Strategies in the prevention of ventilator-associated pneumonia

Etiology of Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP) in Tertiary-Care Hospitals in Thailand: A Multicenter, Retrospective Cohort Study

Purpose

To describe the top three causative organisms of hospital acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in Thailand.

Patients and Methods

This multi-center retrospective cohort study included HAP/VAP patients hospitalized in 2019 in three university-affiliated hospitals and a private hospital in Bangkok, Thailand. Medical records of patients with a documented diagnosis of nosocomial pneumonia (NP) were systematically reviewed to collect data on demographic, clinical, microbiological, and 30-day readmission due to NP.

Results

A total of 240 patients were included in the study, comprises patients with VAP (62.9%), HAP (36.7%), and ventilated HAP (vHAP) (0.4%). All of the patients had late-onset NP, occurring after five days of hospitalization with median time to NP of 13 days (interquartile range [IQR] 6-25 days) from admission. The top three causative pathogens of NP were Acinetobacter baumannii (44.2%), Pseudomonas aeruginosa (34.6%), and Klebsiella pneumoniae (28.3%). A high rate of carbapenem resistance (CR) in A. baumannii (92.5%) was observed. Lower rates of CR were observed in K. pneumoniae (20.6%) and P. aeruginosa isolates (16.9%). Readmission rate due to NP within 30 days after discharge was less than 2% with median time of 4 days (IQR 3-20 days) after discharge. After diagnosis of NP, 19 patients were transferred to intensive care units with median length of stays of 11 days (IQR 3-24 days). Fifty-one percent of HAP patients received mechanical ventilation support after the diagnosis of NP with median length of mechanical ventilation use of 12 days (IQR 6-22 days).

Conclusion

A. baumannii, with its significant carbapenem resistance, presents a major HAP/VAP pathogens and imposes a substantial burden on healthcare resources in this study. Implementation of regular surveillance for causative organisms of NP and their susceptibility profiles are critical for the success of HAP/VAP management, and reducing the related burden of healthcare resources.

Incidence, Risk Factors, and Outcomes of Central Line-Associated Bloodstream Infections in Trauma Patients

Introduction: Central line-associated blood stream infection (CLABSI) is a hospital-acquired infection (HAI) associated with increased morbidity and mortality among the general patient population. However, few studies have evaluated the incidence, outcomes, and risk factors for CLABSI in trauma patients. This study aimed to identify the rate of positive (+)CLABSI in trauma patients and risk factors associated with (+)CLABSI. Methods: The 2017-2021 Trauma Quality Improvement Program database was queried for trauma patients aged ≥18 years undergoing central-line placement. We compared patients with (+)CLABSI vs. (-)CLABSI patients. Bivariate and multivariable logistic regression analyses were performed. Results: From 175,538 patients undergoing central-line placement, 469 (<0.1%) developed CLABSI. The (+)CLABSI patients had higher rates of cirrhosis (3.9% vs. 2.0%, p = 0.003) and chronic kidney disease (CKD) (4.3% vs. 2.6%, p = 0.02). The (+)CLABSI group had increased injury severity score (median: 25 vs. 13, p < 0.001), length of stay (LOS) (median 33.5 vs. 8 days, p < 0.001), intensive care unit LOS (median 21 vs. 6 days, p < 0.001), and mortality (23.7% vs. 19.6%, p = 0.03). Independent associated risk factors for (+)CLABSI included catheter-associated urinary tract infection (CAUTI) (odds ratio [OR] = 5.52, confidence interval [CI] = 3.81-8.01), ventilator-associated pneumonia (VAP) (OR = 4.43, CI = 3.42-5.75), surgical site infection (SSI) (OR = 3.66, CI = 2.55-5.25), small intestine injury (OR = 1.91, CI = 1.29-2.84), CKD (OR = 2.08, CI = 1.25-3.47), and cirrhosis (OR = 1.81, CI = 1.08-3.02) (all p < 0.05). Conclusion: Although CLABSI occurs in <0.1% of trauma patients with central-lines, it significantly impacts LOS and morbidity/mortality. The strongest associated risk factors for (+)CLABSI included HAIs (CAUTI/VAP/SSI), specific injuries (small intestine), and comorbidities. Providers should be aware of these risk factors with efforts made to prevent CLABSI in these patients.

Prevention of ventilator-associated pneumonia with probiotics: an overview of systematic reviews

Background

Probiotics has been used as an adjuvant therapy for the prevention of ventilator-associated pneumonia (VAP). This study aimed to systematically compile, evaluate, and synthesize previous systematic reviews (SRs) and meta-analyses (MAs) on the prevention of VAP with probiotics.

Methods

The methodological quality, reporting quality, and evidence quality of enrolled studies were, respectively evaluated by Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklists, and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

Results

Thirteen eligible publications were analyzed in this overview. The included studies were rated as generally low methodological quality owing to the lack of a registered protocol or a list of exclusion criteria. The inadequate quality of the reports was demonstrated by the lack of reporting on the registration protocols, the lack of reporting on the search strategy, and the lack of reporting on the additional analyses. For GRADE, there were 36.17% (17/47) outcomes graded to be of moderate quality, 42.55% (20/47) to be of low quality, and 21.28% (10/47) to be of very low quality.

Conclusion

Probiotics may be associated with reduced incidence of VAP. However, caution should be exercised when recommending probiotics for the prevention of VAP owing to the poor quality of the current evidence.

Proportion of early extubation and short-term outcomes after esophagectomy: a retrospective cohort study

BACKGROUND

The proportion of early extubation after esophagectomy varies among hospitals; however, the impact on clinical outcomes is unclear. The aim of this retrospective study was to evaluate associations between the proportion of early extubation in hospitals and short-term outcomes after esophagectomy. Because there is no consensus regarding the optimal timing for extubation, the authors considered that hospitals' early extubation proportion reflects the hospital-level extubation strategy.

MATERIALS AND METHODS

Data of patients who underwent oncologic esophagectomy (July 2010-March 2019) were extracted from a Japanese nationwide inpatient database. The proportion of patients who underwent early extubation (extubation on the day of surgery) at each hospital was assessed and grouped by quartiles: very low- (<11%), low- (11-37%), medium- (38-83%), and high-proportion (≥84%) hospitals. The primary outcome was respiratory complications; secondary outcomes included reintubation, anastomotic leakage, other major complications, and hospitalization costs. Multivariable regression analyses were performed, adjusting for patient demographics, cancer treatments, and hospital characteristics. A restricted cubic spline analysis was also performed for the primary outcome.

RESULTS

Among 37 983 eligible patients across 545 hospitals, early extubation was performed in 17 931 (47%) patients. Early extubation proportions ranged from 0-100% across hospitals. Respiratory complications occurred in 10 270 patients (27%). Multivariable regression analyses showed that high- and medium-proportion hospitals were significantly associated with decreased respiratory complications [odds ratio, 0.46 (95% CI, 0.36-0.58) and 0.43 (0.31-0.60), respectively], reintubation, and hospitalization costs when compared with very low-proportion hospitals. The risk of anastomotic leakage and other major complications did not differ among groups. The restricted cubic spline analysis demonstrated a significant inverse dose-dependent association between the early extubation proportion and the risk of respiratory complications.

CONCLUSION

A higher proportion of early extubation in a hospital was associated with a lower occurrence of respiratory complications, highlighting a potential benefit of early extubation after esophagectomy.

Healthcare workers' knowledge of evidence-based guidelines for prevention of ventilator-associated pneumonia in Hodeida, Yemen

OBJECTIVES

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in patients requiring mechanical ventilation in intensive care units (ICUs). VAP is associated with delayed extubation, prolonged hospital stays, increased healthcare costs and mortality rates. The aims of this study to evaluate the level of knowledge for the prevention of VAP among healthcare workers (HCWs) in ICUs and to assess their knowledge in relation to their socio-demographic characteristics.

METHODS

A descriptive, cross-sectional design was conducted to assess HCWs' knowledge of the guidelines for prevention of VAP in the ICUs of public and private hospitals in Hodeida city, Yemen. Around 140 self-administered multiple-choice questionnaires were distributed between April and July 2017.

RESULTS

A total of 120 (85.6%) HCWs completed questionnaire were obtained (20 physicians, 20 anesthesia technicians and 80 nurses) in this study. The total mean score of the HCWs' knowledge was low (41 ± 18). A statistically significant difference was found in the HCWs' knowledge scores according to their specialties and gender. Anesthesia technicians had the highest knowledge score followed by physicians and nurses (52.2 ± 16.2, 45.6 ± 21.2 and 37.1 ± 16.9, respectively, p=0.002). Males had higher scores than females (Median [IQR] 4 [3-5] vs. 3 [2-4], p<0.001). Participants who received information about the prevention of VAP had better knowledge than those who did not (46.2 ± 17.7 vs. 36.8 ± 17.3, p=0.006).

CONCLUSIONS

HCWs had a low knowledge level of the guidelines for the prevention of VAP, which may affect their practice. HCWs' knowledge was affected by their previous received information that increases the necessity to provide them with regular in-service education and training programs.

Pulmonary Hygiene Protocol Reduces Incidence of Lobar Collapse in Severe Traumatic Brain Injury

Background

Traumatic brain injury (TBI) is a common cause of death among injured patients. In addition to neurologic sequelae which may increase mortality risk, trauma patients suffering severe TBI (Glasgow Coma Score≤8) have a predilection for pulmonary complications. We have previously demonstrated that patients with severe TBI who were intubated and mechanically ventilated are at greater risk of radiographic pulmonary lobar collapse that necessitates advanced directional suctioning and/or bronchoscopy. We sought to minimize the potentially deleterious effects of such lobar collapse by using a standardized pulmonary hygiene protocol.

Methods

We performed a retrospective comparison of lobar collapse incidence among three groups over 21 months: patients without severe TBI who were intubated and mechanically ventilated for greater than 24 hours (i.e. “NO TBI”); patients with severe TBI who were intubated and mechanically ventilated for greater than 24 hours who were not treated with a standardized pulmonary hygiene protocol (i.e. historical “CONTROL”); and patients with severe TBI who were intubated and mechanically ventilated for greater than 24 hours and who were treated with a standardized pulmonary hygiene protocol (i.e. “HYGIENE”). Our analysis excluded patients who had any significant neck injury as we had previously found that pulmonary complications are increased in this subpopulation.

Results

We reviewed the charts of 310 trauma patients (NO TBI = 104, CONTROL = 101, HYGIENE = 105) and analyzed demographics, injury severity and outcomes, including the incidence of pulmonary lobar collapse. Pulmonary hygiene protocol demonstrated a significant reduction in the incidence of lobar collapse among the HYGIENE group compared to CONTROL, approximating the incidence among patients with no TBI (11% vs 27% vs 10%, respectively, p = 0.0009). No significant difference was noted in ventilator days, intensive care unit length of stay, hospital length of stay, mortality, nor incidence of pneumonia. 

Conclusion

High-risk TBI patients have a predilection towards the development of pulmonary lobar collapse, which can be significantly reduced by the use of a standardized pulmonary hygiene protocol.

Risk factors for ventilator-associated pneumonia among patients undergoing major oncological surgery for head and neck cancer

Patients undergoing major oncological surgery for head and neck cancer (SHNC) have a particularly high risk of nosocomial infections. We aimed to identify risk factors for ventilator-associated pneumonia (VAP) in patients undergoing SHNC. The study included 465 patients who underwent SHNC between June 2011 and June 2014. The rate of VAP, risk factors for VAP, and biological aspects of VAP were retrospectively evaluated. The incidence of VAP was 19.6% (n = 95) in patients who required more than 48 h of mechanical ventilation. Staphylococcus (37.7%), Enterobacteriaceae (32.1%), Pseudomonas (20.8%), and Haemophilus (16.9%) were the major bacterial species that caused VAP. The independent risk factors for VAP were advanced age, current smoking status, chronic obstructive pulmonary disease, and a higher simplified acute physiology score system II upon admission. Tracheostomy was an independent protective factor for VAP. The median length of stay in the ICU for patients who did or did not develop VAP was 8.0 and 6.5 days, respectively (P = 0.006). Mortality among patients who did or did not develop VAP was 16.8% and 8.4%, respectively (P < 0.001). The potential economic impact of VAP was high because of the significantly extended duration of ventilation. A predictive regression model was developed with a sensitivity of 95.3% and a specificity of 69.4%. VAP is common in patients who are undergoing SHNC and who require more than 48 h of mechanical ventilation. Therefore, innovative preventive measures should be developed and applied in this high-risk population.

Use of Ventilator Bundle and Staff Education to Decrease Ventilator-Associated Pneumonia in Intensive Care Patients

BACKGROUND

Ventilator-associated pneumonia (VAP), one of the most common hospital-acquired infections, has a high mortality rate.

OBJECTIVES

To evaluate the incidence of VAP in a multidisciplinary intensive care unit and to examine the effects of the implementation of ventilator bundles and staff education on its incidence.

METHODS

A 24-month-long before/after study was conducted, divided into baseline, intervention, and postintervention periods. VAP incidence and rate, the microbiological profile, duration of mechanical ventilation, and length of stay in the intensive care unit were recorded and compared between the periods.

RESULTS

Of 1097 patients evaluated, 362 met the inclusion criteria. The baseline VAP rate was 21.6 per 1000 ventilator days. During the postintervention period, it decreased to 11.6 per 1000 ventilator days (P = .01). Length of stay in the intensive care unit decreased from 36 to 27 days (P = .04), and duration of mechanical ventilation decreased from 26 to 21 days (P = .06).

CONCLUSIONS

VAP incidence was high in a general intensive care unit in a Greek hospital. However, implementation of a ventilator bundle and staff education has decreased both VAP incidence and length of stay in the unit.

Prevention of respiratory infections in tracheostomized patients of a pediatric long-term rehabilitation setting

Clinical practice protocols for the control and prevention of respiratory infections in rehabilitation settings, especially regarding pediatric tracheostomized patients, are currently lacking. To tackle this issue, we conducted a systematization of our clinical management protocols, aiming at defining a decisional algorithm and describing its key points in more detail. We focused on infection control, improvement of respiratory functions, and weaning from tracheostomy.

"The National Surgery Quality Improvement Project" (NSQIP): a new tool to increase patient safety and cost efficiency in a surgical intensive care unit

Background

The “National Surgical Quality Improvement Program” (NSQIP) is a nationally validated, risk-adjusted database tracking surgical outcomes. NSQIP has been demonstrated to decrease complications, expenses, and mortality. In the study institution, a high rate of nosocomial pneumonia (PNEU) and prolonged ventilator days ≥48 hours (V48) was observed on the surgical service.

Methods

The hospital studied is a 500 bed university-affiliated teaching hospital performing approximately 20,000 surgical operations per year. A multidisciplinary team was formed and a series of interventions were implemented to address high pneumonia rates and prolonged intubation. Specific interventions included enforcement of protocols and adherence to the Institute for Healthcare Improvement (IHI) ventilator bundles, including head of bed elevation, sedation holidays, extubate when ready, and early nutrition. NSQIP collected pre-operative through 30-day postoperative data prospectively on 1,081 surgical patients in the intensive care unit from January 1, 2010 – July 31, 2012. The variables pneumonia and V48 undergo logistic regression and risk adjusted results of observed versus expected are calculated. Mean and confidence intervals are represented in caterpillar charts and bar graphs. Statistical analysis was via Fisher exact t-test.

Results

Progressive improvements were observed over a two-year period via three semiannual reports (SAR). Corrective measures showed a decrease in V48 with an observed to expected odds ratio (O: E) improving from 1.5 to 1.04, or 1.9% ( 7/368 patients) July 31, 2011 to 1.11% (12/1080 patients) July 31, 2012 respectively. Similarly, pneumonia rates decreased 1.36% (5/368 patients) July 31, 2011 to 1.2% ( 13/1081 patients) July 31, 2012 with O: E = 1.4 and 1.25 respectively. Statistical significance was achieved (p < .05).

Conclusion

Given an estimated annual volume of 20,000 cases per year with a cost of $22,097 per episode of pneumonia and $27,654 per episode of prolonged intubation greater than 48 hours; a projected 32 avoided episodes of pneumonia and 160 avoided episodes of V48 could be realized with potential savings exceeding $5,000,000.

Guidelines for prevention of hospital acquired infections

These guidelines, written for clinicians, contains evidence-based recommendations for the prevention of hospital acquired infections Hospital acquired infections are a major cause of mortality and morbidity and provide challenge to clinicians. Measures of infection control include identifying patients at risk of nosocomial infections, observing hand hygiene, following standard precautions to reduce transmission and strategies to reduce VAP, CR-BSI, CAUTI. Environmental factors and architectural lay out also need to be emphasized upon. Infection prevention in special subsets of patients - burns patients, include identifying sources of organism, identification of organisms, isolation if required, antibiotic prophylaxis to be used selectively, early removal of necrotic tissue, prevention of tetanus, early nutrition and surveillance. Immunodeficient and Transplant recipients are at a higher risk of opportunistic infections. The post tranplant timetable is divided into three time periods for determining risk of infections. Room ventilation, cleaning and decontamination, protective clothing with care regarding food requires special consideration. Monitoring and Surveillance are prioritized depending upon the needs. Designated infection control teams should supervise the process and help in collection and compilation of data. Antibiotic Stewardship Recommendations include constituting a team, close coordination between teams, audit, formulary restriction, de-escalation, optimizing dosing, active use of information technology among other measure. The recommendations in these guidelines are intended to support, and not replace, good clinical judgment. The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of evidence supporting the recommendation, so that readers can ascertain how best to apply the recommendations in their practice environments.

Early metabolic/cellular-level resuscitation following terminal brain stem herniation: implications for organ transplantation

Patients with terminal brain stem herniation experience global physiological consequences and represent a challenging population in critical care practice as a result of multiple factors. The first factor is severe depression of consciousness, with resulting compromise in airway stability and lung ventilation. Second, with increasing severity of brain trauma, progressive brain edema, mass effect, herniation syndromes, and subsequent distortion/displacement of the brain stem follow. Third, with progression of intracranial pathophysiology to terminal brain stem herniation, multisystem consequences occur, including dysfunction of the hypothalamic-pituitary axis, depletion of stress hormones, and decreased thyroid hormone bioavailability as well as biphasic cardiovascular state. Cardiovascular dysfunction in phase 1 is a hyperdynamic and hypertensive state characterized by elevated systemic vascular resistance and cardiac contractility. Cardiovascular dysfunction in phase 2 is a hypotensive state characterized by decreased systemic vascular resistance and tissue perfusion. Rapid changes along the continuum of hyperperfusion versus hypoperfusion increase risk of end-organ damage, specifically pulmonary dysfunction from hemodynamic stress and high-flow states as well as ischemic changes consequent to low-flow states. A pronounced inflammatory state occurs, affecting pulmonary function and gas exchange and contributing to hemodynamic instability as a result of additional vasodilatation. Coagulopathy also occurs as a result of consumption of clotting factors as well as dilution of clotting factors and platelets consequent to aggressive crystalloid administration. Each consequence of terminal brain stem injury complicates clinical management within this patient demographic. In general, these multisystem consequences are managed with mechanism-based interventions within the context of caring for the donor's organs (liver, kidneys, heart, etc.) after death by neurological criteria. These processes begin far earlier in the continuum of injury, at the moment of terminal brain stem herniation. As such, aggressive, mechanism-based care, including hormonal replacement therapy, becomes clinically appropriate before formal brain death declaration to support cardiopulmonary stability following terminal brain stem herniation.

Early Metabolic/Cellular-Level Resuscitation Following Terminal Brain Stem Herniation

Patients with terminal brain stem herniation experience global physiological consequences and represent a challenging population in critical care practice as a result of multiple factors. The first factor is severe depression of consciousness, with resulting compromise in airway stability and lung ventilation. Second, with increasing severity of brain trauma, progressive brain edema, mass effect, herniation syndromes, and subsequent distortion/displacement of the brain stem follow. Third, with progression of intracranial pathophysiology to terminal brain stem herniation, multisystem consequences occur, including dysfunction of the hypothalamic-pituitary axis, depletion of stress hormones, and decreased thyroid hormone bioavailability as well as biphasic cardiovascular state. Cardiovascular dysfunction in phase 1 is a hyperdynamic and hypertensive state characterized by elevated systemic vascular resistance and cardiac contractility. Cardiovascular dysfunction in phase 2 is a hypotensive state characterized by decreased systemic vascular resistance and tissue perfusion. Rapid changes along the continuum of hyperperfusion versus hypoperfusion increase risk of end-organ damage, specifically pulmonary dysfunction from hemodynamic stress and high-flow states as well as ischemic changes consequent to low-flow states. A pronounced inflammatory state occurs, affecting pulmonary function and gas exchange and contributing to hemodynamic instability as a result of additional vasodilatation. Coagulopathy also occurs as a result of consumption of clotting factors as well as dilution of clotting factors and platelets consequent to aggressive crystalloid administration. Each consequence of terminal brain stem injury complicates clinical management within this patient demographic. In general, these multisystem consequences are managed with mechanism-based interventions within the context of caring for the donor’s organs (liver, kidneys, heart, etc.) after death by neurological criteria. These processes begin far earlier in the continuum of injury, at the moment of terminal brain stem herniation. As such, aggressive, mechanism-based care, including hormonal replacement therapy, becomes clinically appropriate before formal brain death declaration to support cardiopulmonary stability following terminal brain stem herniation.

The effect of pneumonia on short-term outcomes and cost of care after head and neck cancer surgery

BACKGROUND

The Centers for Medicare and Medicaid Services has threatened to discontinue reimbursements for ventilator-associated pneumonia (VAP) as a preventable "never event." We sought to determine the relationship between pneumonia and in-hospital mortality, complications, length of hospitalization and costs in head and neck cancer (HNCA) surgery.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

Discharge data from the Nationwide Inpatient Sample for 93,663 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2003 to 2008 were analyzed using cross-tabulations and multivariate regression modeling.

RESULTS

VAP was rarely coded. Infectious pneumonia was significantly associated with chronic pulmonary disease (odds ratio [OR], 1.5; P < .001), while aspiration pneumonia was associated with dysphagia (OR, 2.0; P < .001). Pneumonia from any cause was associated with weight loss (OR, 3.3; P < .001), age >80 years (OR, 2.0; P = .007), comorbidity (OR, 2.3; P < .001), and major procedures (OR, 1.6; P < .001), with increased in-hospital mortality for infectious (OR, 2.9; P < .001) and aspiration pneumonia (OR, 5.3; P < .001). Both infectious and aspiration pneumonia were associated with postoperative medical and surgical complications, increased length of hospitalization, and hospital-related costs.

CONCLUSIONS

Postoperative pneumonia is associated with increased mortality, complications, length of hospitalization, and hospital-related costs in HNCA surgical patients. Variables associated with an increased risk of pneumonia are inherent comorbidities in HNCA and known risk factors for VAP, making this a high-risk group for this never event. Caution must be used in the institution of reforms that threaten to inadequately reimburse the provision of care to this vulnerable population. Aggressive preoperative identification and treatment of underlying pulmonary disease, weight loss, and dysphagia may reduce morbidity and mortality.