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Avisham, Agrawal A, Gupta A. Clinico-Microbiological Correlates of Hospital-Acquired Pneumonia: A Hospital-Based Prospective Cohort Study. Cureus 2023; 15:e50707. [PMID: 38694727 PMCID: PMC11062640 DOI: 10.7759/cureus.50707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 05/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Hospital-acquired pneumonia (HAP) is a life-threatening hospital-acquired infection contributing to poor outcomes and mortality. Though the prevalence is comparable, the burden of comorbidities and malnutrition further worsens the scenario in developing countries. Infective agents responsible for these infections vary between regions due to the variables involved. There is a dearth of data on clinico-microbiological correlates of HAP from Northern India. With this study, we aim to explore the same and add more evidence to fill the gap. METHODOLOGY A hospital-based cohort study was done on ICU patients of the tertiary care center in Northern India including the cohort of patients obeying a strict inclusion criterion. The clinical and microbiological correlates were estimated following an appraisal of quality of study samples. RESULTS We found that the most common clinical feature in patients with HAP was fever (82%) followed by purulent respiratory secretions (72%), tachycardia (52%), and crepitations on auscultation (38%). Approximately 86% of cases were found to be culture-positive while others were bacteriologically sterile. Gram-negative bacilli were more commonly isolated (83% Gram-negative vs 17% Gram-positive). The most common organisms isolated were Klebsiella pneumoniae, Citrobacter freundii, Escherichia coli, Acinetobacter, and Pseudomonas aeruginosa. Staphylococcus aureus was isolated from eight specimens and all isolates were susceptible to vancomycin, linezolid, teicoplanin, and tigecycline. Seven isolates were resistant to clindamycin and all 8 were resistant to macrolides and quinolones. Five strains had methicillin resistance indicating a rising burden of 'superbugs'. The most common side involved was the right side and the right middle zone was the most common zone involved. Forty-four percent of cases had a poor outcome and succumbed to the infection. CONCLUSIONS HAP places patients at a heightened risk of mortality and manifests a distinctive clinical-microbiological profile. It is advisable to adopt a proactive stance in averting HAI by adhering to robust prophylaxis and management protocols in alignment with regional data and hospital guidelines. Despite the study's constrained sample size, it contributes significant insights specific to the region. This underscores the necessity for further exploration through analogous studies and audits in the northern part of India. Such endeavors have the potential to tailor treatment approaches for patients, ultimately enhancing overall outcomes.
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Affiliation(s)
- Avisham
- Department of Respiratory Medicine, Government Doon Medical College, Dehradun, IND
- Department of General Medicine, Himalayan Hospital, Swami Rama Himalayan University, Dehradun, IND
| | - Anurag Agrawal
- Department of Respiratory Medicine, Government Doon Medical College, Dehradun, IND
| | - Abhishek Gupta
- Department of General Medicine, Government Doon Medical College, Dehradun, IND
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Mazwi S, van Blydenstein SA, Mukansi M. Ventilator-associated pneumonia in an academic intensive care unit in Johannesburg, South Africa. Afr J Thorac Crit Care Med 2023; 29:10.7196/AJTCCM.2023.v29i4.154. [PMID: 38078286 PMCID: PMC10699432 DOI: 10.7196/ajtccm.2023.v29i4.154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/10/2023] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) has an estimated incidence of 10 - 41.5 events per 1 000 ventilator days in developing countries, and carries high mortality. Little is known about the incidence and outcomes of VAP in Johannesburg, South Africa. OBJECTIVES To describe VAP in a tertiary public hospital in Johannesburg, assess the microbiological pathogens associated with VAP (both early and late), and outline the outcomes of these patients. METHODS The study was a retrospective record review of patients admitted to the Helen Joseph Hospital intensive care unit (ICU) between March 2013 and January 2016. RESULTS VAP developed in 24/842 ventilated patients (2.9%; 95% confidence interval (CI) 1.8 - 4.2), with an incidence of 23 events per 1 000 ventilator days, during the study period. Of these patients, one-third (29.2%) died and 70.8% were discharged from the ICU. Late-onset VAP (onset ≥5 days after intubation, incidence 45.8%) was associated with higher mortality (54.6%) than early-onset VAP (onset within 4 days after intubation, incidence 54.2% and mortality 7.7%). Commonly isolated organisms were Klebsiellai pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa. There was a trend towards an increased risk of multidrug-resistant organisms with late-onset VAP (adjusted relative risk 2.26; 95% CI 0.92 - 5.57; p=0.077) and airway access through a tracheostomy (relative risk 1.68; 95% CI 0.78 - 3.57). CONCLUSION The study showed a low to moderate incidence of VAP of 23 events per 1 000 ventilator days. A tracheostomy and late-onset VAP were associated with infection by drug-resistant organisms. The mortality rate was 29.2% in this setting, with a seven-fold increase in mortality with late-onset VAP. STUDY SYNOPSIS What the study adds. This study helps to improve understanding of the incidence of ventilator-associated pneumonia in South Africa, a low- to middle-income country, and the commonly encountered causative pathogens. It indicates the importance of a short intensive care unit (ICU) stay as a target outcome for prevention of nosocomial infections and other complications.Implications of the findings. The study: reinforces the importance of preventive mesures in the ICU and keeping up to date with the evidence in the fieldhighlights the importance of knowing local microbial resistance patterns in order to develop precise antibiogramsshows the need for research in ICU care for people of advanced age, and the impact that admission rationing has on our ICU populations.
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Affiliation(s)
- S Mazwi
- Division of Internal Medicine, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - S A van Blydenstein
- Division of Pulmonology, Chris Hani Baragwanath Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Mukansi
- Division of Critical Care, Helen Joseph Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Nisar O, Nisar S, Khattak Haroon Ur Rashid S, Ibne Ali Jaffari SM, Haider Z, Fatima F, Zahra SE, Ijaz AH, Kaneez M, Shairwani GK. Clinical and Etiological Exploration of Ventilator-Associated Pneumonia in the Intensive Care Unit of a Developing Country. Cureus 2023; 15:e47515. [PMID: 38021960 PMCID: PMC10664342 DOI: 10.7759/cureus.47515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is a critical concern in the intensive care unit (ICU), with significant implications for patient outcomes. This retrospective cross-sectional study aimed to determine the prevalence of VAP in an ICU of a developing country, identify the predominant etiological factors, assess patient outcomes, and underscore the need for tailored interventions in high-risk patient groups. Methods This retrospective cross-sectional study included 589 ICU patients who underwent ventilator-assisted breathing for over 48 hours. Among them, 151 developed VAP. The diagnosis was made on clinical, laboratory, and radiological findings, and tracheal aspirate cultures. Exclusions included pediatric patients, less than 48 hours of ventilation, and pre-existing lung infections. Patient data encompassed gender, age, comorbidities, outcomes, admission reasons, isolated microorganisms, and clinical findings. Results 151 patients out of the 589 developed VAP. The age of the patients ranged between 31 to 69 years and the mean age was 45.43 ± 8.92 years. Clinical diagnoses upon ICU admission varied, including sepsis, trauma, stroke, and metabolic disorders. Chest X-rays commonly revealed atelectasis (19.2%), consolidation (21.9%), pleural effusion (11.9%), and lobar pneumonia (45.7%). Tracheal aspirate cultures predominantly isolated multidrug-resistant gram-negative rods, with methicillin-resistant gram-positive cocci and fungal pneumonia prevalent in neutropenic sepsis cases. Notably, only 54 (35.8%) of patients survived, with significantly poorer outcomes observed in sepsis, neutropenic sepsis, and stroke cases compared to trauma and post-operative admissions. Conclusion Multidrug-resistant organisms and the spread of nosocomial infections are the predominant causes of VAP in the ICU. This emphasizes the urgent need for multifaceted interventions to prevent and manage VAP effectively. Developing and implementing targeted strategies, considering the unique challenges faced in resource-constrained healthcare settings can aid in decreasing the mortality associated with it.
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Affiliation(s)
- Omar Nisar
- Internal Medicine, Shalamar Medical and Dental College, Lahore, PAK
| | - Samaha Nisar
- Internal Medicine, Shalamar Medical and Dental College, Lahore, PAK
| | | | | | - Zaki Haider
- Internal Medicine, Rashid Latif Medical College, Lahore, PAK
| | - Fiza Fatima
- Internal Medicine, Shalamar Medical and Dental College, Lahore, PAK
| | - Shan E Zahra
- Internal Medicine, Rashid Latif Medical College, Lahore, PAK
| | - Ali Hassan Ijaz
- Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
| | - Mehwish Kaneez
- Pediatric Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
- Pediatrics, Rawalpindi Medical University, Rawalpindi, PAK
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Chenchula S, Sadasivam B, Shukla A, Pathan S, Saurabh saigal. Health care associated infections, antimicrobial resistance and outcomes in patients admitted to intensive care unit, India: A five-Year retrospective cohort study. J Infect Prev 2023; 24:159-165. [PMID: 37333868 PMCID: PMC10273797 DOI: 10.1177/17571774231161821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/16/2023] [Indexed: 09/20/2023] Open
Abstract
Background The present study was conducted to study the prevalence of HAIs in a newly established MICU, common microorganisms causing HAIs and their antibiotic-sensitivity profile, and antimicrobial utilization and mortality rate. Methods The present retrospective cohort study was carried out at AIIMS, Bhopal (2015-2019). The prevalence of HAIs was determined; sites of HAIs and common causative microorganisms were identified, and their antibiotic-sensitivity profiles were studied. The group of patients with HAIs was matched with a control group drawn from the pool of patients without HAIs; this matching was done with respect to age, gender, and clinical diagnosis. Antimicrobial utilization, Period of ICU stay, comorbidities and patient mortality rates in the two groups were analyzed. The clinical criteria by the CDC- National Nosocomial Infections Surveillance to diagnose HAIs. Results A total of 281 ICU patients' records were analyzed. The mean age was 47.21 ± 19.07 years. Of these 89 were found to have developed ICU-acquired HAIs (Prevalance:32%). Bloodstream infections (33%) and respiratory tract infections (30.68%), catheter-associated urinary tract infections (25.56%), and surgical site infections (6.76%) were the commonest. The most frequently isolated microorganism causing HAIs was K. pneumonia (18%), A. baumannii (14%) and E. coli (12%), 31% isolates of which were multidrug resistant. The average length of ICU stay was high in patients with HAIs (13.85 vs 8.2 days). The most common co-morbidity was type 2 diabetes mellitus (42.86%). Prolonged ICU stays [OR 1.13, (95% CI; 0.04-0.10)] and the presence of HAIs [OR 1.18(95%CI; (0.03-0.15)] were associated with an increased risk of mortality. Conclusions An increased prevalence of HAIs essentially bloodstream infections and respiratory infections with MDR organisms to antimicrobials in the watch group is highly considerable. Acquisition of HAIs with MDR organisms and increased length of hospital stay are considerable risk factors for increased mortality in ICU-admitted patients. Regular antimicrobial stewardship activities and revising existing hospital infection control policies accordingly may reduce HAIs.
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Affiliation(s)
- Santenna Chenchula
- Department of Pharmacology, All India Institute of Medical Sciences Bhopal, Bhopal, India
| | - Balakrishnan Sadasivam
- Department of Pharmacology, All India Institute of Medical Sciences Bhopal, Bhopal, India
| | - Ajay Shukla
- Department of Pharmacology, All India Institute of Medical Sciences Bhopal, Bhopal, India
| | - Saman Pathan
- Department of Pharmacology, All India Institute of Medical Sciences Bhopal, Bhopal, India
| | - Saurabh saigal
- Department of Anaesthesiology & Intensive care, All India Institute of Medical Sciences Bhopal, Bhopal, India
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Gunalan A, Sastry AS, Ramanathan V, Sistla S. Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile. Indian J Crit Care Med 2023; 27:411-415. [PMID: 37378358 PMCID: PMC10291675 DOI: 10.5005/jp-journals-10071-24465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/19/2023] [Indexed: 06/29/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections, which develops in mechanically ventilated patients after 48 hours of mechanical ventilation. The purpose of this study was to determine the incidence rate, various risk factors, microbiological profile, and outcome of early- vs late-onset ventilator-associated pneumonia (VAP) in medical intensive care unit (MICU). Materials and methods This prospective study was conducted on 273 patients admitted to the MICU in JIPMER, Puducherry, from October 2018 to September 2019. Results The incidence of VAP was 39.59 per 1000 ventilation days of MICU patients (93/273). Of these, 53 (56.9%) patients had early-onset VAP and 40 (43.1%) had late-onset VAP. Multiple logistic regression analysis showed that steroid therapy, supine head position, coma or impaired unconsciousness, tracheostomy, and re-intubation were found to be independent predictors of early- and late-onset VAP, respectively. Most cases of VAP were caused by Gram-negative bacteria (90.6%), with nonfermenters contributing to 61.8%. The most frequent pathogens causing early-onset VAP were Acinetobacter baumannii (28.9%) and Pseudomonas aeruginosa (20.6%), while in late-onset VAP, A. baumannii (32.9%) and Klebsiella pneumoniae (21.9%) were the most common. Maximum death rate was seen in patients infected with Escherichia coli (50%) and Stenotrophomonas maltophilia (38.5%). There was no significant association between the presence of VAP and mortality among the studied population. Conclusion The incidence of VAP in our study was high. There were no significant differences in the prevalence of pathogens associated with early-onset or late-onset VAP. Our study shows that early-onset and late-onset VAP have different risk factors, highlighting the need for developing different preventive and therapeutic strategies. How to cite this article Gunalan A, Sastry AS, Ramanathan V, Sistla S. Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile. Indian J Crit Care Med 2023;27(6):411-415.
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Affiliation(s)
- Anitha Gunalan
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Tamil Nadu, India
| | - Apurba Sankar Sastry
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Tamil Nadu, India
| | - Venkateswaran Ramanathan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Tamil Nadu, India
| | - Sujatha Sistla
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Tamil Nadu, India
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Prevalence of multidrug-resistant strains in device associated nosocomial infection and their in vitro killing by nanocomposites. Ann Med Surg (Lond) 2022; 78:103687. [PMID: 35734711 PMCID: PMC9207053 DOI: 10.1016/j.amsu.2022.103687] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/25/2022] [Indexed: 11/24/2022] Open
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Pawlik J, Tomaszek L, Mazurek H, Mędrzycka-Dąbrowska W. Risk Factors and Protective Factors against Ventilator-Associated Pneumonia-A Single-Center Mixed Prospective and Retrospective Cohort Study. J Pers Med 2022; 12:jpm12040597. [PMID: 35455713 PMCID: PMC9025776 DOI: 10.3390/jpm12040597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/02/2022] [Accepted: 04/06/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: Understanding the factors associated with the development of ventilator-associated pneumonia (VAP) in critically ill patients in the intensive care unit (ICU) will allow for better prevention and control of VAP. The aim of the study was to evaluate the incidence of VAP, as well as to determine risk factors and protective factors against VAP. Design: Mixed prospective and retrospective cohort study. Methods: The cohort involved 371 critically ill patients who received standard interventions to prevent VAP. Additionally, patients in the prospective cohort were provided with continuous automatic pressure control in tapered cuffs of endotracheal or tracheostomy tubes and continuous automatic subglottic secretion suction. Logistic regression was used to assess factors affecting VAP. Results: 52 (14%) patients developed VAP, and the incidence density of VAP per 1000 ventilator days was 9.7. The median days to onset of VAP was 7 [4; 13]. Early and late onset VAP was 6.2% and 7.8%, respectively. According to multivariable logistic regression analysis, tracheotomy (OR = 1.6; CI 95%: 1.1 to 2.31), multidrug-resistant bacteria isolated in the culture of lower respiratory secretions (OR = 2.73; Cl 95%: 1.83 to 4.07) and ICU length of stay >5 days (OR = 3.32; Cl 95%: 1.53 to 7.19) were positively correlated with VAP, while continuous control of cuff pressure and subglottic secretion suction used together were negatively correlated with VAP (OR = 0.61; Cl 95%: 0.43 to 0.87). Conclusions: Tracheotomy, multidrug-resistant bacteria, and ICU length of stay >5 days were independent risk factors of VAP, whereas continuous control of cuff pressure and subglottic secretion suction used together were protective factors against VAP.
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Affiliation(s)
- Jarosław Pawlik
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland; (J.P.); or (L.T.)
| | - Lucyna Tomaszek
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland; (J.P.); or (L.T.)
- National Institute of Tuberculosis and Lung Diseases, 34-700 Rabka-Zdroj, Poland
| | - Henryk Mazurek
- Department of Pneumonology and Cystic Fibrosis, National Institute of Tuberculosis and Lung Diseases, 34-700 Rabka-Zdroj, Poland;
- Institute of Health, State University of Applied Sciences in Nowy Sącz, 33-300 Nowy Sącz, Poland
| | - Wioletta Mędrzycka-Dąbrowska
- Department of Anesthesiology Nursing & Intensive Care, Faculty of Health Sciences, Medical University of Gdansk, 80-211 Gdansk, Poland
- Correspondence:
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Singhal T, Rodrigues C, Soman R, Wattal C, Swaminathan S, Nambi S, Talwar D, Singh RK, Todi S. Treatment of MRSA infections in India: Clinical insights from a Delphi analysis. Indian J Med Microbiol 2021; 40:35-45. [PMID: 34785281 DOI: 10.1016/j.ijmmb.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE International and Indian guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections are available, but the local guidelines are not MRSA-specific. This study aimed to provide clinical insights for the treatment of MRSA infections in India. METHODS We used a three-step modified Delphi method to obtain insights. Ten experts comprising infectious disease specialists, microbiologists, pulmonologists, and critical care experts agreed to participate in the analysis. In round 1, a total of 161 statements were circulated to the panel and the experts were asked to 'agree' or 'disagree' by responding 'yes' or 'no' to each statement and provide comments. The same process was used for 73 statements in round 2. Direct interaction with the experts was carried out in round 3 wherein 35 statements were discussed. At least 80% of the experts had to agree for a statement to reach concordance. RESULTS Eighty-eight statements in round 1, thirty-eight statements in round 2, and eight statements in round 3 reached concordance and were accepted without modification. The final document comprised 152 statements on the management of various syndromes associated with MRSA such as skin and soft tissue infections, bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system infections. CONCLUSIONS This analysis will assist clinicians in India to choose an appropriate course of action for MRSA infections.
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Affiliation(s)
- Tanu Singhal
- Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | | | | | - Chand Wattal
- Clinical Microbiology & Immunology, Sir Ganga Ram Hospital, New Delhi, India
| | - Subramanian Swaminathan
- Infectious Diseases and Infection Control at Gleneagles Global Hospitals (Chennai, Bangalore, Hyderabad), India
| | | | - Deepak Talwar
- Metro Respiratory Center Pulmonology & Sleep Medicine, Metro Hospital, Noida, India
| | | | - Subhash Todi
- Critical Care Medicine, Department of Academics & Health Research, AMRI Hospitals, Kolkata, India.
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Dongol S, Kayastha G, Maharjan N, Pyatha S, K. C. R, Thwaites L, Basnyat B, Baker S, Karkey A. Epidemiology, etiology, and diagnosis of health care acquired pneumonia including ventilator-associated pneumonia in Nepal. PLoS One 2021; 16:e0259634. [PMID: 34788314 PMCID: PMC8598067 DOI: 10.1371/journal.pone.0259634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/22/2021] [Indexed: 11/19/2022] Open
Abstract
Epidemiologic data regarding health care acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) from Nepal are negligible. We conducted a prospective observational cohort study in the intensive care unit (ICU) of a major tertiary hospital in Nepal between April 2016 and March 2018, to calculate the incidence of VAP, and to describe clinical variables, microbiological etiology, and outcomes. Four hundred and thirty-eight patients were enrolled in the study. Demographic data, medical history, antimicrobial administration record, chest X-ray, biochemical, microbiological and haematological results, acute physiology and chronic health evaluation II score and the sequential organ failure assessment scores were recorded. Categorical variables were expressed as count and percentage and analyzed using the Fisher's exact test. Continuous variables were expressed as median and interquartile range and analyzed using Kruskal-Wallis rank sum test and the pairwise Wilcoxon rank-sum test. 46.8% (205/438) of the patients required intubation. Pneumonia was common in both intubated (94.14%; 193/205) and non-intubated (52.36%; 122/233) patients. Pneumonia developed among intubated patients in the ICU had longer days of stay in the ICU (median of 10, IQR 5-15, P< 0.001) when compared to non-intubated patients with pneumonia (median of 4, IQR 3-6, P< 0.001). The incidence rate of VAP was 20% (41/205) and incidence density was 16.45 cases per 1,000ventilator days. Mortality was significantly higher in patients with pneumonia requiring intubation (44.6%, 86/193) than patients with pneumonia not requiring intubation (10.7%, 13/122, p<0.001, Fisher's exact test). Gram negative bacteria such as Klebsiella and Acinetobacter species were the dominant organisms from both VAP and non-VAP categories. Multi-drug resistance was highly prevalent in bacterial isolates associated with VAP (90%; 99/110) and non-VAP categories (81.5%; 106/130). HAP including VAP remains to be the most prevalent hospital-acquired infections (HAIs) at Patan hospital. A local study of etiological agents and outcomes of HAP and VAP are required for setting more appropriate guidelines for management of such diseases.
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Affiliation(s)
- Sabina Dongol
- Patan Academy of Health Sciences, Patan Hospital, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Gyan Kayastha
- Patan Academy of Health Sciences, Patan Hospital, Kathmandu, Nepal
| | - Nhukesh Maharjan
- Patan Academy of Health Sciences, Patan Hospital, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Sarita Pyatha
- Patan Academy of Health Sciences, Patan Hospital, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Rajkumar K. C.
- Patan Academy of Health Sciences, Patan Hospital, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Louise Thwaites
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Buddha Basnyat
- Patan Academy of Health Sciences, Patan Hospital, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Abhilasha Karkey
- Patan Academy of Health Sciences, Patan Hospital, Oxford University Clinical Research Unit, Kathmandu, Nepal
- * E-mail:
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Kharel S, Bist A, Mishra SK. Ventilator-associated pneumonia among ICU patients in WHO Southeast Asian region: A systematic review. PLoS One 2021; 16:e0247832. [PMID: 33690663 PMCID: PMC7942996 DOI: 10.1371/journal.pone.0247832] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/14/2021] [Indexed: 12/17/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections and a leading cause of death among patients in Intensive Care Unit (ICU). The South East Asian Region is a part of the world with limited health resources where infectious diseases are still underestimated. We aimed to review the literature in this part of the world to describe incidence, mortality and microbiological evidence of VAP and explore preventive and control strategies. We selected 24 peer-reviewed articles published from January 1, 2000 to September 1, 2020 from electronic databases and manual searching for observational studies among adult patients diagnosed with VAP expressed per thousand days admitted in ICU. The VAP rates ranged from 2.13 to 116 per thousand days, varying among different countries of this region. A significant rate of mortality was observed in 13 studies ranging from 16.2% to 74.1%. Gram negative organisms like Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella pneumoniae and Gram-positive organisms like Staphylococcus aureus and Enterococcus species were frequently found. Our findings suggest an alarming situation of VAP among patients of most of the countries of this region with increasing incidence, mortality and antibiotic resistance. Thus, there is an urgent need for cost effective control and preventive measures like interventional studies and educational programs on staff training, hand hygiene, awareness on antibiotic resistance, implementation of antibiotic stewardship programs and appropriate use of ventilator bundle approach.
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Affiliation(s)
- Sanjeev Kharel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
- * E-mail:
| | - Anil Bist
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Shyam Kumar Mishra
- Department of Microbiology, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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Gunalan A, Sistla S, Sastry AS, Venkateswaran R. Concordance between the National Healthcare Safety Network (NHSN) Surveillance Criteria and Clinical Pulmonary Infection Score (CPIS) Criteria for Diagnosis of Ventilator-associated Pneumonia (VAP). Indian J Crit Care Med 2021; 25:296-298. [PMID: 33790510 PMCID: PMC7991760 DOI: 10.5005/jp-journals-10071-23753] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections among mechanically ventilated patients and the incidence rates are widely used as an index of quality of care given in an ICU. Since there is no gold standard method available to diagnose VAP, the incidence rate varies based on different criteria used for calculation. Therefore, we conducted a study to determine the concordance between the National Healthcare Safety Network (NHSN) surveillance criteria and clinical pulmonary infection score (CPIS) criteria for the diagnosis of VAP. Materials and methods: This was a prospective study that evaluated patients in the medical intensive care units (MICUs) of a tertiary care hospital, India, who were intubated for >48 hours between October 2018 and September 2019. All the patients (n = 273) were followed up daily and assessed using both CPIS and NHSN surveillance criteria for diagnosing VAP. Results: Of these 273 patients, 93 patients (34.1%) had VAP according to CPIS criteria as compared with 33 patients (12.1%) using the NHSN criteria. The corresponding rates of VAP were 39.59 vs 11.53 cases per 1,000 ventilator days, respectively. The agreement of the two sets of criteria was fairly good (kappa statistics, 0.42) Conclusion: The NHSN surveillance criteria have a lower sensitivity in detecting VAP cases and have to be modified to achieve better results. How to cite this article: Gunalan A, Sistla S, Sastry AS, Venkateswaran R. Concordance between the National Healthcare Safety Network (NHSN) Surveillance Criteria and Clinical Pulmonary Infection Score (CPIS) Criteria for Diagnosis of Ventilator-associated Pneumonia (VAP). Indian J Crit Care Med 2021;25(3):296–298.
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Affiliation(s)
- Anitha Gunalan
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sujatha Sistla
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Apurba S Sastry
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ramanathan Venkateswaran
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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12
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Emira AS, Madkour LAEF, Seif NE, Dwedar RA. Expressed and Silent Carbapenemase Genes Detected by Multiplex PCR in both Carbapenem-Resistant and Phenotypically-Susceptible Gram Negative Bacilli. ALEXANDRIA JOURNAL OF MEDICINE 2020. [DOI: 10.1080/20905068.2020.1838749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
| | | | - Nazmy Edward Seif
- Anesthesia and Intensive Care Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Reham Ali Dwedar
- Medical Microbiology & Immunology Department, Faculty of Medicine, Cairo University, Giza, Egypt
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13
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Nusrat T, Akter N, Rahman NAA, Godman B, D Rozario DT, Haque M. Antibiotic resistance and sensitivity pattern of Metallo-β-Lactamase Producing Gram-Negative Bacilli in ventilator-associated pneumonia in the intensive care unit of a public medical school hospital in Bangladesh. Hosp Pract (1995) 2020; 48:128-136. [PMID: 32271642 DOI: 10.1080/21548331.2020.1754687] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/08/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICU), accounting for 25% of all ICU infections. Antimicrobial resistance is increasing and becoming a significant health problem worldwide, increasing hospital length of stay, mortality and costs. Identifying antibiotic resistance patterns in VAP is important as this can cause outbreaks in ICUs. To date, there have been limited studies assessing this in Bangladesh. Consequently, the primary objective of this research was to study the species of bacterial growth and to determine the antibiotic resistance patterns of Metallo-β-Lactamase (MBL) producing gram-negative bacilli among ICU patients with VAP in a public medical school hospital, Bangladesh. In addition, identify the factors associated with a positive culture to provide future guidance. METHOD Cross-sectional study performed in the Chattogram Medical College Hospital, Bangladesh. Mueller Hinton agar plates were used for antibiotic sensitivity testing by the Kirby-Buer disc diffusion test. RESULTS Among 105 clinically suspected VAP cases, qualitative cultures were positive in 95 (90%) of them. The most common bacteria identified were Acinetobacter spp. (43.2%), Klebsiella spp. (20%) and Pseudomonas spp. (18.9%). A positive culture was not associated with patients' age or gender. Among 41 isolated Acinetobacter spp., 38 (92.7%) were resistant to gentamicin followed by 36 (87.8%) to ceftriaxone. Among 24 isolated Klebsiella spp., 22 (83.3%) were resistant to ceftriaxone. Among 18 isolated Pseudomonas spp., 16 (88.8%) were resistant to ciprofloxacin, and 13 (72.2%) were resistant to ceftriaxone. Among nine isolated E. coli, all were resistant to ceftriaxone and ciprofloxacin. All four Proteus spp. (100%) isolated were resistant to ciprofloxacin. Additionally, phenotype MBL producing was 65.22% and genotype was 45.65% among imipenem resistant pathogens. Imipenem resistant pathogens were sensitive to amoxyclav, amikacin¸ azithromycin, ceftazidime, ceftriaxone, colistin and gentamycin. CONCLUSION A positive culture was detected in 90% of VAP patients, but it was not associated with the patients' age and gender. The most common bacteria identified were Acinetobacter spp., Klebsiella spp. and Pseudomonas spp., where the majority of these were resistant to ceftriaxone. The results are being used to provide future guidance on the empiric management of VAP in this hospital.
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Affiliation(s)
- Tanzina Nusrat
- Department of Microbiology, Chittagong Medical College , Panchlaish, Chattogram, Bangladesh
| | - Nasima Akter
- Department of Microbiology, Chittagong Medical College , Panchlaish, Chattogram, Bangladesh
| | - Nor Azlina A Rahman
- Department of Physical Rehabilitation Sciences, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia , Bandar Indera Mahkota, Kuantan, Malaysia
| | - Brian Godman
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde , Glasgow, UK
- Department of Pharmacy, Faculty of Health Sciences, Sefako Makgatho Health Sciences University , Pretoria, South Africa
- Health Economics Centre, University of Liverpool , Liverpool, UK
- Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge , Stockholm, Sweden
| | | | - Mainul Haque
- Faculty of Medicine and Defense Health, Universiti Pertahanan Nasional Malaysia (National Defense University of Malaysia) , Kem Sungai Besi, Kuala Lumpur, Malaysia
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14
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Shokri M, Ghasemian R, Bayani M, Maleh PA, Kamrani M, Sadeghi-Haddad-Zavareh M, Ebrahimpour S. Serum and alveolar procalcitonin had a weak diagnostic value for ventilator-associated pneumonia in patients with pulmonary infection score ≥ 6. ACTA ACUST UNITED AC 2019; 56:9-14. [PMID: 28991776 DOI: 10.1515/rjim-2017-0038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Measuring the serum and alveolar procalcitonin level as inflammatory marker in the diagnosis of ventilator-associated pneumonia (VAP) has been taken into account. In this study, serum and alveolar procalcitonin levels in patients with suspected VAP and patients with confirmed VAP were compared. METHODS This cross-sectional study was conducted using 50 intubated intensive care unit (ICU) patients, connected to ventilator, from October 2014 to April 2015. 50 patients with clinical pulmonary infection score ≥6 were divided into two groups. Patients whose bronchoalveolar lavage (BAL) has shown the growth of more than 104 CFU/mL were included in confirmed VAP group and other patients were included in suspected VAP group. Serum and alveolar procalcitonin levels were measured and compared between both groups. RESULTS Mean age of patients was 69.10 ± 42.13 with a range of 16-90 years, out of which 23 patients were male (46%) and 27 patients were female (54%). Moreover, patients' mean clinical pulmonary infection score was reported to be 7.02 ± 1.07. There was a significant relationship between serum and alveolar procalcitonin in suspected patients and patients with an approved form of pneumonia (p = 0.001 and 0.027). Area under the curve for alveolar procalcitonin was 0.683 (sensitivity = 57%; specificity = 80%) and for serum procalcitonin 0.751 (sensitivity = 71%; specificity = 73%) for the diagnosis of VAP. CONCLUSION According to the results of the present study, we can diagnose ventilator-associated pneumonia earlier and more accurately by measuring procalcitonin level (particularly alveolar type) in intensive care unit patients.
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Affiliation(s)
- Mehran Shokri
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R. Iran
| | - Roya Ghasemian
- Antimicrobial Resistance Research Center, Mazandaran University of Medical Sciences, Sari, I.R. Iran
| | - Masomeh Bayani
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R. Iran
| | - Parviz Amri Maleh
- Department of Anesthesiology, School of Medicine, Babol University of Medical Sciences, Babol, I.R. Iran
| | - Masoumeh Kamrani
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R. Iran
| | - Mahmoud Sadeghi-Haddad-Zavareh
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R. Iran
| | - Soheil Ebrahimpour
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R. Iran
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15
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van Ruissen MCE, Bos LD, Dickson RP, Dondorp AM, Schultsz C, Schultz MJ. Manipulation of the microbiome in critical illness-probiotics as a preventive measure against ventilator-associated pneumonia. Intensive Care Med Exp 2019; 7:37. [PMID: 31346841 PMCID: PMC6658628 DOI: 10.1186/s40635-019-0238-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 03/07/2019] [Indexed: 12/26/2022] Open
Abstract
Objective To describe the possible modes of action of probiotics and provide a systematic review of the current evidence on the efficacy of probiotics to prevent ventilator-associated pneumonia (VAP) in critically ill patients. Methods We conducted an unrestricted search of the English language medical literature. For each individual study, the relative risk of VAP was calculated using the reported primary outcome data. Results The search identified a total of 72 articles. Eight articles enrolling a total of 1229 patients fulfilled the inclusion and exclusion criteria. In four trials, the investigators were blinded for the intervention, and two trials used an intention-to-treat analysis. Loss to follow-up with regard to the primary endpoint ranged from 0 to 14% in the intervention groups and from 0 to 16% in the control groups. The incidence of VAP expressed as the percentage of studied patients was reported in seven trials. The incidence of VAP ranged from 4 to 36% in the intervention groups and from 13 to 50% in the control groups. The relative risk for VAP ranged between 0.30 and 1.41. Three trials showed a significant difference in favor of probiotic therapy between the intervention and the control groups. Conclusions The incidence of VAP tended to be lower in patients treated with probiotics in most trials identified by the systematic search. Due to the heterogeneity of the studies and the low quality of evidence, it remains difficult to draw firm conclusions. The efficacy of preventive probiotics should be studied in more detail in future trials. Application of probiotics for the prevention of VAP seems to be safe with only few side effects reported in the selected trials. Electronic supplementary material The online version of this article (10.1186/s40635-019-0238-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marel C E van Ruissen
- Amsterdam Institute for Global Health and Development (AIGHD), Academic Medical Center, Amsterdam, The Netherlands
| | - Lieuwe D Bos
- Department of Pulmonology, Academic Medical Center, Amsterdam, The Netherlands. .,Department of Intensive Care, Academic Medical Center, C3-425, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Robert P Dickson
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Arjen M Dondorp
- Department of Intensive Care, Academic Medical Center, C3-425, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Constance Schultsz
- Amsterdam Institute for Global Health and Development (AIGHD), Academic Medical Center, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, C3-425, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
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16
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Xie X, Lyu J, Hussain T, Li M. Drug Prevention and Control of Ventilator-Associated Pneumonia. Front Pharmacol 2019; 10:298. [PMID: 31001116 PMCID: PMC6455059 DOI: 10.3389/fphar.2019.00298] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 03/11/2019] [Indexed: 01/10/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) is one of the most prevalent and serious complications of mechanical ventilation, which is considered a common nosocomial infection in critically ill patients. There are some great options for the prevention of VAP: (i) minimize ventilator exposure; (ii) intensive oral care; (iii) aspiration of subglottic secretions; (iv) maintain optimal positioning and encourage mobility; and (v) prophylactic probiotics. Furthermore, clinical management of VAP depends on appropriate antimicrobial therapy, which needs to be selected based on individual patient factors, such as previous antibacterial therapy, history of hospitalization or mechanical ventilation, and bacterial pathogens and antibiotic resistance patterns. In fact, antibiotic resistance has exponentially increased over the last decade, and the isolation of a multidrug-resistant (MDR) pathogen has been identified as an independent predictor of inadequate initial antibiotic therapy and which is significantly associated with increased mortality. Multiple attempts were used in the treatment of VAP, such as novel antibacterial agents, inhaled antibiotics and monoclonal antibodies. In this review, we summarize the current therapeutic options for the prevention and treatment of VAP, aiming to better management of VAP in clinical practice.
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Affiliation(s)
- Xinming Xie
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jun Lyu
- Clinical Research Center, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tafseel Hussain
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Manxiang Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
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17
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Haque M, Sartelli M, McKimm J, Abu Bakar M. Health care-associated infections - an overview. Infect Drug Resist 2018; 11:2321-2333. [PMID: 30532565 PMCID: PMC6245375 DOI: 10.2147/idr.s177247] [Citation(s) in RCA: 521] [Impact Index Per Article: 86.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Health care-associated infections (HCAIs) are infections that occur while receiving health care, developed in a hospital or other health care facility that first appear 48 hours or more after hospital admission, or within 30 days after having received health care. Multiple studies indicate that the common types of adverse events affecting hospitalized patients are adverse drug events, HCAIs, and surgical complications. The US Center for Disease Control and Prevention identifies that nearly 1.7 million hospitalized patients annually acquire HCAIs while being treated for other health issues and that more than 98,000 patients (one in 17) die due to these. Several studies suggest that simple infection-control procedures such as cleaning hands with an alcohol-based hand rub can help prevent HCAIs and save lives, reduce morbidity, and minimize health care costs. Routine educational interventions for health care professionals can help change their hand-washing practices to prevent the spread of infection. In support of this, the WHO has produced guidelines to promote hand-washing practices among member countries.
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Affiliation(s)
- Mainul Haque
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Sungai Besi, 57000 Kuala Lumpur, Malaysia,
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Judy McKimm
- Swansea University School of Medicine, Swansea University, Singleton Park, Swansea, Wales SA2 8PP, UK
| | - Muhamad Abu Bakar
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Sungai Besi, 57000 Kuala Lumpur, Malaysia,
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18
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Zhu Y, Yin H, Zhang R, Ye X, Wei J. Gastric versus postpyloric enteral nutrition in elderly patients (age ≥ 75 years) on mechanical ventilation: a single-center randomized trial. Crit Care 2018; 22:170. [PMID: 29976233 PMCID: PMC6034338 DOI: 10.1186/s13054-018-2092-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 06/08/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The risk of ventilator-associated pneumonia (VAP) is reduced when postpyloric enteral nutrition (EN) is administered compared to when gastric EN is administered in specific populations. In the present study, we tested the hypothesis that postpyloric EN is superior to gastric EN in reducing the incidence of VAP in elderly patients (age ≥ 75 years) who are admitted to the intensive care unit (ICU) and require mechanical ventilation. METHODS We performed a single-center randomized clinical trial involving elderly patients (age ≥ 75 years) who were admitted to the ICU and required mechanical ventilation. The patients were randomly assigned to either the postpyloric EN group or the gastric EN group. The primary outcome was the VAP rate. RESULTS Of the 836 patients screened, 141 patients were included in the study (70 in the postpyloric EN group and 71 in the gastric EN group). The patients in the postpyloric EN group were 82.0 (75.0-99.0) years old (male 61.4%), and those in the gastric EN group were 82.0 (75.0-92.0) years old (male 63.4%). The Acute Physiology and Chronic Health Evaluation II scores were 28.09 ± 6.75 in the postpyloric EN group and 27.80 ± 7.60 in the gastric EN group (P = 0.43). VAP was observed in 8 of 70 patients (11.4%) in the postpyloric EN group and in 18 of 71 patients (25.4%) in the gastric EN group, which resulted in a significant between-group difference (OR 0.38, 95% CI 0.15-0.94; P = 0.04). In the postpyloric EN group, there were significant reductions in vomiting (12 patients in the postpyloric EN group vs 29 patients in the gastric EN group; OR 0.30, 95% CI 0.14-0.65; P = 0.002) and abdominal distension (18 patients in the postpyloric EN group vs 33 patients in the gastric EN group; OR 0.40, 95% CI 0.20-0.81; P = 0.01). No significant differences were observed between the two groups regarding mortality and other secondary outcomes. CONCLUSIONS Our study demonstrated that, compared with gastric EN, postpyloric EN reduced the VAP rate among elderly patients who were admitted to the ICU and required mechanical ventilation. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR-IPR-16008485 . Registered on 17 May 2016.
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Affiliation(s)
- Youfeng Zhu
- 0000 0004 1790 3548grid.258164.cDepartment of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, 510220 China
| | - Haiyan Yin
- 0000 0004 1790 3548grid.258164.cDepartment of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, 510220 China
| | - Rui Zhang
- 0000 0004 1790 3548grid.258164.cDepartment of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, 510220 China
| | - Xiaoling Ye
- 0000 0004 1790 3548grid.258164.cDepartment of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, 510220 China
| | - Jianrui Wei
- 0000 0004 1790 3548grid.258164.cInstitute of Clinical Nutrition, Guangzhou Red Cross Hospital, Medical College, Jinan University, Tongfuzhong Road No. 396, Guangzhou, 510220 China
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19
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Phu VD, Nadjm B, Duy NHA, Co DX, Mai NTH, Trinh DT, Campbell J, Khiem DP, Quang TN, Loan HT, Binh HS, Dinh QD, Thuy DB, Lan HNP, Ha NH, Bonell A, Larsson M, Hoan HM, Tuan ĐQ, Hanberger H, Minh HNV, Yen LM, Van Hao N, Binh NG, Chau NVV, Van Kinh N, Thwaites GE, Wertheim HF, van Doorn HR, Thwaites CL. Ventilator-associated respiratory infection in a resource-restricted setting: impact and etiology. J Intensive Care 2017; 5:69. [PMID: 29276607 PMCID: PMC5738227 DOI: 10.1186/s40560-017-0266-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 11/27/2017] [Indexed: 01/16/2023] Open
Abstract
Background Ventilator-associated respiratory infection (VARI) is a significant problem in resource-restricted intensive care units (ICUs), but differences in casemix and etiology means VARI in resource-restricted ICUs may be different from that found in resource-rich units. Data from these settings are vital to plan preventative interventions and assess their cost-effectiveness, but few are available. Methods We conducted a prospective observational study in four Vietnamese ICUs to assess the incidence and impact of VARI. Patients ≥ 16 years old and expected to be mechanically ventilated > 48 h were enrolled in the study and followed daily for 28 days following ICU admission. Results Four hundred fifty eligible patients were enrolled over 24 months, and after exclusions, 374 patients’ data were analyzed. A total of 92/374 cases of VARI (21.7/1000 ventilator days) were diagnosed; 37 (9.9%) of these met ventilator-associated pneumonia (VAP) criteria (8.7/1000 ventilator days). Patients with any VARI, VAP, or VARI without VAP experienced increased hospital and ICU stay, ICU cost, and antibiotic use (p < 0.01 for all). This was also true for all VARI (p < 0.01 for all) with/without tetanus. There was no increased risk of in-hospital death in patients with VARI compared to those without (VAP HR 1.58, 95% CI 0.75–3.33, p = 0.23; VARI without VAP HR 0.40, 95% CI 0.14–1.17, p = 0.09). In patients with positive endotracheal aspirate cultures, most VARI was caused by Gram-negative organisms; the most frequent were Acinetobacter baumannii (32/73, 43.8%) Klebsiella pneumoniae (26/73, 35.6%), and Pseudomonas aeruginosa (24/73, 32.9%). 40/68 (58.8%) patients with positive cultures for these had carbapenem-resistant isolates. Patients with carbapenem-resistant VARI had significantly greater ICU costs than patients with carbapenem-susceptible isolates (6053 USD (IQR 3806–7824) vs 3131 USD (IQR 2108–7551), p = 0.04) and after correction for adequacy of initial antibiotics and APACHE II score, showed a trend towards increased risk of in-hospital death (HR 2.82, 95% CI 0.75–6.75, p = 0.15). Conclusions VARI in a resource-restricted setting has limited impact on mortality, but shows significant association with increased patient costs, length of stay, and antibiotic use, particularly when caused by carbapenem-resistant bacteria. Evidence-based interventions to reduce VARI in these settings are urgently needed. Electronic supplementary material The online version of this article (10.1186/s40560-017-0266-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vu Dinh Phu
- National Hospital for Tropical Diseases, Hanoi, Vietnam.,Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Behzad Nadjm
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | | | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - James Campbell
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Huynh Thi Loan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Quynh-Dao Dinh
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Duong Bich Thuy
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Huong Nguyen Phu Lan
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Ana Bonell
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | | | | | | | | | | | - Lam Minh Yen
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | | | | | | | - Guy E Thwaites
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Heiman F Wertheim
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, Netherlands
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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20
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Khare V, Gupta P, Haider F, Begum R. Study on MICs of Tigecycline in Clinical Isolates of Carbapenem Resistant Enterobacteriaceae (CRE) at a Tertiary Care Centre in North India. J Clin Diagn Res 2017; 11:DC18-DC21. [PMID: 28511383 DOI: 10.7860/jcdr/2017/24594.9629] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/02/2017] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Members of family Enterobacteriaceae are the most common Gram-negative bacteria isolated from clinical samples. Those Enterobacteriaceae which have acquired resistance to all β-lactams antibiotics including the carbapenems are considered as Carbapenem Resistant Enterobacteriaceae (CRE). These CRE isolates are often resistant to most other classes of antimicrobials as well, making their treatment a great challenge. Tigecycline is one of the last resort antimicrobials against such multidrug resistant bacteria. Decreased tigecycline susceptibility mediated by efflux pump systems is being reported in clinical strains of Enterobacteriaceae. Minimum Inhibitory Concentration (MIC) data would prove useful in managing infections by these multidrug resistant bacteria and optimizing use of tigecycline. AIM To evaluate the MIC values of tigecycline against carbapenem resistant Escherichia coli and Klebsiella pneumoniae isolates. MATERIALS AND METHODS This prospective study was carried out from January 2015 to December 2015 at the Department of Microbiology, Era's Lucknow Medical College and Hospital (ELMCH), Lucknow, Uttar Pradesh, India. Antimicrobial susceptibility by disk diffusion (Kirby-bauer) was done for 491 E. coli and K. pneumoniae strains isolated from 1606 samples collected from patients admitted in various wards and ICUs. Imipenem, meropenem and ertapenem 10 μg disks were used for testing of sensitivity to carbapenems. In all isolates, Tigecycline 15 μg (Hi-Media) disk was used to screen for tigecycline resistance. In CRE isolates, MICs of tigecycline were determined by E-test (Ezy MIC TM TG strips, Hi Media) and interpreted using European Committee on Antimicrobial Susceptibility Testing (EUCAST) 2016 guidelines. RESULTS Out of 491 isolates tested, 186 (37.9%) were found to be CRE showing resistance to at least one of the three carbapenems tested and these included 99 E.coli and 87 K. pneumoniae. Sensitivity pattern of these two bacterial isolates shows a high level of resistance to most classes of antimicrobials. MIC testing for tigecycline was carried out in 144 CRE isolates and tigecycline resistance (MIC >2 μg/ml) was seen in 12 (8.3%) isolates (eight K.pneumoniae and four E. coli). Eight other isolates were found to have MIC of 2 μg/ml and thus the overall prevalence of isolates with decreased susceptibility was 20 (13.9%). CONCLUSION A high prevalence of carbapenem resistance coupled with high tigecycline MICs in clinical isolates of E.coli and K. pneumoniae highlights the judicious use of a combination of antimicrobials. Routine in vitro sensitivity testing to evaluate the clinical utility of tigecycline against such resistant Enterobacteriaceae is warranted.
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Affiliation(s)
- Vineeta Khare
- Associate Professor, Department of Microbiology, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
| | - Prashant Gupta
- Associate Professor, Department of Microbiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Fareya Haider
- Assistant Professor, Department of Microbiology, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
| | - Rehana Begum
- Professor and Head, Department of Microbiology, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
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Gudivada KK, Krishna B, Sriram S. Evaluation of Quality Indicators in an Indian Intensive Care Unit Using "CHITRA" Database. Indian J Crit Care Med 2017; 21:841-846. [PMID: 29307965 PMCID: PMC5752793 DOI: 10.4103/ijccm.ijccm_303_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background: Quality indicators (QIs) are essential for maintaining quality of care in the critically ill. The Indian Society of Critical Care Medicine proposed benchmarks and enabled Indian Intensive Care Units (ICUs) to capture data in an electronic database: Customized Health in Intensive Care Trainable Research and Analysis (CHITRA) tool. The purpose of this study is to report QIs in an Indian ICU using this database. Materials and Methods: Data from patients admitted to ICU between October 2015 and January 2017 were entered into CHITRA. The following QIs were analyzed: standardized mortality ratio (SMR), length of ICU stay (LOS-ICU), pressure ulcer (PU) rate, patient fall rate (FR), ICU readmission rate, reintubation rate, ventilator-associated condition (VAC), central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and iatrogenic pneumothorax rate. Results: A total of 2642 patient's information was suitable for analysis. Median age of ICU admission was 53 years (interquartile range [IQR]: 36–65), with a mean APACHE score of 18 (SD 7.7). Median LOS-ICU was 3 days (IQR 2–6) and SMR was 1.1 (95% confidence interval 1.05–1.38). Pneumothorax rate, PU rate, and FR were 2.6, 4.1, and 0.3 per 1000 respectively, whereas readmission rate was 0.7% and reintubation rate was 3.5%. VAC, CLABSI, and CAUTI were 8.5, 23, 3.1 per 1000 ventilator and catheter days, respectively. Conclusion: This study has successfully evaluated a range of QIs in a mixed ICU of a tertiary hospital utilizing CHITRA database.
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Affiliation(s)
- Kiran Kumar Gudivada
- Department of Critical Care Medicine, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Sampath Sriram
- Department of Critical Care Medicine, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
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Bammigatti C, Doradla S, Belgode HN, Kumar H, Swaminathan RP. Healthcare Associated Infections in a Resource Limited Setting. J Clin Diagn Res 2017; 11:OC01-OC04. [PMID: 28273989 PMCID: PMC5324434 DOI: 10.7860/jcdr/2017/23076.9150] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/10/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Health Care associated Infections (HAI) are the most common complications affecting the hospitalized patients. HAI are more common in developing and under developed countries. However, there are no systematic surveillance programs in these countries. AIM To find out the burden, predisposing factors and multidrug resistant organisms causing HAI in a resource limited setting. MATERIALS AND METHODS This prospective observational study was done at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER). Patients aged 13 years or more with stay of more than 48 hours in a 16 bedded Medical Intensive Care Unit (MICU) between November 2011 and April 2013 were included in the study. Patients were prospectively followed up till discharge or death for the development of HAI. Device associated HAI like Ventilator Associated Pneumonia (VAP), Catheter Related-Blood Stream Infection (CR-BSI) and Catheter Associated-Urinary Tract Infections (CA-UTI) were studied. Standard laboratory methods were used for identification of microorganisms causing HAI and to test their antibiotic sensitivity. RESULTS A total of 346 patients were included in the study with median age of 38 years. Common indications for admission to Medical Intensive Care Unit (MICU) were poisoning (31.5%); neurological illness (23.4%) like Guillian-Barre syndrome, tetanus, meningitis, encephalitis; respiratory illness (14.5%) like pneumonia, acute respiratory distress syndrome and tropical infections (7.2%) like malaria, scrub typhus, leptospirosis. Fifty percent (174/346) patients developed one or more HAI with VAP being the most common. The rates of HAI per 1000 device days for VAP, CR-BSI, CA-UTI were 72.56, 3.98 and 12.4, respectively. Acinetobacter baumannii was the most common organism associated with HAI. Multidrug resistance was seen in 74% of the isolates. CONCLUSION The burden of HAI, especially with MDR organisms, in resource constrained setting like ours is alarming. There is urgent need for infection control and monitoring system to reduce HAI.
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Affiliation(s)
| | - Saikumar Doradla
- Junior Resident, Department of Medicine, JIPMER, Puducherry, India
| | | | - Harichandra Kumar
- Assistant Professor, Department of Biostatistics, JIPMER, Puducherry, India
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Shojaei L, Mohammadi M, Beigmohammadi MT, Doomanlou M, Abdollahi A, Feizabadi MM, Khalili H. Clinical response and outcome of pneumonia due to multi-drug resistant Acinetobacter baumannii in critically ill patients. IRANIAN JOURNAL OF MICROBIOLOGY 2016; 8:288-297. [PMID: 28149487 PMCID: PMC5277596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVES The frequency of multi-drug resistant Acinetobacter spp. infections is increasing in Iran. Considering availability of limited therapeutic options, clinical response and outcome of ventilator-associated pneumonia due to multi-drug resistant A.baumannii were evaluated in critically ill patients. MATERIALS AND METHODS In this prospective study, 29 patients with carbapenem resistance A. baumannii ventilator-associated pneumonia were enrolled. Endotracheal aspirate specimens were analyzed according to the clinical and laboratory standard institute instructions in the hospital's microbiology laboratory. Demographics, clinical, microbiological and laboratory findings were collected for each patient during the treatment course. Therapeutic empirical regimen, change in antibiotic regimen following receiving antibiogram results, clinical and microbiological responses, duration of ICU stay and outcome were collected for each recruited individual. RESULTS All of A. baumanii isolates were resistant to pipracillin-tazobactam, ceftriaxon, amikacin and ciprofloxacin. The resistance rate of A. baumanii species was 41.4% for ampicillin/sulbactabm and 93.1% for meropenem. Patients received either meropenem/colistin (51.7%) or meropenem/ampicillin-sulbactam (48.3%) as the treatment regimens based on the antimicrobial susceptibility patterns of isolates. Ventilator-associated pneumonia clinical response, improvement and failure achieved in 15 (51.7%), 8 (27.6%) and 6 (20.7%) of the patients respectively. Microbiological eradication and intermediate status were observed in 9/29 (31%) and 11/29 (37.9%) of patients, respectively. CONCLUSION The antibiotic regimens showed comparable efficacy in treatment of VAP due to MDR A. baumannii but mortality rate was high. Considering widespread and high mortality rates associated with MDR infections, applying infection control and antibiotic stewardship programs in hospitals are essential.
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Affiliation(s)
- Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Taghi Beigmohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Doomanlou
- Central Laboratory, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Abdollahi
- Department of Pathology, School of Medicine, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran
| | - Mohammad Mehdi Feizabadi
- Department of Medical Microbiology, Tehran University of Medical Sciences, Tehran, Iran,Thoracic Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran,Corresponding author: Hossein Khalili, PhD, Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Enghelab Ave, Tehran, Iran. Postal Code: 1417614411. Tel: +98-912-2979329, Fax: +98-21-66461178, E-mail:
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