Is Zero Ventilator-Associated Pneumonia Achievable?: Practical Approaches to Ventilator-Associated Pneumonia Prevention

Constructing a Nomogram Model to Estimate the Risk of Ventilator-Associated Pneumonia for Elderly Patients in the Intensive Care Unit

BACKGROUND

Ventilator-associated pneumonia (VAP) causes heavy losses in terms of finances, hospitalization, and death for elderly patients in the intensive care unit (ICU); however, the risk is difficult to evaluate due to a lack of reliable assessment tools. We aimed to create and validate a nomogram to estimate VAP risk to provide early intervention for high-risk patients.

METHODS

Between January 2016 and March 2021, 293 patients from a tertiary hospital in China were retrospectively reviewed as a training set. Another 84 patients were enrolled for model validation from April 2021 to February 2022. Least absolute shrinkage and selection operator (LASSO) regression and multivariable logistic regression analysis were employed to select predictors, and a nomogram model was constructed. The calibration, discrimination, and clinical utility of the nomogram were verified. Finally, a web-based online scoring system was created to make the model more practical.

RESULTS

The predictors were hypoproteinemia, long-term combined antibiotic use, intubation time, length of mechanical ventilation, and tracheotomy/intubation. The area under the curve (AUC) was 0.937 and 0.925 in the training and validation dataset, respectively, suggesting the model exhibited effective discrimination. The calibration curve demonstrated high consistency with the observed result and the estimated values. Decision curve analysis (DCA) demonstrated that the nomogram was clinically applicable.

CONCLUSIONS

We have created a novel nomogram model that can be utilized to anticipate VAP risk in elderly ICU patients, which is helpful for healthcare professionals to detect patients at high risk early and adopt protective interventions.

Machine learning to identify risk factors associated with the development of ventilated hospital-acquired pneumonia and mortality: implications for antibiotic therapy selection

Background

Among patients with nosocomial bacterial pneumonia, those who decompensated to requiring mechanical ventilation (vHABP) faced the highest mortality followed by ventilator-associated pneumonia (VABP) and non-ventilated hospital-acquired pneumonia (nvHABP). The objectives of this study were to identify risk factors associated with the development and mortality of vHABP and to evaluate antibiotic management.

Methods

A multicenter retrospective cohort study of adult inpatients with nosocomial pneumonia during 2014-2019 was performed. Groups were stratified by vHABP, nvHABP, and VABP and compared on demographics, clinical characteristics, treatment, and outcomes. Multivariable models were generated via machine learning to identify risk factors for progression to vHABP as well as pneumonia-associated mortality for each cohort.

Results

457 patients (32% nvHABP, 37% vHABP, and 31% VABP) were evaluated. The vHABP and nvHABP groups were similar in age (median age 66.4 years) with 77% having multiple comorbidities but more vHABP patients had liver disease (18.2% vs. 7.7% p = 0.005), alcohol use disorder (27% vs. 7.1%, p < 0.0001), and were hospitalized within the past 30  days (30.4% vs. 19.5%, p = 0.02). An immediate need for ventilatory support occurred in 70% of vHABP patients on the day of diagnosis. Mortality was the highest in vHABP followed by VABP and nvHABP groups (44.6% vs. 36% vs. 14.3%, p < 0.0001). Nearly all (96%) vHABP patients had positive cultures, with Gram-negative pathogens accounting for 58.8% whereby 33.0% were resistant to extended-spectrum β-lactams (ESBLs), ceftriaxone (17.5%), fluoroquinolones (20.6%), and carbapenems (12.4%). Up to half of the vHABP patients with ESBL-Enterobacterales or P. aeruginosa did not receive an effective empiric regimen; over 50% increase in mortality rate was observed among patients whom effective therapy was initiated past the day of pneumonia diagnosis. Risk factors associated with vHABP development were alcohol use disorder, APACHE II score, vasopressor therapy prior to infection, and culture positive for ESBL-Enterobacterales whereas history of hospitalization in the past 30  days, active malignancy, isolation of ceftriaxone-resistant pathogens or Pseudomonas aeruginosa, and vasopressor therapy were risk factors for vHABP-associated mortality.

Conclusion

Patients with vHABP experienced an acute and severe decompensation upon diagnosis. The risk factors identified in this study could provide actionable data for clinicians to identify those at risk for vHABP at the onset of pneumonia and to target antimicrobial stewardship efforts to improve treatment success.

Temporal trends in postoperative and ventilator-associated pneumonia in the United States

OBJECTIVE

To determine change in rates of postoperative pneumonia and ventilator-associated pneumonia among patients hospitalized in the United States during 2009-2019.

DESIGN

Retrospective cohort study.

PATIENTS

Patients hospitalized for major surgical procedures, acute myocardial infarction, heart failure, and pneumonia.

METHODS

We conducted a retrospective review of data from the Medicare Patient Safety Monitoring System, a chart-abstraction-derived database including 21 adverse-event measures among patients hospitalized in the United States. Changes in observed and risk-adjusted rates of postoperative pneumonia and ventilator-associated pneumonia were derived.

RESULTS

Among 58,618 patients undergoing major surgical procedures between 2009 and 2019, the observed rate of postoperative pneumonia from 2009-2011 was 1.9% and decreased to 1.3% during 2017-2019. The adjusted annual risk each year, compared to the prior year, was 0.94 (95% CI, 0.92-0.96). Among 4,007 patients hospitalized for any of these 4 conditions at risk for ventilator-associated pneumonia during 2009-2019, we did not detect a significant change in observed or adjusted rates. Observed rates clustered around 10%, and adjusted annual risk compared to the prior year was 0.99 (95% CI, 0.95-1.02).

CONCLUSIONS

During 2009-2019, the rate of postoperative pneumonia decreased statistically and clinically significantly in among patients hospitalized for major surgical procedures in the United States, but rates of ventilator-associated pneumonia among patients hospitalized for major surgical procedures, acute myocardial infarction, heart failure, and pneumonia did not change.

The Impact of Improved Oral Care Methods on the Oral Health of Patients Undergoing Transoral Mechanical Ventilation

Objective

To explore the effects of improved oral care on the number of oropharyngeal bacteria and the incidence of ventilator-associated pneumonia in patients undergoing mechanical ventilation through oral endotracheal intubation by improving conventional oral care methods and operating procedures and to evaluate the quality of improved oral care and effect.

Methods

A total of 100 cases of mechanically ventilated patients with oral endotracheal intubation who met the inclusion criteria were randomly divided into the observation group and control group with 50 cases each. The control group took routine oral care, that is, scrubbing 3 times per day, and the oral care solution was selected as physiological brine. The observation group improved the conventional oral care method, namely, oral scrubbing before intubation, brushing and washing after intubation, 3 times per day, and 0.1% povidone-iodine in oral care solution. Analysis and comparison of the oral bacterial flora, oral cleanliness, and incidence of ventilator-associated pneumonia, mechanical ventilation time, ICU hospitalization time, and mortality rate of the two groups of patients were analyzed and compared. The relevant data were collected and processed for statistical processing.

Results

The oral bacterial flora of the two groups of patients before oral care after mechanical ventilation after oral tracheal intubation was compared, and there was no significant statistical difference (P > 0.05). After nursing, the oral bacterial flora of the observation group at 8 h, 16 h, and 24 h after intubation was significantly lower than that of the control group. Statistics showed that the difference was statistically significant (P < 0.05). After nursing, the number of patients with oral cleanliness in the observation group was significantly higher than that of the control group, while the incidence of ventilator-associated pneumonia in the observation group was 8% significantly lower than that of the control group 14%. Statistics show that this difference is statistically significant (P < 0.05). After nursing, the observation group's oral cleanliness score, mechanical ventilation time, ICU hospitalization time, and GCS score were better than those of the control group. Statistics showed that the difference was statistically significant (P < 0.05). The mortality of the observation group was significantly lower than that of the control group, which was not statistically significant (P > 0.05).

Conclusion

Oral care can effectively reduce the number of oropharyngeal bacteria in patients who are mechanically ventilated through orotracheal intubation and significantly reduce the incidence of ventilator-associated pneumonia.

Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies

Patients in intensive care units (ICUs) are at high risk for healthcare-acquired infections (HAI) due to the high prevalence of invasive procedures and devices, induced immunosuppression, comorbidity, frailty and increased age. Over the past decade we have seen a successful reduction in the incidence of HAI related to invasive procedures and devices. However, the rate of ICU-acquired infections remains high. Within this context, the ongoing emergence of new pathogens, further complicates treatment and threatens patient outcomes. Additionally, the SARS-CoV-2 (COVID-19) pandemic highlighted the challenge that an emerging pathogen provides in adapting prevention measures regarding both the risk of exposure to caregivers and the need to maintain quality of care. ICU nurses hold a special place in the prevention and management of HAI as they are involved in basic hygienic care, steering and implementing quality improvement initiatives, correct microbiological sampling, and aspects antibiotic stewardship. The emergence of more sensitive microbiological techniques and our increased knowledge about interactions between critically ill patients and their microbiota are leading us to rethink how we define HAIs and best strategies to diagnose, treat and prevent these infections in the ICU. This multidisciplinary expert review, focused on the ICU setting, will summarise the recent epidemiology of ICU-HAI, discuss the place of modern microbiological techniques in their diagnosis, review operational and epidemiological definitions and redefine the place of several controversial preventive measures including antimicrobial-impregnated medical devices, chlorhexidine-impregnated washcloths, catheter dressings and chlorhexidine-based mouthwashes. Finally, general guidance is suggested that may reduce HAI incidence and especially outbreaks in ICUs.

Treatment of ventilator-associated pneumonia (VAP) caused by Acinetobacter: results of prospective and multicenter ID-IRI study

Ventilator-associated pneumonia (VAP) due to Acinetobacter spp. is one of the most common infections in the intensive care unit. Hence, we performed this prospective-observational multicenter study, and described the course and outcome of the disease. This study was performed in 24 centers between January 06, 2014, and December 02, 2016. The patients were evaluated at time of pneumonia diagnosis, when culture results were available, and at 72 h, at the 7th day, and finally at the 28th day of follow-up. Patients with coexistent infections were excluded and only those with a first VAP episode were enrolled. Logistic regression analysis was performed. A total of 177 patients were included; empiric antimicrobial therapy was appropriate (when the patient received at least one antibiotic that the infecting strain was ultimately shown to be susceptible) in only 69 (39%) patients. During the 28-day period, antibiotics were modified for side effects in 27 (15.2%) patients and renal dose adjustment was made in 38 (21.5%). Ultimately, 89 (50.3%) patients died. Predictors of mortality were creatinine level (OR, 1.84 (95% CI 1.279-2.657); p = 0.001), fever (OR, 0.663 (95% CI 0.454-0.967); p = 0.033), malignancy (OR, 7.095 (95% CI 2.142-23.500); p = 0.001), congestive heart failure (OR, 2.341 (95% CI 1.046-5.239); p = 0.038), appropriate empiric antimicrobial treatment (OR, 0.445 (95% CI 0.216-0.914); p = 0.027), and surgery in the last month (OR, 0.137 (95% CI 0.037-0.499); p = 0.003). Appropriate empiric antimicrobial treatment in VAP due to Acinetobacter spp. was associated with survival while renal injury and comorbid conditions increased mortality. Hence, early diagnosis and appropriate antibiotic therapy remain crucial to improve outcomes.

Risk Factors of Ventilator-Associated Pneumonia in Critically III Patients

Ventilator-associated pneumonia (VAP), a hospital acquired pneumonia that occurs more than 48 h after mechanical ventilation, is a common complication of mechanical ventilation with a high mortality rate. VAP can cause patients to have difficulty weaning off the ventilator and to stay in the hospital longer, which results in a huge financial burden to patients and a huge demand for medical resources. Several strategies, such as drugs including chlorhexidine, β-lactam antibiotics and probiotics, have been used to prevent VAP in clinic. The incidence and the mortality rate of VAP have been decreased with the development of preventative strategies in the past decades, but VAP remains one of the most common causes of nosocomial infections and death in the intensive care unit. Current challenges in the management of VAP involved the lack of a gold standard for diagnosis, the absence of effective preventative strategies, and the rise in antibiotic resistance. Therefore, in order to reduce the incidence of VAP and improve the outcome of patients with mechanical ventilation, it is necessary to clarify the risk factors of VAP for clinical prevention and control of VAP. This paper reviews the international risk factors of VAP occurrence reported in recent years, including patient characteristics, increased mechanical ventilation time and prolonged length of hospital stay, disorders of consciousness, burns, comorbidities, prior antibiotic therapy, invasive operations, gene polymorphisms, and mentions the corresponding preventive measures. Each factor is not only an independent risk factor of VAP, but also has an influence on each other. A better understanding of risk factors for VAP is helpful for predicting the occurrence of VAP, improving the prevention and control of VAP, and reducing the morbidity and mortality rates of patients with VAP.

Drug Prevention and Control of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is one of the most prevalent and serious complications of mechanical ventilation, which is considered a common nosocomial infection in critically ill patients. There are some great options for the prevention of VAP: (i) minimize ventilator exposure; (ii) intensive oral care; (iii) aspiration of subglottic secretions; (iv) maintain optimal positioning and encourage mobility; and (v) prophylactic probiotics. Furthermore, clinical management of VAP depends on appropriate antimicrobial therapy, which needs to be selected based on individual patient factors, such as previous antibacterial therapy, history of hospitalization or mechanical ventilation, and bacterial pathogens and antibiotic resistance patterns. In fact, antibiotic resistance has exponentially increased over the last decade, and the isolation of a multidrug-resistant (MDR) pathogen has been identified as an independent predictor of inadequate initial antibiotic therapy and which is significantly associated with increased mortality. Multiple attempts were used in the treatment of VAP, such as novel antibacterial agents, inhaled antibiotics and monoclonal antibodies. In this review, we summarize the current therapeutic options for the prevention and treatment of VAP, aiming to better management of VAP in clinical practice.