was associated with 17 (81%) catheters from patients free from infection following renal transplant. Mixed isolate biofilm with two or more isolates of coagulase-negative staphylococci or Staphylococcus aureus was found on 41% of these catheters. Clearly visible viable biofilm consisting exclusively of Pseudomonas aeruginosa occurred on all four catheters removed due to recurrent peritonitis. Five (71%) catheters retrieved from patients transferred to haemodialysis had viable biofilm. Antibiotic sensitivities of the biofilm isolates were similar in profile to those reported for non-biofilm isolates from infected dialysate. Persistence of catheter biofilm despite direct contact with therapeutic levels of antibiotics in peritoneal dialysate requires that attention be directed towards improving antibiotic efficacy against peritonitis-causing bacteria in biofilm form.
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Affiliation(s)
- S P Gorman
- School of Pharmacy, Queen's University of Belfast, UK
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