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Tanzarella ES, Cutuli SL, Lombardi G, Cammarota F, Caroli A, Franchini E, Sancho Ferrando E, Grieco DL, Antonelli M, De Pascale G. Antimicrobial De-Escalation in Critically Ill Patients. Antibiotics (Basel) 2024; 13:375. [PMID: 38667051 PMCID: PMC11047373 DOI: 10.3390/antibiotics13040375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/03/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
Antimicrobial de-escalation (ADE) is defined as the discontinuation of one or more antimicrobials in empirical therapy, or the replacement of a broad-spectrum antimicrobial with a narrower-spectrum antimicrobial. The aim of this review is to provide an overview of the available literature on the effectiveness and safety of ADE in critically ill patients, with a focus on special conditions such as anti-fungal therapy and high-risk categories. Although it is widely considered a safe strategy for antimicrobial stewardship (AMS), to date, there has been no assessment of the effect of de-escalation on the development of resistance. Conversely, some authors suggest that prolonged antibiotic treatment may be a side effect of de-escalation, especially in high-risk categories such as neutropenic critically ill patients and intra-abdominal infections (IAIs). Moreover, microbiological documentation is crucial for increasing ADE rates in critically ill patients with infections, and efforts should be focused on exploring new diagnostic tools to accelerate pathogen identification. For these reasons, ADE can be safely used in patients with infections, as confirmed by high-quality and reliable microbiological samplings, although further studies are warranted to clarify its applicability in selected populations.
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Affiliation(s)
- Eloisa Sofia Tanzarella
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Gianmarco Lombardi
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Fabiola Cammarota
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Alessandro Caroli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Emanuele Franchini
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | | | - Domenico Luca Grieco
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Massimo Antonelli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Gennaro De Pascale
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
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Martin M, Forveille S, Lascarrou JB, Seguin A, Canet E, Lemarié J, Agbakou M, Desmedt L, Blonz G, Zambon O, Corvec S, Le Thuaut A, Reignier J. Immediate vs. culture-initiated antibiotic therapy in suspected non-severe ventilator-associated pneumonia: a before-after study (DELAVAP). Ann Intensive Care 2024; 14:33. [PMID: 38411756 PMCID: PMC10897643 DOI: 10.1186/s13613-024-01243-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/02/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is the leading nosocomial infection in critical care and is associated with adverse outcomes. When VAP is suspected, starting antibiotic therapy (AT) immediately after pulmonary sampling may expose uninfected patients to unnecessary treatment, whereas waiting for bacteriological confirmation may delay AT in infected patients. As no robust data exist to choose between these strategies, the decision must balance the pre-test diagnostic probability, clinical severity, and risk of antimicrobial resistance. The objective of this study in patients with suspected non-severe VAP was to compare immediate AT started after sampling to conservative AT upon receipt of positive microbiological results. The outcomes were antibiotic sparing, AT suitability, and patient outcomes. METHODS This single-center, before-after study included consecutive patients who underwent distal respiratory sampling for a first suspected non-severe VAP episode (no shock requiring vasopressor therapy or severe acute respiratory distress syndrome). AT was started immediately after sampling in 2019 and upon culture positivity in 2022 (conservative strategy). The primary outcome was the number of days alive without AT by day 28. The secondary outcomes were mechanical ventilation duration, day-28 mortality, and AT suitability (active necessary AT or spared AT). RESULTS The immediate and conservative strategies were applied in 44 and 43 patients, respectively. Conservative and immediate AT were associated with similar days alive without AT (median [interquartile range], 18.0 [0-21.0] vs. 16.0 [0-20.0], p = 0.50) and without broad-spectrum AT (p = 0.53) by day 28. AT was more often suitable in the conservative group (88.4% vs. 63.6%, p = 0.01), in which 27.9% of patients received no AT at all. No significant differences were found for mechanical ventilation duration (median [95%CI], 9.0 [6-19] vs. 9.0 [6-24] days, p = 0.65) or day-28 mortality (hazard ratio [95%CI], 0.85 [0.4-2.0], p = 0.71). CONCLUSION In patients with suspected non-severe VAP, waiting for microbiological confirmation was not associated with antibiotic sparing, compared to immediate AT. This result may be ascribable to low statistical power. AT suitability was better with the conservative strategy. None of the safety outcomes differed between groups. These findings would seem to allow a large, randomized trial comparing immediate and conservative AT strategies.
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Affiliation(s)
- Maëlle Martin
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France.
| | - Solène Forveille
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | | | - Amélie Seguin
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Emmanuel Canet
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Jérémie Lemarié
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Maïté Agbakou
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Luc Desmedt
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Gauthier Blonz
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Olivier Zambon
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Stéphane Corvec
- Nantes Université, CHU Nantes, Institut de Biologie des Hôpitaux de Nantes, Service de Bactériologie Et Des Contrôles Microbiologiques, Nantes, France
| | - Aurélie Le Thuaut
- Nantes Université, CHU Nantes, Plateforme de méthodologie et biostatistique, Direction de la recherche et de l'innovation, Nantes, France
| | - Jean Reignier
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Movement - Interactions - Performance, MIP, UR 4334, Nantes, France
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Jeng M, Orsini EM, Yerke J, Mehkri O, Mireles-Cabodevila E, Khouli H, Mujanovic S, Wang X, Duggal A, Vachharajani V, Scheraga RG. Nonbronchoscopic Bronchoalveolar Lavage Improves Respiratory Culture Accuracy in Critically Ill Patients. Crit Care Explor 2023; 5:e1008. [PMID: 38020848 PMCID: PMC10656098 DOI: 10.1097/cce.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVES Diagnosis of pneumonia is challenging in critically ill, intubated patients due to limited diagnostic modalities. Endotracheal aspirate (EA) cultures are standard of care in many ICUs; however, frequent EA contamination leads to unnecessary antibiotic use. Nonbronchoscopic bronchoalveolar lavage (NBBL) obtains sterile, alveolar cultures, avoiding contamination. However, paired NBBL and EA sampling in the setting of a lack of gold standard for airway culture is a novel approach to improve culture accuracy and limit antibiotic use in the critically ill patients. DESIGN We designed a pilot study to test respiratory culture accuracy between EA and NBBL. Adult, intubated patients with suspected pneumonia received concurrent EA and NBBL cultures by registered respiratory therapists. Respiratory culture microbiology, cell counts, and antibiotic prescribing practices were examined. SETTING We performed a prospective pilot study at the Cleveland Clinic Main Campus Medical ICU in Cleveland, Ohio for 22 months from May 2021 through March 2023. PATIENTS OR SUBJECTS Three hundred forty mechanically ventilated patients with suspected pneumonia were screened. Two hundred fifty-seven patients were excluded for severe hypoxia (Fio2 ≥ 80% or positive end-expiratory pressure ≥ 12 cm H2O), coagulopathy, platelets less than 50,000, hemodynamic instability as determined by the treating team, and COVID-19 infection to prevent aerosolization of the virus. INTERVENTIONS All 83 eligible patients were enrolled and underwent concurrent EA and NBBL. MEASUREMENTS AND MAIN RESULTS More EA cultures (42.17%) were positive than concurrent NBBL cultures (26.51%, p = 0.049), indicating EA contamination. The odds of EA contamination increased by eight-fold 24 hours after intubation. EA was also more likely to be contaminated with oral flora when compared with NBBL cultures. There was a trend toward decreased antibiotic use in patients with positive EA cultures if paired with a negative NBBL culture. Alveolar immune cell populations were recovered from NBBL samples, indicating successful alveolar sampling. There were no major complications from NBBL. CONCLUSIONS NBBL is more accurate than EA for respiratory cultures in critically ill, intubated patients. NBBL provides a safe and effective technique to sample the alveolar space for both clinical and research purposes.
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Affiliation(s)
- Margaret Jeng
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Erica M Orsini
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Jason Yerke
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Omar Mehkri
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | - Hassan Khouli
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Samin Mujanovic
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Xiaofeng Wang
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Abhijit Duggal
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Vidula Vachharajani
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Rachel G Scheraga
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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Martin-Loeches I, Chastre J, Wunderink RG. Bronchoscopy for diagnosis of ventilator-associated pneumonia. Intensive Care Med 2023; 49:79-82. [PMID: 36171440 PMCID: PMC9517962 DOI: 10.1007/s00134-022-06898-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 09/19/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James's street, James' St, Saint James' (part of Phoenix Park), Dublin 8, Dublin, D08 NHY1, Republic of Ireland. .,Pulmonary Intensive Care Unit, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), University of Barcelona, CIBERes, Barcelona, Spain.
| | - Jean Chastre
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Fanning J, Panigada M, Li Bassi G. Nosocomial Pneumonia in the Mechanically Ventilated Patient. Semin Respir Crit Care Med 2022; 43:426-439. [PMID: 35714627 DOI: 10.1055/s-0042-1749448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a common complication occurring in critically ill patients who are mechanically ventilated and is the leading cause of nosocomial infection-related death. Etiologic agents for VAP widely differ based on the population of intensive care unit patients, duration of hospital stay, and prior antimicrobial therapy. VAP due to multidrug-resistant pathogens is associated with the highest morbidity and mortality, likely due to delays in appropriate antimicrobial treatment. International guidelines are currently available to guide diagnostic and therapeutic strategies. VAP can be prevented through various pharmacological and non-pharmacological interventions, which are more effective when grouped as bundles. When VAP is clinically suspected, diagnostic strategies should include early collection of respiratory samples to guide antimicrobial therapy. Empirical treatment should be based on the most likely etiologic microorganisms and antibiotics likely to be active against these microorganisms. Response to therapy should be reassessed after 3 to 5 days and antimicrobials adjusted or de-escalated to reduce the burden of the disease. Finally, considering that drug resistance is increasing worldwide, several novel antibiotics are being tested to efficiently treat VAP in the coming decades.
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Affiliation(s)
- Jonathon Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, Royal Brisbane and Women's Hospital, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Nuffield Department of Population Health, Oxford University, United Kingdom
| | - Mauro Panigada
- Department of Anaesthesiology, Intensive Care and EmergencyFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Queensland University of Technology, Brisbane, Australia.,Intensive Care Unit, The Wesley Hospital, Auchenflower, Queensland, Australia.,Wesley Medical Research, The Wesley Hospital, Auchenflower, Australia
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The Role of Lung Ultrasound Monitoring in Early Detection of Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Observational Study. J Clin Med 2022; 11:jcm11113001. [PMID: 35683392 PMCID: PMC9181291 DOI: 10.3390/jcm11113001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/11/2022] [Accepted: 05/21/2022] [Indexed: 02/08/2023] Open
Abstract
Specific lung ultrasound signs combined with clinical parameters allow for early diagnosis of ventilator-associated pneumonia in the general ICU population. This retrospective cohort study aimed to determine the accuracy of lung ultrasound monitoring for ventilator-associated pneumonia diagnosis in COVID-19 patients. Clinical (i.e., clinical pulmonary infection score) and ultrasound (i.e., presence of consolidation and a dynamic linear−arborescent air bronchogram, lung ultrasound score, ventilator-associated lung ultrasound score) data were collected on the day of the microbiological sample (pneumonia-day) and 48 h before (baseline) on 55 bronchoalveolar lavages of 33 mechanically-ventilated COVID-19 patients who were monitored daily with lung ultrasounds. A total of 26 samples in 23 patients were positive for ventilator-associated pneumonia (pneumonia cases). The onset of a dynamic linear−arborescent air bronchogram was 100% specific for ventilator-associated pneumonia. The ventilator-associated lung ultrasound score was higher in pneumonia-cases (2.5 (IQR 1.0 to 4.0) vs. 1.0 (IQR 1.0 to 1.0); p < 0.001); the lung ultrasound score increased from baseline in pneumonia-cases only (3.5 (IQR 2.0 to 6.0) vs. −1.0 (IQR −2.0 to 1.0); p = 0.0001). The area under the curve for clinical parameters, ventilator-associated pneumonia lung ultrasound score, and lung ultrasound score variations were 0.472, 0.716, and 0.800, respectively. A newly appeared dynamic linear−arborescent air bronchogram is highly specific for ventilator-associated pneumonia in COVID-19 patients. A high ventilator-associated pneumonia lung ultrasound score (or an increase in the lung ultrasound score) orients to ventilator-associated pneumonia.
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A Narrative Review on the Approach to Antimicrobial Use in Ventilated Patients with Multidrug Resistant Organisms in Respiratory Samples—To Treat or Not to Treat? That Is the Question. Antibiotics (Basel) 2022; 11:antibiotics11040452. [PMID: 35453203 PMCID: PMC9031060 DOI: 10.3390/antibiotics11040452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 02/01/2023] Open
Abstract
Multidrug resistant organisms (MDRO) are commonly isolated in respiratory specimens taken from mechanically ventilated patients. The purpose of this narrative review is to discuss the approach to antimicrobial prescription in ventilated patients who have grown a new MDRO isolate in their respiratory specimen. A MEDLINE and PubMed literature search using keywords “multidrug resistant organisms”, “ventilator-associated pneumonia” and “decision making”, “treatment” or “strategy” was used to identify 329 references as background for this review. Lack of universally accepted diagnostic criteria for ventilator-associated pneumonia, or ventilator-associated tracheobronchitis complicates treatment decisions. Consideration of the clinical context including signs of respiratory infection or deterioration in respiratory or other organ function is essential. The higher the quality of respiratory specimens or the presence of bacteremia would suggest the MDRO is a true pathogen, rather than colonization, and warrants antimicrobial therapy. A patient with higher severity of illness has lower safety margins and may require initiation of antimicrobial therapy until an alternative diagnosis is established. A structured approach to the decision to treat with antimicrobial therapy is proposed.
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Scala R, Guidelli L. Clinical Value of Bronchoscopy in Acute Respiratory Failure. Diagnostics (Basel) 2021; 11:diagnostics11101755. [PMID: 34679452 PMCID: PMC8534926 DOI: 10.3390/diagnostics11101755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/16/2022] Open
Abstract
Bronchoscopy may be considered the “added value” in the diagnostic and therapeutic pathway of different clinical scenarios occurring in acute respiratory critically ill patients. Rigid bronchoscopy is mainly employed in emergent clinical situations due to central airways obstruction, haemoptysis, and inhaled foreign body. Flexible bronchoscopy (FBO) has larger fields of acute applications. In intensive care settings, FBO is useful to facilitate intubation in difficult airways, guide percutaneous dilatational tracheostomy, and mucous plugs causing lobar/lung atelectasis. FBO plays a central diagnostic role in acute respiratory failure caused by intra-thoracic tumors, interstitial lung diseases, and suspected severe pneumonia. “Bronchoscopic” sampling has to be considered when “non-invasive” techniques are not diagnostic in suspected ventilator-associated pneumonia and in non-ventilated immunosuppressed patients. The combined use of either noninvasive ventilation (NIV) or High-flow nasal cannula (HFNC) with bronchoscopy is useful in different scenarios; the largest body of proven successful evidence has been found for NIV-supported diagnostic FBO in non-ventilated high risk patients to prevent and avoid intubation. The expected diagnostic/therapeutic goals of acute bronchoscopy should be balanced against the potential severe risks (i.e., cardio-pulmonary complications, bleeding, and pneumothorax). Expertise of the team is fundamental to achieve the best rate of success with the lowest rate of complications of diagnostic and therapeutic bronchoscopic procedures in acute clinical circumstances.
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Antibiotic Stewardship in the Intensive Care Unit. An Official American Thoracic Society Workshop Report in Collaboration with the AACN, CHEST, CDC, and SCCM. Ann Am Thorac Soc 2021; 17:531-540. [PMID: 32356696 PMCID: PMC7193806 DOI: 10.1513/annalsats.202003-188st] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital’s use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is “the right drug at the right time and the right dose for the right bug for the right duration.” A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.
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Rattani S, Farooqi J, Jabeen G, Chandio S, Kash Q, Khan A, Jabeen K. Evaluation of semi-quantitative compared to quantitative cultures of tracheal aspirates for the yield of culturable respiratory pathogens - a cross-sectional study. BMC Pulm Med 2020; 20:284. [PMID: 33121470 PMCID: PMC7594958 DOI: 10.1186/s12890-020-01311-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/11/2020] [Indexed: 11/17/2022] Open
Abstract
Background Diagnosis of lower respiratory tract infections (LRTI) depends on the presence of clinical, radiological and microbiological findings. Endotracheal suction aspirate (ETSA) is the commonest respiratory sample sent for culture from intubated patients. Very few studies have compared quantitative and semi-quantitative processing of ETSA cultures for LRTI diagnosis. We determined the diagnostic accuracy of quantitative and semi-quantitative ETSA culture for LRTI diagnosis, agreement between the quantitative and semi quantitative culture techniques and the yield of respiratory pathogens with both methods. Methods This was a cross-sectional study conducted at the Aga Khan University clinical laboratory, Karachi, Pakistan. One hundred and seventy-eight ETSA samples sent for routine bacteriological cultures were processed quantitatively as part of regular specimen processing method and semi-quantitatively. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy was calculated for both methods using clinical diagnosis of pneumonia as reference standard. Agreement between the quantitative and semi quantitative methods was assessed via the kappa statistic test. Pathogen yield between the two methods was compared using Pearson’s chi-square test. Results The quantitative and semi-quantitative methods yielded pathogens in 81 (45.5%) and 85 (47.8%) cases respectively. There was complete concordance of both techniques in 155 (87.1%) ETSA samples. No growth was observed in 45 (25.3%) ETSA specimens with quantitative culture and 37 (20.8%) cases by semi-quantitative culture. The diagnostic accuracy of both techniques were comparable; 64.6% for quantitative and 64.0% for semi-quantitative culture. The kappa agreement was found to be 0.84 (95% CI, 0.77–0.91) representing almost perfect agreement between the two methods. Although semi-quantitative cultures yielded more pathogens (47.8%) as compared to quantitative ETSA cultures (45.5%), the difference was only 2.3%. However, this difference achieved statistical (chi-square p-value < 0.001) favoring semi-quantitative culture methods over quantitative culture techniques for processing ETSA. Conclusion In conclusion, there is a strong agreement between the performances of both methods of processing ETSA cultures in terms of accuracy of LRTI diagnosis. Semi-quantitative cultures of ETSA yielded more pathogens as compared to quantitative cultures. Although both techniques were comparable, we recommend processing of ETSA using semi-quantitative technique due to its ease and reduced processing time.
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Affiliation(s)
- Salima Rattani
- Department of Pathology & Laboratory Medicine, The Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Joveria Farooqi
- Department of Pathology & Laboratory Medicine, The Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Ghazala Jabeen
- Department of Pathology & Laboratory Medicine, The Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Saeeda Chandio
- Department of Pathology & Laboratory Medicine, The Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Qaiser Kash
- Department of Pathology & Laboratory Medicine, The Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Aijaz Khan
- Department of Pathology & Laboratory Medicine, The Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Kauser Jabeen
- Department of Pathology & Laboratory Medicine, The Aga Khan University, Stadium Road, Karachi, 74800, Pakistan.
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Ma X, Li Y, Liang Y, Liu Y, Yu L, Li C, Liu Q, Chen L. Development of a DNA microarray assay for rapid detection of fifteen bacterial pathogens in pneumonia. BMC Microbiol 2020; 20:177. [PMID: 32576241 PMCID: PMC7310556 DOI: 10.1186/s12866-020-01842-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/03/2020] [Indexed: 01/25/2023] Open
Abstract
Background The rapid identification of pathogenic bacteria is important for determining an appropriate antimicrobial therapy for pneumonia, but traditional bacterial culture is time-consuming and labourious. The aim of this study was to develop and evaluate a DNA microarray assay for the simultaneous detection of fifteen bacterial species directly from respiratory tract specimens in patients with pneumonia. These species included Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Mycoplasma pneumoniae, Enterococcus faecalis, Enterococcus faecium, Enterobacter cloacae, Stenotrophomonas maltophilia, Burkholderia cepacia, Legionella pneumophila and Chlamydia pneumoniae. The 16S rDNA genes and other specific genes of each pathogen were chosen as the amplification targets, amplified via multiplex polymerase chain reaction (PCR), and hybridized to oligonucleotide probes in a microarray. Results The DNA microarray detection limit was 103 copies/μL. Nineteen standard strains and 119 clinical isolates were correctly detected with our microarray, and 3 nontarget species from 4 clinical isolates were not detected. Additionally, bacterial pathogens were accurately identified when two or three bacterial targets were mixed together. Furthermore, the results for 99.4% (156/157) of clinical specimens were the same as those from a conventional assay. Conclusions We developed a DNA microarray that could simultaneously detect various bacterial pathogens in pneumonia. The method described here has the potential to provide considerable labour and time savings due to its ability to screen for 15 bacterial pathogens simultaneously.
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Affiliation(s)
- Xiuqing Ma
- Department of Pulmonary & Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Yanqin Li
- Department of Pulmonary & Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Yuan Liang
- Department of Pulmonary & Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Yang Liu
- Department of Pulmonary & Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Ling Yu
- Department of Pulmonary & Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Chunsun Li
- Department of Pulmonary & Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Qiqi Liu
- Department of Biotechnology, Beijing Institute of Radiation Medicine, Beijing, China
| | - Liangan Chen
- Department of Pulmonary & Critical Care Medicine, Chinese PLA General Hospital, Beijing, China.
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Ventilator-Associated Pneumonia: Diagnostic Test Stewardship and Relevance of Culturing Practices. Curr Infect Dis Rep 2019; 21:50. [PMID: 31754887 DOI: 10.1007/s11908-019-0708-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW Ventilator-associated pneumonia (VAP) is one of the most common infections in the ICU. Prompt diagnosis is vital as mortality increases with delayed antibiotic therapy. However, accurate diagnosis is challenging due to non-specific clinical features in a complicated patient cohort. Microbiological culture data remains a crucial aspect in confirming diagnosis. RECENT FINDINGS Literature data comparing the benefit of invasive respiratory sampling to non-invasive is inconclusive. Differences in culturing practices translate in overidentification of organisms of unclear significance. Positive culture data in a low pre-test probability does not differentiate between true infection and colonization resulting in overtreatment. Furthermore, there are also opportunities for modifying the reporting of respiratory tract cultures that can better guide antimicrobial therapy. Under the umbrella of antimicrobial stewardship, diagnostic stewardship can be incorporated to create a systematic approach that would target culturing practices to match the right pre-test probability. Ideal outcome will be targeting cultures to the right patient population and minimizing unnecessary treatment.
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Abstract
The use of next-generation sequencing and multiomic analysis reveals new insights on the identity of microbes in the lower airways blurring the lines between commensals and pathogens. Microbes are not found in isolation; rather they form complex metacommunities where microbe-host and microbe-microbe interactions play important roles on the host susceptibility to pathogens. In addition, the lower airway microbiota exert significant effects on host immune tone. Thus, this review highlights the roles that microbes in the respiratory tract play in the development of pneumonia.
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Affiliation(s)
- Benjamin G Wu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Human Microbiome Program, New York University School of Medicine, New York, NY 10028, USA
| | - Leopoldo N Segal
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Human Microbiome Program, New York University School of Medicine, New York, NY 10028, USA.
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Paonessa JR, Shah RD, Pickens CI, Lizza BD, Donnelly HK, Malczynski M, Qi C, Wunderink RG. Rapid Detection of Methicillin-Resistant Staphylococcus aureus in BAL: A Pilot Randomized Controlled Trial. Chest 2019; 155:999-1007. [PMID: 30776365 DOI: 10.1016/j.chest.2019.02.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/31/2018] [Accepted: 02/01/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Guidelines recommend empirical vancomycin or linezolid for patients with suspected pneumonia at risk for methicillin-resistant Staphylococcus aureus (MRSA). Unneeded vancomycin or linezolid use may unnecessarily alter host flora and expose patients to toxicity. We therefore sought to determine if rapid testing for MRSA in BAL can safely decrease use of vancomycin or linezolid for suspected MRSA pneumonia. METHODS Operating characteristics of the assay were initially validated against culture on residual BAL. A prospective, unblinded, randomized clinical trial to assess the effect of antibiotic management made on the basis of rapid diagnostic testing (RDT) compared with usual care was subsequently conducted, with primary outcome of duration of vancomycin or linezolid administration. Secondary end points focused on safety. RESULTS Sensitivity of RPCR was 95.7%, with a negative likelihood ratio of 0.04 for MRSA. The clinical trial randomized 45 patients: 22 to antibiotic management made on the basis of RDT and 23 to usual care. Duration of vancomycin or linezolid administration was significantly reduced in the intervention group (32 h [interquartile range, 22-48] vs 72 h [interquartile range, 50-113], P < .001). Proportions with complications and length of stay trended lower in the intervention group. Hospital mortality was 13.6% in the intervention group and 39.1% for usual care (95% CI of difference, -3.3 to 50.3, P = .06). Standardized mortality ratio was 0.48 for the intervention group and 1.18 for usual care. CONCLUSIONS A highly sensitive BAL RDT for MRSA significantly reduced use of vancomycin and linezolid in ventilated patients with suspected pneumonia. Management made on the basis of RDT had no adverse effects, with a trend to lower hospital mortality. TRIAL REGISTRY ClinicalTrials.gov; No. NCT02660554; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Joseph R Paonessa
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Raj D Shah
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwest Hospital and Medical Center, University of Washington Medicine, Seattle, WA
| | - Chiagozie I Pickens
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bryan D Lizza
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL
| | - Helen K Donnelly
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Chao Qi
- Department of Pathology, Northwestern Memorial Hospital, Chicago, IL; Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Richard G Wunderink
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Vandana Kalwaje E, Rello J. Management of ventilator-associated pneumonia: Need for a personalized approach. Expert Rev Anti Infect Ther 2018; 16:641-653. [DOI: 10.1080/14787210.2018.1500899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Eshwara Vandana Kalwaje
- Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Jordi Rello
- Critical Care Department, Vall d’Hebron Barcelona Hospital Campus & Centro de Investigacion Biomedica en Red (CIBERES), Barcelona, Spain
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Dahyot S, Lemee L, Pestel-Caron M. [Description and role of bacteriological techniques in the management of lung infections]. Rev Mal Respir 2017; 34:1098-1113. [PMID: 28688757 PMCID: PMC7134997 DOI: 10.1016/j.rmr.2016.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/28/2016] [Indexed: 01/07/2023]
Abstract
Les pneumopathies aiguës recouvrent des contextes cliniques variés et les étiologies bactériennes impliquées le sont tout autant. Aucun outil microbiologique n’est 100 % sensible ni 100 % spécifique et malgré les investigations, plus de 30 % des pneumopathies restent sans étiologie identifiée. Si aucun prélèvement n’est indiqué pour les patients traités en ambulatoire, les prélèvements respiratoires non invasifs sont à privilégier pour les pneumopathies aiguës hospitalisées (communautaires ou associées aux soins), tandis que les prélèvements invasifs sont indiqués en seconde ligne pour les pneumopathies aiguës communautaires en réanimation, et en première ligne pour les pneumopathies aiguës de l’immunodéprimé. La culture microbiologique garde une place importante, à condition que le malade soit prélevé avant instauration de l’antibiothérapie. Certains contextes peuvent justifier le recours aux hémocultures, à la recherche d’antigènes urinaires ou aux sérologies. Les PCR rendent déjà service au quotidien mais l’avenir à court terme appartient probablement aux panels moléculaires multiplex capables de détecter de nombreux micro-organismes en quelques heures, surtout dans les pneumopathies communautaires sévères de réanimation et les pneumopathies aiguës de l’immunodéprimé. Le séquençage nucléotidique haut débit révolutionnera bientôt le diagnostic microbiologique, en pneumologie comme dans les autres domaines de l’infectiologie.
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Affiliation(s)
- S Dahyot
- UNIROUEN, GRAM EA2656, laboratoire de bactériologie, CHU de Rouen, Normandie université, 76000 Rouen, France.
| | - L Lemee
- UNIROUEN, GRAM EA2656, laboratoire de bactériologie, CHU de Rouen, Normandie université, 76000 Rouen, France
| | - M Pestel-Caron
- UNIROUEN, GRAM EA2656, laboratoire de bactériologie, CHU de Rouen, Normandie université, 76000 Rouen, France
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Kollef MH, Burnham CAD. Ventilator-Associated Pneumonia: The Role of Emerging Diagnostic Technologies. Semin Respir Crit Care Med 2017; 38:253-263. [PMID: 28578550 PMCID: PMC7117076 DOI: 10.1055/s-0037-1599224] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antibiotic resistance has emerged as a key determinant of outcome in patients with serious infections along with the virulence of the underlying pathogen. Within the intensive care unit (ICU) setting, ventilator-associated pneumonia (VAP) is a common nosocomial infection that is frequently caused by multidrug-resistant bacteria. Antimicrobial resistance is a growing challenge in the care of critically ill patients. Escalating rates of antibiotic resistance add substantially to the morbidity, mortality, and cost related to infection in the ICU. Both gram-positive organisms, such as methicillin-resistant Staphylococcus aureus and vancomycin-intermediate S. aureus, and gram-negative bacteria, including Pseudomonas aeruginosa, Acinetobacter species, carbapenem-resistant Enterobacteriaceae, such as the Klebsiella pneumoniae carbapenemase-producing bacteria, and extended spectrum β-lactamase organisms, have contributed to the escalating rates of resistance seen in VAP and other nosocomial infections. The rising rates of antimicrobial resistance have led to the routine empiric administration of broad-spectrum antibiotics even when bacterial infection is not documented. Moreover, there are several new broader-spectrum antibiotics that have recently become available and others scheduled for approval in the near future. The challenge to ICU clinicians is how to most effectively utilize these agents to maximize patient benefits while minimizing further emergence of resistance. Use of rapid diagnostics may hold the key for achieving this important balance. There is an urgent need for integrating the administration of new and existing antibiotics with the emerging rapid diagnostic technologies in a way that is both cost-effective and sustainable for the long run.
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Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
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Siow WT, Koay ESC, Lee CK, Lee HK, Ong V, Ngerng WJ, Lim HF, Tan A, Tang JWT, Phua J. The Use of Polymerase Chain Reaction Amplification for the Detection of Viruses and Bacteria in Severe Community-Acquired Pneumonia. Respiration 2016; 92:286-294. [DOI: 10.1159/000448555] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 07/20/2016] [Indexed: 11/19/2022] Open
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Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratalà J, El Solh AA, Ewig S, Fey PD, File TM, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61-e111. [PMID: 27418577 DOI: 10.1093/cid/ciw353] [Citation(s) in RCA: 1946] [Impact Index Per Article: 243.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.
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Affiliation(s)
- Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha
| | - Mark L Metersky
- Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington
| | - Michael Klompas
- Brigham and Women's Hospital and Harvard Medical School Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - John Muscedere
- Department of Medicine, Critical Care Program, Queens University, Kingston, Ontario, Canada
| | - Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego
| | - Lucy B Palmer
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, State University of New York at Stony Brook
| | - Lena M Napolitano
- Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, University of Michigan, Ann Arbor
| | - Naomi P O'Grady
- Department of Critical Care Medicine, National Institutes of Health, Bethesda
| | - John G Bartlett
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute, Spanish Network for Research in Infectious Diseases, University of Barcelona, Spain
| | - Ali A El Solh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University at Buffalo, Veterans Affairs Western New York Healthcare System, New York
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt Bochum, Germany
| | - Paul D Fey
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha
| | | | - Marcos I Restrepo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, South Texas Veterans Health Care System and University of Texas Health Science Center at San Antonio
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland Royal Brisbane and Women's Hospital, Queensland
| | - Grant W Waterer
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Peggy Cruse
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Jan L Brozek
- Department of Clinical Epidemiology and Biostatistics and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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20
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May AK. An Argument for the Use of Aminoglycosides in the Empiric Treatment of Ventilator-Associated Pneumonia. Surg Infect (Larchmt) 2016; 17:329-33. [PMID: 27035615 DOI: 10.1089/sur.2015.276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Appropriate empiric antibiotic therapy for ventilator-associated pneumonia improves outcomes. Controversy exists regarding the inclusion of aminoglycosides in empiric therapeutic regimens. METHODS The Ovid and Cochrane databases were searched for relevant literature regarding the use of aminoglycosides in combination therapy for ventilator-associated pneumonia. The data supporting the use of aminoglycosides in certain populations and strategies to limit toxicity are summarized. RESULTS In patients at high risk of infection with antibiotic-resistant gram-negative bacilli and in those with severe illness, aminoglycosides improve clinical outcomes. In critically ill populations, short-duration therapy and high-dose extended-interval dosing of aminoglycosides can improve therapeutic efficacy while limiting nephrotoxicity. CONCLUSIONS In selected populations using appropriate dosing strategies, aminoglycosides should be considered for empiric treatment of ventilator-associated pneumonia.
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Affiliation(s)
- Addison K May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
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21
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Pugh R, Grant C, Cooke RPD, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev 2015; 2015:CD007577. [PMID: 26301604 PMCID: PMC7025798 DOI: 10.1002/14651858.cd007577.pub3] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pneumonia is the most common hospital-acquired infection affecting patients in the intensive care unit (ICU). However, current national guidelines for the treatment of hospital-acquired pneumonia (HAP) are several years old and the diagnosis of pneumonia in mechanically ventilated patients (VAP) has been subject to considerable recent attention. The optimal duration of antibiotic therapy for HAP in the critically ill is uncertain. OBJECTIVES To assess the effectiveness of short versus prolonged-course antibiotics for HAP in critically ill adults, including patients with VAP. SEARCH METHODS We searched CENTRAL (2015, Issue 5), MEDLINE (1946 to June 2015), MEDLINE in-process and other non-indexed citations (5 June 2015), EMBASE (2010 to June 2015), LILACS (1982 to June 2015) and Web of Science (1955 to June 2015). SELECTION CRITERIA We considered all randomised controlled trials (RCTs) comparing a fixed 'short' duration of antibiotic therapy with a 'prolonged' course for HAP (including patients with VAP) in critically ill adults. DATA COLLECTION AND ANALYSIS Two review authors conducted data extraction and assessment of risk of bias. We contacted trial authors for additional information. MAIN RESULTS We identified six relevant studies involving 1088 participants. This included two new studies published after the date of our previous review (2011). There was substantial variation in participants, in the diagnostic criteria used to define an episode of pneumonia, in the interventions and in the reported outcomes. We found no evidence relating to patients with a high probability of HAP who were not mechanically ventilated. For patients with VAP, overall a short seven- or eight-day course of antibiotics compared with a prolonged 10- to 15-day course increased 28-day antibiotic-free days (two studies; N = 431; mean difference (MD) 4.02 days; 95% confidence interval (CI) 2.26 to 5.78) and reduced recurrence of VAP due to multi-resistant organisms (one study; N = 110; odds ratio (OR) 0.44; 95% CI 0.21 to 0.95), without adversely affecting mortality and other recurrence outcomes. However, for cases of VAP specifically due to non-fermenting Gram-negative bacilli (NF-GNB), recurrence was greater after short-course therapy (two studies, N = 176; OR 2.18; 95% CI 1.14 to 4.16), though mortality outcomes were not significantly different. One study found that a three-day course of antibiotic therapy for patients with suspected HAP but a low Clinical Pulmonary Infection Score (CPIS) was associated with a significantly lower risk of superinfection or emergence of antimicrobial resistance, compared with standard (prolonged) course therapy. AUTHORS' CONCLUSIONS On the basis of a small number of studies and appreciating the lack of uniform definition of pneumonia, we conclude that for patients with VAP not due to NF-GNB a short, fixed course (seven or eight days) of antibiotic therapy appears not to increase the risk of adverse clinical outcomes, and may reduce the emergence of resistant organisms, compared with a prolonged course (10 to 15 days). However, for patients with VAP due to NF-GNB, there appears to be a higher risk of recurrence following short-course therapy. These findings do not differ from those of our previous review and are broadly consistent with current guidelines. There are few data from RCTs comparing durations of therapy in non-ventilated patients with HAP, but on the basis of a single study, short-course (three-day) therapy for HAP appears not to be associated with worse clinical outcome, and may reduce the risk of subsequent infection or the emergence of resistant organisms when there is low probability of pneumonia according to the CPIS.
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Affiliation(s)
- Richard Pugh
- Glan Clwyd HospitalDepartment of AnaestheticsRhylDenbighshireUKLL18 5UJ
| | - Chris Grant
- University Hospital AintreeDepartment of Critical CareLower LaneLiverpoolMerseysideUKL9 7AL
| | - Richard PD Cooke
- Alder Hey Children's NHS Foundation TrustDepartment of MicrobiologyEaton RoadWest DerbyLiverpoolMerseysideUKL12 2AP
| | - Ged Dempsey
- University Hospital AintreeDepartment of Critical CareLower LaneLiverpoolMerseysideUKL9 7AL
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Corrêa RDA, Luna CM, Anjos JCFVD, Barbosa EA, Rezende CJD, Rezende AP, Pereira FH, Rocha MODC. Quantitative culture of endotracheal aspirate and BAL fluid samples in the management of patients with ventilator-associated pneumonia: a randomized clinical trial. J Bras Pneumol 2015; 40:643-51. [PMID: 25610505 PMCID: PMC4301249 DOI: 10.1590/s1806-37132014000600008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 05/12/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To compare 28-day mortality rates and clinical outcomes in ICU patients with ventilator-associated pneumonia according to the diagnostic strategy used. METHODS: This was a prospective randomized clinical trial. Of the 73 patients included in the study, 36 and 37 were randomized to undergo BAL or endotracheal aspiration (EA), respectively. Antibiotic therapy was based on guidelines and was adjusted according to the results of quantitative cultures. RESULTS: The 28-day mortality rate was similar in the BAL and EA groups (25.0% and 37.8%, respectively; p = 0.353). There were no differences between the groups regarding the duration of mechanical ventilation, antibiotic therapy, secondary complications, VAP recurrence, or length of ICU and hospital stay. Initial antibiotic therapy was deemed appropriate in 28 (77.8%) and 30 (83.3%) of the patients in the BAL and EA groups, respectively (p = 0.551). The 28-day mortality rate was not associated with the appropriateness of initial therapy in the BAL and EA groups (appropriate therapy: 35.7% vs. 43.3%; p = 0.553; and inappropriate therapy: 62.5% vs. 50.0%; p = 1.000). Previous use of antibiotics did not affect the culture yield in the EA or BAL group (p = 0.130 and p = 0.484, respectively). CONCLUSIONS: In the context of this study, the management of VAP patients, based on the results of quantitative endotracheal aspirate cultures, led to similar clinical outcomes to those obtained with the results of quantitative BAL fluid cultures.
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Affiliation(s)
- Ricardo de Amorim Corrêa
- Federal University of Minas Gerais, School of Medicine, Department of Pulmonology and Thoracic Surgery, Belo Horizonte, Brazil. Department of Pulmonology and Thoracic Surgery, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Carlos Michel Luna
- University of Buenos Aires, Hospital de Clínicas, Buenos Aires, Argentina. Hospital de Clínicas, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Eurípedes Alvarenga Barbosa
- Hospital Madre Teresa, Belo Horizonte, Brazil. Laboratory of Microbiology, Hospital Madre Teresa, Belo Horizonte, Brazil
| | - Cláudia Juliana de Rezende
- Hospital Madre Teresa, Department of Radiology, Belo Horizonte, Brazil. Department of Radiology, Hospital Madre Teresa, Belo Horizonte, Brazil
| | - Adriano Pereira Rezende
- Hospital Madre Teresa, Department of Pulmonology and Thoracic Surgery, Belo Horizonte, Brazil. Department of Pulmonology and Thoracic Surgery, Hospital Madre Teresa, Belo Horizonte, Brazil
| | - Fernando Henrique Pereira
- Federal University of Minas Gerais, School of Medicine, Postgraduate Center, Belo Horizonte, Brazil. Postgraduate Center, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Manoel Otávio da Costa Rocha
- Federal University of Minas Gerais, School of Medicine, Belo Horizonte, Brazil. Postgraduate Program in Health Sciences, Infectology and Tropical Medicine, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
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Edelsberg J, Berger A, Weber DJ, Mallick R, Kuznik A, Oster G. Clinical and Economic Consequences of Failure of Initial Antibiotic Therapy for Hospitalized Patients With Complicated Skin and Skin-Structure Infections. Infect Control Hosp Epidemiol 2015; 29:160-9. [DOI: 10.1086/526444] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objective.To estimate the consequences of failure of initial antibiotic therapy for patients with complicated skin and skin-structure infections.Design.Retrospective cohort study.Setting.Large US multihospital database.Patients.We identified a total of 47,219 patients (age 18 years or older) who were admitted to the hospital for complicated skin and skin-structure infections from April 1, 2003, through March 31, 2004, and who received intravenous antibiotics during the first 2 hospital-days (ie, initial antibiotic therapy). Failure of therapy was defined as drainage, debridement, or receipt of other intravenous antibiotics at any subsequent time (except for changes to narrower-spectrum agents or any therapy change immediately before discharge). Predictors of failure of antibiotic therapy and mortality were examined using multivariate logistic regression. Analysis of covariance was used to estimate the impact of treatment failure on duration of intravenous antibiotic therapy, length of stay, and total inpatient charges.Results.For 10,782 admitted patients (22.8%), there was evidence of failure of initial antibiotic therapy. In multivariate analyses, treatment failure was associated with receipt of vasoactive medications during the first 2 hospital-days (odds ratio [OR], 1.66 [95% confidence interval {CI}, 1.19-2.31]), initiation of antibiotic therapy in the intensive care unit (OR, 1.53 [95% CI, 1.28-1.84]), and the patient's Charlson comorbidity index (OR per 1-point increase, 1.06 [95% CI, 1.04-1.08]); treatment failure was also was associated with a 3-fold increase in mortality (OR, 2.91 [95% CI, 2.34-3.62]). Compared with patients for whom initial treatment was successful, patients who experienced treatment failure received intravenous antibiotic therapy for a mean of 5.7 additional days, were hospitalized for a mean of 5.4 additional days, and incurred a mean of $5,285 (in 2003 dollars) in additional inpatient charges (all P <.01).Conclusion.Failure of initial antibiotic therapy in the treatment of complicated skin and skin-structure infections is associated with significantly worse clinical and economic outcomes.
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Berton DC, Kalil AC, Teixeira PJZ. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database Syst Rev 2014; 2014:CD006482. [PMID: 25354013 PMCID: PMC11064766 DOI: 10.1002/14651858.cd006482.pub4] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a common infectious disease in intensive care units (ICUs). The best diagnostic approach to resolve this condition remains uncertain. OBJECTIVES To evaluate whether quantitative cultures of respiratory secretions and invasive strategies are effective in reducing mortality in immunocompetent patients with VAP, compared with qualitative cultures and non-invasive strategies. We also considered changes in antibiotic use, length of ICU stay and mechanical ventilation. SEARCH METHODS We searched CENTRAL (2014, Issue 9), MEDLINE (1966 to October week 2, 2014), EMBASE (1974 to October 2014) and LILACS (1982 to October 2014). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing respiratory samples processed quantitatively or qualitatively, obtained by invasive or non-invasive methods from immunocompetent patients with VAP and which analysed the impact of these methods on antibiotic use and mortality rates. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed the trials identified in the search results and assessed studies for suitability, methodology and quality. We analysed data using Review Manager software. We pooled the included studies to yield the risk ratio (RR) for mortality and antibiotic change with 95% confidence intervals (CI). MAIN RESULTS Of the 5064 references identified from the electronic databases (605 from the updated search in October 2014), five RCTs (1367 patients) met the inclusion criteria. Three studies compared invasive methods using quantitative cultures versus non-invasive methods using qualitative cultures, and we used them to answer the main objective of this review. The other two studies compared invasive versus non-invasive methods, both using quantitative cultures. We combined all five studies to compare invasive versus non-invasive interventions for diagnosing VAP. The studies that compared quantitative and qualitative cultures (1240 patients) showed no statistically significant differences in mortality rates (RR 0.91; 95% CI 0.75 to 1.11). The analysis of all five RCTs showed there was no evidence of reduction in mortality in the invasive group versus the non-invasive group (RR 0.93; 95% CI 0.78 to 1.11). There were no significant differences between the interventions with respect to the number of days on mechanical ventilation, length of ICU stay or antibiotic change. AUTHORS' CONCLUSIONS There is no evidence that the use of quantitative cultures of respiratory secretions results in reduced mortality, reduced time in ICU and on mechanical ventilation, or higher rates of antibiotic change when compared to qualitative cultures in patients with VAP. We observed similar results when invasive strategies were compared with non-invasive strategies.
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Affiliation(s)
- Danilo Cortozi Berton
- Federal University of Health Sciences of Porto Alegre (UFCSPA) and Feevale UniversityDepartment of Pulmonary Medicine ‐ Pavilhão Pereira Filho ‐ Santa Casa de Porto AlegreRua Prof Annes Dias, 295Porto AlegreRio Grande do SulBrazilCEP 90020‐090
| | - Andre C Kalil
- Infectious Diseases Division, University of Nebraska Medical CenterDepartment of Internal MedicineOmahaNebraskaUSA985400
| | - Paulo José Zimermann Teixeira
- Federal University of Health Sciences of Porto Alegre (UFCSPA) and Feevale UniversityDepartment of Pulmonary Medicine ‐ Pavilhão Pereira Filho ‐ Santa Casa de Porto AlegreRua Prof Annes Dias, 295Porto AlegreRio Grande do SulBrazilCEP 90020‐090
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Guidry CA, Mallicote MU, Petroze RT, Hranjec T, Rosenberger LH, Davies SW, Sawyer RG. Influence of bronchoscopy on the diagnosis of and outcomes from ventilator-associated pneumonia. Surg Infect (Larchmt) 2014; 15:527-32. [PMID: 24841750 DOI: 10.1089/sur.2013.142] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection affecting as many as 27% of mechanically ventilated patients. Ventilator-associated pneumonia is an important source of morbidity and mortality in the surgical intensive care unit (SICU). The optimal diagnostic method for VAP has remained controversial and the role of therapeutic bronchoscopy in the clearance of pulmonary secretions with VAP, in essence source control, remains unknown. Our unit utilizes bronchoscopy inconsistently for these purposes and we chose to evaluate its effectiveness in our patient population with the hypothesis that bronchoscopic diagnosis and therapy results in lower mortality rates and faster clinical resolution. METHODS We analyzed retrospectively all patients treated for VAP in a single SICU between September 2003 and December 2011. Patients were divided into groups based upon diagnostic method and receipt of therapeutic bronchoscopy, and were analyzed for differences in time to clinical resolution and mortality. RESULTS A total of 360 patients were included in the study, including 493 episodes of VAP. The diagnostic bronchoscopy group had statistically higher APACHE II scores (p=0.02) and fewer days in hospital prior to diagnosis (p=0.02) when compared with the non-invasive diagnosis group. Diagnostic bronchoscopy was associated with shorter length of stay and shorter duration of antibiotics whereas receipt of a therapeutic bronchoscopy was associated with the opposite effects by multivariable analysis. CONCLUSION Our hypothesis was disproved and our findings are similar to those found in recent publications. This study supports no definitive conclusions, but further consideration of the role of bronchoscopy is urged in both the diagnosis and treatment of VAP. In our population, bronchoscopy for diagnostic or therapeutic purposes in VAP was not associated with better outcomes. However, differences in baseline characteristics suggest a randomized trial may be needed to answer more completely this question.
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Affiliation(s)
- Christopher A Guidry
- 1 Division of Acute Care and Trauma Surgery, The University of Virginia Health System , Charlottesville, Virginia
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Bowers DR, Tam VH. Pseudomonas aeruginosatreatment and transmission reduction. Expert Rev Anti Infect Ther 2014; 11:831-7. [DOI: 10.1586/14787210.2013.816463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Hashimoto S, Shime N. Evaluation of semi-quantitative scoring of Gram staining or semi-quantitative culture for the diagnosis of ventilator-associated pneumonia: a retrospective comparison with quantitative culture. J Intensive Care 2013; 1:2. [PMID: 25705397 PMCID: PMC4336129 DOI: 10.1186/2052-0492-1-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 09/13/2013] [Indexed: 12/02/2022] Open
Abstract
Background Semi-quantitative Gram stain and culture methods are still commonly used for diagnosing ventilator-associated pneumonia (VAP), due to its convenience. Only a few studies, however, have assessed the reliability of these methods when compared with quantitative cultures, a current standard for the diagnosis of VAP. The objective of this study was to assess the utility of semi-quantitative scores obtained using Gram stains and cultures of endotracheal aspirates when compared with quantitative cultures in the diagnosis of VAP. Methods A retrospective chart review of mechanically ventilated patients with clinically suspected VAP in a single intensive care unit was performed. Semi-quantitative scores of Gram stains or culture results were compared with quantitative culture results of endotracheal aspirate for the diagnosis of VAP in 136 samples for 51 patients. Results The semi-quantitative scores of Gram stains and the semi-quantitative culture results significantly correlated with the log value of the quantitative culture results (rs = 0.64 and 0.75). When using a log count ≥6 of quantitative cultures as the reference standard for the diagnosis of VAP, the sensitivity and specificity was 95% and 61% for Gram stain score of ≥1+, and was 42% and 96% for Gram stain score ≥3+, respectively. The sensitivity and specificity was 96% and 40% for the semi-quantitative culture score of ≥2+, and was 59% and 86% for the semi-quantitative culture score of ≥3+, respectively. Conclusions Absence of bacteria in semi-quantitative Gram stain and poor growth (≤1+) in semi-quantitative culture method could be utilized to exclude the possibility of VAP, whereas detection of abundant (≥3+) bacteria in semi-quantitative Gram stain could be utilized to strongly suspect VAP.
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Affiliation(s)
- Soshi Hashimoto
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan ; Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan
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Shahin J, Bielinski M, Guichon C, Flemming C, Kristof AS. Suspected ventilator-associated respiratory infection in severely ill patients: a prospective observational study. Crit Care 2013; 17:R251. [PMID: 24148702 PMCID: PMC4056611 DOI: 10.1186/cc13077] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 09/27/2013] [Indexed: 11/23/2022] Open
Abstract
Introduction Ventilator-associated respiratory infection (VARI) is an important cause of morbidity in critically-ill patients. Clinical trials performed in heterogeneous populations have suggested there are limited benefits from invasive diagnostic testing to identify patients at risk or to target antimicrobial therapy. However, multiple patient subgroups (for example, immunocompromised, antibiotic-treated) have traditionally been excluded from randomization. We hypothesized that a prospective surveillance study would better identify patients with suspected VARI (sVARI) at high risk for adverse clinical outcomes, and who might be specifically targeted in future trials. Methods We performed a prospective observational study in all patients ventilated for greater than 48 hours. sVARI was identified by surveillance for changes in white blood cell count, temperature, sputum, and/or new chest X-ray infiltrates. Indices of disease co-morbidity, as well as mortality, duration of mechanical ventilation, and length of hospital or ICU stay were correlated with sVARI. Results Of 1806 patients admitted to the ICU over 14 months, 267 were ventilated for greater than 48 hours, and 77 developed sVARI. Incidence of sVARI was associated with iatrogenic immunosuppression or admission for respiratory illness. Any sVARI, whether suspected ventilator-associated pneumonia (sVAP) or ventilator-associated tracheobronchitis (sVAT), was associated with increased length of stay and duration of mechanical ventilation. Conclusions Clinical surveillance for sVARI identifies patients at risk for increased morbidity. Iatrogenically immunosuppressed patients, a subgroup previously excluded from randomized clinical trials, represent a growing proportion of the critically-ill at risk for sVARI who might be targeted for future investigations on diagnostic or therapeutic modalities.
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Kneidinger N, Warszawska J, Schenk P, Fuhrmann V, Bojic A, Hirschl A, Herkner H, Madl C, Makristathis A. Storage of bronchoalveolar lavage fluid and accuracy of microbiologic diagnostics in the ICU: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R135. [PMID: 23844796 PMCID: PMC4057171 DOI: 10.1186/cc12814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 07/11/2013] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Early initiation of appropriate antimicrobial treatment is a cornerstone in managing pneumonia. Because microbiologic processing may not be available around the clock, optimal storage of specimens is essential for accurate microbiologic identification of pathogenetic bacteria. The aim of our study was to determine the accuracy of two commonly used storage approaches for delayed processing of bronchoalveolar lavage in critically ill patients with suspected pneumonia. METHODS This study included 132 patients with clinically suspected pneumonia at two medical intensive care units of a tertiary care hospital. Bronchoalveolar lavage samples were obtained and divided into three aliquots: one was used for immediate culture, and two, for delayed culture (DC) after storage for 24 hours at 4°C (DC4) and -80°C (DC-80), respectively. RESULTS Of 259 bronchoalveolar lavage samples, 84 (32.4%) were positive after immediate culture with 115 relevant culture counts (≥104 colony-forming units/ml). Reduced (<104 colony-forming units/ml) or no growth of four and 57 of these isolates was observed in DC4 and DC-80, respectively. The difference between mean bias of immediate culture and DC4 (-0.035; limits of agreement, -0.977 to 0.906) and immediate culture and DC-80 (-1.832; limits of agreement, -4.914 to 1.267) was -1.788 ± 1.682 (P < 0.0001). Sensitivity and negative predictive value were 96.5% and 97.8% for DC4 and 50.4% and 75.4% for DC-80, respectively; the differences were statistically significant (P < 0.0001). CONCLUSIONS Bronchoalveolar lavage samples can be processed for culture when stored up to 24 hours at 4°C without loss of diagnostic accuracy. Delayed culturing after storage at -80°C may not be reliable, in particular with regard to Gram-negative bacteria.
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Empirical Antibiotic Therapy for Ventilator-Associated Pneumonia. Antibiotics (Basel) 2013; 2:339-51. [PMID: 27029307 PMCID: PMC4790268 DOI: 10.3390/antibiotics2030339] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/15/2013] [Accepted: 06/18/2013] [Indexed: 12/29/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is the most common infectious complication in the intensive care unit. It can increase duration of mechanical ventilation, length of stay, costs, and mortality. Improvements in the administration of empirical antibiotic therapy have potential to reduce the complications of VAP. This review will discuss the current data addressing empirical antibiotic therapy and the effect on mortality in patients with VAP. It will also address factors that could improve the administration of empirical antibiotics and directions for future research.
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Craven DE, Lei Y, Ruthazer R, Sarwar A, Hudcova J. Incidence and outcomes of ventilator-associated tracheobronchitis and pneumonia. Am J Med 2013; 126:542-9. [PMID: 23561632 DOI: 10.1016/j.amjmed.2012.12.012] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 11/04/2012] [Accepted: 12/05/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prolonged intubation with mechanical ventilation carries a risk for ventilator-associated respiratory infections manifest as tracheobronchitis or pneumonia. This study analyzed natural history, incidence, and outcomes of patients developing ventilator-associated tracheobronchitis and pneumonia. METHODS We studied 188 mixed intensive care unit (ICU) patients intubated ≥48 hours for the development of tracheobronchitis defined as quantitative endotracheal aspirate ≥10(5) cfu/mL plus at least 2 clinical criteria (fever, leukocytosis, or purulent sputum). Pneumonia was defined as microbiologic criteria for tracheobronchitis and a new and persistent infiltrate on chest radiograph. RESULTS Airways of 41 (22%) patients became heavily colonized with a bacterial pathogen(s) at a concentration of ≥10(5) cfu/mL. Tracheobronchitis developed in 21 (11%) study patients, of which 6 (29%) later progressed to pneumonia. Including these 6 patients, 28 (15%) study patients developed pneumonia. Multidrug-resistant pathogens were isolated in 39% of pneumonia patients. Patients with tracheobronchitis and pneumonia had significantly more ventilator days and longer stays in the ICU (P ≤.02). CONCLUSIONS Approximately one third of tracheobronchitis patients later developed pneumonia. Patients with tracheobronchitis or pneumonia experienced significantly more ventilator days and longer ICU stays, but had no difference in mortality. Better patient outcomes and reduced health care costs may be achieved by earlier treatment of ventilator-associated respiratory infections, manifest as tracheobronchitis or pneumonia.
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Affiliation(s)
- Donald E Craven
- Center for Infectious Diseases & Prevention, Lahey Clinic Medical Center, Burlington, MA 01805, USA.
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Bercault N. Pneumonie acquise sous ventilation mécanique et mortalité : réelle implication ou simple association ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0672-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Berger A, Oster G, Edelsberg J, Huang X, Weber DJ. Initial treatment failure in patients with complicated skin and skin structure infections. Surg Infect (Larchmt) 2013; 14:304-12. [PMID: 23590851 DOI: 10.1089/sur.2012.103] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Consequences of initial antibiotic failure in patients hospitalized for complicated skin and skin-structure infections (cSSSI) are not well understood. METHODS Using data from >100 hospitals in the United States, we identified all adults hospitalized for cSSSI between January 1, 2000 and June 30, 2009. We defined "initial therapy" as all parenteral antibiotics administered <24 h of admission, and such therapy was assumed to have failed if the patient (1) received new antibiotic(s) subsequently (excluding similar/narrower spectrum antibiotics or those begun at discharge), or (2) underwent drainage/debridement/amputation>72 h after admission. We limited attention to the 40 most commonly used antibiotic regimens in 2009. We compared clinical and economic outcomes of patients who experienced initial treatment failure and those who did not. RESULTS The rate of initial treatment failure was 16.6% in acute infections (n=13,498), 34.1% in chronic/ulcerative infections (n=1,116), and 26.7% in surgical site infections (SSIs) (n=2,929). Treatment failure was associated with 4.1-7.3 additional days in the hospital and $11,995-$23,655 in additional inpatient charges; the case fatality rate was from 4- to 12-fold higher in patients who experienced treatment failure than in those who did not (all comparisons, p<0.01). CONCLUSION Initial treatment failure in patients hospitalized for cSSSI is associated with significantly worse clinical outcomes, longer hospital stays, and higher hospital charges than with successful initial treatment.
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Affiliation(s)
- Ariel Berger
- Policy Analysis Inc., Brookline, Massachusetts 02445, USA
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Goel V, Hogade SA, Karadesai S. Ventilator associated pneumonia in a medical intensive care unit: Microbial aetiology, susceptibility patterns of isolated microorganisms and outcome. Indian J Anaesth 2013; 56:558-62. [PMID: 23325941 PMCID: PMC3546243 DOI: 10.4103/0019-5049.104575] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Ventilator-associated pneumonia (VAP) is a common complication of ventilatory support for patients with acute respiratory failure and is associated with increased morbidity and mortality. Aim of the Study: The present study was undertaken to do quantitative cultures of aerobic bacteria, perform the antibiotic susceptibility testing from the endotracheal aspirates and clinical outcome of the clinically suspected patients of VAP. Methods: A prospective study was performed over a period of one year in a tertiary care hospital, enrolling patients on mechanical ventilation (MV) for ≥48 hr. Endotracheal aspirates (ETA) were collected from patients with suspected VAP, and direct gram's stain criteria was used to accept the sample. Quantitative cultures of ETA were performed with the threshold for microbiological diagnosis of VAP was taken as ≥105 colony forming units (cfu)/ml. Results: Out of 53 cases, 2 (3.77%) were polymicrobial. Multidrug resistant bacteria, mainly Acinetobacter baumannii 49.09% (27/55) and Pseudomonas aeruginosa 30.91% (17/55) were the most common pathogens isolated. Metallo-beta lactamases (MBLs) was produced by 47.06% (8/17) of Pseudomonas aeruginosa and 62.96% (17/27) of Acinetobacter baumannii. Conclusion: The bacteriological approach for the management of VAP helps the clinicians in choosing the appropriate antibiotics. This study showed that quantitative cultures of endotracheal aspirate at a cutoff point of 105 cfu/ml is one of the alternative to bronchoscopy in the diagnosis of clinically suspected ventilator associated pneumonia.
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Affiliation(s)
- Varun Goel
- Department of Microbiology, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
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Martin-Loeches I, Artigas A, Gordo F, Añón JM, Rodríguez A, Blanch L, Cuñat J. [Current status of fibreoptic bronchoscopy in intensive care medicine]. Med Intensiva 2012; 36:644-9. [PMID: 23141554 DOI: 10.1016/j.medin.2012.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 09/04/2012] [Accepted: 09/13/2012] [Indexed: 11/27/2022]
Abstract
Flexible bronchoscopy (FB) has been of great help in the management of critically ill patients. Its safety and usefulness in the hands of experienced professionals, with the required measures of caution, has resulted in the increasingly widespread use of the technique even in unstable critical patients subjected to mechanical ventilation and with high oxygen demands. The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), through its Acute Respiratory Failure (GT-IRA) and Infectious Diseases (GT-EI) Work Groups, aims to promote knowledge and standards of quality in the use of FB among all specialists in Intensive Care Medicine. Through an expert committee, the SEMICYUC has established the objective of accrediting such training, with the preparation of a curriculum and definition of those Units qualified for providing training in the different techniques and levels. The accreditation process seeks to stimulate good learning practice and quality in training. Both specialists in Intensive Care Medicine and other specialists, and the patients, will benefit from the commitment and control afforded by such accreditation, and from the learning and training which the mentioned process entails.
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Affiliation(s)
- I Martin-Loeches
- CIBER Enfermedades Respiratorias, Servicio de Medicina Intensiva, Corporació Sanitària i Universitària Parc Taulí, Institut Universitari Parc Taulí, Hospital de Sabadell, Universitat Autònoma de Barcelona, Barcelona, España.
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Piskin N, Aydemir H, Oztoprak N, Akduman D, Comert F, Kokturk F, Celebi G. Inadequate treatment of ventilator-associated and hospital-acquired pneumonia: risk factors and impact on outcomes. BMC Infect Dis 2012; 12:268. [PMID: 23095664 PMCID: PMC3511218 DOI: 10.1186/1471-2334-12-268] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 08/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Initial antimicrobial therapy (AB) is an important determinant of clinical outcome in patients with severe infections as pneumonia, however well-conducted studies regarding prognostic impact of inadequate initial AB in patients who are not undergoing mechanical ventilation (MV) are lacking. In this study we aimed to identify the risk factors for inadequate initial AB and to determine its subsequent impact on outcomes in both ventilator associated pneumonia (VAP) and hospital acquired pneumonia (HAP). METHODS We retrospectively studied the accuracy of initial AB in patients with pneumonia in a university hospital in Turkey. A total of 218 patients with HAP and 130 patients with VAP were included. For each patient clinical, radiological and microbiological data were collected. Stepwise multivariate logistic regression analysis was used for risk factor analysis. Survival analysis was performed by using Kaplan-Meier method with Log-rank test. RESULTS Sixty six percent of patients in VAP group and 41.3% of patients in HAP group received inadequate initial AB. Multiple logistic regression analysis revealed that the risk factors for inadequate initial AB in HAP patients were; late-onset HAP (OR = 2.35 (95% CI, 1.05-5.22; p = 0.037) and APACHE II score at onset of HAP (OR = 1.06 (95% CI, 1.01-1.12); p = 0.018). In VAP patients; antibiotic usage in the previous three months (OR = 3.16 (95% CI, 1.27-7.81); p = 0.013) and admission to a surgical unit (OR = 2.9 (95% CI, 1.17-7.19); p = 0.022) were found to be independent risk factors for inadequate initial AB. No statistically significant difference in crude hospital mortality and 28-day mortality was observed between the treatment groups in both VAP and HAP. However we showed a significant increase in length of hospital stay, duration of mechanical ventilation and a prolonged clinical resolution in the inadequate AB group in both VAP and HAP. CONCLUSION Our data suggests that the risk factors for inadequate initial AB are indirectly associated with the acquisition of resistant bacteria for both VAP and HAP. Although we could not find a positive correlation between adequate initial AB and survival; empirical AB with a broad spectrum should be initiated promptly to improve secondary outcomes.
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Affiliation(s)
- Nihal Piskin
- Departments of Infectious Diseases and Clinical Microbiology, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey.
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Kwon SJ, Jeon T, Seo D, Na M, Choi EG, Son JW, Yoo EH, Park CG, Lee HY, Kim JO, Kim SY, Kang J. Quantitative PCR for Etiologic Diagnosis of Methicillin-Resistant Staphylococcus aureus Pneumonia in Intensive Care Unit. Tuberc Respir Dis (Seoul) 2012; 72:293-301. [PMID: 23227069 PMCID: PMC3510279 DOI: 10.4046/trd.2012.72.3.293] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/09/2012] [Accepted: 01/27/2012] [Indexed: 11/24/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) requires prompt and appropriate treatment. Since methicillin-resistant Staphylococcus aureus (MRSA) is a frequent pathogen in VAP, rapid identification of it, is pivotal. Our aim was to evaluate the utility of quantitative polymerase chain reaction (qPCR) as a useful method for etiologic diagnoses of MRSA pneumonia. Methods We performed qPCR for mecA, S. aureus-specific femA-SA, and S. epidermidis-specific femA-SE genes from bronchoalveolar lavage or bronchial washing samples obtained from clinically-suspected VAP. Molecular identification of MRSA was based on the presence of the mecA and femA-SA gene, with the absence of the femA-SE gene. To compensate for the experimental and clinical conditions, we spiked an internal control in the course of DNA extraction. We estimated number of colony-forming units per mL (CFU/mL) of MRSA samples through a standard curve of a serially-diluted reference MRSA strain. We compared the threshold cycle (Ct) value with the microbiologic results of MRSA. Results We obtained the mecA gene standard curve, which showed the detection limit of the mecA gene to be 100 fg, which corresponds to a copy number of 30. We chose cut-off Ct values of 27.94 (equivalent to 1×104 CFU/mL) and 21.78 (equivalent to 1×105 CFU/mL). The sensitivity and specificity of our assay were 88.9% and 88.9% respectively, when compared with quantitative cultures. Conclusion Our results were valuable for diagnosing and identifying pathogens involved in VAP. We believe our modified qPCR is an appropriate tool for the rapid diagnosis of clinical pathogens regarding patients in the intensive care unit.
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Affiliation(s)
- Sun-Jung Kwon
- Myunggok Medical Research Institute, Konyang University College of Medicine, Daejeon, Korea. ; Department of Internal Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
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Berton DC, Kalil AC, Teixeira PJZ. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database Syst Rev 2012; 1:CD006482. [PMID: 22258968 DOI: 10.1002/14651858.cd006482.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a common infectious disease in intensive care units (ICUs). The best diagnostic approach to resolve this condition remains uncertain. OBJECTIVES To evaluate whether quantitative cultures of respiratory secretions are effective in reducing mortality in immunocompetent patients with VAP, compared with qualitative cultures. We also considered changes in antibiotic use, length of ICU stay and mechanical ventilation. SEARCH METHODS We searched The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2011, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to June Week 4, 2011), EMBASE (1974 to June 2011) and LILACS (1982 to June 2011). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing respiratory samples processed quantitatively or qualitatively, obtained by invasive or non-invasive methods from immunocompetent patients with VAP and which analysed the impact of these methods on antibiotic use and mortality rates. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed and trials identified in the search results and assessed studies for suitability, methodology and quality. We analysed data using Review Manager software. We pooled the included studies to yield the risk ratio (RR) for mortality and antibiotic change with 95% confidence intervals (CI). MAIN RESULTS Of the 4459 references identified from the electronic databases, five RCTs (1367 patients) met the inclusion criteria. Three studies compared invasive methods using quantitative cultures versus non-invasive methods using qualitative cultures, and were used to answer the main objective of this review. The other two studies compared invasive versus non-invasive methods, both using quantitative cultures. We combined all five studies to compare invasive versus non-invasive interventions for diagnosing VAP. The studies that compared quantitative and qualitative cultures (1240 patients) showed no statistically significant differences in mortality rates (RR 0.91; 95% CI 0.75 to 1.11). The analysis of all five RCTs showed there was no evidence of reduction in mortality in the invasive group versus the non-invasive group (RR 0.93; 95% CI 0.78 to 1.11). There were no significant differences between the interventions with respect to the number of days on mechanical ventilation, length of ICU stay or antibiotic change. AUTHORS' CONCLUSIONS There is no evidence that the use of quantitative cultures of respiratory secretions results in reduced mortality, reduced time in ICU and on mechanical ventilation, or higher rates of antibiotic change when compared to qualitative cultures in patients with VAP. Similar results were observed when invasive strategies were compared with non-invasive strategies.
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Affiliation(s)
- Danilo Cortozi Berton
- Department of Pulmonary Medicine - Pavilhão Pereira Filho - Santa Casa de Porto Alegre, Federal University of Health Sciences ofPorto Alegre (UFCSPA) and Feevale University, Porto Alegre, Brazil
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Gupta A, Agrawal A, Mehrotra S, Singh A, Malik S, Khanna A. Incidence, risk stratification, antibiogram of pathogens isolated and clinical outcome of ventilator associated pneumonia. Indian J Crit Care Med 2011; 15:96-101. [PMID: 21814373 PMCID: PMC3145311 DOI: 10.4103/0972-5229.83015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The initial empirical therapy of Ventilator Associated Pneumonia (VAP) modified based on the knowledge of local microbiological data is associated with decreased morbidity and mortality. The objective was to find the incidence and risk factors associated with VAP, the implicated pathogens and their susceptibility pattern as well as to assess the final clinical outcome in VAP. Materials and Methods: This was a prospective cohort study of 107 patients taken on ventilatory support for two or more days and those not suffering from pneumonia prior were to be taken on ventilator. The study was done over a period of one year. VAP was diagnosed using clinical pulmonary infection score of >6. The mortality, incidence of VAP, frequency of different pathogens isolated, their antibiotic sensitivity pattern, duration of mechanical ventilation and duration of hospital stay were assessed. Statistical Analysis: Univariate analysis, χ2 test and paired t-test. Results: The incidence of VAP was 28.04%. Mortality in VAP group was 46.67%, while in the non-VAP group was 27.28%. High APACHE II score was associated with a high mortality rate as well as increased incidence of VAP. The most common organisms isolated from endotracheal aspirate of patients who developed VAP were Pseudomonas aeruginosa, Methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae and Acinetobacter baumannii. Most strains of Pseudomonas (55.56%) were resistant to commonly used beta-lactam antibiotics known to be effective against Pseudomonas. All strains of Staphylococcus aureus were MRSA and most isolates of K. pneumoniae (85.71%) were extended-spectrum beta-lactamase producing. About 50% isolates of Acinetobacter were resistant to carbapenems. Mortality was highest for infections caused by A. baumannii (83.33%) and K. pneumoniae (71.42%). Conclusions: APACHE II score can be used to stratify the risk of development of VAP and overall risk of mortality. Drug-resistant strains of various organisms are an important cause of VAP in our setting.
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Affiliation(s)
- Alok Gupta
- Departments of Medicine, Chhattarpati Shahuji Maharaj Medical University, Lucknow, Uttar Pradesh, India
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Pugh R, Grant C, Cooke RP, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev 2011:CD007577. [PMID: 21975771 DOI: 10.1002/14651858.cd007577.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pneumonia is the most common hospital-acquired infection affecting patients in the intensive care unit (ICU). However, the optimal duration of antibiotic therapy for hospital-acquired pneumonia (HAP) is uncertain. OBJECTIVES To assess the effectiveness of short versus prolonged-course antibiotic administration for HAP in critically ill adults, including patients with ventilator-associated pneumonia (VAP). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to February week 4, 2011), EMBASE (1974 to March 2011), LILACS (1985 to March 2011) and Web of Science (1985 to March 2011). SELECTION CRITERIA We considered all randomised controlled trials (RCTs) comparing fixed durations of antibiotic therapy, or comparing a protocol intended to limit duration of therapy with standard care, for HAP (including patients with VAP) in critically ill adults. DATA COLLECTION AND ANALYSIS Two review authors conducted data extraction and assessment of risk of bias. We contacted trial authors for additional information. MAIN RESULTS Eight studies (1703 patients) were included. Methodology varied considerably and we found little evidence regarding patients with a high probability of HAP who were not mechanically ventilated. For patients with VAP, a short seven to eight-day course of antibiotics compared with a prolonged 10 to 15-day course (three studies, N = 508) increased 28-day antibiotic-free days (odds ratio (OR) 4.02; 95% confidence interval (CI) 2.26 to 5.78) and reduced recurrence of VAP due to multi-resistant organisms (OR 0.44; 95% CI 0.21 to 0.95), without adversely affecting other outcomes. However, for cases of VAP due to non-fermenting Gram-negative bacilli (NF-GNB), recurrence was greater after short-course therapy (OR 2.18; 95% CI 1.14 to 4.16; two studies, N = 176), though other outcome measures did not significantly differ. Discontinuation strategies utilising clinical features (one study; N = 302) or procalcitonin (three studies; N = 323) led to a reduction in duration of therapy and, in the procalcitonin studies, increased 28-day antibiotic-free days (mean difference (MD) 2.80; 95% CI 1.39 to 4.21) without negatively affecting other outcomes. AUTHORS' CONCLUSIONS We conclude that for patients with VAP not due to NF-GNB, a short fixed-course (seven or eight days) antibiotic therapy may be more appropriate than a prolonged course (10 to 15 days). Use of an individualised strategy (incorporating clinical features or serum procalcitonin) appears to safely reduce duration of antibiotic therapy for VAP.
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Affiliation(s)
- Richard Pugh
- Department of Anaesthetics, Glan Clwyd Hospital, Rhyl, Denbighshire, UK, LL18 5UJ
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Murila F, Francis JV, Bland A, Kumbla S, Doherty R, Sehgal A. Interpreting positive cultures of endotracheal aspirates: factors associated with treatment decisions in ventilated neonates. J Paediatr Child Health 2011; 47:728-33. [PMID: 21449902 DOI: 10.1111/j.1440-1754.2011.02041.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS Diagnosis of ventilator-associated pneumonia in newborns is challenging because of ease of colonisation, non-specific chest radiograph changes and lack of a consensus definition. The aims of this study were to review treatment decisions in neonates with culture-positive endotracheal aspirate and to assess impact on respiratory outcomes using blinded review of radiological studies. METHODS Charts from all very low birthweight neonates ventilated for >48 h and with positive culture were assessed. Chest radiographs were reviewed by a radiologist masked to the grouping of the episode (treated/not treated). Clinical, investigational and radiological features used in practice were assessed on impact on treatment decisions. Association between treatment and outcomes was assessed. RESULTS Seventy-four episodes of culture-positive endotracheal aspirate were analysed in 38 babies. Fifty-eight episodes were treated with antibiotics. Gestational age at birth and birthweight in both groups (treated vs. non-treated) were statistically comparable (25.5 ± 3.1 vs. 27.2 ± 2.3 weeks and 809 ± 302 vs. 870 ± 262 g). Comparative chest radiographs were available in 51 of 58 treated episodes; deterioration was noted in 42 (82.3%). Ventilatory parameters were significantly higher in the treatment group and showed a significant improvement after antibiotics. Twenty-three babies developed chronic lung disease. Odds ratio (of having chronic lung disease when treatment is initiated) was 4.5 (95% confidence interval = 0.97-20.8, P= 0.06). CONCLUSIONS Treated culture-positive aspirate episodes were accompanied by higher ventilatory requirements, increased symptoms and elevated septic markers. Need for treatment was associated with greater likelihood of developing chronic lung disease.
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Affiliation(s)
- Florence Murila
- Monash Newborn, Monash Children's , Monash University, Victoria, Australia
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Aguado JM, Torres A, Muñoz P, Soriano A, Carratalá J, Guirao X, Varo E. Severe, non-bacteremic infections in ICU patients. Enferm Infecc Microbiol Clin 2011; 29 Suppl 4:1-9. [PMID: 21458714 DOI: 10.1016/s0213-005x(11)70030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The present article is an update of the literature on various types of infections in ICU patients: ventilator-associated pneumonia, community-acquired pneumonia, the impact of the increasing vancomycin MIC in Staphylococcus aureus in the treatment of infections caused by this microorganism and the usefulness of biomarkers in identifying or ruling out septic complications in ICU patients. A multidisciplinary group of Spanish physicians with an interest in infections in critically-ill patients selected the most important recently published papers produced in the field. One of the members of the group discussed the content of each of the selected papers, with a critical appraisal by other members of the panel.
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Affiliation(s)
- José M Aguado
- Unidad de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Universidad Complutense, Madrid, Spain.
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Sun HY, Fujitani S, Quintiliani R, Yu VL. Pneumonia due to Pseudomonas aeruginosa: part II: antimicrobial resistance, pharmacodynamic concepts, and antibiotic therapy. Chest 2011; 139:1172-1185. [PMID: 21540216 DOI: 10.1378/chest.10-0167] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pseudomonas aeruginosa carries a notably higher mortality rate than other pneumonia pathogens. Because of its multiple mechanisms of antibiotic resistance, therapy has always been challenging. This problem has been magnified in recent years with the emergence of multidrug-resistant (MDR) pathogens often unharmed by almost all classes of antimicrobials. The objective of this article is to assess optimal antimicrobial therapy based on in vitro activity, animal studies, and pharmacokinetic/pharmacodynamic (PK/PD) observations so that evidence-based recommendations can be developed to maximize favorable clinical outcomes. Mechanisms of antimicrobial resistance of P aeruginosa are reviewed. A selective literature review of laboratory studies, PK/PD concepts, and controlled clinical trials of antibiotic therapy directed at P aeruginosa pneumonia was performed. P aeruginosa possesses multiple mechanisms for inducing antibiotic resistance to antimicrobial agents. Continuous infusion of antipseudomonal β-lactam antibiotics enhances bacterial killing. Although the advantages of combination therapy remain contentious, in vitro and animal model studies plus selected meta-analyses of clinical trials support its use, especially in the era of MDR. Colistin use and the role of antibiotic aerosolization are reviewed. An evidence-based algorithmic approach based on severity of illness, Clinical Pulmonary Infection Score, and combination antibiotic therapy is presented; clinical outcomes may be improved, and the emergence of MDR pathogens should be minimized with this approach.
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Affiliation(s)
- Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University, Kawasaki-City, Kanagawa, Japan
| | | | - Victor L Yu
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA.
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Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2011; 19:19-53. [PMID: 19145262 DOI: 10.1155/2008/593289] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 12/19/2007] [Indexed: 02/07/2023]
Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are important causes of morbidity and mortality, with mortality rates approaching 62%. HAP and VAP are the second most common cause of nosocomial infection overall, but are the most common cause documented in the intensive care unit setting. In addition, HAP and VAP produce the highest mortality associated with nosocomial infection. As a result, evidence-based guidelines were prepared detailing the epidemiology, microbial etiology, risk factors and clinical manifestations of HAP and VAP. Furthermore, an approach based on the available data, expert opinion and current practice for the provision of care within the Canadian health care system was used to determine risk stratification schemas to enable appropriate diagnosis, antimicrobial management and nonantimicrobial management of HAP and VAP. Finally, prevention and risk-reduction strategies to reduce the risk of acquiring these infections were collated. Future initiatives to enhance more rapid diagnosis and to effect better treatment for resistant pathogens are necessary to reduce morbidity and improve survival.
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Diagnosis of ventilator-acquired Pneumonia: Where Do We Go From Here? Can J Infect Dis 2011; 14:77-80. [PMID: 18159427 DOI: 10.1155/2003/581071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Vaz AP, Amorim A, Espinar MJ, Oliveira T, Pereira JM, Paiva JA. [Positive bronchoalveolar lavage and quantitative cultures results in suspected late-onset ventilator associated penumonia evaluation--retrospective study]. REVISTA PORTUGUESA DE PNEUMOLOGIA 2011; 17:117-23. [PMID: 21549670 DOI: 10.1016/j.rppneu.2011.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Accepted: 11/16/2010] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Bronchoalveolar lavage (BAL) with quantitative cultures has been used in order to increase ventilator associated pneumonia (VAP) diagnosis specificity, although the accurate technique for this entity diagnosis remains controversial. OBJECTIVES To evaluate the influence of using positive BAL and quantitative cultures results in microbiologic diagnosis and treatment of patients with suspected late VAP and prior antibiotherapy. MATERIAL AND METHODS Retrospective analysis of intensive care unit (UCI) patients, during a one year period, with clinical suspicion of late VAP and prior use of antibiotics that presented a growth in BAL cultures. RESULTS Of 243 BAL performed, there were 71 (29.2%) positive cultures (60 patients, 76.7% male, 54 ± 19 years). BAL was done after 13 days (median) of invasive mechanical ventilation, 11 days of ICU antibiotherapy and in the day in which a new antibiotic for VAP suspicion was started. Colony forming units (CFU)/ml count was performed in 71.8% and endotracheal aspirate (ETA) simultaneously collected for qualitative analysis in 85.9%. Therapeutic approach was changed in 38.0%: correction (16.9%), de-escalation (12.7%) and directed antibiotherapy start (8.4%). Therapeutic changes were made in the presence of CFU > 10(4) in 84.2% and in agreement with ETA in 70.8%. In cases in which antibiotherapy was maintained (62.0%), quantitative cultures would have allowed de-escalation in 9.1%. Changes in prescription were more frequent when CFU was > 10(4) (48.5%), comparing with situations in which counts were lower and BAL analysis was qualitative (28.9%), p = 0.091. There were no significant differences between patients submitted to different therapeutic approaches concerning to ICU mortality or length of stay. CONCLUSION In late onset VAP, positive BAL and quantitative cultures allowed therapeutic changes, leading to antibiotic adequacy and consumption reduction, which can however be maximised.
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Affiliation(s)
- A P Vaz
- Serviço de Pneumologia, Hospital de São João - EPE, Porto, Portugal.
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Shorr AF, Chan CM, Zilberberg MD. Diagnostics and epidemiology in ventilator-associated pneumonia. Ther Adv Respir Dis 2011; 5:121-30. [DOI: 10.1177/1753465810390262] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Andrew F. Shorr
- Pulmonary and Critical Care Medicine, Room 2A-68D, Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, USA
| | - Chee M. Chan
- Section of Pulmonary and Critical Care Medicine, Washington Hospital Center, Washington, DC, USA
| | - Marya D. Zilberberg
- EviMed Research Group, LLC, Goshen, MA and University of Massachusetts, Amherst, MA, USA
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Affiliation(s)
- Heung Bum Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Hyo Jin Han
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
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Spellberg B, Talbot G. Recommended design features of future clinical trials of antibacterial agents for hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia. Clin Infect Dis 2010; 51 Suppl 1:S150-70. [PMID: 20597666 DOI: 10.1086/653065] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
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- Division of General Internal Medicine, Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles Medical Center, Los Angeles, California, USA.
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Joseph NM, Sistla S, Dutta TK, Badhe AS, Parija SC. Ventilator-associated pneumonia: a review. Eur J Intern Med 2010; 21:360-8. [PMID: 20816584 DOI: 10.1016/j.ejim.2010.07.006] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 05/24/2010] [Accepted: 07/08/2010] [Indexed: 01/08/2023]
Abstract
Ventilator-associated pneumonia (VAP) is the most frequent intensive-care-unit (ICU)-acquired infection, with an incidence ranging from 6 to 52% [1,2,3,4]. Several studies have shown that critically ill patients are at high risk for getting such nosocomial infections [3,4]. VAP continues to be a major cause of morbidity, mortality and increased financial burden in ICUs [5,6,7,8]. Over the years there has been a significant advance in our understanding of ventilator associated pneumonia. This article reviews the various aspects of VAP such as definition, risk factors, etiological agents, diagnosis, treatment and prevention with emphasis on the recent advances.
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Affiliation(s)
- Noyal Mariya Joseph
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
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