Ventilator-associated pneumonia and its prevention

In-vitro anti-inflammatory and antagonistic efficacy of polymyxin B capped silver nanoparticles in multi drug resistant Acinetobacter baumannii

Multidrug resistant Acinetobacter baumannii is declared as crucial level precedence pathogen by World Health Organization that needs new and upgraded antibiotics for better treatment. Against a vast extent of microbes, many silver nanoparticles have displayed anti-microbial activity because of their numerous methods of antimicrobial actions. This study was aimed to isolate and characterize the Acinetobacter baumannii by using standard microbiological technique and to analyze the anti-inflammatory and antagonistic effect of PB capped AgNPs in isolated A. baumannii. In antagonistic activity, PB capped AgNPs showed antagonistic effect in 8 out of 20 isolates tested and PB when combined with AgNPs showed antagonistic effect in all isolates tested. In in-vitro anti-inflammatory egg albumin assay, PB capped AgNPs gave inhibition rate of 96% at 12.5 µg, 93% at 25 µg, 82% at 50 µg and 62% at 100 µg whereas in Polymyxin B combined AgNPs it gave inhibition rate of 97% at the dose of 50 µg. In-silico analysis also showed that PB in combination with tri-sodium citrate gave good binding energy than tri-sodium citrate and Polymyxin used alone. Hence, this study represented that silver nanoparticles when used in combination proved to be a good alternative in the treatment of MDR Acinetobacter baumannii.

Clinical evaluation of laryngeal mask airways in video-assisted thoracic surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Endotracheal intubation is often associated with postoperative complications such as sore throat discomfort and hoarseness, reducing patient satisfaction and prolonging hospital stays. Laryngeal mask airway (LMA) plays a critical role in reducing airway complications related to endotracheal intubation. This meta-analysis was performed to determine the efficacy and safety of LMA in video-assisted thoracic surgery (VATS).

METHODS

The PubMed, Embase, Cochrane Library, Medline and Web of Science databases were searched for eligible studies from inception until October 5, 2023. Cochrane's tool (RoB 2) was used to evaluate the possibility biases of RCTs. We performed sensitivity analysis and subgroup analysis to assess the robustness of the results.

RESULTS

Seven articles were included in this meta-analysis. Compared with endotracheal intubation, there was no significant difference in the postoperative hospital stay (SMD = -0.47, 95% CI = -0.98-0.03, P = 0.06), intraoperative minimum SpO2 (SMD = 0.00, 95% CI = -0.49-0.49, P = 1.00), hypoxemia (RR = 1.00, 95% CI = 0.26-3.89, P = 1.00), intraoperative highest PetCO2 (SMD = 0.51, 95% CI = -0.12-1.15, P = 0.11), surgical field satisfaction (RR = 1.01, 95% CI = 0.98-1.03, P = 0.61), anesthesia time (SMD = -0.10, 95% CI = -0.30-0.10, P = 0.31), operation time (SMD = 0.06, 95% CI = -0.13-0.24, P = 0.55) and blood loss (SMD =- 0.13, 95% CI = -0.33-0.07, P = 0.21) in LMA group. However, LMA was associated with a lower incidence of throat discomfort (RR = 0.28, 95% CI = 0.17-0.48, P < 0.00001) and postoperative hoarseness (RR = 0.36, 95% CI = 0.16-0.81, P = 0.01), endotracheal intubation was found in connection with a longer postoperative awake time (SMD = -2.19, 95% CI = -3.49 - -0.89, P = 0.001).

CONCLUSION

Compared with endotracheal intubation, LMA can effectively reduce the incidence of throat discomfort and hoarseness post-VATS, and can accelerate the recovery from anesthesia. LMA appears to be an alternative to endotracheal intubation for some specific thoracic surgical procedures, and the efficacy and safety of LMA in VATS need to be further explored in the future.

Accuracy of pilot balloon palpation for cuff pressure assessment in small versus large sized tubes: a prospective non-randomized observational study

Pilot balloon palpation is still a commonly used method to evaluate cuff pressure of the endotracheal tube after intubation. This study determined whether the size of the tracheal tube influenced the accuracy of pilot balloon palpation. A prospective observational analysis of 208 patients intubated with an endotracheal tube of internal diameter (ID) 6.0 or 8.0 was conducted. An anesthesiologist judged the cuff pressure by manual pilot balloon palpation, and then measured the cuff pressure with a pressure gauge. Cuff pressure exceeding 20-30 cmH₂O was defined as false recognition. The intracuff pressure was significantly higher in ID 6.0 tube than in the ID 8.0 tube (41.9 ± 18.8 cmH₂O vs. 30.3 ± 11.9 cmH₂O, p < 0.001). The number of patients that were mistakenly perceived to have appropriate cuff pressure by pilot balloon palpation was significantly higher in the ID 6.0 group compared to the ID 8.0 group (85 (81.7%) vs. 64 (61.5%), p = 0.001). Therefore, a smaller tube size may further increase risk of inaccurate measurement by pilot balloon palpation and although pressure gauge is recommended for all sizes to maximize accuracy, groups with increased risk factors should be targeted for standardized use of the pressure gauge.

Prediction and prognosis of reintubation after surgery for Stanford type A aortic dissection

Background

Reintubation is a serious adverse respiratory event after Stanford type A aortic dissection surgery (AADS), however, published studies focused on reintubation after AADS are very limited worldwide. The objectives of the current study were to establish an early risk prediction model for reintubation after AADS and to clarify its relationship with short-term and long-term prognosis.

Methods

Patients undergoing AADS between 2016–2019 in a single institution were identified and divided into two groups based on whether reintubation was performed. Independent predictors were identified by univariable and multivariable analysis and a clinical prediction model was then established. Internal validation was performed using bootstrap method with 1,000 replications. The relationship between reintubation and clinical outcomes was determined by univariable and propensity score matching analysis.

Results

Reintubation were performed in 72 of the 492 included patients (14.6%). Three preoperative and one intraoperative predictors for reintubation were identified by multivariable analysis, including older age, smoking history, renal insufficiency and transfusion of intraoperative red blood cells. The model established using the above four predictors showed moderate discrimination (AUC = 0.753, 95% CI, [0.695–0.811]), good calibration (Hosmer-Lemeshow χ² value = 3.282, P = 0.915) and clinical utility. Risk stratification was performed and three risk intervals were identified. Reintubation was closely associated with poorer in-hospital outcomes, however, no statistically significant association between reintubation and long-term outcomes has been observed in patients who were discharged successfully after surgery.

Conclusions

The requirement of reintubation after AADS is prevalent, closely related to adverse in-hospital outcomes, but there is no statistically significant association between reintubation and long-term outcomes. Predictors were identified and a risk model predicting reintubation was established, which may have clinical utility in early individualized risk assessment and targeted intervention.

Pneumonia After Cardiovascular Surgery: Incidence, Risk Factors and Interventions

Postoperative pneumonia (POP) is prevalent in patients undergoing cardiovascular surgery, associated with poor clinical outcomes, prolonged hospital stay and increased medical costs. This article aims to clarify the incidence, risk factors, and interventions for POP after cardiovascular surgery. A comprehensive literature search was performed to identify previous reports involving POP after cardiovascular surgery. Current situation, predictors and preventive measures on the development of POP were collected and summarized. Many studies showed that POP was prevalent in various cardiovascular surgical types, and predictors varied in different studies, including advanced age, smoking, chronic lung disease, chronic kidney disease, cardiac surgery history, cardiac function, anemia, body mass index, diabetes mellitus, surgical types, cardiopulmonary bypass time, blood transfusion, duration of mechanical ventilation, repeated endotracheal intubation, and some other risk factors. At the same time, several targeted interventions have been widely reported to be effective to reduce the risk of POP and improve prognosis, including preoperative respiratory physiotherapy, oral care and subglottic secretion drainage. Through the review of the current status, risk factors and intervention measures, this article may play an important role in clinical prevention and treatment of POP after cardiovascular surgery.

Synthesis, Molecular and Supramolecular Structure Aspects, and Antimicrobial Activity of the Centrosymmetric [Ag(5-Nitroquinoline)2]ClO4 Complex

The new homoleptic [Ag(5-nitroquinoline)2]ClO4 centrosymmetric complex was synthesized and its structure aspects were investigated. It crystallized in the monoclinic space group C2/c with a = 10.0279(2) Å, b = 13.2295(3) Å, c = 14.7552(3) Å and β = 102.1050(10)° while V = 1913.96(7) Å3 and half molecule as asymmetric formula. The Ag(I) is coordinated with two symmetrically related 5-nitroquinoline ligand units via the heterocyclic nitrogen atom with Ag-N distance of 2.146(6) Å and N1-Ag-N1 angle of 173.0(3)°. The two coordinated 5-nitroquinoline have anti configuration to one another and the perchlorate anion is set freely uncoordinated. The only Ag…O interactions are Ag1…O2 (3.110 Å) and Ag1…O1 (3.189 Å) which occur between the Ag(I) in one complex unit and the O-atoms from the NO2 groups in the neighbouring complex units. Hence, Ag(I) has coordination number 2 and its coordination geometry is slightly bent. Hirshfeld analysis indicated that the O…H (51.1%), C…H (11.8%), H…H (10.8%) and C…C (8.9%) contacts are the most common. Exclusively, the O…H, C…O, N…O, O…O and Ag…O contacts are the only shorter contacts than the vdWs radii sum of the interacting atoms. The studied Ag(I) complex showed good antimicrobial activity. It has comparable antibacterial activity against P. vulgaris (MIC = 9.7 μg/mL) and S. aureus (39.1 μg/mL) to Gentamycin (4.8 and 9.7 μg/mL, respectively) while better antifungal activity against A. fumigatus (MIC = 39.1 μg/mL) than Ketoconazole (156.2 μg/mL).

Studies on safety and efficacy of particles containing a mixture of hydroxyapatite–argentum–titanium oxide (HAT) and sheets coated with HAT particles to be used in masks to improve nasal allergy: II. Cellular, in vivo, and clinical studies

Purpose

We report the manufacture of particles containing a mixture of hydroxyapatite–argentum–titanium oxide (HAT), followed by attachment to nonwoven polyester fabrics to produce HAT-coated sheets (HATS) for use in masks. The purpose of the present study was to perform cellular, in vivo, and clinical studies to further examine the safety of HATS for use in masks to improve nasal allergy.

Methods

Reverse mutation tests for HAT were performed using five bacterial strains. A cellular toxicity test was performed using a Chinese hamster cell line incubated with the HATS extracts. Skin reactions after intradermal administration were examined in rabbits. Skin sensitization tests in guinea pigs were performed using the HATS extracts. HAT was administered to the nasal cavity and conjunctival sac of the rabbits. An oral administration study was performed in rats. Finally, a human skin patch test was performed using the HATS.

Results

Reverse mutation tests showed negative results. The cellular toxicity test showed that the HATS extract had moderate cytotoxicity. The intradermal skin reaction and skin sensitization tests were all negative. The administration of HAT to the nasal cavity and intraocular administration showed negative results. No toxicity was observed after oral administration of HAT powder up to a dose of 2000 mg/kg. Finally, the skin patch test result was negative.

Conclusion

Although HAT showed moderate cytotoxicity, in vivo results indicated that HAT is safe because it does not come in direct contact with cells in normal usage, and HATS is safe when used in masks.

Clinical risk score for postoperative pneumonia following heart valve surgery

Background:

Postoperative pneumonia (POP) is one of the most common infections following heart valve surgery (HVS) and is associated with a significant increase in morbidity, mortality, and health care costs. This study aimed to identify the major risk factors associated with the occurrence of POP following HVS and to derive and validate a clinical risk score.

Methods:

Adults undergoing open HVS between January 2016 and December 2019 at a single institution were enrolled in this study. Patients were randomly assigned to the derivation and validation sets at 1:1 ratio. A prediction model was developed with multivariable logistic regression analysis in the derivation set. Points were assigned to independent risk factors based on their regression coefficients.

Results:

POP occurred in 316 of the 3853 patients (8.2%). Multivariable analysis identified ten significant predictors for POP in the derivation set, including older age, smoking history, chronic obstructive pulmonary disease, diabetes mellitus, renal insufficiency, poor cardiac function, heart surgery history, longer cardiopulmonary bypass, blood transfusion, and concomitant coronary and/or aortic surgery. A 22-point risk score based on the multivariable model was then generated, demonstrating good discrimination (C-statistic: 0.81), and calibration (Hosmer-Lemeshow χ² = 8.234, P = 0.312). The prediction rule also showed adequate discriminative power (C-statistic: 0.83) and calibration (Hosmer-Lemeshow χ² = 5.606, P = 0.691) in the validation set. Three risk intervals were defined as low-, medium-, and high-risk groups.

Conclusion:

We derived and validated a 22-point risk score for POP following HVS, which may be useful in preventive interventions and risk management.

Trial Registration:

Chictr.org, ChiCTR1900028127; http://www.chictr.org.cn/showproj.aspx?proj=46932

Effects of Head and Neck Position on Nasotracheal Tube Intracuff Pressure: A Prospective Observational Study

To prevent endotracheal tube-related barotrauma or leakage, the intracuff pressure should be adjusted to 20-30 cm H₂O. However, changes in the nasotracheal tube intracuff pressure relative to neck posture are unclear. In this study, we investigated the effect of head and neck positioning on nasotracheal tube intracuff pressure. Fifty adult patients with nasotracheal tubes who were scheduled for surgery under general anesthesia were enrolled. Following intubation, intracuff pressure was measured by connecting the pilot balloon to a device that continuously monitors the intracuff pressure. Subsequently, the intracuff pressure was set to 24.48 cm H₂O (=18 mmHg) for the neutral position. We recorded the intracuff pressures based on the patients' position during head flexion, extension, and rotation. The initial intracuff pressure was 42.2 cm H₂O [29.6-73.1] in the neutral position. After pressure adjustment in the neutral position, the intracuff pressure was significantly different from the neutral to flexed (p < 0.001), extended (p = 0.003), or rotated (p < 0.001) positions. Although the median change in intracuff pressure was <3 cm H₂O when each patient's position was changed, overinflation to >30 cm H₂O occurred in 12% of patients. Therefore, it is necessary to adjust the intracuff pressure after tracheal intubation and each positional change.

Critical care nurses' compliance and barriers toward ventilator-associated pneumonia prevention guidelines: cross-sectional survey

OBJECTIVES

This study aims to determine the compliance of critical care nurses with the ventilator-associated pneumonia prevention guidelines and the factors that affect their compliance. We also explored the barriers faced by the nurses in the implementation of these guidelines.

METHODS

A cross-sectional descriptive survey was conducted using a self-administered questionnaire containing 17 recommended strategies to prevent ventilator-associated pneumonia and 15 possible barriers. All critical care nurses of varying qualifications, levels of experience, and nationalities working in adult ICUs were invited. Between January and March 2018, the questionnaire was distributed to 283 nurses at eight ICUs in five public hospitals in Almadinah Almunawwarah, KSA.

RESULTS

A total of 229 invitees responded to the questionnaire. The mean compliance score was 85.9%. More than half (54%) of the sample had a high or acceptable compliance level. The lowest compliance rate was reported for the suctioning of subglottic secretions. The main reported barriers were the shortage of nursing staff, forgetfulness, and hospital cost control policies. Working in general ICUs with the capacity of 10-15 beds or prior education related to ventilator-associated pneumonia prevention influenced the nurses' compliance.

CONCLUSION

In our study, the overall compliance of the critical care nurses with the ventilator-associated pneumonia prevention guidelines is acceptable. Shortage of nursing staff, forgetfulness, and cost control policies were the main reported barriers to compliance.

Risk factors for postoperative pneumonia after cardiac surgery: a prediction model

Background

Postoperative pneumonia is the main infectious complication following cardiac surgery and is associated with significant increases in morbidity, mortality and health care costs. The aim of this study was to identify potential risk factors related to the occurrence of postoperative pneumonia in adult patients undergoing cardiac surgery and to develop a predictive system.

Methods

Adult patients who underwent open heart surgery in our institution between 2016 and 2019 were enrolled in this study. Preoperative and intraoperative variables were collected and analyzed. A multivariate prediction model for evaluating the risk of postoperative pneumonia was established using logistic regression analysis via forward stepwise selection, and points were assigned to significant risk factors based on their regression coefficient values.

Results

Postoperative pneumonia occurred in 530 of the 5,323 patients (9.96%). Prolonged stays in the postoperative intensive care unit (ICU) and hospital, as well as higher mortality (25.66% versus 0.65%), were observed in patients with postoperative pneumonia. Multivariate analysis identified 13 independent risk factors including patient demographics, comorbidities, cardiac function, cardiopulmonary bypass (CPB) duration, and blood transfusion. The prediction model showed good discrimination (C-statistic: 0.80) and was well calibrated (Hosmer-Lemeshow χ²=7.907, P value =0.443). A 32-point risk score was generated, and then three risk intervals were defined.

Conclusions

We derived and validated a prediction model for postoperative pneumonia after cardiac surgery incorporating 13 easily discernible risk factors. The scoring system may be helpful for individualized risk estimations and clinical decision-making.

A bundled approach to care: reducing the incidence of postoperative pneumonia in patients undergoing hepatectomy and Whipple procedures

Postoperative occurrence of pneumonia can increase lengths of stay, risk of morbidity and death and health care costs. At Toronto General Hospital, we identified a high incidence of postoperative pneumonia in patients undergoing hepatectomy and Whipple procedures in 2016. To reduce the incidence of postoperative pneumonia, we implemented an evidence-based bundle approach in 2017. The bundle included the following components: oral care, incentive spirometry, coughing and deep breathing, physical activity, elevation of the head of the bed, and patient and family education. In addition to the bundle components, we provided staff education and created patient education and monitoring tools to ensure competency and compliance with the bundle components. Data collected as part of the National Surgical Quality Improvement Program were reviewed to monitor progress. In this article, we discuss our approach, aimed to reduce the incidence of postoperative pneumonia and associated health care costs in the general surgery population.

Pulmonary infections complicating ARDS

Pulmonary infection is one of the main complications occurring in patients suffering from acute respiratory distress syndrome (ARDS). Besides traditional risk factors, dysregulation of lung immune defenses and microbiota may play an important role in ARDS patients. Prone positioning does not seem to be associated with a higher risk of pulmonary infection. Although bacteria associated with ventilator-associated pneumonia (VAP) in ARDS patients are similar to those in patients without ARDS, atypical pathogens (Aspergillus, herpes simplex virus and cytomegalovirus) may also be responsible for infection in ARDS patients. Diagnosing pulmonary infection in ARDS patients is challenging, and requires a combination of clinical, biological and microbiological criteria. The role of modern tools (e.g., molecular methods, metagenomic sequencing, etc.) remains to be evaluated in this setting. One of the challenges of antimicrobial treatment is antibiotics diffusion into the lungs. Although targeted delivery of antibiotics using nebulization may be interesting, their place in ARDS patients remains to be explored. The use of extracorporeal membrane oxygenation in the most severe patients is associated with a high rate of infection and raises several challenges, diagnostic issues and pharmacokinetics/pharmacodynamics changes being at the top. Prevention of pulmonary infection is a key issue in ARDS patients, but there is no specific measure for these high-risk patients. Reinforcing preventive measures using bundles seems to be the best option.

Ventilator-Associated Pneumonia: How Do the Different Criteria for Diagnosis Match Up?

Ventilator-associated pneumonia (VAP) affects up to 30 per cent of ICU patients and has been associated with increased morbidity and mortality. We identified factors associated with prolonged latency of VAP and evaluated its effects on survival and additional outcomes. We also determined the sensitivity of various clinical definitions of VAP, including the Centers for Disease Control and Prevention (CDC) 2013 criteria. We hypothesized that the CDC 2013 criteria would have poor sensitivity. We collected data on 102 subjects who developed VAP between 2012 and 2017. We conducted a Kaplan-Meier survival analysis with Cox proportional hazards regression and generalized linear models/ANOVA to look at predictor variables along with multivariate models for each outcome. White patients, nonsurgical patients, patients with renal failure, altered mental status, increased FiO2, and increased positive end-expiratory pressure had worse survival. Trauma patients, patients with positive sputum cultures, and patients with suspected pneumonia had better survival. Sensitivity of the CDC 2013 criteria was only 44.1 per cent. Our results emphasize the importance of having a high index of suspicion for VAP in ventilator-dependent patients. The 2013 CDC criteria failed to detect 55.9 per cent of confirmed VAP cases. These results are concerning because undetected VAP can have devastating consequences for patients.

Prevention of ventilator-associated pneumonia in intensive care units: Barriers and compliance

AIM

The purpose of this study was to evaluate the compliance of Jordanian nurses with ventilator-associated pneumonia prevention guidelines and the barriers to compliance.

METHOD

A descriptive, cross-sectional design was used. A convenience sample of 294 nurses from nine hospitals in Jordan completed a self-reported questionnaire.

RESULTS

According to the study compliance categories, 45.6% of the participants reported 'insufficient compliance,' 24.8% 'weak compliance' and 29.6% 'sufficient compliance.' Nurses with more experience and previous education on ventilator-associated pneumonia reported higher compliance scores than their counterparts with less experience and no previous education. Nurses reported several barriers that limited their own compliance, such as lack of education, lack of policies and protocols, lack of resources and the shortage of staff.

CONCLUSION

The compliance of nursing staff with the prevention guidelines was poor. Applying tailored educational programs may help improve their level of compliance. These programs must target new graduate nurses and be conducted in those hospitals with limited resources.

Sepsis in the Context of Nonventilator Hospital-Acquired Pneumonia

BACKGROUND

Sepsis is a leading cause of mortality among hospitalized patients and is the most expensive condition affecting the US health care system. Pneumonia is associated with about half of sepsis cases, yet limited research has described the incidence of sepsis in the context of nonventilator hospital-acquired pneumonia (NV-HAP). Persons with NV-HAP who are at risk for sepsis must be identified so that interventions to reduce the burden of NV-HAP and improve outcomes among patients with sepsis can be designed.

OBJECTIVE

To determine the proportion of persons with NV-HAP in whom sepsis develops and to describe the demographic and clinical characteristics of persons with NV-HAP in whom sepsis develops.

METHODS

In this retrospective, population-based study, data were extracted from the National Inpatient Sample from the 2012 Healthcare Cost and Utilization Project dataset. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify adult patients at least 18 years of age who had a stay of at least 48 hours, had no documented diagnosis of ventilator-associated pneumonia, and had secondary diagnoses of both NV-HAP and sepsis, neither of which was present on admission.

RESULTS

In the 2012 calendar year, 119 075 adults had NV-HAP develop; sepsis developed in 36.3% of these cases. Male and black patients were overrepresented in the sample, and patients had a mean of 7 comorbid conditions (SD, 3.3).

CONCLUSIONS

Sepsis in the context of NV-HAP is a key concern. Additional research is needed to identify factors associated with the development of sepsis among patients with NV-HAP.

A review of the antimicrobial potential of precious metal derived nanoparticle constructs

The field of nanotechnology is rapidly growing. The promise of pharmacotherapeutics emerging from this vast field has drawn the attention of many researchers. However, with the increase in the prevalence of antibiotic resistant microorganisms, the manifestations of these promises are needed now more than ever. Many have postulated the antimicrobial potential of nanoparticle constructs derived from precious metals/noble metals nanoparticles (NMNPs), such as silver nanoparticles that show activity against multidrug resistant bacteria. In this review we will evaluate the current studies and explore the data to obtain a clear picture of the potential of these particles and the validity of the claims of drug resistant treatments with NMNPs.

Medication Use and Risk of Delirium in Mechanically Ventilated Patients

One of the principal complications in patients in the intensive care unit, particularly in those receiving mechanical ventilation, is medication-induced delirium. The present study aimed to intensively analyze pharmaceutical factors affecting the development of delirium in mechanically ventilated patients using the electronic health records. The present study was designed as a retrospective case-control study. The delirium group included 500 mechanically ventilated patients. The non-delirium group included 2,000 patients who were hospitalized during the same period as the delirium group and received mechanical ventilation. A total of seven types of medications (narcotic analgesics, non-narcotic analgesics, psychopharmaceuticals, sleep aid medications, anticholinergics, steroids, and diuretics), conventionally used to manage mechanical ventilation, were found to be major risk factors associated with the occurrence of delirium. Since these medications are an integral part of managing mechanically ventilated patients, prudent protocol-based medication approaches are essential to decrease the risk of delirium.

Patterns in the longitudinal oropharyngeal microbiome evolution related to ventilator-associated pneumonia

Background

The aim of the study was to evaluate the composition and the temporal evolution of the oropharyngeal microbiome in antibiotic-naïve patients requiring mechanical ventilation and to gain new insights into the pathogenesis of ventilator-associated pneumonia (VAP).

Methods

Prospective, observational single-center nested case-control study. Patients with acute critical illness and anticipated duration of mechanical ventilation > 4 days were eligible. We took oropharyngeal swabs (and if available, tracheal secretions) daily, starting at the day of intubation. The microbiota was characterized by 16S rRNA high-throughput sequencing and compared between patients developing VAP versus controls.

Results

Five patients developed VAP. In three patient the causative pathogens were Enterobacteriaceae and in two Haemophilus influenzae. Locally weighted polynomial regression suggested that the within diversity (=alpha) was lower in Enterobacteriaceae VAP patients between days two to five of mechanical ventilation when compared to controls. Detection of Enterobacteriaceae in the oropharynx occurred on day two of follow-up and consisted of a single operational taxonomic unit in 2/3 patients with enterobacterial VAP.

Conclusions

In acutely-ill patients who developed enterobacterial VAP the causative pathogen gained access to the oropharynx early after starting mechanical ventilation and outgrew the commensal members of the microbiome. Whether a specific pattern of the oropharyngeal microbiome between days three to five of mechanical ventilation may predict VAP enterobacterial VAP has to be evaluated in further studies.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0530-6) contains supplementary material, which is available to authorized users.

Acinetobacter baumannii Ventilator-Associated Pneumonia: Clinical Efficacy of Combined Antimicrobial Therapy and in vitro Drug Sensitivity Test Results

Objective: To evaluate therapeutic efficacy of different combined antimicrobial treatments against Acinetobacter baumannii ventilator-associated pneumonia (VAP). Methods: Clinical outcomes were retrospectively analyzed to elucidate the efficacy of four combined antimicrobial regimens. The chessboard and micro broth dilution methods determined the minimum inhibitory concentrations (MICs) of four antiseptic drugs singly used and combined two drugs against 36 isolates of multidrug-resistant (MDR) A. baumannii. Results: The incidence of VAP was approximately 6.9% (237/3424) between January 1, 2015 and December 31, and 35.9% (85/237) of the cases were caused by A. baumannii. Among these cases, 60 belonged to AB-VAP, for whom antimicrobial treatment plan was centralized and clinical data was complete. Moreover, all 60 strains of A. baumannii were MDR bacteria from reports microbiological laboratory. Resistance rate was lowest for amikacin (68.3%) and ampicillin sulbactam (71.7%). Resistance rate for imipenem increased from 63.2 to 90.9% during the 3 years. However, in these 60 cases of AB-VAP, the combination between 4 antibiotics was effective in most cases: the effective rate was 75% (18/24) for sulbactam combined with etilmicin, 71.4% (10/14) for sulbactam combined with levofloxacin, 72.7% (8/11) for meropenem combined with etilmicin, and 63.6% (7/11) for meropenem combined with levofloxacin. There was no statistical difference between four regimens (P > 0.05). Sulbactam combined with etilmicin decreased 1/2 of MIC50 and MIC90 of sulbactam while the decreases in etilmicin were more obviously than single drug. When adopting meropenem combined with levofloxacin or etilmicin, the MIC of meropenem reduced to 1/2 of that in applying single drug. As for sulbactam or meropenem combined with levofloxacin, it also lessened the MIC50 of levofloxacin to 1/2 of that for single drug. FIC results suggested that the effects of four combined antimicrobial regimens were additive or unrelated. When sulbactam was combined with etimicin, the additive effect was 63.89%. Conclusion: Drug combination sensitivity test in vitro may be helpful for choosing antimicrobial treatment plans. Sulbactam or meropenem as the basis of treatment regimens can function as the alternatives against AB-VAP. Sulbactam combined with etimicin has been regarded as a recommended regimen in Suizhou, Hubei, China.

Endotracheal tube cuff pressure changes during manual cuff pressure control manoeuvres: An in-vitro assessment

BACKGROUND

Endotracheal tube (ETT) cuffs are designed to seal the lower airway for precise ventilation and to protect against ingress of pathogens from the pharyngeal space. Therefore, a minimal continuous cuff pressure must be maintained. Aim of this study was to analyse the course of cuff pressure in an in-vitro model during manual cuff pressure control manoeuvres.

METHODS

An artificial trachea was intubated with an appropriately sized ETT and cuff pressure set to 20 cm H₂ O. Thirty-two experienced ICU nurses each performed six cuff pressure control manoeuvres (three times in two different ETTs) using a manual cuff pressure manometer. Course of cuff pressure from connecting the manometer to disconnecting it from the cuff pilot balloon was recorded using a pressure transducer.

RESULTS

There were 190 cuff pressure control manoeuvres suitable for analysis. In all control manoeuvres a cuff pressure below 20 cm H₂ O was noted. In 20.0% of the control manoeuvres the cuff pressure dropped below 10 cm H₂ O. Cuff pressure drops were mainly caused by initially connecting the manometer to the pilot balloon, less frequently by manipulating the pressure gauge of the manometer. Disconnecting the manometer after the control manoeuvre caused a cuff pressure drop in 78.1% of cases, contributing to a final cuff pressure below 20 cm H₂ O in 31.3% of control manoeuvres.

CONCLUSION

Routine manual cuff pressure control manoeuvres in ETT cuffs result in considerable cuff pressure drops. This may have an impact on silent aspiration of pharyngeal contents passing along the cuff into the lower airway.

Short- and Long-term Outcomes between Young and Older HCC Patients Exceeding The Milan Criteria after Hepatectomy

AIM

The objective of this study was to evaluate short- and long-term survival after surgical treatment between young and older hepatocellular carcinoma (HCC) patients beyond the Milan criteria.

MATERIAL AND METHODS

One hundred fifty-seven HCC patients (≤ 55 years old) were categorized into group A, and one hundred fifty-eight HCC patients (&gt; 55 years old) were categorized into group B. Postoperative complications and overall survival were retrospectively analyzed.

RESULTS

Older HCC patients had a higher rate of delayed extubation after surgery and suffered more complications after surgery, especially major complications. Intraoperative blood transfusion, liver fibrosis/cirrhosis and delayed extubation were risk factors related to postoperative complications. Microvascular invasion (MVI), tumor diameter, postoperative alpha-fetoprotein and the presence of satellites were independent risk factors for long-term survival. Young patients had more advanced tumors. Overall survival rates at 1, 3 and 5-years were 78.1%, 45.1% and 27.4% for young patients, respectively, and 86.5%, 57.5% and 42.4% for older patients, respectively (p = 0.007).

CONCLUSION

The category A group had poorer tumor characteristics and worse prognoses than the category B group.

Impact of a multifaceted prevention program on ventilator-associated pneumonia including selective oropharyngeal decontamination

PURPOSE

We describe the impact of a multifaceted program for decreasing ventilator-associated pneumonia (VAP) after implementing nine preventive measures, including selective oropharyngeal decontamination (SOD).

METHODS

We compared VAP rates during an 8-month pre-intervention period, a 12-month intervention period, and an 11-month post-intervention period in a cohort of patients who received mechanical ventilation (MV) for > 48 h. The primary objective was to assess the effect on first VAP occurrence, using a Cox cause-specific proportional hazards model. Secondary objectives included the impact on emergence of antimicrobial resistance, antibiotic consumption, duration of MV, and ICU mortality.

RESULTS

Pre-intervention, intervention and post-intervention VAP rates were 24.0, 11.0 and 3.9 VAP episodes per 1000 ventilation-days, respectively. VAP rates decreased by 56% [hazard ratio (HR) 0.44, 95% CI 0.29-0.65; P < 0.001] in the intervention and by 85% (HR 0.15, 95% CI 0.08-0.27; P < 0.001) in the post-intervention periods. During the intervention period, VAP rates decreased by 42% (HR 0.58, 95% CI 0.38-0.87; P < 0.001) after implementation of eight preventive measures without SOD, and by 70% after adding SOD (HR 0.30, 95% CI 0.13-0.72; P < 0.001) compared to the pre-intervention period. The incidence density of intrinsically resistant bacteria (to colistin or tobramycin) did not increase. We documented a significant reduction of days of therapy per 1000 patient-days of broad-spectrum antibiotic used to treat lower respiratory tract infection (P < 0.028), median duration of MV (from 7.1 to 6.4 days; P < 0.003) and ICU mortality (from 16.2 to 13.5%; P < 0.049) for patients ventilated > 48 h between the pre- and post-intervention periods.

CONCLUSIONS

Our preventive program produced a sustained decrease in VAP incidence. SOD provides an additive value.

Unexpected formation of polymeric silver(I) complexes of azine-type ligand via self-assembly of Ag-salts with isatin oxamohydrazide

Isatin oxamohydrazide (L) reacted with the aqueous solution of silver nitrate at room temperature afforded the polymeric silver(I) nitrato complex, [Ag₂L'(NO₃)₂] _n , (1) of the azine ligand (L'). Similarly, the reaction of L with silver(I) perchlorate gave the [Ag₂L'₂(ClO₄)₂] _n , (2) coordination polymer. Careful inspection of the crystals from the nitrato complex preparation showed the presence of another crystalline product which is found to be [Ag(Isatin-3-hydrazone)NO₃], (3) suggesting that the reaction between silver(I) nitrate and L proceeds first by the hydrolysis of L to the isatin hydrazone which attacks another molecule of L to afford L'. Testing metal salts such as Ni²⁺, Co²⁺, Mn²⁺, Cu²⁺ and Cd²⁺ did not undergo any reaction with L either under the same reaction conditions or with heating under reflux up to 24 h. Treatment of the warm alcoholic solution of L with few drops of 1 : 1 (v/v) hydrochloric acid gave the free ligand (L') in good yield. The [Ag₂L'(NO₃)₂] _n complex forms a two-dimensional infinite coordination polymer, while the [Ag₂L'₂(ClO₄)₂] _n forms one-dimensional infinite chains with an alternating silver-azine backbone. Quantitative analysis of the intermolecular interactions in their crystals is made using Hirshfeld surface analysis. Density functional theory studies were performed to investigate the coordination bonding in the studied complexes.

Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on rates of ventilator-associated pneumonia in intensive care units of two hospitals in Kuwait

OBJECTIVE

To analyse the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach (IMA) on ventilator-associated pneumonia (VAP) rates in three intensive care units (ICUs) from two hospitals in Kuwait City from January 2014 to March 2015.

DESIGN

A prospective, before-after study on 2507 adult ICU patients. During baseline, we performed outcome surveillance of VAP applying CDC/NHSN definitions. During intervention, we implemented the IMA through the INICC Surveillance Online System (ISOS), which included: (1) a bundle of infection prevention interventions; (2) education; (3) outcome surveillance; and (4) feedback on VAP rates and consequences. Logistic regression analysis was performed to estimate the effect of the intervention on VAP, controlling for potential bias.

RESULTS

During baseline, 1990 mechanical ventilator (MV)-days and 14 VAPs were recorded, accounting for 7.0 VAPs per 1000 MV-days. During intervention, 9786 MV-days and 35 VAPs were recorded, accounting for 3.0 VAPs per 1000 MV-days. The VAP rate was reduced by 57.1% (incidence-density ratio = 0.51; 95% CI = 0.28-0.93; p = 0.042). Logistic regression showed a significant reduction in VAP rate during the intervention phase (OR = 0.39, 95% CI = 0.18-0.83), with 61% effectiveness.

CONCLUSIONS

Implementing IMA through ISOS was associated with a significant reduction in the VAP rate in Kuwait ICUs.

A comparison between laryngeal mask airway and endotracheal intubation for anaesthesia in adult patients undergoing NUSS procedure

Background

This study evaluates and compares the feasibility and safety of application of laryngeal mask airway (LMA) and endotracheal intubation (ETT) for anaesthesia in adult patients undergoing thoracoscopic surgery.

Methods

Sixty adult patients with pectus excavatum (PE) undergoing video-assisted thoracoscopic surgery for the NUSS procedure (VATS-NUSS) between September 2016 and March 2017 were selected and randomly separated into two groups with different methods of airway management. In one group, LMA was applied for general anaesthesia, and in the other group, ETT was used. The clinical parameters before, during and after the surgery in patients from both groups were collected from multiple data resources in a hospital. SPSS software was used for the analysis.

Results

Of all the selected patients, the physiological parameters showed similarity between the LMA and ETT groups, indicating consistency in the clinical characteristics of the study sample. Additionally, no significant differences were discovered between the two groups in terms of the anaesthesia and surgical time, peak PetCO₂ during operation, anaesthetic satisfaction score, and amount of blood loss as well as inpatient time for recovery. However, with a similar level of anaesthesia effects and suitable parameters for mechanical ventilation, patients in the LMA group showed much more stability in the physiological indicators for inflammation and haemodynamics, including white blood cell count (ΔWBC) and percentage of neutrophil granulocytes (ΔNEU%) in the blood as well as heart rate (ΔHR) and mean arterial pressure (ΔMAP). Moreover, the LMA patients had a significantly shorter time for recovery of consciousness and food/water intake. Finally, compared to the ETT group, patients in the LMA group also had a significantly lower incidence of side effects induced by the anaesthesia procedure after surgery, such as gastrointestinal reactions, throat discomfort and hoarseness.

Conclusions

Compared with ETT, the application of LMA for general anaesthesia may demonstrate promising advantages in airway management for the VATS-NUSS procedure.

Impact of the International Nosocomial Infection Control Consortium's multidimensional approach on rates of ventilator-associated pneumonia in 14 intensive care units in 11 hospitals of 5 cities within Argentina

BACKGROUND

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach (IMA) on ventilator-associated pneumonia (VAP) rates in 11 hospitals within 5 cities of Argentina from January 2014-April 2017.

METHODS

A multicenter, prospective, before-after surveillance study was conducted through the use of International Nosocomial Infection Control Consortium Surveillance Online System. During baseline, we performed outcome surveillance of VAP applying the definitions of the Centers for Disease Control andPrevention's National Healthcare Safety Network. During intervention, we implemented the IMA, which included a bundle of infection prevention practice interventions, education, outcome surveillance, process surveillance, feedback on VAP rates and consequences, and performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention.

RESULTS

We recorded 3,940 patients admitted to 14 intensive care units. At baseline, there were 19.9 VAPs per 1,000 mechanical ventilator (MV)-days-with 2,920 MV-days and 58 VAPs, which was reduced during intervention to 9.4 VAPs per 1,000 MV-days-with 9,261 MV-days and 103 VAPs. This accounted for a 52% rate reduction (incidence density rate, 0.48; 95% confidence interval, 0.3-0.7; P .001).

CONCLUSIONS

Implementing the IMA was associated with significant reductions in VAP rates in intensive care units within Argentina.

A Retrospective Study of Non-Ventilator-Associated Hospital Acquired Pneumonia Incidence and Missed Opportunities for Nursing Care

OBJECTIVE

To determine non-ventilator-associated hospital-acquired pneumonia (NV-HAP) incidence, assess negative impacts on patient outcomes and cost, and identify missed preventive nursing care opportunities.

BACKGROUND

NV-HAP is inadequately studied and underreported. Missed nursing care opportunities, particularly oral care, may aid NV-HAP prevention.

METHODS

This descriptive, observational, retrospective chart review identified adult NV-HAP cases and associated demographic and hospital care data.

RESULTS

Two hundred five NV-HAP cases occurred in 1 year at Montefiore Medical Center, equating to an incidence of 0.47 per 1000 patient-days and an estimated excess cost of $8.2 million. ICU transfer following pneumonia occurred in 15.6% of cases. Care requirements from specialist nursing facilities increased at discharge (26.8%), as compared with care requirements on admission (17.6%). Complete nursing care documentation was missing for most patients, with oral care undocumented 60.5% of the time.

CONCLUSIONS

Preventable NV-HAP cases and their negative impact on cost and patient outcomes may decrease through improved basic nursing care.

Ventilator-Associated Pneumonia Prevention Bundle Significantly Reduces the Risk of Ventilator-Associated Pneumonia in Critically Ill Burn Patients

Ventilator-associated pneumonia (VAP) is a common cause of morbidity and mortality for critically ill burn patients. Prevention of VAP through bundled preventative measures may reduce the risk and incidence of VAP in burn patients. A retrospective chart review was performed of all mechanically ventilated adult (age ≥ 18 years) burn patients before and after VAP prevention bundle implementation. Data collected included age, TBSA, gender, diagnosis of inhalation injury, mechanism of injury, comorbid illnesses, length of mechanical ventilation, length of hospital stay, development of VAP, discharge disposition, and mortality. Burn patients with VAP had larger burn injuries (47.6 ± 22.2 vs 23.9 ± 23.01), more inhalation injuries (44.6% vs 27%), prolonged mechanical ventilation, and longer intensive care unit (ICU) and hospital stays. Mortality was also higher in burn patients who developed VAP (34% vs 19%). On multivariate regression analysis, TBSA and ventilator days were independent risk factors for VAP. In 2010, a VAP prevention bundle was implemented in the burn ICU and overseen by a nurse champion. Compliance with bundle implementation was more than 95%. By 2012, independent of age, TBSA, inhalation injury, ventilator days, ICU and hospital length of stay, VAP prevention bundles resulted in a significantly reduced risk of developing VAP (odds ratio of 0.15). Burn patients with an inhalation injury and a large burn injury are at increased risk of developing VAP. The incidence and risk of VAP can be significantly reduced in burn patients with VAP prevention bundles.

The epidemiology of nonventilator hospital-acquired pneumonia in the United States

BACKGROUND

Nonventilator hospital-acquired pneumonia (NV-HAP) is among the most common hospital-acquired infections. The purpose of our study was to quantify the incidence and influence of NV-HAP in the United States using a national dataset.

METHODS

The 2012 US National Inpatient Sample dataset was used to compare an NV-HAP group to 4 additional group cohorts: pneumonia on admission, general hospital admissions, matched on mortality and disease severity, and ventilator-associated pneumonia (VAP). The main outcome was NV-HAP incidence. The secondary outcome was to compare hospital length of stay, total hospital charges, and mortality between the NV-HAP group and the 4 additional group cohorts.

RESULTS

The overall incidence of NV-HAP was 1.6%, which represents a rate of 3.63 per 1,000 patient-days. NV-HAP was associated with increased total hospital charges, a longer hospital length of stay, and greater likelihood of death in comparison to all groups except patients with VAP.

CONCLUSION

NV-HAP is an underappreciated and serious patient safety issue, resulting in significant increases in cost, length of stay, and mortality. Efforts toward prevention of NV-HAP should be raised to the same level of concern as VAP prevention.

Update on ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is the most frequent life-threatening nosocomial infection in intensive care units. The diagnostic is difficult because radiological and clinical signs are inaccurate and could be associated with various respiratory diseases. The concept of infection-related ventilator-associated complication has been proposed as a surrogate of VAP to be used as a benchmark indicator of quality of care. Indeed, bundles of prevention measures are effective in decreasing the VAP rate. In case of VAP suspicion, respiratory secretions must be collected for bacteriological secretions before any new antimicrobials. Quantitative distal bacteriological exams may be preferable for a more reliable diagnosis and therefore a more appropriate use antimicrobials. To improve the prognosis, the treatment should be adequate as soon as possible but should avoid unnecessary broad-spectrum antimicrobials to limit antibiotic selection pressure. For empiric treatments, the selection of antimicrobials should consider the local prevalence of microorganisms along with their associated susceptibility profiles. Critically ill patients require high dosages of antimicrobials and more specifically continuous or prolonged infusions for beta-lactams. After patient stabilization, antimicrobials should be maintained for 7-8 days. The evaluation of VAP treatment based on 28-day mortality is being challenged by regulatory agencies, which are working on alternative surrogate endpoints and on trial design optimization.

Risk factors for ventilator-associated pneumonia: among trauma patients with and without brain injury

Ventilator-associated pneumonia (VAP) rates remain highest among trauma and brain injured patients; yet, no research compares VAP risk factors between the 2 groups. This retrospective, case-controlled study identified risk factors for VAP among critically ill trauma patients with and without brain injury. Data were abstracted on trauma patients with (cases) and without (controls) brain injury. Data gathered on n = 157 subjects. Trauma patients with brain injury had more emergent and field intubations. Age was strongest predictor of VAP in cases, and ventilator days predicted VAP in controls. Trauma patients with brain injury may be at higher risk for VAP.

Healthcare-associated pneumonia among U.S. combat casualties, 2009 to 2010

Although there is literature evaluating infectious complications associated with combat-related injuries from Iraq and Afghanistan, none have evaluated pneumonia specifically. Therefore, we assessed a series of pneumonia cases among wounded military personnel admitted to Landstuhl Regional Medical Center, and then evacuated further to participating U.S. military hospitals. Of the 423 casualties evacuated to the United States, 36 developed pneumonia (8.5%) and 30 of these (83.3%) were ventilator-associated. Restricting to 162 subjects admitted to intensive care, 30 patients had pneumonia (18.5%). The median Injury Severity Score was higher among subjects with pneumonia (23.0 vs. 6.0; p < 0.01). There were 61 first-isolate respiratory specimens recovered from 31 pneumonia subjects, of which 56.1% were gram-negative, 18.2% were gram-positive, and 18.2% were fungal. Staphylococcus aureus and Pseudomonas aeruginosa were most commonly recovered (10.6%, and 9.1%, respectively). Thirteen bacterial isolates (26.5%) were multidrug-resistant. Outcome data were available for 32 patients, of which 26 resolved their infection without progression, 5 resolved after initial progression, and 1 died. Overall, combat-injured casualties suffer a relatively high rate of pneumonia, particularly those requiring mechanical ventilation. Although gram-negative pathogens were common, S. aureus was most frequently isolated. Continued focus on pneumonia prevention strategies is necessary for improving combat care.

Frequency of hospital acquired pneumonia and its microbiological etiology in medical intensive care unit

OBJECTIVE

The objectives were to assess the frequency of hospital acquired pneumonia (HAP) in patients admitted to intensive care unit (ICU) and to determine the frequencies of different etiological organisms in these patients.

METHODS

This was descriptive cross sectional study, which was carried out in medical ICU of Shifa International Hospital Islamabad from January 2013 to January 2014. A total of 1866 patients were admitted in the department of medicine including medical ICU. They were evaluated for HAP and the causative organisms were cultured from these patients. Identification was carried out by standard biochemical profile of the organisms.

RESULTS

The total number of patients admitted in medical ICU for any reason were 346. HAP was diagnosed in 88 patients (25.4%). The average age of patients admitted in Medical ICU with HAP was 48 years with the range of 16 to 82 years. 56 were male and 32 females. 42 patients (47.7%) died in medical ICU with HAP. Microbiological analysis showed that Pseudomonas aeruginosa were 27 (30.6%), Acinetobacter spp. were 12 (13.6%), Candida albicans were 12 (13.6%), Klebsiellapneumoniae were 9 (10.2%), Streptococcus spp. were 9 (10.2%), Escherichia coli were 5 (5.6%), Stenotrophomonas spp. were 4(4.5%), Methicillin Resistant Staphylococcus Aureus (MRSA) were 4 (4.5%) others organisms 6 (6.8%).

CONCLUSION

The frequency of HAP in Medical ICU of our hospital is 88 out of 346 (25.4%). The commonest organism identified was Pseudomonas aeruginosa (30.6%) followed by Acinetobacter and Candida albican (13.6% each).

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Burden of Hospital Acquired Infections and Antimicrobial Use in Vietnamese Adult Intensive Care Units

Background

Vietnam is a lower middle-income country with no national surveillance system for hospital-acquired infections (HAIs). We assessed the prevalence of hospital-acquired infections and antimicrobial use in adult intensive care units (ICUs) across Vietnam.

Methods

Monthly repeated point prevalence surveys were systematically conducted to assess HAI prevalence and antimicrobial use in 15 adult ICUs across Vietnam. Adults admitted to participating ICUs before 08:00 a.m. on the survey day were included.

Results

Among 3287 patients enrolled, the HAI prevalence was 29.5% (965/3266 patients, 21 missing). Pneumonia accounted for 79.4% (804/1012) of HAIs Most HAIs (84.5% [855/1012]) were acquired in the survey hospital with 42.5% (363/855) acquired prior to ICU admission and 57.5% (492/855) developed during ICU admission. In multivariate analysis, the strongest risk factors for HAI acquired in ICU were: intubation (OR 2.76), urinary catheter (OR 2.12), no involvement of a family member in patient care (OR 1.94), and surgery after admission (OR 1.66). 726 bacterial isolates were cultured from 622/1012 HAIs, most frequently Acinetobacter baumannii (177/726 [24.4%]), Pseudomonas aeruginosa (100/726 [13.8%]), and Klebsiella pneumoniae (84/726 [11.6%]), with carbapenem resistance rates of 89.2%, 55.7%, and 14.9% respectively. Antimicrobials were prescribed for 84.8% (2787/3287) patients, with 73.7% of patients receiving two or more. The most common antimicrobial groups were third generation cephalosporins, fluoroquinolones, and carbapenems (20.1%, 19.4%, and 14.1% of total antimicrobials, respectively).

Conclusion

A high prevalence of HAIs was observed, mainly caused by Gram-negative bacteria with high carbapenem resistance rates. This in combination with a high rate of antimicrobial use illustrates the urgent need to improve rational antimicrobial use and infection control efforts.

The effect of daily sedation interruption protocol on early incidence of ventilator-associated pneumonia among patients hospitalized in critical care units receiving mechanical ventilation

Background:

Ventilator-associated pneumonia (VAP) is a common side effect in patients who receive intravenous sedation infusion. In routine care, after starting sedation infusion for patients who receive mechanical ventilation, interruption of sedation starts without protocol. This study aimed to evaluate the effect of daily sedation vacation protocol on the incidence of VAP in mechanically ventilated patients.

Materials and Methods:

In this clinical trial study, 80 patients with intravenous sedation infusion were selected and randomly allocated to intervention and control groups. In the intervention group, daily sedation vacation protocol and in the control group, routine sedation vacation was followed. Modified clinical pulmonary infection score questionnaire was completed before intervention and on the third, fourth, and fifth days after intervention. Data were analyzed by using repeated measures analysis of variance (ANOVA), Chi-square, and independent t-test.

Results:

The results of this study showed that the incidence rate of VAP in the intervention and control groups was 0% versus 15% on the third day of intervention, 12.5% versus 50% on the fourth day, and 27.5% versus 55.3% on the fifth day of intervention in the intervention and control groups, respectively. The incidence of VAP in the intervention group was significantly lower than in the control group (P < 0.05).

Conclusions:

The results of this study showed that in patients with intravenous sedation, infusion of a daily sedation vacation protocol may reduce the incidence of VAP. Therefore, in order to prevent VAP, nurses are recommended to use this daily sedation vacation protocol.

Ventilator-Associated Events: Prevalence, Outcome, and Relationship With Ventilator-Associated Pneumonia

OBJECTIVES

Centers for Disease Control and Prevention built up new surveillance paradigms for the patients on mechanical ventilation and the ventilator-associated events, comprising ventilator-associated conditions and infection-related ventilator-associated complications. We assess 1) the current epidemiology of ventilator-associated event, 2) the relationship between ventilator-associated event and ventilator-associated pneumonia, and 3) the impact of ventilator-associated event on antimicrobials consumption and mechanical ventilation duration.

DESIGN

Inception cohort study from the longitudinal prospective French multicenter OUTCOMEREA database (1996-2012).

PATIENTS

Patients on mechanical ventilation for greater than or equal to 5 consecutive days were classified as to the presence of a ventilator-associated event episode, using slightly modified Centers for Disease Control and Prevention definitions.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Among the 3,028 patients, 2,331 patients (77%) had at least one ventilator-associated condition, and 869 patients (29%) had one infection-related ventilator-associated complication episode. Multiple causes, or the lack of identified cause, were frequent. The leading causes associated with ventilator-associated condition and infection-related ventilator-associated complication were nosocomial infections (27.3% and 43.8%), including ventilator-associated pneumonia (14.5% and 27.6%). Sensitivity and specificity of diagnosing ventilator-associated pneumonia were 0.92 and 0.28 for ventilator-associated condition and 0.67 and 0.75 for infection-related ventilator-associated complication, respectively. A good correlation was observed between ventilator-associated condition and infection-related ventilator-associated complication episodes, and ventilator-associated pneumonia occurrence: R = 0.69 and 0.82 (p < 0.0001). The median number of days alive without antibiotics and mechanical ventilation at day 28 was significantly higher in patients without any ventilator-associated event (p < 0.05). Ventilator-associated condition and infection-related ventilator-associated complication rates were closely correlated with antibiotic use within each ICU: R = 0.987 and 0.99, respectively (p < 0.0001).

CONCLUSIONS

Ventilator-associated event is very common in a population at risk and more importantly highly related to antimicrobial consumption and may serve as surrogate quality indicator for improvement programs.

Hydrogel Antimicrobial Capture Coatings for Endotracheal Tubes: A Pharmaceutical Strategy Designed to Prevent Ventilator-Associated Pneumonia

This paper presents a novel strategy for the prevention of ventilator-associated pneumonia that involves coating poly(vinyl chloride, PVC) endotracheal tubes (ET) with hydrogels that may be subsequently used to entrap nebulized antimicrobial solutions. Candidate hydrogels were prepared containing a range of ratios of hydroxyethyl methacrylate (HEMA) and methacrylic acid (MAA) from 100:0 to 70:30 using free radical polymerization and, when required, simultaneous attachment to PVC was performed. The mechanical properties, glass transition temperatures, swelling kinetics, uptake of gentamicin from an aqueous medium, and gentamicin release were characterized. Increasing the MAA content of the hydrogels significantly decreased the ultimate tensile strength, % elongation at break, Young's modulus, and increased the glass transition temperature, the swelling ratio, and gentamicin uptake. Microbial (Staphylococcus aureus and Pseudomonas aeruginosa) adherence to control (drug-free) hydrogels was observed; however, while adherence to gentamicin-containing p(HEMA) occurred, no adherence occurred to gentamicin-containing HEMA:MAA copolymers. Antimicrobial persistence of gentamicin-containing hydrogels was examined by determining the zone of inhibition against each microorganism on successive days. Hydrogel composition affected the observed antimicrobial persistence, with the hydrogel composed of 70:30 HEMA:MAA exhibiting >20 days persistence against S. aureus and P. aeruginosa, respectively. To simulate clinical use, the hydrogels (coated onto PVC) were first exposed to a nebulized solution of gentamicin (4 mL, 80 mg for 20 min), and then to nebulized bacteria (4 mL ca. 1×10(9) colony forming units mL(-1), 30 min). Viable bacteria were not observed on the gentamicin-treated p(HEMA: MAA) copolymers, whereas growth was observed on gentamicin-treated p(HEMA). In light of the excellent antimicrobial activity and physicochemical properties, p(HEMA: MAA) copolymers composed of ratios of 80:20 or 70:30 HEMA: MAA were identified as potentially useful coatings of endotracheal tubes to be used in conjunction with the clinical nebulization of gentamicin and designed for the prevention of ventilator-associated pneumonia.

In vitro permeability of silver nanoparticles through porcine oromucosal membrane

Silver nanoparticles (AgNPs) can come in contact with human oral mucosa due to their wide use in food industry and hygiene devices. We evaluate transmucosal absorption of 19 nm AgNPs using excised porcine buccal mucosa applied on Franz diffusion cells. Two donor solutions were used: one containing AgNPs (0.5 g/L) and one derived from the ultrafiltration of the former and containing only Ag in its soluble form. Experiments were carried out separately for 4 h. Silver flux permeation was demonstrated through oral mucosa, showing similar values for AgNPs (6.8±4.5 ng cm(-2) h(-1)) and Ag ions (5.2±4.3 ng cm(-2) h(-1)). Our study demonstrates that silver can permeate the oromucosal barrier and that absorption is substantially due to Ag ions, since no permeation difference was found using the two solutions. Mucosal absorption has to be considered in further risk assessment studies.

Discontinuous versus Continuous Weaning in Stroke Patients

Background: An increasing number of stroke patients have to be supported by mechanical ventilation in intensive care units (ICU), with a relevant proportion of them requiring gradual withdrawal from a respirator. To date, weaning studies have focused merely on mixed patient groups, COPD patients or patients after cardiac surgery. Therefore, the best weaning strategy for stroke patients remains to be determined. Methods: Here, we designed a prospective randomized controlled study comparing adaptive support ventilation (ASV), a continuous weaning strategy, with biphasic positive airway pressure (BIPAP) in combination with spontaneous breathing trials, a discontinuous technique, in the treatment of stroke patients. The primary endpoint was the duration of the weaning process. Results: Only the 40 (out of 54) patients failing in an initial spontaneous breathing trial (T-piece test) were included into the study; the failure proportion is considerably larger compared to previous studies. Eligible patients were pseudo-randomly assigned to one of the two weaning groups. Both groups did not differ regarding age, gender, and severity of stroke. The results showed that the median weaning duration was 10.7 days (±SD 7.0) in the discontinuous weaning group, and 8 days (±SD 4.5) in the continuous weaning group (p < 0.05). Conclusions: To the best of our knowledge, this is the first clinical study to show that continuous weaning is significantly more effective compared to discontinuous weaning in mechanically ventilated stroke patients. We suppose that the reason for the superiority of continuous weaning using ASV as well as the bad performance of our patients in the 2 h T-piece test is caused by the patients' compliance. Compared to patients on surgical and medical ICUs, neurological patients more often suffer from reduced vigilance, lack of adverse-effects reflexes, dysphagia, and cerebral dysfunction. Therefore, stroke patients may profit from a more gradual withdrawal of weaning.