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Symonds NE, Meng EXM, Boyd JG, Boyd T, Day A, Hobbs H, Maslove DM, Norman PA, Semrau JS, Sibley S, Muscedere J. Ceragenin-coated endotracheal tubes for the reduction of ventilator-associated pneumonia: a prospective, longitudinal, cross-over, interrupted time, implementation study protocol (CEASE VAP study). BMJ Open 2024; 14:e076720. [PMID: 38309761 PMCID: PMC10840065 DOI: 10.1136/bmjopen-2023-076720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/11/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Critically ill patients are at high risk of acquiring ventilator-associated pneumonia (VAP), which occurs in approximately 20% of mechanically ventilated patients. VAP results either from aspiration of pathogen-contaminated oropharyngeal secretions or contaminated biofilms that form on endotracheal tubes (ETTs) after intubation. VAP results in increased duration of mechanical ventilation, increased intensive care unit and hospital length of stay, increased risk of death and increased healthcare costs. Because of its impact on patient outcomes and the healthcare system, VAP is regarded as an important patient safety issue and there is an urgent need for better evidence on the efficacy of prevention strategies. Modified ETTs that reduce aspiration of oropharyngeal secretions with subglottic secretion drainage or reduce the occurrence of biofilm with a coating of ceragenins (CSAs) are available for clinical use in Canada. In this implementation study, we will evaluate the efficacy of these two types of Health Canada-licensed ETTs on the occurrence of VAP, and impact on patient-centred outcomes. METHODS In this ongoing, pragmatic, prospective, longitudinal, interrupted time, cross-over implementation study, we will compare the efficacy of a CSA-coated ETT (CeraShield N8 Pharma) with an ETT with subglottic secretion drainage (Taper Guard, Covidien). The study periods consist of four alternating time periods of 11 or 12 weeks or a total of 23 weeks for each ETT. All patients intubated with the study ETT in each time period will be included in an intention-to-treat analysis. Outcomes will include VAP incidence, mortality and health services utilisation including antibiotic use and length of stay. ETHICS AND DISSEMINATION This study has been approved by the Health Sciences Research Ethics Board at Queen's University. The results of this study will be actively disseminated through manuscript publication and conference presentations. TRIAL REGISTRATION NUMBER NCT05761613.
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Affiliation(s)
| | | | - John Gordon Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Tracy Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Andrew Day
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Hailey Hobbs
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Joanna S Semrau
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie Sibley
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
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Deane AM, Alhazzani W, Guyatt G, Finfer S, Marshall JC, Myburgh J, Zytaruk N, Hardie M, Saunders L, Knowles S, Lauzier F, Chapman MJ, English S, Muscedere J, Arabi Y, Ostermann M, Venkatesh B, Young P, Thabane L, Billot L, Heels-Ansdell D, Al-Fares AA, Hammond NE, Hall R, Rajbhandari D, Poole A, Johnson D, Iqbal M, Reis G, Xie F, Cook DJ. REVISE: Re- Evaluating the Inhibition of Stress Erosions in the ICU: a randomised trial protocol. BMJ Open 2023; 13:e075588. [PMID: 37968012 PMCID: PMC10660838 DOI: 10.1136/bmjopen-2023-075588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/23/2023] [Indexed: 11/17/2023] Open
Abstract
INTRODUCTION The Re-Evaluating the Inhibition of Stress Erosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE. METHODS AND ANALYSIS REVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial. ETHICS AND DISSEMINATION All participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to - Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide. TRIAL REGISTRATION NUMBER NCT03374800.
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Affiliation(s)
- Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Waleed Alhazzani
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - John C Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Nicole Zytaruk
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Miranda Hardie
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Lois Saunders
- Research Institute, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Serena Knowles
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Francois Lauzier
- Departments of Anesthesiology, Medicine & Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval, Laval, Quebec, Canada
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Shane English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - Yaseen Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | | | - Paul Young
- Intensive Care Department, Wellington Hospital, London, UK
| | - Lehana Thabane
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Abdulrahman A Al-Fares
- Departments of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Naomi E Hammond
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - R Hall
- Departments of Anesthesia, Critical Care and Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dorrilyn Rajbhandari
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Alexis Poole
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Daniel Johnson
- Departments of Critical Care and Anesthesia, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mobeen Iqbal
- Intensive Care Department, Maroof International Hospital, Islamabad, Pakistan
| | - Gilmar Reis
- Cardresearch-Cardiologia Assistencial e de Pesquisa LTDA, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
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Definitions, rates and associated mortality of ICU-acquired pneumonia: A multicenter cohort study. J Crit Care 2023; 75:154284. [PMID: 36870801 DOI: 10.1016/j.jcrc.2023.154284] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION We aimed to analyze intensive care unit (ICU)-acquired pneumonia according to 7 definitions, estimating associated hospital mortality. METHODS This cohort study was nested within an international randomized trial, evaluating the effect of probiotics on ICU-acquired pneumonia in 2650 mechanically ventilated adults. Each clinically suspected pneumonia was adjudicated by two physicians blinded to allocation and center. The primary outcome was ventilator-associated pneumonia (VAP) informed by ventilation for ≥2 days, new, progressive or persistent infiltrate plus 2 of: temperature > 38 °C or < 36 °C; leukopenia (<3 × 10(Fernando et al., 20206)/L) or leukocytosis (>10 × 10(Fernando et al., 20206)/L); and purulent sputum. We also used 6 other definitions estimating the risk of hospital mortality. RESULTS The frequency of ICU-acquired pneumonia varied by definition: the trial primary outcome VAP (21.6%), Clinical Pulmonary Infection Score (CPIS) (24.9%), American College Chest Physicians (ACCP) (25.0%), International Sepsis Forum (ISF) (24.4%), Reducing Oxidative Stress Study (REDOXS) (17.6%), Centers for Disease Control (CDC) (7.8%), and invasively microbiologically confirmed (1.9%). The trial primary outcome VAP (HR 1.31 [1.08, 1.60]), ISF (HR 1.32 [1.09,1.60]), CPIS (HR 1.30 [1.08,1.58]) and ACCP definitions (HR 1.22 [1.00,1.47]) were associated with hospital mortality. CONCLUSIONS Rates of ICU-acquired pneumonia vary by definition and are associated with differential increased risk of death.
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Li C, Lu F, Chen J, Ma J, Xu N. Probiotic Supplementation Prevents the Development of Ventilator-Associated Pneumonia for Mechanically Ventilated ICU Patients: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Front Nutr 2022; 9:919156. [PMID: 35879981 PMCID: PMC9307490 DOI: 10.3389/fnut.2022.919156] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is one of the common critical complications of nosocomial infection (NI) in invasive mechanically ventilated intensive care unit (ICU) patients. The efficacy of total parenteral nutrition (TPN), enteral nutrition and/or adjuvant peripheral parenteral nutrition (EPN) supplemented with or without probiotic, prebiotic, and synbiotic therapies in preventing VAP among these patients has been questioned. We aimed to systematically and comprehensively summarize all available studies to generate the best evidence of VAP prevention for invasive mechanically ventilated ICU patients. Methods Randomized controlled trials (RCTs) for the administration of TPN, EPN, probiotics-supplemented EPN, prebiotics-supplemented EPN, and synbiotics-supplemented EPN for VAP prevention in invasive mechanically ventilated ICU patients were systematically retrieved from four electronic databases. The incidence of VAP was the primary outcome and was determined by the random-effects model of a Bayesian framework. The secondary outcomes were NI, ICU and hospital mortality, ICU and hospital length of stay, and mechanical ventilation duration. The registration number of Prospero is CRD42020195773. Results A total of 8339 patients from 31 RCTs were finally included in network meta-analysis. The primary outcome showed that probiotic-supplemented EPN had a higher correlation with the alleviation of VAP than EPN in critically invasive mechanically ventilated patients (odds ratio [OR] 0.75; 95% credible intervals [CrI] 0.58–0.95). Subgroup analyses showed that probiotic-supplemented EPN prevented VAP in trauma patients (OR 0.30; 95% CrI 0.13–0.83), mixed probiotic strain therapy was more effective in preventing VAP than EPN therapy (OR 0.55; 95% CrI 0.31–0.97), and low-dose probiotic therapy (less than 1010 CFU per day) was more associated with lowered incidence of VAP than EPN therapy (OR 0.16; 95% CrI 0.04–0.64). Secondary outcomes indicated that synbiotic-supplemented EPN therapy was more significantly related to decreased incidence of NI than EPN therapy (OR 0.34; 95% CrI 0.11–0.85). Prebiotic-supplemented EPN administration was the most effective in preventing diarrhea (OR 0.05; 95% CrI 0.00–0.71). Conclusion Probiotic supplementation shows promise in reducing the incidence of VAP in critically invasive mechanically ventilated patients. Currently, low quality of evidence reduces strong clinical recommendations. Further high-quality RCTs are needed to conclusively prove these findings. Systamatic Review Registration [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020195773], identifier [CRD42020195773].
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Affiliation(s)
- Cong Li
- Department of Emergency Medicine, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- Laboratory of Morphology, Xuzhou Medical University, Xuzhou, China
| | - Fangjie Lu
- Department of Critical Care Medicine, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, China
| | - Jing Chen
- Laboratory of Morphology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Provincial Institute of Health Emergency, Xuzhou Medical University, Xuzhou, China
| | - Jiawei Ma
- Department of Critical Care Medicine, The Affiliated Wuxi No. 2 People’s Hospital of Nanjing Medical University, Wuxi, China
- *Correspondence: Jiawei Ma,
| | - Nana Xu
- Department of Emergency Medicine, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- Laboratory of Morphology, Xuzhou Medical University, Xuzhou, China
- Jiangsu Provincial Institute of Health Emergency, Xuzhou Medical University, Xuzhou, China
- Nana Xu,
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Renaud C, Kollef MH. Classical and Molecular Techniques to Diagnose HAP/VAP. Semin Respir Crit Care Med 2022; 43:219-228. [PMID: 35042263 DOI: 10.1055/s-0041-1739359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Nosocomial pneumonia, including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), are the most common nosocomial infections occurring in critically ill patients requiring intensive care. However, challenges exist in making a timely and accurate diagnosis of HAP and VAP. Under diagnosis of HAP and VAP can result in greater mortality risk, especially if accompanied by delays in the administration of appropriate antimicrobial treatment. Over diagnosis of HAP and VAP results in the unnecessary administration of broad spectrum antibiotics that can lead to further escalation of antibiotic resistance. Optimal diagnosis and management of HAP and VAP require a systematic approach that combines clinical and radiographic assessments along with proper microbiologic techniques. The use of more invasive sampling methods (bronchoalveolar lavage and protected specimen brush) may enhance specimen collection resulting in more specific diagnoses to limit unnecessary antibiotic exposure. Molecular techniques, currently in use and investigational technique, may improve the diagnosis of HAP and VAP by allowing more rapid identification of offending pathogens, if present, thus increasing both appropriate antibiotic treatment and avoiding unnecessary drug exposure.
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Affiliation(s)
- Cherie Renaud
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
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Johnstone J, Meade M, Lauzier F, Marshall J, Duan E, Dionne J, Arabi YM, Heels-Ansdell D, Thabane L, Lamarche D, Surette M, Zytaruk N, Mehta S, Dodek P, McIntyre L, English S, Rochwerg B, Karachi T, Henderson W, Wood G, Ovakim D, Herridge M, Granton J, Wilcox ME, Goffi A, Stelfox HT, Niven D, Muscedere J, Lamontagne F, D’Aragon F, St.-Arnaud C, Ball I, Nagpal D, Girard M, Aslanian P, Charbonney E, Williamson D, Sligl W, Friedrich J, Adhikari NK, Marquis F, Archambault P, Khwaja K, Kristof A, Kutsogiannis J, Zarychanski R, Paunovic B, Reeve B, Lellouche F, Hosek P, Tsang J, Binnie A, Trop S, Loubani O, Hall R, Cirone R, Reynolds S, Lysecki P, Golan E, Cartin-Ceba R, Taylor R, Cook D. Effect of Probiotics on Incident Ventilator-Associated Pneumonia in Critically Ill Patients: A Randomized Clinical Trial. JAMA 2021; 326:1024-1033. [PMID: 34546300 PMCID: PMC8456390 DOI: 10.1001/jama.2021.13355] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported. OBJECTIVE To evaluate the effect of Lactobacillus rhamnosus GG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU). DESIGN, SETTING, AND PARTICIPANTS Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020). INTERVENTIONS Enteral L rhamnosus GG (1 × 1010 colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU. MAIN OUTCOMES AND MEASURES The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections including Clostridioides difficile infection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality. RESULTS Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.] with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22; P = .73, absolute difference, 0.6%, 95% CI, -2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event of L rhamnosus in a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58; P < .001). CONCLUSIONS AND RELEVANCE Among critically ill patients requiring mechanical ventilation, administration of the probiotic L rhamnosus GG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use of L rhamnosus GG in critically ill patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02462590.
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Affiliation(s)
| | | | | | | | | | | | - Yaseen M. Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | | | | | | | | | | | - Peter Dodek
- University of British Columbia, Vancouver, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ian Ball
- Western University, London, Canada
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Silva PUJ, Paranhos LR, Meneses-Santos D, Blumenberg C, Macedo DR, Cardoso SV. Combination of toothbrushing and chlorhexidine compared with exclusive use of chlorhexidine to reduce the risk of ventilator-associated pneumonia: A systematic review with meta-analysis. Clinics (Sao Paulo) 2021; 76:e2659. [PMID: 34133659 PMCID: PMC8158674 DOI: 10.6061/clinics/2021/e2659] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/15/2021] [Indexed: 01/08/2023] Open
Abstract
This study aimed to compare the effectiveness of 0.12% chlorhexidine alone and 0.12% chlorhexidine in combination with toothbrushing to prevent ventilator-associated pneumonia (VAP) in mechanically ventilated patients. The Embase, Latin American and Caribbean Health Science Literature, PubMed, Scientific Electronic Library Online, Scopus, LIVIVO, Web of Science, Cochrane Library, OpenThesis, and Open Access Thesis and Dissertations databases were used. Only randomized controlled trials without restrictions on the year or language of publication were included. Two reviewers assessed the risk of bias using the Joanna Briggs Institute Critical Appraisal Tool. A meta-analysis using a random-effects model estimated the combined relative risk (RR). The Grading of Recommendations, Assessment, Development and Evaluations approach was used to assess the certainty of the evidence. Initially, 2,337 studies were identified, of which 4 were considered in the systematic review and 3 in the meta-analysis (total sample: 796 patients). The studies were published between 2009 and 2017. All eligible studies had a low risk of bias. The meta-analysis revealed that the risk of VAP was 24% lower in patients receiving chlorhexidine combined with toothbrushing than in those receiving chlorhexidine alone (RR: 0.76; 95% confidence interval: 0.55-1.06), with moderate certainty of evidence and without statistical significance. In conclusion, considering the limitations of this study, a standard protocol for the prevention of VAP is not yet recommended. More studies with larger sample sizes are needed to draw strong conclusions. However, considering that toothbrushing is a simple intervention, it should be a common practice in mechanically ventilated patients, especially among patients with coronavirus disease.
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Affiliation(s)
- Pedro Urquiza Jayme Silva
- Programa de Pos-Graduacao em Odontologia, Faculdade de Odontologia, Universidade Federal de Uberlandia, Uberlandia, MG, BR
| | - Luiz Renato Paranhos
- Area de Odontologia Preventiva e Social, Faculdade de Odontologia, Universidade Federal de Uberlandia, Uberlandia, MG, BR
- Corresponding author. E-mail:
| | - Daniela Meneses-Santos
- Programa de Residencia em Cirurgia e Traumatologia Buco-Maxilo-Facial, Faculdade de Medicina, Universidade Federal de Uberlandia, Uberlandia, MG, BR
| | - Cauane Blumenberg
- Programa de Pos-Graduacao em Epidemiologia, Faculdade de Medicina, Universidade Federal de Pelotas, Pelotas, RS, BR
| | | | - Sérgio Vitorino Cardoso
- Area de Patologia, Faculdade de Odontologia, Universidade Federal de Uberlandia, Uberlandia, MG, BR
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Johnstone J, Heels-Ansdell D, Thabane L, Meade M, Marshall J, Lauzier F, Duan EH, Zytaruk N, Lamarche D, Surette M, Cook DJ. Evaluating probiotics for the prevention of ventilator-associated pneumonia: a randomised placebo-controlled multicentre trial protocol and statistical analysis plan for PROSPECT. BMJ Open 2019; 9:e025228. [PMID: 31227528 PMCID: PMC6596980 DOI: 10.1136/bmjopen-2018-025228] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in critically ill patients. Prior studies suggest that probiotics may reduce VAP and other infections in critically ill patients; however, most previous randomised trials were small, single centre studies. The Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT) aims to determine the impact of the probiotic Lactobacillus rhamnosus GG on VAP and other clinically important outcomes in critically ill adults. METHODS PROSPECT is a multicentre, concealed, randomised, stratified, blinded, controlled trial in patients ≥18 years old, anticipated to be mechanically ventilated ≥72 hours, in intensive care units (ICUs) in Canada, the USA and Saudi Arabia. Patients receive either 1×1010 colony forming units of L. rhamnosus GG twice daily or an identical appearing placebo. Those at increased risk of probiotic infection are excluded. The primary outcome is VAP. Secondary outcomes are other ICU-acquired infections including Clostridioides difficile infection, diarrhoea (including antibiotic-associated diarrhoea), antimicrobial use, ICU and hospital length of stay and mortality. The planned sample size of 2650 patients is based on an estimated 15% VAP rate and will provide 80% power to detect a 25% relative risk reduction. ETHICS AND DISSEMINATION This protocol and statistical analysis plan outlines the methodology, primary and secondary analyses, sensitivity analyses and subgroup analyses. PROSPECT is approved by Health Canada (#9427-M1133-45C), the research ethics boards of all participating hospitals and Public Health Ontario. Results will be disseminated via academic channels (peer reviewed journal publications, professional healthcare fora including international conferences) and conventional and social media. The results of PROSPECT will inform practice guidelines worldwide. TRIALREGISTRATION NUMBER NCT02462590; Pre-results.
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Affiliation(s)
- Jennie Johnstone
- Public Health Ontario, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Maureen Meade
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - John Marshall
- Surgery/Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Francois Lauzier
- Critical Care, CHU de Quebec-Universite Laval, Quebec, Quebec, Canada
| | | | - Nicole Zytaruk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daphnee Lamarche
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael Surette
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Abstract
Ventilator-associated tracheobronchitis (VAT) might represent an intermediate process between lower respiratory tract colonization and ventilator-associated pneumonia (VAP), or even a less severe spectrum of VAP. There is an urgent need for new concepts in the arena of ventilator-associated lower respiratory tract infections. Ideally, the gold standard of care is based on prevention rather than treatment of respiratory infection. However, despite numerous and sometimes imaginative efforts to validate the benefit of these measures, most clinicians now accept that currently available measures have failed to eradicate VAP. Stopping the progression from VAT to VAP could improve patient outcomes.
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Hart R, McNeill S, Maclean S, Hornsby J, Ramsay S. The prevalence of suspected ventilator-associated pneumonia in Scottish intensive care units. J Intensive Care Soc 2019; 21:140-147. [PMID: 32489410 DOI: 10.1177/1751143719854984] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Ventilator-associated pneumonia is the most common healthcare-associated infection in mechanically ventilated patients. Despite this, accurate diagnosis of ventilator-associated pneumonia is difficult owing to the variety of criteria that exist. In this prospective national audit, we aim to quantify the existence of patients with suspected ventilator-associated pneumonia that would not be detected by our standard healthcare-associated infection screening process. Furthermore, we aim to assess the impact of tracheostomy insertion, subglottic drainage endotracheal tubes and chlorhexidine gel on ventilator-associated pneumonia rate. Of the 227 patients recruited, suspected ventilator-associated pneumonia occurred in 32 of these patients. Using the HELICS definition, 13/32 (40.6%) patients were diagnosed with ventilator-associated pneumonia (H-posVAP). Suspected ventilator-associated pneumonia rate was increased in our tracheostomy population, decreased in the subglottic drainage endotracheal tube group and unchanged in the chlorhexidine group. The diagnosis of ventilator-associated pneumonia remains a contentious issue. The formalisation of the HELICS criteria by the European CDC should allow standardised data collection throughout Europe, which will enable more consistent data collection and meaningful data comparison in the future. Our data add weight to the argument against routine oral chlorhexidine. The use of subglottic drainage endotracheal tubes in preventing ventilator-associated pneumonia is interesting and requires further investigation.
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Affiliation(s)
- Robert Hart
- Queen Elizabeth University Hospital, Glasgow, UK
| | | | | | | | - Sarah Ramsay
- Queen Elizabeth University Hospital, Glasgow, UK
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11
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Fonkou MDM, Dufour JC, Dubourg G, Raoult D. Repertoire of bacterial species cultured from the human oral cavity and respiratory tract. Future Microbiol 2018; 13:1611-1624. [DOI: 10.2217/fmb-2018-0181] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
While the gut microbiota is currently in the spotlight, the airway microbiome has been recently associated with several pulmonary diseases and carcinogenesis. As there are several biases associated with high-throughput sequencing methods, cultivation techniques are crucial for the investigation of the human microbiome. We thus aimed to build an exhaustive database, including a list of microbes isolated by culture from respiratory specimens, by performing a review of the literature. Herein, we have listed a total of 756 species cultured from the human respiratory tract. This represents 27.23% of the overall bacterial richness captured from human being by culture methods. This repertoire could be valuable for the elucidation of the interactions between the respiratory microbiome and human health.
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Affiliation(s)
- Maxime DM Fonkou
- Aix Marseille Univ., IRD, MEPHI, IHU Méditerranée Infection, Marseille, France
| | - Jean-Charles Dufour
- Aix Marseille Univ., INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
- APHM, Hôpital de la Timone, Service Biostatistique et Technologies de l'Information et de la Communication, Marseille, France
| | - Grégory Dubourg
- Aix Marseille Univ., IRD, MEPHI, IHU Méditerranée Infection, Marseille, France
| | - Didier Raoult
- Aix Marseille Univ., IRD, MEPHI, IHU Méditerranée Infection, Marseille, France
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12
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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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14
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Abstract
Critical care medicine is a young specialty that has experienced an expansion of research efforts in the last decade. Many physiologic and therapeutic principles or “dogmas” have been challenged, resulting in major “shifts” and minor “drifts” in thinking. This article reviews the available literature about some of these important and sometimes controversial changes, with emphasis on the practical implications of the concepts. Specific areas discussed include supply-dependent oxygen consumption in critical illness, manipulation of the cytokine cascade in sepsis, ventilation in the acute respiratory distress syndrome (ARDS), blood transfusion in the critically ill, the concept of the multiple organ dysfunction syndrome (MODS), the need for nutritional support in the critically ill, and others. Many of the changes discussed involve the recognition that the host response to a severe insult is exceedingly complex, and the understanding of this response and the effects of it at a tissue and cellular level are incomplete. As a result, the ability to impact the outcome of sepsis and MODS has thus far been disappointing, with the possible exception of “lung-protective” ventilation. The final challenge in critical care medicine is to gain information that will allow the practitioner to better understand, prevent, and treat the complex events that result in organ and cellular dysfunction. Future changes in dogma are welcome if they help achieve these goals.
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Affiliation(s)
- Ari Robin Joffe
- Department of Pediatrics, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada.
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15
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Marik PE, Lynott J, Croxton M, Palmer E, Miller L, Zaloga GP. The Effect of Blind-Protected Specimen Brush Sampling on Antibiotic Use in Patients with Suspected Ventilator-Associated Pneumonia. J Intensive Care Med 2016. [DOI: 10.1177/088506660101600105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The diagnosis of pneumonia in ventilated patients is exceedingly difficult. Although culture of tracheal aspirates have poor diagnostic value they are frequently used to diagnose ventilator-associated pneumonia (VAP). Recently a number of studies have reported on the diagnostic value of “blind” protected specimen brush (B-PSB) sampling in the diagnosis of VAP. B-PSB sampling can readily and safely be performed by respiratory care practitioners (RCPs). The aim of this study was to determine the cost-effectiveness of B-PSB sampling performed by respiratory therapists in patients with suspected VAP. During a 3-month run-in period, patients in our medical intensive care unit (MICU) with suspected VAP were treated based on clinical criteria and tracheal aspirate culture. Following this run-in period the house staff, nurses, and RCPs were prevented from sending tracheal aspirates for culture. All patients suspected of having VAP underwent B-PSB sampling with quantitative culture. The B-PSB sampling was performed by RCPs who had been trained to perform the technique. A PSB with a potential bacterial pathogen concentration greater than 500 CFU/ml was regarded as positive. During the 3-month run-in period 172 patients received mechanical ventilation with an average of 4.9 ±3.1 ventilator days/patient. During this period 79 patients were treated for VAP. During the 3-month study period 160 patients received mechanical ventilation, with an average of 5.1 ± 2.9 ventilator days/patient (NS). Fifty-eight B-PSB samplings were performed in 50 patients for suspected VAP. No complications related to the procedure were reported. No tracheal aspirates were cultured during this time period. Eight patients had positive PSB cultures. Antibiotics were changed in three of these patients based on the PSB results. Thirty-eight courses of antibiotics (in 36 patients) were stopped based on negative PSB results. Twelve cases of VAP were suspected in six patients receiving antibiotics for other reasons. No change in antibiotics were made in these cases based on the negative PSB results. The length of mechanical ventilation was 5.4 ± 3.2 days in the 38 culture-negative patients in whom antibiotics were stopped compared to 8.2 ± 4.7 days in the 8 patients with PSB-positive VAP (NS; p = 0.14). The direct cost savings as a result of discontinuing antibiotics was $9,500. There were additional cost savings due to the reduced number of culture specimens sent to the laboratory (approximately $3,000; taking the $23 cost of the PSB brush into account), with a projected annual cost savings of $50,000. B-PSB sampling is a simple and cost-efficient diagnostic test that can safely be performed by adequately trained RCPs. Furthermore, this study confirms that antibiotics may be safely discontinued in patients with negative quantitative culture results.
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Affiliation(s)
- Paul E. Marik
- Divisions of Critical Care Medicine, The Mercy Hospital of Pittsburgh, Pittsburgh, PA
| | - Joseph Lynott
- Divisions of Respiratory Services, Washington Hospital Center, Washington, DC
| | | | - Edward Palmer
- Divisions of Respiratory Services, Washington Hospital Center, Washington, DC
| | - Larry Miller
- Divisions of Respiratory Services, Washington Hospital Center, Washington, DC
| | - Gary P. Zaloga
- Division of Critical Care Medicine, Suburban Hospital, Bethesda, MD
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Alhazzani W, Guyatt G, Marshall JC, Hall R, Muscedere J, Lauzier F, Thabane L, Alshahrani M, English SW, Arabi YM, Deane AM, Karachi T, Rochwerg B, Finfer S, Daneman N, Zytaruk N, Heel-Ansdell D, Cook D, Of OB. Re-evaluating the Inhibition of Stress Erosions (REVISE): a protocol for pilot randomized controlled trial. Ann Saudi Med 2016; 36:427-433. [PMID: 27920416 PMCID: PMC6074211 DOI: 10.5144/0256-4947.2016.427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Clinicians routinely administer stress ulcer prophylaxis to mechanically ventilated patients in the intensive care unit (ICU), most commonly prescribing proton pump inhibitors (PPIs). However, the incidence of gastrointestinal (GI) bleeding from stress ulceration is low and recent observational studies suggest these agents may increase infections. Therefore, a large randomized clinical trial (RCT) is needed to inform modern practice. The aim of this multicenter pilot trial is to determine the feasibility of performing a large RCT to investigate the efficacy and safety of withholding intravenous pantoprazole. METHODS AND ANALYSIS We will include adult critically ill patients who have an anticipated duration of ventilation of >=48 hours. We will exclude patients with acute or recent GI bleeding, pregnancy, dual antiplatelet therapy, poor prognosis or intent to withdraw life support, or previous enrolment in this or a confounding trial. Following informed consent, patients will be randomized to receive the intervention of placebo (0.9% NaCl) or intravenous pantoprazole 40 mg daily. Patients, families, clinicians, data collectors, adjudicators of outcome and statisticians will be blind to allocation. The three primary feasibility outcomes are the informed consent rate, recruitment rate, and protocol adherence. Clinical outcomes include clinically important upper GI bleeding, ventilator-associated pneumonia (VAP), Clostridium difficile infection, length of stay and mortality in ICU and hospital. ETHICS AND APPROVAL This study has been approved by Health Canada, and research ethics board (REB) at each of the participating centers. TRIAL REGISTRATION NUMBER This trial was registered on 31 October 2014. The trial registration number is NCT02290327. FUNDING REVISE Pilot Trial is funded by Research Grant awarded by Physicians Services Incorporated, Dammam University Research Funds, Capital Health Authority Research Award Halifax, and Royal Adelaide Hospital Project Committee Grant.
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Affiliation(s)
- Waleed Alhazzani
- Dr. Waleed Alhazzani, Critical Care Medicine, McMaster University,, 50 Charlton Avenue East,, Hamilton, Ontario,, L8N 4A6, Canada, T: +1905-522-1155 ext 32800, F: +1905-521-6068 , ORCID: http://orcid.org/0000-0001-8076-9626
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17
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Wang G, Ji X, Xu Y, Xiang X. Lung ultrasound: a promising tool to monitor ventilator-associated pneumonia in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:320. [PMID: 27784331 PMCID: PMC5081926 DOI: 10.1186/s13054-016-1487-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Ventilator-associated pneumonia (VAP) is the most frequent intensive care unit (ICU)-acquired infection that is independently associated with mortality. Accurate diagnosis and timely treatment have been shown to improve the prognosis of VAP. Chest X-ray or computed tomography imaging are used for conventional assessment of VAP, but these methods are impractical for real-time measurement in critical patients. Therefore, lung ultrasound (LUS) has been increasingly used for the assessment of VAP in the ICU. Traditionally, LUS has seemed unsuitable for the detection of lung parenchyma owing to the high acoustic impedance of air; however, the fact that the reflection and reverberation in the detection region of the ultrasound reflect the underlying pathology of lung diseases has led to the increased use of ultrasound imaging as a standard of care supported by evidence-based and expert consensus in the ICU. Considering that any type of pneumonia causes air volume changes in the lungs, accumulating evidence has shown that LUS effectively measures the presence of VAP as well as dynamic changes in VAP. This review offers evidence for ultrasound as a noninvasive, easily repeatable, and bedside means to assess VAP; in addition, it establishes a protocol for qualitative and quantitative monitoring of VAP.
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Affiliation(s)
- Guyi Wang
- Department of Intensive Care Unit, The Second Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
| | - Xiaoying Ji
- Department of General Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
| | - Yongshan Xu
- Department of General Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xudong Xiang
- Department of Emergency, The Second Xiangya Hospital, Central South University, Changsha City, Hunan Province, China
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18
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Baughman RP, Kerr MA. Ventilator-Associated Pneumonia Patients who Do Not Reduce Bacteria from the Lungs have a Worse Prognosis. J Intensive Care Med 2016; 18:269-74. [PMID: 15035762 DOI: 10.1177/0885066603256012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The authors determined the significance of serial semi-quantitative bronchoalveolar lavage (BAL) culture results in patients undergoing therapy for ventilator-associated pneumonia. A total of 32 patients underwent at least 2 nonbronchoscopic BAL studies. Fourteen patients had methicillin-resistant Staphylococcus aureus(MRSA). Of these, 11 had more than 100 colony-forming units (cfu) of MRSA/mL of BAL from the follow-up BAL. Eighteen patients had an organism other than MRSA, and 7 of these patients had > 100 cfu of bacteria/mL of BAL from the follow-up BAL. Of the 18 patients with > 100 cfu of bacteria/mL of BAL at follow-up, 14 (79%) died, whereas only 5 of 14 (36%) patients who cleared their bacteria at follow-up died within 28 days. The inability to reduce the bacterial burden from the lower respiratory tract within the first few days of therapy for ventilator-associated pneumonia was associated with increased mortality.
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MESH Headings
- Anti-Bacterial Agents/adverse effects
- Anti-Bacterial Agents/therapeutic use
- Bronchoalveolar Lavage Fluid/microbiology
- Colony Count, Microbial
- Cross Infection/etiology
- Cross Infection/mortality
- Cross Infection/therapy
- Hospital Mortality
- Humans
- Likelihood Functions
- Methicillin Resistance
- Monitoring, Physiologic/methods
- Monitoring, Physiologic/standards
- Mucociliary Clearance
- Pneumonia, Bacterial/etiology
- Pneumonia, Bacterial/mortality
- Pneumonia, Bacterial/therapy
- Pneumonia, Pneumococcal/etiology
- Pneumonia, Pneumococcal/mortality
- Pneumonia, Pneumococcal/therapy
- Pneumonia, Staphylococcal/etiology
- Pneumonia, Staphylococcal/mortality
- Pneumonia, Staphylococcal/therapy
- Prognosis
- Respiration, Artificial/adverse effects
- Retrospective Studies
- Sensitivity and Specificity
- Serratia Infections/etiology
- Serratia Infections/mortality
- Serratia Infections/therapy
- Sputum/microbiology
- Staphylococcus aureus
- Survival Analysis
- Time Factors
- Vancomycin/adverse effects
- Vancomycin/therapeutic use
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Affiliation(s)
- Robert P Baughman
- University of Cincinnati Medical Center, Cincinnati, OH 45267-0565, USA.
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19
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Clinical significance of ventilator-associated event. J Crit Care 2016; 35:19-23. [PMID: 27481731 DOI: 10.1016/j.jcrc.2016.04.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 03/23/2016] [Accepted: 04/26/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE A novel surveillance algorithm of ventilator-associated event (VAE) was introduced to overcome the subjectivity of conventional ventilator-associated pneumonia. We investigated the risk factors and prognostic values of VAE. METHODS We conducted a retrospective study of 869 patients treated with mechanical ventilation for greater than or equal to 2 calendar days from January 2013 to June 2014. We compared the episodes of mechanical ventilation with or without VAE and analyzed risk factors and clinical outcomes of VAE. RESULTS Among 1031 episodes of mechanical ventilation, 92 episodes were complicated with VAE. VAE occurred more frequently when the initial causes of mechanical ventilation were trauma (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-6.3) and pulmonary edema (OR, 2.4; 95% CI, 1.2-4.7). VAE was significantly associated with prolonged mechanical ventilation (5 vs 12 days; P<.001), reduced rate of successful extubation (50.1% vs 17.5%; P<.001), and increased 30-day mortality (35.6% vs 74.2%; P<.001). VAE was a significant risk factor of 30-day mortality on multivariate regression analysis (OR, 3.6; 95% CI, 2.0-6.6; P<.001). CONCLUSIONS Patients treated with mechanical ventilation due to pulmonary edema or trauma had increased risk of VAE, with its development indicative of adverse clinical outcomes.
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Abstract
Nosocomial pneumonia or hospital-acquired pneumonia (HAP) causes considerable morbidity and mortality. It is the second most common nosocomial infection and the leading cause of death from hospital-acquired infections. In 1996 the American Thoracic Society (ATS) published guidelines for empirical therapy of HAP. This review focuses on the literature that has appeared since the ATS statement. Early diagnosis of HAP and its etiology is crucial in guiding empirical therapy. Since 1996, it has become clear that differentiating mere colonization from etiologic pathogens infecting the lower respiratory tract is best achieved by employing bronchoalveolar lavage (BAL) or protected specimen brush (PSB) in combination with quantitative culture and detection of intracellular microorganisms. Endotracheal aspirate and non-bronchoscopic BAL/PSB in combination with quantitative culture provide a good alternative in patients suspected of ventilator-associated pneumonia. Since culture results take 2–3 days, initial therapy of HAP is by definition empirical. Epidemiologic studies have identified the most frequently involved pathogens: Enterobacteriaceae, Haemophilus influenzae, Streptococcus pneumoniae and Staphylococcus aureus (‘core pathogens’). Empirical therapy covering only the ‘core pathogens’ will suffice in patients without risk factors for resistant microorganisms. Studies that have appeared since the ATS statement issued in 1996, demonstrate several new risk factors for HAP with multiresistant pathogens. In patients with risk factors, empirical therapy should consist of antibacterials with a broader spectrum. The most important risk factors for resistant microorganisms are late onset of HAP (≥5 days after admission), recent use of antibacterial therapy, and mechanical ventilation. Multiresistant bacteria of specific interest are methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, Acinetobacter calcoaceticus- baumannii, Stenotrophomonas maltophilia and extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae. Each of these organisms has its specific susceptibility pattern, demanding appropriate antibacterial treatment. To further improve outcomes, specific therapeutic options for multiresistant pathogens and pharmacological factors are discussed. Antibacterials developed since 1996 or antibacterials with renewed interest (linezolid, quinupristin/dalfopristin, teicoplanin, meropenem, new fluoroquinolones, and fourth-generation cephalosporins) are discussed in the light of developing resistance. Since the ATS statement, many reports have shown increasing incidences of resistant microorganisms. Therefore, one of the most important conclusions from this review is that empirical therapy for HAP should not be based on general guidelines alone, but that local epidemiology should be taken into account and used in the formulation of local guidelines.
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Affiliation(s)
- Gunnar I Andriesse
- Eijkman-Winkler Institute for Medical and Clinical Microbiology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
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21
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22
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Chelkeba L, Ahmadi A, Abdollahi M, Najafi A, Ghadimi MH, Mosaed R, Mojtahedzadeh M. The effect of parenteral selenium on outcomes of mechanically ventilated patients following sepsis: a prospective randomized clinical trial. Ann Intensive Care 2015; 5:29. [PMID: 26429356 PMCID: PMC4591221 DOI: 10.1186/s13613-015-0071-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/14/2015] [Indexed: 01/05/2023] Open
Abstract
Background Sepsis and septic shock is characterized by oxidative stress that mainly promotes systemic inflammation and organ failure due to
excessive free radical production and depletion of antioxidant defenses. Therefore, we investigated the effect of selenium administration on antioxidant status, levels of cytokines and clinical outcomes. Methodology This study was a prospective randomized control trial (RCT) whereby patients received selenium as sodium selenite (2 mg IV bolus followed by 1.5 mg continuous infusion for 14 days) plus standard therapy. The control group received standard therapy without selenium. The primary endpoint was 28-day mortality. The changes in the mean levels of glutathione peroxidase (GPX) activity, IL-6, IL-8 and IL-10, the incidence of ventilator-associated pneumonia (VAP) and other secondary endpoints were also recorded. VAP was broken down into early VAP and late VAP to see the clinical significance of each. We also recorded any adverse outcomes from selenium infusion. Results Over 24-month period, 54 patients were recruited and randomized and an intention to treat (ITT) principle was applied (selenium, n = 29; control, n = 25) in the final analysis. There was no statistically significant difference between the two groups in 28-day mortality although it was lower in the selenium group compared with the control group: 9 (31 %) in the selenium versus 10 (40 %) in the control groups (p = 0.49). At day 0, GPX activity was 0.185 ± 0.3 versus 0.19 ± 0.3 U/mL (p = 0.9), day 3, GPX activity was 0.52 ± 0.5 versus 0.17 ± 0.2 U/mL (p = 0.02), at day 7 it was 0.55 ± 0.5 versus 0.24 ± 0.3 U/mL (p = 0.032), at day 10 it was 0.62 ± 0.7 versus 0.33 ± 0.4 U/mL (p = 0.048) and at day 14 it was 1.1 ± 1 versus 0.89 ± 1 U/mL (p = 0.70) for the selenium versus control groups, respectively. However, there were no significant differences between the mean plasma levels of all the three inflammatory cytokines at any point in time between the two groups. There was a significant reduction in occurrence of VAP in the selenium group compared with the control group (55.2 versus 84 %, p = 0.023), respectively. Conclusion High-dose selenium administration within the time frame of early goal-directed therapy was not resulted in reduction of 28-day mortality, but increased the activity of glutathione peroxidase with no effect on the levels of inflammatory cytokines at any point in time in mechanically ventilated septic patients. However, selenium supplementation in mechanically ventilated patients following sepsis was associated with reduced occurrence of VAP. Trial registration: IRCT201212082887N4 at WHO Clinical Trial Registry, August 29, 2014
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Affiliation(s)
- Legese Chelkeba
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, International campus (TUMS-IC), Tehran, Iran. .,Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. .,Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Clinical Pharmacy, Colleague of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia.
| | - Arezoo Ahmadi
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Abdollahi
- Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Atabak Najafi
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Hosein Ghadimi
- Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Reza Mosaed
- Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, International campus (TUMS-IC), Tehran, Iran. .,Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. .,Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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Wallace FA, Alexander PDG, Spencer C, Naisbitt J, Moore JA, McGrath BA. A comparison of ventilator-associated pneumonia rates determined by different scoring systems in four intensive care units in the North West of England. Anaesthesia 2015; 70:1274-80. [DOI: 10.1111/anae.13211] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2015] [Indexed: 12/24/2022]
Affiliation(s)
| | - P. D. G. Alexander
- University Hospital of South Manchester NHS Foundation Trust; Manchester UK
| | - C. Spencer
- Lancashire Teaching Hospitals NHS Foundation Trust; Preston UK
| | - J. Naisbitt
- Salford Royal NHS Foundation Trust; Salford UK
| | - J. A. Moore
- Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
| | - B. A. McGrath
- University Hospital of South Manchester NHS Foundation Trust; Manchester UK
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Scholte JBJ, van der Velde JIM, Linssen CFM, van Dessel HA, Bergmans DCJJ, Savelkoul PHM, Roekaerts PMHJ, van Mook WNKA. Ventilator-associated Pneumonia caused by commensal oropharyngeal Flora; [corrected] a retrospective Analysis of a prospectively collected Database. BMC Pulm Med 2015; 15:86. [PMID: 26264828 PMCID: PMC4531521 DOI: 10.1186/s12890-015-0087-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 07/30/2015] [Indexed: 12/13/2022] Open
Abstract
Background The significance of commensal oropharyngeal flora (COF) as a potential cause of ventilator-associated pneumonia (VAP) is scarcely investigated and consequently unknown. Therefore, the aim of this study was to explore whether COF may cause VAP. Methods Retrospective clinical, microbiological and radiographic analysis of all prospectively collected suspected VAP cases in which bronchoalveolar lavage fluid exclusively yielded ≥ 104 cfu/ml COF during a 9.5-year period. Characteristics of 899 recent intensive care unit (ICU) admissions were used as a reference population. Results Out of the prospectively collected database containing 159 VAP cases, 23 patients were included. In these patients, VAP developed after a median of 8 days of mechanical ventilation. The patients faced a prolonged total ICU length of stay (35 days [P < .001]), hospital length of stay (45 days [P = .001]), and a trend to higher mortality (39 % vs. 26 %, [P = .158]; standardized mortality ratio 1.26 vs. 0.77, [P = .137]) compared to the reference population. After clinical, microbiological and radiographic analysis, COF was the most likely cause of respiratory deterioration in 15 patients (9.4 % of all VAP cases) and a possible cause in 2 patients. Conclusion Commensal oropharyngeal flora appears to be a potential cause of VAP in limited numbers of ICU patients as is probably associated with an increased length of stay in both ICU and hospital. As COF-VAP develops late in the course of ICU admission, it is possibly associated with the immunocompromised status of ICU patients.
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Affiliation(s)
- Johannes B J Scholte
- Department of Intensive Care Medicine, Luzerner Kantonspital, 6000, Luzern 16, Switzerland.
| | - Johan I M van der Velde
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Catharina F M Linssen
- Department of Medical Microbiology, Atrium Medical Centre, P.O. box 4446, 6401 CX, Heerlen, The Netherlands.
| | - Helke A van Dessel
- Department of Medical Microbiology, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Paul H M Savelkoul
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Paul M H J Roekaerts
- Department of Medical Microbiology, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Walther N K A van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
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Johnstone J, Meade M, Marshall J, Heyland DK, Surette MG, Bowdish DME, Lauzier F, Thebane L, Cook DJ. Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial-PROSPECT: protocol for a feasibility randomized pilot trial. Pilot Feasibility Stud 2015; 1:19. [PMID: 27965798 PMCID: PMC5154039 DOI: 10.1186/s40814-015-0013-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 05/13/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Probiotics are defined as live microorganisms that may confer health benefits when ingested. Meta-analysis of probiotic trials suggests a 25 % lower ventilator-associated pneumonia (VAP) and 18 % lower infection rates overall when administered to patients in the intensive care unit (ICU). However, prior trials are small, largely single center, and at high risk of bias. Before a large rigorous trial is launched, testing whether probiotics confer benefit, harm, or have no impact, a pilot trial is needed. The aim of the PROSPECT Pilot Trial is to determine the feasibility of performing a larger trial in mechanically ventilated critically ill patients investigating Lactobacillus rhamnosus GG. A priori, we determined that the feasibility of the larger trial would be based on timely recruitment, high protocol adherence, minimal contamination, and an acceptable VAP rate. METHODS/DESIGN Patients ≥18 years old in the ICU who are anticipated to receive mechanical ventilation for ≥72 hours will be included. Patients are excluded if they are at increased risk of probiotic-associated infection, have strict enteral medication contraindications, are pregnant, previously enrolled in a related trial, or are receiving palliative care. Following informed consent, patients are randomized in variable unspecified block sizes in a fixed 1:1 ratio, stratified by ICU, and medical, surgical, or trauma admitting diagnosis. Patients receive 1 × 1010 colony forming units of L. rhamnosus GG (Culturelle, Locin Industries Ltd) or an identical placebo suspended in tap water administered twice daily via nasogastric tube in the ICU. Clinical and research staff, patients, and families are blinded. DISCUSSION The primary outcomes for this pilot trial are the following: (1) recruitment success, (2) ≥90 % protocol adherence, (3) ≤5 % contamination, and (4) ~10 % VAP rate. Additional clinical outcomes are VAP, other infections, diarrhea (total, antibiotic associated, and Clostridium difficile), ICU and hospital length of stay, and mortality. The morbidity, mortality, and cost of VAP underscore the need for cost-effective prophylactic interventions. The PROSPECT Pilot Trial is the initial step toward rigorously evaluating whether probiotics decrease nosocomial infections, have no effect, or actually cause infections in critically ill patients. TRIAL REGISTRATION ClinicalTrials.gov. NCT01782755.
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Affiliation(s)
- Jennie Johnstone
- Public Health Ontario, Toronto, Ontario Canada
- St. Joseph’s Health Center, Toronto, Ontario Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Maureen Meade
- Department of Medicine, McMaster Health Sciences Center, Room 2C11, 1200 Main Street W, Hamilton, Ontario Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - John Marshall
- Department of Medicine, University of Toronto, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Daren K Heyland
- Department of Medicine, Queen’s University, Kingston, Canada
| | - Michael G Surette
- Department of Medicine, McMaster Health Sciences Center, Room 2C11, 1200 Main Street W, Hamilton, Ontario Canada
| | - Dawn ME Bowdish
- Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Francois Lauzier
- Department of Medicine, Research Center of the CHU de Québec, Population Health and Optimal Health Practices Research Unit, Québec, Canada
| | - Lehana Thebane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
- Biostatistics Unit, St Joseph’s Healthcare—Hamilton, Hamilton, Ontario Canada
| | - Deborah J Cook
- Department of Medicine, McMaster Health Sciences Center, Room 2C11, 1200 Main Street W, Hamilton, Ontario Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - For the PROSPECT Investigators and the Canadian Critical Care Trials Group
- Public Health Ontario, Toronto, Ontario Canada
- St. Joseph’s Health Center, Toronto, Ontario Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, McMaster Health Sciences Center, Room 2C11, 1200 Main Street W, Hamilton, Ontario Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Department of Medicine, Queen’s University, Kingston, Canada
- Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
- Department of Medicine, Research Center of the CHU de Québec, Population Health and Optimal Health Practices Research Unit, Québec, Canada
- Biostatistics Unit, St Joseph’s Healthcare—Hamilton, Hamilton, Ontario Canada
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Ego A, Preiser JC, Vincent JL. Impact of diagnostic criteria on the incidence of ventilator-associated pneumonia. Chest 2015; 147:347-355. [PMID: 25340476 DOI: 10.1378/chest.14-0610] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a frequent complication of prolonged invasive ventilation. Because VAP is largely preventable, its incidence has been used as an index of quality of care in the ICU. However, the incidence of VAP varies according to which criteria are used to identify it. We compared the incidence of VAP obtained with different sets of criteria. METHODS We collected data from all adult patients admitted to our 35-bed ICU over a 7-month period who had no pulmonary infection on admission or within the first 48 h and who required mechanical ventilation for > 48 h. To diagnose VAP, we applied six published sets of criteria and 89 combinations of criteria for hypoxemia, inflammatory response, purulence of tracheal secretions, chest radiography findings, and microbiologic findings of varying levels of severity. The variables used in each diagnostic algorithm were assessed daily. RESULTS Of 1,824 patients admitted to the ICU during the study period, 91 were eligible for inclusion. The incidence of VAP ranged from 4% to 42% when using the six published sets of criteria and from 0% to 44% when using the 89 combinations. The delay before diagnosis of VAP increased from 4 to 8 days with increasingly stringent criteria, and mortality increased from 50% to 80%. CONCLUSIONS Applying different diagnostic criteria to the same patient population can result in wide variation in the incidence of VAP. The use of different criteria can also influence the time of diagnosis and the associated mortality rate.
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Affiliation(s)
- Amédée Ego
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Waghray P, Tummuru VR, Koteshwara Rao A, Veena V, Hasnani R. Mini BAL vs bronchoscopic BAL in intubated patients in a tertiary care centre, Mahabubnagar, AP: Our experience. APOLLO MEDICINE 2015. [DOI: 10.1016/j.apme.2015.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kanafani ZA, Kara L, Hayek S, Kanj SS. Ventilator-Associated Pneumonia at a Tertiary-Care Center in a Developing Country: Incidence, Microbiology, and Susceptibility Patterns of Isolated Microorganisms. Infect Control Hosp Epidemiol 2015; 24:864-9. [PMID: 14649777 DOI: 10.1086/502151] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AbstractObjective:Ventilator-associated pneumonia (VAP) complicates the course of up to 24% of intubated patients. Data from the Middle East are scarce. The objective of this study was to evaluate the incidence, microbiology, and antimicrobial susceptibility patterns of isolated microorganisms in VAP in a developing country.Design:Prospective observational cohort study.Setting:The American University of Beirut Medical Center, a tertiary-care center that serves as a major referral center for Lebanon and neighboring countries.Patients:All patients admitted to the intensive care and respiratory care units from March to September 2001, and who had been receiving mechanical ventilation for at least 48 hours, were included in the study. Results of samples submitted for culture were recorded and antimicrobial susceptibility testing of isolated pathogens was performed.Results:Seventy patients were entered into the study. The incidence of VAP was 47%. Gram-negative bacilli accounted for 83% of all isolates. The most commonly identified organism was Acinetobacter anitratus, followed by Pseudomonas aeruginosa. Fifty percent of all gram-negative bacterial isolates were classified as antibiotic resistant. Compared with patients without VAP, patients with VAP remained intubated for a longer period and stayed in the intensive care unit longer. VAP was not associated with an increased mortality rate.Conclusion:Compared with other studies, the results from this referral center in Lebanon indicate a higher incidence of VAP and a high prevalence of resistant organisms. These data are relevant because they direct the choice of empiric antibiotic therapy for VAP.
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Affiliation(s)
- Zeina A Kanafani
- Department of Medicine, Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
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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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Overtesting and overtreatment: the role of tracheal aspirate cultures in the diagnosis and management of ventilator-associated infections. Pediatr Crit Care Med 2014; 15:773-5. [PMID: 25280147 DOI: 10.1097/pcc.0000000000000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lumsdaine W, Easton RM, Lott NJ, White A, Malmanche TLD, Lemmert K, Weber DG, Balogh ZJ. Neutrophil oxidative burst capacity for peri-operative immune monitoring in trauma patients. Injury 2014; 45:1144-8. [PMID: 24815374 DOI: 10.1016/j.injury.2014.04.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/18/2014] [Accepted: 04/05/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Post injury immune dysfunction can result in serious complications. Measurement of biomarkers may guide the optimal timing of surgery in clinically borderline patients and therefore prevent complications. AIM peri-operative measurement of neutrophil oxidative burst capacity as an indicator of the immune response to major orthopaedic surgical procedures. METHODS Prospective cohort study of trauma patients aged ≥16 yrs with pelvic, acetabular, femoral shaft or tibial shaft fractures requiring surgical intervention. Blood samples were taken immediately pre-op and at 30 min, 7, 24 and 72-9 6 h post-operatively. Neutrophil oxidative burst capacity was measured both with and without stimulation by formyl-methionyl-leucyl-phenylalanine (fMLP, a chemotactic factor). Clinical outcomes measured were mortality, length of stay, MOF, pneumonia, acute respiratory distress syndrome (ARDS) and sepsis. RESULTS 100 consecutive orthopaedic trauma patients were enrolled over a 16 month period. 78% were male, with a mean age of 42 ± 18 years and an average ISS of 19 ± 13. Neutrophil oxidative burst capacity was significantly elevated at 7 h (p = 0.006) and 24 h (p = 0.022) post operatively. Patients who developed infective complications (pneumonia and sepsis) had higher levels of oxidative burst capacity pre-operatively (pneumonia: 1.52 ± 0.93 v 0.99 ± 0.66 p = 0.032, sepsis: 1.39 ± 0.86 v 0.97 ± 0.56 p = 0.024) and at 24 h post op (pneumonia: 2.72 ± 2.38 v 1.12 ± 0.63 p = < 0.001, sepsis: 2.16 ± 2.09 v 1.10 ± 0.54 p = < 0.001). When analysed by operation type, no statistical difference was seen between major and minor operations. No correlation was found between length of stay, length of ICU stay, ISS or age and neutrophil oxidative burst capacity at any time point. CONCLUSIONS Neutrophil oxidative burst capacity response to orthopaedic trauma surgery is associated with the infective post injury complications. There was no correlation between magnitude of injury or operation and oxidative burst capacity. These results are promising for the development of tools for prediction of post-operative complications and guidance for optimal timing for surgical intervention.
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Affiliation(s)
- William Lumsdaine
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Ruth Miriam Easton
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Natalie Jane Lott
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Amanda White
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Theo L de Malmanche
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Karla Lemmert
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Dieter Georg Weber
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Zsolt J Balogh
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia.
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Evans LT, Lollis SS, Ball PA. Management of acute spinal cord injury in the neurocritical care unit. Neurosurg Clin N Am 2013; 24:339-47. [PMID: 23809029 DOI: 10.1016/j.nec.2013.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute spinal cord injury (SCI) is associated with widespread disturbances not only affecting neurologic function but also leading to hemodynamic instability and respiratory failure. Traumatic SCI rarely occurs in isolation, and frequently is accompanied by trauma to other organ systems. Management of individuals with SCI is complex, requiring aggressive monitoring and prompt treatment when complications arise. Typically this level of care is provided in the neurocritical care unit. This article reviews the pathophysiology of the neurologic, cardiovascular, and pulmonary derangements following traumatic SCI and their management in the critical care setting.
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Affiliation(s)
- Linton T Evans
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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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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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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Altintas ND, Aydin K, Türkoğlu MA, Abbasoğlu O, Topeli A. Effect of enteral versus parenteral nutrition on outcome of medical patients requiring mechanical ventilation. Nutr Clin Pract 2011; 26:322-9. [PMID: 21531737 DOI: 10.1177/0884533611405790] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Early enteral nutrition (EN) in patients receiving mechanical ventilation commonly has been advocated, based mainly on studies conducted in mixed populations of trauma and surgery patients. In this study, ventilator-associated pneumonia rates and outcomes were compared in mechanically ventilated medical intensive care unit (ICU) patients receiving enteral versus parenteral nutrition. METHODS Patients fulfilling inclusion criteria between February 1, 2004, and January 31, 2006, were included. Patients were randomized to enteral or parenteral nutrition (PN) within 48 hours of intubation. Development of ventilator-associated pneumonia, assessment as to whether day feeding goal was attained, duration of mechanical ventilation, ICU and hospital length of stay (LOS), and mortality rates were recorded. RESULTS Of 249 consecutive patients receiving mechanical ventilation, 71 patients were included. Thirty (42.3%) patients received EN, and 41 (57.7%) received PN. There was no difference between groups for age, sex, body mass index, and scores on the Acute Physiology and Chronic Health Evaluation II. Ventilator-associated pneumonia rate, ICU and hospital LOS, and mortality rates were similar for both groups. In the parenterally fed group, duration of mechanical ventilation was longer (p = .023), but the feeding goal was attained earlier (p = .012). CONCLUSIONS In mechanically ventilated patients in the medical ICU, ventilator-associated pneumonia rates, ICU and hospital lengths of stay, and ICU and hospital mortality rates of patients receiving PN are not significantly different than those in patients receiving EN, and feeding goals can more effectively be attained by PN. Yet, duration of mechanical ventilation is slightly longer in patients receiving PN.
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MUÑOZ MANUEL, ARIZA DANIEL, GÓMEZ-RAMÍREZ SUSANA, HERNÁNDEZ PAULA, GARCÍA-ERCE JOSÉA, LEAL-NOVAL SANTIAGOR. Preoperative anemia in elective cardiac surgery: prevalence, risk factors, and influence on postoperative outcome. ACTA ACUST UNITED AC 2010. [DOI: 10.1111/j.1778-428x.2010.01126.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Eachempati SR, Hydo LJ, Shou J, Barie PS. The pathogen of ventilator-associated pneumonia does not influence the mortality rate of surgical intensive care unit patients treated with a rotational antibiotic system. Surg Infect (Larchmt) 2010; 11:13-20. [PMID: 20163258 DOI: 10.1089/sur.2008.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is one of the leading causes of morbidity in critically ill surgical patients. Certain pathogens (e.g., methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa) have been associated with an excess mortality rate from sepsis in several studies, but not in the surgical setting specifically or when protocol-driven antibiotic therapy is administered. PURPOSE We sought to determine which factors and, in particular, whether the individual pathogen affected the mortality rate in our surgical intensive care unit (ICU), where a rotational antibiotic system has been employed continuously since 1997. We hypothesized that the type of pathogen and illness severity were the primary influences on the mortality rate of patients with VAP. METHODS A total of 198 consecutive patients from a university surgical ICU, with clinical signs of VAP confirmed by quantified isolation of significant numbers of a pathogen (> or =10(4) colony-forming units [cfu]/mL) from bronchoalveolar (BAL) fluid obtained by fiberoptic bronchoscopy, were identified prospectively from January 2001 to November 2004. The data collected were age, sex, Acute Physiology and Chronic Health Evaluation (APACHE) III score, multiple organ dysfunction score, unit day of diagnosis, time (h) to antibiotic administration (TTA), appropriateness of initial therapy (AIT), unit and hospital length of stay, and mortality rate. Pathogens were classified as non-lactose-fermenting gram-negative bacilli (NGNB), lactose-fermenting gram-negative bacilli (LGNB), methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus, yeast, community-acquired pneumonia (e.g., Streptococcus pneumoniae), or other pathogens. Patients with a polymicrobial isolate were placed in the "other" category. RESULTS The overall mortality rate was 32.3% vs. 55% as predicted by APACHE III normative data. The overall AIT was 92%. The mortality rate for NGNB infections was 35.6% vs. 29.4% for LGNB infections (p = NS). By logistic regression, neither TTA, AIT, nor pathogen influenced the mortality rate. CONCLUSIONS The type of pathogen does not influence death in surgical ICU patients with VAP diagnosed rigorously and treated by a rotational antibiotic system. The high proportion of AIT as a result of the rotational antibiotic administration system optimizes bacterial killing and negates the impact of bacterial resistance, contributing to better outcomes.
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Affiliation(s)
- Soumitra R Eachempati
- Department of Surgery, Weill Medical College of Cornell University, 525 E. 68th St., New York, NY 10021, USA.
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A European care bundle for prevention of ventilator-associated pneumonia. Intensive Care Med 2010; 36:773-80. [DOI: 10.1007/s00134-010-1841-5] [Citation(s) in RCA: 159] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Accepted: 12/11/2009] [Indexed: 01/09/2023]
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Impact of patient position on the incidence of ventilator-associated pneumonia: A meta-analysis of randomized controlled trials. J Crit Care 2009; 24:515-22. [DOI: 10.1016/j.jcrc.2008.09.003] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 08/27/2008] [Accepted: 09/29/2008] [Indexed: 11/24/2022]
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Better infrastructure for critical care trials: nomenclature, etymology, and informatics. Crit Care Med 2009; 37:S173-7. [PMID: 19104220 DOI: 10.1097/ccm.0b013e3181920ee8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The goals of this review article are to review the importance and value of standardized definitions in clinical research, as well as to propose the necessary tools and infrastructure needed to advance nosology and medial taxonomy to improve the quality of clinical trials in the field of critical care. DATA SOURCES We searched MEDLINE for relevant articles, reviewed those selected and their reference lists, and consulted personal files for relevant information. DATA SYNTHESIS When the pathobiology of diseases is well understood, standard disease definitions can be extremely specific and precise; however, when the pathobiology of the disease is less well understood or more complex, biological markers may not be diagnostically useful or even available. In these cases, syndromic definitions effectively classify and group illnesses with similar symptoms and clinical signs. There is no clear gold standard for the diagnosis of many clinical entities in the intensive care unit, including notably both acute respiratory distress syndrome and sepsis. There are several types of consensus methods that can be used to explicate the judgmental approach that is often needed in these cases, including interactive or consensus groups, the nominal group technique, and the Delphi technique. Ideally, the definition development process will create clear and unambiguous language in which each definition accurately reflects the current understanding of the disease state. CONCLUSIONS The development, implementation, evaluation, revision, and reevaluation of standardized definitions are keys for advancing the quality of clinical trials in the critical care arena.
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Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2009; 29 Suppl 1:S31-40. [PMID: 18840087 DOI: 10.1086/591062] [Citation(s) in RCA: 230] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Occurrence of VAP in acute care facilities.a. VAP is one of the most common infections acquired by adults and children in intensive care units (ICUs).i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP. More-recent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but rates may exceed 10 cases per 1,000 ventilator-days in some neonatal and surgical patient populations. The results of recent quality improvement initiatives, however, suggest that many cases of VAP might be prevented by careful attention to the process of care.2. Outcomes associated with VAPa. VAP is a cause of significant patient morbidity and mortality, increased utilization of healthcare resources, and excess cost.i. The mortality attributable to VAP may exceed 10%.ii. Patients with VAP require prolonged periods of mechanical ventilation, extended hospitalizations, excess use of antimicrobial medications, and increased direct medical costs.
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Affiliation(s)
- Susan E Coffin
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Berton DC, Kalil AC, Cavalcanti M, Teixeira PJZ. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database Syst Rev 2008:CD006482. [PMID: 18843718 DOI: 10.1002/14651858.cd006482.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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 STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 4), which contains the Acute Respiratory Infections Group's Specialized Register; MEDLINE (1966 to December 2007); EMBASE (1974 to December 2007); and LILACS (1982 to December 2007). SELECTION CRITERIA Randomized controlled trials (RCTs) comparing respiratory samples processed quantitatively or qualitatively, obtained by invasive or non-invasive methods from immunocompetent patients with VAP, and which analyzed the impact of these methods on antibiotic use and mortality rates. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed and selected trials from the search results, and assessed studies for suitability, methodology and quality. We analyzed 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 3931 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. All five studies were combined 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 mortality reduction 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 Pulmonology - Pavilhão Pereira Filho, Complexo Hospitalar Santa Casa, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil, CEP 90020-090
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Physiotherapy does not prevent, or hasten recovery from, ventilator-associated pneumonia in patients with acquired brain injury. Intensive Care Med 2008; 35:258-65. [DOI: 10.1007/s00134-008-1278-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2007] [Accepted: 08/11/2008] [Indexed: 01/15/2023]
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Ferguson ND, Frutos-Vivar F, Esteban A, Gordo F, Honrubia T, Peñuelas O, Algora A, García G, Bustos A, Rodríguez I. Clinical risk conditions for acute lung injury in the intensive care unit and hospital ward: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R96. [PMID: 17784960 PMCID: PMC2556739 DOI: 10.1186/cc6113] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 08/23/2007] [Accepted: 09/04/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND Little is known about the development of acute lung injury outside the intensive care unit. We set out to document the following: the association between predefined clinical conditions and the development of acute lung injury by using the American-European consensus definition; the frequency of lung injury development outside the intensive care unit; and the temporal relationship between antecedent clinical risk conditions, intensive care admission, and diagnosis of lung injury. METHODS We conducted a 4-month prospective observational study in three Spanish teaching hospitals, enrolling consecutive patients who developed clinical conditions previously linked to lung injury, both inside and outside the intensive care unit. Patients were followed prospectively for outcomes, including the diagnosis of acute lung injury or acute respiratory distress syndrome. RESULTS A total 815 patients were identified with at least one clinical insult; the most common were sepsis, pneumonia, and pancreatitis. Pulmonary risk conditions were observed in 30% of cases. Fifty-three patients (6.5%) developed acute lung injury; 33 of these (4.0%) met criteria for acute respiratory distress syndrome. Lung injury occurred most commonly in the setting of sepsis (46/53; 86.7%), but shock (21/59; 36%) and pneumonia (20/211; 9.5%) portended the highest proportional risk; this risk was higher in patients with increasing numbers of clinical risk conditions (2.2%, 14%, and 21% (P < 0.001) in patients with one, two, and three conditions, respectively). Median days (interquartile range) from risk condition to diagnosis of lung injury was shorter with pulmonary (0 (0 to 2)) versus extrapulmonary (3 (1 to 5)) (P = 0.029) risk conditions. Admission to the intensive care unit was provided to 9/20 (45%) patients with acute lung injury and to 29/33 (88%) of those with acute respiratory distress syndrome. Lung injury patients had higher mortality than others (acute lung injury 25.0%; acute respiratory distress syndrome 45.5%; others 10.3%; P < 0.001). CONCLUSION The time course from clinical insult to diagnosis of lung injury was rapid, but may be longer for extrapulmonary cases. Some patients with lung injury receive care and die outside the intensive care unit; this observation needs further study.
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Affiliation(s)
- Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, and Department of Medicine, Division of Respirology, University Health Network, University of Toronto, 399 Bathurst Street, F2-150, Toronto, Ontario M5T 2S8, Canada
| | - Fernando Frutos-Vivar
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
| | - Andrés Esteban
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
| | - Federico Gordo
- Intensive Care Unit, Fundacíon Hospital de Alcorcón, c/Budapest 1, 28922 Alcorcón, Madrid, Spain
| | - Teresa Honrubia
- Intensive Care Unit, Hospital de Móstoles, c/Río Jucar, 28935 Móstoles, Madrid, Spain
| | - Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
| | - Alejandro Algora
- Intensive Care Unit, Fundacíon Hospital de Alcorcón, c/Budapest 1, 28922 Alcorcón, Madrid, Spain
| | - Gema García
- Intensive Care Unit, Hospital de Móstoles, c/Río Jucar, 28935 Móstoles, Madrid, Spain
| | - Alejandra Bustos
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
| | - Inmaculada Rodríguez
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermades Respiratorios, Carretera de Toledo Km 12,500, 28905 Madrid, Spain
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Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2008; 62:5-34. [PMID: 18445577 PMCID: PMC7110234 DOI: 10.1093/jac/dkn162] [Citation(s) in RCA: 236] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
These evidence-based guidelines have been produced after a systematic literature review of a range of issues involving prevention, diagnosis and treatment of hospital-acquired pneumonia (HAP). Prevention is structured into sections addressing general issues, equipment, patient procedures and the environment, whereas in treatment, the structure addresses the use of antimicrobials in prevention and treatment, adjunctive therapies and the application of clinical protocols. The sections dealing with diagnosis are presented against the clinical, radiological and microbiological diagnosis of HAP. Recommendations are also made upon the role of invasive sampling and quantitative microbiology of respiratory secretions in directing antibiotic therapy in HAP/ventilator-associated pneumonia.
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Kollef M, Morrow L, Baughman R, Craven D, McGowan, Jr. J, Micek S, Niederman M, Ost D, Paterson D, Segreti J. Health Care–Associated Pneumonia (HCAP): A Critical Appraisal to Improve Identification, Management, and Outcomes—Proceedings of the HCAP Summit. Clin Infect Dis 2008; 46 Suppl 4:S296-334; quiz 335-8. [DOI: 10.1086/526355] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Linssen CFM, Jacobs JA, Schouten JSAG, van Mook WNKA, Ramsay G, Drent M. Influence of antibiotic therapy on the cytological diagnosis of ventilator-associated pneumonia. Intensive Care Med 2008; 34:865-72. [PMID: 18251009 DOI: 10.1007/s00134-008-1015-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Accepted: 01/06/2008] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the influence of antibiotics on the value of various cytological parameters, and their combinations, in diagnosing ventilator-associated pneumonia (VAP). DESIGN Prospective study. SETTING The general intensive care unit (17 beds) of the University Hospital Maastricht. PATIENTS Three hundred and thirty-five episodes of clinically suspected VAP (defined by the clinical and radiological criteria previously described by Bonten et al.) in 282 patients were studied. INTERVENTIONS No additional interventions were conducted. MEASUREMENTS AND RESULTS Bronchoalveolar lavage fluid cytology included a total cell count per millilitre, differential cell count and the percentage of infected cells (cells containing phagocytised organisms). Antibiotic therapy from 72 h prior to lavage was recorded. Areas under the curve (AUCs) of receiver operating characteristic curves were calculated for various cytological parameters and their combinations, in patients with and without antibiotic therapy. In 126 episodes (37.6%) in 106 patients, VAP was confirmed. There was no difference in AUCs between patients with and without antibiotic therapy for any parameter studied. The most prominent AUCs were (for patient groups with and without antibiotics combined): total cell count, 0.65; percentage polymorphonuclear neutrophils, 0.71; and percentage infected cells, 0.90. The combination of percentage infected cells with any other cytological parameter did not increase the AUC. CONCLUSION Antibiotic therapy did not influence the predictive value of the percentage infected cells in BALF in diagnosing VAP.
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Affiliation(s)
- Catharina F M Linssen
- Department of Medical Microbiology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
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Baciewicz FA. Thoracic and Pulmonary Infections. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Khan FY, Ibrahim AS, Al Ani A. An Elderly Man with Non-Resolving Fever and a Pulmonary Infiltrate. Qatar Med J 2007. [DOI: 10.5339/qmj.2007.2.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 62-year-old Pakistani man presented with fever and chest pain of five-day duration. He was non-smoker and he had no history of hemoptysis, wheezing, loss of weight or exposure to tuberculosis. Other history was unremarkable. Physical examination revealed a heart rate of 116 beats/min, BP of 121/ 58 mm Hg, temperature of 38.5°C, and a room air oxygen saturation of 92 %. There was no cervical, axillary, or inguinal lymphadenopathy. Chest examination revealed bronchial breath sounds in the right middle and lower zones. Cardiac examination revealed tachycardia with no gallops or murmurs. Abdomen was nontender without hepatosplenomegaly. Extremities were free of cyanosis, edema, and clubbing. There were no skin lesions
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Affiliation(s)
- F. Y. Khan
- Departmentof Medicine, Hamad Medical Corporation Doha, Qatar
| | - A. S. Ibrahim
- Departmentof Medicine, Hamad Medical Corporation Doha, Qatar
| | - A. Al Ani
- Departmentof Medicine, Hamad Medical Corporation Doha, Qatar
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Hedrick TL, Smith PW, Gazoni LM, Sawyer RG. The Appropriate Use of Antibiotics in Surgery: A Review of Surgical Infections. Curr Probl Surg 2007; 44:635-75. [DOI: 10.1067/j.cpsurg.2007.06.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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