Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

High-dose inhaled NO for the prevention of nosocomial pneumonia after cardiac surgery under cardiopulmonary bypass: A proof-of-concept prospective randomised study

OBJECTIVE

This study aimed to assess the safety and potential efficacy of high-dose inhaled nitric oxide therapy for the prevention of postoperative pneumonia in cardiac surgery patients.

METHODS

A prospective randomised controlled pilot study included 74 patients with moderate risk of postoperative pneumonia after elective cardiac surgery under cardiopulmonary bypass. Patients were randomised into two groups. The main group (NO-group) (n = 37) received inhaled nitric oxide at a dose of 200 ppm for 30 minutes 2 times a day for 5 days or until pneumonia developed. The control group received conventional postoperative care (n = 37). The primary endpoint was the incidence of postoperative pneumonia during in-hospital stay.

RESULTS

Preventive nitric oxide inhalations were associated with a reduced incidence of postoperative nosocomial pneumonia (2 (5.4%) cases in the main group (NO-group) vs. 9 (24.3%) cases in the control group, p = 0.046; OR = 0.178, 95% CI = 0.036-0.89)). There was no decrease in either peak expiratory flow, or peak inspiratory flow in comparison with the preoperative values in the NO-group. Inhaled nitric oxide therapy is safe. It did not lead to an increase in the incidence of acute kidney injury.

CONCLUSIONS

High-dose inhaled nitric oxide therapy is safe and effective for the prevention of postoperative nosocomial pneumonia in cardiac surgery.

M28 family peptidase derived from Peribacillus frigoritolerans initiates trained immunity to prevent MRSA via the complosome-phosphatidylcholine axis

Methicillin-resistant Staphylococcus aureus (MRSA) represents a major global health threat due to its resistance to conventional antibiotics. The commensal microbiota maintains a symbiotic relationship with the host, playing essential roles in metabolism, energy regulation, immune modulation, and pathogen control. Mammals harbor a wide range of commensal bacteria capable of producing unique metabolites with potential therapeutic properties. This study demonstrated that M28 family peptidase (M28), derived from commensal bacteria Peribacillus frigoritolerans (P. f), provided protective effects against MRSA-induced pneumonia. M28 enhanced the phagocytosis and bactericidal activity of macrophages by inducing trained immunity. RNA sequencing and metabolomic analyses identified the CFB-C3a-C3aR-HIF-1α axis-mediated phosphatidylcholine accumulation as the key mechanism for M28-induced trained immunity. Phosphatidylcholine, like M28, also induced trained immunity. To enhance M28-mediated therapeutic potential, it was encapsulated in liposomes (M28-LNPs), which exhibited superior immune-stimulating properties compared to M28 alone. In vivo experiments revealed that M28-LNPs significantly reduced bacterial loads and lung damage following MRSA infection, which also provided enhanced protection against Klebsiella pneumoniae and Candida albicans. We first confirmed a link between complement activation and trained immunity, offering valuable insights into the treatment and prevention of complement-related autoimmune diseases.

Population pharmacokinetics study on nebulized and intravenous administration of polymyxin B in patients with pneumonia caused by multidrug-resistant gram-negative bacteria

Polymyxin B (PMB) remains a last-line therapeutic agent for multidrug-resistant gram-negative bacteria (MDR-GNB) infections. However, reliable pharmacokinetic (PK) data to guide nebulized PMB dosing regimens in critically ill patients are limited. This study aimed to establish a population pharmacokinetic (PopPK) model for PMB in both epithelial lining fluid (ELF) and plasma of critically ill patients with MDR-GNB pneumonia and to optimize dosing regimens. A prospective PK study was conducted in 76 adult patients receiving nebulized PMB either as monotherapy or in combination with intravenous administration. PK data were analyzed using non-linear mixed-effect modeling, with PMB concentration-time profiles described by a coupled model integrating separate two-compartment models for plasma and ELF. The final model identified albumin levels and age as significant covariates influencing PK variability. Monte Carlo simulations demonstrated that nebulization therapy either alone or combined with intravenous administration significantly enhances ELF concentration and the probability of target attainment. Additionally, Pseudomonas aeruginosa requires higher nebulized doses than Klebsiella pneumoniae and Acinetobacter baumannii. This study develops a PopPK model of PMB in ELF and plasma, providing critical insights to optimize PMB treatment strategies for patients with MDR-GNB pneumonia.

Nosocomial lower respiratory tract infections in patients with immunosuppression: a cohort study

BACKGROUND

This post-hoc analysis of a multinational, multicenter study aimed to describe and compare clinical characteristics, microbiology, and outcomes between immunosuppressed and non-immunosuppressed patients with nosocomial lower respiratory tract infections (nLRTI). The study utilized data from the European Network for ICU-related Respiratory Infections, including 1,060 adult ICU patients diagnosed with nLRTI. Descriptive statistics were used to compare baseline characteristics and pathogen distribution between groups. A Cox proportional hazards model stratified by immunosuppression status was applied to assess 28-day mortality risk, adjusting for disease severity and key clinical variables.

RESULTS

Immunosuppression was observed in 24.9% (264/1060) of the patients, and oncological conditions were the most common etiology of immunosuppression. Chronic pulmonary and cardiovascular diseases were the most frequent comorbidities. In both groups, Pseudomonas aeruginosa was the predominant microorganism, particularly affecting patients with immunosuppression (25.3% vs. 16.7%, p = 0.032). Cox regression model adjusted for disease severity (SAPS II), polytraumatized status, altered consciousness, and postoperative status, SAPS II remained a strong independent predictor of mortality, with each one-point increase associated with a 2.3% higher risk of death (HR: 1.023, 95% CI 1.017-1.030, p < 0.001). The analysis also revealed significant heterogeneity in mortality risk among immunosuppressed patients, with hematological malignancies, recent chemotherapy, and bone marrow transplantation associated with the highest mortality.

CONCLUSIONS

Immunosuppressed patients had a lower adjusted survival probability compared to non-immunosuppressed patients. Moreover, P. aeruginosa was the most frequently identified etiological pathogen in immunosuppressed patients.

Antibiotic de-escalation patterns and outcomes in critically ill patients with suspected pneumonia as informed by bronchoalveolar lavage results

PURPOSE

Antibiotic stewardship in critically ill pneumonia patients is crucial yet challenging, partly due to the limitations of noninvasive diagnostic tests. This study reports an antibiotic de-escalation pattern informed by bronchoalveolar lavage (BAL) results, incorporating quantitative cultures and multiplex PCR rapid diagnostic tests.

METHODS

We analyzed data from SCRIPT, a single-center prospective cohort study of mechanically ventilated patients who underwent a BAL for suspected pneumonia. We used the Narrow Antibiotic Therapy (NAT) score to quantify day-by-day antibiotic prescription patterns for each suspected pneumonia episode etiology (bacterial, viral, mixed bacterial/viral, microbiology-negative, and non-pneumonia control). The primary outcome was a composite of in-hospital mortality, discharge to hospice, or requiring lung transplantation during hospitalization, which we referred to as unfavorable outcomes. The secondary outcomes were duration of ICU stay, duration of intubation, and Clostridium difficile during admission. Outcomes were compared across pneumonia etiologies with the Mann-Whitney U test and Fisher's exact test.

RESULTS

Among 686 patients (409 men, 276 women) with 927 pneumonia episodes, NAT score analysis showed consistent antibiotic de-escalation in all pneumonia etiologies except resistant bacterial pneumonia. Microbiology-negative pneumonia was treated similarly to susceptible bacterial pneumonia. 44% viral episodes had antibiotic cessation by post-BAL day 5. Unfavorable outcomes were comparable across all pneumonia etiologies. Patients with viral and mixed bacterial/viral pneumonia had longer durations of ICU stay and intubation. Clostridium difficile was detected in 14 (2%) patients.

CONCLUSIONS

BAL quantitative cultures and multiplex PCR rapid diagnostic tests resulted in prompt antibiotic de-escalation in critically ill pneumonia patients. There was no evidence of increased unfavorable outcomes.

Inhaled alone versus inhaled plus intravenous polymyxin B for the treatment of pneumonia due to carbapenem-resistant gram-negative bacteria: A prospective randomized controlled trial

OBJECTIVES

Infections due to carbapenem-resistant Gram-negative bacteria (CR-GNB) are associated with considerable morbidity and mortality. Polymyxin B (PMB) is a first-line agent for CR-GNB-associated pneumonia, but limited data exist on the clinical use of inhaled (IH) PMB.

METHODS

A single-center, prospective randomized controlled trial was conducted in China to compare IH PMB alone with IH plus intravenous (IV) PMB between February 2022 and February 2024. The primary outcome was the clinical cure rate.

RESULTS

Twenty-two evaluable patients were assigned to the IH group, and 56 patients were included in the IH+IV group. Baseline characteristics were comparable between the two groups. No significant differences were observed in clinical cure rates, favorable clinical outcomes, microbiological outcomes, all-cause mortality, or pneumonia-related mortality. However, IH PMB alone was associated with a lower incidence of nephrotoxicity (P = 0.030). IH PMB demonstrated significantly higher drug concentrations in the epithelial lining fluid (ELF) compared to systemic administration. Patients with immunosuppressive therapy (OR, 0.066; 95% CI, 0.010-0.433; P = 0.005), malignancies (OR, 0.112; 95% CI, 0.016-0.797; P = 0.029), and higher SOFA scores (OR, 0.693; 95% CI, 0.518-0.929; P = 0.014) were less likely to achieve favorable clinical outcomes. Conversely, higher PMB ELF 1-hour concentrations (OR, 1.085; 95% CI, 1.026-1.148; P = 0.004) were associated with more favorable clinical outcomes. The combination of these four indicators demonstrated excellent diagnostic performance (AUC = 0.882). Plasma 1-hour PMB concentrations showed acceptable predictive performance for nephrotoxicity (AUC = 0.766).

CONCLUSIONS

The potential benefits of IH PMB outweigh the risks, making it an effective treatment for CR-GNB-associated pneumonia in combination with other empirical antimicrobial agents.

Prognostic Impact of Early Appropriate Antimicrobial Therapy in Critically Ill Patients With Nosocomial Pneumonia Due to Gram-Negative Pathogens: A Multicenter Cohort Study

OBJECTIVES

To evaluate whether early appropriate antimicrobial therapy (EAAT) is associated with improved outcomes in critically ill patients with hospital-acquired pneumonia (HAP), ventilated HAP (vHAP), or ventilator-associated pneumonia (VAP) involving Gram-negative bacteria (GNB).

DESIGN

Retrospective cohort study based on prospectively collected data.

SETTING

Thirty-two French ICUs (OutcomeRéa network).

PATIENTS

All patients with a first HAP, vHAP, or VAP due to GNB during their ICU stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The relationship between EAAT and day 28 all-cause mortality (primary endpoint) was explored through Cox proportional-hazard models, with subgroup analyses according to pneumonia types, causative GNB, features of EAAT, and the occurrence of septic shock at pneumonia diagnosis. The course of Sequential Organ Failure Assessment (SOFA) score values, the clinical cure rate at day 14, and the time to mechanical ventilation (MV) weaning and ICU discharge after pneumonia diagnosis were investigated as secondary endpoints. Among the 804 included patients, 495 (61.6%) received EAAT (single-drug, 25.4%; combination, 36.2%). Day 28 mortality was 32.6%. EAAT was not independently associated with this outcome (adjusted hazard ratio, 0.87; 95% CI, 0.67-1.12). This result was confirmed in subgroup analyses as in a second model considering all episodes of pneumonia occurring during the ICU stay. EAAT was not associated with a faster decrease in SOFA score values ( p = 0.11), a higher day 14 clinical cure rate (overall, 43.7%), or a shorter MV duration (cause-specific hazard ratio [HR] for extubation, 0.84; 95% CI, 0.69-1.01) or ICU stay (cause-specific HR for discharge alive, 0.85; 95% CI, 0.72-1.00).

CONCLUSIONS

In this study, EAAT was not associated with a reduced day 28 mortality, a faster resolution of organ failure, a higher day 14 clinical cure rate, or a shorter time to MV weaning or ICU discharge in critically ill patients with HAP, vHAP, or VAP due to GNB. However, a prognostic benefit from EAAT cannot be ruled out due to lack of statistical power.

Association Between Type of Immunosuppression and the Incidence, Microbiology, and Outcomes of Bacterial Ventilator-Associated Lower Respiratory Tract Infections: A Retrospective Multicenter Study

OBJECTIVES

Ventilator-associated lower respiratory tract infections (VALRTIs) are among the most common ICU-acquired infections in patients receiving invasive mechanical ventilation (IMV). Immunocompromised patients may have a lower incidence of VALRTI when compared with nonimmunocompromised patients, but the influence of the type of immunosuppression on the epidemiology of VALRTI has not been investigated. The study objectives were to assess the association of the type of immunosuppression with the incidence, microbiology, and outcomes (ICU mortality, ICU length of stay, and duration of IMV) of VALRTI related to bacterial pathogens.

DESIGN

Multicenter, international retrospective cohort study.

SETTING

One hundred eighteen ICUs (118) in nine countries.

PATIENTS

Eight hundred fifty-four immunocompromised adult patients (median age, 65 yr; 57.6% males) requiring IMV for greater than 48 hours, including 162 with hematologic malignancies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients with hematologic malignancies had a lower 28-day cumulative incidence of bacterial VALRTI than patients with other types of immunosuppression (13.6% vs. 20.1%; adjusted cause-specific hazard ratio, 0.61; 95% CI, 0.37-0.97), mostly due to a lower incidence of ventilator-associated pneumonia (9.3% vs. 13.9%). The proportion of VALRTI cases related to multidrug-resistant bacteria was similar between groups. Occurrence of bacterial VALRTI was associated with an increased mortality and a longer ICU length of stay, but this effect was independent of the type of immunosuppression.

CONCLUSIONS

Patients with hematologic malignancies had a lower 28-day cumulative incidence of bacterial VALRTI than patients with other types of immunosuppression, mainly due to a lower incidence of ventilator-associated pneumonia.

Nurses' compliance to ventilator-associated pneumonia prevention bundle and its effect on patient outcomes in intensive care units

BACKGROUND

Ventilator-associated pneumonia (VAP) is a significant healthcare-associated infection. Compliance with VAP guidelines reduces infection and leads to better patient outcomes.

AIM

The study investigated the VAP rate, nurses' compliance with the VAP bundle and the correlation between nurses' compliance with the VAP bundle and key patient-related outcomes.

STUDY DESIGN

This descriptive correlational prospective study was conducted at two tertiary hospitals. All intensive care unit patients on mechanical ventilators who met the inclusion criteria for 48 h or more were recruited. Data were analysed using descriptive statistics, Chi-square, independent t-test and Spearman's rank correlation.

RESULTS

Out of the 103 patients recruited, 22.3% of patients developed VAP, with a VAP rate of 5.6 per thousand ventilator days. Nurses' compliance with VAP guidelines in both hospitals was 69% and decreased over the admission period. Compliance with the VAP bundle was linked to less length of stay (rho = -0.260, p < .008), fewer mechanical ventilation days (rho = -0.300, p < .002) and less hospital cost (rho = -0.266, p < .007). The mean compliance with the VAP care bundle was higher in the non-VAP group (M = 72.9, SD = 23.79) than in patients who developed VAP (M = 56.6, SD = 18.96).

CONCLUSIONS

The findings underscore the critical need for healthcare organizations to prioritize strategies to enhance compliance with VAP guidelines for improved patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

Ongoing quality improvement efforts through regular audits of the VAP bundle implementation are crucial for reducing infections and complications and improving patient outcomes. Future research is recommended to investigate factors that impact nurses' adherence to VAP guidelines to develop interventions to enhance compliance.

Immune biomarkers for predicting postoperative pneumonia following hip fracture surgery

OBJECTIVE

Abnormalities of lymphocyte subsets have been observed in patients with pneumonia. This study investigated the diagnostic efficiency of lymphocyte subsets in the detection of early-stage postoperative pneumonia (POP) among older patients undergoing hip fracture surgery.

METHODS

A total of 576 patients with hip fracture were recruited and analyzed for lymphocyte subsets on the first postoperative day.

RESULTS

The incidence of POP was 10.6% (61/576) from March 2016 to December 2023. The area under the curve for the percentage of CD8+ HLA-DR+ T cells was higher than that of CD4+ T and CD4+ CD45RA+ T cells. A high percentage of CD8+ HLA-DR+ T cells was significantly associated with an increased occurrence of POP. The positive findings remained significant after adjusting for confounding factors. Among the multiple complications, patients with diabetes tended to have higher percentages of CD8+ HLA-DR+ T cells.

CONCLUSIONS

The percentage of CD8+ HLA-DR+ T cells had a good predictive value for detecting early-stage POP. Multi-center prospective studies with larger sample sizes are needed to verify this finding.

Infectious complications of Stevens-Johnson syndrome and toxic epidermal necrolysis: A systematic review and meta-analysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare severe cutaneous adverse reactions to medications characterized by keratinocyte necrosis leading to loss of protective barrier function and increased susceptibility to infection. Infection is a major cause of morbidity, and septicemia is the leading cause of mortality in this population. This systematic review and meta-analysis aimed to determine infectious complications' prevalence and risk factors in adults with SJS and TEN. This review was registered with the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) and conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Thirty-six articles describing results from 1446 cases were included. Skin infection was the most commonly diagnosed infection. The pooled prevalence of sepsis, respiratory tract infection, skin infection, and urinary tract infection was 27.3%, 21.5%, 37.5%, and 21.8%, respectively. Staphylococcus aureus was the most commonly identified organism. The overall quality of the studies was suboptimal, and the level of heterogeneity was high. The skin, bloodstream, respiratory, and urinary tracts are most commonly infected in the course of adult SJS and TEN. During hospitalization, clinicians should closely monitor and promptly investigate for these as well as several other infectious complications. More research is needed, with greater attention to the risk factors and causative organisms that cause these infections.

Detectable Concentrations With Inhaled Tobramycin in Critically Ill Infants and Children Following Implementation of Standardized Protocol

BACKGROUND

A protocol was established for ventilator-associated tracheitis or pneumonia using inhaled tobramycin 300 mg every 12 hours in mechanically ventilated children via a vibrating mesh nebulizer, 30 cm from the endotracheal tube in the inspiratory loop of the mechanical ventilator.

OBJECTIVES

The primary objective was to determine the incidence of detectable tobramycin trough concentrations >0.5 µg/mL. Secondary objectives included a comparison of clinical characteristics between those with and without detectable concentrations and identification of patients with acute kidney injury (AKI) as defined by the Kidney Diseases Improving Global Outcomes (KDIGO) criteria.

METHODS

This was a single-center retrospective study of critically ill children <18 years without cystic fibrosis receiving inhaled tobramycin between July 1, 2016, and August 31, 2021. Data collection included demographics, tobramycin regimen, and renal function. Analysis was performed using SAS 9.4, with a P-value <0.05, and a multivariable regression model was performed to identify factors for detectable concentrations and AKI.

RESULTS

Forty-four patients (66 courses) were included, with an overall age of 0.83 years. Thirty (68%) patients had detectable concentrations and 9 (20.5%) developed AKI. No significant differences in demographics, diagnosis, mechanical ventilation settings, and number of nephrotoxins were noted between those with and without detectable concentrations or AKI. Multivariable regressions did not identify factors associated with detectable concentrations or AKI.

CONCLUSION AND RELEVANCE

Detectable concentrations occurred with the majority of courses, with AKI associated with approximately one-fourth of courses. Clinicians should consider utilizing trough monitoring for all mechanically ventilated critically ill children receiving inhaled tobramycin.

Factors Associated with Successful Treatment of Carbapenem-Resistant Gram-Negative Bacilli Infections Using Intravenous Colistin Sulfate in China: A Real-World Retrospective Study

Objective

To evaluate the efficacy of intravenous colistin sulfate (CS) in the treatment of carbapenem-resistant Gram-negative bacilli (CR-GNB) infections in real-world clinical settings and to identify factors influencing its therapeutic outcomes, with the aim of promoting the rational use of CS.

Methods

A retrospective analysis was conducted on the clinical characteristics and treatment outcomes of 174 patients diagnosed with CR-GNB infection who received intravenous CS at our center between January 2021 and December 2023. The study evaluated both clinical efficacy and adverse drug reactions (ADRs).

Results

Among the 174 patients, 118 cases (67.8%) demonstrated clinical improvement, and the bacterial clearance rate was 53.9%. Multivariate logistic regression analysis identified several factors significantly associated with treatment efficacy: neurological disease (OR [95% CI]: 0.100 [0.019-0.541]; p = 0.006), admission to a surgical ward (OR [95% CI]: 0.136 [0.023-0.801]; p = 0.027), septic shock (OR [95% CI]: 5.147 [1.901-14.096]; p = 0.001), and empirical use of CS (OR [95% CI]: 4.250 [1.109-16.291]; p = 0.035). Additionally, 10 cases (5.8%) of acute kidney injury (AKI) were attributed to nephrotoxicity from CS, with 2 cases recovering after discontinuation of the drug.

Conclusion

Our findings suggest that intravenous colistin sulfate may be an effective treatment option for CR-GNB infections when used appropriately. However, further studies are required to better understand its real-world efficacy and safety profile.

Epidemiology and prediction of non-targeted bacteria by the filmarray pneumonia plus panel in culture-positive ventilator-associated pneumonia: a retrospective multicentre analysis

BACKGROUND

Ventilator-associated pneumonia (VAP) is a prevalent nosocomial infection in intensive care units (ICUs) with significant impacts on patient outcomes and healthcare costs. Multiplex PCR could allow for personalized empirical treatment of VAP and optimize antibiotic therapy.

METHODS

This multicenter retrospective study analyzed culture-positive VAP cases from January 2016 to March 2021 across 12 ICUs in France. The prevalence of non-targeted bacteria was evaluated according to the bacterial species included in the BioFire® FilmArray® Pneumonia Panel (FAPPP), and associated risk factors were identified. A non-targeted bacteria was defined as a bacterial species isolated during VAP, not included in the FilmArray panel, but considered by the clinician in the final antibiotic therapy.

RESULTS

Among 332 patients with 385 culture-positive VAP episodes, non-targeted pathogens were observed in 23% of cases (87/385) and represented 21% (110/534) of isolated bacteria (After excluding bacteria with low pathogenicity, the rate of VAP with a non-targeted bacterium was 21%). The most common non-targeted bacteria identified were Stenotrophomonas maltophilia (22%), Citrobacter koseri, and Hafnia alvei. Gram stain results poorly correlated with definitive cultures (42% of concordance). The proportion of culture-positive VAP with non-targeted bacteria varied significantly between ICUs, ranging from 12 to 37%, (p = 0.013). Polymicrobial culture-positive VAP had a twofold higher risk of non-targeted bacteria (47% vs. 25%, p < 0.001). In the multivariate analysis, in-ICU antibiotic exposure was associated with a twofold increased risk of non-targeted bacteria (25.3% vs. 12.9%, p = 0.042), and age over 70 years was associated with a threefold increased risk (p = 0.027). Among the 48 culture-positive VAP cases with ineffective empiric treatment, Pseudomonas aeruginosa (22%), Stenotrophomonas maltophilia (14%), and Enterobacter cloacae complex (8%) were the most frequent bacteria. Additionally, 67% of the culture-positive VAP cases with ineffective empirical antibiotic therapy involved targeted bacteria, of which 59% could have received effective empirical antibiotic therapy if panel results had been available, according to bacterial species identification and current guidelines.

CONCLUSIONS

A significant rate of culture-positive VAP cases with non-targeted bacteria was observed in this study, raising concerns about the interpretation of FAPPP results. Only positive FAPPP results may assist clinicians in the early personalization of antibiotic therapy for VAP.

Management practices and mortality predictors among Klebsiella pneumoniae infections across Lebanese hospitals: a multicenter retrospective study

BACKGROUND

Klebsiella pneumoniae is a significant cause of both community-acquired and nosocomial infections, leading to high morbidity and mortality rates. The increasing antimicrobial resistance among K. pneumoniae strains poses a critical challenge to effective treatment. This study aimed to assess the appropriateness of initial antimicrobial therapy, determine the 30-day all-cause mortality rate, and identify predictors of mortality among patients infected with K. pneumoniae in Lebanese hospitals.

METHODS

A multicenter retrospective observational study was conducted across three university hospitals in Beirut, Lebanon. The study included hospitalized adult patients with confirmed K. pneumoniae infections. Kaplan-Meier survival analysis and log-rank tests were used to analyze time-to-mortality. Binary logistic regression was performed to identify predictors of mortality.

RESULTS

Of 2,655 cases screened, 410 patients were enrolled, and 395 cases were included in the final analysis of the 30-day mortality after excluding those lost to follow-up. Nearly one-third of the isolates (36.8%) were extended-spectrum β-lactamase (ESBL)-producing, while 6.8% were carbapenem-resistant K. pneumoniae (CRKP). The most commonly prescribed empirical antibiotics were meropenem (31.7%), amikacin (28.5%), and ceftriaxone (22.2%). Around one-third of the patients (32.9%) received inappropriate initial antimicrobial therapy. The 30-day mortality rate was 14.4%. Main predictors significantly associated with mortality in patients with K. pneumoniae infection were solid cancer (adjusted odds ratio [AOR] = 7.82, P < 0.01), coronary artery disease (AOR = 4.81, P = 0.01), age ≥ 65 years (AOR = 4.22, P = 0.02), type II diabetes mellitus (AOR = 3.96, P = 0.01), receiving inappropriate initial antimicrobial therapy (AOR = 2.96, P = 0.02), infection with CRKP isolates (AOR = 2.53, P = 0.03), and having a higher Charlson comorbidity index (AOR = 1.61, P = 0.001).

CONCLUSIONS

The study highlights the critical need for effective antimicrobial stewardship and tailored infection control protocols to mitigate the high resistance rates and improve patient outcomes in Lebanon. Emphasis should be placed on enhancing the monitoring of local resistance patterns and using these data to guide the selection of appropriate empirical therapy to reduce mortality associated with K. pneumoniae infections.

Dementia, Systemic Biomarkers, and Risk of 30-Day Readmission After Pneumonia: A Multi-Center Cohort Study

Background

Dementia is a significant risk factor for adverse health outcomes, including pneumonia-related hospitalizations and readmissions. While comorbidities have been shown as predictors of poor pneumonia outcomes, the interplay between chronic comorbidities and acute physiological conditions, reflected by systemic biomarkers, remains underexplored. This study investigates the independent and joint effects of dementia and acute biomarkers on 30-day readmission risk following pneumonia hospitalization.

Subjects and Methods

We conducted a multicenter cohort study using data from three hospitals within the Taipei Medical University Clinical Research Database. Patients aged ≥45 years hospitalized for pneumonia between 2014 and 2021 were included. Dementia status was identified via ICD-9/10 codes, and acute systemic biomarkers were measured at the time of emergency department presentation. The primary outcome was 30-day all-cause readmission. Multivariable logistic regression assessed independent associations, while joint-effects models examined the combined impact of dementia with biomarker abnormalities and comorbidities.

Results

Among 11,989 patients, 6.7% experienced 30-day readmission. Dementia was independently associated with readmission (adjusted OR: 1.31, 95% CI: 1.07-1.61). Other significant predictors included abnormal hemoglobin (OR: 1.55), creatinine (OR: 1.42), glucose (OR: 1.32), and comorbidities such as cancer, chronic kidney disease, and diabetes mellitus. Joint-effects models showed that dementia amplified the impact of abnormal biomarkers, eg, patients with low hemoglobin and dementia had an OR of 1.98 compared to those with normal hemoglobin and no dementia.

Conclusion

Dementia and acute biomarker abnormalities independently and synergistically increase 30-day readmission risk after pneumonia hospitalization, underscoring the need for integrated management strategies targeting both cognitive and systemic health.

Serum procalcitonin in the diagnosis of pneumonia in the neurosurgical intensive care unit

Procalcitonin (PCT) is a biomarker for bacterial infections, with controversial utility in diagnosing hospital-acquired pneumonia (HAP) in neurosurgical intensive care unit (NICU) patients. Establishing an optimal PCT cutoff value could enhance diagnostic accuracy. This retrospective single-center study included NICU patients hospitalized between January 1, 2021, and December 31, 2022, who underwent routine serum PCT measurement. HAP was diagnosed based on clinical, biochemical, microbiological, and radiological data. The optimal PCT cutoff value was identified using the Youden Index. Associations between PCT levels, radiological findings, sputum cultures, and confirmed HAP were analyzed using chi-square tests. A multivariate logistic regression was performed to identify independent predictors of elevated PCT. Among 2363 patients, 193 met inclusion criteria, and 148 were diagnosed with HAP. The optimal PCT cutoff value was 0.095 ng/mL, yielding a sensitivity of 89.2% and specificity of 93.3% (p < 0.001). This cutoff resulted in a positive likelihood ratio of 13.3 and a negative likelihood ratio of 0.116. Radiological signs of pneumonia and positive sputum cultures were observed in 48.4% and 78.4% of HAP cases, respectively, but neither showed a significant association with HAP (p = 0.135 and p = 0.056). Leukocytosis was significantly associated with HAP but had low specificity, while CRP showed a non-significant trend. In multivariate analysis, only confirmed HAP independently predicted PCT elevation. PCT, with a cutoff value of 0.095 ng/mL, shows high diagnostic accuracy for HAP in NICU patients and could enhance early identification and treatment. Our findings suggest that elevated PCT is primarily driven by HAP rather than non-infectious inflammatory triggers such as trauma or recent surgery. Further prospective studies are warranted to validate these findings.

The pathogenesis of ventilator-associated pneumonia: old and new mechanisms

INTRODUCTION

Ventilator-associated pneumonia (VAP), defined as a lung infection that occurs in patients after 48 hours on mechanical ventilation, is among the most frequently found nosocomial infections in intensive care units around the world and is associated with increased morbidity, mortality, and economic burden.

AREAS COVERED

We review the classical mechanisms of VAP development and explore more recent ones, such as dysbiosis, which has changed our view of the pathogenesis of the disease; whereas in the past the lower respiratory tract was classically considered a sterile organ, the use of new diagnostic techniques has shown that the lungs of healthy humans are inhabited by a large, dynamic ecosystem of microorganisms. Dysbiosis is the disruption of this ecosystem and is a key factor in the development of VAP. Recent findings have demonstrated that host immunity is microbiome-regulated and, consequently, is profoundly affected by dysbiosis. In this paper the significance of the microbiome-immunity crosstalk in the pathophysiology of VAP will be discussed.

EXPERT OPINION

A deeper understanding of mechanisms of VAP pathogenesis should help to devise new preventive, diagnostic and therapeutic strategies for reducing the incidence of this condition and for improving patient prognosis.

Holy water not so holy: Potential source of Elizabethkingia pneumonia and bacteremia in an immunocompromised host

Elizabethkingia species are Gram-negative, glucose-non-fermenting bacilli predominantly found in soil and water, with Elizabethkingia anophelis increasingly recognized as a human pathogen. E. anophelis has also been reported in hospital outbreaks, suggesting the potential role of contaminated institutional water sources. Conventional microbiological methods often lead to misidentifying this pathogen for other members of the genus Elizabethkingia, suggesting a role for molecular methods for identification. We report a 67-year-old female who developed multiorgan failure requiring intensive care unit admission and mechanical ventilation while being treated with chemotherapy for Burkitt lymphoma. She developed pneumonia with Gram-negative bacilli isolated from her endotracheal aspirate culture, later identified as E. anophelis. She later developed bacteremia due to the same pathogen, which was confirmed by MALDI-TOF and whole genome sequencing. Waterborne transmission via holy water administration was postulated to be potential source of infection. Our case report highlights that E. anophelis may cause significant infection and should not be disregarded as contaminant, especially in immunosuppressed individuals. As a waterborne pathogen that may be brought into hospital environments, emphasis on educating family members, close nursing monitoring, and reporting of suspected, unsupervised manipulation of medical equipment should be undertaken to prevent contamination by this organism from outside sources.

Predicting nosocomial pneumonia of patients with acute brain injury in intensive care unit using machine-learning models

Introduction

The aim of this study is to construct and validate new machine learning models to predict pneumonia events in intensive care unit (ICU) patients with acute brain injury.

Methods

Acute brain injury patients in ICU of hospitals from January 1, 2020, to December 31, 2021 were retrospective reviewed. Patients were divided into training, and validation sets. The primary outcome was nosocomial pneumonia infection during ICU stay. Machine learning models including XGBoost, DecisionTree, Random Forest, Light GBM, Adaptive Boost, BP, and TabNet were used for model derivation. The predictive value of each model was evaluated using accuracy, precision, recall, F1-score, and area under the curve (AUC), and internal and external validation was performed.

Results

A total of 280 ICU patients with acute brain injury were included. Five independent variables for nosocomial pneumonia infection were identified and selected for machine learning model derivations and validations, including tracheotomy time, antibiotic use days, blood glucose, ventilator-assisted ventilation time, and C-reactive protein. The training set revealed the superior and robust performance of the XGBoost with the highest AUC value (0.956), while the Random Forest and Adaptive Boost had the highest AUC value (0.883) in validation set.

Conclusion

Machine learning models can effectively predict the risk of nosocomial pneumonia infection in patients with acute brain injury in the ICU. Despite differences in populations and algorithms, the models we constructed demonstrated reliable predictive performance.

The Potential of Probiotics in Reducing Ventilator-Associated Pneumonia: A Literature-Based Analysis

Ventilator-associated pneumonia (VAP) remains a significant concern in intensive care units (ICUs), contributing to increased morbidity, mortality, and healthcare costs. Probiotics and synbiotics have been explored as potential preventive measures due to their ability to modulate gut microbiota, reduce pathogenic colonization, enhance immune responses, and maintain intestinal barrier integrity. While some randomized controlled trials (RCTs) suggest that specific strains, such as Lactobacillus rhamnosus GG and Bifidobacterium breve, may reduce VAP incidence, larger trials have not confirmed significant benefits. Systematic reviews and meta-analyses indicate a potential 28-38% relative risk reduction in VAP, but evidence quality remains low due to methodological limitations and study heterogeneity. Economic evaluations also question the cost effectiveness of probiotic use in ICU settings. Future research should focus on large-scale, multicenter RCTs to determine the optimal strains, dosages, and administration methods, along with standardized diagnostic criteria. Until stronger evidence emerges, probiotics should be considered an adjunctive rather than a primary VAP prevention strategy.

The Potential of Probiotics in Reducing Ventilator-Associated Pneumonia: A Literature-Based Analysis

Ventilator-associated pneumonia (VAP) remains a significant concern in intensive care units (ICUs), contributing to increased morbidity, mortality, and healthcare costs. Probiotics and synbiotics have been explored as potential preventive measures due to their ability to modulate gut microbiota, reduce pathogenic colonization, enhance immune responses, and maintain intestinal barrier integrity. While some randomized controlled trials (RCTs) suggest that specific strains, such as Lactobacillus rhamnosus GG and Bifidobacterium breve, may reduce VAP incidence, larger trials have not confirmed significant benefits. Systematic reviews and meta-analyses indicate a potential 28–38% relative risk reduction in VAP, but evidence quality remains low due to methodological limitations and study heterogeneity. Economic evaluations also question the cost effectiveness of probiotic use in ICU settings. Future research should focus on large-scale, multicenter RCTs to determine the optimal strains, dosages, and administration methods, along with standardized diagnostic criteria. Until stronger evidence emerges, probiotics should be considered an adjunctive rather than a primary VAP prevention strategy.

Lung and gut microbiota profiling in intensive care unit patients: a prospective pilot study

BACKGROUND

The gut and lung microbiomes play crucial roles in host defense and mayserve as predictive markersfor clinical outcomes in critically ill patients. Despite this, the simultaneous dynamics of lung and gut microbiomes during critical illness remain unclear. This study aims to assess the longitudinal changes in lung and gut microbiota among mechanically ventilated ICU patients with and without infection and to identify microbial features predictive of clinical outcomes, including the development of ventilator associated pneumonia (VAP).

METHODS

In this prospective observational study, we analyzed 73 endotracheal aspirates (ETA) and 93 rectal swabs collected from 38 ICU patients over multiple timepoints (intubation, infection onset, post-antibiotic, and extubation/discharge). Patients were categorized into three groups: (1) VAP, (2) other infections, and (3) uninfected controls. Lung and gut microbiota were characterized using 16S rRNA gene sequencing. Primary outcomes included microbial diversity and community composition; secondary outcomes included ICU length of stay and ventilator-free days.

RESULTS

Alpha diversity declined more significantly in infected patients than in controls during the ICU stay, with the most pronounced changes in lung microbiota. We found an enrichment of Enterobacteriaceae and other Proteobacteria in the lung microbiome of pneumonia patients, while the gut microbiota remained relatively stable. Relative abundances of key taxa such as Mogibacterium were associated with mechanical ventilation duration.

CONCLUSIONS

This study reveals that distinct microbial patterns in both lung and gut microbiota are associated with infection and clinical outcomes in critically ill patients. Understanding these dynamics is crucial for developing targeted microbiota interventions, potentially improving outcomes such as VAP prevention and management.

TRIAL REGISTRATION

Ethics Committee of Canton Vaud, Switzerland (2017-01820).

Prevalence and predictors of multidrug resistant organism infections in critically ill patients with opioid use disorder: a multicenter retrospective cohort study

OBJECTIVE

Patients with Opioid Use Disorder (OUD) are prone to Multidrug-Resistant Organism (MDRO) colonization and infections, thus at risk for worse outcomes during critical illness. Understanding the prevalence and predictors of MDRO infections is essential to optimize interventions and treatments.

DESIGN

Retrospective cohort study.

METHODS

The study evaluated the prevalence of MDRO isolation among adults with OUD admitted to an intensive care unit (ICU) between January 1, 2018, and July 31, 2023. It included adults admitted to an ICU with bacterial infections and positive cultures obtained within 48 hours of admission. Demographics, clinical traits, and MDRO isolation rates were analyzed using descriptive statistics, univariate methods, and Least Absolute Shrinkage and Selection Operator (LASSO) regression.

RESULTS

MDRO isolation occurred in 178 of 790 patients (22.5%), with methicillin-resistant Staphylococcus aureus as the most frequently isolated organism. LASSO regression identified housing insecurity (OR: 1.79, 95% CI 1.09-2.93, P = .022), no receipt of medications for OUD treatment (OR: 1.56, 95% CI 1.06-2.29, P = .023), positive hepatitis C virus (HCV) status (OR: 2.19, 95% CI 1.19-4.03, P = .012), and intravenous antibiotic use in the prior 90 days (OR: 1.04 per 24 h, 95% CI 1.01-1.07, P = .007) as significant predictors of MDRO isolation.

CONCLUSIONS

The study highlights a high prevalence of MDRO isolation in critically ill OUD patients admitted for infection-related issues with positive cultures obtained within 48 hours of admission, influenced by factors like housing insecurity, no receipt of medications for OUD treatment, HCV status, and prior antibiotic use.

Longitudinal assessment of the effect of invasive fungal infections on transplant success in kidney transplant recipients

Invasive fungal infections (IFIs) significantly impact morbidity and mortality in kidney transplant recipients (KTRs), but their effect on allograft function remains poorly defined. This retrospective study examined adult KTRs transplanted at Johns Hopkins from 2012 to 2018, with follow-up through 2023. The association of IFIs with a composite outcome of graft failure and mortality was assessed using negative binomial regression. The association of IFI exposure on composite outcome was quantified by matching using a stochastic extension stratification method, followed by Cox regression. Among 1453 KTRs, 79 were diagnosed with proven/probable IFIs, predominantly invasive candidiasis (46.8%). KTRs with IFIs had worse outcome-free survival with higher composite outcome rates (53/79 [67.1%] vs 411/1338 [30.7%]; P < .001). The composite outcome incidence rate was 4.61-fold higher when IFIs occurred in the first 6 months posttransplant and decreased to 2.13-fold higher after 36 months (P < .001). IFI exposure was associated with 3.45-fold increased hazard of composite outcome (95% CI, 1.54-7.70; P < .01) and a 3.23-fold increased hazard of all-cause mortality (95% CI, 1.53-6.83; P < .01). The association of IFIs with increased risk of poor kidney transplant outcomes, particularly in the early posttransplant period, highlights the need for improved strategies for early IFI detection and management in KTRs.

Independent risk factors and outcomes for ventilator-associated pneumonia due to multidrug-resistant organisms after cardiac valvular surgery

Background

Although numerous studies have documented the risk factors for ventilator-associated pneumonia (VAP) after cardiac surgery, most of these studies included heterogeneous patient populations. This study aimed to explore the risk factors for VAP caused by multidrug-resistant organisms (MDRO) in patients admitted to the cardiosurgery intensive care unit (CSICU) following cardiac valvular surgery.

Methods

This was a single-center, retrospective study. The clinical data of adult VAP patients following cardiac valvular surgery from January 2021 to December 2023 were analyzed. Patients were divided into MDRO VAP and non-MDRO VAP groups. Perioperative clinical data and postoperative follow-up results were collected for both groups. Univariable and multivariable logistic regression analyses were performed to identify risk factors for MDRO VAP, and the outcomes of MDRO VAP patients were analyzed. The species of pathogens isolated from the VAP patients were also investigated.

Results

A total of 109 VAP patients were included in this study, including 47 patients with MDRO VAP and 62 patients with non-MDRO VAP. Multivariable logistic regression analysis identified that independent risk factors for MDRO VAP included preoperative hypoalbuminemia (OR, 0.838; CI, 0.733-0.957; p = 0.009), prolonged mechanical ventilation (OR, 1.173; CI, 1.005-1.369; p = 0.043), and extended broad-spectrum antibiotic therapy (OR, 1.112; CI, 1.019-1.213; p = 0.018). Patients with MDRO VAP had significantly longer ICU stays, total hospital stays, and higher hospitalization costs than non-MDRO VAP patients. The in-hospital mortality rate of the MDRO VAP group was significantly higher than that of the non-MDRO VAP group (29.79% vs. 1.61%, p < 0.001). Gram-negative bacilli were the predominant pathogens in MDRO VAP patients (97.87%), with the highest rate of Pseudomonas aeruginosa (29.79%).

Conclusion

Postoperative MDRO VAP in patients undergoing cardiac valvular surgery is linked to severe clinical outcomes. Greater attention should be given to patients with prolonged mechanical ventilation, extended broad-spectrum antibiotic therapy, and preoperative hypoalbuminemia to prevent MDRO VAP infections.

Frailty and hospital outcomes among patients with neurological disorders

INTRODUCTION

Patients with neurological disorders, particularly those who are chronologically and biologically older, may display highly varied clinical courses and trajectories. The present study explored the association between frailty and hospital outcomes among patients with acute neurological presentations admitted to an Italian university hospital.

MATERIALS AND METHODS

A cross-sectional study considered all patients consecutively admitted to the Neurology Unit of the Policlinico Umberto I University Hospital of Rome (Italy). A 40-item Frailty Index (FI) was retrospectively developed based on the clinical information collected in the Emergency Department (ED). Data on hospitalization outcomes were prospectively collected during the patient's stay at the Neurology Unit. Linear and logistic regression models were conducted to test the association between FI and hospital outcomes.

RESULTS

Overall, 185 participants (women 50.3%; mean age 68.6, SD 18.6 years) were included. FI scores ranged between 0 and 0.43, with a median value of 0.15 [IQR 0.10], and were positively correlated with age (Spearman's rho 0.55, p < 0.001). In a linear regression model adjusted by age, sex, and diagnosis, FI was significantly associated with the number of days spent in the Neurology Unit (B 2.18, 95%CI 0.25-4.11, per 0.1 increase; p = 0.03). In bivariate logistic regression models adjusted by age, sex, and diagnosis, increasing FI scores were significantly associated with a lower likelihood of being discharged at home (OR 0.37, 95%CI 0.20-0.63, per 0.1 increase; p < 0.001), with higher odds of nosocomial infections (OR 1.67, 95%CI 1.05-2.73 per 0.1 increase; p = 0.03), and prescription of antibiotics (OR 1.77, 95%CI 1.11-2.92, per 0.1 increase; p = 0.02).

CONCLUSION

Frailty is adversely associated with hospital outcomes in patients with acute neurological disorders. Assessing frailty could improve patient stratification, prognostication, and care planning, with a relevant impact on healthcare resources.

A Non-Contact Privacy Protection Bed Angle Estimation Method Based on LiDAR

Accurate bed angle monitoring is crucial in healthcare settings, particularly in Intensive Care Units (ICUs), where improper bed positioning can lead to severe complications such as ventilator-associated pneumonia. Traditional camera-based solutions, while effective, often raise significant privacy concerns. This study proposes a non-intrusive bed angle detection system based on LiDAR technology, utilizing the Intel RealSense L515 sensor. By leveraging time-of-flight principles, the system enables real-time, privacy-preserving monitoring of head-of-bed elevation angles without direct visual surveillance. Our methodology integrates advanced techniques, including coordinate system transformation, plane fitting, and a deep learning framework combining YOLO-X with an enhanced A2J algorithm. Customized loss functions further improve angle estimation accuracy. Experimental results in ICU environments demonstrate the system's effectiveness, with an average angle detection error of less than 3 degrees.

Comparison of trimethoprim-sulfamethoxazole versus minocycline monotherapy for treatment of Stenotrophomonas maltophilia pneumonia

OBJECTIVE

To compare the rate of clinical cure and adverse effects in patients receiving definitive treatment with trimethoprim-sulfamethoxazole versus minocycline monotherapy for Stenotrophomonas maltophilia pneumonia.

METHODS

A single-centre, retrospective cohort study of patients with S. maltophilia pneumonia admitted 1 March 2018-30 September 2023 was conducted comparing treatment with trimethoprim-sulfamethoxazole versus minocycline monotherapy. The primary outcome was the rate of clinical cure, defined as meeting two of the three prespecified criteria for a period of 48 hours while on definitive therapy: normalization of white blood cell count, absence of fever and hypothermia and decreased oxygen support. Secondary outcomes evaluated included time to clinical cure, infection-related and in-hospital mortality, pneumonia recurrence and incidence of adverse effects, which was a composite of acute kidney injury (AKI), hyperkalaemia and thrombocytopenia.

RESULTS

Of 93 patients included, 48 received trimethoprim-sulfamethoxazole and 45 received minocycline. There was no difference in the primary outcome of clinical cure between the trimethoprim-sulfamethoxazole and minocycline groups (72.9% versus 66.7%, P = 0.51). S. maltophilia pneumonia recurrence was more common in the minocycline group compared to the trimethoprim-sulfamethoxazole group (35.6% versus 10.4%, P = 0.006). In-hospital mortality was higher in the trimethoprim-sulfamethoxazole group although there was no difference in infection-related in-hospital mortality (6.3% versus 2.3%, P = 0.62). The incidence of AKI, hyperkalaemia and thrombocytopenia did not differ between groups.

CONCLUSION

There was no difference in clinical cure rate for S. maltophilia pneumonia treatment between trimethoprim-sulfamethoxazole and minocycline monotherapy although higher rates of recurrent pneumonia were observed in patients treated with minocycline. Rates of adverse effects were similar between groups.

Nebulized Antibiotics for Preventing and Treating Gram-Negative Respiratory Infections in Critically Ill Patients: An Overview of Reviews

BACKGROUND

Ventilator-associated tracheobronchitis (VAT) and pneumonia (VAP) are the most frequent nosocomial infections in the critical care setting and are associated with increased morbidity. At the same time, VAP is also associated with attributable mortality, especially when caused by difficult-to-treat (DTR) Gram-negative bacteria (GNB) that have limited treatment options. Studies have assessed the impact of nebulized aminoglycosides or colistin to improve VAT and VAP outcomes or as an adjunct to intravenous antimicrobial treatment or as a preventive approach.

OBJECTIVE

This overview aimed to assess systematic reviews that examine the efficacy and safety of antimicrobial nebulization for preventing and treating ventilator-associated infections in the critically ill.

METHODS

Systematic reviews, meta-analyses, and original randomized controlled trials and prospective observational studies were included. Searches were conducted in MEDLINE (via PubMed), the Cochrane, Epistemonikos, and PROSPERO. The methodological quality assessment was performed using standardized tools.

RESULTS

Regarding VAP treatment, the included systematic reviews presented critically low quality. The clinical response effect size to amikacin and colistin nebulization were RR 1.23 (95% CI 1.13-1.34), I2 = 47% and OR 1.39 (0.87-2.20), I2 = 56%. The main safety concern was bronchospasm with RR 2.55 (1.40-4.66), I2 = 0% and OR 5.19 (1.05-25.52), I2 = 0%. The certainty of evidence was usually very low. For VAT treatment, limited evidence showed a better clinical response and less emergence of resistant bacteria. Regarding VAP prevention, data are limited to two trials; however, only the larger one presented a low risk of bias and resulted in a reduced VAP rate.

CONCLUSIONS

Delivery via nebulization might be considered in addition to IV antimicrobial treatment of GNB ventilator-associated infections. The available evidence is weak, and more studies focused on infections due to DTR-GNBs should be prioritized.

[Epidemiology, diagnosis and treatment of adult patients with nosocomial pneumonia]

BACKGROUND

 Nosocomial pneumonia, encompassing hospital-acquired (HAP) and ventilator-associated pneumonia (VAP), remains a major cause of morbidity and mortality in hospitalized adults. In response to evolving pathogen profiles and emerging resistance patterns, this updated S3 guideline (AWMF Register No. 020-013) provides an evidence-based framework to enhance the diagnosis, risk stratification, and treatment of nosocomial pneumonia.

METHODS

 The guideline update was developed by a multidisciplinary panel representing key German professional societies. A systematic literature review was conducted with subsequent critical appraisal using the GRADE methodology. Structured consensus conferences and external reviews ensured that the recommendations were clinically relevant, methodologically sound, and aligned with current antimicrobial stewardship principles.

RESULTS

 For the management of nosocomial pneumonia patients should be divided in those with and without risk factors for multidrug-resistant pathogens and/or Pseudomonas aeruginosa. Bacterial multiplex-polymerase chain reaction (PCR) should not be used routinely. Bronchoscopic diagnosis is not considered superior to non-bronchoscopic sampling in terms of main outcomes. Combination antibiotic therapy is now reserved for patients in septic shock and high risk for multidrug-resistant pathogens, while select patients may be managed with monotherapy (e. g., meropenem). In clinically stabilized patients, antibiotic therapy should be de-escalated and focused, as well as duration shortened to 7-8 days. In critically ill patients, prolonged application of suitable beta-lactam antibiotics should be preferred. Patients on the intensive care unit (ICU) are at risk for invasive pulmonary aspergillosis (IPA). Diagnostics for Aspergillus should be performed with an antigen test from bronchial lavage fluid.

CONCLUSION

 This updated S3 guideline offers a comprehensive, multidisciplinary approach to the management of nosocomial pneumonia in adults. By integrating novel diagnostic modalities and refined therapeutic strategies, it aims to standardize care, improve patient outcomes, and enhance antimicrobial stewardship to curb the emergence of resistant pathogens.

Impact of Empirical Treatment Recommendations From 2017 European Guidelines for Nosocomial Pneumonia

BACKGROUND

The management of nosocomial pneumonia represents a major challenge in the ICU. European guidelines from 2017 proposed an algorithm for the prescription of empirical antimicrobial treatment based on medical history, local ecology, and severity (ie, presence or absence of septic shock). We assessed this algorithm's usefulness by comparing outcomes with and without guideline adherence in a population at high risk of multiresistance and mortality.

RESEARCH QUESTION

Are the recommendations of the latest European guidelines effective in reducing the incidence of adverse outcomes in patients with nosocomial pneumonia admitted to the ICU?

STUDY DESIGN AND METHODS

We retrospectively analyzed data from a prospective cohort of 507 patients from 6 ICUs in our center. To minimize bias, we only included patients with microbiologically confirmed pneumonia. The primary outcome was 28-day mortality. Secondary outcomes were 90-day mortality, ICU mortality, inadequate treatment, treatment failure, and overtreatment.

RESULTS

In total, 315 patients met the inclusion criteria. Outcomes were comparable in the groups with and without guideline adherence, except for overtreatment, which was higher when guidelines were followed (42.5% vs 66.3%; P < .001). In the subgroup without septic shock treated according to guidelines, reductions were noted in both ICU mortality (28.8% vs 14.5%; P = .031) and adjusted 28-day mortality (hazard ratio, 3.07; 95% CI, 1.13-7.85; P = .027). By contrast, no benefit was observed when patients presented with septic shock at diagnosis.

INTERPRETATION

Our findings indicate that the European guideline treatment algorithm is effective in reducing mortality in patients without septic shock but not in those with septic shock at the time of diagnosis. Future studies should clarify whether adjustments need to be made to improve outcomes in patients with septic shock.

Whether to continue combining carbapenems to treat carbapenem-resistant Acinetobacter baumannii nosocomial pneumonia in critically ill patients: a retrospective efficacy and safety analysis

To explore the efficacy and safety of non-carbapenem-containing (NCC) regimens and carbapenem-containing regimens (CC) regimens, along with the factors influencing the outcomes in critically ill patients with carbapenem-resistant Acinetobacter baumannii (CRAB) pneumonia. This study retrospectively enrolled critically ill patients with CRAB pneumonia who were treated with NCC and CC regimens in a teaching hospital. The primary efficacy outcome was the 28-day clinical efficacy rate, and the safety outcome was the incidence of nephrotoxicity. After the propensity score matching analysis removed the differences between the two groups, the differences in outcomes were statistically analyzed. Cox regression and logistic regression models were used to analyze the factors influencing the outcomes of critically ill patients with CRAB pneumonia. Data from 168 critically ill patients with CRAB pneumonia were eventually included in this study for analysis (NCC = 84, CC = 84). The 28-day clinical efficacy rate was significantly lower in the CC group compared to the NCC group (40.5% vs. 57.1%, P = 0.031), and the incidence of nephrotoxicity was not significantly different in the two groups (P > 0.05). Logistic analysis showed that the prescription of carbapenems was the risk factor of decreased clinical efficacy (aOR = 0.494, 95%CI = 0.262-0.932, P = 0.029) and reduced microbiological eradication (aOR = 0.397, 95%CI = 0.201-0.783, P = 0.008) in patients. CC regimen may not contribute to the 28-day clinical efficacy of CRAB pneumonia and further studies are necessary to elucidate the CC regimen when treating CRAB pneumonia in critically ill patients.

Incidence, Risk Factors, Microbiology and Outcomes of VAP at an NCU in India: A Prospective Observational Study

Background

Ventilator-associated pneumonia (VAP) remains a major challenge while managing ventilated critically ill patients in neurocritical care units (NCUs).

Materials and methods

This was a prospective, single-center, observational study. All adult patients admitted to our NCU requiring mechanical ventilation (MV) for >48 hours were screened for VAP as per clinical pulmonary infectious score (CPIS) criteria. The primary outcome was the incidence of VAP in the ICU. Secondary outcomes were risk factors, microbiology, percentage of MDR/XDR organisms, mortality, and length of stay (LOS) of VAP.

Results

A total of 24.94% (114 of 457) patients developed VAP. The incidence of VAP was 39.43/1000 ventilator days. Multivariate analysis of the risk factors identified, male gender, low Glasgow coma scale (GCS) of 3-8, prolonged ventilation, and diabetes mellitus as significant risk factors for the development of VAP (p < 0.05). Acinetobacter baumannii (31.58%), Klebsiella pneumoniae (28.95%), and Pseudomonas aeruginosa (13.16%) were the most common organisms responsible for VAP. Most of these isolates were multidrug resistant (MDR) (81.58%), and extensively drug-resistant (XDR) organisms (12.28%). Although VAP patients had longer ICU-LOS (26.2 ± 24.2 vs 11.8 ± 6.9 days, p < 0.0001), it did not affect the mortality (18.4% for VAP vs 14.3% for non-VAP, p = 0.5).

Conclusion

Ventilator-associated pneumonia has a high incidence of 39.43 per 1,000 ventilator days in the Indian neurocritical care setting.

How to cite this article

Zirpe K, Kapse U, Sharma A, Kulkarni AP, Gurav S, Tiwari A, et al. Incidence, Risk Factors, Microbiology and Outcomes of VAP at an NCU in India: A Prospective Observational Study. Indian J Crit Care Med 2025;29(4):308-313.

Antimicrobials in the Management of Sepsis in the Intensive Care Unit (ICU)

Sepsis is a severe and often life-threatening condition which can lead to widespread organ dysfunction, septic shock, and even death. Antimicrobials are critical in improving outcomes for patients with sepsis. This chapter details the general principles of antimicrobial therapy, appropriate selection and de-escalation of antimicrobials, and challenges in antimicrobial stewardship.

Diagnostic Stewardship of Endotracheal Aspirate Cultures in Hospitalized Children With Artificial Airways: Expert Consensus Statements From the BrighT STAR (Testing STewardship for Antibiotic Reduction) Respiratory Collaborative

OBJECTIVE

To develop consensus statements that clinicians can apply to standardize and optimize endotracheal aspirate culture (EAC) practices in hospitalized children with artificial airways who are being evaluated for a bacterial lower respiratory tract infection (LRTI).

DESIGN

A modified Delphi consensus process with expert panelists. Panelists conducted a "pre-survey" to itemize respiratory signs of bacterial LRTI. Round 1 included a literature summary and electronic survey of 50 potential statements sent to all panelists. We surveyed panelist opinions using a 5-point Likert scale. We grouped the responses "agree" and "strongly agree" as agreement. Consensus was defined as statements reaching greater than 75% agreement. Round 2 was moderated by an independent expert in consensus methodology. Panelists convened in person in November 2023, discussed any statements not reaching consensus or statements with disagreement, were resurveyed, and finalized statements in real time.

SETTING

Electronic surveys and in-person meetings in Baltimore, MD.

SUBJECTS

The BrighT STAR (Testing STewardship for Antibiotic Reduction) collaborative along with U.S.-based pediatric experts in critical care, cardiac critical care, infectious diseases, hospital medicine, otolaryngology, pulmonology, and clinical microbiology.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirty-eight of 40 invited panelists completed round 1. Of 50 initial statements, 28 reached greater than 90% agreement, 16 had 75-89% agreement, and 6 had less than 75% agreement. Twenty-eight statements were finalized. Round 2 involved 37 panelists: 23 statements were discussed, of which 17 reached an agreement and 6 did not reach consensus. We concluded with 30 statements and 15 sub-statements, 37 of which had greater than 90% agreement. Final statements informed a clinical decision support algorithm.

CONCLUSIONS

The BrighT STAR collaborative group achieved consensus for 45 clinical practice statements that can standardize EAC practices, including indications to consider for testing, reasons to defer, optimal specimen collection, and result interpretation. These statements offer a starting point for clinical decision support tools and diagnostic stewardship programs for EAC practices in patients with artificial airways.

Development of a prognostic oxidative stress-immune-inflammation score and online calculators for predicting survival and recurrence in gastric cancer: a multicenter study

BACKGROUND

Oxidative stress, immune response, and inflammation play an important role in the occurrence and progression of gastric cancer (GC). This study is to develop a novel prognostic oxidative stress-immune-inflammation score (POSII score) and to explore the clinical value of the novel nomograms incorporating this factor in survival and recurrence risk.

METHODS

This study included 3612 GC patients who underwent radical gastrectomy at three tertiary hospitals from 2009 to 2020. One hospital formed the training and internal validation cohorts, while the other two constituted the external validation cohort. Twelve hematological markers were collected and analyzed to develop the POSII score via LASSO regression. Two online calculators were developed and validated.

RESULTS

The POSII score categorized patients into low and high POSII groups, with the low POSII group showing significantly improved 5-year overall survival (OS) and disease-free survival (DFS) rates, as well as a markedly reduced risk of recurrence (all P < 0.05). Multivariate COX regression showed that the POSII score was an independent prognostic factor. Based on the POSII score, two nomograms (OS: AUC = 0.837; DFS: AUC = 0.834, respectively) for individualized prognostic prediction were constructed. To enhance clinical usability, we further developed two user-friendly online calculators. The high-risk group had an earlier, more persistent peak of recurrence and a high incidence of multiple recurrence patterns.

CONCLUSION

Two novel online calculators based on the POSII score can be used as reliable tools for predicting survival and recurrence after radical gastrectomy. Our findings provide new insights into the role of cancer-related immune dysregulation, inflammation, and oxidative stress imbalances.

Biomarkers in lower respiratory tract samples in the diagnosis of ventilator-associated pneumonia: a systematic review

BACKGROUND

Ventilator-associated pneumonia (VAP) is the most common intensive care unit-acquired infection, yet its diagnosis is complicated by the lack of reliable diagnostic criteria and validated biomarkers. Due to the compartmentalisation of the immune response, host proteins in respiratory tract samples are more likely than serum proteins to accurately identify VAP. However, a reliable biomarker is still missing and it is generally agreed that >90% sensitivity and specificity are required for the introduction of a VAP biomarker into clinical routine.

METHODS

A structured database search was performed to identify publications aimed at deriving or verifying human respiratory tract VAP biomarkers. The results were screened by two independent reviewers and summarised using statistical and narrative synthesis.

RESULTS

40 articles were identified, focusing on 29 unique biomarkers with clinical and microbiological diagnoses of VAP as the reference standard. The most frequently studied biomarker was soluble triggering receptor expressed on myeloid cell 1 (sTREM-1) (n=16), followed by various interleukins (n=7), neutrophil-related proteins (n=8) and amylase as a surrogate for microaspiration (n=4). The target accuracy of >90% specificity and sensitivity for VAP was reported in four publications on sTREM-1, one on pentraxin-3 (PTX3) and one on heparin-binding protein (HBP). Meta-analysis of sTREM-1 resulted in a sensitivity of 78% (95% CI 61-89%) and specificity of 76% (95% CI 49-91%).

DISCUSSION

This systematic review found that no biomarker can currently be recommended for clinical use due to performance below 90% specificity or sensitivity, or insufficient data (PTX3 and HBP). Accurate clinical phenotyping into VAP subcategories may enable the discovery of VAP biomarkers with higher accuracy.

Short-course antibiotic strategies for ventilator-associated pneumonia

PURPOSE OF REVIEW

Evidence behind antibiotic duration while treating ventilator-associated pneumonia (VAP) remains unclear. There is a need to balance minimizing the development of antimicrobial resistance without compromising clinical outcomes given the high mortality.

RECENT FINDINGS

Recent studies have suggested that shorter antibiotic courses, when individualized to clinical response, may be adequate for treating VAP without increasing the incidence of mortality or recurrence, regardless of pathogens. Moreover, shortening duration may reduce the risk of adverse events, including acute kidney injury.

SUMMARY

Shortening the duration of antibiotic treatment for VAP, in the setting of appropriate clinical response, is a reasonable strategy to reduce costs and selective pressure driving antimicrobial resistance. This was demonstrated in the latest REGARD-VAP study, even among VAP patients with nonfermenting Gram-negative bacilli or carbapenem-resistant pathogens. Given the challenges in diagnosing VAP, such pragmatic approaches would be essential as part of overall antibiotic stewardship programmes. Further refinement to the criteria for antibiotic cessation may be possible.

Infectious diseases and infection control prevention strategies in adult and pediatric population on ECMO

As survival after ECMO improves and use of ECMO support increases in both pediatric and adult population, there is a need to focus on both the morbidities and complications associated with ECMO and how to manage and prevent them. Infectious complications during ECMO often have a significant clinical impact, resulting in increased morbidity or mortality irrespective of the underlying etiology necessitating cardiorespiratory support. In this review article, we discuss the prevention, management, challenges, and differences of infectious complications in adult and pediatric patients receiving ECMO support.

Relative faecal abundance to predict extended-spectrum β-lactamase-producing Enterobacterales related ventilator‑associated pneumonia

BACKGROUND

Antimicrobial stewardship (AMS) for ventilator-associated pneumonia (VAP) in carriers of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) presents significant challenges. The abundance of ESBL-E rectal carriage has emerged as a potentially valuable tool for predicting ESBL-E-related VAP.

METHODS

This single-center, retrospective study was conducted between October 2019 and April 2023 in the medical ICU of a university hospital. The relative abundance of ESBL-E rectal carriage (RAC) was calculated as the ratio of ESBL-E counts to the total number of aerotolerant bacteria. The aim was to evaluate the predictive value of RAC for diagnosing ESBL-E-related VAP in patients with confirmed VAP who were ESBL-E carriers.

RESULTS

During the study period, 478 patients with ESBL-E carriage were admitted to the ICU, of whom 231 (48%) required mechanical ventilation. Eighty-three patients (17%) developed a total of 131 confirmed VAP episodes, of which 62 episodes (47%) were ESBL-E-related VAP. The median interval between the last rectal screening and VAP occurrence was 4 [3-7] days. RAC was not associated with ESBL-E-related VAP in the entire cohort (p = 0.39). Similar findings were observed in several sensitivity analyses, including the following subsets: recent and high-quality screening (interval between screening and VAP ≤ 7 days and bacterial load on rectal swab > 104 CFU/mL, p = 0.21); first VAP episodes only (p = 0.41); cases involving Escherichia coli exclusively (p = 0.08) or other ESBL-E strains (p = 0.29); and VAP associated with Gram-negative bacteria (p = 0.26) or Enterobacterales (p = 0.34). However, in a multivariable model, rectal colonization with non-Escherichia coli ESBL strains was independently associated with ESBL-E-related VAP (adjusted odds ratio [aOR] 1.213 [95% CI 1.005-1.463], p = 0.045).

CONCLUSION

RAC was not associated with confirmed VAP in ESBL-E carriers. Further studies are needed to explore effective strategies for improving AMS in ESBL-E carriers with suspected VAP.

Experience of implementing metagenomic next-generation sequencing in patients with suspected pulmonary infection in clinical practice

Pulmonary infections remain a leading cause of infectious disease-related hospitalizations. Metagenomic next-generation sequencing (mNGS) has emerged as a promising diagnostic tool for identifying pathogens responsible for pulmonary infections. However, implementing mNGS in clinical practice presents several challenges. We conducted a retrospective analysis of 97 patients with suspected pulmonary infections who were admitted to our hospital and underwent mNGS alongside conventional microbiologic tests (CMT) over the past three years. We compared the diagnostic efficacy of mNGS versus CMT and assessed the clinical applications and challenges associated with mNGS in managing pulmonary infections. mNGS detected pathogens in 63.9% of cases, outperforming CMT (27.8%) and showing notable improvements in identifying Mycobacterium, fungal species, and rare pathogens. Antibiotic regimens were adjusted for 77.4% of patients with positive mNGS results, with clinical improvement observed in 93.5%. Of the 138 microbial strains initially identified by mNGS as possible pathogens, 65 (47.1%) were reclassified as colonizing organisms upon further clinical evaluation, including bacteria and fungi commonly associated with pulmonary infections. Notably, one patient was diagnosed with aspiration pneumonia due to oral anaerobes, which mNGS had categorized as normal microbial flora. In conclusion, mNGS serves as a valuable diagnostic approach for pulmonary infections, enhancing etiologic precision and informing patient management. Nevertheless, a comprehensive clinical interpretation of mNGS-identified microorganisms is essential to achieve accurate diagnosis.

High bacterial coinfection rates and associated mortality among hospitalized older adults with laboratory-confirmed respiratory syncytial virus infection

BACKGROUND

Emerging evidence highlights that respiratory syncytial virus (RSV) poses a significant risk to older adults. However, detailed clinical data on elderly patients hospitalized with RSV remains limited. This study investigates the clinical characteristics and outcomes of older adults (aged ≥50 years) hospitalized with RSV infection.

METHODS

This retrospective cohort study included hospitalized patients aged ≥50 years with respiratory symptoms and laboratory-confirmed RSV infection at China Medical University Hospital between January 1, 2011, and December 31, 2023. Data on demographic characteristics and clinical presentations were collected. RSV infection-related outcomes were analyzed across various subgroups.

RESULTS

This study included 36 patients, with the most prevalent comorbidities being diabetes mellitus (47.2 %), immunocompromised status (36.1 %), and chronic lung disease (30.6 %). Pneumonia was identified in 72.2 % of patients, while 41.7 % required invasive mechanical ventilation, and the hospital mortality rate was 33.3 %. Non-survivors had higher rates of comorbidities, particularly chronic lung disease (66.7 % vs. 12.5 %, p = 0.002), higher disease severity, elevated procalcitonin levels, and were more likely to develop septic shock and acute respiratory distress syndrome. A bacterial coinfection rate of 33.3 % was observed, with patients experiencing pneumonia or bacterial coinfection showing poorer outcomes. Moreover, patients with chronic lung disease exhibited significantly worse day-28 survival (log-rank p < 0.001).

CONCLUSIONS

The disease burden of RSV in older adults is amplified by comorbidities such as chronic lung disease, with pneumonia and bacterial coinfections further worsening outcomes. Our findings highlight the need for a more comprehensive understanding and effective preventive strategies to protect this vulnerable population.

Overlap and correlation of reperfusion lung injury with postoperative pneumonia following pulmonary thromboendarterectomy: incidence, characteristics, and outcomes in chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) can be treated with pulmonary thromboendarterectomy (PTE) which may lead to reperfusion lung injury (RPLI) and postoperative pneumonia. We aimed to describe the incidence, diagnostic characteristics, and clinical outcomes of post-PTE pneumonia compared to RPLI. A retrospective study involving CTEPH subjects who underwent PTE at a large referral center was conducted. Data included demographics, hemodynamics, microbiologic diagnostics, and clinical outcomes. Post-PTE pneumonia was diagnosed based on documentation, signs/symptoms, or microbiologic sampling within seven days of surgery. Among 75 PTE subjects, 21 (28%) had RPLI, and 18 (24%) had post-PTE pneumonia. Of those with RPLI, 48% had pneumonia, suggesting overlap. Eight of 75 (11%) subjects underwent bronchoscopic sampling, and five (63%) samples yielded positive results indicative of infection. Subjects with post-PTE pneumonia and RPLI had longer hospital and ICU lengths of stay and mechanical ventilation duration than either group alone. Post-PTE pneumonia is prevalent and overlaps with RPLI in CTEPH subjects. The study highlights the importance of systematic evaluation and early detection of pneumonia in subjects with RPLI post-PTE. Timely diagnosis and management of pneumonia may improve outcomes. Further research is needed to understand risk factors and develop preventive strategies for post-PTE pneumonia.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

Relationship of phase angle with postoperative pneumonia and survival prognosis in patients with esophageal cancer: A retrospective cohort study

OBJECTIVES

Phase angle (PhA), derived from bioelectrical impedance analysis (BIA), is an indicator of cell membrane health. Low PhA values reflect poor cellular function and low muscle mass. However, consensus regarding the appropriate cutoff value of PhA remains insufficient, and its impact on outcomes after esophagectomy in patients with esophageal malignancies is not well studied. We aimed to investigate whether preoperative PhA is associated with postoperative complication risk and survival prognosis and whether PhA decrease during the surgical preparation period is a prognostic factor in patients with esophageal cancer.

METHODS

This retrospective cohort study analyzed data from 194 patients who had undergone esophagectomy for esophageal malignancies. A PhA measured several days before surgery, with cutoff values of 5.0° for men and 4.2° for women, was used. The relationship between postoperative pneumonia and clinicopathological factors and between low PhA and postoperative outcomes and survival prognosis was investigated. The preoperative PhA decline and survival prognosis were analyzed in 134 patients whose PhA was measured twice before surgery.

RESULTS

Overall, 93 and 101 patients were classified into the low and high PhA groups, respectively. A multivariate analysis showed that a serum albumin level lower than 3.5 g/dL and low PhA were independent risk factors for pneumonia (odds ratio [OR] = 3.40, P = 0.03; OR = 3.42, P = 0.03, respectively). The low PhA group exhibited significantly higher intraoperative fluid balance (6.7 versus 6.0 mL/kg/h, P = 0.01) and a higher proportion of patients who failed to achieve early mobilization on the first postoperative day (46 versus 32%, P = 0.04) than did the high PhA group. Multivariate analysis using a Cox proportional hazards model revealed that low PhA was a poor survival prognostic factor, independent of the clinical stage of esophageal cancer (hazard ratio = 2.61, P < 0.01). In patients whose PhA was measured twice preoperatively, a decrease in PhA during the preoperative period was a significant indicator of poor survival (hazard ratio = 2.59, P < 0.01). The group with a decrease in PhA during the preoperative period had significantly fewer steps than the group with an increase in PhA (6220 ± 2880 versus 8200 ± 2850, P < 0.01).

CONCLUSIONS

Low PhA was a risk factor for postoperative pneumonia in patients who had undergone esophagectomy and was associated with poor survival prognosis. A decrease in PhA during the preoperative period was a significant poor prognostic factor. Increasing physical activity before surgery may lead to an increase in PhA. Thus, it is important to measure and evaluate PhA changes sequentially in patients with esophageal cancer.