Ventilator-associated pneumonia diagnosis: a prioritization exercise based on multi-criteria decision analysis

Multi-criteria decision analysis method for differential diagnosis of tropical febrile diseases

This paper employs the Analytical Hierarchy Process (AHP) to enhance the accuracy of differential diagnosis for febrile diseases, particularly prevalent in tropical regions where misdiagnosis may have severe consequences. The migration of health workers from developing countries has resulted in frontline health workers (FHWs) using inadequate protocols for the diagnosis of complex health conditions. The study introduces an innovative AHP-based Medical Decision Support System (MDSS) incorporating disease risk factors derived from physicians' experiential knowledge to address this challenge. The system's aggregate diagnostic factor index determines the likelihood of febrile illnesses. Compared to existing literature, AHP models with risk factors demonstrate superior prediction accuracy, closely aligning with physicians' suspected diagnoses. The model's accuracy ranges from 85.4% to 96.9% for various diseases, surpassing physicians' predictions for Lassa, Dengue, and Yellow Fevers. The MDSS is recommended for use by FHWs in communities lacking medical experts, facilitating timely and precise diagnoses, efficient application of diagnostic test kits, and reducing overhead expenses for administrators.

Efficacy of preventive interventions against ventilator-associated pneumonia in critically ill patients: an umbrella review of meta-analyses

Many meta-analyses have assessed the efficacy of preventive interventions against ventilator-associated pneumonia (VAP) in critically ill patients. However, there has been no comprehensive analysis of the strength and quality of evidence to date. Systematic reviews of randomized and quasi-randomized controlled trials, which evaluated the effect of preventive strategies on the incidence of VAP in critically ill patients receiving mechanical ventilation for at least 48 h, were included in this article. We identified a total of 34 interventions derived from 31 studies. Among these interventions, 19 resulted in a significantly reduced incidence of VAP. Among numerous strategies, only selective decontamination of the digestive tract (SDD) was supported by highly suggestive (Class II) evidence (risk ratio (RR)=0.439, 95% CI: 0.362-0.532). Based on data from the sensitivity analysis, the evidence for the efficacy of non-invasive ventilation in weaning from mechanical ventilation (NIV) was upgraded from weak (Class IV) to highly suggestive (Class II) (RR=0.32, 95% CI: 0.22-0.46). All preventive interventions were not supported by robust evidence for reducing mortality. Early mobilization exhibited suggestive (Class III) evidence in shortening both intensive length of stay (LOS) in the intensive care unit (ICU) (mean difference (MD)=-0.85, 95% CI: -1.21 to -0.49) and duration of mechanical ventilation (MD=-1.02, 95% CI: -1.41 to -0.63). In conclusion, SDD and NIV are supported by robust evidence for prevention against VAP, while early mobilization has been shown to significantly shorten the LOS in the ICU and the duration of mechanical ventilation. These three strategies are recommendable for inclusion in the ventilator bundle to lower the risk of VAP and improve the prognosis of critically ill patients.

A Path towards Timely VAP Diagnosis: Proof-of-Concept Study on Pyocyanin Sensing with Cu-Mg Doped Graphene Oxide

In response to the urgent requirement for rapid, precise, and cost-effective detection in intensive care units (ICUs) for ventilated patients, as well as the need to overcome the limitations of traditional detection methods, researchers have turned their attention towards advancing novel technologies. Among these, biosensors have emerged as a reliable platform for achieving accurate and early diagnoses. In this study, we explore the possibility of using Pyocyanin analysis for early detection of pathogens in ventilator-associated pneumonia (VAP) and lower respiratory tract infections in ventilated patients. To achieve this, we developed an electrochemical sensor utilizing a graphene oxide-copper oxide-doped MgO (GO - Cu - Mgo) (GCM) catalyst for Pyocyanin detection. Pyocyanin is a virulence factor in the phenazine group that is produced by Pseudomonas aeruginosa strains, leading to infections such as pneumonia, urinary tract infections, and cystic fibrosis. We additionally investigated the use of DNA aptamers for detecting Pyocyanin as a biomarker of Pseudomonas aeruginosa, a common causative agent of VAP. The results of this study indicated that electrochemical detection of Pyocyanin using a GCM catalyst shows promising potential for various applications, including clinical diagnostics and drug discovery.

Multi-criteria decision analysis for supporting the selection of subclinical mastitis screening tests to use in large- and small-scale dairy farms in Türkiye

The production of high-quality and safe milk is closely associated with the udder health of dairy cows. While there are many mastitis diagnostic tests/methods available, choosing the most appropriate diagnostic test for a sustainable udder health control program could be a challenge. This study was aimed at selecting tests for the screening of subclinical mastitis on small- and large-scale dairy farms in Türkiye, using multi-criteria decision-making methods. An integrated approach employing the analytical hierarchy process (AHP) and technique for order preference by similarity to ideal solution (TOPSIS) together was used to select subclinical mastitis screening tests for on-farm use. While the AHP determines the weights of the evaluation criteria, the TOPSIS provides a final ranking. Nine different subclinical mastitis screening (SCM) methods (DeLaval somatic cell counter, PortaSCC test, California mastitis test (CMT), rapid culture, portable/hand-held electrical conductivity meter, infrared thermography, leukocyte esterase strip test, milk pH, UdderCheck test) were analyzed on the basis of five selection criteria (the market availability of the test, the diagnostic accuracy of the test, the cost of the test, the cow-side use of the test, and the practicality of the test). The selection criteria were determined based on literature review and stakeholder input. The weighting of the criteria with the AHP was based on the pairwise comparison of the criteria by stakeholders. The criteria were weighted from 1 to 9 according to their relative importance as follows: "1: equally important," "3: moderately important," "5: strongly important," "7: very strongly important," "9: extremely important," and "2, 4, 6, 8: intermediate values." Final ranking of SCM tests with the TOPSIS was based on the stakeholder evaluations of fulfillment of the criteria by the alternatives. The most appropriate screening test for both large- and small-scale dairy farms was determined to be the CMT. The CMT is a very useful, easy to perform, and low-cost tool for detecting subclinical mastitis. Being a major element of udder health control programs, the CMT, if regularly used on dairy farms in Türkiye, would enable the culling of chronically infected animals and the reduction of mastitis-associated economic losses. Furthermore, regular CMTs would contribute to reducing milk SCC and improving milk quality. In conclusion, multi-criteria decision-making methods not only provide a systematic approach that may assist both veterinarians and farmers in deciding on the best choice among the different tests available for the screening of subclinical mastitis but also offer potential benefits to policymakers, researchers, and other industry stakeholders.

Evaluation of the Kinetics of Pancreatic Stone Protein as a Predictor of Ventilator-Associated Pneumonia

BACKGROUND

Ventilator-associated pneumonia (VAP) is a severe condition. Early and adequate antibiotic treatment is the most important strategy for improving prognosis. Pancreatic Stone Protein (PSP) has been described as a biomarker that increases values 3-4 days before the clinical diagnosis of nosocomial sepsis in different clinical settings. We hypothesized that serial measures of PSP and its kinetics allow for an early diagnosis of VAP.

METHODS

The BioVAP study was a prospective observational study designed to evaluate the role of biomarker dynamics in the diagnosis of VAP. To determine the association between repeatedly measured PSP and the risk of VAP, we used joint models for longitudinal and time-to-event data.

RESULTS

Of 209 patients, 43 (20.6%) patients developed VAP, with a median time of 4 days. Multivariate joint models with PSP, CRP, and PCT did not show an association between biomarkers and VAP for the daily absolute value, with a hazard ratio (HR) for PSP of 1.01 (95% credible interval: 0.97 to 1.05), for CRP of 1.00 (0.83 to 1.22), and for PCT of 0.95 (0.82 to 1.08). The daily change of biomarkers provided similar results, with an HR for PSP of 1.15 (0.94 to 1.41), for CRP of 0.76 (0.35 to 1.58), and for PCT of 0.77 (0.40 to 1.45).

CONCLUSION

Neither absolute PSP values nor PSP kinetics alone nor in combination with other biomarkers were useful in improving the prediction diagnosis accuracy in patients with VAP.

CLINICAL TRIAL REGISTRATION

Registered retrospectively on August 3rd, 2012. NCT02078999.

Exploring the complex relationship between the lung microbiome and ventilator-associated pneumonia

INTRODUCTION

Understanding the presence and function of a diverse lung microbiome in acute lung infections, particularly ventilator-associated pneumonia (VAP), is still limited, evidencing significant gaps in our knowledge.

AREAS COVERED

In this comprehensive narrative review, we aim to elucidate the contribution of the respiratory microbiome in the development of VAP by examining the current knowledge on the interactions among microorganisms. By exploring these intricate connections, we endeavor to enhance our understanding of the disease's pathophysiology and pave the way for novel ideas and interventions in studying the respiratory tract microbiome.

EXPERT OPINION

The conventional perception of lungs as sterile is deprecated since it is currently recognized the existence of a diverse microbial community within them. However, despite extensive research on the role of the respiratory microbiome in healthy lungs, respiratory chronic diseases and acute lung infections such as pneumonia are not fully understood. It is crucial to investigate further the relationship between the pathophysiology of VAP and the pulmonary microbiome, elucidating the mechanisms underlying the interactions between the microbiome, host immune response and mechanical ventilation for the development of VAP.

Predictive Score for Carbapenem-Resistant Gram-Negative Bacilli Sepsis: Single-Center Prospective Cohort Study

A clinical-epidemiological score to predict CR-GNB sepsis to guide empirical antimicrobial therapy (EAT), using local data, persists as an unmet need. On the basis of a case-case-control design in a prospective cohort study, the predictive factors for CR-GNB sepsis were previously determined as prior infection, use of mechanical ventilation and carbapenem, and length of hospital stay. In this study, each factor was scored according to the logistic regression coefficients, and the ROC curve analysis determined its accuracy in predicting CR-GNB sepsis in the entire cohort. Among the total of 629 admissions followed by 7797 patient-days, 329 single or recurrent episodes of SIRS/sepsis were enrolled, from August 2015 to March 2017. At least one species of CR-GNB was identified as the etiology in 108 (33%) episodes, and 221 were classified as the control group. The cutoff point of ≥3 (maximum of 4) had the best sensitivity/specificity, while ≤1 showed excellent sensitivity to exclude CR-GNB sepsis. The area under the curve was 0.80 (95% CI: 0.76-0.85) and the number needed to treat was 2.0. The score may improve CR-GNB coverage and spare polymyxins with 22% (95% CI: 17-28%) adequacy rate change. The score has a good ability to predict CR-GNB sepsis and to guide EAT in the future.

Management of pneumonia in critically ill patients

Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.

Procalcitonin as a biomarker for ventilator associated pneumonia in COVID-19 patients: Is it an useful stewardship tool?

Ventilator associated pneumonia(VAP) is a severe complication that can lead to high mortality when not early identified or when therapy is delayed. The aim of this study was to evaluate procalcitonin(PCT) as a biomarker for VAP development. In total, 73 hospitalized patients with COVID-19 were analyzed. PCT levels greater than 0.975ng/mL were more related to VAP. No association was found for C-reactive protein (CRP). The results show that procalcitonin may be a pertinent biomarker for VAP diagnosis and can be a helpful tool for antibiotic withdrawal.

Nosocomial Pneumonia in the Era of Multidrug-Resistance: Updates in Diagnosis and Management

Nosocomial pneumonia (NP), including hospital-acquired pneumonia in non-intubated patients and ventilator-associated pneumonia, is one of the most frequent hospital-acquired infections, especially in the intensive care unit. NP has a significant impact on morbidity, mortality and health care costs, especially when the implicated pathogens are multidrug-resistant ones. This narrative review aims to critically review what is new in the field of NP, specifically, diagnosis and antibiotic treatment. Regarding novel imaging modalities, the current role of lung ultrasound and low radiation computed tomography are discussed, while regarding etiological diagnosis, recent developments in rapid microbiological confirmation, such as syndromic rapid multiplex Polymerase Chain Reaction panels are presented and compared with conventional cultures. Additionally, the volatile compounds/electronic nose, a promising diagnostic tool for the future is briefly presented. With respect to NP management, antibiotics approved for the indication of NP during the last decade are discussed, namely, ceftobiprole medocaril, telavancin, ceftolozane/tazobactam, ceftazidime/avibactam, and meropenem/vaborbactam.

Nosocomial pneumonia diagnosis revisited

PURPOSE OF REVIEW

Nosocomial pneumonia represents a significant burden even for the most resilient healthcare systems. Timely and reliable diagnosis is critical but remains a deficient field. This review critically revises the latest literature on the diagnosis of nosocomial pneumonia, including advances in imaging techniques, as well as the utility of rapid microbiological tests in establishing the etiological diagnosis.

RECENT FINDINGS

Studies on low radiation computed tomography (CT) and lung ultrasound (LUS) have shown promising results for early nosocomial pneumonia diagnosis; however, further data on their sensitivity and specificity are needed, especially for picking up subtle and nonspecific radiographic findings. Moreover, data supporting their superiority in pneumonia diagnosis is still limited. As for microbiological diagnosis, several culture-independent molecular diagnostic techniques have been developed, identifying both causative microorganisms as well as determinants of antimicrobial resistance, but more studies are needed to delineate their role in nosocomial pneumonia diagnosis.

SUMMARY

The development of nonculture dependent tests has launched a new era in microbiological nosocomial pneumonia diagnosis. These modalities along with the use of LUS and/or low radiation CT might improve the sensitivity and specificity of nosocomial pneumonia diagnosis, enhance early detection and guide the antimicrobial therapy but more studies are needed to further evaluate them and determine their role for the routine clinical practice.

Quality of evidence supporting Surviving Sepsis Campaign Recommendations

Introduction

The Surviving Sepsis Campaign (SSC) guidelines, released in 2017, are a combination of expert opinion and evidence-based medicine, adopted by many institutions as a standard of practice. The aim was to analyse the quality of evidence supporting recommendations on the management of sepsis.

Methods

The strength and quality of evidence (high, moderate, low-very low and best practice statements) of each recommendation were extracted. Randomised controlled trials were required to qualify as high-quality evidence.

Results

A total of 96 recommendations were formulated, and 87 were included. Among thirty-one (43%) strong recommendations, only 15.2% were supported by high-quality evidence. Overall, thirty-seven (42.5%) recommendations were based on low-quality evidence, followed by 28 (32.2%) based on moderate-quality, 15 (17.2%) were best practice statements and only seven (8.0%) were supported by high-quality evidence. Randomised controlled trials supported 21.4%, 9.5% and 8.6% recommendations on mechanical ventilation, resuscitation, and management/adjuvant therapy, respectively. In contrast, none high-quality evidence recommendation supported antimicrobial/source control (82.4% were low-very low evidence or best practice statements), and nutrition.

Conclusions

In the SSC guidelines most recommendations were informed by indirect evidence and non-systematic observations. While awaiting trials results, Delphi-like approaches or multi-criteria decision analyses should guide recommendations.