Details behind the dots: How different intensive care units used common and contrasting methods to prevent ventilator associated pneumonia.
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SUBMITTER: Daniel M
PROVIDER: S-EPMC4645939 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND: On average 7% of patients admitted to intensive-care units (ICUs) suffer from a potentially preventable ventilator-associated pneumonia (VAP). Our objective was to survey attitudes and practices of ICUs doctors in the field of VAP prevention. METHODS: A questionnaire was made available online in 6 languages from April, 1st to September 1st, 2012 and disseminated through international and national ICU societies. We investigated reported practices as regards (1) established clinical guidelines for VAP prevention, and (2) measurement of process and outcomes, under the assumption "if you cannot measure it, you cannot improve it"; as well as attitudes towards the implementation of a measurement system. Weighted estimations for Europe were computed based on countries for which at least 10 completed replies were available, using total country population as a weight. Data from other countries were pooled together. Detailed country-specific results are presented in an online additional file. RESULTS: A total of 1730 replies were received from 77 countries; 1281 from 16 countries were used to compute weighted European estimates, as follows: care for intubated patients, combined with a measure of compliance to this guideline at least once a year, was reported by 57% of the respondents (95% CI: 54-60) for hand hygiene, 28% (95% CI: 24-33) for systematic daily interruption of sedation and weaning protocol, and 27% (95%: 23-30) for oral care with chlorhexidine. Only 20% (95% CI: 17-22) were able to provide an estimation of outcome data (VAP rate) in their ICU, still 93% (95% CI: 91-94) agreed that "Monitoring of VAP-related measures stimulates quality improvement". Results for 449 respondents from 61 countries not included in the European estimates are broadly comparable. CONCLUSIONS: This study shows a low compliance with VAP prevention practices, as reported by ICU doctors in Europe and elsewhere, and identifies priorities for improvement.
| S-EPMC3623895 | biostudies-other
Project description:BackgroundIt is essential to determine the distribution of the causative microorganisms in the region and the status of local antibiotic resistance for the proper treatment of hospital-acquired pneumonia/ventilator-associated pneumonia (HAP/VAP). This study aimed to investigate the occurrence and causative strains of HAP/VAP, distribution of resistant bacteria, use of antibiotics, and the ensuing outcomes of patients in Korea.MethodsA multicenter prospective observational cohort study was conducted among patients with HAP/VAP admitted to the medical intensive care unit of 5 tertiary referral centers between August 2012 and June 2015. Patients' demographic and clinical data were collected.ResultsA total of 381 patients were diagnosed with HAP/VAP. Their median age was 69 (59-76) years and 71% were males. A majority of the patients (88%) had late-onset (> 5 days) HAP/VAP. One-quarter of the patients (n = 99) had at least one risk factor for multidrug-resistant (MDR) pathogens, such as prior intravenous antibiotic use within the last 90 days. Microbiological specimens were mostly obtained noninvasively (87%) using sputum or endotracheal aspirates. Pathogens were identified in 235 (62%) of the 381 patients. The most common bacterial pathogen was Acinetobacter baumannii (n = 89), followed by Staphylococcus aureus (n = 52), Klebsiella pneumoniae (n = 25) and Pseudomonas aeruginosa (n = 22). Most of isolated A. baumannii (97%) and S. aureus (88%) were multidrug resistant. The most commonly used empirical antibiotic regimens were carbapenem-based antibiotics (38%), followed by extended-spectrum penicillin/β-lactamase inhibitor (34%). Glycopeptide or linezolid were also used in combination in 54% of patients. The 28-day mortality rate of the patients with HAP/VAP was 30% and the 60-day mortality was 46%. Patients who used empirical antibiotics appropriately had significantly lower mortality rates than those who did not (28-day mortality: 25% vs. 40%, P = 0.032; 60-day mortality: 41% vs. 55%, P = 0.032, respectively). Administration of appropriate empirical antibiotics (odds ratio [OR], 0.282; confidence interval [CI], 0.092-0.859; P = 0.026), Day 7 treatment failure (OR, 4.515; CI, 1.545-13.192; P = 0.006), and APACHE II score on day 1 (OR, 1.326; CI, 0.988-1.779; P = 0.012) were the factors that determined the 28-day mortality in patients with HAP who had identified bacteria as pathogens.ConclusionIn HAP/VAP patients, there was a large burden of MDR pathogens, and their associated mortality rate was high. Proper selection of empirical antibiotics was significantly associated with the patient's prognosis; however, there was a discrepancy between major pathogens and empirical antibiotic therapy.
| S-EPMC8546312 | biostudies-literature
Project description:IntroductionThe preventive impact of hospital-acquired infection (HAI) surveillance is difficult to assess. Our objective was to investigate the effect of HAI surveillance disruption on ventilator-associated pneumonia (VAP) incidence.MethodsA quasi-experimental study with an intervention group and a control group was conducted between 1 January 2004 and 31 December 2010 in two intensive care units (ICUs) of a university hospital that participated in a national HAI surveillance network. Surveillance was interrupted during the year 2007 in unit A (intervention group) and was continuous in unit B (control group). Period 1 (pre-test period) comprised patients hospitalized during 2004 to 2006, and period 2 (post-test period) involved patients hospitalized during 2008 to 2010. Patients hospitalized ? 48 hours and intubated during their stay were included. Multivariate Poisson regression was fitted to ascertain the influence of surveillance disruption.ResultsA total of 2,771 patients, accounting for 19,848 intubation-days at risk, were studied; 307 had VAP. The VAP attack rate increased in unit A from 7.8% during period 1 to 17.1% during period 2 (P <0.001); in unit B, it was 7.2% and 11.2% for the two periods respectively (P = 0.17). Adjusted VAP incidence rose in unit A after surveillance disruption (incidence rate ratio = 2.17, 95% confidence interval 1.05 to 4.47, P = 0.036), independently of VAP trend; no change was observed in unit B. All-cause mortality and length of stay increased (P = 0.028 and P = 0.038, respectively) in unit A between periods 1 and 2. In unit B, no change in mortality was observed (P = 0.22), while length of stay decreased between periods 1 and 2 (P = 0.002).ConclusionsVAP incidence, length of stay and all-cause mortality rose after HAI surveillance disruption in ICU, which suggests a specific effect of HAI surveillance on VAP prevention and reinforces the role of data feedback and counselling as a mechanism to facilitate performance improvement.
| S-EPMC3580751 | biostudies-literature
Project description:BackgroundCOVID-19 patients requiring mechanical ventilation are particularly at risk of developing ventilator-associated pneumonia (VAP). Risk factors and the prognostic impact of developing VAP during critical COVID-19 have not been fully documented.MethodsPatients invasively ventilated for at least 48 h from the prospective multicentre COVID-ICU database were included in the analyses. Cause-specific Cox regression models were used to determine factors associated with the occurrence of VAP. Cox-regression multivariable models were used to determine VAP prognosis. Risk factors and the prognostic impact of early vs. late VAP, and Pseudomonas-related vs. non-Pseudomonas-related VAP were also determined.Main findings3388 patients were analysed (63 [55-70] years, 75.8% males). VAP occurred in 1523/3388 (45.5%) patients after 7 [5-9] days of ventilation. Identified bacteria were mainly Enterobacteriaceae followed by Staphylococcus aureus and Pseudomonas aeruginosa. VAP risk factors were male gender (Hazard Ratio (HR) 1.26, 95% Confidence Interval [1.09-1.46]), concomitant bacterial pneumonia at ICU admission (HR 1.36 [1.10-1.67]), PaO2/FiO2 ratio at intubation (HR 0.99 [0.98-0.99] per 10 mmHg increase), neuromuscular-blocking agents (HR 0.89 [0.76-0.998]), and corticosteroids (HR 1.27 [1.09-1.47]). VAP was associated with 90-mortality (HR 1.34 [1.16-1.55]), predominantly due to late VAP (HR 1.51 [1.26-1.81]). The impact of Pseudomonas-related and non-Pseudomonas-related VAP on mortality was similar.ConclusionVAP affected almost half of mechanically ventilated COVID-19 patients. Several risk factors have been identified, among which modifiable risk factors deserve further investigation. VAP had a specific negative impact on 90-day mortality, particularly when it occurred between the end of the first week and the third week of ventilation.
| S-EPMC9731925 | biostudies-literature
Project description:BackgroundEffective approaches to practice improvement require development of tailored interventions in collaboration with knowledge users.ObjectivesTo explore critical care nurses' knowledge and adherence to best practice guidelines for management of patients with an artificial airway to minimise development of ventilator-associated pneumonia.MethodsA cross-sectional study was undertaken across four intensive care units that involved three phases: (1) survey of critical care nurses regarding their current practice; (2) observation of respiratory care delivery; and (3) chart audit. Key care processes evaluated were: (1) technique and adherence to standard precautions when performing endotracheal suction, cuff pressure checks and extubation; and (2) frequency of endotracheal suctioning and mouth care.ResultsObservational and chart audit data on the provision and documentation of respiratory care were collected for 36 nurse/patient dyads. Forty-six nurses were surveyed and the majority responded that endotracheal suctioning and mouth care should be performed 'as required' or every 2 hours (h). During observations of practice, no patient received mouth care every 2 h, nor had documentation of such. Inconsistent adherence to standard precautions and hand hygiene during respiratory care provision was observed. Chart audit indicated that nurses varied in the frequency of suctioning consistent with documented clinical assessment findings.ConclusionAlthough nurses had good knowledge for the management of artificial airways, this was not consistently translated into practice. Gaps were identified in relation to respiratory related infection prevention, the prevention of micro-aspiration of oropharyngeal secretions and in the provision of mouth care.
| S-EPMC7328504 | biostudies-literature
Project description: Not available
| S-EPMC8111488 | biostudies-literature
Project description:BackgroundVentilator-associated pneumonia (VAP) is an important diagnosis in critical care. VAP research is complicated by the lack of agreed diagnostic criteria and reference standard test criteria. Our aim was to review which reference standard tests are used to evaluate novel index tests for suspected VAP.MethodsWe conducted a comprehensive search using electronic databases and hand reference checks. The Cochrane Library, MEDLINE, CINHAL, EMBASE, and web of science were searched from 2008 until November 2018. All terms related to VAP diagnostics in the intensive treatment unit were used to conduct the search. We adopted a checklist from the critical appraisal skills programme checklist for diagnostic studies to assess the quality of the included studies.ResultsWe identified 2441 records, of which 178 were selected for full-text review. Following methodological examination and quality assessment, 44 studies were included in narrative data synthesis. Thirty-two (72.7%) studies utilised a sole microbiological reference standard; the remaining 12 studies utilised a composite reference standard, nine of which included a mandatory microbiological criterion. Histopathological criteria were optional in four studies but mandatory in none.ConclusionsNearly all reference standards for VAP used in diagnostic test research required some microbiological confirmation of infection, with BAL culture being the most common reference standard used.
| S-EPMC8189711 | biostudies-literature
Project description:Ventilator-associated pneumonia (VAP) is a prevalent and costly nosocomial infection related to instrumentation of the airway with an endotracheal tube (ETT), enabling microaspiration of contaminated secretions. Modification of the ETT design to reduce microaspiration and/or biofilm formation may play an important role in VAP prevention. However, there is insufficient evidence to provide strong recommendations regarding the use of modified ETT and unaddressed safety concerns.We performed a pilot randomized controlled trial comparing two modified ETTs designed specifically to prevent VAP, with the standard ETT, to test the feasibility of and inform planning for a large, pivotal, randomized trial.This study was conducted with institutional review board approval under exception from informed consent. We randomized in a blinded fashion patients undergoing emergency endotracheal intubation both out of and in hospital to receive one of three different ETT types: (1) a polyurethane-cuffed tube (PUC-ETT), (2) a polyurethane-cuffed tube equipped with a port for continuous aspiration of subglottic secretions (PUC-CASS-ETT), or a (3) standard polyvinylchloride-cuffed tube (PVC-ETT). In addition to investigating feasibility and safety, the study coprimary end points were tracheal bacterial colonization reaching a cfu count >10(6) cfu per milliliter and the incidence of invasively diagnosed VAP.A total of 102 subjects were randomized and met the eligibility criteria. Randomization procedures performed well and integrity of blinding at randomization was maintained. The majority of intubations occurred in the hospital setting (n?=?77), and the remainder occurred out of hospital (n?=?25). Compared with the PVC-ETT, there were no significant differences in tracheal colonization for PUC-ETT (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.31-3.09) or for PUC-CASS-ETT (OR, 1.26; 95% CI, 0.42-3.76). There were no differences in the risk of invasively diagnosed VAP (OR, 1.14; 95% CI, 0.21-6.08 for PUC-ETT; OR, 1.47; 95% CI, 0.30-7.10 for PUC-CASS-ETT), or of clinically diagnosed VAP by either clinical signs or chest radiograph criteria. We did not observe unexpected or serious adverse events related to the devices.A randomized trial of ETTs inserted during emergency intubation for the prevention of VAP is feasible and did not appear to carry heightened safety concerns. These preliminary data did not suggest different patterns of tracheal colonization or occurrence of VAP among the study groups. Clinical trial registered with www.clinicaltrials.gov (NCT01744483).
| S-EPMC4722846 | biostudies-literature
Project description:BackgroundThe endotracheal tube (ETT) is an essential medical device to secure the airway patency in patients undergoing mechanical ventilation or general anesthesia. However, long-term intubation eventually leads to complete occlusion, ETTs potentiate biofilm-related infections, such as ventilator-associated pneumonia. ETTs are mainly composed of medical polyvinyl chloride (PVC), which adheres to microorganisms to form biofilms. Thus, a simple and efficient method was developed to fabricate CS-AgNPs@PAAm-Gelatin nanocomposite coating to achieve dual antibacterial and antifouling effects.ResultsThe PAAm-Gelatin (PAAm = polyacrylamide) molecular chain gel has an interpenetrating network with a good hydrophilicity and formed strong covalent bonds with PVC-ETTs, wherein silver nanoparticles were used as antibacterial agents. The CS-AgNPs@PAAm-Gelatin coating showed great resistance and antibacterial effects against Staphylococcus aureus and Pseudomonas aeruginosa. Its antifouling ability was tested using cell, protein, and platelet adhesion assays. Additionally, both properties were comprehensively evaluated using an artificial broncho-lung model in vitro and a porcine mechanical ventilation model in vivo. These remarkable results were further confirmed that the CS-AgNPs@PAAm-Gelatin coating exhibited an excellent antibacterial capacity, an excellent stain resistance, and a good biocompatibility.ConclusionsThe CS-AgNPs@PAAm-Gelatin nanocomposite coating effectively prevents the occlusion and biofilm-related infection of PVC-ETTs by enhancing the antibacterial and antifouling properties, and so has great potential for future clinical applications.
| S-EPMC8897767 | biostudies-literature
Project description:Ventilator-associated pneumonia occurs in patients who have been intubated for at least 2–3 days with significant exposure to hospital-acquired organisms. Treatment should be initiated rapidly and cover Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumonia, and methicillin-resistant Staphylococcus aureus(MRSA). Within 72 h or with the availability of culture results, antibiotics should be narrowed. Active research is on-going to identify patients at risk for ventilator-associated complications and to minimize the likelihood of infection in these patients.
| S-EPMC7120513 | biostudies-literature