Clinical epidemiology and outcomes of ventilator-associated pneumonia in critically ill adult patients: protocol for a large-scale systematic review and planned meta-analysis

Evaluating antibiotic therapy for ventilator-associated pneumonia caused by gram-negative bacilli

Introduction

Ventilator-associated pneumonias (VAPs) are a complication of mechanical ventilation in the intensive care unit (ICU) that increase length of stay, morbidity, and mortality. While identifying and treating infections early is paramount to improving patient outcomes, more and more data demonstrate limited courses of antibiotics improve outcomes. Prolonged (10-14 day) courses of antibiotics have remained the standard of care for pneumonia due to gram-negative bacilli (GNR). We aimed to review our GNR VAPs to assess risk factors for recurrent GNR infections.

Methods

We reviewed trauma patients who developed VAP from 02/2019 through 05/2022. Demographics, injury characteristics, and outcomes were reviewed with a focus on pneumonia details including the cultured pathogen(s), antibiotic(s) used, treatment duration, and presence of recurrent infections. We then compared single episode VAPs to multiple episode VAPs among patients infected by GNRs.

Results

Eleven of the fifty trauma patients admitted to the ICU suffered a VAP caused by a GNR. Of these eleven patients, six experienced a recurrent infection, four of which were caused by Pseudomonas aeruginosa and two of which were caused by Enterobacter aerogenes. Among the patients who received ten days of antibiotic treatment, half suffered a recurrence. Although, there was no difference in the microbiology or antibiotic duration between the recurrences and single episodes.

Conclusion

Despite prolonged use of antibiotics, we found that the risk of recurrent or persistent infections was high among patients with VAP due to GNB. Further study is needed to determine optimal treatment to minimize the risk of these recurrences.

Key message

Ventilator-associated pneumonia due to gram-negative bacilli is a rare but high morbidity complication in intensive care units. Despite prolonged duration of therapy, these infections still appear to account for many recurrent infections and further study into optimal therapy is warranted.

Clinical and Etiological Exploration of Ventilator-Associated Pneumonia in the Intensive Care Unit of a Developing Country

Background Ventilator-associated pneumonia (VAP) is a critical concern in the intensive care unit (ICU), with significant implications for patient outcomes. This retrospective cross-sectional study aimed to determine the prevalence of VAP in an ICU of a developing country, identify the predominant etiological factors, assess patient outcomes, and underscore the need for tailored interventions in high-risk patient groups. Methods This retrospective cross-sectional study included 589 ICU patients who underwent ventilator-assisted breathing for over 48 hours. Among them, 151 developed VAP. The diagnosis was made on clinical, laboratory, and radiological findings, and tracheal aspirate cultures. Exclusions included pediatric patients, less than 48 hours of ventilation, and pre-existing lung infections. Patient data encompassed gender, age, comorbidities, outcomes, admission reasons, isolated microorganisms, and clinical findings. Results 151 patients out of the 589 developed VAP. The age of the patients ranged between 31 to 69 years and the mean age was 45.43 ± 8.92 years. Clinical diagnoses upon ICU admission varied, including sepsis, trauma, stroke, and metabolic disorders. Chest X-rays commonly revealed atelectasis (19.2%), consolidation (21.9%), pleural effusion (11.9%), and lobar pneumonia (45.7%). Tracheal aspirate cultures predominantly isolated multidrug-resistant gram-negative rods, with methicillin-resistant gram-positive cocci and fungal pneumonia prevalent in neutropenic sepsis cases. Notably, only 54 (35.8%) of patients survived, with significantly poorer outcomes observed in sepsis, neutropenic sepsis, and stroke cases compared to trauma and post-operative admissions. Conclusion Multidrug-resistant organisms and the spread of nosocomial infections are the predominant causes of VAP in the ICU. This emphasizes the urgent need for multifaceted interventions to prevent and manage VAP effectively. Developing and implementing targeted strategies, considering the unique challenges faced in resource-constrained healthcare settings can aid in decreasing the mortality associated with it.

Clinical Decision Support System to Detect the Occurrence of Ventilator-Associated Pneumonia in Pediatric Intensive Care

OBJECTIVES

Ventilator-associated pneumonia (VAP) is a severe care-related disease. The Centers for Disease Control defined the diagnosis criteria; however, the pediatric criteria are mainly subjective and retrospective. Clinical decision support systems have recently been developed in healthcare to help the physician to be more accurate for the early detection of severe pathology. We aimed at developing a predictive model to provide early diagnosis of VAP at the bedside in a pediatric intensive care unit (PICU).

METHODS

We performed a retrospective single-center study at a tertiary-care pediatric teaching hospital. All patients treated by invasive mechanical ventilation between September 2013 and October 2019 were included. Data were collected in the PICU electronic medical record and high-resolution research database. Development of the clinical decision support was then performed using open-access R software (Version 3.6.1®).

MEASUREMENTS AND MAIN RESULTS

In total, 2077 children were mechanically ventilated. We identified 827 episodes with almost 48 h of mechanical invasive ventilation and 77 patients who suffered from at least one VAP event. We split our database at the patient level in a training set of 461 patients free of VAP and 45 patients with VAP and in a testing set of 199 patients free of VAP and 20 patients with VAP. The Imbalanced Random Forest model was considered as the best fit with an area under the ROC curve from fitting the Imbalanced Random Forest model on the testing set being 0.82 (95% CI: (0.71, 0.93)). An optimal threshold of 0.41 gave a sensitivity of 79.7% and a specificity of 72.7%, with a positive predictive value (PPV) of 9% and a negative predictive value of 99%, and with an accuracy of 79.5% (95% CI: (0.77, 0.82)).

CONCLUSIONS

Using machine learning, we developed a clinical predictive algorithm based on clinical data stored prospectively in a database. The next step will be to implement the algorithm in PICUs to provide early, automatic detection of ventilator-associated pneumonia.

Epidemiological profile and risk factors associated with death in patients receiving invasive mechanical ventilation in an adult intensive care unit from Brazil: a retrospective study

Introduction

Understanding the epidemiological profile and risk factors associated with invasive mechanical ventilation (IMV) is essential to manage the patients better and to improve health services. Therefore, our objective was to describe the epidemiological profile of adult patients in intensive care that required IMV in-hospital treatment. Also, to evaluate the risks associated with death and the influence of positive end-expiratory pressure (PEEP) and arterial oxygen pressure (PaO2) at admission in the clinical outcome.

Methods

We conducted an epidemiological study analyzing medical records of inpatients who received IMV from January 2016 to December 2019 prior to the Coronavirus Disease (COVID)-19 pandemic in Brazil. We considered the following characteristics in the statistical analysis: demographic data, diagnostic hypothesis, hospitalization data, and PEEP and PaO2 during IMV. We associated the patients' features with the risk of death using a multivariate binary logistic regression analysis. We adopted an alpha error of 0.05.

Results

We analyzed 1,443 medical records; out of those, 570 (39.5%) recorded the patients' deaths. The binary logistic regression was significant in predicting the patients' risk of death [X2(9) = 288.335; p < 0.001]. Among predictors, the most significant in relation to death risk were: age [elderly ≥65 years old; OR = 2.226 (95%CI = 1.728-2.867)]; male sex (OR = 0.754; 95%CI = 0.593-0.959); sepsis diagnosis (OR = 1.961; 95%CI = 1.481-2.595); need for elective surgery (OR = 0.469; 95%CI = 0.362-0.608); the presence of cerebrovascular accident (OR = 2.304; 95%CI = 1.502-3.534); time of hospital care (OR = 0.946; 95%CI = 0.935-0.956); hypoxemia at admission (OR = 1.635; 95%CI = 1.024-2.611), and PEEP >8 cmH2O at admission (OR = 2.153; 95%CI = 1.426-3.250).

Conclusion

The death rate of the studied intensive care unit was equivalent to that of other similar units. Regarding risk predictors, several demographic and clinical characteristics were associated with enhanced mortality in intensive care unit patients under mechanical ventilation, such as diabetes mellitus, systemic arterial hypertension, and older age. The PEEP >8 cmH2O at admission was also associated with increased mortality since this value is a marker of initially severe hypoxia.

Effect of clove mouthwash on the incidence of ventilator-associated pneumonia in intensive care unit patients: a comparative randomized triple-blind clinical trial

OBJECTIVES

Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in intensive care units (ICUs), and the use of mouthwash is the most widely used method to prevent its incidence. The aim of this study was to investigate effect of clove mouthwash on the incidence of VAP in the ICU.

MATERIALS AND METHODS

This comparative, randomized, triple-blind, clinical trial was conducted on 168 eligible ICU patients at Kosar Hospital in Semnan, Iran, during 2021-2022, who were divided into intervention and control groups using random blocks. The intervention group received clove extract mouthwash at 6.66% concentration, and the control group received chlorhexidine 0.2% twice a day for 5 days (routine care). Data were collected using a demographic questionnaire, and disease severity was measured based on the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, oral health status was examined using the Beck Oral Assessment Scale (BOAS), and VAP diagnosis was made based on the Modified Clinical Pulmonary Infection Score (MCPIS).

RESULTS

Before the intervention, there was no significant difference in disease severity (p = 0.412) and oral health status (p = 0.239) between the patients in the two groups. After the intervention, 20.2% of the patients in the intervention group and 41.7% of those in the control group acquired VAP. The risk of VAP was 2.06 times higher in the control group than in the intervention group (p = 0.005, 95% CI: 1.26-3.37, RR = 2.06), but the severity of VAP did not differ significantly between the patients in the two groups (p = 0.557).

CONCLUSION

The findings showed that clove mouthwash reduces the incidence of VAP significantly.

CLINICAL RELEVANCE

Clove mouthwash can be used as a simple and low-cost method to prevent VAP in ICU patients.

Correlation of ICU Nurses' Cognitive Level with Their Attitude and Behavior toward the Prevention of Ventilator-Associated Pneumonia

Objective

To analyze the correlation of ICU nurses' cognitive level with their attitude and behavior toward the prevention of ventilator-associated pneumonia (VAP).

Methods

A total of 90 ICU nurses working in the adult internal medicine ICU, adult surgery ICU, subacute respiratory care ward, etc. from January 2018 to June 2019 were chosen as the subjects to carry out questionnaire survey with the cognition scale, and the correlation analysis on their cognitive level, attitude, and behavior toward the prevention of VAP was conducted.

Results

The linear fitting analysis finding showed that the cognitive level presented a positive correlation with the attitude score and behavior score (R ² = 0.668, 0.734).

Conclusion

Improving ICU nurses' cognitive level, attitude, and behavior toward preventing VAP is conducive to the upgrade of their quality of nursing services. In addition, the ICU nurses' cognitive level is positively correlated with their attitude and behavior.

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.

The effect of ventilator-associated pneumonia on the prognosis of intensive care unit patients within 90 days and 180 days

BACKGROUND

Mechanical ventilation (MV) is often applied in critically ill patients in intensive care unit (ICU) to protect the airway from aspiration, and supplement more oxygen. MV may result in ventilator-associated pneumonia (VAP) in ICU patients. This study was to estimate the 90-day and 180-day mortalities of ICU patients with VAP, and to explore the influence of VAP on the outcomes of ICU patients.

METHODS

Totally, 8182 patients who aged ≥18 years and received mechanical ventilation (MV) in ICU from Medical Information Mart for Intensive Care III (MIMIC III) database were involved in this study. All subjects were divided into the VAP group (n = 537) and the non-VAP group (n = 7626) based on the occurrence of VAP. Clinical data of all participants were collected. The effect of VAP on the prognosis of ICU patients was explored by binary logistic regression analysis.

RESULTS

The results delineated that the 90-day mortality of VAP patients in ICU was 33.33% and 180-day mortality was 37.62%. The 90-day and 180-day mortality rates were higher in the VAP group than in the non-VAP group. After adjusting the confounders including age, ethnicity, heart failure, septicemia, simplified acute physiology score II (SAPSII) score, sequential organ failure assessment (SOFA) score, serum lactate, white blood cell (WBC), length of ICU stay, length of hospital stay, length of ventilation, antibiotic treatment, Pseudomonas aeruginosa (P.aeruginosa), methicillin-resistant Staphylococcus aureus (MRSA), other pathogens, the risk of 90-day and 180-day mortalities in VAP patients were 1.465 times (OR = 1.465, 95%CI: 1.188-1.807, P < 0.001) and 1.635 times (OR = 1.635, 95%CI: 1.333-2.005, P < 0.001) higher than those in non-VAP patients, respectively.

CONCLUSIONS

Our study revealed that ICU patients with VAP had poorer prognosis than those without VAP. The results of this study might offer a deeper insight into preventing the occurrence of VAP.