Accurately Measuring Preventable Ventilator-associated Pneumonia Deaths Using Observational Data: It's about Time.
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ABSTRACT:
SUBMITTER: Albin OR
PROVIDER: S-EPMC8086539 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Ventilator-associated pneumonia (VAP) remains a challenge to intensive care units, with secure diagnosis relying on microbiological cultures that take up to 72 hours to provide a result. We sought to derive and validate a novel, real-time 16S rRNA gene PCR for rapid exclusion of VAP. Bronchoalveolar lavage (BAL) was obtained from two independent cohorts of patients with suspected VAP. Patients were recruited in a 2-centre derivation cohort and a 12-centre confirmation cohort. Confirmed VAP was defined as growth of >104 colony forming units/ml on semiquantitative culture and compared with a 16S PCR assay. Samples were tested from 67 patients in the derivation cohort, 10 (15%) of whom had confirmed VAP. Using cycles to cross threshold (Ct) values as the result of the 16S PCR test, the area under the receiver operating characteristic (ROC) curve (AUROC) was 0.94 (95% CI 0.86 to 1.0, p<0.0001). Samples from 92 patients were available from the confirmation cohort, 26 (28%) of whom had confirmed VAP. The AUROC for Ct in this cohort was 0.89 (95% CI 0.83 to 0.95, p<0.0001). This study has derived and assessed the diagnostic accuracy of a novel application for 16S PCR. This suggests that 16S PCR in BAL could be used as a rapid test in suspected VAP and may allow better stewardship of antibiotics.VAPRAPID trial ref NCT01972425.
| S-EPMC5738539 | biostudies-literature
Project description:ObjectivesCritical care teams are encouraged to follow best practice protocols to help wean mechanically ventilated patients from the ventilator to reduce ventilator-associated events including ventilator-associated conditions, probable ventilator-associated pneumonias, and infection-related ventilator-associated conditions. Providers monitor for alerts suggestive of possible ventilator-associated events and advise when patients should undergo spontaneous breathing trials. Compliance with protocols in most units is suboptimal.DesignRetrospective review of clinical data over 24 months.SettingSt. Joseph Mercy Hospital Candler Hospital Medical-Surgical ICU.PatientsAll mechanically ventilated patients.InterventionsThe Respiratory Knowledge Portal was implemented in our ICU. For 13 months, Respiratory Knowledge Portal data were ported to ICU workstations (control). For the following 11 months, Respiratory Knowledge Portal data were also presented on tablet computers (intervention) for use during multidisciplinary rounds. We performed a retrospective review of Respiratory Knowledge Portal data from before and after the implementation of the tablet computers.Measurements and main resultsData were collected from 337 patients (187 control group, 150 intervention group). A decrease in the occurrence of ventilator-associated events was observed during the intervention group compared with the control group. Only 2.0% of patients in the intervention group experienced any category of ventilator-associated event, while 11.2% of patients in the control group experienced one event (p = 0.003). Intervention patients experienced less ventilator-associated conditions (p = 0.002), infection-related ventilator-associated conditions (p = 0.026), and probable ventilator-associated pneumonias (p = 0.036) than control patients. Twenty-one of the 24 patients with any ventilator-associated events were in the control group. There was no significant difference between the days spent on ventilation nor hospital length of stay in the control compared with intervention group patients.ConclusionsFewer ventilator-associated events, ventilator-associated conditions, infection-related ventilator-associated conditions, and probable ventilator-associated pneumonias were seen during the period when Respiratory Knowledge Portal monitoring data was presented on tablet computers. There was no difference in time on ventilator nor overall length of stay.
| S-EPMC8021382 | 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
Project description:Ventilator-associated pneumonia is the most common infection in intensive care unit patients associated with high morbidity rates and elevated economic costs; Pseudomonas aeruginosa is one of the most frequent bacteria linked with this entity, with a high attributable mortality despite adequate treatment that is increased in the presence of multiresistant strains, a situation that is becoming more common in intensive care units. In this manuscript, we review the current management of ventilator-associated pneumonia due to P. aeruginosa, the most recent antipseudomonal agents, and new adjunctive therapies that are shifting the way we treat these infections. We support early initiation of broad-spectrum antipseudomonal antibiotics in present, followed by culture-guided monotherapy de-escalation when susceptibilities are available. Future management should be directed at blocking virulence; the role of alternative strategies such as new antibiotics, nebulized treatments, and vaccines is promising.
| S-EPMC4725638 | biostudies-other
Project description:BackgroundStrong evidence suggests a correlation between pharmacodynamics (PD) index and antibiotic efficacy while dose adjustment should be considered in critically ill patients due to modified pharmacokinetic (PK) parameters and/or higher minimum inhibitory concentrations (MICs). This study aimed to assess pharmacodynamic (PD) target attainment considering both antibiotics serum concentrations and measured MICs in these patients.MethodA multicentric prospective open-label trial conducted in 11 French ICUs involved patients with Gram-negative bacilli (GNB) ventilator-associated pneumonia (VAP) confirmed by quantitative cultures.ResultsWe included 117 patients. Causative GNBs were P. aeruginosa (40%), Enterobacter spp. (23%), E. coli (20%), and Klebsiella spp. (16%). Hence, 117 (100%) patients received β-lactams, 65 (58%) aminoglycosides, and two (1.5%) fluoroquinolones. For β-lactams, 83% of the patients achieved a Cmin/MIC > 1 and 70% had a Cmin/MIC > 4. In the case of high creatinine clearance (CrCL > 100 mL/min/1.73 m2), 70.4% of the patients achieved a Cmin/MIC ratio > 1 versus 91% otherwise (p = 0.041), and 52% achieved a Cmin/MIC ratio > 4 versus 81% (p = 0.018). For aminoglycosides, 94% of the patients had a Cmax/MIC ratio > 8. Neither β-lactams nor aminoglycosides PK/PD parameters were associated clinical outcomes, but our data suggest a correlation between β-lactams Cmin/MIC and microbiological success.ConclusionIn our ICU patients treated for GNB VAP, using recommended antibiotic dosage led in most cases to PK/PD targets attainment for aminoglycosides and β-lactams. High creatinine clearance should encourage clinicians to focus on PK/PD issues.
| S-EPMC9686941 | biostudies-literature
Project description:Ventilator-associated pneumonia (VAP) is the most frequent life-threatening nosocomial infection in intensive care units. The diagnostic is difficult because radiological and clinical signs are inaccurate and could be associated with various respiratory diseases. The concept of infection-related ventilator-associated complication has been proposed as a surrogate of VAP to be used as a benchmark indicator of quality of care. Indeed, bundles of prevention measures are effective in decreasing the VAP rate. In case of VAP suspicion, respiratory secretions must be collected for bacteriological secretions before any new antimicrobials. Quantitative distal bacteriological exams may be preferable for a more reliable diagnosis and therefore a more appropriate use antimicrobials. To improve the prognosis, the treatment should be adequate as soon as possible but should avoid unnecessary broad-spectrum antimicrobials to limit antibiotic selection pressure. For empiric treatments, the selection of antimicrobials should consider the local prevalence of microorganisms along with their associated susceptibility profiles. Critically ill patients require high dosages of antimicrobials and more specifically continuous or prolonged infusions for beta-lactams. After patient stabilization, antimicrobials should be maintained for 7-8 days. The evaluation of VAP treatment based on 28-day mortality is being challenged by regulatory agencies, which are working on alternative surrogate endpoints and on trial design optimization.
| S-EPMC5710313 | biostudies-literature
Project description:Ventilator-associated pneumonia, broadly defined as pneumonia that develops after 48 hours of intubation, is a common mechanical ventilation complication that causes significant morbidity and mortality in critically ill patients. Prevention strategies are continually evolving to decrease the impact of this serious and costly disease.
| S-EPMC2948395 | biostudies-other
Project description: Not available
| S-EPMC4283465 | biostudies-literature
Project description:AbstractVentilator-associated pneumonia (VAP) is the most common and fatal nosocomial infection in intensive care units (ICUs). Existing methods for identifying VAP display low accuracy, and their use may delay antimicrobial therapy. VAP diagnostics derived from machine learning (ML) methods that utilize electronic health record (EHR) data have not yet been explored. The objective of this study is to compare the performance of a variety of ML models trained to predict whether VAP will be diagnosed during the patient stay.A retrospective study examined data from 6126 adult ICU encounters lasting at least 48 hours following the initiation of mechanical ventilation. The gold standard was the presence of a diagnostic code for VAP. Five different ML models were trained to predict VAP 48 hours after initiation of mechanical ventilation. Model performance was evaluated with regard to the area under the receiver operating characteristic (AUROC) curve on a 20% hold-out test set. Feature importance was measured in terms of Shapley values.The highest performing model achieved an AUROC value of 0.854. The most important features for the best-performing model were the length of time on mechanical ventilation, the presence of antibiotics, sputum test frequency, and the most recent Glasgow Coma Scale assessment.Supervised ML using patient EHR data is promising for VAP diagnosis and warrants further validation. This tool has the potential to aid the timely diagnosis of VAP.
| S-EPMC8202554 | biostudies-literature
Project description:Public health encompasses a broad array of programs designed to prevent the occurrence of disease and injury within communities. But policy makers have little evidence to draw on when determining the value of investments in these program activities, which currently account for less than 5 percent of US health spending. We examine whether changes in spending by local public health agencies over a thirteen-year period contributed to changes in rates of community mortality from preventable causes of death, including infant mortality and deaths due to cardiovascular disease, diabetes, and cancer. We found that mortality rates fell between 1.1 percent and 6.9 percent for each 10 percent increase in local public health spending. These results suggest that increased public health investments can produce measurable improvements in health, especially in low-resource communities. However, more money by itself is unlikely to generate significant and sustainable health gains; improvements in public health practices are needed as well.
| S-EPMC4019932 | biostudies-literature