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Abstract Objective: Rates of ventilator-associated pneumonia (VAP) in low- and middle-income countries (LMIC) are several times above those of high-income countries. The objective of this study was to identify risk factors (RFs) for VAP cases in ICUs of LMICs. Design: Prospective cohort study. Setting: This study was conducted across 743 ICUs of 282 hospitals in 144 cities in 42 Asian, African, European, Latin American, and Middle Eastern countries. Participants: The study included patients admitted to ICUs across 24 years. Results: In total, 289,643 patients were followed during 1,951,405 patient days and acquired 8,236 VAPs. We analyzed 10 independent variables. Multiple logistic regression identified the following independent VAP RFs: male sex (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.16–1.28; P < .0001); longer length of stay (LOS), which increased the risk 7% per day (aOR, 1.07; 95% CI, 1.07–1.08; P < .0001); mechanical ventilation (MV) utilization ratio (aOR, 1.27; 95% CI, 1.23–1.31; P < .0001); continuous positive airway pressure (CPAP), which was associated with the highest risk (aOR, 13.38; 95% CI, 11.57–15.48; P < .0001); tracheostomy connected to a MV, which was associated with the next-highest risk (aOR, 8.31; 95% CI, 7.21–9.58; P < .0001); endotracheal tube connected to a MV (aOR, 6.76; 95% CI, 6.34–7.21; P < .0001); surgical hospitalization (aOR, 1.23; 95% CI, 1.17–1.29; P < .0001); admission to a public hospital (aOR, 1.59; 95% CI, 1.35-1.86; P < .0001); middle-income country (aOR, 1.22; 95% CI, 15–1.29; P < .0001); admission to an adult-oncology ICU, which was associated with the highest risk (aOR, 4.05; 95% CI, 3.22–5.09; P < .0001), admission to a neurologic ICU, which was associated with the next-highest risk (aOR, 2.48; 95% CI, 1.78–3.45; P < .0001); and admission to a respiratory ICU (aOR, 2.35; 95% CI, 1.79–3.07; P < .0001). Admission to a coronary ICU showed the lowest risk (aOR, 0.63; 95% CI, 0.51–0.77; P < .0001). Conclusions: Some identified VAP RFs are unlikely to change: sex, hospitalization type, ICU type, facility ownership, and country income level. Based on our results, we recommend focusing on strategies to reduce LOS, to reduce the MV utilization ratio, to limit CPAP use and implementing a set of evidence-based VAP prevention recommendations.

Background In the neurosurgical patient community, infection rate depends on the severity of neurological injuries at the time of presentation, which is measured by the Glasgow coma score (GCS). In addition, associated comorbidities; exposure to invasive devices such as endotracheal tube, central venous catheters, and urinary catheters; and neuroscience-specific devices, such as ventricular/lumbar catheters, increase chances of infection. We share our experience from a dedicated neurosurgical intensive care unit (NSICU) of a super speciality tertiary care hospital in north India. Patients and Methods This is a 3-year retrospective and observational study from January 2014 to December 2016. Total 2,608 patients were admitted to NSICU during this period; 229 patients were included whose cultures were collected after 48 hours of admission and were positive. We have analyzed patient's risk factors, length of stay (LOS), outcome, organism details, and those health care–associated infections (HAI) that fulfilled the CDC (Centers for Disease Control and Prevention) criteria. Results Out of 2,608 patients admitted, 229 were culture positive after 48 hours of admission and 53 developed HAIs (53/2,608 [2.03%]). Male-to-female ratio was 2:1. One hundred three patients had a low GCS (5–8) and 126 had a high GCS (9–15). Average LOS in ICU was 6 days, and mortality was 17.4% (40/229). A total of 57 laboratory-confirmed positive cultures were identified in 53 patients. This included 35 from urine, 15 from blood, 2 from surgical wound, and 1 from respiratory tract. Among the HAI, the rate of ventilator-associated pneumonia (VAP) was 0.22, central line-associated bloodstream infection (CLABSI) 3.43, catheter-associated urinary tract infection (CAUTI) 5.93, and surgical site infection (SSI) 0.9%. Conclusion Neurosurgical patients are particularly vulnerable to infection because of the formidable nature of their illness, frequency of associated trauma, and presence of invasive devices. In our study, lower rate of HAIs was observed because we have a dedicated NSICU, strict infection control practices, an appropriate antimicrobial stewardship program, and early shifting of neurosurgical patients to an appropriately staffed high-dependency unit/ward.

Intractable intracranial hypertension is a nerve wrecking clinical challenge which is associated with high morbidity and mortality. Barbiturate coma therapy (BCT) is one of the recommended options for such a challenge but is associated with its own set of complications. Multimodality monitoring is a new advent in neurocritical care and provides a new vision to judiciously cater to such challenges. We hereby report a case of successfully treating intractable intracranial hypertension after maximal possible surgical decompression and evidence of well-formed cerebral ischaemic zones with intracranial multimodality monitoring guided BCT. The positive outcome was to the extent of almost complete reversal of cerebral ischaemic zones and return to normal life schedule.