Ventilator-associated pneumonia in intensive care units in Hubei Province, China: a multicentre prospective cohort survey

The Prevalence of Multidrug-Resistant and Extensively Drug-Resistant Infections in Respiratory Intensive Care Unit, Causative Microorganisms and Mortality

Aim

This study aims to analyze the incidence of multidrug-resistant (MDR) retrospectively and extensively drug-resistant (XDR) infections, characteristics of patients with these infections, causative microorganisms, and mortality rates in a tertiary respiratory intensive care unit (ICU).

Material and Method

Between 01.01.2022 and 31.12.2023, the data of patients treated in the third-level respiratory ICU were analyzed retrospectively. Adult patients over 18 years of age with MDR and XDR infections were included in the study. Demographic characteristics, age, gender, comorbid systemic diseases, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, mechanical ventilation support status, duration of ICU stay and prognosis of the patients were analyzed and recorded through the hospital information management system.

Results

The study included 261 patients. Of these patients, 184 (70.5%) were male, 77 (29.5%) were female, and their ages were 65.54 ± 14.43 years. The majority of the patients had chronic diseases such as chronic obstructive pulmonary disease, hypertension, coronary artery disease, malignancy, and diabetes mellitus. There was no statistically significant difference between the resistance status of Klebsiella spp. Pseudomonas spp. and Acinetobacter spp. and the prognosis of the patients (p>0.05). No statistically significant difference was found between MDR and XDR Klebsiella spp. Pseudomonas spp. and Acinetobacter spp. patients in terms of the need for invasive mechanical ventilation, non-invasive mechanical ventilation, respiratory support therapy with high flow, APACHE II score, SOFA score, length of stay in the ICU, and prognosis (p>0.05).

Conclusion

Early detection and close monitoring of MDR, XDR, and PDR bacterial strains are vital to combat antimicrobial resistance. This study shows that MDR and XDR infections are a major health problem in ICUs and that these infections have significant negative effects on patient prognosis.

Nomogram to predict ventilator-associated pneumonia in large vessel occlusion stroke after endovascular treatment: a retrospective study

Background

Ventilator-Associated Pneumonia (VAP) severely impacts stroke patients' prognosis after endovascular treatment. Hence, this study created a nomogram to predict the occurrence of VAP after endovascular treatment.

Methods

The individuals with acute ischemic stroke and large vessel occlusion (AIS-LVO) who received mechanical ventilation and endovascular therapy between July 2020 and August 2023 were included in this retrospective study. The predictive model and nomogram were generated by performing feature selection optimization using the LASSO regression model and multifactor logistic regression analysis and assessed the evaluation, verification and clinical application.

Results

A total of 184 individuals (average age 61.85 ± 13.25 years, 73.37% male) were enrolled, and the rate of VAP occurrence was found to be 57.07%. Factors such as the Glasgow Coma Scale (GCS) score, duration of stay in the Intensive Care Unit (ICU), dysphagia, Fazekas scale 2 and admission diastolic blood pressure were found to be associated with the occurrence of VAP in the nomogram that demonstrating a strong discriminatory power with AUC of 0.862 (95% CI, 0.810-0.914), and a favorable clinical net benefit.

Conclusion

This nomogram, comprising GCS score, ICU duration, dysphagia, Fazekas scale 2 and admission diastolic blood pressure, can aid clinicians in predicting the identification of high-risk patients for VAP following endovascular treatment in large vessel occlusion stroke.

Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay

Could rebound explain the paradoxical lack of prevention effect against Staphylococcus aureus blood stream infections (BSIs) with antibiotic-based decontamination intervention (BDI) methods among studies of ICU patients within the literature? Two meta-regression models were applied, each versus the group mean length of stay (LOS). Firstly, the prevention effects against S. aureus BSI [and S. aureus VAP] among 136 studies of antibiotic-BDI versus other interventions were analyzed. Secondly, the S. aureus BSI [and S. aureus VAP] incidence in 268 control and intervention cohorts from studies of antibiotic-BDI versus that among 165 observational cohorts as a benchmark was modelled. In model one, the meta-regression line versus group mean LOS crossed the null, with the antibiotic-BDI prevention effect against S. aureus BSI at mean LOS day 7 (OR 0.45; 0.30 to 0.68) inverted at mean LOS day 20 (OR 1.7; 1.1 to 2.6). In model two, the meta-regression line versus group mean LOS crossed the benchmark line, and the predicted S. aureus BSI incidence for antibiotic-BDI groups was 0.47; 0.09-0.84 percentage points below versus 3.0; 0.12-5.9 above the benchmark in studies with 7 versus 20 days mean LOS, respectively. Rebound within the intervention groups attenuated and inverted the prevention effect of antibiotic-BDI against S. aureus VAP and BSI, respectively. This explains the paradoxical findings.

Risk factors for ventilator-associated pneumonia due to multi-drug resistant organisms after cardiac surgery in adults

Background

Ventilator-associated pneumonia (VAP) is one of the most common intensive care unit (ICU)-acquired infections, which can cause multiple adverse events. Due to bacterial mutation and overuse of antimicrobial drugs, multidrug-resistant organisms (MDRO) has become one of the major causes of postoperative VAP infections in cardiac patients. Therefore, this study aims to explore the risk factors for VAP with MDRO following cardiac surgery in adults.

Methods

The clinical data of adult VAP patients following cardiac surgery in the hospital from Jan 2017 to May 2021 were analyzed retrospectively, and the patients were divided into the MDRO VAP group and the non-MDRO VAP group. Univariable and multivariable logistic regression analyses were performed on risk factors in patients with MDRO VAP. The species and drug sensitivity of pathogens isolated from the VAP patients were also analyzed.

Results

A total of 61 VAP cases were involved in this study, with 34 cases in the MDRO VAP group (55.7%) and 27 cases in the non-MDRO VAP group (44.3%). Multivariable logistic regression analysis showed that independent risk factors for MDRO VAP included preoperative creatinine clearance rate (CCR) ≥ 86.6ml, intraoperative cardiopulmonary bypass (CPB) time ≥ 151 min, postoperative acute kidney injury (AKI) and nasal feeding. Gram-negative bacilli were the main pathogens in VAP patients (n = 54, 90.0%), with the highest rate of Acinetobacter baumannii (n = 24, 40.0%). Additionally, patients with MDRO VAP had a significantly longer postoperative intensive care unit (ICU) duration and higher hospitalization costs than non-MDRO VAP patients, but there was no notable difference in the 28-day mortality rate between the two groups.

Conclusion

Based on implementing measures to prevent VAP, clinicians should pay more attention to patients with kidney disease, longer intraoperative CPB time, and postoperative nasal feeding to avoid MDRO infections.

Knowledge, Practice, Compliance, and Barriers toward Ventilator-Associated Pneumonia among Critical Care Nurses in Eastern Mediterranean Region: A Systematic Review

BACKGROUND

Ventilator-associated pneumonia (VAP) has been identified as a serious complication among hospitalized patients and is associated with prolonged hospitalizations and increased costs. The purpose of this study was to examine the knowledge, practices, compliance, and barriers related to ventilator-associated pneumonia among critical care nurses in the eastern Mediterranean region.

METHODS

The PRISMA guidelines guided this systematic review. Four electronic databases (EMBASE, MEDLINE (via PubMed), SCOPUS, and Web of Science) were used to find studies that were published from 2000 to October 2021.

RESULTS

Knowledge of ventilator-associated pneumonia was the highest outcome measure used in 14 of the 23 studies. The review results confirmed that nurses demonstrated low levels of knowledge of ventilator-associated pneumonia, with 11 studies assessing critical care nurses' compliance with and practice with respect to ventilator-associated pneumonia. Overall, the results showed that most sampled nurses had insufficient levels of compliance with and practices related to ventilator-associated pneumonia. The main barriers reported across the reviewed studies were a lack of education (N = 6), shortage of nursing staff (N = 5), lack of policies and protocols (N = 4), and lack of time (N = 4).

CONCLUSIONS

The review confirmed the need for comprehensive interventions to improve critical care nurses' knowledge, compliance, and practice toward ventilator-associated pneumonia. Nurse managers must address barriers that impact nurses' levels of knowledge, compliance with, and practices related to ventilator-associated pneumonia.

Assessing the Impact of Gender and COPD on the Incidence and Mortality of Hospital-Acquired Pneumonia. A Retrospective Cohort Study Using the Spanish National Discharge Database (2016-2019)

BACKGROUND

We aim to analyze incidence and outcomes of patients hospitalized with hospital-acquired pneumonia (HAP) according to chronic obstructive pulmonary disease (COPD) status and sex in Spain (2016-2019).

METHODS

We conducted a retrospective cohort study using national hospital discharge data of patients ≥40 years with a primary diagnosis of HAP, using the specific diagnostics of non-ventilator (NV)-HAP and ventilator-associated pneumonia (VAP).

RESULTS

We identified 37,029 patients with HAP ((NV)-HAP 87.28%, VAP 12.72%), 13.40% with COPD. HAP incidence increased over time, but only in subjects without COPD (p < 0.001). In women, incidence of HAP and (NV)-HAP was similar regardless of COPD status, but VAP incidence was lower in COPD women (p = 0.007). In men, the incidence of (NV)-HAP was significantly higher in those with COPD, while VAP incidence was lower in COPD men (p < 0.001). The in-hospital mortality (IHM) was similar in men and women with and without COPD. The risk of dying in hospital increased with age, congestive heart failure, cancer, and dialysis among men and women with COPD. Men that underwent surgery had a lower risk of IHM. VAP increased 2.58-times the probability of dying in men and women. Finally, sex was not associated with IHM among COPD patients.

CONCLUSIONS

Incidence of HAP was significantly higher in COPD patients than in those without COPD, at the expense of (NV)-HAP but not of VAP. When stratifying by sex, we found that the difference was caused by men. IHM was similar in COPD and non-COPD patients, with no significant change overtime. In addition, sex was not associated with IHM.

The effect of ventilator-associated pneumonia on the prognosis of intensive care unit patients within 90 days and 180 days

BACKGROUND

Mechanical ventilation (MV) is often applied in critically ill patients in intensive care unit (ICU) to protect the airway from aspiration, and supplement more oxygen. MV may result in ventilator-associated pneumonia (VAP) in ICU patients. This study was to estimate the 90-day and 180-day mortalities of ICU patients with VAP, and to explore the influence of VAP on the outcomes of ICU patients.

METHODS

Totally, 8182 patients who aged ≥18 years and received mechanical ventilation (MV) in ICU from Medical Information Mart for Intensive Care III (MIMIC III) database were involved in this study. All subjects were divided into the VAP group (n = 537) and the non-VAP group (n = 7626) based on the occurrence of VAP. Clinical data of all participants were collected. The effect of VAP on the prognosis of ICU patients was explored by binary logistic regression analysis.

RESULTS

The results delineated that the 90-day mortality of VAP patients in ICU was 33.33% and 180-day mortality was 37.62%. The 90-day and 180-day mortality rates were higher in the VAP group than in the non-VAP group. After adjusting the confounders including age, ethnicity, heart failure, septicemia, simplified acute physiology score II (SAPSII) score, sequential organ failure assessment (SOFA) score, serum lactate, white blood cell (WBC), length of ICU stay, length of hospital stay, length of ventilation, antibiotic treatment, Pseudomonas aeruginosa (P.aeruginosa), methicillin-resistant Staphylococcus aureus (MRSA), other pathogens, the risk of 90-day and 180-day mortalities in VAP patients were 1.465 times (OR = 1.465, 95%CI: 1.188-1.807, P < 0.001) and 1.635 times (OR = 1.635, 95%CI: 1.333-2.005, P < 0.001) higher than those in non-VAP patients, respectively.

CONCLUSIONS

Our study revealed that ICU patients with VAP had poorer prognosis than those without VAP. The results of this study might offer a deeper insight into preventing the occurrence of VAP.

A comparison of diagnostic algorithms and clinical parameters to diagnose ventilator-associated pneumonia: a prospective observational study

Background

Suspicion and clinical criteria continue to serve as the foundation for ventilator-associated pneumonia (VAP) diagnosis, however the criteria used to diagnose VAP vary widely. Data from head-to-head comparisons of clinical diagnostic algorithms is lacking, thus a prospective observational study was performed to determine the performance characteristics of the Johanson criteria, Clinical Pulmonary Infection Score (CPIS), and Centers for Disease Control and Prevention’s National Healthcare Safety Network (CDC/NHSN) criteria as compared to Hospital in Europe Link for Infection Control through Surveillance (HELICS) reference standard.

Methods

A prospective observational cohort study was performed in three mixed medical-surgical ICUs from one academic medical center from 1 October 2016 to 30 April 2018. VAP diagnostic criteria were applied to each patient including CDC/NHSN, CPIS, HELICS and Johanson criteria. Tracheal aspirate cultures (TAC) and serum procalcitonin values were obtained for each patient.

Results

Eighty-five patients were enrolled (VAP 45, controls 40). Using HELICS as the reference standard, the sensitivity and specificity for each of the assessed diagnostic algorithms were: CDC/NHSN (Sensitivity 54.2%; Specificity 100%), CPIS (Sensitivity 68.75%; Specificity 95.23%), Johanson (Sensitivity 67.69%; Specificity 95%). The positive TAC rate was 81.2%. The sensitivity for positive TAC with the serum procalcitonin level > 0.5 ng/ml was 51.8%.

Conclusion

VAP remains a considerable source of morbidity and mortality in modern intensive care units. The optimal diagnostic method remains unclear. Using HELICS criteria as the reference standard, CPIS had the greatest comparative diagnostic accuracy, whereas the sensitivity of the CDC/NHSN was only marginally better than a positive TAC plus serum procalcitonin > 0.5 ng/ml. Algorithm accuracy was improved by adding serum procalcitonin > 0.5 ng/ml, but not positive quantitative TAC.

Trial Registration: Not indicated for this study type.

Emergence of multidrug-resistant non-fermentative gram negative bacterial infection in hospitalized patients in a tertiary care center of Nepal

Objective

This study was designed for the characterization and establishment of antibiotic susceptibility profiles of non-fermentative gram negative bacteria isolated from hospitalized patients in a tertiary care hospital of Nepal.

Results

A total of 402 non-fermentative gram negative bacteria was isolated in 1486 culture-positive cases from 6216 different clinical samples obtained from hospitalized patients. Among total non-fermentative gram negative bacterial isolates, the highest number was recovered from specimens collected from lower respiratory tract infections (n = 173, 43.0%) of hospitalized patients followed by pus/swab samples (n = 99, 24.6%) and urinary tract infections (n = 49, 12.2%). The most common non-fermentative gram negative bacteria identified were Acinetobacter baumannii (n = 177, 44.0%), Pseudomonas aeruginosa (n = 161, 40.1%) and Burkholderia cepacia complex (n = 33, 8.2%). These bacterial isolates exhibited a higher rate of insusceptibility to beta-lactam antibiotics, fluoroquinolones, and aminoglycosides. On the other hand, all the isolates of P. aeruginosa and A. baumannii were completely susceptible to colistin sulfate and polymyxin B. Among total isolates, 78.1% (n = 314) were multidrug-resistant with a high rate of multidrug-resistant among A. baumannii (91.0%).

A mobile terminal application program was used for endotracheal tube cuff pressure measurement

We studied the application of a mobile terminal application program in endotracheal tube (ETT) cuff pressure measurement to improve the implementation rate of scientific ETT cuff pressure measurement and to ensure that the pressure falls within the recommended range. A pre-post controlled study lasting for 18 months was undertaken in a 40-bed general intensive care unit (GICU). This included a 6-month baseline period (baseline group) and a 6-month intervention period (intervention group). The mobile terminal application program was applied to monitor the cuff pressure of endotracheal intubation as an intervention measure during the intervention period. ETT pressure was the main outcome measure, while gender, age, causes for ICU admission, sedation score, duration of prior intubation, size of ETT, and number of VAP patients were secondary outcomes. ETT cuff pressure was monitored 742 times in both the baseline group and the intervention group. A total of 56.9% of the cuff pressure measurements in the baseline group were within the recommended range, while 78.4% of measurements in the intervention group were within the recommended range, reflecting a statistically significant difference (P < 0.05). The application of the mobile terminal application program used for ETT cuff pressure measurement could improve the percentage of ETT cuff pressure measurements falling within the recommended range.

Burden of Multidrug-Resistant Acinetobacter baumannii Infection in Hospitalized Patients in a Tertiary Care Hospital of Nepal

Introduction

Acinetobacter baumannii has emerged as a significant multidrug-resistant (MDR) nosocomial pathogen worldwide and is responsible for various healthcare-associated infections. The MDR strains have been reported increasingly during the last decades in hospitalized patients. They have developed resistance to most of the available antibiotics and are known to produce various acquired β-lactamases. The β-lactamase producing strains have a potential for rapid dissemination in hospital settings, as it is often plasmid-mediated. The Infectious Diseases Society of America (ISDA) stated A. baumannii as one of the “red alert” pathogens that greatly threatens the utility of our current antibacterial armamentarium. The study attempted to investigate the spectrum and antimicrobial resistance among MDR A. baumannii and their potential implications in hospitalized patients in a tertiary care hospital of Nepal.

Methods

This study was conducted at Tribhuvan University Teaching Hospital (TUTH), Nepal from January 2017 to December 2017. A total of 177 A. baumannii isolated from hospitalized patients were included in the study. The AST was performed by disc diffusion method. The MDR strains were identified by the criteria of Magiorakos et al, ESBL production by CLSI guidelines, and AmpC β-lactamase production by the AmpC disc test. MBL and KPC production were detected as per the method of Tsakris et al.

Results

Out of 177 A. baumannii, 91.0% were MDR isolates. Among the MDR isolates, the majority were isolated from respiratory tract specimens and were isolated from ICU patients. Most of the MDR isolates were resistant to all first-line antibiotics and all were completely sensitive to only polymyxin B and colistin sulfate. MBL (67.7%) was the common β-lactamase production among MDR isolates.

Conclusion

Acinetobacter baumannii can cause a vast variety of infections in hospitalized patients. The highly resistant MDR strains are common in tertiary care hospitals. This bacteria lead to high morbidity and mortality as we are left with the only option of treating them by potentially toxic antibiotics like colistin sulfate and polymyxin B. Detection of drug resistance and rational use of antibiotics play a crucial role in the fight against this MDR pathogen.

Microbial Etiology and Prognostic Factors of Ventilator-associated Pneumonia: A Multicenter Retrospective Study in Shanghai

Background

The microbial etiology and mortality risk factors of ventilator-associated pneumonia (VAP) have not been investigated extensively in Shanghai.

Methods

VAP cases were identified from the patients hospitalized during the period from 1 January 2013 to 30 December 2017 in Shanghai. The relevant data were reviewed and analyzed retrospectively.

Results

One hundred ninety-four VAP cases were included in this analysis. The overall mortality rate was 32.47%. The respiratory pathogens isolated from these patients included 212 bacterial strains and 54 fungal strains. The leading pathogens were Acinetobacter baumannii (33.96%), Klebsiella pneumoniae (23.58%), Pseudomonas aeruginosa (19.81%), and Staphylococcus aureus (7.08%). Candida colonization was associated with higher mortality of VAP patients compared to those without Candida colonization (45.45% vs 28.67%, P < .05). The VAP patients with Candida colonization also showed higher prevalence of P. aeruginosa, carbapenem-resistant P. aeruginosa (CRPA), K. pneumoniae, carbapenem-resistant K. pneumoniae (CRKP), A. baumannii, and carbapenem-resistant A. baumannii (CRAB) (P < .05). VAP nonsurvivors had higher prevalence of CRPA, K. pneumoniae, CRAB, and Candida than VAP survivors (P < .05). Multivariate analysis showed that prior antibiotic use was a significant risk factor for Candida colonization, while hypertension and length of hospital stay were significant risk factors of VAP mortality (P < .05).

Conclusions

The top pathogens of VAP patients in Shanghai tertiary teaching hospitals are A. baumannii, K. pneumoniae, and P. aeruginosa, with high prevalence of carbapenem resistance. Carbapenem-resistant bacterial pathogens and Candida may predict poor outcome.

Emergency nurses' knowledge about ventilator-associated pneumonia

INTRODUCTION

Given the increasing number of patients requiring mechanical ventilation in emergency departments in recent years, prevention of ventilator-associated pneumonia is very important. Nurses play a significant role in prevention of ventilator-associated pneumonia. This study aimed to determine the emergency nurses knowledge about prevention of ventilator-associated pneumonia.

METHODS

The present descriptive study was conducted in Iran, from July to October 2018. All the nurses with at least a bachelor degree, who are working in two emergency departments of two teaching hospitals, were asked to participate in this study. The "knowledge about ventilator-associated pneumonia" questionnaire consisting of 9 items was used to assess the knowledge of nurses. The results were analyzed using SPSS-16.

RESULTS

In total, 53 nurses participated in this study. The mean score of correct answers of nurses to these 9 items was 4.4 ± 1.6. Nurses give the most correct answer to the item about patient's position on the bed so as to reduce the risk of pneumonia with a correct answer of 72.9%. The least correct answer was also given to the item about how humidifier was changed with a correct answer of 1.9%. None of the nurses participating in the study were able to answer all the items correctly. The mean score of knowledge of nurses who had participated in workshops about taking care of patients on mechanical ventilation was significantly higher than those who had not participated in such workshops (4.8 vs. 3.8) (p = 0.045). The mean score of knowledge in nurses who were familiar with the international guidelines for ventilator-associated pneumonia prevention was significantly higher than those who were not familiar with such guidelines (5.1 vs. 4.1) (p = 0.045).

CONCLUSION

Emergency nurses participated in this study had inadequate knowledge about the prevention of ventilator-associated pneumonia. Nurse's knowledge affected by participation in related workshop and familiarity with ventilator-associated pneumonia guidelines. Considering the importance of this issue, it is necessary to improve the knowledge of the emergency nurses in this matter by holding training courses.

A quality assessment of evidence-based guidelines for the prevention and management of ventilator-associated pneumonia: a systematic review

Background

Numerous evidence-based guidelines (EBGs) pertaining to ventilator-associated pneumonia (VAP) have been published by domestic and international organizations, but their qualities have not been reported.

Methods

A systematic search of the literature was performed up to July 2018 for relevant guidelines. Guidelines were eligible for inclusion if they incorporated recommendation statements for prevention and/or management in adults or children with VAP and were developed on a systematic evidence-based method. Four reviewers evaluated each guideline using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, which comprises 23 items organized into six domains in addition to two overall items.

Results

Thirteen EBGs were identified for review. An overall high degree of agreement among reviewers was reached [intra-class correlation coefficient (ICC), 0.885; 95% CI, 0.862-0.905] during their review. The scores (mean, range) for the six AGREE domains were: scope and purpose (61%, 51-74%), stakeholder involvement (36%, 18-68%), rigor of development (41%, 22-59%), clarity and presentation (56%, 47-71%), applicability (38%, 21-59%) and editorial independence (50%, 0-77%). Only two EBGs (15.4%) were rated "recommended" for clinical practice. Approximately 86% of recommendations were based on moderate or low levels of evidence (levels B-D were 46.2%, 19.0%, and 21.2%, respectively). The recommendations for prevention and management of VAP were similar among the different EBGs.

Conclusions

The overall quality of the identified EBGs pertaining to VAP was classified as moderate. The management of VAP varied by guideline. More high-quality evidence is needed to improve guideline recommendations.

The Effects of Oral Care Protocol on the Incidence of Ventilation-Associated Pneumonia in Selected Intensive Care Units in Jordan

PURPOSE

This study aims to evaluate the effects of oral care protocol on the incidence of ventilator-associated pneumonia (VAP) at selected intensive care units (ICUs) in Jordan using clinical pulmonary infection score.

METHODS

A quasi-experimental design was used, and 1 large teaching hospital from the Jordanian capital, along with 2 hospitals from the southern region, was selected. A total of 218 patients participated, among which VAP risk in 2 independent groups was evaluated through the Clinical Pulmonary Infection Score sheet.

RESULTS

The VAP incidence rate was significantly lower in the intervention group (n = 102) as compared with control group (n = 116) (21.6 vs 35.3, respectively; P = .018); in addition, ICU stay and intubation period were significantly shorter among the intervention group. A higher risk of VAP was independently predicted by previous lung diseases (odds ratio [OR], 1.441; 95% confidence interval [CI], 1.185-1.88), open suctioning system (OR, 2.536; 95% CI, 1.261-5.101), and duration of intubation (OR, 1.770; 95% CI, 0.845-2.220). The oral care protocol has effectively improved ventilated patients' oral health, which has statistically reduced the incidence of VAP. It occurred more frequently among patients who have lung disease and those who were intubated for more than 7 days and have an open suctioning system.

CONCLUSION

Health care teams should ensure that effective care protocol is implemented among patients.

One functional variant in the 3'-untranslated region of TLR4 is associated with the elevated risk of ventilator-associated pneumonia in the patients with chronic obstructive pulmonary disease

The aim of this study was to identify the association polymorphism (rs11536889) in the 3'-untranslated region (3'-UTR) of Toll-like receptors 4 (TLR4) and the risk for ventilator-associated pneumonia (VAP). miRNA database online and luciferase assays were used to validate TLR4 as the target gene of miR-1236. Enzyme-linked immunosorbent assay analysis and western blot were used to analyze the level of TLR4 in different genotype groups. In the present study, miR-1236 was predicted to bind to the rs11536889 G allele rather than the rs11536889 C allele, which was further confirmed by the luciferase activity suppressed by a fragment of 3'-UTR containing the rs11536889 G allele induced by lipopolysaccharide (LPS) and interleukin-6 (IL-6). Bronchial epithelial cells isolated from participants genotyped as GG, GC, and CC, with no remarkable difference in TLR4 messenger RNA (mRNA) levels were observed among these genotype groups. After stimulating by LPS, a TLR4 ligand, the CC-genotyped cells expressed higher levels of IL-8, IL-6, and tumor necrosis factor alpha (TNF-α) on their surfaces than cells with the other genotypes. Finally, the western blot analysis results showed that the expression level of IL-8, IL-6, and TNF-α protein was much higher in the CC group than the GC and GG groups subsequent to stimulation by LPS, and the IL-8, IL-6, and TNF-α protein levels in the GC were grouped much lower compared with the GG group. These findings indicated the regulatory association of miR-1236 with TLR4 and the abnormal expression of TLR4 caused by the presence of rs11536889 in the 3'-UTR of mRNA, which interfere with its interaction with the miR-1236, contributing to the risk of VAP.

Distribution and drug resistance of pathogenic bacteria in ventilator-associated pneumonia at a local hospital of North-eastern China

Purpose

To study the distribution of pathogenic bacteria in ventilator-associated pneumonia (VAP), and epidemiological characteristics of extended-spectrum β lactamase (ESBL)-producing bacteria.

Patients and methods

Lower respiratory tract secretions from 156 patients with mechanical ventilation were collected using a protective specimen brush (PSB), with quantitative bacterial culture carried out and antibiotic sensitivity measured. ESBLs produced by Gram-negative bacilli were detected using the double disk diffusion method and monitored by plasmid profiles.

Results

Gram-negative bacilli accounted for 78.9% of VAP pathogens, with Acinetobacter baumannii (25%), Pseudomonas aeruginosa (19.7%), and Klebsiella pneumoniae (14.5%) as the most common strains. There were 12 Gram-positive strains detected (15.8%); mostly methicillin-resistant. Staphylococcus aureus and methicillin-resistant coagulase-negative Staphylococcus. There were also four strains of Candida albicans detected (5.26%). Most Gram-negative bacilli are sensitive to imipenem, but A. baumannii is serious resistant. ESBLs were detected in nine strains of Gram-negative bacilli; mainly produced by K. pneumoniae and Escherichia coli, to different degrees of multidrug resistance. Five strains of K. pneumoniae-producing ESBLs were from the same clonal origin, as confirmed by plasmid restriction endonuclease analysis.

Conclusion

VAP was mainly caused by Gram-negative bacteria, with high antibiotic resistance rates. Plasmids played an important role in the spread of antibiotic resistance among bacteria.

Gastric versus postpyloric enteral nutrition in elderly patients (age ≥ 75 years) on mechanical ventilation: a single-center randomized trial

BACKGROUND

The risk of ventilator-associated pneumonia (VAP) is reduced when postpyloric enteral nutrition (EN) is administered compared to when gastric EN is administered in specific populations. In the present study, we tested the hypothesis that postpyloric EN is superior to gastric EN in reducing the incidence of VAP in elderly patients (age ≥ 75 years) who are admitted to the intensive care unit (ICU) and require mechanical ventilation.

METHODS

We performed a single-center randomized clinical trial involving elderly patients (age ≥ 75 years) who were admitted to the ICU and required mechanical ventilation. The patients were randomly assigned to either the postpyloric EN group or the gastric EN group. The primary outcome was the VAP rate.

RESULTS

Of the 836 patients screened, 141 patients were included in the study (70 in the postpyloric EN group and 71 in the gastric EN group). The patients in the postpyloric EN group were 82.0 (75.0-99.0) years old (male 61.4%), and those in the gastric EN group were 82.0 (75.0-92.0) years old (male 63.4%). The Acute Physiology and Chronic Health Evaluation II scores were 28.09 ± 6.75 in the postpyloric EN group and 27.80 ± 7.60 in the gastric EN group (P = 0.43). VAP was observed in 8 of 70 patients (11.4%) in the postpyloric EN group and in 18 of 71 patients (25.4%) in the gastric EN group, which resulted in a significant between-group difference (OR 0.38, 95% CI 0.15-0.94; P = 0.04). In the postpyloric EN group, there were significant reductions in vomiting (12 patients in the postpyloric EN group vs 29 patients in the gastric EN group; OR 0.30, 95% CI 0.14-0.65; P = 0.002) and abdominal distension (18 patients in the postpyloric EN group vs 33 patients in the gastric EN group; OR 0.40, 95% CI 0.20-0.81; P = 0.01). No significant differences were observed between the two groups regarding mortality and other secondary outcomes.

CONCLUSIONS

Our study demonstrated that, compared with gastric EN, postpyloric EN reduced the VAP rate among elderly patients who were admitted to the ICU and required mechanical ventilation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IPR-16008485 . Registered on 17 May 2016.

World-Wide Variation in Incidence of Staphylococcus aureus Associated Ventilator-Associated Pneumonia: A Meta-Regression

Staphylococcus aureus (S. aureus) is a common Ventilator-Associated Pneumonia (VAP) isolate. The objective here is to define the extent and possible reasons for geographic variation in the incidences of S. aureus-associated VAP, MRSA-VAP and overall VAP. A meta-regression model of S. aureus-associated VAP incidence per 1000 Mechanical Ventilation Days (MVD) was undertaken using random effects methods among publications obtained from a search of the English language literature. This model incorporated group level factors such as admission to a trauma ICU, year of publication and use of bronchoscopic sampling towards VAP diagnosis. The search identified 133 publications from seven worldwide regions published over three decades. The summary S. aureus-associated VAP incidence was 4.5 (3.9–5.3) per 1000 MVD. The highest S. aureus-associated VAP incidence is amongst reports from the Mediterranean (mean; 95% confidence interval; 6.1; 4.1–8.5) versus that from Asian ICUs (2.1; 1.5–3.0). The incidence of S. aureus-associated VAP varies by up to three-fold (for the lowest versus highest incidence) among seven geographic regions worldwide, whereas the incidence of VAP varies by less than two-fold. Admission to a trauma unit is the most important group level correlate for S. aureus-associated VAP.

Unusually High Incidences of Staphylococcus aureus Infection within Studies of Ventilator Associated Pneumonia Prevention Using Topical Antibiotics: Benchmarking the Evidence Base

Selective digestive decontamination (SDD, topical antibiotic regimens applied to the respiratory tract) appears effective for preventing ventilator associated pneumonia (VAP) in intensive care unit (ICU) patients. However, potential contextual effects of SDD on Staphylococcus aureus infections in the ICU remain unclear. The S. aureus ventilator associated pneumonia (S. aureus VAP), VAP overall and S. aureus bacteremia incidences within component (control and intervention) groups within 27 SDD studies were benchmarked against 115 observational groups. Component groups from 66 studies of various interventions other than SDD provided additional points of reference. In 27 SDD study control groups, the mean S. aureus VAP incidence is 9.6% (95% CI; 6.9–13.2) versus a benchmark derived from 115 observational groups being 4.8% (95% CI; 4.2–5.6). In nine SDD study control groups the mean S. aureus bacteremia incidence is 3.8% (95% CI; 2.1–5.7) versus a benchmark derived from 10 observational groups being 2.1% (95% CI; 1.1–4.1). The incidences of S. aureus VAP and S. aureus bacteremia within the control groups of SDD studies are each higher than literature derived benchmarks. Paradoxically, within the SDD intervention groups, the incidences of both S. aureus VAP and VAP overall are more similar to the benchmarks.

Risk factors for health care-associated infection in hospitalized adults: Systematic review and meta-analysis

BACKGROUND

Health care-associated infections (HAIs) are a public health problem that increase health care costs. This article aimed to systematically review the literature and meta-analyze studies investigating risk factors (RFs) independently associated with HAIs in hospitalized adults.

METHODS

Electronic databases (MEDLINE, Embase, and LILACS) were searched to identify studies from 2009-2016. Pooled risk ratios (RRs) or odds ratios (ORs) or mean differences (MDs) and 95% confidence intervals (CIs) were calculated and compared across the groups. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Of 867 studies, 65 met the criteria for review, and the data of 18 were summarized in the meta-analysis. The major RFs independently associated with HAIs were diabetes mellitus (RR, 1.76; 95% CI, 1.27-2.44), immunosuppression (RR, 1.24; 95% CI, 1.04-1.47), body temperature (MD, 0.62; 95% CI, 0.41-0.83), surgery time in minutes (MD, 34.53; 95% CI, 22.17-46.89), reoperation (RR, 7.94; 95% CI, 5.49-11.48), cephalosporin exposure (RR, 1.77; 95% CI, 1.30-2.42), days of exposure to central venous catheter (MD, 5.20; 95% CI, 4.91-5.48), intensive care unit (ICU) admission (RR, 3.76; 95% CI, 1.79-7.92), ICU stay in days (MD, 21.30; 95% CI, 19.81-22.79), and mechanical ventilation (OR, 12.95; 95% CI, 6.28-26.73).

CONCLUSIONS

Identifying RFs that contribute to develop HAIs may support the implementation of strategies for their prevention, therefore maximizing patient safety.

Incidence, temporal trend and factors associated with ventilator-associated pneumonia in mainland China: a systematic review and meta-analysis

Background

Data to date is far from sufficient to describe the recent epidemiology of ventilator-associated pneumonia (VAP) in mainland China. This study aimed to estimate the overall incidence of VAP, with a special focus on its temporal trend and associated factors.

Methods

Meta-analyses of 195 studies published from 2010 to 2015 were conducted, followed by subgroup analyses by methodological quality, pre-defined setting characteristics and attributes of populations.

Results

The overall cumulative VAP incidence in mainland China was 23.8% (95% confidence interval (CI) 20.6–27.2%), with the results showing high heterogeneity. The pooled incidence densities were 24.14 (95% CI 21.19–27.51) episodes and 22.83 (95% CI 19.88–26.23) patients per 1000 ventilator-days. A decline in the cumulative incidence was observed from 2006 (49.5%, 95% CI 40.0–59.0%) to 2014 (19.6%, 95% CI 10.4–31.0%); differences in the incidence rates were also documented according to Chinese provinces and diagnostic criteria (p < 0.001). Older age (≥60 years), coma, re-intubation, tracheotomy and prolonged ventilation were the factors significantly associated with the occurrence of VAP.

Conclusions

The incidence of VAP remains high in mainland China but has decreased since 2006. The reported rates vary considerably across individual studies, probably due to variations in diagnosis and geographical region. More studies using standard definitions and cut-off points are needed to better clarify the epidemiology of VAP across the country.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2566-7) contains supplementary material, which is available to authorized users.

High burden of antimicrobial resistance among gram negative bacteria causing healthcare associated infections in a critical care unit of Nepal

Background

Healthcare associated infections (HCAI) and antimicrobial resistance are principal threats to the patients of intensive care units and are the major determining factors for patient outcome. They are associated with increased morbidity, mortality, excess hospitalization and financial costs. The present study is an attempt to investigate the spectrum and antimicrobial resistance of bacterial isolates involved in healthcare associated infections (HCAI) in the patients of a critical care unit at a tertiary care university hospital in Kathmandu, Nepal.

Methods

A laboratory based study was conducted over the period of 15 months (January 2014 to March 2015) among the patients of intensive care unit of Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Clinical specimens from patients with suspected healthcare-associated infection were processed and bacterial isolates were identified with standard microbiological methods. Antimicrobial susceptibilities of the isolated strains were determined according to the CLSI guidelines and β-lactamases (ESBL, AmpC, MBL and KPC) were detected by various phenotypic tests.

Results

One hundred and forty nine clinical specimens received from 135 patients suspected of HCAI (out of 491 patients) were found with significant bacterial growth. Specimens were from patients suspected of hospital-acquired pneumonia (16%, 79/491), bloodstream infections (5.7%, 28/491), surgical site infections (4.7%, 23/491), and urinary tract infections (3.9%, 19/491). Acinetobacter spp., Klebsiella spp., Escherichia coli and Burkholderia cepacia were the leading bacterial pathogens. Extremely high level of drug resistance (95.8%) along with the production of β-lactamases (ESBL; 43.7%, AmpC; 27.5%), MBL; 50.2% and KPC; 4.2%) was observed among Gram negative bacterial isolates.

Conclusion

Healthcare associated infections are very common in our ICU. Gram negative bacterial pathogens are major culprits associated with these infections and there is alarming state of drug resistance among these isolates. Continuous surveillance and establishment of preventive and control measures of healthcare associated infections are urgently needed in our setting.

An assessment of ventilator-associated pneumonias and risk factors identified in the Intensive Care Unit

Objectives:

Ventilator-associated pneumonia (VAP) is a significant cause of hospital-related infections, one that must be prevented due to its high morbidity and mortality. The purpose of this study was to evaluate the incidence and risk factors in patients developing VAP in our intensive care units (ICUs).

Methods:

This retrospective cohort study involved in mechanically ventilated patients hospitalized for more than 48 hours. VAP diagnosed patients were divided into two groups, those developing pneumonia (VAP(+)) and those not (VAP(-)).\

Results:

We researched 1560 patients in adult ICUs, 1152 (73.8%) of whom were mechanically ventilated. The MV use rate was 52%. VAP developed in 15.4% of patients. The VAP rate was calculated as 15.7/1000 ventilator days. Mean length of stay in the ICU for VAP(+) and VAP(-) patients were (26.7±16.3 and 18.1±12.7 days (p<0.001)) and mean length of MV use was (23.5±10.3 and 12.6±7.4 days (p<0.001)). High APACHE II and Charlson co-morbidity index scores, extended length of hospitalization and MV time, previous history of hospitalization and antibiotherapy, reintubation, enteral nutrition, chronic obstructive pulmonary disease, cerebrovascular disease, diabetes mellitus and organ failure were determined as significant risk factors for VAP. The mortality rate in the VAP(+) was 65.2%, with 23.6% being attributed to VAP.

Conclusion:

VAPs are prominent nosocomial infections that can cause considerable morbidity and mortality in ICUs. Patient care procedures for the early diagnosis of patients with a high risk of VAP and for the reduction of risk factors must be implemented by providing training concerning risk factors related to VAP for ICU personnel, and preventable risk factors must be reduced to a minimum.

Impact of selective digestive decontamination on respiratory tract Candida among patients with suspected ventilator-associated pneumonia. A meta-analysis

The purpose here is to establish the incidence of respiratory tract colonization with Candida (RT Candida) among ICU patients receiving mechanical ventilation within studies in the literature. Also of interest is its relationship with candidemia and the relative importance of topical antibiotic (TA) use as within studies of selective digestive decontamination (SDD) versus other candidate risk factors towards it. The incidence of RT Candida was extracted from component (control and intervention) groups decanted from studies of various TA and non-TA ICU infection prevention methods with summary estimates derived using random effects. A benchmark RT Candida incidence to provide overarching calibration was derived using (observational) groups from studies without any prevention method under study. A multi-level regression model of group level data was undertaken using generalized estimating equation (GEE) methods. RT Candida data were sourced from 113 studies. The benchmark RT Candida incidence is 1.3; 0.9-1.8 % (mean and 95 % confidence intervals). Membership of a concurrent control group of a study of SDD (p = 0.02), the group-wide presence of candidemia risk factors (p < 0.001), and proportion of trauma admissions (p = 0.004), but neither the year of study publication, nor membership of any other component group, nor the mode of respiratory sampling are predictive of the RT Candida incidence. RT Candida and candidemia incidences are correlated. RT Candida incidence can serve as a basis for benchmarking. Several relationships have been identified. The increased incidence among concurrent control groups of SDD studies cannot be appreciated in any single study examined in isolation.

Candida spp. airway colonization: A potential risk factor for Acinetobacter baumannii ventilator-associated pneumonia

This retrospective study was conducted to identify potential risk factors for Acinetobacter baumannii (A. baumannii) ventilator-associated pneumonia (VAP) and evaluate the association between Candida spp. airway colonization and A. baumannii VAP. Intensive care unit (ICU) patients who were on mechanical ventilation (MV) for ≥48 hours were divided into the following groups: patients with and without Candida spp. airway colonization; colonized patients receiving antifungal treatment or not; patients with A. baumannii VAP and those without VAP. Logistic regression analysis and propensity score matching were used to identify factors independently associated with A. baumannii VAP. Among 618 eligible patients, 264 (43%) had Candida spp. airway colonization and 114 (18%) developed A. baumannii VAP. Along with MV for ≥7 days (adjusted odds ratio [aOR] 8.9, 95% confidence intervals [95% CI] 4.9-15.8) and presence of a central venous catheter (aOR 3.2, 95% CI 1.1-9), Candida spp. airway colonization (aOR 2.6, 95% CI 1.6-4.3) was identified as an independent risk factor for A. baumannii VAP. Patients with Candida spp. airway colonization were more likely to develop A. baumannii VAP than non-colonized patients (23% vs 15%, P=.01 and 34% vs. 15%, P<.001 in propensity score-matched subgroups). Administration of antifungal agents was not associated with A. baumannii VAP (29% vs. 21%, P=.153) but with higher in-hospital mortality (53% vs. 39%, P=.037). Candida spp. airway colonization (43%) and A. baumannii VAP (18%) were common in ICU patients who were on mechanical ventilation for at least 48 hours. Candida spp. airway colonization was an independent risk factor for subsequent A. baumannii VAP.

A three-year survey of the antimicrobial resistance of microorganisms at a Chinese hospital

The present retrospective study aimed to investigate the antibiotic susceptibility of bacteria at Shanghai First People's Hospital (Shanghai, China) between 2009 and 2011. An increasing trend of antibiotic resistance was observed in this hospital between 2009 and 2011. Escherichia coli, Acinetobacter baumannii and Staphylococcus aureus were the most prevalent resistant strains. Antimicrobial susceptibility was detected using standard Kirby-Bauer disk diffusion and analyzed using World Health Organization software. E. coli was demonstrated to be the most prevalent bacterium in the present survey between 2009 and 2011 (16.2, 20.0 and 19.6%, respectively); followed by A. baumannii (13.5, 13.3 and 10.6%, respectively) and S. aureus. Notably, >70% of E. coli and 70% of S. aureus were resistant to common antibiotics; whereas 60% of A. baumannii and 20% of Pseudomonas aeruginosa were resistant to the majority of the antibiotics investigated. In 2011, Enterococcus faecalis exhibited a resistance rate of 55.6% against levofloxacin and E. faecium exhibited a 53.2% resistance rate. The present survey demonstrated an increasing trend in bacterial resistance against antibiotics; therefore, more stringent guidelines for antibiotics should be advocated.

COPD patients with ventilator-associated pneumonia: implications for management

Data on the occurrence and outcome of patients with chronic obstructive pulmonary disease (COPD) and ventilator-associated pneumonia (VAP) are quite limited. The aim of this study was to determine if COPD intensive care unit (ICU) patients have a higher rate of VAP development, different microbiological aetiology or have worse outcomes than other patients without VAP. A secondary analysis of a large prospective, observational study conducted in 27 European ICUs was carried out. Trauma patients were excluded. Of 2082 intubated patients included in the study, 397 (19.1%) had COPD; 79 (19.9%) patients with COPD and 332 (19.7%) patients without COPD developed VAP. ICU mortality increased by 17% (p < 0.05) when COPD patients developed VAP, remaining an independent predictor of mortality [odds ratio (OR) 2.28; 95% confidence interval (CI) 1.35-3.87]. The development of VAP in COPD patients was associated with a median increase of 12 days in the duration of mechanical ventilation and >13 days in ICU stay (p < 0.05). Pseudomonas aeruginosa was more common in VAP when COPD was present (29.1% vs. 18.7%, p = 0.04) and was the most frequent isolate in COPD patients with early-onset VAP, with a frequency 2.5 times higher than in patients without early-onset VAP (33.3% vs. 13.3%, p = 0.03). COPD patients are not more predisposed to VAP than other ICU patients, but if COPD patients develop VAP, they have a worse outcome. Antibiotic coverage for non-fermenters needs to be included in the empiric therapy of all COPD patients, even in early-onset VAP.

Reducing ventilator-associated pneumonia in neonatal intensive care unit using "VAP prevention Bundle": a cohort study

BACKGROUND

Ventilator-associated pneumonia (VAP) is a serious health care-associated infection, resulting in high morbidity and mortality. It also prolongs hospital stay and drives up hospital costs. Measures employed in preventing ventilator-associated pneumonia in developing countries are rarely reported. In this study we tried to assess the efficacy of our designed "VAP prevention bundle" in reducing VAP rate in our neonatal intensive care unit (NICU).

METHOD

This prospective before-and-after study was conducted at university hospital NICU, all neonates who had mechanical ventilation for ≥ 48 h were eligible. VAP rates were evaluated before (phase-I) and after (phase-II) full implementation of comprehensive preventive measures specifically designed by our infection control team.

RESULTS

Of 143 mechanically ventilated neonates, 73 patients developed VAP (51%) throughout the study period (2500 mechanical ventilation days). The rate of VAP was significantly reduced from 67.8% (42/62) corresponding to 36.4 VAP episodes/1000 mechanical ventilation days (MV days) in phase-I to 38.2% (31/81) corresponding to 23 VAP/1000 MV days (RR 0.565, 95% confidence interval 0.408-0.782, p = 0.0006) after VAP prevention bundle implementation (phase-II). Parallel significant reduction in MV days/case were documented in post-intervention period (21.50 ± 7.6 days in phase-I versus 10.36 ± 5.2 days in phase-II, p = 0.000). There were a trend toward reduction in NICU length of stay (23.9 ± 10.3 versus 22.8 ± 9.6 days, p = 0.56) and overall mortality (25% versus 17.3%, p = 0.215) between the two phases but didn't reach statistical significance. The commonest micro-organisms isolated throughout the study were gram-negative bacteria (63/66, 95.5%) particularly Klebsilla pneumonia (55/66, 83.4%).

CONCLUSION

Implementation of multifaceted infection control bundle resulted in reduction of VAP rate, length of stay in our NICU.

Trimethoprim/sulfamethoxazole for Acinetobacter spp.: A review of current microbiological and clinical evidence

Clinicians nowadays are confronted with an epidemic of multidrug-resistant (MDR) Acinetobacter infections and are forced to consider every treatment alternative, including older antibiotic agents, not conventionally used. This review aimed to evaluate the published evidence on the antimicrobial activity and clinical effectiveness of trimethoprim/sulfamethoxazole (TMP-SMX) against Acinetobacter spp. Selected in vitro studies included antimicrobial surveillance reports, microbiological studies regarding the activity of TMP-SMX against MDR Acinetobacter isolates, and clinical studies published after the year 2000. Non-susceptibility rates for Acinetobacter spp. in surveillance studies ranged from 4% to 98.2%; in 23 of 28 studies, non-susceptibility to TMP-SMX was >50% and in a subset of 15 studies non-susceptibility was >70%. In studies regarding MDR Acinetobacter spp., non-susceptibility rates ranged from 5.9% to 100%; however, 19 of 21 studies reported >70% non-susceptibility. Extensively drug-resistant Acinetobacter baumannii complex had total (100%) resistance in five of six studies. Carbapenem-resistant Acinetobacter spp. had non-susceptibility rates to TMP-SMX of >80% in 22 of 26 studies. One study on polymyxin-resistant A. baumannii showed a susceptibility rate of 54.2% (13/24). Only seven case reports evaluated TMP-SMX for Acinetobacter spp. infections, mainly in combination with other agents; all cases were deemed therapeutic successes. Although TMP-SMX is not usually active against Acinetobacter spp., it might be considered in cases where there are no other options.

Ventilator-associated pneumonia prevention methods using topical antibiotics: herd protection or herd peril?

Ventilator-associated pneumonia (VAP) develops in approximately 20% of patients in the ICU receiving prolonged mechanical ventilation (MV). Among the range of methods for preventing VAP, the evidence base for topical antibiotics (TAs), including selective digestive decontamination, appears to be the most compelling. However, several observations are puzzling, and the contextual influence resulting from concurrent use of both topical placebo and TA within an ICU remains untested. As with herd protection conferred by vaccination, contextual influences resulting from a population-based intervention cannot be estimated at the level of a single trial. Estimating contextual effects requires multilevel random-effects methods. In this way the dispersion in VAP incidence across groups from 206 studies, as cited in various-source systematic reviews, was calibrated. The benchmark mean VAP incidence derived from 49 observational groups of patients receiving MV is 23.7% (95% CI, 20.6%-27.2%). In contrast, for 20 and 15 concurrent control groups from the TA evidence base that did vs did not receive topical placebo, respectively, this incidence is 38% (95% CI, 29%-48%) and 33% (95% CI, 20%-50%). This contextual influence remains significant in a meta-regression model adjusted for group-level variables, such as within a trauma ICU context. The mean VAP incidence for five other categories of control groups from the broader evidence base is within four percentage points of the benchmark. The contextual effect of TA is paradoxic, peculiar, potent, perfidious, and potentially perilous. The TA evidence base requires reappraisal to consider this herd peril.

Meta-analysis of high doses of ambroxol treatment for acute lung injury/acute respiratory distress syndrome based on randomized controlled trials

This study seeks to evaluate the potential benefits of high doses of ambroxol treatment for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) by conducting a meta-analysis based on randomized controlled trials (RCTs). We searched the Pubmed, Embase, China National Knowledge Infrastructure, and Wanfang databases through December 2013. Only RCTs evaluating high doses of ambroxol (≥15 mg/kg or 1000 mg/day) treatment for patients with ALI/ARDS were selected. We included 10 RCTs involving 508 patients. Adjuvant treatment with high doses of ambroxol increased PaO(2)/FiO(2) (weight mean differences [WMD] = 69.18, 95% confidence intervals [CI]: 41.71-96.65), PO(2) (WMD = 11.74, 95% CI: 8.50-14.99), and SaO(2) (WMD = 2.15, 95% CI: 1.60-2.71) compared with usual treatment. Treatment with high doses of ambroxol appeared to reduce serum tumor necrosis factor-α level (WMD -7.92 µg/L; 95% CI, -10.94 to -4.9) and interleukin-6 level (WMD = -20.65 µg/L, 95% CI: -24.74 to -16.55) and to increase serum superoxide dismutase level (WMD = 19.07 NU/mL, 95% CI: 6.16-31.97). The findings suggest that treatment with high doses of ambroxol appears to improve PaO(2)/FiO(2), PO(2), and SaO(2), and the benefits might be related to ambroxol's anti-oxidant and anti-inflammatory properties.

Ventilator-associated pneumonia due to extensive drug-resistant Acinetobacter baumannii: risk factors, clinical features, and outcomes

Acinetobacter baumannii is characterized by a rapid development of resistance to the commonly used antimicrobial agents. We investigated the risk factors, clinical features, and outcomes in ventilator-associated pneumonia (VAP) caused by extensive drug-resistant Acinetobacter baumannii (XDRAB). Clinical parameters and overall in-hospital mortality rates were compared between the VAP with and without XDRAB infection groups. This study showed that VAP caused by XDRAB was not associated with in-hospital mortality. However, it was related to high Simplified Acute Physiology Score II scores and increasing durations of hospital stays.

Relationship between nasal colonization and ventilator-associated pneumonia and the role of the environment in transmission of Staphylococcus aureus in intensive care units

BACKGROUND

This study assessed the relationship between nasal colonization and ventilator-associated pneumonia (VAP) by Staphylococcus aureus, as well the role of the environment in the transmission of this organism.

METHODS

We performed a cohort study of patients with VAP caused by methicillin-resistant S aureus (MRSA) or methicillin-sensitive S aureus during 2 years in an adult intensive care unit (ICU). All patients had nasal swab specimens obtained at admission and during the ICU stay. Clinical samples also were collected for analysis, as were samples from the hands of health care professionals and the environment, and were typed using pulsed-field gel electrophoresis.

RESULTS

S aureus VAP represented 12.5% of the cases, and statistical analysis identified colonization as a risk factor for the development of this infection. MRSA was isolated from the environment and hands, indicating the existence of a secondary reservoir. Molecular typing revealed a polyclonal profile; however, clone J was the most frequent (45.5%) among isolates of MRSA tested, with a greater profile of resistance than the other isolates. There was strong evidence suggesting transmission of MRSA to patients from the environment.

CONCLUSION

Nasal colonization for S aureus is a risk factor for development of VAP.

Efficacy of an infection control program in reducing ventilator-associated pneumonia in a Chinese neonatal intensive care unit

BACKGROUND

Measures employed in preventing ventilator-associated pneumonia (VAP) in developing countries are rarely reported. This study evaluates the efficacy of an infection control program in reducing VAP in a neonatal intensive care unit (NICU) in China.

METHODS

All neonates who received mechanical ventilation for at least 48 hours and were hospitalized in the NICU for ≥5 days during 3 epochs were included. The hospital relocated to a new site during phase 2 and a bundle of comprehensive preventive measures against VAP were gradually implemented using the evidence-based practice for improving quality method. Research physicians recorded associated information of patients diagnosed with VAP.

RESULTS

Of 491 patients receiving mechanical ventilation, 92 (18.7%) developed VAP corresponding to 27.33 per 1,000 ventilator-days. The rate decreased from 48.84 per 1,000 ventilator-days in phase 1 to 25.73 per 1,000 ventilator-days in phase 2 and further diminished to 18.50 per 1,000 ventilator-days in phase 3 (P < .001). Overall mortality rate of admitted neonates significantly decreased from 14.0% in phase 1 to 2.9% in phase 2 and 2.7% in phase 3 (P = .000). Gram-negative bacteria (95.5%) were the predominant organisms in VAP and Acinetobacter baumannii (65.2%) was the most frequently isolated microorganism.

CONCLUSIONS

Implementing a multifaceted infection control program resulted in a significant reduction in VAP rate with long-term effects. Such interventions could be extended to other low-income countries.

Antimicrobial resistance in Asia: current epidemiology and clinical implications

Antimicrobial resistance has become one of the most serious public health concerns worldwide. Although circumstances may vary by region or country, it is clear that some Asian countries are epicenters of resistance, having seen rapid increases in the prevalence of antimicrobial resistance of major bacterial pathogens. In these locations, however, the public health infrastructure to combat this problem is very poor. The prevalence rates of methicillin-resistant Staphylococcus aureus (MRSA), macrolide-resistant Streptococcus pneumoniae, and multidrug-resistant enteric pathogens are very high due to the recent emergence of extremely drug-resistant gram-negative bacilli in Asia. Because antimicrobial options for these pathogens are extremely limited, infections caused by antimicrobial-resistant bacteria are often associated with inappropriate antimicrobial therapy and poor clinical outcomes. Physicians should be aware of the current epidemiological status of resistance and understand the appropriate use of antimicrobial agents in clinical practice. This review focuses on describing the epidemiology and clinical implications of antimicrobial-resistant bacterial infections in Asian countries.

High-dose ambroxol reduces pulmonary complications in patients with acute cervical spinal cord injury after surgery

BACKGROUND

Ambroxol has a very high affinity for lung tissues; its concentration is approximately 20 times higher in the lung than in the serum. We aimed to evaluate the effectiveness of high-dose ambroxol (990 mg/day) in the improvement of oxygenation and prevention of postoperative respiratory complications in the patients with acute cervical spinal cord injury (CSCI).

METHODS

A total of 61 acute CSCI patients admitted to the Intensive Care Unit (ICU) of our hospital between January 2009 and June 2011 were included in the study. They were graded as ASIA A and ASIA B according to the classification of the American Spinal Injury Association (ASIA) and were randomly divided into two groups: one group received intravenous ambroxol at 990 mg/day for 5 consecutive days after operation; the other group treated without ambroxol served as control. The results of arterial blood gas analysis on postoperative day 3 and 5 and occurrence of pulmonary complications within 5 days after operation were evaluated.

RESULTS

The group treated with high-dose ambroxol showed a lower rate of postoperative pneumonia and hypoxemia within 5 days after operation. On the 3rd and 5th days, the oxygenation index in the high-dose ambroxol group (291.02 ± 34.96 and 301.28 ± 37.69) was significantly higher than in the control group (230.08 ± 26.25 and 253.82 ± 26.26), with significant differences between the two groups (P = 0.045 and 0.041).

CONCLUSION

Administration of high-dose ambroxol should be considered as an alternative and effective approach to reduce the postoperative respiratory complications and improve the oxygenation status in acute CSCI patients.

Impact of a multidimensional approach on ventilator-associated pneumonia rates in a hospital of Shanghai: findings of the International Nosocomial Infection Control Consortium

PURPOSE

The aim of this study was to analyze the impact of a multidimensional infection control approach on the reduction of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) patients of one hospital in China.

MATERIALS AND METHODS

We conducted a before-after study from January 2005 to July 2009, which was divided into baseline (phase 1) and intervention (phase 2) periods. During phase 1, active prospective outcome surveillance of VAP was performed by applying the definitions of the Centers for Disease Control and Prevention/National Health Safety Network, and the methodology of the International Nosocomial Infection Control Consortium. During phase 2, the multidimensional approach was implemented. Ventilator-associated pneumonia rates obtained in phases 1 and 2 were compared in yearly periods.

RESULTS

We recorded data from 16,429 patients hospitalized in 3 ICUs, for a total of 74,116 ICU bed days. The VAP baseline rate was 24.1 per 1000 ventilator-days. During phase 2, the VAP rate significantly decreased to 5.7 per 1000 ventilator-days in 2009 (2009 vs 2005: relative risk, 0.31; 95% confidence interval, 0.16-0.36; P = .0001), amounting to a 79% cumulative VAP rate reduction.

CONCLUSIONS

Implementing a multidimensional infection control intervention for VAP was associated with a significant cumulative reduction in the VAP rate in our ICUs.