Nosocomial sinusitis with isolation of anaerobic bacteria in ICU patients

The Relationship of Paranasal Sinus Opacification to Hospital-Acquired Pneumonia in the Neurologic Intensive Care Unit Patient

BACKGROUND

The association between intensive care unit (ICU) sinusitis and the development of lower airway infections remains unclear. The objective of this study was to determine the correlation between the development of radiographic sinus opacification and pneumonia in the neurologic ICU setting.

METHODS

A retrospective review of head computed tomography or magnetic resonance imaging of 612 patients admitted to the neurocritical care unit at a tertiary care center from April 2013 through April 2014 was performed. Paranasal sinus opacification was measured using Lund-Mackay scores (LMS). A diagnosis of pneumonia was determined by the ICU team from radiographic, laboratory, and pulmonary data. Exclusion criteria included a history of endonasal surgery, sinonasal malignancy, facial fractures, ICU admission less than 3 days, or inadequate imaging.

RESULTS

Worsening sinus opacification occurred in 42.6% of patients and pneumonia in 18.5% of patients during ICU admission. Of the patients who developed pneumonia, 71.7% also developed worsening sinus opacification (P < .001). In 80.2% of cases, the sinus opacification developed prior to the diagnosis of pneumonia. The mean highest LMS for patients who developed pneumonia was 4.24 compared to 1.99 in patients who did not develop pneumonia (P < .001). Sinus air-fluid levels or complete sinus opacification occurred in a larger proportion of patients who developed pneumonia (46.9% vs 19.4%, P < .001). Mortality rates for patients with no pneumonia or sinusitis, pneumonia only, sinusitis only, and sinusitis with pneumonia were 7.6%, 15.6%, 18.3%, and 25.9%, respectively (P < .001).

CONCLUSIONS

This study finds a strong relationship between worsening sinus opacification in the neurologic ICU patient to the development of hospital-acquired pneumonia and increased mortality.

Microbial biofilms and gastrointestinal diseases

The majority of bacteria live not planktonically, but as residents of sessile biofilm communities. Such populations have been defined as 'matrix-enclosed microbial accretions, which adhere to both biological and nonbiological surfaces'. Bacterial formation of biofilm is implicated in many chronic disease states. Growth in this mode promotes survival by increasing community recalcitrance to clearance by host immune effectors and therapeutic antimicrobials. The human gastrointestinal (GI) tract encompasses a plethora of nutritional and physicochemical environments, many of which are ideal for biofilm formation and survival. However, little is known of the nature, function, and clinical relevance of these communities. This review summarizes current knowledge of the composition and association with health and disease of biofilm communities in the GI tract.

Safety of sphenoid aspiration for diagnosis and treatment of intensive care unit rhinosinusitis

BACKGROUND

In intensive care units (ICUs), critically ill patients may be exposed to several risk factors for developing acute rhinosinusitis, including nasogastric tubes, mechanical ventilation, and prolonged periods in the supine position. The incidence of acute rhinosinusitis can be as high as 83%, the third or fourth most frequent ICU infection and it increases the risk of developing ventilator-associated pneumonia. Diagnosis and therapeutic approaches should be more aggressive than in non-ICU patients. Antral puncture plays a central role in the diagnosis and treatment of these patients. This study was designed to show the development of a method for sphenoid puncture in the diagnosis and treatment of acute infectious rhinosinusitis in critically ill patients, analyzing safety and complications.

METHODS

Patients in ICUs with endoscopic and radiological diagnosis of acute rhinosinusitis were included. Maxillary puncture was performed through the inferior meatus; sphenoid puncture was performed by endoscopic identification of the sphenoethmoidal recess. An aspiration probe was introduced into the natural sphenoidal ostium, followed by aspiration of secretions and saline irrigation.

RESULTS

Twenty-nine patients were included. Twenty-seven patients (93.1%) presented with sphenoidal sinusitis, 24 patients (82.7%) had maxillary sinusitis, 21 patients (72.4%) had ethmoidal sinusitis, and 13 patients (44.8%) had frontal sinusitis. Forty-seven sphenoidal and 39 maxillary punctures were performed. No major bleeding or other complications were recorded.

CONCLUSION

The sphenoid puncture is a possible procedure to be performed in an ICU and might complement the paranasal puncture in cases of acute rhinosinusitis.

Ventilator-Associated Pneumonia

The area of the alveolar epithelium of the lung is approximately 70 m². This area is constantly in contact with the ambient air and is therefore vulnerable to contamination with airborne microbes and particles of respirable size. Due to the configuration of the respiratory tract, airborne particles having diameters in the range of 0.5-2.0 μ can reach and deposit in the terminal part of the tracheobronchial tree - most bacteria are of this size. In reality, very few bacteria cause infections by spreading via the airborne route (e.g., mycobacteria, viruses, and legionella). Most bacteria cause pneumonia by first colonizing the upper respiratory tract and later descending into the tracheobronchial tree.

Sinusitis nosocomial en la Unidad de Cuidados Intensivos: incidencia, características clínicas y evolución

OBJECTIVE

To describe incidence, epidemiologic characteristics, clinical manifestations, tomographic features, microbiologic findings and evolution of patients with nosocomial sinusitis (NS) in an Intensive Care Unit (ICU).

DESIGN

Retrospective and descriptive study.

SETTING

24-bed ICU from a public hospital.

PATIENTS

Patients admitted to the ICU for more than 48 hours who fulfilled CDC criteria of NS.

RESULTS

We found 18 cases of NS, that accounts for an incidence of 1.1% of all admitted patients. Average age was 46.3 +/- 18.3 years, with a predominance of males (89%): Average APACHE II was 20.2 +/- 6.3. All the cases had endotracheal intubation and 89% had a nasogastric tube. All the patients had fever and 83% purulent rhinorrhea or oral secretions. The maxillary sinus was the most affected (72%) followed by ethmoidal sinus (67%). A total of 66% of the patients had other SN associated infectious complications. ICU mortality was 5% and hospital mortality was 33%.

CONCLUSIONS

NS incidence in this study was low, but the risk of infectious complications was high.

Transnasal puncture based on echographic sinusitis evidence in mechanically ventilated patients with suspicion of nosocomial maxillary sinusitis

OBJECTIVE

The aim of this prospective study was to evaluate the value of sinus echography results to directly indicate a transnasal puncture in intubated patients with suspicion of nosocomial maxillary sinusitis.

DESIGN

prospective clinical investigation.

SETTING

medical intensive care unit.

PATIENTS

sixty patients undergoing intubation and mechanical ventilation more than 2 days, with a clinical suspicion of maxillary sinusitis with purulent nasal discharge.

INTERVENTIONS

120 sinuses were examined by sinus ultrasound. The image defined as normal was an acoustic shadow arising from the front wall. Two levels of positive echography were described: (1) a partial sinusogram was defined as the visualization of the hyperechogenic posterior wall of the sinus; and (2) a complete sinusogram was defined as the hyperechogenic visualization of posterior wall and the extension by the internal and external walls of the sinus. When sinus ultrasound was positive, a transnasal puncture was performed the same day. The transnasal puncture was positive if a fluid was obtained from sinus aspiration. The transnasal puncture was negative if there was no aspirated material.

MEASUREMENTS AND RESULTS

sinus ultrasound was positive in 84 cases (54 complete sinusograms and 30 partial sinusograms). Seventy-eight of 84 transnasal punctures were positive. Sensitivity of a sinusogram for obtaining positive transnasal puncture was 100%, and specificity was 86% (100% in case of complete sinusogram) in a clinically selected population. The only six negative transnasal punctures were performed in patients with partial sinusogram.

CONCLUSIONS

Ultrasound sinusitis evidence seems to be of value to indicate and perform a transnasal puncture directly, avoiding CT exam.

Prevention of nosocomial maxillary sinusitis in the ICU: the effects of topically applied α-adrenergic agonists and corticosteroids

OBJECTIVE

We investigated the efficacy of locally applied nasal decongestant agents and corticosteroids for preventing nosocomial maxillary sinusitis in mechanically ventilated patients with multiple trauma.

DESIGN AND SETTING

A prospective, open-label randomized study in two intensive care units (ICUs).

PATIENTS

79 consecutive multiple trauma patients admitted to the ICU who were expected to be mechanically ventilated for more than 3 days.

INTERVENTIONS

Patients were randomly assigned to receive either a combination of a locally applied nasal decongestant agents: 2 drops twice/day of xylometazoline nasal solution 0.1% and 100microg budesonide (NDCA group, n=39) or placebo (control group, n=40).

MEASUREMENTS

For the diagnosis of radiological maxillary sinusitis patients underwent paranasal computed tomography within 48h of admission and thereafter every 4-7 days. Infectious maxillary sinusitis was diagnosed by microbiological analysis of fluid aspirated after transnasal puncture of maxillary sinuses.

RESULTS

Radiological maxillary sinusitis was detected in 54% of patients in the NDCA group (n=21) but in 82% of controls (p<0.01), and infectious maxillary sinusitis in 8% of the NDCA group (n=3) but in 20% of controls (n=8; p=0.11). The most common pathogen micro-organisms identified from maxillary aspirates were Acinetobacter (32%) followed by anaerobes (21%).

CONCLUSION

Our results indicate that the combination of locally applied xylometazoline hydrochloride and budesonide reduces the incidence of radiological maxillary sinusitis and may reduce also that of nosocomial maxillary sinusitis in mechanically ventilated patients with multiple trauma.

Nonresolving Pneumonia

Uncertainty over the expected clinical course of a community-acquired or nosocomial pneumonia is a common reason for pulmonary consultation. Determining which patients with prolonged pneumonia and at what point during therapy they should undergo further evaluation can be challenging. This article reviews "normal" resolution times for the most common pneumonias, risk factors for delayed resolution, and infectious and noninfectious conditions that can cause nonresolving pneumonia. An approach to the evaluation of the patient with this common problem is described.

Sinusitis and fever of unknown origin

It is relatively uncommon to document sinusitis as a cause of fever with much certainty. Therefore, investigation for sinusitis should be undertaken only after more likely causes have been excluded. and the actions taken should reflect the individual patient's circumstances. Aggressive evaluation and treatment should be geared to minimizing the patient's overall morbidity and to identifying the more aggressive forms of sinusitis and their potential complications.

Treatment failures in patients with ventilator-associated pneumonia

Treatment failures in patients with VAP are a complex issue and form a major challenge for clinicians. The following key elements inherent to a rational approach to treatment failures have been elucidated: (1) the presence of treatment failure must be thoroughly defined and assessed; (2) the many causes behind treatment failures must be realized, particularly the possibility of pneumonia-related and extrapulmonary reasons; (3) the recognition of different patterns of treatment failures as a useful framework for decisions about modalities and intensity of diagnostic reassessment; and (4) the establishment of a protocol for the search of pulmonary and extrapulmonary sites of infection and noninfectious causes of nonresponse. Only such a rational approach precludes the adverse effects of blind empiricism, which always implies a dangerous and costly overtreatment. Many issues related to treatment failures remain unsettled, and efforts will have to be made in the future to improve current clinical attitudes to treatment failures in VAP.

Hospital-acquired pneumonia: etiologic considerations

The development of pneumonia requires the pathogen to reach the alveoli and the host defenses to be overwhelmed, either by microorganism virulence or by inoculums size. The endogenous sources of microorganisms are nasal carriers, sinusitis, mouth, oropharynx, gastric, or tracheal colonization, and hematogenous spread. The exogenous sources of microorganisms are biofilm of the tracheal tube, ventilator circuits, nebulizers, and humidifiers. Health care workers may also play a role in this setting. Different microorganisms can be found depending on the onset time of pneumonia and on the local pattern variation encountered between different institutions and countries. Healthy patients may be chronically colonized. A very important, unresolved issue is the definition of early and late-onset pneumonia; it still remains uncertain from the literature whether the given threshold refers to the number of days in hospital or to the number of days following intubation. Noninvasive ventilation is demonstrating that the term "ventilator-associated pneumonia" is perhaps inaccurate and should be referred to as "intubation-associated pneumonia."

A rational approach to the evaluation and treatment of the infected patient in the intensive care unit

Critically ill patients are at increased risk of acquiring nosocomial infections. A thorough clinical evaluation and the selection of appropriate diagnostic techniques are important elements in the evaluation of these patients. Nonetheless, this selection process can be difficult because of the wide spectrum of disease that is seen in the ICU and the lack of standardized studies that have evaluated the different diagnostic methods that are available. Many different antimicrobials are available for the treatment of ICU-acquired infections. Most antimicrobial regimens have not been evaluated in large-scale, prospective, randomized trials. Until this information is available, the clinician must make an effort to be familiar with the different clinical and epidemiologic variables that can be used to stratify patients at the moment of selecting antimicrobial therapy. The information provided in this article, used in association with good clinical judgment, will help the critical care physician provide optimal initial management of the infected patient in the ICU.

Long-term complications of artificial airways

In summary, long-term complications of artificial airways are rare but important sequelae of artificial airways. Many of the potential long-term complications of translaryngeal intubation and tracheotomy are similar and overlapping. Although most patients who undergo these procedures tend to tolerate them without difficulties, significant morbidity and mortality may occur. Identifying the exact cause of the complication may not be possible at times, due to the multiple risk factors involved in the pathogenesis. It is hoped that understanding these potential complications will lead to a more vigilant preventive measures during the institution of long-term artificial airways and a judicious early search for the underlying pathology when a complication is suspected.

Molecular analysis of bacterial flora associated with chronically inflamed maxillary sinuses

Chronic maxillary sinusitis is a chronic inflammatory condition in which the role of microbial infection remains undefined. Bacteria have been isolated from chronically inflamed sinuses; however, their role in the chronicity of inflammation is unknown. The objective of this study was to determine whether bacteria are present in clinical samples from chronic maxillary sinusitis and to assess the diversity of the flora present. Washes and/or tissue samples from endoscopic sinus surgery on 11 patients with chronic maxillary sinusitis were subjected to PCR amplification of bacterial 16S rDNA using three universal primer pairs, followed by cloning and sequencing. The samples were also assessed for the presence of bacteria and fungi by conventional culture methods. Viable bacteria and/or bacterial 16S rDNA were detected from maxillary sinus samples of five of the 11 patients examined (45 %). Three sinus samples were positive by both PCR and culture methods, one was positive only by PCR, and one only by culture. Thirteen bacterial species were identified: Abiotrophia defectiva, Enterococcus avium, Eubacterium sp., Granulicatella elegans, Neisseria sp., Prevotella sp., Pseudomonas aeruginosa, Serratia marcescens, Staphylococcus aureus, Stenotrophomonas maltophilia, Streptococcus gordonii, Streptococcus mitis/Streptococcus oralis and Streptococcus sp. Fungi were not detected. In one patient Streptococcus mitis/Streptococcus oralis, and in another patient Pseudomonas aeruginosa, were detected from both the sinus and the oral cavity using species-specific PCR primers. These results suggest that both aerobic and anaerobic bacteria can be detected in nearly half of chronic maxillary sinusitis cases.

Otolaryngologic critical care

In this chapter we have reviewed the complicated medical conditions that exist in many head and neck surgical patients. Common surgical procedures that frequently require postoperative monitoring and several infectious disorders requiring intensive care unit admission were also reviewed. Intensivists need to be familiar with these procedures and diseases. Collaboration with the surgical specialist is required to optimize patient care.

Ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. When fiberoptic bronchoscopy is not available to physicians treating patients clinically suspected of having VAP, we recommend using either a simplified nonbronchoscopic diagnostic procedure or following a strategy in which decisions regarding antibiotic therapy are based on a clinical score constructed from seven variables. Selection of the initial antimicrobial therapy should be based on predominant flora responsible for VAP at each institution, clinical setting, information provided by direct examination of pulmonary secretions, and intrinsic antibacterial activities of antimicrobial agents and their pharmacokinetic characteristics. Further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.

Infection control in the ICU

Nosocomial infections (NIs) now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to ICUs. The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices. This overview is targeted at ICU physicians to convince them that the principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. The principles of general preventive measures such as the implementation of standard and isolation precautions, and the control of antibiotic use are reviewed. Specific practical measures, targeted at the practical prevention and control of ventilator-associated pneumonia, sinusitis, and bloodstream, urinary tract, and surgical site infections are detailed. Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care.

Value of antral puncture in the intensive care patient with fever of unknown origin

OBJECTIVE

To evaluate the use of maxillary sinus puncture as a routine diagnostic procedure to exclude or confirm purulent sinusitis in intensive care unit (ICU) patients presenting with fever or a septic state of unknown origin.

STUDY DESIGN

Retrospective.

METHODS

All patients admitted to the ICU at the University Hospital Ghent who required ENT examination to exclude acute sinusitis as possible cause of their otherwise inexplicable fever or septic state underwent maxillary sinus puncture via the inferior meatus. The results of clinical examination and the relation between the presence of foreign bodies (e.g., nasogastric tubes) and culture results from the middle meatus and sinuses were analyzed.

RESULTS

One hundred five punctures were performed in 53 patients. Macroscopic purulent effusions were obtained from 25 and nonpurulent effusions from 19 sinuses. The presence of a nasogastric tube did not influence puncture results but significantly increased colonization of the middle meatus. Staphylococcus aureus and Gram-negative agents were frequently cultured from sinus aspirates. Although purulent secretions often reveal no growth, most patients present with a multibacterial (40%) or monobacterial (28%) infection. Simple anterior rhinoscopy reduces the need for antral puncture. Only 8% of punctures in patients with a normal clinical examination were positive.

CONCLUSIONS

Antral puncture proves to be a simple, fast, safe, inexpensive, and effective procedure for immediate diagnosis of acute nosocomial sinusitis in ICU patients and is therefore recommended as first procedure in these patients, even when only minor clinical abnormalities are present.