Microbial Profile of Ventilator Associated Pneumonia in a Medical Intensive Care Unit of a Tertiary Care Hospital in Bangalore.

Ventilator Associated Pneumonia (VAP) is an important infection most often encountered in mechanical ventilation (MV) patients in intensive care units in hospital. VAP occurs in approximately 9 - 27% of patients who are intubated. The morbidity and mortality associated with VAP is more inspite of recent advances in diagnosis and accurate management. Emergence of multidrug resistance among the pathogens causing VAP is also contributing to the outcome. We wanted to isolate the bacterial pathogens, study the antibiotic susceptibility pattern of the isolates and detect the presence of drug resistance in various pathogens.METHODSThis is a retrospective, cross sectional study done on samples received between 2016 to 2018 among patients on MV for >/= 48 hours. Endotracheal aspirates were collected from 85 patients with assumed VAP, clinical pulmonary infection score (CPIS) was noted and aerobic quantitative cultures were performed on all samples. VAP was diagnosed by count of pathogenic organisms isolated >/= 105 cfu/mL. Identification and antibiotic susceptibility of the isolates were done as per the standard laboratory procedures. Patients with characteristic features i.e. clinical and radiological signs of pneumonia on admission were excluded from the study.RESULTS50 cases were diagnosed as VAP by CPIS. Gender ratio was 30:20 (male to female) higher incidence 42% of VAP was seen in the age group of 46-60 years. Majority were Gram negative bacilli; 96%- Klebsiella 36%, Acinetobacter 26% E. coli 16%, Pseudomonas 14%, and Citrobacter 4% along with coagulase positive Staphylococcus in 4%. Of the 50 VAP patients, single organism was isolated in 92% and polymicrobial in 8%. Most of the isolates showed resistance to Amoxiclav, Cefepime, Cefixime and Meropenem.CONCLUSIONSGood compliance with VAP bundle adopted in critical care areas by the health care workers will reduce the incidence of VAP. Early and accurate diagnosis, appropriate empirical and specific antimicrobial use may significantly improve patient outcome.

Intubation Performed In The Emergency Department Is Associated With Increased Pulmonary Complications

Ventilator Associated Pneumonia (VAP) is among the most common hospital acquired infections. Trauma patients are known to have a unique predisposition to the development of pneumonia. At our urban level 1 trauma center, we noticed variability in the incidence of aspiration and pneumonia among intubated patients with similar levels of injury severity. In an attempt to discern why, we hypothesized that location of intubation was a risk factor for development of in-hospital complications. We performed a retrospective cohort study over a 6 month period using adult patients admitted to our trauma service. Intubations performed were reported from four different locations: Emergency Department (ED), operating room (OR), intensive care unit (ICU) and the surgical floor. Data obtained included location of intubation, age, Acute Injury Score (AIS), days on a ventilator, incidence of pulmonary infection, incidence of aspiration, intubation difficulty, ICU length of stay (ICU-LOS), hospital length of stay (HLOS), and survival. One way analysis of variance (ANOVA) was then performed. Our study included 96 enrolled patients consisting of 13 women and 83 men with a mean age of 49.5. Patients intubated in the ED, in comparison to patients intubated on the surgical floor, ICU or OR, were noted to have a statically significant increase in ventilator days (10.9 days), ICU length of stay (12.1 days), HLOS (18.8 days). Additionally, incidence of pulmonary infection (63.9%) and incidence of aspiration (37.7%) were noted to be increased with no statistically significant change in survival. In conclusion, trauma patients requiring emergent intubation in the ED are uniquely predisposed towards development of pneumonia and inhospital morbidity. These patients should be aggressively managed with strategies aimed at VAPprevention.

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.

Prevalent strains of pathogens with antibiotic resistance isolated from patients with ventilator-associated pneumonia in pediatric intensive care unit / 中华急诊医学杂志

Objective To study the pathogenic bacteria strains with drug-resistance prevailing in patients with ventilator-associated pneumonia(VAP)in Pediatric Intensive Care Unit(PICU)in order to provide a reasonable guidance to the clinical use of suitable antibiotics.Method A retrospective clinical study in 46 patients with VAP was carried out in PICU of Wuhan Children's Hospital between January 2008 and June 2010.The prevalent strains of the pathogenic bacteria with drug-resistance isolated from lower respiratory tract by aspiration were analyzed.Results In total,119 pathogenic microbial strains were isolated including Gram-negative bacilli(G-,65.55%),fungi(21.01%)and Gram-positive cocci(G+,13.45%).Among pathogens,the most common pathogenic strains were Acinetobacter baummannii, Escherichia coli,Klebsiella pneumoniae,candida albicans and coagulase-negative staphylococci.Antibiotic susceptibility tests indicated that the situation of the multiple drug-resistances to antibiotics found in G- and G+ Was serious. Most of G- were sensitive to ciprofloxacin, amikacin, imipenem, meropenem,cefoperazone-sulbaetam and piperacillin-tazobactam.The G+ cocci were 100% susceptibility to vancomycin, teicoplanin and linezolid.Fungi were almost sensitive to all the anti-funaus agents. Conclusions The oredominant oathogens of VAP were G- bacilli,and their multiple drug-resistances to antibiotics were the serious problems.The monitoring of the drugresistance should be emphasized, and the option of antibiotics should depend on the antibiotic sensitivity test.

Risk factors for ventilator-associated pneumonia in patiens with multiple organ dysfunction sysdrome / 中华急诊医学杂志

60 years old)was significantly higher (41)than that in patients

Distribution and Drug Resisance of Pathogens Isolated from Ventilator-associated Pneumonia Patients in ICU / 中华医院感染学杂志

OBJECTIVE To know the distribution and drug resistance of the ventilator-associated pneumonia(VAP) bacteria in the intensive care unit(ICU),and to provide a reasonable basis for the clinical use of antibiotics. METHODS We used the Tiek Biagnostic systems to identifly microorganisms and antibiotic susceptibility.The result of the drug sensitivity test was analyzed with SPSS13.0. RESULTS A total of 538 strains were isolated from the sputum samples of the ventilator-associated pneumonia patients in the ICU over the last 4 years,in which Gram-negative bacteria were 361(the isolation rate 69.3%).Pseudomonas aeruginosa was the most common.Gram-positive bacteria were 143(the isolation rate 26.6%),in which Staphylococcus aureus was the most common.Twenty-two strain were fungi(the isolation rate 4.1%).Most of the pathogenic bacteria maintained high sensitivity rate to imipenem,vancomycin and quinupristin/daefopristin;but the drug resistance rate to other antibiotics was high and on the rise year by year. CONCLUSIONS The pathogens types of VAP was,complex,and multi-drug resistant.We should emphasize the reasonable application of the antibiotics and strengthen the monitoring of drug resistantce,and rational use of antibiotics to improve the cure rate.

A Prospective Study on the lncidence of Ventilator-associated Pneumonia in Patients with Circuit Changes every 3 days Versus Weekly Changes / 병원감염관리

BACKGROUND: Ventilator associated pneumonia (VAP) is the most serious nosocomial infection of intensive care units. Several studies have investigated the relationship between the interval of ventilator circuit changes and the incidence of pneumonia in foreign countries, but there are no reports about it in Korea yet. So we performed this study to compare the clinical and cost impact between 3 days and 7 days interval in ventilator circuit changes. METHODS: Seoul National University Hospital is a 1,500-bed, university affiliated, tertiary and acute care hospital. All patients admitted to medical intensive care unit (MICU) and surgical intensive care unlt (SICU) between April 1, 1998 and October 31, 1998, requiring mechanical ventilation were included. Patients were divided into two groups of a-cay circuit changes and weekly changes. Daily surveillance was conducted using the criteria of VAP of the National Nosocomial Infection Surveillance System. Incidence of VAP and risk factors for VAP were evaluated. Standard microbiologic methods were used for the identification of clinical and environmental isolates. Statistical analysis was done by SAS Program (version 6.12), analysis of difference in variables was performed using chi-square test and t-test. Analysis of odds ratios was done with logistic regression analysis. RESULTS: VAP developed at a rate of 12.2 per 1,000 ventilator-days in the 3 days change group and 15.6 per 1,000 ventilator-days in the weekly change group (P=0.7240). The only statistically significant risk factor of VAP was duration of mechanical ventilation, The risk of VAP in patients with more than 7 days was 2.23 times higher than in patients with 7 days and below (OR; 2.2296). Estimated annual savings of nursing time by extending ventilator circuit change interval from 3 days to 7 days were 26,806 min 48 sec and estimated savings of cost by reduction of nursing times was calculated as 6,701,700 won. CONCLUSIONS: Weekly ventilator circuit changes in patients undergoing ventilation therapy in the ICU do not contribute to increased the rates of VAP and are cost-effective.

Implication of quantitative culture of bronchoalveolar lavage fluid in the diagnosis of ventilator assocaited pneumonia in patients with antimicrobial therapy / 결핵

BACKGROUNDS: Authors evaluated the quantitative culture of bronchoalveolar lavage fluid(BALF) in patients who were being treated with antimicrobial agents and the characteristics of isolated microorganism. METHOD: A prospective study was done with 25 patients under mechanical ventilation and antimicrobial treatment in ICU and NCU of Yongdong Severance Hospital from Apr. to Sep. 1999. Patients were classified into two groups: control group (n=5) and patients with VAP (n=20). The threshold of quantitative culture of BAL fluid in the diagnosis of VAP was 104 cfu/ml. RESULTS: 1) In gram staining of BALF, one patient in the control group and four in the VAP group showed positive results. Quantitative culture of BALF showed no organisms in the patients in the control group and in 9 VAP patients. Therefore the overall sensitivity was 43.8%. 2) Frequency of isolated organisms cultured above diagnostic threshold was in the following other : E. cloacae, S. aureus, K. pneumoniae, and A. baumani. S. aureus and Staphylococcus coagulase(-) were all resistant to oxacillin. Seven out of 10 isolated G (-) organisms were suspected to be organisms producing extended spectrum β-lactamase (ESBL). 3) The concurrence between gram staining of sputum aspiration and that of BALF was only in 1 case. And the concurrence of culture results was observed in 3 cases. CONCLUSION: The sensitivity of gram staining and quantitative culture of BALF from patients under antibiotic therapy and the concordance rate between conventional tracheal aspiration and BAL were low, facts which were important in interpretation the data. Since the frequency of drug resistance organisms was not different from that of foreign data, antibiotics must be prudently selected and used.

Curative Effects of Houtuynia Cordata Injection as A Aajuvant on Ventilator-associated Pneumonia Complicated with Respiratory Muscle Paralysis Caused by Acute Organophosphorus Pesticide Poisoning / 中成药

0.05), but the symptom of fever and character of respiratory tract's secretion of the patients in experiment group took turns for better obviously than the control group's ( P