Prevalence, risk factors, and mortality for ventilator-associated pneumonia in middle-aged, old, and very old critically ill patients*

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.

Comparison of antimicrobial resistance in Pseudomonas aeruginosa from intensive care and non-intensive care units and its impact on treatment decisions

Emergence of difficult-to-treat-resistance (DTR) P. aeruginosa has significant implications for the selection of empirical therapies. This study aims to compare antimicrobial resistance of P. aeruginosa from ICU and non-ICU patients and to discuss empirical treatment options. Three-hundred-nine P. aeruginosa strains isolated from hospitalized patients in 2023 were included. Antimicrobial susceptibility results for six classes with potential activity against P. aeruginosa were collected. Resistance between strains isolated from ICU and non-ICU was compared. Among 309 strains, 30% were isolated from ICU patients, while 70% from non-ICU. Resistance to ciprofloxacin was significantly higher in non-ICU compared to ICU patients (64% vs. 15%, p-value = 0.0001). Resistance to piperacillin-tazobactam was higher in ICU compared to non-ICU patients (36% vs. 22%, p-value = 0.012). Prevalence of DTR P. aeruginosa was similar between the two groups (21% in ICU and 19% in non-ICU patients). Joint resistance to imipenem and ceftazidime was more prevalent in ICU patients (27% vs. 10%, p-value 0.0001). Additionally, carbapenemase-producing strains were more frequent in ICU patients (20% vs. 5%, p-value = 0.0001). Ceftolozane-tazobactam, whose effectiveness against DTR P. aeruginosa remains preserved, as empirical treatment, would improve its adequacy by 21% in ICU and 19% in non-ICU patients, compared to the currently recommended first-line treatments.

Ultrasound-Guided Erector Spinae Plane Block in Elderly Patients Undergoing Total Hip Arthroplasty: A Triple-Blind, Randomized Controlled Trial

BACKGROUND

Total hip arthroplasty (THA) induces postoperative pain in elderly individuals. The erector spinae plane block (ESPB) is a novel analgesic approach for postoperative pain control. This randomized controlled trial evaluated the effectiveness of ultrasound-guided ESPB with ropivacaine in reducing pain in elderly patients undergoing THA.

METHODS

Patients aged 60 to 80 years who had an American society of Anesthesiologists physical statuses I to III were eligible for this study. There were 50 patients who were randomized into two groups: the ESPB group receiving ultrasound-guided ESPB with ropivacaine, and the control group receiving ESPB with normal saline. All patients underwent general anesthesia, and the mean arterial pressure (MAP) heart rate (HR) intraoperative opioid consumption, numerical rating scale (NRS)scores, and postoperative adverse reactions were recorded throughout the perioperative period.

RESULTS

A significant reduction in NRS scores was observed in the ESPB group compared to the control group at various time points, including in the recovery room and at 12 and 24 hours postoperatively (P < 0.05). When the observation period was extended to 48 hours, no significant difference in NRS scores was noted between the two groups (P > 0.05). No significant differences in MAP and HR were found between the two groups, but the ESPB group showed lower coefficients of variation for both MAP and HR. Moreover, the ESPB group demonstrated significantly lower total remifentanil consumption than the control group. There was no significant difference in complications between these two groups (P < 0.05).

CONCLUSIONS

Ultrasound-guided ESPB enhances the perioperative stability of MAP and HR, providing effective analgesia within the initial 24 hours postsurgery, thereby reducing opioid requirements and improving overall postoperative recovery quality for elderly THA patients.

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.

Ventilator-Associated Pneumonia in Intensive Care Units: A Comparison of Pre-Pandemic and COVID-19 Periods

Background/Objectives: The COVID-19 pandemic has significantly increased the burden of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) globally. However, epidemiological data on VAP in Slovak ICUs, particularly in the context of the pandemic, remain limited. This study aimed to evaluate the incidence, microbial profiles, and risk factors of VAP in Slovak ICU settings, particularly during the COVID-19 pandemic. Methods: A retrospective analysis of VAP data was conducted for respiratory intensive care unit (ICU) patients in a Slovak university hospital, comparing data from the pre-pandemic and pandemic periods. The CDC/NHSN definitions for VAP were applied, and statistical analyses were performed using STATISTICA 13.1. Results: A total of 803 patients were analyzed, representing 8385 bed days and 5836 mechanical ventilator days. VAP rates increased significantly during the pandemic by 111%, from 8.46 to 17.86 events per 1000 MV days (p < 0.001). VAP rates in non-COVID-19 patients increased by 86% during the pandemic compared to pre-pandemic levels. Pandemic conditions also increased ICU mortality from 25.66% to 40.52% (p < 0.001). VAP was identified as a critical determinant of ICU mortality, contributing to a 21.62% higher mortality rate among patients during the pandemic. Younger age, prolonged mechanical ventilation, and medical (vs. surgical) hospitalizations were associated with higher VAP incidence. Gram-negative bacteria dominated the pathogen profiles, with significant increases observed in Pseudomonas aeruginosa (183%), Klebsiella pneumoniae (150%), and Acinetobacter spp. (100%). Conclusions: The COVID-19 pandemic has significantly affected the incidence and epidemiology of VAP in Slovak ICUs, highlighting systemic vulnerabilities in HAI surveillance and IPC practices.

Stepwise implementation of prevention strategies and their impact on ventilator-associated pneumonia incidence: A 13-Year observational surveillance study

OBJECTIVE

To describe the practice of ventilator-associated pneumonia (VAP) prevention and control through the incremental introduction of prevention strategies and assess the effect on VAP incidence.

DESIGN

Historical observational surveillance study conducted over 13 years.

SETTING

A 12-bed adult intensive care unit (ICU) in a general hospital in Belgium.

PARTICIPANTS

Patients admitted between 2007 and 2019, with ICU stays of ≥48 h.

INTERVENTIONS

Incremental introduction of VAP preventive measures from 2008, including head-of-bed elevation, cuff pressure control, endotracheal tubes with tapered cuffs, subglottic secretion drainage, chlorhexidine oral care, and daily sedation assessment.

MEASUREMENTS AND MAIN RESULTS

A significant decline in VAP incidence density rates was observed, from 18.3 to 2.6 cases per 1000 ventilator days from the baseline to the final period.

CONCLUSIONS

Systematic implementation of VAP preventive measures significantly reduced VAP incidence. However, this reduction did not translate into decreased overall ICU mortality.

IMPLICATIONS FOR PRACTICE

The study underscores the importance of continuous VAP surveillance and preventive measures in reducing VAP incidence.

Ventilator-Associated Pneumonia After Cardiac Arrest and Prevention Strategies: A Narrative Review

Background and Objectives: Ventilator-associated pneumonia (VAP) poses a significant threat to the clinical outcomes and hospital stays of mechanically ventilated patients, particularly those recovering from cardiac arrest. Given the already elevated mortality rates in cardiac arrest cases, the addition of VAP further diminishes the chances of survival. Consequently, a paramount focus on VAP prevention becomes imperative. This review endeavors to comprehensively delve into the nuances of VAP, specifically in patients requiring mechanical ventilation in post-cardiac arrest care. The overarching objectives encompass (I) exploring the etiology, risk factors, and pathophysiology of VAP, (II) delving into available diagnostic modalities, and (III) providing insights into the management options and recent treatment guidelines. Methods: A literature search was conducted using PubMed, MEDLINE, and Google Scholar databases for articles about VAP and Cardiac arrest. We used the MeSH terms "VAP", "Cardiac arrest", "postcardiac arrest syndrome", and "postcardiac arrest syndrome". The clinical presentation, diagnostic, and management strategies of VAP were summarized, and all authors reviewed the selection and decided which studies to include. Key Content and Findings: The incidence and mortality rates of VAP exhibit significant variability, yet a recurring pattern emerges, marked by prolonged hospitalization and exacerbated clinical outcomes. This pattern is attributed to the elevated incidence of drug-resistant infections and the delayed initiation of antimicrobial treatment. This review focuses on VAP, aiming to offer valuable insights into the efficient identification and management of this fatal complication in post-cardiac arrest patients. Conclusion: The prognosis for survival after cardiac arrest is already challenging, and the outlook becomes even more daunting when complicated by VAP. The timely diagnosis of VAP and initiation of antibiotics pose considerable challenges, primarily due to the invasive nature of obtaining high-quality samples and the time required for speciation and identification of antimicrobial sensitivity. The controversy surrounding prophylactic antibiotics persists, but promising new strategies have been proposed; however, they are still awaiting well-designed clinical trials.

Exploring Ventilator-Associated Pneumonia: Microbial Clues and Biomarker Insights from a Retrospective Study

Background and Objectives: Ventilator-associated pneumonia (VAP) is a common complication in critically ill patients receiving mechanical ventilation. The incidence rates of VAP vary, and it poses significant challenges due to microbial resistance and the potential for adverse outcomes. This study aims to explore the microbial profile of VAP and evaluate the utility of biomarkers and illness severity scores in predicting survival. Materials and Methods: A retrospective cohort study was conducted involving 130 patients diagnosed with VAP. Microbial analysis of bronchoalveolar lavage (BAL) fluid, as well as measurements of C-reactive protein (CRP) and procalcitonin (PCT) levels, were performed. Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated to assess illness severity. Statistical analyses were conducted to determine correlations and associations. Results: The study revealed that Klebsiella pneumoniae (K. pneumoniae) (50.7%) and Pseudomonas aeruginosa (P. aeruginosa) (27.69%) were the most identified microorganisms in VAP cases. SOFA (p-value < 0.0001) and APACHE II (p-value < 0.0001) scores were effective in assessing the severity of illness and predicting mortality in VAP patients. Additionally, our investigation highlighted the prognostic potential of CRP levels (odds ratio [OR]: 0.980, 95% confidence interval [CI] 0.968 to 0.992, p = 0.001). Elevated levels of CRP were associated with reduced survival probabilities in VAP patients. Conclusion: This study highlights the microbial profile of VAP and the importance of biomarkers and illness severity scores in predicting survival. Conclusions: The findings emphasize the need for appropriate management strategies to combat microbial resistance and improve outcomes in VAP patients.

Risk Factors, Pathogens, and Outcomes of Ventilator-Associated Pneumonia in Non-Cardiac Surgical Patients: A Retrospective Analysis

Ventilator-associated pneumonia (VAP) is a critical hospital-acquired infection following non-cardiac surgeries, leading to poor outcomes. This study identifies VAP risk factors in non-cardiac surgical patients and determines the causative pathogens. A retrospective analysis with 1:4 propensity-score matching was conducted on patients in a surgical intensive care unit (ICU) from 2010 to 2020 at a private tertiary medical center. Among 99 VAP patients, the mortality rate was 64.7%. VAP risk factors included prolonged mechanical ventilation (odds ratio [OR] 6.435; p < 0.001), repeat intubation (OR 6.438; p < 0.001), lower oxygenation levels upon ICU admission (OR 0.950; p < 0.001), and undergoing gastrointestinal surgery (OR 2.257; p = 0.021). The 30-day mortality risk factors in the VAP group were late-onset VAP (OR 3.450; p = 0.022), inappropriate antibiotic treatment (OR 4.083; p = 0.041), and undergoing gastrointestinal surgeries (OR 4.776; p = 0.019). Nearly half of the Gram-negative infections were resistant strains, and a third were polymicrobial infections. Non-cardiac surgical patients with VAP face adverse hospital outcomes. Identifying high-risk patients and understanding VAP's resistant and microbial nature are crucial for appropriate treatment and improved health outcomes.

Diagnostic Role of Opsonic Activity in Acinetobacter baumannii Ventilator-Associated Pneumonia

In this study, we investigated the diagnostic value of opsonic activity against Acinetobacter baumannii in Ventilator-Associated Pneumonia (VAP) among 50 patients, compared to 102 negative and positive controls. Out of the 50 patients, only 33 (66 %) were diagnosed with VAP using the Clinical Pulmonary Infection Score (CPIS). The opsonic activity assay demonstrated three key findings: (i) 95 % sensitivity and 91.7 % specificity, with a Receiver Operating Characteristic (ROC) area of 0.976 for distinguishing A. baumannii culture positives from negatives; (ii) 95 % sensitivity and 78.7 % specificity, with a 0.915 ROC area, in differentiating VAP/blood culture positive patients from colonized/negative groups; (iii) An ROC area of 0.553 for VAP and colonization, as identified by CPIS alone, indicating an indeterminate threshold. These results highlight that CPIS, microbiological, and clinical evaluations were not correlated, suggesting that opsonic activity against A. baumannii could be a potential VAP diagnostic tool, with the need for large-scale validations.

Hospital-acquired bacterial pneumonia in critically ill patients: from research to clinical practice

INTRODUCTION

Hospital-acquired pneumonia (HAP) represents a significant cause of mortality among critically ill patients admitted to Intensive Care Units (ICUs). Timely and precise diagnosis is imperative to enhance therapeutic efficacy and patient outcomes. However, the diagnostic process is challenged by test limitations and a wide-ranging list of differential diagnoses, particularly in patients exhibiting escalating oxygen requirements, leukocytosis, and increased secretions.

AREAS COVERED

This narrative review aims to update diagnostic modalities, facilitating the prompt identification of nosocomial pneumonia while guiding, developing, and assessing therapeutic interventions. A comprehensive literature review was conducted utilizing the MEDLINE/PubMed database from 2013 to April 2024.

EXPERT OPINION

An integrated approach that integrates clinical, microbiological, and imaging tools is paramount. Progress in diagnostic techniques, including novel molecular methods, the expanding utilization and accuracy of bedside ultrasound, and the emergence of Artificial Intelligence, coupled with an improved comprehension of lung microbiota and host-pathogen interactions, continues to enhance our capability to accurately and swiftly identify HAP and its causative agents. This advancement enables the refinement of treatment strategies and facilitates the implementation of precision medicine approaches.

Pneumonia Characteristics in an Intensive Care Unit Setting during and after the COVID-19 Pandemic-A Single-Center Prospective Study

Background: During and after the COVID-19 pandemic, there was a suspicion of varying rates of respiratory tract infections (RTIs), particularly pneumonia (PN). Methods: This research evaluated epidemiological indicators of community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP) in the COVID-19 pandemic and post-pandemic period, including pathogens, ventilator-associated pneumonia (VAP), selected risk factors, and PN mortality. Results: At 1740 patients, throughout the 22,774 patient-days (Pt-D) and 18,039 ventilation days (Vt-D), there were 681 PN cases (39.14%): CAP 336 (19.31%) and HAP 345 (19.83%). CAP caused by SARS-CoV-2 was diagnosed in 257/336 (76.49%) patients. The clinical manifestations of PNs were CAP with 336/681 (49.34%), VAP with 232/681 (34.07%), and non-ventilator HAP (NV-HAP) with 113/681 cases (16.59%). The incidence rate of CAP/1000 Pt-D has been over 3 times higher in the pandemic period of 2020-2021 (20.25) than in the post-pandemic period of 2022 (5.86), p = 0.000. Similarly, higher incidence rates of VAP/1000 Pt-D were found in the pandemic period (p = 0.050). For NV-HAP, this difference was not statistically significant (p = 0.585). VAP occurred more frequently in the group of patients with PN in the course of COVID-19 compared to patients without COVID-19 (52/234 [22.2%] vs. 180/1506 [11.95%]); (p = 0.000). The most common CAP pathogen (during the pandemic) was SARS CoV-2 234/291 (80.4%), followed by MSSA/MRSA 8/291 (2.75%), whereas the most common VAP/NV-HAP pathogen was Acinetobacter baumannii XDR/MDR. The highest PN mortality was found in the patients with CAP caused by SARS-CoV-2 159/257 (61.87%). Conclusions: Pneumonias were diagnosed in nearly 40% of Intensive Care Unit (ICU) patients. Surveillance of pneumonias during the specific observation period was beneficial in the epidemiological and microbiological analysis of the ICU patients.

Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial

BACKGROUND

Patients with acute brain injury are at high risk of ventilator-associated pneumonia (VAP). The benefit of short-term antibiotic prophylaxis remains debated. We aimed to establish the effect of an early, single dose of the antibiotic ceftriaxone on the incidence of early VAP in patients with severe brain injury who required mechanical ventilation.

METHODS

PROPHY-VAP was a multicentre, randomised, double-blind, placebo-controlled, assessor-masked, superiority trial conducted in nine intensive care units in eight French university hospitals. We randomly assigned comatose (Glasgow Coma Scale score [GCS] ≤12) adult patients (age ≥18 years) who required mechanical ventilation for at least 48 h after acute brain injury to receive intravenous ceftriaxone 2 g or placebo once within the 12 h following tracheal intubation. Participants did not receive selective oropharyngeal and digestive tract decontamination. The primary outcome was the proportion of patients developing early VAP from the 2nd to the 7th day of mechanical ventilation, confirmed by masked assessors. The analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew or did not give consent to continue and those who did not receive the allocated treatment because they met a criterion for non-eligibility. The trial is registered with ClinicalTrials.gov, NCT02265406.

FINDINGS

From Oct 14, 2015, to May 27, 2020, 345 patients were randomly assigned (1:1) to receive ceftriaxone (n=171) or placebo (n=174); 330 received the allocated intervention and 319 were included in the analysis (162 in the ceftriaxone group and 157 in the placebo group). 166 (52%) participants in the analysis were men and 153 (48%) were women. 15 patients did not receive the allocated intervention after randomisation and 11 withdrew their consent. Adjudication confirmed 93 cases of VAP, including 74 early infections. The incidence of early VAP was lower in the ceftriaxone group than in the placebo group (23 [14%] vs 51 [32%]; hazard ratio 0·60 [95% CI 0·38-0·95], p=0·030), with no microbiological impact and no adverse effects attributable to ceftriaxone.

INTERPRETATION

In patients with acute brain injury, a single ceftriaxone dose decreased the risk of early VAP. On the basis of our findings, we recommend that an early, single dose of ceftriaxone be included in all bundles for the prevention of VAP in patients with brain injury who require mechanical ventilation.

FUNDING

French Ministry of Social Affairs and Health.

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.

Compromised Nutritional Status as a Risk Factor for the Incidence of Nosocomial Infections

Background Poor nutritional status may lead to longer hospital stays, increased mortality and morbidity, increased cost, and higher suffering. Nosocomial infections (NI) are a global health concern, and several risk factors are associated with their higher incidence. This study aimed to reveal that compromised nutritional status is one of the risk factors for developing NIs. Methodology The study was conducted in a tertiary care hospital in Pune, India. This was a prospective cohort study with a sample size of 200 hospitalized participants. Data collection was based on standard tools and structured forms which had two parts. In the first part, the assessment of nutritional status was done for which patients were categorized into two groups, namely, well-nourished and undernourished. Additionally, biochemical parameters (serum albumin) were also assessed. The second part included a follow-up of participants to evaluate the development of NIs including their laboratory investigation. Results were analyzed statistically using R software. Results Among 200 participants, 60 were female, of whom 15% developed NIs. Of the 140 males, 8% had NIs. Among 200 participants, 101 (51%) were well-nourished, of whom two (2%) developed NIs. Of the 99 (49%) undernourished participants, 18 (18%) had NIs. Those who were undernourished (univariate relative risk = 6.10, 95% confidence interval) were more prone to developing NIs compared to the well-nourished group. Conclusions NIs are widespread globally but are less studied and given less emphasis in developing countries. This study reports various types of NIs along with their incidence in well-nourished and undernourished groups. The incidence of NI observed in this study may reflect the higher severity of illness, age, poor nutritional status, and longer hospital stays. Identifying risk factors that can contribute to developing NI may help in their prevention by maximizing patient safety.

Clinical Sepsis Phenotypes in Critically Ill Patients

Sepsis, defined as the life-threatening dysregulated host response to an infection leading to organ dysfunction, is considered as one of the leading causes of mortality worldwide, especially in intensive care units (ICU). Moreover, sepsis remains an enigmatic clinical syndrome, with complex pathophysiology incompletely understood and a great heterogeneity both in terms of clinical expression, patient response to currently available therapeutic interventions and outcomes. This heterogeneity proves to be a major obstacle in our quest to deliver improved treatment in septic critical care patients; thus, identification of clinical phenotypes is absolutely necessary. Although this might be seen as an extremely difficult task, nowadays, artificial intelligence and machine learning techniques can be recruited to quantify similarities between individuals within sepsis population and differentiate them into distinct phenotypes regarding not only temperature, hemodynamics or type of organ dysfunction, but also fluid status/responsiveness, trajectories in ICU and outcome. Hopefully, we will eventually manage to determine both the subgroup of septic patients that will benefit from a therapeutic intervention and the correct timing of applying the intervention during the disease process.

Preperitoneal Pelvic Packing versus Angioembolization for Patients with Hemodynamically Unstable Pelvic Fractures with Pelvic Bleeding: A Single-Centered Retrospective Study

The aim of this study was to compare the outcomes of preperitoneal pelvic packing (PPP) and angioembolization (AE) for patients with equivocal vital signs after initial resuscitation. This single-centered retrospective study included information from the database of a regional trauma center from April 2014 to December 2022 for patients with pelvic fractures with a systolic blood pressure of 80-100 mmHg after initial fluid resuscitation. The patients' characteristics, outcomes, and details of AE after resuscitative endovascular balloon occlusion of the aorta (REBOA) placed in zone III were collected. The follow-up duration was from hospital admission to discharge. A total of 65 patients were enrolled in this study. Their mean age was 59.2 ± 18.1 years, and 40 were males. We divided the enrolled patients into PPP (n = 43) and AE (n = 22) groups. The median time from emergency department (ED) to procedure and the median duration of ED stay were significantly longer in the AE group than in the PPP group (p ≤ 0.001 for both). The median mechanical ventilation (MV) duration was significantly shorter (p = 0.046) in the AE group. The number of patients with complications, overall mortality, and mortality due to hemorrhage did not differ between the two groups. Three patients (13.6%) were successfully treated with AE after REBOA. AE may be beneficial for patients with hemodynamically unstable pelvic fractures who show equivocal vital signs after initial fluid resuscitation in terms of reducing the MV duration and incidence of infectious complications.

Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile

Background

Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections, which develops in mechanically ventilated patients after 48 hours of mechanical ventilation. The purpose of this study was to determine the incidence rate, various risk factors, microbiological profile, and outcome of early- vs late-onset ventilator-associated pneumonia (VAP) in medical intensive care unit (MICU).

Materials and methods

This prospective study was conducted on 273 patients admitted to the MICU in JIPMER, Puducherry, from October 2018 to September 2019.

Results

The incidence of VAP was 39.59 per 1000 ventilation days of MICU patients (93/273). Of these, 53 (56.9%) patients had early-onset VAP and 40 (43.1%) had late-onset VAP. Multiple logistic regression analysis showed that steroid therapy, supine head position, coma or impaired unconsciousness, tracheostomy, and re-intubation were found to be independent predictors of early- and late-onset VAP, respectively. Most cases of VAP were caused by Gram-negative bacteria (90.6%), with nonfermenters contributing to 61.8%. The most frequent pathogens causing early-onset VAP were Acinetobacter baumannii (28.9%) and Pseudomonas aeruginosa (20.6%), while in late-onset VAP, A. baumannii (32.9%) and Klebsiella pneumoniae (21.9%) were the most common. Maximum death rate was seen in patients infected with Escherichia coli (50%) and Stenotrophomonas maltophilia (38.5%). There was no significant association between the presence of VAP and mortality among the studied population.

Conclusion

The incidence of VAP in our study was high. There were no significant differences in the prevalence of pathogens associated with early-onset or late-onset VAP. Our study shows that early-onset and late-onset VAP have different risk factors, highlighting the need for developing different preventive and therapeutic strategies.

How to cite this article

Gunalan A, Sastry AS, Ramanathan V, Sistla S. Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile. Indian J Crit Care Med 2023;27(6):411-415.

Epidemiological, Microbiological, and Clinical Characteristics of Multi-Resistant Pseudomonas aeruginosa Isolates in King Fahad Medical City, Riyadh, Saudi Arabia

Increasing rates of serious multi-drug resistant (MDR) Pseudomonas aeruginosa infections have been reported globally, including in Saudi Arabia. This retrospective study investigates the epidemiological, microbiological, and clinical characteristics of multi-resistant P. aeruginosa (n3579 clinical isolates) in King Fahad Medical City, Riyadh, Saudi Arabia (2019–2021). Information on antimicrobial susceptibility and medical history was collected from the hospital database. P. aeruginosa infections occurred in 55.6% of males and 44.4% of females, and P. aeruginosa was more prevalent in children than in adults. Our analysis showed that P. aeruginosa had the highest sensitivity to amikacin (92.6%) and greatest resistance to aztreonam (29.8%), imipenem (29.5%), ceftazidime (26.1%), meropenem (25.6%), and cefepime (24.3%). MDR and extensively drug resistant (XDR) strains were more prevalent in male than female patients. Female patients showed higher rates of infection with pan-drug resistant (PDR) strains. Respiratory samples contained the majority of resistant isolates. Septic shock and liver disease were strongly correlated with mortality in the ICU patient group after analysing the relative risk associated with mortality. Our study emphasises the threat of multi-resistant P. aeruginosa in Saudi Arabia (and potentially the Middle East) and highlights important sources and contexts of infection that inhibit its effective control and clinical management.

Multidrug-resistant Gram-negative bacilli recovered from respiratory and blood specimens from adults: the ATLAS surveillance program in European hospitals, 2018-2020

The population of people ≥65 years of age is increasing in Europe. Pneumonia is a prominent cause of infection in this age group. These patients may be at heightened risk of infection caused by multidrug-resistant (MDR) organisms owing to their frequent and prolonged contact with healthcare facilities as well as frequent exposure to antimicrobials and medical devices. However, ATLAS surveillance data did not demonstrate any difference in the incidence of MDR Gram-negative pathogens among patients ≥65 years of age and those aged <65 years. Higher rates of carbapenem-resistant Enterobacterales (CRE) and MDR Pseudomonas aeruginosa were observed in patients aged 18-64 years (10.7% and 32.3%, respectively) than in patients aged ≥65 years (5.0% and 25.4%, respectively). Significant therapeutic gaps were identified for CRE, carbapenem-resistant Acinetobacter baumannii (65.9% of isolates tested) and MDR P. aeruginosa, which continue to be prevalent in European hospitals. Among the antimicrobials evaluated, only colistin provided >75% in vitro coverage for these pathogens.

Epidemiology, risk factors and prognosis of ventilator-associated pneumonia during severe COVID-19: Multicenter observational study across 149 European Intensive Care Units

BACKGROUND

COVID-19 patients requiring mechanical ventilation are particularly at risk of developing ventilator-associated pneumonia (VAP). Risk factors and the prognostic impact of developing VAP during critical COVID-19 have not been fully documented.

METHODS

Patients invasively ventilated for at least 48 h from the prospective multicentre COVID-ICU database were included in the analyses. Cause-specific Cox regression models were used to determine factors associated with the occurrence of VAP. Cox-regression multivariable models were used to determine VAP prognosis. Risk factors and the prognostic impact of early vs. late VAP, and Pseudomonas-related vs. non-Pseudomonas-related VAP were also determined.

MAIN FINDINGS

3388 patients were analysed (63 [55-70] years, 75.8% males). VAP occurred in 1523/3388 (45.5%) patients after 7 [5-9] days of ventilation. Identified bacteria were mainly Enterobacteriaceae followed by Staphylococcus aureus and Pseudomonas aeruginosa. VAP risk factors were male gender (Hazard Ratio (HR) 1.26, 95% Confidence Interval [1.09-1.46]), concomitant bacterial pneumonia at ICU admission (HR 1.36 [1.10-1.67]), PaO₂/FiO₂ ratio at intubation (HR 0.99 [0.98-0.99] per 10 mmHg increase), neuromuscular-blocking agents (HR 0.89 [0.76-0.998]), and corticosteroids (HR 1.27 [1.09-1.47]). VAP was associated with 90-mortality (HR 1.34 [1.16-1.55]), predominantly due to late VAP (HR 1.51 [1.26-1.81]). The impact of Pseudomonas-related and non-Pseudomonas-related VAP on mortality was similar.

CONCLUSION

VAP affected almost half of mechanically ventilated COVID-19 patients. Several risk factors have been identified, among which modifiable risk factors deserve further investigation. VAP had a specific negative impact on 90-day mortality, particularly when it occurred between the end of the first week and the third week of ventilation.

The impact of age on intensive care

Caring for the elderly has always been challenging for the intensive care unit (ICU) physician. Concerns like frailty, comorbidities, polypharmacy and advanced directives come up even before admission into the unit. The COVID-19 pandemic has put forward a variety of issues concerning elderly populations, making the topic more relevant than ever. Admittance to the ICU, an unequivocally multifactorial decision, requires special consideration from the side of the physician when caring for an elderly person. Patients' wishes are to be respected and thus given priority. Triage assessment must also account for age-related physiological alterations and functional status. Once in the ICU, special attention should be given to age-related specificities, such as therapeutic interventions' controversial role, infection susceptibility, and post-operative care, that could potentially alter the course of hospitalization and affect outcomes. Following ICU discharge, ensuring proper rehabilitation for both survivors and their caregivers can improve long-term outcomes and subsequent quality of life. The pandemic and its implications may limit the standard of care for the elderly requiring ICU support. Socioeconomic factors that further perplex the situation must be addressed. Elderly patients currently represent a vast expanding population in ICU. Tailoring safe treatment plans to match patients' wishes, and personalized needs will guide critical care for the elderly from this time forward.

Efficacy of Intermittent and Continuous Subglottic Secretion Drainage in Preventing the Risk of Ventilator-Associated Pneumonia: A Meta-Analysis of Randomized Control Trials

Ventilator-associated pneumonia (VAP) is hospital-acquired pneumonia that develops 48 h or longer following mechanical ventilation. However, cuff pressure fluctuates significantly due to patient or tube movement, which might result in microaspiration. Subglottic secretion drainage (SSD) has been suggested as a method for VAP prevention bundles. This systematic review and meta-analysis aims to investigate the efficacy and safety of subglottic SSD in preventing VAP. The secondary outcomes of this study are to investigate the intensive care unit (ICU) stay length and mortality rate regarding VAP. This study followed the Preferred Reporting Item for Systematic Review and Meta-Analysis guidelines. A thorough search of PubMed, Embase, and the Web of Science was conducted between June and August 2022. The study analysis used the Mantel-Haenszel method, and the quality of the included study was assessed using the Cochrane Risk of Bias 2. Eighteen randomized controlled trials with a total of 2537 intubated patients were included. It was found that SSD was associated with a lower risk of VAP (RR 1.44; 95% CI; 1.20-1.73; p < 0.0001). The subgroup analysis (utilizing intermittent and continuous methods) found no statistically significant difference between the two groups (p = 0.28). The secondary endpoints showed that there was no significant difference in mortality (RR 1.02; 95% CI; 0.87-1.20; p = 0.83), but there were substantial differences in ICU stays (mean difference, 3.42 days; 95% CI; 2.07-4.76; p < 0.00001) in favor of the SSD group. This was based on a very low certainty of evidence due to concerns linked to the risk of bias and inconsistency. The use of SSD was associated with a reduction in VAP incidence and ICU stay length, but there was no significant difference in the mortality rate.

Construction and Validation of a Predictive Model for the Risk of Ventilator-Associated Pneumonia in Elderly ICU Patients

Background

Ventilator-associated pneumonia (VAP) is among the most important hospital-acquired infections in an intensive-care unit setting. However, clinical practice lacks effective theoretical tools for preventing VAP in the elderly.

Aim

To describe the independent factors associated with VAP in elderly intensive-care unit (ICU) patients on mechanical ventilation (MV) and to construct a risk prediction model.

Methods

A total of 1851 elderly patients with MV in ICUs from January 2015 to September 2019 were selected from 12 tertiary hospitals. Study subjects were divided into a model group (n = 1219) and a validation group (n = 632). Two groups of patients were divided into a VAP group and a non-VAP group and compared. Univariate and logistic regression analyses were used to explore influencing factors for VAP in elderly ICU patients with MV, establish a risk prediction model, and draw a nomogram. We used the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test to evaluate the predictive effect of the model. Findings regarding the length of ICU stay, surgery, C-reactive protein (CRP), and the number of reintubations were independent risk factors for VAP in elderly ICU patients with MV. Predictive-model verification results showed that the area under the curve (AUC) of VAP risk after MV in the modeling and verification groups was 0.859 and 0.813 (P < 0.001), respectively, while P values for the Hosmer-Lemeshow test in these two groups were 0.365 and 0.485, respectively.

Conclusion

The model could effectively predict the occurrence of VAP in elderly patients with MV in ICUs. This study is a retrospective study, so it has not been registered as a clinical study.

ADDITIONAL RISKS ARISING IN THE PROCESS OF PROVIDING MEDICAL AID TO PATIENTS WITH COVID-19

OBJECTIVE

The aim: In order to assess the degree of transforming danger, for face masks, used in the providing respiratory support process to specialized department patients with varying degrees of the COVID-19 course severity, we conducted a series of bacteriological studies into an additional opportunistic bacteria reservoir. With the purpose of assessment of the face respiratory masks inner surface bacterial contamination intensity during their use to provide respiratory support to patients with COVID-19.

PATIENTS AND METHODS

Materials and methods: A bacteriological study of the inner surface of 60 disposable individual face respiratory masks was carried out at different times of providing respiratory support to patients with COVID-19.

RESULTS

Results: It is shown that during use, the inner surface of the respiratory mask is colonized by staphylococci and gram-negative opportunistic bacteria. With increasing time of the mask using, the density of colonization of its inner surface increases.

CONCLUSION

Conclusions: In the process of long-term non-invasive lung ventilation and oxygen therapy for patients with COVID-19, the inner surface of face respiratory masks is colonized with opportunistic bacteria, which creates the risk of contamination by the latter of the pathologically changed lung parenchyma and the addition of secondary bacterial infection.

Pseudomonas aeruginosa PAO1 outer membrane vesicles-diphtheria toxoid conjugate as a vaccine candidate in a murine burn model

Pseudomonas aeruginosa is an opportunistic pathogen considered a common cause of nosocomial infection with high morbidity and mortality in burn patients. Immunoprophylaxis techniques may lower the mortality rate of patients with burn wounds infected by P. aeruginosa; consequently, this may be an efficient strategy to manage infections caused by this bacterium. Several pathogenic Gram-negative bacteria like P. aeruginosa release outer membrane vesicles (OMVs), and structurally OMV consists of several antigenic components capable of generating a wide range of immune responses. Here, we evaluated the immunogenicity and efficacy of P. aeruginosa PA-OMVs (PA-OMVs) conjugated with the diphtheria toxoid (DT) formulated with alum adjuvant (PA-OMVs-DT + adj) in a mice model of burn wound infection. ELISA results showed that in the group of mice immunized with PA-OMVs-DT + adj conjugated, there was a significant increase in specific antibodies titer compared to non-conjugated PA-OMVs or control groups. In addition, the vaccination of mice with PA-OMVs-DT + adj conjugated generated greater protective effectiveness, as seen by lower bacterial loads, and eightfold decreased inflammatory cell infiltration with less tissue damage in the mice burn model compared to the control group. The opsonophagocytic killing results confirmed that humoral immune response might be critical for PA-OMVs mediated protection. These findings suggest that PA-OMV-DT conjugated might be used as a new vaccine against P. aeruginosa in burn wound infection.

Ventilatör İlişkili Pnömonili Hastaların Retrospektif Olarak Değerlendirilmesi: Altı Yıllık Veri

Amaç: Bu çalışmada yoğun bakım ünitesinde takip edilen ventilatör ilişkili pnömoni (VİP) olgularının demografik özelliklerinin, VİP etkenlerinin ve prognozunun değerlendirilmesi ve bu özelliklerin mortalite ile olan ilişkisinin ortaya konulması amaçlanmıştır. Gereç ve Yöntem: Çalışma retrospektif ve tek merkezli olarak Ocak 2012-Aralık 2017 tarihleri arasında yapılmıştır. Hastanemizde VİP tanısı ile yatan ≥18 yaş hastalar ve 48 saatten uzun süre mekanik ventilasyon altında olan 533 hasta çalışmaya dahil edilmiştir. Veriler, hastane veri sistemi ve hasta dosyaları incelenerek değerlendirildi. Hastalara ait yaş, cinsiyet, yattığı klinik, kültür antibiyogram sonuçları, komorbidite durumu, hastanede kalış süresi ve hastanın son durumu (taburcu/eksitus) gibi veriler kaydedildi. Bulgular: Çalışmaya dahil edilen olguların 337’si (%63.2) erkek, 196’sı (%36.8) kadın cinsiyette olup yaş ortalaması 63.8±20.4 yıldı. Hastaların %93.1’inde Gram negatif bakteri, %6.4’ünde Gram pozitif bakteri ve %0.6’sında mantar üremesi saptandı. En sık saptanan etkenler Acinetobacter baumannii (%42.2), Pseudomonas aeruginosa (%19.3), Klebsiella pneumoniae (%12.2) idi. VİP olgularının % 66.2’si mortalite ile sonuçlandı. Prognozu etkileyen risk faktörleri ve eşlik eden hastalıklardan; serebrovasküler hastalıklar, koroner arter hastalığı, malignite, bilinç kapalılığı, peptik ülser profilaksisi, hemodiyalize girme, immünsupresyon varlığı, kardiyopulmoner resusitasyon ve santral venöz kateter varlığının (sırasıyla OR:1.20, 0.38, 0.15, 0.96, 0.76, 0.25, 1.67, 0.19, 0.62) mortaliteyi arttırdığı saptanmıştır. Hastaların tanı anındaki C-reaktif protein (AUC:0.588 p=0,001), prokalsitonin (AUC:0.658 p

Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes

BACKGROUND

Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management.

OBJECTIVE

Our aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries.

METHODS

We performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center.

RESULTS

A total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia.

CONCLUSIONS

Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

Age itself or age-associated comorbidities? A nationwide analysis of outcomes of geriatric trauma

PURPOSE

Geriatric trauma patients present physiological challenges to care providers. A nationwide analysis was performed to evaluate the roles of age alone versus age-associated comorbidities in the morbidity and mortality of elderly patients with blunt abdominal trauma (BAT).

METHODS

Patients with BAT registered in the National Trauma Data Bank from 2013 to 2015 were analyzed using propensity score matching (PSM) to evaluate the mortality rate, complication rate, hospital length of stay (LOS), intensive care unit (ICU) LOS and ventilator days between young (age < 65) and elderly (age ≥ 65) patients. An adjusted multivariate logistic regression (MLR) model was also used to evaluate the effect of age itself and age-associated comorbidities on mortality.

RESULTS

There were 41,880 patients with BAT during the study period. In elderly patients, the injury severity score (ISS) decreased with age, but the mortality rate increased inversely (from 5.0 to 13.5%). Under a similar condition and proportion of age-associated comorbidities after a well-batched PSM analysis, elderly patients had significantly higher mortality rates (8.0% vs. 1.9%, p < 0.001), higher complication rates (35.1% vs. 30.6%, p < 0.001), longer hospital LOS (8.9 vs. 8.1 days, p < 0.001), longer ICU LOS (3.7 vs. 2.7 days, p < 0.001) and more ventilator days (1.1 vs. 0.5 days, p < 0.001) than young patients. Furthermore, the MLR analysis showed that age itself served as an independent factor for mortality (odds ratio: 1.049, 95% CI 1.043-1.055, p < 0.001), but age-associated comorbidity was not.

CONCLUSION

In patients with BAT, age itself appeared to have an independent and deleterious effect on mortality, but age-associated comorbidity did not.

Effectiveness of Continuous Cuff Pressure Control in Preventing Ventilator-Associated Pneumonia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Microaspiration of subglottic secretions is the main pathogenic mechanism for ventilator-associated pneumonia (VAP). Adequate inflation of the endotracheal cuff is pivotal to providing an optimal seal of the extraluminal airway. However, cuff pressure substantially fluctuates due to patient or tube movements, which can induce microaspiration. Therefore, devices for continuous cuff pressure control (CCPC) have been developed in recent years. The purpose of this systematic review and meta-analysis is to assess the effectiveness of CCPC in VAP prevention.

DATA SOURCES

A systematic search of Embase, the Cochrane Central Register of Controlled Trials, and the International Clinical Trials Registry Platform was conducted up to February 2022.

STUDY SELECTION

Eligible studies were randomized controlled trials (RCTs) and quasi-RCTs comparing the impact of CCPC versus intermittent cuff pressure control on the occurrence of VAP.

DATA EXTRACTION

Random-effects meta-analysis was used to calculate odds ratio (OR) and 95% CI for VAP incidence between groups. Secondary outcome measures included mortality and duration of mechanical ventilation (MV) and ICU stay. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.

DATA SYNTHESIS

Eleven RCTs with 2,092 adult intubated patients were included. The use of CCPC was associated with a reduced risk of VAP (OR, 0.51). Meta-analyses of secondary endpoints showed no significant difference in mortality but significant differences in durations of MV (mean difference, -1.07 d) and ICU stay (mean difference, -3.41 d) in favor of CCPC. However, the risk of both reporting and individual study bias was considered important. The main issues were the lack of blinding, potential commercial conflicts of interest of study authors and high heterogeneity due to methodological differences between studies, differences in devices used for CCPC and in applied baseline preventive measures. Certainty of the evidence was considered "very low."

CONCLUSIONS

The use of CCPC was associated with a reduction in VAP incidence; however, this was based on very low certainty of evidence due to concerns related to risk of bias and inconsistency.

Risk factors for pneumonia in hospitalized older people with femoral fractures: Results from a Brazilian prospective cohort

BACKGROUND

Pneumonia is a common complication in older people who are hospitalized to treat different fractures, which increases morbimortality in this population.

OBJECTIVES

Estimating the pneumonia incidence density in older people hospitalized to treat femoral fractures and identifying risk factors for this infection.

METHODS

Prospective cohort study whose data were collected from a population of older people who were being treated for femoral fractures at a hospital in the central region of Brazil between September 2016 and February 2017. The pneumonia diagnosis was based on radiography and clinical tests. Incidence density was estimated according to gender, age, Charlson comorbidity index, polypharmacy, chronic pulmonary disease, admission to the intensive care unit, surgical treatment, and nasoenteral tube feeding. Magnitude of the associations was estimated by multiple Poisson regression.

RESULTS

Among the 200 patients, the pneumonia incidence density was 13.04/1,000 person-days. For men and older people 80 years old or older, the pneumonia incidence density was 15.6/1,000 person-days and 18.3/1,000 person-days, respectively. After adjusting for age, gender, chronic pulmonary disease, and admission to the intensive care unit, use of nasoenteral tubes remained associated with occurrence of pneumonia in older people, and the risk of developing the infection was eight times higher in the population who received nasoenteral feeding than that calculated for the population that did not use the devices (p ≤ 0.001).

CONCLUSION

Using nasoenteral tubes during hospital stays increased the risk of developing pneumonia in hospitalized older people, which reinforces the need for continuous care monitoring regarding use of tubes to prevent complications.

Frequency, Etiology, Mortality, Cost, and Prevention of Respiratory Tract Infections—Prospective, One Center Study

Background: Ventilator-associated pneumonia (VAP) is the most monitored form of respiratory tract infections (RTIs). A small number of epidemiological studies have monitored community-acquired pneumonia (CAP), non-ventilator hospital-acquired pneumonia (NV-HAP) and ventilator-associated tracheobronchitis (VAT) in intensive care units (ICUs). The objective of this study was to assess the frequency, etiology, mortality, and additional costs of RTIs. Methods: One-year prospective RTI surveillance at a 30-bed ICU. The study assessed the rates and microbiological profiles of CAP, VAP, NV-HAP, VAT, and VAP prevention factors, the impact of VAP and NV-HAP on the length of ICU stays, and the additional costs of RTI treatment and mortality. Results: Among 578 patients, RTIs were found in 30%. The CAP, NV-HAP, VAP, and VAT rates/100 admissions were 5.9, 9.0, 8.65, and 6.05, respectively. The VAP incidence density/1000 MV-days was 10.8. The most common pathogen of RTI was Acinetobacter baumannii MDR. ICU stays were extended by VAP and NV-HAP for 17.8 and 3.7 days, respectively, and these RTIs increased the cost of therapy by 13,029 and 2708 EUR per patient, respectively. The mortality rate was higher by 11.55% in patients with VAP than those without device-associated and healthcare-associated infections (p = 0.0861). Conclusions: RTIs are a serious epidemiological problem in patients who are admitted and treated in ICU, as they may affect one-third of patients. Hospital-acquired RTIs extend hospitalization time, increase the cost of treatment, and worsen outcomes.

Epidemiology and Age-Related Mortality in Critically Ill Patients With Intra-Abdominal Infection or Sepsis: An International Cohort Study

BACKGROUND

The objective of this study is to describe the epidemiology and age-related mortality in older critically ill adults with intra-abdominal infections.

METHODS

This is a secondary analysis of a prospective, multinational, observational study (AbSeS, ClinicalTrials.gov #NCT03270345) including patients with intra-abdominal infection from 309 ICUs in 42 countries (January-December, 2016). Mortality was considered as ICU mortality with a minimum of 28 days of observation when patients were discharged earlier. Relationships with mortality were assessed by logistic regression analysis.

RESULTS

The cohort included 2337 patients. Four age groups were defined: middle-aged patients as reference category (40-59 years; n=659 [28.2%]), young-old (60-69 years; n=622 [26.6%]), middle-old (70-79 years; n=667 [28.5%]) and very-old patients (≥80 years; n=389 [16.6%]). Secondary peritonitis was the predominant infection (68.7%) and equally prevalent across age groups. Mortality increased with age: 20.9% in middle-aged patients, 30.5% in young-old, 31.2% in middle-old, and 44.7% in very-old patients (p<0.001). Compared to middle-aged patients, young-old age (OR 1.62, 95% CI 1.21-2.17), middle-old age (OR 1.80, 95% CI 1.35-2.41), and very-old age (OR 3.69, 95% CI 2.66-5.12) were independently associated with mortality. Other independent risk factors for mortality included late-onset hospital-acquired intra-abdominal infection, diffuse peritonitis, sepsis/septic shock, source control failure, liver disease, congestive heart failure, diabetes, and malnutrition.

CONCLUSIONS

For ICU patients with intra-abdominal infections, age above 60 years was associated with mortality while patients above 80 years had the worst prognosis. Comorbidities and overall disease severity further compromised survival. As all these factors are non-modifiable it remains unclear how to improve outcomes.

A Novel Design of Multi-epitope Peptide Vaccine Against Pseudomonas aeruginosa

Background:

As an opportunistic pathogen, Pseudomonas aeruginosa causes many different hazardous infections. The high mortality rate resulting from infection with this antibiotic-resistant pathogen has made it a major challenge in clinical treatment; it has been listed as the most harmful bacterium to humans by the WHO. So far, no vaccine has been approved for P. aeruginosa.

Objective:

Infections performed by bacterial attachment and colonization with type IV pili (T4P), known as the most essential adhesive vital for adhesion, while pilQ is necessary for the biogenesis of T4P, also outer membrane proteins of a pathogen is also effective in stimulating the immune system; in this regard, pilQ, OprF, and OprI, are excellent candidate antigens for production of an effective vaccine against P. aeruginosa.

Methods:

In this research, various bioinformatics methods were employed in order to design a new multiepitope peptide vaccine versus P. aeruginosa. Since T CD4+ cell immunity is important in eradicating P. aeruginosa, OprF, OprI, and pilQ antigens were analyzed to determine Helper T cell Lymphocyte (HTL) epitopes by many different immunoinformatics servers. One of the receptor agonists 2 (TLR2), a segment of the Por B protein from Neisseria meningitides was used as an adjuvant in order to stimulate an effective cellular immune response, and suitable linkers were used to connect all the above mentioned parts. In the vaccine construct, linear B cell epitopes were also identified.

Results:

Conforming the bioinformatics forecasts, the designed vaccine possesses high antigenicity and is not allergen.

Conclusion:

In this regard, the designed vaccine candidate is strongly believed to possess the potential of inducing cellular and humoral immunity against P. aeruginosa.

Trends and Factors Associated With Ventilator-Associated Pneumonia: A National Perspective

Background: Ventilator-associated pneumonia (VAP) is a hospital-acquired pneumonia that occurs more than 48 hours after mechanical ventilation. Studies showing temporal trends, predictors, and outcomes of VAP are very limited.

Objective: We used the National database to delineate the trends and predictors of VAP from 2009 to 2017.

Methods: We analyzed data from the Nationwide Inpatient Sample (NIS) for adult hospitalizations who received mechanical ventilation (MV) by using ICD-9/10-CM procedures codes. We excluded hospitalizations with length of stay (LOS) less than two days. VAP and other diagnoses of interest were identified by ICD-9/10-CM diagnosis codes. We then utilized the Cochran Armitage trend test and multivariate survey logistic regression models to analyze the data.

Results: Out of a total of 5,155,068 hospitalizations who received mechanical ventilation, 93,432 (1.81%) developed VAP. Incidence of VAP decreased from 20/1000 in 2008 to 17/1000 in 2017 with a 5% decrease. Patients who developed VAP had lower mean age (59 vs 61; p<0.001) and higher LOS (25 days vs. 12 days; p<0.001). In multivariable regression analysis, we identified that males, African Americans, teaching hospitals and co-morbidities like neurological disorders, pulmonary circulation disorders and electrolyte disorders are associated with the increased odds of developing VAP. VAP was also associated with higher rates of discharge to facilities and increased LOS.

Conclusion: Our study identified the trends along with the risk predictors of VAP in MV patients. Our goal is to lay the foundation for further in-depth analysis of this trend for better risk stratification and development of preventive strategies to reduce the incidence of VAP among MV patients.

Empiric Treatment in HAP/VAP: “Don’t You Want to Take a Leap of Faith?”

Ventilator-associated pneumonia is a frequent cause of ICU-acquired infections. These infections are associated with high morbidity and mortality. The increase in antibiotic resistance, particularly among Gram-negative bacilli, makes the choice of empiric antibiotic therapy complex for physicians. Multidrug-resistant organisms (MDROs) related infections are associated with a high risk of initial therapeutic inadequacy. It is, therefore, necessary to quickly identify the bacterial species involved and their susceptibility to antibiotics. New diagnostic tools have recently been commercialized to assist in the management of these infections. Moreover, the recent enrichment of the therapeutic arsenal effective on Gram-negative bacilli raises the question of their place in the therapeutic management of these infections. Most national and international guidelines recommend limiting their use to microbiologically documented infections. However, many clinical situations and, in particular, the knowledge of digestive or respiratory carriage by MDROs should lead to the discussion of the use of these new molecules, especially the new combinations with beta-lactamase inhibitors in empirical therapy. In this review, we present the current epidemiological data, particularly in terms of MDRO, as well as the clinical and microbiological elements that may be taken into account in the discussion of empirical antibiotic therapy for patients managed for ventilator-associated pneumonia.

Dexamethasone as risk-factor for ICU-acquired respiratory tract infections in severe COVID-19

PURPOSE

Dexamethasone is the only drug that has consistently reduced mortality in patients with COVID-19, especially in patients needing oxygen or invasive mechanical ventilation. However, there is a growing concern about the relation of dexamethasone with the unprecedented rates of ICU-acquired respiratory tract infections (ICU-RTI) observed in patients with severe COVID-19.

METHODS

This was a multicenter, prospective cohort study; conducted in ten countries in Latin America and Europe. We included patients older than 18 with confirmed SARS-CoV-2 requiring ICU admission. A multivariate logistic regression and propensity score matching (PSM) analysis was conducted to determine the relation between dexamethasone treatment and ICU-RTI.

RESULTS

A total of 3777 patients were included. 2065 (54.7%) were treated with dexamethasone within the first 24 h of admission. After performing the PSM, patients treated with dexamethasone showed significantly higher proportions of VAP (282/1652 [17.1%] Vs. 218/1652 [13.2%], p = 0.014). Also, dexamethasone treatment was identified as an adjusted risk factor of ICU-RTI in the multivariate logistic regression model (OR 1.64; 95%CI: 1.37-1.97; p < 0.001).

CONCLUSION

Patients treated with dexamethasone for severe COVID-19 had a higher risk of developing ICU-acquired respiratory tract infections after adjusting for days of invasive mechanical ventilation and ICU length of stay, suggesting a cautious use of this treatment.

Ventilator-Associated Lower Respiratory Tract Bacterial Infections in COVID-19 Compared With Non-COVID-19 Patients

Ventilator-associated lower respiratory tract infections (VA-LRTIs) are associated with prolonged length of stay and increased mortality. We aimed to investigate the occurrence of bacterial VA-LRTI among mechanically ventilated COVID-19 patients and compare these findings to non-COVID-19 cohorts throughout the first and second wave of the pandemic.

Investigating patient outcomes and healthcare costs associated with ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia is the most frequent infection seen in intensive care units. Of those patients with an endotracheal tube, many will develop ventilator-associated pneumonia within 48 hours of being mechanically ventilated. There are many issues related to mechanical ventilation including costs, patient outcomes and the amount of suffering patients experience during the process.

AIM

To determine the relationship between development of ventilator-associated pneumonia and patient outcomes and costs, including length of stay on mechanical ventilation, in intensive care units (ICU) and in hospital, and mortality rates and to compare results between ventilator-associated pneumonia and non-ventilator-associated pneumonia groups.

METHOD

Cross-sectional, observational design. A convenience sample of 151 patients on mechanical ventilation (101 with ventilator-associated pneumonia and 50 with non-ventilator-associated pneumonia) were recruited from ICUs in two public hospitals in Jordan. APACHE-II scores, SOFA scores and clinical pulmonary infection scores (CPIS) were assessed.

RESULTS

The incidence rate of ventilator-associated pneumonia was 50.9/1000 mechanical ventilation days and the cumulative incidence rate was 66.9% among patients on mechanical ventilation. The mean score of hospital length of stay and CPIS was significantly higher in the ventilator-associated pneumonia than the non-ventilator-associated pneumonia group. Higher disease severity and higher organ failure scores increase the risk of mortality in patients with ventilator-associated pneumonia.

CONCLUSION

A high ventilator-associated pneumonia incidence rate is associated with increased mechanical ventilation, ICU and hospital length of stays, higher mortality and attributed costs. There is a need for continuing education and training for ICU staff to reduce ventilator-associated pneumonia incidence in ICUs.

Analysis of risk factors for early-onset ventilator-associated pneumonia in a neurosurgical intensive care unit

Background

Ventilator-associated pneumonia (VAP) is a severe infection among patients in the neurosurgery intensive care unit (NICU).

Methods

We retrospectively evaluated risk factors for early-onset ventilator-associated pneumonia (EOVAP) from January 2019 to December 2019 at a NICU. A total of 89 NICU patients who were intubated within 48 h of onset and whose mechanical ventilation time was at least 7 days were enrolled. We evaluated EOVAP that occurred within the first 7 days after the onset of mechanical ventilation. The enrolled patients had no history of chronic lung disease and no clinical manifestations of infection before intubation. Clinical data of patients were recorded, and the incidence of and risk factors for EOVAP were analyzed. Patients were also grouped by age (≥ 65 vs. < 65 years) and whether they had received hypothermia treatment or not.

Results

Among 89 mechanically ventilated patients (49 men and 40 women; the mean age ± SD was 60.1 ± 14.3 years), 40 patients (44.9%) developed EOVAP within 7 days and 14 patients (15.7%) had a multidrug resistant bacterial infection. Binary logistic regression analysis indicated that older age (≥ 65 years) (odds ratio [OR]:3.53, 95% confidence interval [CI]:1.27–9.79, P = 0.015) and therapeutic hypothermia (OR:3.68, CI:1.10–12.31, p = 0.034) were independent predictors of EOVAP. Levels of peripheral blood leukocytes, neutrophils and platelets were lower in the therapeutic hypothermia group than those who did not receive hypothermia treatment.

Conclusions

This study found that older age (≥ 65 years) and therapeutic hypothermia were independently associated with the risk of EOVAP in NICU patients.

Research on Effects of Oropharyngeal Aspiration on Incidence of Ventilator-Associated Pneumonia in Patients with Cerebral Hemorrhage in ICU

Cerebral hemorrhage is a kind of intracranial hemorrhage caused by nontraumatic vascular rupture of the cerebral parenchyma, which is a common cerebrovascular disease with a high disability rate and mortality. This study aimed to explore the effects of oropharyngeal aspiration in reducing ventilator-associated pneumonia in patients with cerebral hemorrhage in ICU. In this study, 96 patients with cerebral hemorrhage were selected as the subjects. They received surgical treatment, and then they were transferred into ICU of Fourth Affiliated Hospital of Harbin Medical University from December 2019 to March 2020. The patients were randomly divided into intervention group and control group, with 48 in each group. The intervention group received periodic oropharyngeal aspiration, while the control group received routine nursing measures. After the intervention, the incidence of ventilator-associated pneumonia and the positive rate of amylase α-trachea cannula specimens were recorded and compared between the two groups. After the intervention, the incidence of ventilator-associated pneumonia was 14.89% in the intervention group and 39.58% in the control group, with a statistically significant difference. And, the α-amylase positive rate, mechanical ventilation time, and ICU care duration of endotrachea cannula specimens in the intervention group were significantly lower than those in the control group. In conclusion, oropharyngeal aspiration can effectively reduce the incidence of ventilator-associated pneumonia after cerebral hemorrhage and shorten mechanical ventilation and ICU care duration. It promotes the rehabilitation of patients.

Development of Multi-epitope Subunit Vaccine Against Pseudomonas aeruginosa Using OprF/OprI and PopB Proteins

Background: The emerging problem of antibiotic resistance in Pseudomonas aeruginosa is a global health concern; hence, revealing innovative therapeutic approaches (such as designing an immunogenic vaccine candidate) is needed. There is no evidence of the availability of an effective vaccine that can combat the infection caused by this microorganism. Objectives: This research was conducted to develop a potential chimeric vaccine against P. aeruginosa using reverse vaccinology approaches. Methods: The present vaccine candidate comprised outer membrane protein F and I (OprF/OprI) and PopB with appropriate linkers. After applying meticulous immune-informatics investigation, the multi-epitope vaccine was created, including helper T lymphocyte (HTL), cytotoxic T lymphocyte (CTL), interferon gamma (IFN-γ), and interleukin 4 (IL-4) epitopes. Then, the physicochemical characteristics, allergenicity, toxicity, and antigenicity were analyzed. After investigating the secondary structure, the tertiary structure (3D) model was generated, refined, and validated via computational methods. Besides, the strong protein-ligand interaction and stability between the vaccine candidate and toll-like receptor 4 (TLR4) were determined via molecular docking and dynamics analyses. Moreover, in silico cloning accompanied by pET-22b (+) was used to achieve high translation efficiency. Results: Our results presumed that the chimeric-designed vaccine was thermostable and contained optimal physicochemical properties. This vaccine candidate was nontoxic and highly soluble and had stable protein and TLR4 interaction, adequately overexpressed in Escherichia coli. Overall, it could induce immune responses and repress this microorganism. Conclusions: Therefore, to inhibit Pseudomonas infections experimentally, the efficacy and safety of the vaccine design need to be validated.

Clinical Usefulness of Red Cell Distribution Width/Albumin Ratio to Discriminate 28-Day Mortality in Critically Ill Patients with Pneumonia Receiving Invasive Mechanical Ventilation, Compared with Lacate/Albumin Ratio: A Retrospective Cohort Study

The value of the red cell distribution width (RDW) is associated with prognosis in critically ill patients. A simplex combined index—the RDW/albumin ratio—has been proposed for the prediction of mortality, as has the lactate/albumin ratio. The aim of this study was to evaluate the clinical utility of the RDW/albumin ratio regarding 28-day mortality in critically ill patients with pneumonia. Clinical data of critically ill patients with pneumonia who were hospitalized in the medical intensive care unit from May 2018 to December 2020, and received invasive mechanical ventilation (IMV), were reviewed retrospectively. The values of RDW, lactate, and albumin measured at the time of IMV, were used for the index calculations. Of the 234 patients, the median age was 76 years, and 74.2% were male. The 28-day mortality rate was 47.3%. The median RDW/albumin ratio was significantly higher in non-survivors than survivors at 28 days (5.8 vs. 4.9, p < 0.001). A higher RDW/albumin ratio was significantly associated with increased 28-day mortality (odds ratio [OR] 1.338, 95% confidence interval [CI] 1.094–1.637, p = 0.005). The area under the receiver operating curve (AUROC) was 0.694 (95% CI: 0.630–758, p < 0.005) to discern 28-day mortality without significant difference, compared with that of the lactate/albumin ratio. Our data suggest that high RDW/albumin ratio has a similar predictability to the lactate/albumin ratio in critically ill patients with pneumonia receiving IMV.

Management of pneumonia in critically ill patients

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

Prognostic biomarkers in predicting mortality in respiratory patients with ventilator-associated pneumonia

Background

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection. Red cell distribution width (RDW) and neutrophil-lymphocyte ratio (NLR) are prognostic factors to mortality in different diseases. The aim of this study is to evaluate prognostic efficiency RDW, NLR, and the Sequential Organ Failure Assessment (SOFA) score for mortality prediction in respiratory patients with VAP.

Results

One hundred thirty-six patients mechanically ventilated and developed VAP were included. Clinical characteristics and SOFA score on the day of admission and at diagnosis of VAP, RDW, and NLR were assessed and correlated to mortality. The average age of patients was 58.80 ± 10.53. These variables had a good diagnostic performance for mortality prediction AUC 0.811 for SOFA at diagnosis of VAP, 0.777 for RDW, 0.728 for NLR, and 0.840 for combined of NLR and RDW. The combination of the three parameters demonstrated excellent diagnostic performance (AUC 0.889). A positive correlation was found between SOFA at diagnosis of VAP and RDW (r = 0.446, P < 0.000) and with NLR (r = 0.220, P < 0.010).

Conclusions

NLR and RDW are non-specific inflammatory markers that could be calculated quickly and easily via routine hemogram examination. These markers have comparable prognostic accuracy to severity scores. Consequently, RDW and NLR are simple, yet promising markers for ICU physicians in monitoring the clinical course, assessment of organ dysfunction, and predicting mortality in mechanically ventilated patients. Therefore, this study recommends the use of blood biomarkers with the one of the simplest ICU score (SOFA score) in the rapid diagnosis of critical patients as a daily works in ICU.

Diagnostic Stewardship: Appropriate Testing and Judicious Treatments

Diagnostic stewardship encompasses the entire diagnosis-to-treatment paradigm in the intensive care unit (ICU). Initially born of the antimicrobial stewardship movement, contemporary diagnostic stewardship aims to promote timely and appropriate diagnostic testing that directly links to management decisions. In the stewardship framework, excessive diagnostic testing in low probability cases is discouraged due to its tendency to generate false-positive results, which have their own downstream consequences. Though the evidence basis for diagnostic stewardship initiatives in the ICU is nascent and largely limited to retrospective analyses, available literature generally suggests that these initiatives are safe, feasible, and associated with similar patient outcomes. As diagnostic testing of critically ill patients becomes increasingly sophisticated in the ensuing decade, a stewardship mindset will aid bedside clinicians in interpreting and incorporating new diagnostic strategies in the ICU.

Outer Membrane Vesicles Displaying a Heterologous PcrV-HitA Fusion Antigen Promote Protection against Pulmonary Pseudomonas aeruginosa Infection

Along with surging threats and antibiotic resistance of Pseudomonas aeruginosa in health care settings, it is imperative to develop effective vaccines against P. aeruginosa infection. In this study, we used an Asd (aspartate-semialdehyde dehydrogenase)-based balanced-lethal host-vector system of a recombinant Yersinia pseudotuberculosis mutant to produce self-adjuvanting outer membrane vesicles (OMVs). The OMVs were used as a carrier to deliver the heterologous PcrV-HitA_T (PH) fusion antigen of P. aeruginosa for vaccine evaluation. Intramuscular vaccination with OMVs carrying the PH antigen (referred to rOMV-PH) afforded 73% protection against intranasal challenge with 5 × 10⁶ (25 50% lethal doses) of the cytotoxic PA103 strain and complete protection against a noncytotoxic PAO1 strain. In contrast, vaccination with the PH-deficient OMVs or PH antigen alone failed to offer effective protection against the same challenge. Immune analysis showed that the rOMV-PH vaccination induced potent humoral and Th1/Th17 responses compared to the PH vaccination. The rOMV-PH vaccination rapidly cleared P. aeruginosa burdens with coordinated production of proinflammatory cytokines in mice. Moreover, antigen-specific CD4⁺ and CD8⁺ T cells and their producing cytokines (tumor necrosis factor alpha and interleukin-17A), rather than antibodies, were essential for protection against pneumonic P. aeruginosa infection. Our studies demonstrated that the recombinant Y. pseudotuberculosis OMVs delivering heterologous P. aeruginosa antigens could be a new promising vaccine candidate for preventing the spread of drug-resistant P. aeruginosa.

IMPORTANCE Hospital- and community-acquired infections with Pseudomonas aeruginosa cause a high rate of morbidity and mortality in patients who have underlying medical conditions. The spread of multidrug-resistant P. aeruginosa strains is becoming a great challenge for treatment using antibiotics. Thus, a vaccine as one of the alternative strategies is urgently required to prevent P. aeruginosa infection.

Recent chemical syntheses of bacteria related oligosaccharides using modern expeditious approaches

Apart from some essential and crucial roles in life processes carbohydrates also are involved in a few detrimental courses of action related to human health, like infections by pathogenic microbes, cancer metastasis, transplanted tissue rejection, etc. Regarding management of pathogenesis by microbes, keeping in mind of multi drug-resistant bacteria and epidemic or endemic incidents, preventive measure by vaccination is the best pathway as also recommended by the WHO; by vaccination, eradication of bacterial diseases is also possible. Although some valid vaccines based on attenuated bacterial cells or isolated pure polysaccharide-antigens or the corresponding conjugates thereof are available in the market for prevention of several bacterial diseases, but these are not devoid of some disadvantages also. In order to develop improved conjugate T-cell dependent vaccines oligosaccharides related to bacterial antigens are synthesized and converted to the corresponding carrier protein conjugates. Marketed Cuban Quimi-Hib is such a vaccine being used since 2004 to resist Haemophilus influenza b infections. During nearly the past two decades research is going on worldwide for improved synthesis of bacteria related oligosaccharides or polysaccharides towards development of such semisynthetic or synthetic glycoconjugate vaccines. The present dissertation is an endeavour to encompass the recent syntheses of several pathogenic bacterial oligosaccharides or polysaccharides, made during the past ten-eleven years with special reference to modern expeditious syntheses.

The Consequences of Aging On the Response to Injury and Critical Illness

Changing demographic trends have led to an increase in the overall geriatric trauma patient volume. Furthermore, the intersection of aging and injury can be problematic because geriatric patients have multiple comorbidities, geriatric-specific syndromes, and reduced physiological reserve. Despite mounting evidence that frail geriatric patients have inferior outcomes following trauma, very few studies have examined the effect of aging on the biological response to injury. In the present article, we review the current literature and explore the pathophysiological rationale underlying observed data, available evidence, and future directions on this topic.

Effect of heart rate on hospital mortality in critically ill patients may be modified by age: a retrospective observational study from large database

BACKGROUND

Heart rate has been found associated with mortality in critically ill patients. However, whether the association differs between the elderly and non-elderly patients was unknown.

METHODS

We conducted a retrospective observational study of adult patients admitted to the intensive care unit (ICU) in the United States. Demographic, vital signs, laboratory tests, and interventions were extracted and compared between the elderly and non-elderly patients. The main exposure was heart rate, the proportion of time spent in heart rate (PTS-HR) was calculated. The primary outcome was hospital mortality. The multivariable logistic regression model was performed to assess the relationship between PTS-HR and hospital mortality, and interaction between PTS-HR and age categories was explored.

RESULTS

104,276 patients were included, of which 52,378 (50.2%) were elderly patients and 51,898 (49.8%) were non-elderly patients. The median age was 66 (IQR 54-76) years. After adjusting for confounders, PTS-HR < 60 beats per minute (bpm) (OR 0.972, 95% CI [0.945, 0.998], p = 0.031, P_interaction = 0.001) and 60-80 bpm (OR 0.925, 95% CI [0.912, 0.938], p < 0.001, P_interaction = 0.553) were associated with decreased risk of mortality; PTS-HR 80-100 bpm was associated with decreased mortality in the non-elderly patients (OR 0.955, 95% CI [0.941,0.975], p < 0.001) but was associated with increased mortality in the very elderly patients (OR 1.018, 95% CI [1.003,1.029], p = 0.017, P_interaction < 0.001). PTS-HR > 100 bpm (OR 1.093, 95% CI [1.081,1.105], p < 0.001, P_interaction = 0.004) was associated with increased mortality.

CONCLUSIONS

The effect of heart rate on hospital mortality differs between the elderly and non-elderly critically ill patients.