Prevalence, outcomes, and predictors of multidrug-resistant nosocomial lower respiratory tract infections among patients in an ICU / Prevalência, desfechos e preditores de infecções nosocomiais do trato respiratório inferior multirresistentes em pacientes em uma UTI

ABSTRACT Objective: To determine the prevalence, outcomes, and predictors of multidrug-resistant nosocomial lower respiratory tract infections (LRTI) in patients in an ICU. Methods: This was an observational cohort study involving patients with nosocomial LRTI (health care-associated pneumonia, hospital-acquired pneumonia, or ventilator-associated pneumonia). Data were prospectively collected between 2015 and 2019. The multidrug-resistant pathogens (MDRPs) identified in the isolates studied included resistant to extended-spectrum cephalosporin-resistant and carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa, carbapenem-resistant Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus at microbiological diagnosis. Results: During the study period, 267 patients in the ICU were diagnosed with LRTI, microbiological confirmation of LRTI having been obtained in 237. Of these, 146 (62%) had at least one MDRP isolate. Patients infected with MDRP were found to have poorer outcomes than patients infected with susceptible strains, such as prolonged mechanical ventilation (18.0 days vs. 12.0 days; p < 0.001), prolonged ICU length of stay (23.0 days vs.16.0 days; p < 0.001), and higher mortality (73% vs. 53%; p < 0.001) when compared with patients infected with susceptible strains. Hospital length of stay ≥ 5 days (OR = 3.20; 95% CI: 1.39-7.39; p = 0.005) and prolonged use vasoactive drugs (OR = 3.15; 95% CI: 1.42-7.01; p = 0.004) were independent predictors of LRTI caused by MDRPs (LRTI-MDRP). The presence of LRTI-MDRP was found to be an independent predictor of death (OR = 2.311; 95% CI: 1.091-4.894; p = 0.028). Conclusions: Prolonged use of vasoactive drugs and prolonged hospital length of stay were independent predictors of LRTI-MDRP in this population of critically ill patients with very poor outcomes.

RESUMO Objetivo: Determinar a prevalência, os desfechos e os preditores de infecções do trato respiratório inferior (ITRI) nosocomiais em pacientes em uma UTI. Métodos: Estudo observacional de coorte com pacientes com ITRI nosocomiais (pneumonia associada à assistência à saúde, pneumonia adquirida no hospital ou pneumonia associada à ventilação mecânica). Os dados foram coletados prospectivamente entre 2015 e 2019. Os patógenos multirresistentes (PMR) identificados nos isolados estudados incluíram Acinetobacter baumannii, Klebsiella pneumoniae e Pseudomonas aeruginosa resistentes a cefalosporinas de espectro estendido e carbapenêmicos, enterobactérias resistentes a carbapenêmicos e Staphylococcus aureus resistente à meticilina no diagnóstico microbiológico. Resultados: Durante o período do estudo, 267 pacientes internados na UTI foram diagnosticados com ITRI, 237 dos quais tiveram confirmação microbiológica de ITRI. Destes, 146 (62%) apresentaram pelo menos um isolado de PMR. Os pacientes infectados por PMR tiveram piores desfechos do que os infectados por cepas sensíveis, como ventilação mecânica prolongada (18,0 dias vs. 12,0 dias; p < 0,001), tempo prolongado de internação na UTI (23,0 dias vs. 16,0 dias; p < 0,001) e maior mortalidade (73% vs. 53%; p < 0,001). Tempo de internação hospitalar ≥ 5 dias (OR = 3,20; IC95%: 1,39-7,39; p = 0,005) e uso prolongado de drogas vasoativas (OR = 3,15; IC95%: 1,42-7,01; p = 0,004) foram preditores independentes de ITRI por PMR (ITRI-PMR). A presença de ITRI-PMR foi um preditor independente de óbito (OR = 2,311; IC95%: 1,091-4,894; p = 0,028). Conclusões: O uso prolongado de drogas vasoativas e o tempo prolongado de internação hospitalar foram preditores independentes de ITRI-PMR nesta população de pacientes críticos com desfechos muito ruins.

Fatores de sucesso em colaborativa para redução de infecções relacionadas à assistência à saúde em unidades de terapia intensiva no Nordeste do Brasil / Success factors of a collaborative project to reduce healthcare-associated infections in intensive care units in Northeastern Brazil

RESUMO Objetivo: Descrever a implementação e os resultados da colaborativa PROADI-SUS, do Ministério da Saúde Brasileiro, para redução das infecções relacionadas à assistência à saúde: pneumonia associada à ventilação mecânica, infecção primária da corrente sanguínea associada ao cateter venoso central e infecção do trato urinário associada ao cateter vesical de demora. Métodos: Estudo observacional prospectivo que pesquisou as etapas da implementação e dos resultados por 18 meses, em cinco unidades de terapia intensiva de Recife. As reduções de infecções relacionadas à assistência à saúde em cada unidade foram calculadas pelas medianas anteriores comparadas ao período do estudo. Resultados: A meta de redução das três infecções relacionadas à assistência à saúde, ou seja, 30% em 18 meses, foi obtida em no mínimo uma das infecções relacionadas à assistência à saúde nas cinco unidades de terapia intensiva, sendo ainda atingida para duas infecções relacionadas à assistência à saúde em dois hospitais e nas três infecções relacionadas à assistência à saúde em apenas um hospital; este último atingiu a meta prevista para 36 meses. Foram ações consideradas essenciais pelas equipes gestoras locais a implantação dos bundles e o acompanhamento dos resultados pelos profissionais. Também, aquisição de insumos e disponibilização junto aos leitos, sinalização, checklists, conscientização da equipe, adaptação, criação de times, treinamento e comemoração de conquistas foram avaliados como relevantes para redução das infecções relacionadas à assistência à saúde. Conclusão: A colaborativa reduziu infecções relacionadas à assistência à saúde, apesar da adesão parcial aos bundles. A hipótese é a de que o êxito se relacione com a metodologia do projeto e equipes multiprofissionais motivadas, especialmente a enfermagem.

ABSTRACT Objective: To describe the implementation and results of the collaborative PROADI-SUS project by the Brazilian Ministry of Health to reduce healthcare-associated infections: ventilator-associated pneumonia, primary central line-associated bloodstream infection and catheter-associated urinary tract infections. Methods: This was a prospective observational study that investigated the implementation stages and outcomes during 18 months in five intensive care units in the city of Recife. Reductions in healthcare-associated infections in each unit were calculated using previous medians compared to those of the study period. Results: The goal of reducing the three healthcare-associated infections, i.e., 30% in 18 months, was achieved in at least one of the healthcare-associated infections and was also achieved for two healthcare-associated infections in two hospitals and three healthcare-associated infections in just one hospital; the latter reached the target of 36 months. Implementing the bundles and monitoring the results by the professionals were considered essential actions by the local management teams. In addition, the acquisition of supplies and their availability alongside the beds, signage, checklists, staff awareness, adaptation, team building, training and celebration of achievements were assessed as being relevant for reducing healthcare-associated infections. Conclusion: The collaborative approach reduced healthcare-associated infections, despite partial adherence to the bundles. The hypothesis is that success is related to the project methodology and motivated multidisciplinary teams, especially nursing teams.

Características de los pacientes con neumonía asociada a la ventilación mecánica en el Hospital Nacional

Resumen Introducción: La neumonía asociada a la ventilación mecánica (NAVM) es una de las infecciones intrahospitalarias más frecuente en cuidados intensivos. Aunque su mortalidad es controversial, se asocia con una mayor morbimortalidad, siendo la segunda en frecuencia de las infecciones asociadas a la atención de salud. Materiales y métodos: Estudio observacional, descriptivo de corte transversal con muestreo no probabilístico de casos consecutivos de pacientes con neumonía asociada a la ventilación mecánica del Hospital Nacional de enero a agosto de 2021. Resultados: Se incluyeron un total de 47 pacientes con edades comprendidas entre 19 a 76 (48,77±13,39). El 61,7% (n=29) pertenecía al sexo masculino. Se aisló Acinetobacter baumannii en el 11% de los hemocultivos y en el 19% de las secreciones traqueales. Se utilizó triple terapia antibiótica, siendo la combinación más frecuente meropenem junto con colistina y tigeciclina. Conclusión: El microorganismo más frecuente fue el Acinetobacter baumannii, tanto en hemocultivo como en secreción traqueal. La mayoría de los pacientes perteneció al sexo masculino y a una edad comprendida entre 36 y 45 años.

Abstract Introduction: Pneumonia associated with mechanical ventilation (VAP) is one of the most frequent intrahospital infections in intensive care, although its mortality is controversial, it is associated with higher morbidity and mortality, being the second in frequency in Healthcare-Associated infections. Materials and methods: Observational, descriptive cross-sectional study with non-probabilistic sampling of consecutive cases of patients with pneumonia associated with mechanical ventilation at the National Hospital from January to August 2021. Results: A total of 47 patients with ages ranging from 19 to 76 (48.77 ± 13.39) were included. 61.7% (n = 29) belonged to the male sex. Acinetobacter baumannii was isolated from 11% of blood cultures and 19% of tracheal secretions. Triple antibiotic therapy was used, the most frequent combination being meropenem plus colistin plus tigecycline. Conclusion: The most frequent microorganism was Acinetobacter baumannii, both in blood culture and in tracheal secretion. Most of the patients were male and aged between 36 and 45 years.

Infecciones nosocomiales en unidades de observación de emergencia y su asociación con el hacinamiento y la ventilación / Nosocomial infections in emergency observation units and their association with overcrowding and ventilation

RESUMEN Con el objetivo de medir la frecuencia de las infecciones nosocomiales en las unidades de observación de medicina interna de los servicios de emergencia en dos hospitales de nivel III de Lima, se realizó un estudio de prevalencia de periodo durante cinco días en pacientes admitidos después de las 72 horas de observación y con descarte de infección comunitaria, utilizando datos obtenidos de las historias clínicas. Adicionalmente, se evaluó el hacinamiento y la ventilación de las salas de hospitalización. La frecuencia de las infecciones nosocomiales en los servicios de emergencia fue 8,1%, cuatro veces lo reportado como prevalencia de periodo en el Perú. Los factores de riesgo asociados fueron el tiempo prolongado de estancia y la carencia de ventilación apropiada del ambiente hospitalario. La ventilación inapropiada triplica el riesgo de aparición de infecciones nosocomiales.

ABSTRACT The aim of this study was to measure the frequency of nosocomial infections in the internal medicine observation units of the emergency services in two level III hospitals in Lima. A 5-day prevalence study was carried out on patients admitted after a 72 hours observation period, in whom community-based infections were ruled out. Data was obtained from clinical records. Additionally, overcrowding and ventilation in the hospitalization rooms were evaluated. The frequency of nosocomial infections in the emergency services was found to be 8.1%, four times what was reported as period prevalence in Peru. The associated risk factors were prolonged length of stay and lack of proper ventilation in the hospital environment. Inadequate ventilation triples the risk of nosocomial infections.

Ventilación e intubación respiratoria como factores de riesgo para neumonía en un hospital del tercer nivel / Respiratory ventilation and intubation as risk factors for pneumonia in a tertiary hospital

Introducción: La neumonía asociada a la atención de salud empeora el pronóstico clínico del paciente y genera presión económica sobre los sistemas de salud. Objetivo: Determinar el riesgo de adquirir esta enfermedad en pacientes expuestos a ventilación/intubación y otros factores intrínsecos y extrínsecos. Métodos: Estudio transversal analítico. Población de estudio, pacientes hospitalizados en el Hospital Nacional Adolfo Guevara Velazco del Cusco en el 2017. Se seleccionó una muestra conformada por dos grupos: con diagnóstico de neumonía y sin este. El tamaño de muestra calculado fue de 67 (15 grupo neumonía y 52 grupo no neumonía). El análisis inferencial se realizó en dos etapas, utilizando pruebas de contraste de hipótesis y luego regresión logística. Se recogieron factores intrínsecos y extrínsecos de cada paciente. Resultados: La mayoría de pacientes correspondió al sexo femenino (53,7 por ciento). La mediana de edad fue de 70,6 años. El servicio de unidad de cuidados intensivos tuvo la mayor proporción de casos (42,9 por ciento). Se encontró asociación significativa con el uso de ventilación/ intubación y, además con los factores extrínsecos como traqueostomía, aspiración de secreciones, nutrición enteral y transfusión sanguínea. Ninguno de los factores intrínsecos tuvo asociación significativa en el análisis bivariado. En el análisis de regresión logística los pacientes sometidos a ventilación/intubación tuvieron 5,27 veces el riesgo de contraer neumonía y los pacientes sometidos a transfusión sanguínea tuvieron 12,75 veces el riesgo. Conclusiones: Los pacientes expuestos a ventilación/intubación tuvieron mayor riesgo de desarrollar neumonía asociada a la atención de salud. La transfusión sanguínea también fue un factor asociado(AU)

Introduction: Healthcare-associated pneumonia worsens the clinical prognosis of patients and exerts economic pressure on health systems. Objective: Determine the risk for healthcare-associated pneumonia among patients exposed to ventilation / intubation and other intrinsic and extrinsic factors. Methods: An analytical cross-sectional study was conducted of the patients admitted to Adolfo Guevara Velazco National Hospital in Cusco in the year 2017. A sample was chosen which was composed of two groups: with and without a pneumonia diagnosis. The estimated sample size was 67 (15 in the pneumonia group and 52 in the non-pneumonia group). Inferential analysis was performed along two stages, using hypothesis contrast tests followed by logistic regression. Intrinsic and extrinsic factors were collected for each patient. Results: Most patients were female (53.7 percent). Mean age was 70.6 years. The intensive care unit service had the highest proportion of cases (42.9 percent). A significant association was found with the use of ventilation / intubation, as well as with extrinsic factors such as tracheostomy, secretions aspiration, enteral nutrition and blood transfusion. None of the intrinsic factors had a significant association in the bivariate analysis. In the logistic regression analysis, patients subjected to ventilation / intubation had 5.27 times the risk of contracting pneumonia, whereas patients subjected to blood transfusion had 12.75 times the risk. Conclusions: Patients exposed to ventilation / intubation were at greater risk of developing healthcare-associated pneumonia. Blood transfusion was another associated factor(AU)

Conocimiento y prácticas del profesional de enfermería sobre prevención de neumonía asociada a ventilación mecánica / Knowledge and practice of nursing personnel in the prevention of mechanical ventilation associated pneumonia

RESUMEN Fundamento: la neumonía asociada a ventilación mecánica representa uno de los mayores problemas en las unidades de cuidados intensivos debido a que agrava el cuadro clínico del paciente, prolonga su estancia en el hospital e incrementa el costo, por todo esto es que el personal de enfermería es el principal actor en el control de estas infecciones ya que estos son eventos asociados a la asistencia sanitaria y en su mayoría prevenibles. Objetivo: evaluar el conocimiento y la práctica del personal de enfermería acerca de las medidas de prevención de neumonía nosocomial en los pacientes con ventilación mecánica. Métodos: se realizó un estudio transversal con enfoque cuantitativo durante el 1ro de junio hasta 31 agosto de 2018, la población de estudio fueron el personal de enfermería de la unidad de cuidados intensivos constituida por 22 enfermeros a los que se les aplicó un cuestionario y una guía de observación estructurada. Resultados: de los enfermero/as evaluados, se evidencia que poseen conocimientos teóricos y prácticos, se resalta los relacionados con el uso de barreras de protección, posición adecuada para realizar la aspiración endotraqueal así como la frecuencia en que se debe aplicar. Conclusiones: existe un adecuado conocimiento teórico y desempeño práctico del personal de enfermería en la atención al paciente crítico ventilado, donde se evidencia que la cantidad de la experiencia laboral no afecta la calidad del cuidado brindada a los pacientes.

ABSTRACT Background: ventilator associated pneumonia represents one of the major problems in the intensive care unit due to the fact that it aggravates the patient's clinical condition, prolongs hospital stay and increases the cost of hospitalization. As infection is preventable and healthcare related, its control is mainly attributed to the nursing staff. Objective: to evaluate the knowledge and nursing practice involved in the methods of prevention of hospital acquired pneumonia in patients with mechanical ventilation. Methods: a quantitative, cross-sectional study was employed from June 1st until August 31st, 2018. A structured, observational guide and a questionnaire was applied to the population composed of 22 nursing personnel in the intensive care unit. Results: of the evaluated nurses, it was found out that they possess knowledge of both theory and practice, particularly, regarding the use of protective barriers, correct position for endotracheal aspiration and as well as the number of times the procedure should be applied. Conclusions: adequate knowledge about theory and practice exists among nurses who attended mechanically ventilated patients in critical condition. Moreover, the quantity of nursing work experience does not affect the quality of care given to the patients.

Neumonía asociada a la ventilación mecánica en pacientes atendidos en una unidad de cuidados intensivos / Pneumonia associated with mechanical ventilation in patients treated in an intensive care unit

RESUMEN Introducción: la neumonía asociada a la ventilación mecánica presenta alta incidencia y mortalidad en las unidades de cuidados intensivos. Objetivo: caracterizar a los pacientes con ventilación mecánica, ingresados en la Unidad de Cuidados Intensivos No. 2 del Hospital General Docente Abel Santamaría durante el año 2018 Método: se realizó un estudio observacional descriptivo de corte transversal, en pacientes con diagnóstico de neumonía asociada a la ventilación mecánica. El universo estuvo constituido por los 92, con los que se trabajó en su totalidad. Se empleó la prueba Chi Cuadrado y Odds Ratio, así como la distribución mediante frecuencia absoluta y relativa porcentual Resultados: se encontró predominio de pacientes del sexo masculino (54,35 %), del grupo etario de 70 a 79 años de edad (32,6 %), y diagnóstico al ingreso de enfermedad cerebrovascular (36,96 %). La neumonía asociada a la ventilación mecánica tardía representó el 76,08 % y los gérmenes Gram negativos el 86,96 %, predominaron los pacientes con Enterobacter, sp (47,83 %). La ventilación mecánica de más de 14 días representó el 58,7 %. Se encontró mayor riesgo de fallecer en los pacientes mayores de 70 años de edad (OR=10,8) y aquellos con ventilación mecánica mayor de 14 días (OR=2,93). Conclusiones: las enfermedades cerebrovasculares fueron comunes como diagnostico al ingreso. La infección por gérmenes Gram negativos desarrollados durante un proceso de ventilación tardía fue comunes. Las edades mayores de 70 años y una ventilación mecánica prolongada constituyeron factores de riesgo para la mortalidad.

ABSTRACT Introduction: pneumonia associated with mechanical ventilation has a high incidence and mortality in intensive care units. Objective: to characterize patients with mechanical ventilation admitted the Intensive Care Unit No. 2 at Abel Santamaría General Teaching Hospital during 2018. Methods: a descriptive, observational and cross-sectional study was conducted in patients with a diagnosis of pneumonia associated with mechanical ventilation. The target group consisted of 92, working with the totality of them. Chi Square and Odds Ratio tests were used, as well as the distribution by absolute frequency and relative percentage. Results: a predominance of male patients (54,35 %) was found, age group 70 to 79 years old (32,60 %) and diagnosis on admission of cerebrovascular disease (36,96 %). Pneumonia associated with prolonged mechanical ventilation represented 76,08 % and Gram-negative germs 86,96 %, patients with Enterobacter.sp (47,83 %) predominating. Mechanical ventilation of more than 14 days represented 58,7 %. Patients older than 70 years old (OR=10,8) and those with mechanical ventilation of more than 14 days (OR=2,93) had a higher risk of death. Conclusions: cerebrovascular diseases were common as a diagnosis at admission. Infection with Gram-negative germs developed during a prolonged mechanical ventilation process was common. Ages over 70 years and prolonged mechanical ventilation were risk factors for mortality.

Traqueobronquite associada à ventilação mecânica: uma atualização / Ventilator-associated tracheobronchitis: an update

RESUMO As infecções do trato respiratório inferior associadas à ventilação mecânica são uma das complicações mais frequentes em pacientes em ventilação mecânica. Há muitos anos, a traqueobronquite associada à ventilação mecânica tem sido considerada uma doença que não demanda antibioticoterapia. Na última década, diversos estudos demonstraram que a traqueobronquite associada à ventilação mecânica deve ser considerada um processo intermediário que leva à pneumonia associada à ventilação mecânica, uma vez que apesar de ter impacto limitado sobre a mortalidade dos pacientes gravemente enfermos internados nas unidades de terapia intensiva, em contrapartida, demonstra associação significativa com o aumento dos custos hospitalares desses pacientes, assim como do tempo de internação na unidade de terapia intensiva e hospitalar, do uso de antibióticos, e da duração da ventilação mecânica. Embora ainda necessitemos de evidências científicas mais robustas, especialmente no que tange às modalidades terapêuticas, os dados atuais a respeito da traqueobronquite associada à ventilação mecânica salientam que há desfechos suficientemente importantes que exigem vigilância epidemiológica e controle clínico adequados.

ABSTRACT Ventilator-associated lower respiratory tract infection is one of the most frequent complications in mechanically ventilated patients. Ventilator-associated tracheobronchitis has been considered a disease that does not warrant antibiotic treatment by the medical community for many years. In the last decade, several studies have shown that tracheobronchitis could be considered an intermediate process that leads to ventilator-associated pneumonia. Furthermore, ventilator-associated tracheobronchitis has a limited impact on overall mortality but shows a significant association with increased patient costs, length of stay, antibiotic use, and duration of mechanical ventilation. Although we still need clear evidence, especially concerning treatment modalities, the present study on ventilator-associated tracheobronchitis highlights that there are important impacts of including this condition in clinical management and epidemiological and infection surveillance.

Determinación de la incidencia de infección de vías respiratorias inferiores e identificación de microorganismos en pacientes postquirúrgicos de cirugía cardiovascular / Determination of the incidence of respiratory tract infection and identification of microorganisms in postsurgical patients of cardiovascular surgery / Determinação da incidencia de infecção do trato respiratório inferior e identificação de microorganismos em pacientes no período pós-operatório de cirurgia cardiovascular

Resumen: Introducción: Pacientes sometidos a cirugías cardiotorácicas requieren atención postquirúrgica en la Unidad de Cuidados Intensivos, un inadecuado manejo postquirúrgico incide negativamente en la evolución e incrementa el riesgo de complicaciones orgánicas. Objetivo: Determinar la incidencia de infección de vías respiratorias inferiores e identificación de microorganismos en pacientes postquirúrgicos de cirugía cardiovascular. Material y métodos: Estudio descriptivo, observacional, transversal y retrospectivo, durante el periodo de enero a diciembre de 2017. Resultados: Se revisaron 147 expedientes, donde 47% fueron mujeres y 53% hombres, edad promedio: 53.70 ± 15.70 años. Diagnóstico de ingreso, predominó la estenosis aórtica severa en 29.93% de los casos. La cirugía más realizada fue cambio valvular aórtico (40.82%). Microorganismos aislados: 76.87% de los cultivos fueron negativos; staphylococcus epidermidis sobresalió con 4.76%. La sensibilidad antibiótica fue: nitrofurantoína 26.47%, trimetoprim con sulfametoxazol 11.76, y 8.82% levofloxacino, respectivamente. La evolución de los pacientes, 90.50% fue buen pronóstico; en el caso de las complicaciones, 64.63% no las presentó. Conclusión: La presencia de infecciones respiratorias inferiores y su resistencia antibiótica en pacientes postoperados de cirugía cardiovascular, representa una problemática mundial, y afecta su adecuada evolución debido a la falla de tratamientos en las Áreas de Cuidados Intensivos.

Abstract: Introduction: Patients undergoing cardiothoracic surgery require post-surgical care in the Intensive Care Unit, an inadequate postoperative management has a negative impact on the patient's recovery and increases the probability of presenting organic complications. Objective: To determine the incidence of lower respiratory tract infection and identification of microorganisms in postsurgical patients of cardiovascular surgery. Material and methods: This is a descriptive, observational, transversal and retrospective study. The period covered was from January to December 2017. Results: 147 cases were reviewed, where 47% corresponded to women and 53% to men, with an average age of 53.70 ± 15.70 years. Regarding the diagnosis of admission, severe aortic stenosis predominated, registering 29.93% of the cases. The surgery that was most performed was the aortic valve change (40.82%). Regarding the isolation of microorganisms, 76.87% of the patients were negative or not performed; however, Staphylococcus epidermidis stood out with 4.76%. Of the patients who were positive for isolation, 26.47% were sensitive to nitrofurantoin, 11.76% to trimethoprim with sulfamethoxazole, and 8.82% to fluconazole and levofloxacin, respectively. Regarding the evolution of patients, 90.50% had a good prognosis; in the case of complications, 64.63% did not present any. Conclusion: The presence of lower respiratory infections in patients postoperated by cardiovascular surgery, combined with resistance by administered antibiotics, represents a global problem, and that significantly affects the efficient medical attention due to the failure of treatments in the Intensive Care Areas.

Resumo: Introdução: Pacientes submetidos à cirurgia cardiotorácica necessitam de cuidados pós-cirúrgicos em Unidade de Terapia Intensiva, uma conduta pós-operatória inadequada tem impacto negativo na recuperação do paciente e aumenta a probabilidade de apresentar complicações orgânicas. Objetivo: Determinar a incidência de infecção do trato respiratório inferior e identificação de microrganismos em pacientes pós-cirúrgicos de cirurgia cardiovascular. Material e métodos: Trata-se de um estudo descritivo, observacional, transversal e retrospectivo. O período abrangido foi de janeiro a dezembro de 2017. Resultados: Foram revistos 147 casos, onde 47% correspondiam a mulheres e 53% a homens, com média de idade de 53,70 ± 15,70 anos. Em relação ao diagnóstico de internação, predominou estenose aórtica grave, registrando 29,93% dos casos. A cirurgia mais realizada foi a troca da valva aórtica (40,82%). Em relação ao isolamento de microrganismos, 76,87% dos pacientes foram negativos ou não realizaram; no entanto, Staphylococcus epidermidis destacou-se com 4,76%. Dos pacientes que foram positivos para o isolamento, 26,47% eram sensíveis à nitrofurantoína, 11,76% à trimetoprima com sulfametoxazol e 8,82% ao fluconazol e à levofloxacina, respectivamente. Em relação à evolução dos pacientes, 90,50% tiveram um bom prognóstico; no caso de complicações, 64,63% não apresentaram nenhuma. Conclusão: A presença de infecções respiratórias inferiores em pacientes no pós-operatório de cirurgia cardiovascular, combinada à resistência por antibióticos administrados, representa um problema global e que afeta significativamente o atendimento médico eficiente devido ao insucesso dos tratamentos nas áreas de Terapia Intensiva.

Risk factors for healthcare-associated pneumonia caused by carbapenem-resistant Enterobacter cloacae in patients in intensive care unit / 中国感染控制杂志

Objective To explore risk factors for healthcare-associated pneumonia (HAP) caused by carbapenemresistant Enterobacter cloacae (CREC) in patients in intensive care unit (ICU).Methods From July 2013 to June 2017, 64 patients with CREC-HAP in ICU of a hospital were collected as case group, and 64 patients with carbapenem-sensitive Enterobacter cloacae HAP (CSEC-HAP) were as control group, risk factors for the occurrence of CREC-HAP were analyzed retrospectively by 1∶1 matched case-control study.Results Univariate analysis showed that APACHE II score≥20, long length of ICU stay, use of ventilator, long length of ventilator use, use of carbapenems, long duration of antimicrobial use, and at least 2 kinds of antimicrobial agents combined use were associated with the occurrence of CREC-HAP (all P＜0.05).Multivariate logistic regression analysis showed that APACHE II score≥20, use of ventilator, long length of ventilator use, use of carbapenems, and long duration of antimicrobial use were independent risk factors for occurrence of CREC-HAP (all P＜0.05).Conclusion Risk factors for occurrence of CREC-HAP in ICU patients include the use of carbapenems, long length of ventilator use, long duration of antimicrobial use, and APACHE II score≥20.Effective preventive and control measures can be formulated and taken in view of the above risk factors.

Risk factors for healthcare-associated pneumonia in patients with orthopedic injury / 中国感染控制杂志

Objective To analyze the risk factors for healthcare-associated pneumonia (HAP) in patients with orthopedic injury,provide the basis for making prevention and control measures.Methods HAP occurred in patients with orthopedic injury and admitted to the department of orthopedics of a hospital from June 2011 to May 2015 were investigated retrospectively,risk factors were analyzed by univariate and multivariate logistic regression methods.Results A total of 2 578 patients with orthopedic injury were investigated,92 patients developed HAI,incidence of HAP was 3.57％.107 strains of pathogens were detected,the major were Klebsiella pneumoniae (n =22,20.56％),Escherichia coli (n =14,13.08％),and Acinetobacter baumannii (n =13,12.15％).Risk factors for HAP in patients with orthopedic injury were length of hospital stay≥15 days,smoking history≥3 years,bedridden ≥7 days,associated with underlying diseases,complications,indwelling catheter≥7 days,surgical operation,mechanical ventilation,admitted to intensive care unit,open injury,blood sugar≥11 mmol/L,plasma albumin＜30 g/ L,hemoglobin concentration＜90 g/L,and use of glucocorticoid≥4 days (all P＜0.05).Multivariate logistic regression analysis showed that smoking,bedridden,surgery,mechanical ventilation,glucocorticoid use,and anaemia were independent risk factors for HAP in patients with orthopedic injury.Conclusion The occurrence of HAP in patients with orthopedic injury is related with multiple factors,the major are surgical operation,mechanical ventilation,glucocorticoid use,long term smoking,bedridden,and anaemia.

Clinical efficacy and adverse reactions of tigecycline in treatment of healthcare-associated pneumonia caused by extensively drug-resistant Acinetobacter baumannii / 中国感染控制杂志

Objective To observe the clinical efficacy and adverse reactions of tigecycline in treatment of health-care-associated pneumonia (HAP ) caused by extensively drug-resistant Acinetobacter baumannii (XDRAB ). Methods Clinical data of patients who used tigecycline for the treatment of XDRAB HAP in intensive care units of a hospital from March 2013 to June 2014 were retrospectively analyzed.Results XDRAB isolated from 31 patients with HAP were all sensitive to tigecycline,the resistance rates to carbapenems and sulbactams (including cefopera-zone-sulbactam,SCF)were all 100%,17 cases (54.84%)were mixed infection.Combined use rates of tigecycline and SCF were 85.71 %(12/14)in respiratory intensive care unit(RICU)and 47.06%(8/17)in general intensive care unit(GICU).Of 31 patients,the cure rate,effective rate,bacterial clearance rate,and antimicrobial adverse reac-tion rate were 29.03%,45.16%,61 .29%,and 16.13% respectively,no serious adverse drug reactions occurred. In RICU group and GICU group,the cure rates were 42.86% and 17.65% respectively,effective rates were 71 .43% and 23.53% respectively,and bacterial clearance rates were 78.57 % and 47.06% respectively,difference in effective rate between two groups was significant (P <0.05).Among patients receiving combination of tigecycline and SCF as well as not receiving combined SCF,the cure rates were 35.00% and 18.18% respectively,effective rates were 60.00% and 18.18% respectively,and bacterial clearance rates were 65.00% and 54.55% respectively, difference in effective rate between two groups was significant (P <0.05).Conclusion Tigecycline has a good clini-cal efficacy and little adverse reaction in treating XDRAB HAP;tigecycline combined with SCF is a good choice.

Intermediate risk of multidrug-resistant organisms in patients who admitted intensive care unit with healthcare-associated pneumonia

BACKGROUND/AIMS: Healthcare-associated pneumonia (HCAP) was proposed asa new pneumonia category in 2005, and treatment recommendations includebroad-spectrum antibiotics directed at multidrug-resistant (MDR) pathogens.However, this concept continues to be controversial, and microbiological data arelacking for HCAP patients in the intensive care unit (ICU). This study was conductedto determine the rate and type of antibiotic-resistant organisms and theclinical outcomes in patients with HCAP in the ICU, compared to patients withcommunity-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP). METHODS: We conducted a retrospective cohort analysis of patients with pneumonia(n = 195) who admitted to medical ICU in tertiary teaching hospital fromMarch 2011 to February 2013. Clinical characteristics, microbiological distributions,treatment outcomes, and prognosis of HCAP (n = 74) were compared tothose of CAP (n = 75) and HAP (n = 46). RESULTS: MDR pathogens were significantly higher in HCAP patients (39.1%) thanin CAP (13.5%) and lower than in HAP (79.3%, p < 0.001). The initial use of inappropriateantibiotic treatment occurred more frequently in the HCAP (32.6%) andHAP (51.7%) groups than in the CAP group (11.8%, p = 0.006). There were no differencesin clinical outcomes. The significant prognostic factors were pneumoniaseverity and treatment response. CONCLUSIONS: MDR pathogens were isolated in HCAP patients requiring ICU admissionat intermediate rates between those of CAP and HAP.

Influencing factors of hospitalization cost and mortality of patients with pulmonary infection / 中国感染控制杂志

Objective To investigate the hospitalization cost,length of stay in hospital,and mortality in patients with pulmonary infection in a hospital,and evaluate the influencing factors,so as to provide scientific basis for mak-ing targeted infection control measures.Methods Medical records of patients with pulmonary infection between January 2011 and December 2012 were collected,the difference and influencing factors of hospitalization cost,aver-age length of stay,and prognosis among patients with different types of pulmonary infection were compared and an-alyzed by univariate analysis,multiple linear regression analysis,and logistic regression analysis.Results Of 10 431 patients with pulmonary infection,the average hospitalization cost was (29 081 .95 ± 38 682.92 )yuan (RMB),the median cost was 16 085.25 yuan(RMB),and the average length of stay was (15.93 ±20.54)d,the median was 13.00 d,a total of 828 patients died due to invalid treatment,mortality was 7.94%.There were signifi-cant differences in hospitalization cost,average length of stay among patients with different genders,ages,modes of payment,admission status of illness,types of pulmonary infection,and operation or not (all P <0.05),and the differences in mortality were also significant among patients of above characteristics except gender(all P <0.05 ). Influencing factors for hospitalization cost were as follows:length of stay,whether or not operated,modes of pay-ment,types of pulmonary infection(healthcare-associated pneumonia,HAP),age,gender,and so on,influencing factors for length of stay were whether or not operated and types of pulmonary infection,factors leading to death were admission condition, types of pulmonary infection (HAP ),and whether or not operated, and so on. Conclusion Control of healthcare-associated pulmonary infection is important for controlling hospitalization cost, shortening average length of stay,and improving survival rate of patients.

Etiología y mortalidad por neumonía asociada a los cuidados de la salud en pediatría / Etiology and Mortality of Health Care Associated Pneumonia in Pediatrics

Introducción: la neumonía asociada a los cuidados de la salud (NACS) es la segunda causa de infección intrahospitalaria en Estados Unidos y constituye 60% de la mortalidad global de las infecciones nosocomiales (mortalidad cruda 20-50% y mortalidad atribuible 30-33%). Frecuentemente, la etiología se ha asociado con microorganismos Gram negativos, en especial Klebsiella pneumoniae y Pseudomonas aeruginosa, y Gram positivos como Staphylococcus aureus y Staphylococcus epidermidis. Objetivos: determinar la etiología y mortalidad por NACS en el Hospital JM de los Ríos (HJMR) desde Enero de 2008 a Junio de 2012. Métodos: estudio prospectivo, que incluyó a los pacientes que desarrollaron infección respiratoria luego de 48 horas de ingresar al HJMR o que presentaron síntomas respiratorios dentro de los primeros 7 días posteriores a su egreso. Resultados: se incluyeron 308 casos NACS, de los cuales 46,80% fueron lactantes y 25% fueron neumonías asociadas a ventilación mecánica (NAVM). Del total, 23,38% ingresaron por alguna patología no infecciosa. Se identificó la etiología en 15,91% de los casos, aislando un total de 92 microorganismos: 61,39% Gram negativos, 25,74% Gram positivos y 12,87% hongos. Los más frecuentes fueron P. aeruginosa 32,61%, Staphylococcus coagulasa negativo 13,04% y K. pneumoniae 8,69%. La mortalidad global fue de 12,66% y para NAVM fue de 20,78%. Conclusiones: la mortalidad no superó lo estimado en la literatura; casi la mitad de la población estudiada estuvo representada por lactantes y los microorganismos aislados con mayor frecuencia fueron los Gram negativos.

Introduction: Healthcare associated pneumonia (HCAP) is the second leading cause of nosocomial infections in the United States. It constitutes 60% of the global mortality of hospital-acquired infections (20-50% crude mortality, and attributable mortality 30-33%). The etiology is most often associated with Gram negative rods, especially Klebsiellapneumoniae, Pseudomonas aeruginosa,and Gram positive such as Staphylococcus aureus and Staphylococcus epidermidis. Objectives: to determine the etiology and mortality of HCAP at the Hospital JM de los Rios (HJMR), Caracas-Venezuela, from January 2008 to June 2012. Methods: we conducted a prospective study, which included patients who developed respiratory infection 48 hours after the admission at the HJMR or who had respiratory symptoms within the first 7 days after discharge. Results: 308 cases were included as HCAP. 46.8% were infants and 25% were mechanical ventilation associated pneumonia (VAP). 23.38% of total cases were admitted as noninfectious pathology. In 15.91% of the cases, the etiologic agent was identified. We had a total of 92 isolated microorganisms: 61.39% Gram negative, 25.74% Gram positive, and 12, 87% fungi. The most frequent were P. aeruginosa: 32.61%, coagulase negative Staphylococcus: 13.04% and K. pneumoniae: 8.69%. The overall mortality rate was 12.66%. Mortality from VAP was 20.78%. Conclusions: The mortality did not exceed the estimates in the literature, almost a half of the studied population is represented by infants and the most frequently bacterial isolation was Gram negative.

Comparison of Methicillin-Resistant Staphylococcus aureus Community-Acquired and Healthcare-Associated Pneumonia

PURPOSE: Methicillin-resistant Staphylococcus aureus (MRSA) is recognized as an important cause of not only healthcare-associated pneumonia (HCAP) but also community-acquired pneumonia (CAP). We determined the impact of MRSA on differences in clinical characteristics, courses, and outcomes between CAP and HCAP. MATERIALS AND METHODS: We conducted a retrospective observational study on 78 adult patients admitted with MRSA pneumonia at a university-affiliated tertiary hospital between January 2008 and December 2011. We compared baseline characteristics, chest radiographs, treatment outcomes, and drug resistance patterns between the CAP and HCAP groups. RESULTS: Of the 78 patients with MRSA pneumonia, 57 (73.1%) were HCAP and 21 (26.9%) were CAP. MRSA infection history in the previous year (29.8% vs. 14.3%, p=0.244) tended to be more common in HCAP than in CAP. Despite similar Pneumonia Severity Index scores (151 in CAP vs. 142 in HCAP), intubation rates (38.1% vs. 17.5%; p=0.072) and intensive care unit admission (42.9% vs. 22.8%; p=0.095) tended to be higher in the CAP group, while 28-day mortality was higher in the HCAP group (14.3% vs. 26.3%; p=0.368), although without statistical significance. All patients showed sensitivity to vancomycin and linezolid; meanwhile, HCAP patients showed greater resistance to gentamicin than CAP patients (58.3% vs. 16.6%; p=0.037). The median total hospital charges were 6899 American dollars for CAP and 5715 American dollars for HCAP (p=0.161). CONCLUSION: MRSA pneumonia showed significantly differences in baseline characteristics, chest radiographs, treatment outcomes, and medical expenses between HCAP and CAP groups.

The clinical and microbial characteristics of healthcare-associated pneumonia / 대한내과학회지

Healthcare associated pneumonia resembles hospital acquired pneumonia in patient characteristics and in causative microorganisms. Patients from healthcare facililties are are likely to be of old age, disabilitated and have associated comorbidities. Most frequently associated organisms are enteric gram negative rods and staphylococcus aureus. However patients referred from healthcare facilities are comprised of heterogeneous risk groups, so individual risk for harboring resistant pathogens should be assessed before treatment. People residing in healthcare facilities are also at risk for atypical pneumonia and viral pneumonia. Pathogens such as legionella and chlamydia should also be taken into account, as well as viral agents like influenza and RSV which could result in seasonal, mass infection in patients residing in healthcare facilities like nursing homes. Considering the high rates of antibiotic resistance in korea, a prospective trial comparing community acquired and healthcare associated pneumonia is needed.

The clinical and microbial characteristics of healthcare-associated pneumonia / 대한내과학회지

BACKGROUND/AIMS: Healthcare-associated pneumonia (HCAP) occurs outside hospitals, but its characteristics are similar to those of hospital-acquired pneumonia (HAP). We evaluated the clinical and microbial characteristics of HCAP in Korea. METHODS: Of 130 subjects with suspected pneumonia, 49 were classified as HCAP and 81 as HAP. We retrospectively examined the clinical presentations, outcomes, pathogens, and drug resistance rates of Pseudomonas aeruginosae in both groups. RESULTS: The clinical presentations, including the symptoms and laboratory findings, at the time of hospitalization were comparable in both groups. The hospital mortalities of HCAP (28.6%) and HAP (34.6%) did not differ significantly; the length of the hospital stay was similar for all of the survivors (14 vs. 17 days, respectively). Of the identified pathogens, methicillin-resistant Staphylococcus aureus was significantly less common in HCAP than in HAP (two vs. 18 cases, respectively, p<0.01), whereas Klebsiella pneumoniae was more common in HCAP (five vs. zero cases, respectively, p<0.01). The frequency of other Gram-negative rods was similar in both groups. The rate of resistance to antibiotics in P. aeruginosae in both groups was substantial, with the highest resistant rate to ciprofloxacin (50% and 61.5% in HCAP and HAP, respectively). CONCLUSIONS: Although the clinical features and outcomes of HCAP were comparable to those of HAP in the study population, the frequency of methicillin-resistant S. aureus was significantly lower in HCAP compared to HAP.

Clinical analysis of healthcare-associated pneumonia / 中国感染与化疗杂志

Objective To study the clinical characteristics of healthcare-associated pneumonia (HCAP).Methods A retrospective cohort study was conducted on consecutive hospitalized pneumonia cases from January 2007 through April 2008.Results HCAP group of 75 patients was compared with 133 patients of community-acquired pneumonia (CAP) and 76 patients of hospital-acquired pneumonia (HAP). Most of HCAP patients had a history of recent hospitalization (47 cases), clinical IV infusion (27 cases), and prior chemotherapy or antibiotic therapy (27 cases). Underlying diseases were identified in 71 (94.7%) of HCAP patients, significantly higher than that in CAP group (37.6%, P<0.01). Positive sputum culture in CAP, HCAP and HAP was 22.6%, 56.9%, 77.6% respectively. Antibiotic resistance of bacteria in HCAP (71.43%) and HAP (80%) was comparable (P>0.05). Initial antibiotic therapy was effective in 47 (62.6%) cases of HCAP. Only 52.9% of the identified pathogens were sensitive to initial antibiotic therapies. The mortality of HCAP (12%) was similar to HAP (23%, P>0.05), but significantly higher than CAP (3%, P<0.05).Conclusions HCAP is a common type of pneumonia, which is characterized by more resistant pathogens, higher mortality, more comorbidities and poor outcomes. Antibiotic therapy should cover the hospital acquired bacterial pathogens.

Pneumonia in the elderly patients / 대한내과학회지

Community-acquired pneumonia (CAP) is one of major medical illness and leading causes of death in the elderly patients. They account for the majority of CAP-related hospital admission, and suffer from more severe degree of illness that often requires broad-spectrum antibiotics and intensive care unit (ICU) admission. Recently, the incidence and mortality of CAP is rising. Therefore, the economic and clinical burden is expected to increase consistently at present time and also in the future. Although Streptococcus pneumoniae is still the most common pathogen identified, pneumonia in elderly patients is different from that in younger patients, with regard to the etiology, clinical course, and treatment response. The most striking characteristic of pneumonia in older patients is its clinical presentation: classic symptoms are often absent. Therefore, appropriate diagnosis and treatment can be delayed. When approaching the treatment for pneumonia in older patients, patients with healthcare-associated pneumonia (HCAP) should be distinguished from those with CAP. Patients with HCAP are at high risk for multidrug-resistant (MDR) pathogens and tend to have much more severe illness due to multiple co-morbidities and decreased functional status, which are associated with poor outcome. Prevention should also be implemented, focusing on smoking cessation, aspiration prevention, and influenza and pneumococcal vaccination.