Search

2023 Acuerdos transformativos CRUE. Versión en línea del registro antes de su inclusión en un número, Objective: To design, develop and validate a new tool, called NEUMOBACT, to evalu-ate critical care nurses' knowledge and skills in ventilator-associated pneumonia (VAP) and catheter- related bacteraemia (CRB) prevention through simulation scenarios in-volving central venous catheter (CVC), endotracheal suctioning (ETS) and mechani-cally ventilated patient care (PC) stations.Background: Simulation- based training is an excellent way for nurses to learn preven-tion measures in VAP and CRB.Design: Descriptive metric study to develop NEUMOBACT and analyse its content and face validity that followed the COSMIN Study Design checklist for patient- reported outcome measurement instruments.Methods: The first version was developed with the content of training modules in use at the time (NEUMOBACT-1). Delphi rounds were used to assess item relevance with experts in VAP and CRB prevention measures, resulting in NEUMOBACT-2. Experts in simulation methods then assessed feasibility, resulting in NEUMOBACT-3. Finally, a pilot test was conducted among 30 intensive care unit (ICU) nurses to assess the applicability of the evaluation tool in clinical practice.Results: Seven national experts in VAP and CRB prevention and seven national simula-tion experts participated in the analysis to assess the relevance and feasibility of each item, respectively. After two Delphi rounds with infection experts, four Delphi rounds with simulation experts, and pilot testing with 30 ICU nurses, the NEUMOBACT- FINAL tool consisted of 17, 26 and 21 items, respectively, for CVC, ETS and PC.Conclusion: NEUMOBACT-FINAL is useful and valid for assessing ICU nurses' knowl-edge and skills in VAP and CRB prevention, acquired through simulation. Relevance for Clinical Practice: Our validated and clinically tested tool could facilitate the transfer of ICU nurses' knowledge and skills learning in VAP and CRB prevention to critically ill patients, decreasing infection rates and, therefore, improving patient safety, Sociedad Española de Simulación Clínica y Seguridad del Paciente (SESSEP), Depto. de Enfermería, Fac. de Enfermería, Fisioterapia y Podología, TRUE, pub, APC financiada por la UCM

Background: The effect of the Coronavirus Disease 2019 (COVID-19) pandemic on gram-negative bacteria nonsusceptibility to antibiotics is unclear. Methods: Between January 1, 2010, and December 31, 2021, the respiratory samples of intensive care unit patients at 3 University Hospitals in Brussels were retrieved. Based on the nonsusceptibility to antimicrobial classes, drug-resistance patterns were defined as multi-drug-resistant, extensively drug-resistant, and pan-drug-resistant. The study time frame was divided into 6 periods of 2 years each, and the impact of the COVID-19 pandemic (last period: 2020-2021) was assessed. Results: During the current study, 10,577 samples were identified from 5,889 patients. While a significant augmentation of multi-drug-resistant isolates was noticed once comparing 2 prepandemic periods (2012-2013 and 2014-2015), all 3 patterns of nonsusceptibility significantly increased, comparing the years before and throughout the COVID-19 pandemic (2018-2019 and 2020-2021). Globally, the greatest increase in antimicrobial nonsusceptibility, comparing the last 2 periods, was reported for piperacillin-tazobactam (from 28% to 38%). Pseudomonas aeruginosa was the most isolated species, and the most involved in the appearance of resistance, with an augmentation of nonsusceptibility percentage to meropenem of 22% (from 25% to 47%), between the prepandemic and the pandemic periods. Conclusions: The COVID-19 pandemic was associated with increasing trends of antimicrobial resistance in respiratory samples of patients admitted to the intensive care units in university hospitals with well-implemented antibiotic stewardship programs., SCOPUS: ar.j, info:eu-repo/semantics/published

Background: To examine the incidence, characteristics and outcomes of community-acquired pneumonia (CAP), ventilator-associated pneumonia (VAP) and nonventilator hospital-acquired pneumonia (NV-HAP) in patients with or without COPD; compare in-hospital outcomes; and identify factors associated with in-hospital mortality (IHM) for pneumonia. Methods: We carried out a retrospective observational study using the hospital discharge records from 2016-17 of the Spanish National Health System. Propensity score matching was used for data analysis. Results: We found 245,905 patients (≥40 years) with pneumonia; we identified CAP in 228,139 patients (19.85% with COPD), VAP in 2,771 patients (8.55% with COPD) and NV-HAP in 14,995 patients (14.17% with COPD). The incidence for the three types of pneumonia was higher in COPD patients (CAP: incidence rate ratio (IRR) 2.23, 95% CI 2.21-2.26; VAP: IRR 1.25, 95% CI 1.08-1.42; and NV-HAP: IRR 1.55, 95% CI 1.48-1.63). The IHM for CAP was 10.35% in COPD patients and 12.91% in the controls (p<0.001). In patients with VAP and NV HAP, IHM was not significantly different between those with and without COPD (43.88% vs. 41.77%;p=0.643 and 29.21% vs. 30.57%;p=0.331, respectively). Factors associated with IHM for all types of pneumonia ana lyzed in COPD patients were older age and receiving dialysis. Conclusions: The incidence of hospitalizations for all types of pneumonia was significantly higher in COPD patients than in the non-COPD population. In contrast, IHM was significantly lower among COPD patients with CAP than among matched non-COPD patients. Higher mortality rates in COPD patients with any pneumonia type were associated with increasing age and receiving dialysis., Sociedad Española de Neumología y Cirugía Torácica, Sociedad Madrileña de Neumología y Cirugía de Tórax, Instituto de Salud Carlos III, Fondo Europeo de Desarrollo Regional, Depto. de Medicina, Fac. de Medicina, TRUE, pub

Introduction: Because the risk of health-care associated infections (HAIs) is high in intensive care units, and HAIs are one of the causes of morbidity and mortality and affects the overall quality of health care, the continuous monitoring of HAIs in intensive care patients is essential.Aim and objectives: This descriptive cross-sectional study was carried out over a period of five years in a tertiary-care teaching hospital. The aim of the study was to investigate the main and specific types of health-care associated Infections and determine the microbiological profile and antimicrobial susceptibility rates of isolates in patients with HAI.Methods : The active surveillance method was used to detect HAIs in patients who spent over 48 hr in a targeted ICU. Patients with blood stream infections (BSI), central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infections (CAUTI) and ventilator-associated events (VAE) were included in the study. HAI were diagnosed based on the Centre for Disease Control (CDC)'s National Healthcare Safety Network (NHSN) updated definitions of HAIs.Results: A total of 121,051 patient days, including 7,989 central line days, 64,557 urinary catheter days, and 18,443 ventilator days, were recorded in the study population and 832 HAIs were diagnosed (incidence rate 6.9%). The overall rates of BSI, CLABSI, CAUTI and possible ventilator-associated pneumonia (p-VAP) were 3.7, 10.6, 2.1 and 13.4/1,000 device days, respectively. The most common organism isolated from BSI was Acinetobacter baumanii (n=322, 29%), followed by Klebsiella pneumoniae 225 (n=225, 20.3%). 79.8% of Acinetobacter baumanii strains were resistant to imipenem, 77.1% to ciprofloxacin and 76.4% to ampicillin. The most common organisms isolated from CAUTI were non-albicans Candida species (n=38, 18%), followed by E. coli and Citrobacter spp. (each n=33, each 15.7%). Conclusions: A trend of increasing resistance of Acinetobacter baumannii to carbapene, Einleitung: Weil die Gefährdung durch Health-care assoziierte Infektionen (HAI) in Intensivtherapieeinheiten besonders hoch ist, HAI eine wesentliche Ursache für Morbidität und Letalität sind und die Gesamtqualität der Gesundheitsversorgung durch HAI beeinträchtigt wird, ist ein kontinuierliches Monitoring von HAI bei Intensivtherapiepatienten unerlässlich.Zielsetzung: Die deskriptive Querschnittsstudie wurde über einen Zeitraum von fünf Jahren in einem Lehrkrankenhaus der Tertiärversorgung durchgeführt. Ziel war es, die wichtigsten und spezifischen Arten von HAI zu untersuchen sowie das mikrobiologische Profil und die Antibiotikaempfindlichkeit der Isolate zu bestimmen.Methode: Es wurde die Methode der aktiven Surveillance eingesetzt, um HAI bei Patienten zu erkennen, die mehr als 48 h auf den Intensivstationen untergebracht waren. In die Studie wurden Patienten mit Blutstrominfektionen (BSI), ZVK-assoziierten Infektionen (CLABSI), Katheter-assoziierten Harnweginfektionen (CAUTI) und Beatmungsassoziierte Pneumonien (VAP) aufgenommen. Die HAI wurden auf der Grundlage der aktuellen Definitionen für HAI des National Healthcare Safety Network (NHSN) des Centers for Disease Control (CDC) diagnostiziert.Ergebnisse: Es wurden 121.051 Patiententage, 7.989 Zentralvenenkathetertage, 64.557 Harnkathetertage, 18.443 Beatmungstage erfasst und 832 HAI diagnostiziert (Inzidenzrate 6,9%). Die Gesamtraten von BSI, CLABSI, CAUTI und möglicher VAP betrugen 3,7, 10,6, 2,1 bzw. 13,4/1.000 Devicetage. Die am häufigsten bei Blutstrominfektionen isolierte Species war Acinetobacter baumanii (n=322, 29 %), gefolgt von Klebsiella pneumoniae (n=225, 20,3%). 79,8% der Acinetobacter baumani i Stämme waren gegen Imipenem, 77,1% gegen Ciprofloxacin und 76,4% gegen Ampicillin resistent. Die häufigsten Mikroorganismen, die bei CAUTI isoliert wurden, waren non-albicans Candida- Spezies (n=38; 18%), gefolgt von E. coli und Citrobacter spp. (je n=33; je15,7%).Schlussfolgerung: Es wurde ein Trend zur z

Bakgrund: Ventilator associerad pneumoni (VAP) är ett medicinskt tillstånd som innebär allvarliga konsekvenser för den drabbade intensivvårdspatienten, i form av hotad livskvalité och överhängande risk för morbiditet och mortalitet. Direkta konsekvenser såsom till exempel förlängd vårdtid innebär större kostnader för sjukvården och samhället därav är det av vikt att implementera effektiva interventioner som skulle kunna minska incidensen av VAP. Syfte: Syftet var att beskriva preventiva åtgärder för ventilatorassocierad pneumoni, VAP, utifrån senaste 5 årens forskning. Metod: 2018–2023. Systematisk litteraturstudie av randomiserade kontroll studier (RCT engelska förkortningen) datainsamlingen genomfördes i databaserna CINAHL och PubMed, åtta studier inkluderades efter kvalitetsgranskningen. Resultat: tre av åtta publicerade artiklar visade interventioner med statistisk signifikant minskning av VAP incidens. Effektiva interventioner visades vara vinkeln av huvudändan, (optimal vinkel 45 grader, 20% versus 55%, p= 0,022), munvård med klorhexidin 34,5% versus 60,7% %, p= 0,043 och probiotikans 26,9 % versus 60% p= 0,03 utifrån effekt på incidensen av VAP. Konklusion: Underlaget i litteraturstudien är för otillräckligt, för att dra några konkreta slutsatser. Mer forskning behövs för att konkludera om probiotika, eller höjd huvudända kan vara en effektiv intervention mot VAP, Klorhexidin däremot, används redan frekvent inom vården.

[Resumen] Introducción: La NAVM es una infección del parénquima pulmonar que se adquiere en el medio hospitalario y se desarrolla en pacientes que precisan soporte ventilatorio. En las UCI su prevalencia es mayor. Dada la importancia de prevención, es necesario disponer de una guía de cuidados actualizada que recoja las mejores prácticas con el objetivo de unificar las actuaciones. Objetivos: Realizar una revisión bibliográfica de la más reciente evidencia científica sobre prevención de neumonía asociada a ventilación mecánica en pacientes críticos. Metodología: A partir de la pregunta de investigación se realizó una búsqueda bibliográfica en las bases de datos MEDLINE vía PUBMED, LILACS, CINAHL y SCOPUS y en otros recursos electrónicos como SCIELO. Se obtuvieron siete artículos válidos para la realización de este trabajo. Discusión: Según los objetivos marcados en este trabajo se procedió a realizar la comparación entre las actividades preventivas incluidas en cada estudio, la incidencia de NAVM resultado de las actuaciones y las propuestas innovadoras. Conclusiones: Dada la eficacia del uso de una guía de cuidados preventivos para la NAVM, se confirma la necesidad de basar las actuaciones enfermeras en un protocolo que incorpore las mejores prácticas y se mantenga actualizado mediante revisiones periódicas., [Resumo] Introdución: A PAV é unha infección do parénquima pulmonar que se adquire no medio hospitalario e se desenvolve en pacientes que precisan soporte ventilatorio. Nas UCI a súa prevalencia é maior. Dada a importancia de prevención, é necesario dispoñer dunha guía de coidados actualizada que recolla as mellores prácticas co obxectivo de unificar as actuacións. Obxectivos: Realizar unha revisión bibliográfica das máis recentes evidencias científicas sobre prevención da pneumonía asociada a ventilación mecánica en pacientes críticos. Metodoloxía: A partir da pregunta de investigación, realizouse unha busca bibliográfica nas bases de datos MEDLINE vía PUBMED, LILACS, CINAHL y SCOPUS e noutros recursos electrónicos como SCIELO. Obtivéronse sete artigos válidos para a realización deste traballo. Discusión: Segundo os obxectivos marcados neste traballo fin de grao procedeuse a realizar a comparación entre as actividades preventivas incluídas en cada estudo, a incidencia de NAVM resultado das actuacións e as propostas innovadoras. Conclusións: Dada a eficacia do uso dunha guía de coidados preventivos para a PAV, confírmase a necesidade de basear as actuacións enfermeiras nun protocolo que incorpore as mellores prácticas e se manteña ctualizado mediante revisións periódicas., [Abstract] Introduction: VAP is a lung parenchymal infection that is acquired in the hospital environment, and it is developed in patients who require ventilatory support. Its prevalence is higher in the ICU. Given the importance of prevention, it is necessary to have an updated care guide that includes the best practices in order to unify actions. Objectives: Carry out a bibliographic review of the most recent scientific evidence on prevention of ventilator-associated pneumonia in critically ill patients. Methodology: Based on the research question, a bibliographic search was performed in MEDLINE via PUBMED, LILACS, CINAHL and SCOPUS databases, also, in other electronic resources such as SCIELO. Seven valid articles were obtained for this study. Discussion: According to the objectives set in this work, a comparison was made between the preventive activities included in each study, the incidence of VAP resulting from the actions and the innovative proposals. Conclusion: Given the efficacy of the use of a preventive care guideline for VAP, the need of basing nursing actions on a protocol that incorporates the best practices and is also kept up to date through periodic reviews is confirmed.

Objectives: To compare intensivist-diagnosed ventilator-associated pneumonia (iVAP) with four established definitions, assessing their agreement in detecting new episodes. Methods: A multi-centric prospective study on pulmonary microbiota was carried out in patients requiring mechanical ventilation (MV). Data collected were used to compare hypothetical VAP onset according to iVAP with the study consensus criteria, the European Centre for Disease Control and Prevention definition, and two versions of the latter adjusted for leukocyte count and fever. Results: In our cohort of 186 adult patients, iVAPs were 36.6% (68/186, 95% confidence interval 30.0–44.0%), with an incidence rate of 4.64/100 patient-MV-days, and median MV-day at diagnosis of 6. Forty-seven percent of patients (87/186) were identified as VAP by at least one criterion, with a median MV-day at diagnosis of 5. Agreement between intensivist judgement (iVAP/no-iVAP) and the criteria was highest for the study consensus criteria (50/87, 57.4%), but still one-third of iVAP were not identified and 9% of patients were identified as VAP contrary to intensivist diagnosis. VAP proportion differed between criteria (25.2–30.1%). Conclusions: Caution is needed when evaluating studies describing VAP incidence. Pre-agreed criteria and definitions that capture VAP's evolving nature provide greater consistency, but new clinically driven definitions are needed to align surveillance and diagnostic criteria with clinical practice.

(1) Background: Colistin-only susceptible (COS) Acinetobacter baumannii (AB) ventilator-associated pneumonia (VAP) represents a clinical challenge in the Intensive Care Unit (ICU) due to the negligible lung diffusion of this molecule and the low-grade evidence on efficacy of its nebulization. (2) Methods: We conducted a prospective observational study on 134 ICU patients with COS-AB VAP to describe the 'real life' clinical use of high-dose (5 MIU q8) aerosolized colistin, using a vibrating mesh nebulizer. Lung pharmacokinetics and microbiome features were investigated. (3) Results: Patients were enrolled during the COVID-19 pandemic with the ICU presenting a SAPS II of 42 [32-57]. At VAP diagnosis, the median PaO2/FiO(2) was 120 [100-164], 40.3% were in septic shock, and 24.6% had secondary bacteremia. The twenty-eight day mortality was 50.7% with 60.4% and 40.3% rates of clinical cure and microbiological eradication, respectively. We did not observe any drug-related adverse events. Epithelial lining fluid colistin concentrations were far above the CRAB minimal-inhibitory concentration and the duration of nebulized therapy was an independent predictor of microbiological eradication (12 [9.75-14] vs. 7 [4-13] days, OR (95% CI): 1.069 (1.003-1.138), p = 0.039). (4) Conclusions: High-dose and prolonged colistin nebulization, using a vibrating mesh, was a safe adjunctive therapeutic strategy for COS-AB VAP. Its right place and efficacy in this setting warrant investigation in interventional studies.

Background: The role of upper airways microbiota and its association with ventilator-associated pneumonia (VAP) development in mechanically ventilated (MV) patients is unclear. Taking advantage of data collected in a prospective study aimed to assess the composition and over-time variation of upper airway microbiota in patients MV for non-pulmonary reasons, we describe upper airway microbiota characteristics among VAP and NO-VAP patients. Methods: Exploratory analysis of data collected in a prospective observational study on patients intubated for non-pulmonary conditions. Microbiota analysis (trough 16S-rRNA gene profiling) was performed on endotracheal aspirates (at intubation, T0, and after 72 h, T3) of patients with VAP (cases cohort) and a subgroup of NO-VAP patients (control cohort, matched according to total intubation time). Results: Samples from 13 VAP patients and 22 NO-VAP matched controls were analyzed. At intubation (T0), patients with VAP revealed a significantly lower microbial complexity of the microbiota of the upper airways compared to NO-VAP controls (alpha diversity index of 84 ± 37 and 160 ± 102, in VAP and NO_VAP group, respectively, p-value < 0.012). Furthermore, an overall decrease in microbial diversity was observed in both groups at T3 as compared to T0. At T3, a loss of some genera (Prevotella 7, Fusobacterium, Neisseria, Escherichia–Shigella and Haemophilus) was found in VAP patients. In contrast, eight genera belonging to the Bacteroidetes, Firmicutes and Fusobacteria phyla was predominant in this group. However, it is unclear whether VAP caused dysbiosis or dysbiosis caused VAP. Conclusions: In a small sample size of intubated patients, microbial diversity at intubation was less in patients with VAP compared to patients without VAP.

Ventilator-associated pneumonia remains commonplace in critically ill patients and is associated with an increased morbidity and mortality. Multidrug-resistant Gram-negative bacillary pathogens, such as Pseudomonas aeruginosa, are commonly implicated in the pathogenesis of ventilator-associated pneumonia. Increasing rates of antibiotic resistance have led to increasing interest in repurposing old antibiotics with alternative administration methods and the development of new antibiotics that have activity against these multidrug-resistant isolates. Moreover, ensuring that the optimal dose is used is of paramount importance to improve patient outcomes and prevent resistance emergence to these novel antibiotic therapies. Amikacin, an aminoglycoside antibiotic, is of interest in the management of ventilator-associated pneumonia given that it retains activity in up to 70% of multi-drug resistant P. aeruginosa isolates. However, amikacin penetrates poorly into the infection site in patients with ventilator-associated pneumonia, resulting in subtherapeutic exposures when administered intravenously. Therefore, there has been renewed interest in dosing for innovative administration methods, such as inhaled dosing for direct drug delivery to the site of infection. Alternatively, new agents such as ceftolozane/tazobactam, have been developed and are increasingly used clinically, particularly for multidrug-resistant P. aeruginosa. However, a paucity of pharmacodynamic studies exist to assist clinicians with prescribing a dose that both increases the probability of treatment success and minimises the emergence of resistance. Therefore, the primary aims of this thesis are to describe the infection site pharmacodynamics of amikacin and ceftolozane/tazobactam against P. aeruginosa, to determine the likely dosing strategies for both agents that will achieve maximal bacterial killing and minimise the risk of resistance emerging. A series of in vitro studies and in silico simulations, Thesis (PhD Doctorate), Doctor of Philosophy (PhD), School of Medicine & Dentistry, Griffith Health, Full Text

Background: Acute brain injured (ABI) patients are at high risk of developing ventilator-associated pneumonia (VAP). However, incidence, risk factors and effects on outcome of VAP are not completely elucidated in this population. The primary aim of this study was to determine the incidence of VAP in a cohort of ABI patients. The secondary objectives included the identification of risk factors for development of VAP, and the impact of VAP on clinical outcomes. Clinical outcomes were defined as intensive care unit length of stay (ICU-LOS), duration of invasive mechanical ventilation (IMV), and ICU mortality. Methods: Pre-planned sub-analysis of the Extubation strategies in Neuro-Intensive care unit (ICU) patients and associations with Outcomes (ENIO) international multi-center prospective observational study. Patients with available data on VAP, who received at least 48 h of IMV and ICU-LOS ≥ 72 h were included. Results: Out of 1512 patients included in the ENIO study, 1285 were eligible for this analysis. The prevalence of VAP was 39.5% (33.7 cases /1000 ventilator-days), with a high heterogeneity across countries and according to the type of brain injury. VAP was significantly more frequent in male patients, in those with smoke habits and when intraparenchymal probe (IP), external ventricular drain (EVD) or hypothermia (p < 0.001) were used. Independent risk factors for VAP occurrence were male gender, the use of IP, hypothermia, and the occurrence of tracheobronchitis during ICU stay. VAP was not an independent risk factor for ICU mortality (Hazard Ratio, HR = 0.71 95%CI 0.43–1.16, p = 0.168), but was independently associated with longer ICU stay (OR = 2.55 95%CI 2.01–3.23, p < 0.001). Conclusions: VAP is common in ABI patients. Male gender, IP and EVD insertion, tracheobronchitis, and the use of therapeutic hypothermia were significantly associated with VAP occurrence. VAP did not affect mortality but increased ICU-LOS., SCOPUS: ar.j, info:eu-repo/semantics/published

Background: Data on the benefits of rapid microbiological testing on antimicrobial consumption (AC) and antimicrobial resistance patterns (ARPs) are scarce. We evaluated the impact of a protocol based on rapid techniques on AC and ARP in intensive care (ICU) patients. Methods: A retrospective pre- (2018) and post-intervention (2019–2021) study was conducted in ICU patients. A rapid diagnostic algorithm was applied starting in 2019 in patients with a lower respiratory tract infection. The incidence of nosocomial infections, ARPs, and AC as DDDs (defined daily doses) were monitored. Results: A total of 3635 patients were included: 987 in the pre-intervention group and 2648 in the post-intervention group. The median age was 60 years, the sample was 64% male, and the average APACHE II and SOFA scores were 19 points and 3 points. The overall ICU mortality was 17.2% without any differences between the groups. An increase in the number of infections was observed in the post-intervention group (44.5% vs. 17.9%, p < 0.01), especially due to an increase in the incidence of ventilator-associated pneumonia (44.6% vs. 25%, p < 0.001). AC decreased from 128.7 DDD in 2018 to 66.0 DDD in 2021 (rate ratio = 0.51). An increase in Pseudomonas aeruginosa susceptibility of 23% for Piperacillin/tazobactam and 31% for Meropenem was observed. Conclusion: The implementation of an algorithm based on rapid microbiological diagnostic techniques allowed for a significant reduction in AC and ARPs without affecting the prognosis of critically ill patients.

Pneumonia is a growing problem worldwide and remains an important cause of morbidity, hospitalizations, intensive care unit admission and mortality. Viruses are the causative agents in almost a fourth of cases of community-acquired pneumonia (CAP) in adults, with an important representation of influenza virus and SARS-CoV-2 pneumonia. Moreover, mixed viral and bacterial pneumonia is common and a risk factor for severity of disease. It is critical for clinicians the early identification of the pathogen causing infection to avoid inappropriate antibiotics, as well as to predict clinical outcomes. It has been extensively reported that biomarkers could be useful for these purposes. This review describe current evidence and provide recommendations about the use of biomarkers in influenza and SARS-CoV-2 pneumonia, focusing mainly on procalcitonin (PCT) and C-reactive protein (CRP). Evidence was based on a qualitative analysis of the available scientific literature (meta-analyses, randomized controlled trials, observational studies and clinical guidelines). Both PCT and CRP levels provide valuable information about the prognosis of influenza and SARS-CoV-2 pneumonia. Additionally, PCT levels, considered along with other clinical, radiological and laboratory data, are useful for early diagnosis of mixed viral and bacterial CAP, allowing the proper management of the disease and adequate antibiotics prescription. The authors propose a practical PCT algorithm for clinical decision-making to guide antibiotic initiation in cases of influenza and SARS-CoV-2 pneumonia. Further well-design studies are needed to validate PCT algorithm among these patients and to confirm whether other biomarkers are indeed useful as diagnostic or prognostic tools in viral pneumonia.

Aim: Secondary bloodstream infections (SBSIs) are caused by another infection and differ from primary bloodstream infections (PBSIs) in terms of prevention and treatment strategies. The aim of this study was to determine the risk factors for bloodstream infections which were secondary to the most common healthcare-associated infections caused by the most common microorganisms in intensive care units (ICUs) and to examine whether extended-spectrum beta lactamase (ESBL) production and carbapenem resistance is related to the higher risk or not.Methods: The study population consisted of patients in ICUs with ventilator-associated pneumonia (VAP), ventilator-associated event (VAE) or catheter-associated urinary tract infection (CAUTI) caused by E. coli, K. pneumoniae, P. aeruginosa or A. baumannii between 2014 and 2019. The data were obtained through the National Healthcare-associated Infections Surveillance Network. Multivariate logistic regression analysis was performed separately for VAP/VAE and CAUTI to determine the risk factors for the development of SBSI.Results: Microorganism, ICU type, bed capasity and carbapenem resistance were found to be risk factors for SBSI for both types of infection. For VAPs/VAEs, female gender and hospital type were also identified as risk factors. The highest risk was in K.pneumoniae and in emergency ICUs. Among the hospitals, the highest risk in VAPs/VAEs was found in government education and research hospitals. ESBL production for K . pneumoniae and E. coli increased the risk in patients with VAP/VAE; however, it did not increase in patients with CAUTI.Discussion: By using the risk factors, it may be possible to recognize SBSIs earlier, especially in patients with CAUTIs or VAPs/VAEs caused by carbapenem-resistant or ESBL-producing K. pneumoniae ., Hintergrund: Bei der sekundären Blutstrominfektion (SBI) gelangt der Erreger von einem anderen Infektionsort in die Blutbahn; daher unterscheidet sich die Präventions- und Behandlungsstrategie von der primären Blutstrominfektion (PBI). Ziel der Studie war es, Risikofaktoren für SBI, die zu den häufigsten nosokomialen Infektionen gehören, zu bestimmen und zu untersuchen, ob Extended-Spectrum-Beta-Laktamase (ESBL) Bildner und Carbapenemresistenz mit einem höheren Risiko für SBI assoziiert sind.Methode: Die Studienpopulation bestand aus Patienten auf Intensivstationen mit Beatmungs-assoziierter Pneumonie (VAP), Beatmungs-assoziiertem Ereignis (VAE) oder Katheter-assoziierter Harnweginfektion (CAUTI), die durch E. coli , K. pneumoniae , P. aeruginosa oder A. baumannii zwischen 2014-2019 verursacht wurden. Die Daten wurden über das National Healthcare-associated Infections Surveillance Network erhalten. Die multivariate logistische Regressionsanalyse wurde getrennt für VAP/VAE und HWI durchgeführt, um die Risikofaktoren für die Entwicklung einer SBI zu bestimmen.Ergebnisse: Mikroorganismen, Art der ITS, Bettenkapazität und Carbapenemresistenz wurden als Risikofaktoren für SBI für beide Infektionsarten gefunden. Für VAP/VAE wurden zusätzlich weibliches Geschlecht und der Krankenhaustyp als Risikofaktoren identifiziert. Das höchste Risiko bestand bei K. pneumoniae und auf Notfall-Intensivstationen. Unter den Krankenhäusern wurde das höchste Risiko für VAP/VAE in staatlichen Lehr- und Forschungskrankenhäusern festgestellt. Die ESBL-Bildung bei K. pneumoniae und E. coli erhöhte das Risiko einer SBI bei Patienten für VAP/VAE, nicht jedoch bei Patienten mit HWI.Schlussfolgerung: Durch die Kenntnis von Risikofaktoren können SBI möglicherweise früher erkannt werden, insbesondere bei Patienten mit HWI oder VAP/VAE, die durch Carbapenem-resistente oder ESBL-produzierende K. pneumoniae verursacht werden.

Introduction: Ventilator-associated pneumonia (VAP) is the second most common infection acquired in hospitals, after bloodstream infection, and is associated with high mortality and involves a high impact on the economic burden of medical care of these patients. To Objective: identify risk factors for VAP in critically-ill children. Materials and Methods:This was a case-control study carried out at the “Dr. Agustín Zubillaga” Pediatric University Hospital (Barquisimeto, Lara State, Venezuela), between 2017 and 2019. We used binary logistic regression. Results: A total of 172 mechanically ventilated children were included in the analysis. Using a binary logistic regression model, the following were identified as independent predictors for the development of VAP: Fluid overload (OR=5.537; 95% CI: 1.903 - 16.113; p = 0.002), gastric acidity suppression (OR=5.360; 95% CI: 1.584 – 18.136; p = 0.007), enteral nutrition (OR=2.354; 95% CI: 1.079 –5.136; p = 0.032), reintubation (OR=4.423; 95% CI: 1.821 –10.743; p = 0.001) and receiving more than two transfusions of red blood cells (OR=2.267; 95% CI: 1.002 – 5.127; p = 0.049). In addition, the cases with VAP presented longer length-of-stay in the intensive care unit (ICU) (7.5 ± 3.5 vs. 10.8 ± 4.6 days; p < 0.0001), a longer total duration of mechanical ventilation (4.4 ± 2.3 vs. 7.3 ± 3.8; p < 0.0001) and higher mortality in the ICU (10.9% vs. 34.9%; p < 0.0001).Conclusion:Fluid overload, the use of gastric acidity suppressants, enteral nutrition, reintubation and receiving more than two red blood cell transfusions are risk factors for developing VAP., Introducción: La neumonía asociada al ventilador (NAV) es la segunda infección más común adquirida en los hospitales, después de la infección del torrente sanguíneo, y está asociada a una alta mortalidad e involucra, un alto impacto en la carga económica de la atención médica de estos pacientes. Objetivo: Identificar factores de riesgo para NAV en niños críticamente enfermos. Materiales y Métodos: Estudio de casos y controles realizado en el Hospital Universitario de Pediatría “Dr. Agustín Zubillaga” (Barquisimeto, Estado Lara, Venezuela), entre 2017 y 2019. Regresión logística binaria. Resultados: Un total de 172 niños ventilados mecánicamente fueron incluidos en el análisis. Mediante un modelo de regresión logística binaria se identificaron como predictores independientes para el desarrollo de NAV: Sobrecarga hídrica (OR=5,537; IC95%: 1,903 – 16,113; p = 0,002), supresor de acidez gástrica (OR=5,360; IC95%: 1,584 – 18,136; p = 0,007), nutrición enteral (OR=2,354; IC95%: 1,079 – 5,136; p = 0,032), reintubación (OR=4,423; IC95%: 1,821 – 10,743; p = 0,001) y recibir más de dos transfusiones de glóbulos rojos (OR=2,267; IC95%: 1,002 – 5,127; p = 0,049). Además, los casos con NAV presentaron más días en la unidad de cuidados intensivos (UCI) (7,5 ± 3,5 vs. 10,8 ± 4,6 días; p < 0,0001), mayor tiempo de duración total de ventilación mecánica (4,4 ± 2,3 vs. 7,3 ± 3,8; p < 0,0001) y mayor mortalidad en UCI (10,9% vs. 34,9%; p < 0,0001). Conclusión: La sobrecarga hídrica, el uso de supresores de acidez gástrica, la nutrición enteral, la reintubación y recibir más de dos transfusiones de glóbulos rojos son factores de riesgo para desarrollar NAV.

Purpose: Existing expert systems have not improved the diagnostic accuracy of ventilator-associated pneumonia (VAP). The aim of this systematic literature review was to review and summarize state-of-the-art prediction models detecting or predicting VAP from exhaled breath, patient reports and demographic and clinical characteristics. Methods: Both diagnostic and prognostic prediction models were searched from a representative list of multidisciplinary databases. An extensive list of validated search terms was added to the search to cover papers failing to mention predictive research in their title or abstract. Two authors independently selected studies, while three authors extracted data using predefined criteria and data extraction forms. The Prediction Model Risk of Bias Assessment Tool was used to assess both the risk of bias and the applicability of the prediction modelling studies. Technology readiness was also assessed. Results: Out of 2052 identified studies, 20 were included. Fourteen (70%) studies reported the predictive performance of diagnostic models to detect VAP from exhaled human breath with a high degree of sensitivity and a moderate specificity. In addition, the majority of them were validated on a realistic dataset. The rest of the studies reported the predictive performance of diagnostic and prognostic prediction models to detect VAP from unstructured narratives [2 (10%)] as well as baseline demographics and clinical characteristics [4 (20%)]. All studies, however, had either a high or unclear risk of bias without significant improvements in applicability. Conclusions: The development and deployment of prediction modelling studies are limited in VAP and related outcomes. More computational, translational, and clinical research is needed to bring these tools from the bench to the bedside.

Introducción: Se conocen como IRAS las infecciones relacionadas con la asistencia sanitaria. Podemos definir la neumonía asociada a ventilación mecánica (NAV) como la infección de las vías aéreas inferiores que aparece en pacientes que llevan por lo menos 48 horas conectados a un ventilador. En España se elaboró el proyecto Neumonía Zero de cara a su prevención. El estudio EVIDENCE, realizado en 22 países europeos, fue el primero en evaluar el conocimiento de las enfermeras sobre la prevención de la NAV. Objetivos: Determinar el grado de conocimiento que tienen las enfermeras de las unidades de críticos de los hospitales del área de Santiago sobre la prevención de la NAV, conocer si este se ve influenciado por variables sociodemográficas y comparar los resultados de las unidades. Métodos: Estudio descriptivo y transversal realizado mediante un cuestionario compuesto por 9 preguntas del estudio EVIDENCE y 11 preguntas de carácter sociodemográfico. El cuestionario fue autocumplimentado por las enfermeras de las unidades de críticos del área de Santiago durante los meses comprendidos entre enero y abril de 2022. Resultados: Se recopilaron un total de 68 cuestionarios. Se obtuvo una puntuación media de 5,31 (± 1,44) sobre 9. Al relacionar la puntuación y la formación en Neumonía Zero se obtuvo una significación de 0,020; al confrontar la puntuación y el cuidado de pacientes COVID19: 0,022. La puntuación correlaciona positivamente con la edad y la experiencia en la profesión. No se hallaron diferencias estadísticamente significativas entre las puntuaciones de las unidades. Conclusiones: Los resultados obtenidos señalaron un grado de conocimiento medio al compararlos con otros estudios. La formación en Neumonía Zero y el cuidado de pacientes COVID19 contribuyeron a un mayor grado de conocimiento, así como se observó que existe una tendencia a tener mayor conocimiento cuanto mayor es la edad y los años trabajados como enfermera., Introdución: Coñécense como IRAS as infeccións relacionadas coa asistencia sanitaria. Podemos definir a neumonía asociada a ventilación mecánica (NAV) como a infección das vías aéreas inferiores que aparece en pacientes que levan polo menos 48 horas conectados a un ventilador. En España elaborouse o proxecto Neumonía Zero coa finalidade de previla. O estudo EVIDENCE, realizado en 22 países europeos, foi o primeiro en avaliar o coñecemento das enfermeiras sobre a prevención da NAV. Obxectivos: Determinar o grao de coñecemento que teñen as enfermeiras das unidades de críticos dos hospitais da área de Santiago sobre a prevención da NAV, coñecer se este se ve influído por variables sociodemográficas e comparar os resultados das unidades. Métodos: Estudo descritivo e transversal realizado mediante un cuestionario composto por 9 preguntas do estudio EVIDENCE e 11 preguntas de carácter sociodemográfico. O cuestionario foi autocumplimentado polas enfermeiras das unidades de críticos da área de Santiago durante os meses comprendidos entre xaneiro e abril de 2022. Resultados: Recopiláronse un total de 68 cuestionarios. Obtívose unha puntuación media de 5,31 (± 1,44) sobre 9. Ao relacionar a puntuación e a formación en Neumonía Zero obtívose unha significación de 0,020; ao confrontar a puntuación e o coidado de pacientes COVID19: 0,022. A puntuación correlaciona positivamente coa idade e a experiencia na profesión. Non se atoparon diferencias estadísticamente significativas entre as puntuacións das unidades. Conclusións: Os resultados obtidos sinalaron un grao de coñecemento medio ao comparalos con outros estudos. A formación en Neumonía Zero e o coidado de pacientes COVID19 contribuíron a un maior grao de coñecemento. Tamén se observou que existe unha tendencia a ter maior coñecemento canto maior é a idade e os anos traballados como enfermeira., Introduction: We can define ventilator-associated pneumonia (VAP) as the infection of the lower airways that appears in patients who have been connected to a ventilator for at least 48 hours. In Spain, the Neumonía Zero project was developed for its prevention. The EVIDENCE study, which was conducted in 22 European countries, was the first one to assess nurses' knowledge of VAP prevention. Objectives: To determine the level of knowledge about prevention of ventilator-associated pneumonia that nurses working in critical care units of Santiago de Compostela have, to know if it is influenced by sociodemographic variables and to compare the results between the critical care units. Methods: A descriptive and cross-sectional study was conducted through a questionnaire composed of 9 questions from the EVIDENCE study and 11 sociodemographic questions. The questionnaire was self-completed by nurses from critical care units in Santiago de Compostela during the period January - April 2022. Results: 68 questionnaires were obtained. The mean score was 5.31 (± 1.44) out of 9. When comparing the score and the knowledge about Neumonía Zero project a significance of 0.020 was obtained; when comparing the score and the treatment of COVID19 patients we obtained a significance of 0.022. The score correlates positively with age and experience as a nurse. No statistically significant differences were found between the critical care unit scores. Conclusions: The results showed a medium level of knowledge when compared with other studies. The knowledge about Neumonía Zero project and the treatment of COVID19 patients contributed to higher scores. There is also a tendency to have greater knowledge the older the age and the years worked as a nurse.

We conducted a proof of concept study where Anapnoguard endotracheal tubes and its control unit were used in 15 patients with COVID-19 acute respiratory distress syndrome. Anapnoguard system provides suction, venting, rinsing of subglottic space and controls cuff pressure detecting air leakage through the cuff. Alpha-amylase and pepsin levels, as oropharyngeal and gastric microaspiration markers, were assessed from 85 tracheal aspirates in the first 72 h after connection to the system. Oropharyngeal microaspiration occurred in 47 cases (55\%). Episodes of gastric microaspiration were not detected. Patient positioning, either prone or supine, did not affect alpha-amylase and pepsin concentration in tracheal secretions. Ventilator-associated pneumonia (VAP) rate was 40\%. The use of the AG system provided effective cuff pressure control and subglottic secretions drainage. Despite this, no reduction in the incidence of VAP has been demonstrated, compared to data reported in the current COVID-19 literature. The value of this new technology is worth of being evaluated for the prevention of ventilator-associated respiratory tract infections.

OBJECTIVE: To assess the impact of treatment with steroids on the incidence and outcome of ventilator-associated pneumonia (VAP) in mechanically ventilated COVID-19 patients. DESIGN: Propensity-matched retrospective cohort study from February 24 to December 31, 2020, in 4 dedicated COVID-19 Intensive Care Units (ICU) in Lombardy (Italy). PATIENTS: Adult consecutive mechanically ventilated COVID-19 patients were subdivided into two groups: (1) treated with low-dose corticosteroids (dexamethasone 6 mg/day intravenous for 10 days) (DEXA+); (2) not treated with corticosteroids (DEXA-). A propensity score matching procedure (1:1 ratio) identified patients' cohorts based on: age, weight, PEEP Level, PaO2/FiO2 ratio, non-respiratory Sequential Organ Failure Assessment (SOFA) score, Charlson Comorbidity Index (CCI), C reactive protein plasma concentration at admission, sex and admission hospital (exact matching). INTERVENTION: Dexamethasone 6 mg/day intravenous for 10 days from hospital admission. MEASUREMENTS AND MAIN RESULTS: Seven hundred and thirty-nine patients were included, and the propensity-score matching identified two groups of 158 subjects each. Eighty-nine (56%) DEXA+ versus 55 (34%) DEXA- patients developed a VAP (RR 1.61 (1.26-2.098), p = 0.0001), after similar time from hospitalization, ICU admission and intubation. DEXA+ patients had higher crude VAP incidence rate (49.58 (49.26-49.91) vs. 31.65 (31.38-31.91)VAP*1000/pd), (IRR 1.57 (1.55-1.58), p < 0.0001) and risk for VAP (HR 1.81 (1.31-2.50), p = 0.0003), with longer ICU LOS and invasive mechanical ventilation but similar mortality (RR 1.17 (0.85-1.63), p = 0.3332). VAPs were similarly due to G+ bacteria (mostly Staphylococcus aureus) and G- bacteria (mostly Enterobacterales). Forty-one (28%) VAPs were due to multi-drug resistant bacteria. VAP was associated with almost doubled ICU and hospital LOS and invasive mechanical ventilation, and increased mortality (RR 1.64 [1.02-2.65], p = 0.040) with no dif

Purpose: Dexamethasone is the only drug that has consistently reduced mortality in patients with COVID-19, es-pecially in patients needing oxygen or invasive mechanical ventilation. However, there is a growing concern about the relation of dexamethasone with the unprecedented rates of ICU-acquired respiratory tract infections (ICU-RTI) observed in patients with severe COVID-19. Methods: This was a multicenter, prospective cohort study; conducted in ten countries in Latin America and Europe. We included patients older than 18 with confirmed SARS-CoV-2 requiring ICU admission. A multivariate logistic regression and propensity score matching (PSM) analysis was conducted to determine the relation be-tween dexamethasone treatment and ICU-RTI. Results: A total of 3777 patients were included. 2065 (54.7%) were treated with dexamethasone within the first 24 h of admission. After performing the PSM, patients treated with dexamethasone showed significantly higher proportions of VAP (282/1652 [17.1%] Vs. 218/1652 [13.2%], p = 0.014). Also, dexamethasone treatment was identified as an adjusted risk factor of ICU-RTI in the multivariate logistic regression model (OR 1.64; 95%CI: 1.37-1.97; p < 0.001).

(1) Background: the purpose of this study is to analyze the incidence and in-hospital mortality (IHM) of community-acquired pneumonia (CAP) needing hospital admission and hospital-acquired pneumonia (HAP) in Spain (2016–2019). (2) Methods: using the Spanish Register of Specialized Care-Basic Minimum Database, we estimated the incidence of CAP and HAP. We matched each woman with a man with an identical age, according to comorbidities. (3) Results: we analyzed 518,838 cases of CAP and 38,705 cases of HAP, and 5192 ventilator-associated HAPs (13.4%). The incidence of CAP increased over time in both men (from 384.5 to 449.8 cases/105 population) and women (from 244.9 to 301.2 cases/105 population). Men showed a 47% higher adjusted incidence of CAP than women. The incidence of HAP increased over time in both men (from 302.3 to 342.2 cases/105 population) and women (from 139.2 to 167.6 cases/105 population). Men showed a 98% higher adjusted incidence of HAP than women. IHM was higher in men admitted for CAP than in women (12.9% vs. 12.2%; p < 0.001), but not in men who developed HAP (28.9% vs. 28.0%; p = 0.107). Men admitted for CAP (OR: 1.13; 95% CI: 1.10–1.15) and men who developed HAP (OR: 1.05; 95% CI: 1.01–1.10) had higher IHM than women. (4) Conclusions: men had higher incidence rates of CAP and HAP than women. Men admitted for CAP and men who developed HAP had higher IHM than women., Depto. de Medicina, Depto. de Salud Pública y Materno - Infantil, Fac. de Medicina, TRUE, pub

This study is a part of the research funded by the FIS (Fondo de Investigaciones Sanitarias—Health Research Fund, Instituto de Salud Carlos III) and co-financed by the European Union through the Fondo Europeo de Desarrollo Regional (FEDER, “Una manera de hacer Europa”): grant no. PI20/00118., Background: To analyze the incidence, clinical characteristics, use of procedures, and in-hospital outcomes in patients who developed pneumonia during their hospital admission according to sex and to the presence of type 2 diabetes mellitus (T2DM). (2) Methods: Retrospective cohort study using data from the Spanish National Hospital Discharge Database. Hospital-acquired pneumonia (HAP) was classed as non-ventilator HAP and ventilator-associated pneumonia (VAP). Separate analyses were performed for men and women with and without T2DM. Population subgroups were compared using propensity score matching. (3) Results: HAP was identified in 38,814 patients (24.07% with T2DM). The adjusted incidence of HAP was higher in patients with T2DM (both sexes) (IRR 1.28; 95% CI 1.25–1.31). The incidence of HAP was higher in men with T2DM than in women with T2DM (adjusted-IR 1.47; 95% CI 1.41–1.53). The incidence of HAP among T2DM patients increased over time. In-hospital mortality (IHM) was around 28% irrespective of T2DM status and sex. After adjusting for confounders and sex, VAP was associated to higher IHM among patients with T2DM (OR 2.09; 95% CI 1.7–2.57). (4) Conclusions: T2DM is associated with a higher risk of HAP, whose incidence increased over time. Men with T2DM have an almost 50% higher risk of HAP than women with T2DM. The probability of dying in the hospital was not associated with sex or T2DM., Unión Europea, Instituto de Salud Carlos III, Depto. de Salud Pública y Materno - Infantil, Fac. de Enfermería, Fisioterapia y Podología, Fac. de Medicina, TRUE, pub

Background: We aim to analyze incidence and outcomes of patients hospitalized with hospital-acquired pneumonia (HAP) according to chronic obstructive pulmonary disease (COPD) status and sex in Spain (2016–2019). Methods: We conducted a retrospective cohort study using national hospital discharge data of patients ≥40 years with a primary diagnosis of HAP, using the specific diagnostics of non-ventilator (NV)-HAP and ventilator-associated pneumonia (VAP). Results: We identified 37,029 patients with HAP ((NV)-HAP 87.28%, VAP 12.72%), 13.40% with COPD. HAP incidence increased over time, but only in subjects without COPD (p < 0.001). In women, incidence of HAP and (NV)-HAP was similar regardless of COPD status, but VAP incidence was lower in COPD women (p = 0.007). In men, the incidence of (NV)-HAP was significantly higher in those with COPD, while VAP incidence was lower in COPD men (p < 0.001). The in-hospital mortality (IHM) was similar in men and women with and without COPD. The risk of dying in hospital increased with age, congestive heart failure, cancer, and dialysis among men and women with COPD. Men that underwent surgery had a lower risk of IHM. VAP increased 2.58-times the probability of dying in men and women. Finally, sex was not associated with IHM among COPD patients. Conclusions: Incidence of HAP was significantly higher in COPD patients than in those without COPD, at the expense of (NV)-HAP but not of VAP. When stratifying by sex, we found that the difference was caused by men. IHM was similar in COPD and non-COPD patients, with no significant change overtime. In addition, sex was not associated with IHM., Depto. de Medicina, Depto. de Salud Pública y Materno - Infantil, Fac. de Medicina, TRUE, pub

Background P. aeruginosa possesses antibiotic resistance, making treatment difficult. Polyclonal anti-P. aeruginosa IgY-antibodies (Pa-IgY) have antibacterial effects, but have not been studied in large animal pneumonia. Objectives To test if Pa-IgY decreases the concentration of P. aeruginosa in bronchoalveolar lavage in experimental porcine pneumonia over 27 hours. Method Norwegian landrace pigs were anesthetized, mechanically ventilated, and subject to invasive monitoring. The animals were randomized to receive either P. aeruginosa (control, n = 12) or P aeruginosa + Pa-IgY antibodies with a repeated dose of Pa-IgY after 12 hours (intervention, n = 12) in the right lower pulmonary lobe. Bronchoalveolar lavage (BAL) cultures and physiological measurements were obtained repeatedly for 27 hours after which the pigs were sacrificed. Results BAL bacterial concentration increased in both groups and peaked at 107.28 ± 100.21 CFU/mL in the intervention group vs 107.36 ± 100.50 CFU/mL in the control group (n.s.). BAL bacterial concentration decreased during the experiment to 105.35 ± 100.39 CFU/mL in the intervention group vs 105.19 ± 100.37 in the control group (n.s.). The intervention group had lower heart rate (P < .001), lower cardiac index (P < .01), and lower arterial lactate (P < .001) compared to the control group. The core temperature was lower in the intervention group than in the control group (P < .001). Conclusion The chosen dose of Pa-IgY did not decrease concentrations of P. aeruginosa in BAL over 27 hours. We conclude that it is unlikely that there is a large effect of this specific dose and route of administration of Pa-IgY in this type of model.

Background Ventilator-associated pneumonia is common and is treated using nebulized antibiotics. Although adequate pulmonary biodistribution is important for antibiotic effect, there is a lack of data for both intravenous (IV) and nebulized antibiotic administration during mechanical ventilation. Objective To describe the comparative pulmonary regional distribution of IV and nebulized technetium-99m-labeled tobramycin (99mTc-tobramycin) 400 mg in a mechanically-ventilated ovine model. MethodsThe study was performed in a mechanically-ventilated ovine model. 99mTc-tobramycin 400 mg was obtained using a radiolabeling process. Computed tomography (CT) was performed. Ten sheep were given 99mTc-tobramycin 400 mg via either an IV (five sheep) or nebulized (five sheep) route. Planar images (dorsal, ventral, left lateral and right lateral) were obtained using a gamma camera. Blood samples were obtained every 15 min for 1 h (4 time points) and lung, liver, both kidney, and urine samples were obtained post-mortem. ResultsTen sheep were anesthetized and mechanically ventilated. Whole-lung deposition of nebulized 99mTc-tobramycin 400 mg was significantly lower than with IV (8.8% vs. 57.1%, P<0.001). For both administration routes, there was significantly lower deposition in upper lung zones compared with the rest of the lungs. Dorsal deposition was significantly higher with nebulized 99mTc-tobramycin 400 mg compared with IV (68.9% vs. 58.9%, P=0.003). Lung concentrations of 99mTc-tobramycin were higher with IV compared with nebulized administration. There were significantly higher concentrations of 99mTc-tobramycin in blood, liver and urine with IV administration compared with nebulized. Conclusions Nebulization resulted in lower whole and regional lung deposition of 99mTc-tobramycin compared with IV administration and appeared to be asso

Clinical evidence suggests that nebulized colistimethate sodium (CMS) has benefits for treating lower respiratory tract infections caused by multidrug-resistant Gram-negative bacteria (GNB). Colistin is positively charged, while CMS is negatively charged, and both have a high molecular mass and are hydrophilic. These physico-chemical characteristics impair crossing of the alveolo-capillary membrane but enable the disruption of the bacterial wall of GNB and the aggregation of the circulating lipopolysaccharide. Intravenous CMS is rapidly cleared by glomerular filtration and tubular excretion, and 20-25% is spontaneously hydrolyzed to colistin. Urine colistin is substantially reabsorbed by tubular cells and eliminated by biliary excretion. Colistin is a concentration-dependent antibiotic with post-antibiotic and inoculum effects. As CMS conversion to colistin is slower than its renal clearance, intravenous administration can lead to low plasma and lung colistin concentrations that risk treatment failure. Following nebulization of high doses, colistin (200,000 international units/24h) lung tissue concentrations are > five times minimum inhibitory concentration (MIC) of GNB in regions with multiple foci of bronchopneumonia and in the range of MIC breakpoints in regions with confluent pneumonia. Future research should include: (1) experimental studies using lung microdialysis to assess the PK/PD in the interstitial fluid of the lung following nebulization of high doses of colistin; (2) superiority multicenter randomized controlled trials comparing nebulized and intravenous CMS in patients with pandrug-resistant GNB ventilator-associated pneumonia and ventilator-associated tracheobronchitis; (3) non-inferiority multicenter randomized controlled trials comparing nebulized CMS to intravenous new cephalosporines/ß-lactamase inhibitors in patients with extensive drug-resistant GNB ventilator-associated pneumonia and ventilator-associated tracheobronchitis.

Patients with infection can develop sepsis, and their mortality can be high. An important aspect in the treatment of sepsis is adequate management of the infection.Data sourcesUsing a modified Delphi approach, the Surviving Sepsis Campaign research committee recently published a series of 26 priorities for sepsis and septic shock.Study selectionTask force members with specific expertise were tasked with generating expanded reviews for all infection questions and a subset of adjunctive therapy questions from the larger list of sepsis priorities. Each question was addressed by one of the six task force members.Data extractionIn-depth reviews were then edited by the group as a whole, with added input from the committee cochairs.Data synthesisSix questions were addressed: 1) should empiric antibiotic combination therapy be used in sepsis or septic shock? 2) does optimization of antimicrobial pharmacokinetics and pharmacodynamics impact patient outcomes in sepsis? 3) should viral reactivation resulting from sepsis-induced immunosuppression be treated with antiviral therapy in critically ill septic patients? 4) should rapid diagnostic tests be implemented in clinical practice? 5) what is the role of lung-protective ventilation in sepsis patients without acute respiratory distress syndrome? and 6) how do we determine the efficacy of "blood purification" therapies such as endotoxin absorbers, cytokine absorbers, and plasmapheresis.ConclusionsThe research committee members for the Surviving Sepsis Campaign aimed to explore research questions in order to provide existing evidence and highlight areas of uncertainty and future directions.

Background: Hospitalized patients with COVID-19 admitted to the intensive care unit (ICU) and requiring mechanical ventilation are at risk of ventilator-associated bacterial infections secondary to SARS-CoV-2 infection. Our study aimed to investigate clinical features of Staphylococcus aureus ventilator-associated pneumonia (SA-VAP) and, if bronchoalveolar lavage samples were available, lung bacterial community features in ICU patients with or without COVID-19. Methods: We prospectively included hospitalized patients with COVID-19 across two medical ICUs of the Fondazione Policlinico Universitario A. Gemelli IRCCS (Rome, Italy), who developed SA-VAP between 20 March 2020 and 30 October 2020 (thereafter referred to as cases). After 1:2 matching based on the simplified acute physiology score II (SAPS II) and the sequential organ failure assessment (SOFA) score, cases were compared with SA-VAP patients without COVID-19 (controls). Clinical, microbiological, and lung microbiota data were analyzed. Results: We studied two groups of patients (40 COVID-19 and 80 non-COVID-19). COVID-19 patients had a higher rate of late-onset (87.5% versus 63.8%; p = 0.01), methicillin-resistant (65.0% vs 27.5%; p < 0.01) or bacteremic (47.5% vs 6.3%; p < 0.01) infections compared with non-COVID-19 patients. No statistically significant differences between the patient groups were observed in ICU mortality (p = 0.12), clinical cure (p = 0.20) and microbiological eradication (p = 0.31). On multivariable logistic regression analysis, SAPS II and initial inappropriate antimicrobial therapy were independently associated with ICU mortality. Then, lung microbiota characterization in 10 COVID-19 and 16 non-COVID-19 patients revealed that the overall microbial community composition was significantly different between the patient groups (unweighted UniFrac distance, R2 0.15349; p < 0.01). Species diversity was lower in COVID-19 than in non COVID-19 patients (94.4 ± 44.9 vs 152.5 ± 41.8; p &

© 2020 American College of Chest Physicians Background: Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role. Research Question: What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP? Study Design and Methods: This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups. Results: We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P =.021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P <.001) when compared with patients with severe CAP/AspRF+ and severe CAP/AspRF-, respectively. Most patients (>50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics. Int

Background: When postneurosurgery patients develop fever, there are no convenient methods to immediately indicate the site of infection. The choice of empirical antibiotic therapy is evidently different in nosocomial meningitis compared with ventilator-associated pneumonia or urinary tract infection. Conventional bacterial cultures run a risk of being false negative due to antibiotic prophylaxis, and direct microscopic analysis of cerebrospinal fluid (CSF) from such patients has limited diagnostic value. Because of the substantial mortality associated with nosocomial meningitis, broad spectrum antibiotics in high dosage are, therefore, commonly administered. Neutrophils as a part of the innate immunity system, trap and kill bacteria by neutrophil extracellular traps (NETs). Neutrophil extracellular traps are composed of extracellular DNA which is released to the CSF during bacterial meningitis. Using a combination of sulphated-glucosaminoglycan and aniline dyes, a measurement method was developed that reacts to extracellular host DNA and changes color within 1 minute in proportion to the amount of NETs in the body fluid tested. The present study aimed to evaluate the sensitivity and specificity of the "rapid NETs test" in identifying the site of infection. Methods: We performed analysis on the left-over CSF samples (n = 199) that were collected routinely at neurosurgical intensive care unit. No samples were included after patients were transferred to the ward. Besides CSF, bronchoalveolar fluid, and urine samples were collected in febrile patients. The "rapid NETs test" was used for simultaneous analysis of the fresh left-over samples. The final diagnosis was settled at discharge. Results: A total of 75 (64%) patients had received empirical antibiotic therapy against nosocomial meningitis, whereas only 19 patients of these cases (16%) had a verified diagnosis. The rapid NETs test could distinguish a verified meningitis (n = 19) with 89.5% sensitivity and 92.5% speci

Animal studies demonstrate that nebulised aminoglycosides and colimycin (polymyxin E) deliver higher antibiotic concentrations and greater bactericidal activity in the lung parenchyma infected by both sensitive and multidrug-resistant (MDR) Gramnegative bacteria (GNB) [1]. However, superiority of nebulised over intravenous (IV) aminoglycosides and colimycin in patients with ventilator-associated pneumonia (VAP) remains to be demonstrated. Clinical studies are sparse, heterogeneous in terms of aims and methods, and have enrolled a limited number of patients. As a consequence, recommendations from American and European academic societies for using nebulised antibiotics are limited, based on a weak level-of-evidence and sometimes divergent.[...]

Background: No large prospective data, to our knowledge, are available on ventilator-associated pneumonia (VAP) in patients with traumatic brain injury (TBI). Research Question: To evaluate the incidence, timing, and risk factors of VAP after TBI and its effect on patient outcome. Study Design and Methods: This analysis is of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury data set, from a large, multicenter, prospective, observational study including patients with TBI admitted to European ICUs, receiving mechanical ventilation for ≥ 48 hours and with an ICU length of stay (LOS) ≥ 72 hours. Characteristics of patients with VAP vs characteristics of patients without VAP were compared, and outcome was assessed at 6 months after injury by using the Glasgow Outcome Scale Extended. Results: The study included 962 patients: 196 (20.4%) developed a VAP at a median interval of 5 days (interquartile range [IQR], 3-7 days) after intubation. Patients who developed VAP were younger (median age, 39.5 [IQR, 25-55] years vs 51 [IQR, 30-66] years; P < .001), with a higher incidence of alcohol abuse (36.6% vs 27.6%; P = .026) and drug abuse (10.1% vs 4.2%; P = .009), more frequent thoracic trauma (53% vs 43%; P = .014), and more episodes of respiratory failure during ICU stay (69.9% vs 28.1%; P < .001). Age (hazard ratio [HR], 0.99; 95% CI, 0.98-0.99; P = .001), chest trauma (HR, 1.4; 95% CI, 1.03-1.90; P = .033), histamine-receptor antagonist intake (HR, 2.16; 95% CI, 1.37-3.39; P = .001), and antibiotic prophylaxis (HR, 0.69; 95% CI, 0.50-0.96; P = .026) were associated with the risk of VAP. Patients with VAP had a longer duration of mechanical ventilation (median, 15 [IQR, 10-22] days vs 8 [IQR, 5-14] days; P < .001) and ICU LOS (median, 20 [IQR, 14-29] days vs 13 [IQR, 8-21] days; P < .001). However, VAP was not associated with increased mortality or worse neurological outcome. Overall mortality at 6 months was 22%. Interpretat

Background: No large prospective data, to our knowledge, are available on ventilator-associated pneumonia (VAP) in patients with traumatic brain injury (TBI). Research Question: To evaluate the incidence, timing, and risk factors of VAP after TBI and its effect on patient outcome. Study Design and Methods: This analysis is of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury data set, from a large, multicenter, prospective, observational study including patients with TBI admitted to European ICUs, receiving mechanical ventilation for ≥ 48 hours and with an ICU length of stay (LOS) ≥ 72 hours. Characteristics of patients with VAP vs characteristics of patients without VAP were compared, and outcome was assessed at 6 months after injury by using the Glasgow Outcome Scale Extended. Results: The study included 962 patients: 196 (20.4%) developed a VAP at a median interval of 5 days (interquartile range [IQR], 3-7 days) after intubation. Patients who developed VAP were younger (median age, 39.5 [IQR, 25-55] years vs 51 [IQR, 30-66] years; P < .001), with a higher incidence of alcohol abuse (36.6% vs 27.6%; P = .026) and drug abuse (10.1% vs 4.2%; P = .009), more frequent thoracic trauma (53% vs 43%; P = .014), and more episodes of respiratory failure during ICU stay (69.9% vs 28.1%; P < .001). Age (hazard ratio [HR], 0.99; 95% CI, 0.98-0.99; P = .001), chest trauma (HR, 1.4; 95% CI, 1.03-1.90; P = .033), histamine-receptor antagonist intake (HR, 2.16; 95% CI, 1.37-3.39; P = .001), and antibiotic prophylaxis (HR, 0.69; 95% CI, 0.50-0.96; P = .026) were associated with the risk of VAP. Patients with VAP had a longer duration of mechanical ventilation (median, 15 [IQR, 10-22] days vs 8 [IQR, 5-14] days; P < .001) and ICU LOS (median, 20 [IQR, 14-29] days vs 13 [IQR, 8-21] days; P < .001). However, VAP was not associated with increased mortality or worse neurological outcome. Overall mortality at 6 months was 22%. Interpre

Carbapenemase-producing Enterobacterales and specifically Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp) are rapidly spreading worldwide. The prognosis of ventilator-associated pneumonia (VAP) caused by KPC-Kp is not well known. Our study tries to assess whether ventilator-associated pneumonia caused by a KPC-Kp strain is associated with higher all-cause mortality than that caused by carbapenem-susceptible isolates. This is a retrospective cohort study of patients with VAP due to K. pneumoniae from a 35-bed polyvalent intensive care unit in a university hospital (>40,000 annual admissions) between January 2012 and December 2016. Adjusted multivariate analysis was used to study the association of KPC-Kp with 30-day all-cause mortality (Cox regression). We analyze 69 cases of K. pneumoniae VAP, of which 39 were produced by a KPC-Kp strain with high-level resistance to meropenem (MIC > 16 mg/ml). All-cause mortality at 30 days was 41% in the KPC-Kp group (16/39) and 33.3% in the carbapenem-susceptible cases (10/30). KPC-Kp etiology was not associated with higher mortality when controlled for confounders (adjusted hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.46 to 3.41). Adequate targeted therapy (HR, 0.03; 95% CI, <0.01 to 0.23) was associated with all-cause mortality. Assuming the limitations due to the available sample size, the prognosis of VAP caused by KPC-Kp is similar to VAPs caused by carbapenem-susceptible K. pneumoniae when appropriate treatment is used.

Background: Humans exist in mutualistic balance with a large range of microbiota. Illness and hospitalization can disturb this balance and contribute to hospital-acquired infections (HAIs), which occur most often in critically ill patients. The use of medical devices such as central venous catheters (CVCs) and endotracheal tubes (ETTs) is essential in the care of critically ill patients. At the same time, they increase the risk of HAI by forcing or disrupting the normal barriers in the human body. All such devices eventually become colonized with microbes (usually normal flora), that form biofilms on the surface of the foreign material and subsequently lead to infection. The three types of devices related to the majority of HAIs in the intensive care unit are ETTs, urinary catheters, and CVCs.Aim: The present research was conducted to study: (i) changes in oropharyngeal microbial flora during hospitalization; (ii) compare biofilm formation on widely used ETTs with different surface properties and to explore factors potentially predictive of biofilm formation; (iii) the incidence of catheter-related infections and the impact of implementing a simple hygiene insertion bundle; (iiii) compare the blood compatibility of widely used CVCs.Paper I: In a clinical observational study, oropharyngeal cultures were collected from 487 individuals: 77 controls, 193 ward patients, and 217 critically ill patients. The results indicated that occurrence of an abnormal oropharyngeal flora is an early and frequent event in hospitalized patients, particularly the critically ill. Also, colonization with gut flora in the oropharynx was common in critically ill patients. Treatment with proton pump inhibitors was associated with colonization of gut flora in the oropharynx. The result of paper I reinforces the hypothesis that proton pump inhibitor use increases the risk of pneumonia by changing the oral flora, harboring gut bacteria which then may be micro aspirated into the lungs.Paper II: I

During critical illness, there are a multitude of forces such as antibiotic use, mechanical ventilation, diet changes and inflammatory responses that could bring the microbiome out of balance. This so-called dysbiosis of the microbiome seems to be involved in immunological responses and may influence outcomes even in individuals who are not as vulnerable as a critically ill ICU population. It is therefore probable that dysbiosis of the microbiome is a consequence of critical illness and may, subsequently, shape an inadequate response to these circumstances.Bronchoscopic studies have revealed that the carina represents the densest site of bacterial DNA along healthy airways, with a tapering density with further bifurcations. This likely reflects the influence of micro-aspiration as the primary route of microbial immigration in healthy adults. Though bacterial DNA density grows extremely sparse at smaller airways, bacterial signal is still consistently detectable in bronchoalveolar lavage fluid, likely reflecting the fact that lavage via a wedged bronchoscope samples an enormous surface area of small airways and alveoli. The dogma of lung sterility also violated numerous observations that long predated culture-independent microbiology.The body's resident microbial consortia (gut and/or respiratory microbiota) affect normal host inflammatory and immune response mechanisms. Disruptions in these host-pathogen interactions have been associated with infection and altered innate immunity.In this narrative review, we will focus on the rationale and current evidence for a pathogenic role of the lung microbiome in the exacerbation of complications of critical illness, such as acute respiratory distress syndrome and ventilator-associated pneumonia., SCOPUS: re.j, info:eu-repo/semantics/published

Background and Purpose: Since the 1950’s when researchers first acknowledged gram-negative bacillus pneumonia as the key pathogenic component to hospital-acquired infections there have been many studies suggesting how ventilator-associated pneumonia (VAP) continues to cause increase morbidity and mortality in mechanically ventilated patients. Initiatives to mitigate this pathology have been implemented and have ranged from increasing nursing knowledge and implementation of chlorhexidine gluconate oral care to selective oropharynx decontamination prophylactic strategies. The purpose of this study was to 1) Assess the need for continual and in-depth nursing education about VAP pathophysiology and prophylactic strategies; and 2) Assess individual perception/attitude towards the prophylactic tasks. Methods: ICU nurses at St. Luke’s Phoenix Hospital were asked to volunteer in a pre-test survey followed by an education module and post-test. The survey included four knowledge-based questions and five perception/attitude assessment questions. The education module was focused on pathophysiology of VAP and proper application process of prophylactic strategies. Results: 13 nurses completed the pre/post-test and education module. Summary data of the pre-test and post-test score percentages (± SD) assessing VAP knowledge were 78.9% ± 0.27 and 98.1% ± 0.07, respectively, implying that the education module significantly improved VAP knowledge (p < 0.05, paired t-test, n = 13). On the other hand, change in perception/attitude towards VAP prophylactic tasks was not statistically significant (p > 0.05). However, 69.23% of the participants expressed interest in alternative techniques. Significance: Data supported an increase in nursing knowledge of VAP, suggesting a need for further education (p < 0.05). Findings suggest that the education intervention increased knowledge but did not alter perceptions/attitudes.

Objective: To assess whether ventilator-associated lower respiratory tract infections (VA-LRTIs) are associated with mortality in critically ill patients with acute respiratory distress syndrome (ARDS). Materials and Methods: Post hoc analysis of prospective cohort study including mechanically ventilated patients from a multicenter prospective observational study (TAVeM study); VA-LRTI was defined as either ventilator-associated tracheobronchitis (VAT) or ventilator-associated pneumonia (VAP) based on clinical criteria and microbiological confirmation. Association between intensive care unit (ICU) mortality in patients having ARDS with and without VA-LRTI was assessed through logistic regression controlling for relevant confounders. Association between VA-LRTI and duration of mechanical ventilation and ICU stay was assessed through competing risk analysis. Contribution of VA-LRTI to a mortality model over time was assessed through sequential random forest models. Results: The cohort included 2960 patients of which 524 fulfilled criteria for ARDS; 21% had VA-LRTI (VAT = 10.3% and VAP = 10.7%). After controlling for illness severity and baseline health status, we could not find an association between VA-LRTI and ICU mortality (odds ratio: 1.07; 95% confidence interval: 0.62-1.83; P = .796); VA-LRTI was also not associated with prolonged ICU length of stay or duration of mechanical ventilation. The relative contribution of VA-LRTI to the random forest mortality model remained constant during time. The attributable VA-LRTI mortality for ARDS was higher than the attributable mortality for VA-LRTI alone. Conclusion: After controlling for relevant confounders, we could not find an association between occurrence of VA-LRTI and ICU mortality in patients with ARDS.

Background: Colistin is recommended in the empirical treatment of ventilator-associated pneumonia (VAP) with a high prevalence of carbapenem-resistant gram-negative bacilli (CR-GNB). However, the efficacy and safety of colistin are not well defined. Methods: A multicenter prospective randomized trial conducted in 32 European centers compared the efficacy and safety of colistin (4.5 million unit loading dose followed by a maintenance dose of 3 million units every 8 h) versus meropenem (2 g every 8 h), both in combination with levofloxacin (500 mg every 12 h) for 7–14 days in patients with late VAP. Between May 2012 and October 2015, 232 patients were randomly assigned to the 2 treatment groups. The primary endpoint was mortality at 28 days after randomization in the microbiologically modified intention-to-treat (mMITT) population. Secondary outcomes included clinical and microbiological cure, renal function at the end of the treatment, and serious adverse events. The study was interrupted after the interim analysis due to excessive nephrotoxicity in the colistin group; therefore, the sample size was not achieved. Results: A total of 157 (67.7%) patients were included in the mMITT population, 36 of whom (22.9%) had VAP caused by CR-GNB. In the mMITT population, no significant difference in mortality between the colistin group (19/82, 23.2%) and the meropenem group (19/75, 25.3%) was observed, with a risk difference of − 2.16 (− 15.59 to 11.26, p = 0.377); the noninferiority of colistin was not demonstrated due to early termination and limited number of patients infected by carbapenem-resistant pathogens. Colistin plus levofloxacin increased the incidence of renal failure (40/120, 33.3%, versus 21/112, 18.8%; p = 0.012) and renal replacement therapy (11/120, 9.1%, versus 2/112, 1.8%; p = 0.015). Conclusions: This study did not demonstrate the noninferiority of colistin compared with meropenem, both combined with levofloxacin, in terms of efficacy in the empirical treat

Background: Mechanically ventilated patients in the ICU are at a high risk for ventilator-associated pneumonia (VAP), and the rate of this hospital-acquired infection (HAI) is problematic. Nursing interventions utilize evidence-based practice (EBP) VAP prevention guidelines to decrease the incidence. The purpose of this paper is to examine the effects of staff education on the reduction of VAP in the critical care setting.Methods: Literature search was performed on two databases, CINAHL and PubMed. Search results were narrowed based on type of research article, relevance, and publication date, and eventually three studies were chosen. Results: In two of the studies, VAP incidence was shown to have decreased after staff education and one study had insignificant results, although there was a trend towards decreased VAP incidence. Length of stay significantly decreased post-intervention in two studies. Nurse adherence/concordance significantly increased in all studies.Conclusions: These findings show that staff education may decrease VAP incidence in ICUs, but further research needs to be performed to confirm these findings, as well as to determine the best form of education. Nurses are the primary individuals to prevent mechanically ventilated patients from acquiring VAP, and thus the next step would be focusing on how to improve long-term nurse adherence to preventative interventions and how to implement them into bedside practice.

BACKGROUND: Biofilm on the surface of endotracheal tubes (ETTs) is associated with ventilator-associated pneumonia. The use of silver-coated ETTs has been suggested to reduce the occurrence of ventilator-associated pneumonia by preventing biofilm formation. However, mucus accumulation can reduce the antibacterial activity of silver-coated ETTs by isolating bacterial colonies from the silver surface. We hypothesized that, in mechanically ventilated subjects, periodic removal of secretions through the use of a cleaning device would enhance the antimicrobial properties of silver-coated ETTs and thus reduce bacterial colonization. METHODS: Subjects were randomized to either standard suctioning (blind tracheal suctioning, control group) or blind tracheal suctioning plus cleaning maneuver every 8 h (treatment group). Tracheal aspirates were collected immediately before extubation for microbiological culture. After extubation, ETTs were collected for both cultural and non-cultural microbiological analysis and biofilm isolation. RESULTS: 39 subjects expected to be ventilated for > 48 h were enrolled; 36 ETTs (18 control, 18 treatment) and 29 tracheal samples (15 control, 14 treatment) were collected. Among the ETTs positive for bacterial colonization (15 vs 9, P =.18), cleaning maneuvers did not reduce microbial load, shown as the decimal logarithm of colony-forming units (CFU) per mL (1.6 ± 1.2 vs 0.9 ± 1.2 logCFU/mL, P =.15). There was a trend toward decreased biofilm deposition (439.5 ± 29.0 vs 288.9 ± 157.7 mg, P =.09) in the treated ETTs. No significant differences were observed in the number of positive tracheal aspirates (13 vs 10, P =.39) or in the microbial load (4.8 ± 4.0 vs 4.2 ± 3.8 logCFU/mL, P =.70) of tracheal secretions. Finally, no differences in the microbial load of Gram-positive organisms, Gram-negative organisms, or yeasts were found between the ETTs and tracheal aspirates of the 2 groups. CONCLUSIONS: In 39 critically-ill subjects intubated with silver

BACKGROUND: Endotracheal suctioning is mandatory to prevent complications caused by the retention of tracheal secretions. Endotracheal suctioning is often performed late, when patients show signs of respiratory and hemodynamic alterations. We conceived a prototype device that, when synchronized with the ventilator, automatically removes secretions collected below the endotracheal tube (ETT) cuff, thus avoiding endotracheal suctioning. The aim of our investigation was to assess the performance of this novel prototype in vitro. METHODS: Three studies were performed to examine the characteristics of the prototype. We tested device’s ability to generate an effective artificial cough flow (artificial cough maneuver) > 1 L/s by rapidly deflating the ETT cuff within the time of a sustained inflation (at 30 and at 40 cm H2O) (cough flow study). We also tested the prototype’s ability to remove the fluid positioned below the ETT cuff using saline dye (fluid removal study), and to prevent the aspiration of saline dye from above the ETT cuff during the deflation phase of the ETT cuff (aspiration study). The trachea model was positioned at 45° in the aspiration study, and horizontally in the other two studies. RESULTS: In the cough flow study, the prototype provided an effective artificial cough maneuver, with a mean ± SD of 1.78 ± 0.19 L/s (range, 1.42–2.14 L/s). The tracheal pressure after ETT cuff deflation never decreased below the PEEP level. In the fluid removal study, the prototype cleared the fluid from below the ETT cuff and the experimental trachea. No fluid was aspirated from the area above the ETT cuff toward the lower airways. CONCLUSIONS: We conceived an system capable of automatically expelling fluid from below the ETT cuff outside an experimental trachea by generating an artificial cough maneuver. This system may decrease the use of endotracheal suctioning and its complications. Future in vivo studies are needed to confirm this first in vitro evaluation.

Background: INTELLiVENT®-ASV (iASV) is a respiration mode on the Hamilton G5. The ventilator uses a closed-loop mechanism that automatically adjusts settings related to oxygenation and ventilation. Case presentation: A 47-year-old man underwent reconstruction surgery with free musculocutaneous flap for tongue resection. After surgery, the patient entered the ICU, and the iASV, which automatically changed only the percent minute volume (%MV) in respiration mode, was selected. On the second day, ventilator-associated pneumonia (VAP) was diagnosed, and the antibiotic treatment was changed. Using the settings of the iASV, automated FiO2 and positive end-expiratory pressure (PEEP) control were added to the ventilator mode. The patient’s oxygenation was improved. Conclusions: In a patient who developed VAP after surgery, ventilation was continued using iASV, and automated changes in PEEP and FiO2 settings were successfully made according to the open lung strategy, under short-staffed circumstances.

Background: Considerable discrepancies have been observed in the implementation of strategies to liberate patients from mechanical ventilation. The aim of this study was to describe critical care nurses’ knowledge of and self-reported and documented adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate and evaluate how these practices differ between patients with and without ventilator-associated pneumonia and between survivors and nonsurvivors. Methods: The survey was conducted in a tertiary-level hospital in Finland from October 2014 to June 2015. Actual adherence was evaluated based on documentation of performed practices. Results: A total of 86 critical care nurses responded to the survey, and 85 patients were followed. The levels of knowledge of and self-reported adherence to low tidal ventilation were 84.5% and 90.2%, respectively, and the median tidal volume was at a target level in 74.4% of patients. Regarding daily sedation interruption, the level of knowledge was 85.7%, the level of self-reported adherence was 77.3%, and documented adherence was 33.3%. The levels of knowledge and self-reported adherence regarding spontaneous breathing trials were 61.9% and 71.6%, respectively. Adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate did not differ between patients with (n = 20) and without (n = 65) ventilator-associated pneumonia and between survivors (n = 55) and nonsurvivors (n = 30). Conclusions: Lung-protective ventilation, including low-tidal ventilation and avoidance of high inspiratory plateau pressures, was well implemented and adhered to. The levels of knowledge and self-reported adherence versus documented adherence regarding daily sedation interruption and spontaneous breathing trial demonstrated insufficient implementation of local guidelines. There was no effect on the outcome.

Background: Nurse understaffing and increased nursing workload have been associated with increased risk of adverse patient outcomes and even mortality. Aim: To determine whether nurse staffing and nursing workload are associated with ventilator-associated pneumonia and mortality. Methods: This prospective, observational cohort study was conducted in a single tertiary-level teaching hospital in Finland during 2014–2015. The association between nurse staffing, nursing workload and prognosis was determined using daily nurse-to-patient ratios, Therapeutic Intervention Scoring System and Intensive Care Nursing Scoring System scores, and Intensive Care Nursing Scoring System indices. Ventilator-associated pneumonia was defined according to the Centers for Disease Control and Prevention criteria. Findings: Evaluable data was available for 85 patients. The overall ventilator-associated pneumonia and 28-day mortality rates were 23.5% and 35.3%, respectively. Nurse staffing, measured as the daily lowest nurse-to-patient ratio (P = 0.006) and median Intensive Care Nursing Scoring System index (P = 0.046), were significantly lower in patients with ventilator-associated pneumonia. In addition, nursing workload, measured as median scores obtained by the Therapeutic Intervention Scoring System (P = 0.009) and Intensive Care Nursing Scoring System (P = 0.03), was significantly higher in infected patients. The median (P = 0.02) and daily highest (P = 0.03) Intensive Care Nursing Scoring System scores were significantly higher in non-survivors. Conclusions: Lower nurse staffing and increased nursing workload are associated with ventilator-associated pneumonia and mortality, demonstrating that adequate staffing is a prerequisite for the availability and quality of critical care services.

High-dose colistin (COL) ensures adequate treatment of pneumonia caused by multidrug resistant gram-negative bacteria (MDR-GNB) but must be weighed against a higher risk of nephrotoxicity. Continuous veno-venous hemofiltration (CVVH) clears COL by filtering and membrane adsorption that permits to avoid dose accumulation and excessively high peak concentrations. We evaluated clinical/microbiological efficacy of the high-dose COL treatment under CVVH in patients with newly diagnosed MDR-GNB ventilator-associated pneumonia (VAP)., SCOPUS: ar.j, info:eu-repo/semantics/published

[Background]: Colistin is recommended in the empirical treatment of ventilator-associated pneumonia (VAP) with a high prevalence of carbapenem-resistant gram-negative bacilli (CR-GNB). However, the efficacy and safety of colistin are not well defined. [Methods]: A multicenter prospective randomized trial conducted in 32 European centers compared the efficacy and safety of colistin (4.5 million unit loading dose followed by a maintenance dose of 3 million units every 8 h) versus meropenem (2 g every 8 h), both in combination with levofloxacin (500 mg every 12 h) for 7-14 days in patients with late VAP. Between May 2012 and October 2015, 232 patients were randomly assigned to the 2 treatment groups. The primary endpoint was mortality at 28 days after randomization in the microbiologically modified intention-to-treat (mMITT) population. Secondary outcomes included clinical and microbiological cure, renal function at the end of the treatment, and serious adverse events. The study was interrupted after the interim analysis due to excessive nephrotoxicity in the colistin group; therefore, the sample size was not achieved. [Results]: A total of 157 (67.7%) patients were included in the mMITT population, 36 of whom (22.9%) had VAP caused by CR-GNB. In the mMITT population, no significant difference in mortality between the colistin group (19/82, 23.2%) and the meropenem group (19/75, 25.3%) was observed, with a risk difference of - 2.16 (- 15.59 to 11.26, p = 0.377); the noninferiority of colistin was not demonstrated due to early termination and limited number of patients infected by carbapenem-resistant pathogens. Colistin plus levofloxacin increased the incidence of renal failure (40/120, 33.3%, versus 21/112, 18.8%; p = 0.012) and renal replacement therapy (11/120, 9.1%, versus 2/112, 1.8%; p = 0.015). [Conclusions]: This study did not demonstrate the noninferiority of colistin compared with meropenem, both combined with levofloxacin, in terms of efficacy in the empiric

Objective: To evaluate the ability of the BioFire FilmArray Blood Culture Identification (BCID) panel to rapidly detect pathogens producing late-onset ventilator-associated pneumonia (VAP), a severe infection often produced by Gram-negative bacteria. These microorganisms are frequently multidrug resistant and typically require broad-spectrum empiric treatment. Methods: In the context of an international multicentre clinical trial (MagicBullet), respiratory samples were collected at the time of suspicion of VAP from 165 patients in 32 participating hospitals in Spain, Greece and Italy. Microorganisms were identified using the BCID panel and compared with results ob- tained by conventional microbiologic techniques. Results: Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae were the most commonly identified species, representing 54.7% (70/128) of microorganisms. The BCID panel showed high global specificity (98.1%; 95% confidence interval, 96e100) and negative predictive values (96.6%) and a global sensitivity and positive predictive value of 78.6% (95% confidence interval, 70e88) and 87.3%, respectively, for these microorganisms. Importantly, the BCID panel provided results in only 1 hour directly from respiratory samples with minimal sample processing times. Conclusions: The BCID panel may have clinical utility in rapidly ruling out microorganisms causing VAP, specifically multidrug-resistant Gram-negative species. This could facilitate the optimization of empiric treatment.

Background: Pathogenic enteric bacteria aspirated from the oropharynx are the main cause of ventilator-associated pneumonia (VAP). Using chlorhexidine (CHX) orally or selective decontamination has been shown to reduce VAP. In a pilot study we found that oral care with the probiotic bacterium Lactobacillus plantarum 299 (Lp299) was as effective as CHX in reducing enteric bacteria in the oropharynx. To confirm those results, in this expanded study with an identical protocol we increased the number of patients and participating centres. Methods: One hundred and fifty critically ill patients on mechanical ventilation were randomised to oral care with either standard 0.1% CHX solution (control group) or a procedure comprising final application of an emulsion of Lp299. Samples for microbiological analyses were taken from the oropharynx and trachea at inclusion and subsequently at defined intervals. Student’s t test was used for comparisons of parameters recorded daily and Fisher’s exact test was used to compare the results of microbiological cultures. Results: Potentially pathogenic enteric bacteria not present at inclusion were identified in oropharyngeal samples from 29 patients in the CHX group and in 31 samples in the probiotic group. Considering cultures of tracheal secretions, enteric bacteria were found in 17 and 19 samples, respectively. Risk ratios show a difference in favour of the Lp group for fungi in oropharyngeal cultures. VAP was diagnosed in seven patients in the Lp group and in 10 patients among the controls. Conclusions: In this multicentre study, we could not demonstrate any difference between Lp299 and CHX used in oral care procedures regarding their impact on colonisation with emerging potentially pathogenic enteric bacteria in the oropharynx and trachea. Trial registration: ClinicalTrials.gov, NCT01105819. Registered on 9 April 2010. First part: Current Controlled Trials, ISRCTN00472141. Registered on 22 November 2007 (published Critical Care 2008, 1