72-Hour Clinical Pulmonary Infection Score May Have Prognostic Value Among Trauma Patients With Ventilator Associated Pneumonia

Background: Ventilator-associated pneumonia (VAP) is a common, serious nosocomial infection; reduction of morbidity and mortality is achieved by prompt diagnosis and early initiation of appropriate empiric antimicrobial therapy. While Clinical Pulmonary Infection Score (CPIS) on the day of VAPdiagnosis has not been proven a consistently effective device, we postulate the CPIS 72 hours after VAPdiagnosis may serve as a clinical prognostic indicator. The purpose of this study is to assess the potential value of CPIS in trauma patients with VAP. Methods:We performed a retrospective chart review of 50 intubated trauma patients with VAPadmitted to the intensive care unit (ICU) of an urban level-I trauma center from January-December 2013. Patients were consecutively identied via trauma registry, and data were abstracted on demographics; injury severity score (ISS); vital signs; laboratory values; microbiological cultures; ventilator settings; antibiotic therapy; time of VAP diagnosis; outcomes; and survival to discharge. We calculated modied CPIS at initial diagnosis and 72-hours post-diagnosis. Incomplete records were excluded from analysis. Results: Forty-nine patients, 25 females and 24 males, with mean age of 66.1±5.2 years were analyzed. Overall mortality was 18.4% (n=9); mean ISS was 18.3±1.2; mean length of stay (LOS) was 20.7±3 days; mean ICU-LOS was 16.7±3.1 days; mean ventilator days was 15±3.2; mean day-1 CPIS was 5.8±0.5; and mean day-3 CPIS was 4.9±0.6. Multidrug resistant organisms (MDROs) were identied in 26 patients and associated with higher 72-hour CPIS (5.8±0.9 vs 3.7±0.7, p=0.025). 72-hour CPIS <6 was signicantly associated with shorter LOS (16.8±3.1 vs 27.3±5.2 d), shorter ICU-LOS (12.4±2.9 vs 24.1±5.6 d), shorter duration of mechanical ventilation (10.8±3 vs 22.1±5.9 d), and earlier VAPdiagnoses (hospital day 4.4±0.6 vs 7.1±1.4, p<0.001). Conclusions:Initial CPIS calculations after VAPdiagnosis have no clinical value. While not associated with survival to discharge, CPIS calculated 72 hours after VAPdiagnosis may be used as a prognostic indicator for MDROs and improved short-term outcomes for trauma patients.

Exhaled Nitric Oxide in Patients with Ventilator Associated Pneumonia / 대한구급학회지

BACKGROUND: Fraction of exhaled nitric oxide (FENO) is known as a marker of inflammation in asthma, cystic fibrosis and exacerbation of COPD. However, its importance has not been established in patients using mechanical ventilation. We assessed whether FENO is elevated in patients with ventilator associated pneumonia (VAP), and physiologic or pathologic factors affecting levels of FENO in patients with mechanical ventilation. METHODS: All patients (over 18-year-old) using mechanical ventilation were included, and among them, VAP patients were diagnosed on the basis of clinical pulmonary infection score (CPIS). We measured FENO in air collected during the end-expiratory pause via an off-line method. We compared the levels of FENO between patients with VAP and without, and assessed the relationship between FENO and other physiologic or pathologic characteristics; age, gender, PaO2, oxygenation index, CPIS. RESULTS: A total of 43 patients (23 male, mean age 67.7 +/- 10.7) in an ICU were enrolled; 19 of them were VAP-patients (10 male, mean age 64.8 +/- 12.9). The level of FENO in the VAP-patients was substantially higher than in the non-VAP group (55.8 +/- 25.3 ppb Vs. 31.8 +/- 13.5 ppb, p < 0.001). CPIS on day 1 and day 3, and duration of mechanical ventilation, were associated with the level of FENO, but oxygenation index, PaO2, PaO2/FiO2, and the mean PEEP were not. CONCLUSIONS: FENO may be useful for the diagnosis of VAP, and is related to CPIS, as well as the duration of mechanical ventilation.

Clinical usefulness of Clinical Pulmonary Infection Score of ICU Patients with Sputum Culture positive for Multi-drug resistant Acinetobacter baumannii / 결핵

BACKGROUND: The hospital-acquired pneumonia is the most common nosocomial infection. Recently, the Acinetobacter baummannii infections are rapidly increasing, especially the frequency of Multi-drug resistant A. baumannii. Therefore we assessed clinical features and prognosis of patients in the ICU with Multi-drug resistant A. baumannii from the sputum culture using the Clinical Pulmonary Infection Score(CPIS). METHODS: The medical records of 43 patients with Multi-drug resistant A. baumannii from sputum culture who were suspected had clinically pneumonia and admitted to the ICU from January 2000 to July 2002 were retrospectively analyzed. RESULT: 19 patients were CPIS greater than 6 and 24 patients were CPIS less than or equal to 6. Mean age for the former was 71+/-11 years old, and the latter was 61+/-19 years old. The mean APACHE II score on admission and on sputum study was not different between two groups(17.4+/-5.7 vs 18.5+/-6.1, p=0.553, 20+/-6 vs 17+/-8, p=0.078). But the mortality rate was 73.7% for the former, and 16.7% for the latter(p<0.001). CONCLUSION: In ICU patients who had clinically suspected pneumonia with sputum culture positive for Multi-drug resistant A. baumannii, the mortality was significantly higher if CPIS was greater than 6.