Implementation of a ventilator-associated pneumonia prevention bundle in a teaching hospital / Implementação de um bundle de prevenção de pneumonia associada à ventilação mecânica em um hospital universitário / Implementación de un paquete de prevención de neumonía asociada a ventilador en un hospital escuela

Background and objectives: the implementation of ventilator-associated pneumonia (VAP) prevention bundles in Intensive Care Units (ICU) has been recommended due to the considerable increase in hospital costs, length of stay, morbidity and mortality in affected hospitalized patients. However, the results of its effectiveness are still controversial. This study aimed to assess the impact of implementing a VAP prevention bundle in an Adult ICU of a university hospital. Methods: a quasi-experimental study, with implementation of a VAP prevention bundle in an Adult ICU and analysis of indicators. This study addressed secondary data from hospital records recommended in the routine of the Hospital Infection Control Commission team and from the medical records of patients undergoing mechanical ventilation, from June 2016 to July 2019, who developed VAP. Results: VAP incidence density before the intervention was 4.13 infections, and after the intervention, it was 7.15 infections per thousand patients on ventilation/day. When performing the linear regression test, we showed that VAP density decreased as sedation was reduced, extubation was increased, and when compliance with all bundle elements occurred. Conclusion: there was no reduction in VAP incidence after the adoption of preventive measures, perhaps due to an underreporting of cases in the period prior to the bundle and a low team compliance with the bundle components. However, we noticed a decrease in VAP notifications after the eighth month of implementation of bundle of measures.(AU)

Justificativa e objetivos: a implementação de bundles de prevenção de pneumonia associada à ventilação mecânica (PAV) em Unidades de Terapia Intensiva (UTI) tem sido recomendada devido ao aumento considerável dos custos hospitalares, tempo de internação, morbidade e mortalidade em pacientes hospitalizados acometidos. No entanto, os resultados de sua eficácia ainda são controversos. Este estudo teve como objetivo avaliar o impacto da implantação de um bundle de prevenção de PAV em uma UTI Adulto de um hospital universitário. Métodos: estudo quase experimental, com implantação de bundle de prevenção de PAV em UTI Adulto e análise de indicadores. Este estudo abordou dados secundários de prontuários hospitalares recomendados na rotina da equipe da Comissão de Controle de Infecção Hospitalar e dos prontuários de pacientes em ventilação mecânica, no período de junho de 2016 a julho de 2019, que desenvolveram PAV. Resultados: A densidade de incidência de PAV antes da intervenção foi de 4,13 infecções e após a intervenção foi de 7,15 infecções por mil pacientes em ventilação/dia. Ao realizar o teste de regressão linear, mostramos que a densidade da PAV diminuiu à medida que a sedação era reduzida, a extubação aumentava e quando ocorria complacência com todos os elementos do feixe. Conclusão: não houve redução da incidência de PAV após a adoção de medidas preventivas, talvez pela subnotificação de casos no período anterior ao bundle e baixa adesão da equipe aos componentes do bundle. No entanto, notamos diminuição das notificações de PAV após o oitavo mês de implantação do bundle de medidas.(AU)

Justificación y objetivos: la implementación de paquetes de prevención de neumonía asociada al ventilador (NAV) en las Unidades de Cuidados Intensivos (UCI) ha sido recomendada debido al aumento considerable de los costos hospitalarios, la estancia hospitalaria, la morbilidad y la mortalidad en los pacientes hospitalizados afectados. Sin embargo, los resultados de su eficacia aún son controvertidos. Este estudio tuvo como objetivo evaluar el impacto de la implementación de un paquete de prevención de NAVM en una UCI de adultos de un hospital universitario. Métodos: estudio cuasi-experimental, con implementación de un paquete de prevención de NAVM en una UCI de Adultos y análisis de indicadores. Este estudio abordó datos secundarios de registros hospitalarios recomendados en la rutina del equipo de la Comisión de Control de Infecciones Hospitalarias y de los registros médicos de pacientes en ventilación mecánica, de junio de 2016 a julio de 2019, que desarrollaron NAV. Resultados: La densidad de incidencia de NAVM antes de la intervención fue de 4,13 infecciones y después de la intervención fue de 7,15 infecciones por mil pacientes en ventilación/día. Al realizar la prueba de regresión lineal, mostramos que la densidad de VAP disminuyó a medida que se redujo la sedación, se incrementó la extubación y cuando se produjo el cumplimiento de todos los elementos del paquete. Conclusión: no hubo reducción en la incidencia de NAVM después de la adopción de las medidas preventivas, quizás debido a un subregistro de casos en el período anterior al paquete y al bajo cumplimiento del equipo con los componentes del paquete. Sin embargo, notamos una disminución en las notificaciones de VAP después del octavo mes de implementación del paquete de medidas.(Au)

Effects of the implementation of a hand hygiene education program among ICU professionals: an interrupted time-series analysis / Efeitos da implementação de um programa de educação de higienização das mãos entre profissionais de uma UTI: análise de séries temporais interrompidas

ABSTRACT Objective: To evaluate the effects that a hand hygiene education program has on the compliance of health professionals in an ICU. Methods: This was a quasi-experimental study with an interrupted time-series design, conducted over a 12-month period: the 5 months preceding the implementation of a hand hygiene education program (baseline period); the 2 months of the intensive (intervention) phase of the program; and the first 5 months thereafter (post-intervention phase). Hand hygiene compliance was monitored by one of the researchers, unbeknownst to the ICU team. The primary outcome measure was the variation in the rate of hand hygiene compliance. We also evaluated the duration of mechanical ventilation (MV), as well as the incidence of ventilator-associated pneumonia (VAP) at 28 days and 60 days, together with mortality at 28 days and 60 days. Results: On the basis of 959 observations, we found a significant increase in hand hygiene compliance rates-from 31.5% at baseline to 65.8% during the intervention phase and 83.8% during the post-intervention phase, corresponding to prevalence ratios of 2.09 and 2.66, respectively, in comparison with the baseline rate (p < 0.001). Despite that improvement, there were no significant changes in duration of MV, VAP incidence (at 28 or 60 days), or mortality (at 28 or 60 days). Conclusions: Our findings indicate that a hand hygiene education program can increase hand hygiene compliance among ICU professionals, although it appears to have no impact on VAP incidence, duration of MV, or mortality.

RESUMO Objetivo: Avaliar os efeitos da implementação de um programa de educação sobre higienização das mãos e a adesão a essa prática entre profissionais de uma UTI. Métodos: Estudo quase-experimental com séries temporais interrompidas conduzido ao longo de 12 meses: 5 meses antes do programa de educação (período basal), 2 meses durante a fase intensiva do programa (período de intervenção) e 5 meses durante a fase de manutenção do programa (período pós-intervenção). A avaliação da adesão às práticas de higienização das mãos foi feita por um dos pesquisadores sem conhecimento da equipe da UTI. O desfecho primário foi a variação da taxa de adesão à higienização das mãos. Também foram avaliadas a duração da ventilação mecânica (VM), a incidência de pneumonia associada à ventilação mecânica (PAVM) em 28 e 60 dias e mortalidade nos mesmos momentos. Resultados: Com base em 959 observações, houve um aumento nas taxas de adesão à higienização das mãos de 31,5% no período basal para 65,8% no período de intervenção e para 83,8% no período pós-intervenção, representando uma razão de prevalência 2,09 e 2,66 maior que o período basal, respectivamente (p < 0,001). Apesar desse aumento, não houve diferenças significativas em relação à duração da VM ou à incidência de PAVM e taxa de mortalidade em 28 e 60 dias. Conclusões: Neste estudo, o programa de educação em higienização das mãos aumentou a adesão a esse procedimento durante o período de monitorização, sem alterar as taxas de PAVM, a duração da VM e a mortalidade.

Risk factors for mortality in patients with ventilator-associated pneumonia caused by carbapenem-resistant Enterobacteriaceae

Abstract Background: The ideal therapeutic option for ventilator associated pneumonia caused by carbapenem-resistant Enterobacteriaceae is not defined. The aim of this study was to assess mortality-associated risk factors in patients with VAP by CRE and determine the outcome of several treatment options. Methods: This was a retrospective study performed in two tertiary hospitals involving patients with VAP caused by CRE between January 2010 and August 2014. The outcomes were mortality within 30 days of VAP diagnosis and overall mortality during hospital admission. Risk factors for mortality were assessed by comparing variables of survivors and non-survivors. Results: One hundred and twelve patients with CRE-VAP were included, 73 (65%) male, median age 56 years. The 30-day mortality was 57.1% and the overall hospital mortality was 67%. In the binary logistic regression analysis, only age >50 years was independently associated to increased mortality. Polymyxin was the most used drug (47.5%), followed by tigecycline (29.2%) and aminoglycosides (2.4%). Combined therapy with two active drugs was used by 17 patients (20.8%). No therapeutic option was independently associated to survival. However, combined therapy with two active drugs was superior to the therapy with a single active drug when inappropriate therapy was the comparator (p = 0.044). The addition of carbapenem was not associated with increased survival. Conclusion: The best therapeutic option for VAP by CRE is still not completely defined, but the therapy with at least two active drugs was superior in this study.

Ventilator-associated pneumonia: the influence of bacterial resistance, prescription errors, and de-escalation of antimicrobial therapy on mortality rates

Abstract Ventilator-associated pneumonia is the most prevalent nosocomial infection in intensive care units and is associated with high mortality rates (14–70%). Aim This study evaluated factors influencing mortality of patients with Ventilator-associated pneumonia (VAP), including bacterial resistance, prescription errors, and de-escalation of antibiotic therapy. Methods This retrospective study included 120 cases of Ventilator-associated pneumonia admitted to the adult adult intensive care unit of the Federal University of Uberlândia. The chi-square test was used to compare qualitative variables. Student's t-test was used for quantitative variables and multiple logistic regression analysis to identify independent predictors of mortality. Findings De-escalation of antibiotic therapy and resistant bacteria did not influence mortality. Mortality was 4 times and 3 times higher, respectively, in patients who received an inappropriate antibiotic loading dose and in patients whose antibiotic dose was not adjusted for renal function. Multiple logistic regression analysis revealed the incorrect adjustment for renal function was the only independent factor associated with increased mortality. Conclusion Prescription errors influenced mortality of patients with Ventilator-associated pneumonia, underscoring the challenge of proper Ventilator-associated pneumonia treatment, which requires continuous reevaluation to ensure that clinical response to therapy meets expectations.

The effectiveness of a bundle in the prevention of ventilator-associated pneumonia

Abstract Objectives The aim of this study was to evaluate the impact of a bundle called FAST HUG in ventilator-associated pneumonia, weigh the healthcare costs of ventilator-associated pneumonia patients in the intensive care unit, and hospital mortality due to ventilator-associated pneumonia. Material and methods The study was performed in a private hospital that has an 8-bed intensive care unit. It was divided into two phases: before implementing FAST HUG, from August 2011 to August 2012 and after the implementation of FAST HUG, from September 2012 to December 2013. An individual form for each patient in the study was filled out by using information taken electronically from the hospital medical records. The following data was obtained from each patient: age, gender, reason for hospitalization, use of three or more antibiotics, length of stay, intubation time, and outcome. Results After the implementation of FAST HUG, there was an observable decrease in the occurrence of ventilator-associated pneumonia (p < 0.01), as well as a reduction in mortality rates (p < 0.01). In addition, the intervention resulted in a significant reduction in intensive care unit hospital costs (p < 0.05). Conclusion The implementation of FAST HUG reduced the number of ventilator-associated pneumonia cases. Thus, decreasing costs, reducing mortality rates and length of stay, which therefore resulted in an improvement to the overall quality of care.

Quantitative culture of endotracheal aspirate and BAL fluid samples in the management of patients with ventilator-associated pneumonia: a randomized clinical trial / Cultura quantitativa de aspirado traqueal e lavado broncoalveolar no manejo de pacientes com pneumonia associada à ventilação mecânica: um ensaio clínico randomizado

OBJECTIVE: To compare 28-day mortality rates and clinical outcomes in ICU patients with ventilator-associated pneumonia according to the diagnostic strategy used. METHODS: This was a prospective randomized clinical trial. Of the 73 patients included in the study, 36 and 37 were randomized to undergo BAL or endotracheal aspiration (EA), respectively. Antibiotic therapy was based on guidelines and was adjusted according to the results of quantitative cultures. RESULTS: The 28-day mortality rate was similar in the BAL and EA groups (25.0% and 37.8%, respectively; p = 0.353). There were no differences between the groups regarding the duration of mechanical ventilation, antibiotic therapy, secondary complications, VAP recurrence, or length of ICU and hospital stay. Initial antibiotic therapy was deemed appropriate in 28 (77.8%) and 30 (83.3%) of the patients in the BAL and EA groups, respectively (p = 0.551). The 28-day mortality rate was not associated with the appropriateness of initial therapy in the BAL and EA groups (appropriate therapy: 35.7% vs. 43.3%; p = 0.553; and inappropriate therapy: 62.5% vs. 50.0%; p = 1.000). Previous use of antibiotics did not affect the culture yield in the EA or BAL group (p = 0.130 and p = 0.484, respectively). CONCLUSIONS: In the context of this study, the management of VAP patients, based on the results of quantitative endotracheal aspirate cultures, led to similar clinical outcomes to those obtained with the results of quantitative BAL fluid cultures. .

OBJETIVO: Comparar a mortalidade em 28 dias e desfechos clínicos em pacientes com pneumonia associada à ventilação mecânica (PAVM) internados em UTI conforme a estratégia diagnóstica utilizada. MÉTODOS: Ensaio clínico randomizado prospectivo. Dos 73 pacientes incluídos no estudo, 36 e 37, respectivamente, foram randomizados para a realização de LBA ou aspiração traqueal (AT). A antibioticoterapia inicial baseou-se em diretrizes e foi ajustada de acordo com os resultados das culturas quantitativas. RESULTADOS: A taxa de mortalidade em 28 dias foi semelhante nos grupos LBA e AT (25,0% e 37,8%, respectivamente; p = 0,353). Não houve diferenças entre os grupos em relação a duração da ventilação mecânica, antibioticoterapia, complicações secundárias, recidiva de PAVM ou tempo de permanência hospitalar e na UTI. A antibioticoterapia inicial foi considerada adequada em 28 (77,8%) e 30 (83,3%) dos pacientes nos grupos LBA e AT, respectivamente (p = 0,551). A mortalidade em 28 dias não se associou com a adequação da antibioticoterapia inicial nos grupos LBA e AT (tratamento apropriado: 35,7% vs. 43,3%; p = 0,553; e tratamento inapropriado: 62,5% vs. 50,0%; p = 1,000). O uso prévio de antibióticos não interferiu no rendimento das culturas nos grupos AT e LBA (p = 0,130 e p = 0,484, respectivamente). CONCLUSÕES: No contexto deste estudo, o manejo dos pacientes com PAVM, baseado nos resultados da cultura quantitativa do aspirado traqueal, resultou em desfechos clínicos semelhantes aos obtidos com os resultados da cultura quantitativa do LBA. (Registro Brasileiro de Ensaios ...

Impacto del cobre en la reducción de infecciones intrahospitalarias, mortalidad y gasto en antimicrobianos en una Unidad de Cuidados Intensivo de adultos / Impact of copper in the reduction of hospital-acquired infections, mortality and antimicrobial costs in the Adult Intensive Care Unit

We conducted a clinical trial to determine the impact of coating surfaces with copper in reducing hospital-acquired infections, mortality associated with nosocomial infections and antimicrobial costs in the UCI. The study took place at Carlos Van Buren Hospital, Valparaíso, Chile. No differences in the frequency of nosocomial infections were found. Not in rates of ventilator-associated pneumonia (p = 0.9), nor in catheter- associated urinary tract infection (p = 0.9) or in central venous catheter associated bacteremia (p = 0.3). There were no differences in infection-free survival (p = 0.9). There were less costs of antimicrobials in patients in which copper was used. The fact that the sample size was not completed could explain that no significant differences in infections were found. Conclusion: The use of copper as a surface in the ICU showed no statistically significant differences in rates of nosocomial infections during the study period, however, these results could be related to the sample size.

Introducción: Las infecciones nosocomiales incrementan la mortalidad y costos en las instituciones de salud. El revestimiento con cobre, de superficies de alto contacto en la unidad clínica en torno a los pacientes, reduce la colonización bacteriana de las mismas. Objetivo: Determinar el impacto del revestimiento de las superficies con cobre en la disminución de las infecciones intrahospitalarias, la mortalidad asociada a las infecciones intrahospitalarias y los costos en antimicrobianos en pacientes hospitalizados en UCI adultos en el Hospital Carlos Van Buren. Pacientes y Métodos: Estudio prospectivo, comparativo, mayo de 2011-mayo de 2012. Asignación aleatoria de pacientes adultos ingresados en UCI, que permanecieran al menos por 24 h en dicha unidad, a unidades de aislamiento recubiertas (n: 7) o no recubiertas con cobre (n: 7). Resultados: Ingresaron al estudio 440 pacientes, 217 pacientes (49,3%) en el grupo sin cobre y 223 en el grupo con cobre (50,7%). No se encontraron diferencias en la frecuencia de infecciones intrahospitalarias en ambos grupos. Tampoco se encontraron diferencias significativas en las tasas de neumonía asociada a ventilación mecánica (p = 0,9), infección urinaria asociada a catéter urinario (p = 0,9) y bacteremias asociada a catéter venoso central (p = 0,3). Tampoco se encontraron diferencias en la sobrevida libre de infección (p = 0,9). Se encontró un gasto menor de antimicrobianos en pacientes atendidos en unidades revestidas con cobre. Durante el período del estudio no se completó el tamaño de muestra y las diferencias no significativas podrían deberse a este hecho. Conclusión: El uso del cobre como revestimiento de las superficies hospitalarias en UCI, mostró diferencia en la tasa de bacteriemia asociada a dispositivos venosos, aunque no significativa, y no mostró diferencia en neumonías e infecciones urinarias. Las diferencias no significativas pueden deberse a que no se completó el tamaño de la muestra. Se observó un mayor gasto de antimicrobianos en pacientes de unidades no cobrizadas, lo que plantea una nueva área de investigación.

Comparação da acurácia de preditores de mortalidade na pneumonia associada à ventilação mecânica / Comparing the accuracy of predictors of mortality in ventilator-associated pneumonia

OBJETIVO: Níveis de procalcitonina, midregional pro-atrial natriuretic peptide (MR-proANP, pró-peptídeo natriurético atrial midregional),, C-terminal provasopressin (copeptina), proteína C reativa (CRP) e escore do Sequential Organ Failure Assessment (SOFA) são associados a gravidade e descritos como preditores de desfechos na pneumonia associada a ventilação mecânica (PAVM). Este estudo procurou comparar o valor preditivo de mortalidade desses biomarcadores na PAVM. MÉTODOS: Estudo observacional com 71 pacientes com PAVM. Níveis de procalcitonina, MR-proANP, copeptina e PCR, bem como escore de SOFA foram obtidos no dia do diagnóstico de PAVM, designado dia zero (D0), e no quarto dia de tratamento (D4) Os pacientes receberam tratamento antimicrobiano empírico, com modificações baseadas nos resultados de cultura. Os pacientes que morreram antes de D28 foram classificados como não sobreviventes. RESULTADOS: Dos 71 pacientes, 45 sobreviveram. Dos 45 sobreviventes, 35 (77,8 por cento) receberam tratamento antimicrobiano adequado, comparados com 18 (69,2 por cento) dos 26 não sobreviventes (p = 0,57). Os sobreviventes apresentaram valores significativamente mais baixos em todos os biomarcadores estudados, inclusive no escore de SOFA (exceto PCR) em D0 e D4. Em D0 e D4, a área sob a curva ROC foi maior para procalcitonina. Em D0, MR-proANP teve a maior razão de verossimilhança positiva (2,71) e valor preditivo positivo (0,60), mas a procalcitonina apresentou o maior valor preditivo negativo (0,87). Em D4, a procalcitonina apresentou a maior razão de verossimilhança positiva (3,46), o maior valor preditivo positivo (0,66) e o maior valor preditivo negativo (0,93). CONCLUSIONS: Os biomarcadores procalcitonina, MR-proANP e copeptina podem predizer mortalidade na PAVM, assim como o escore de SOFA. A procalcitonina tem o maior poder preditivo de mortalidade na PAVM.

OBJECTIVE: Levels of procalcitonin, midregional pro-atrial natriuretic peptide (MR-proANP), C-terminal provasopressin (copeptin), and C-reactive protein (CRP), as well as Sequential Organ Failure Assessment (SOFA) scores, are associated with severity and described as predictors of outcome in ventilator-associated pneumonia (VAP). This study sought to compare the predictive value of these biomarkers for mortality in VAP. METHODS: An observational study of 71 patients with VAP. Levels of procalcitonin, MR-proANP, copeptin, and CRP, together with SOFA scores, were determined at VAP onset, designated day 0 (D0), and on day 4 of treatment (D4). Patients received empirical antimicrobial therapy, with modifications based on culture results. Patients who died before D28 were classified as nonsurvivors. RESULTS: Of the 71 patients evaluated, 45 were classified as survivors. Of the 45 survivors, 35 (77.8 percent) received appropriate antimicrobial therapy, compared with 18 (69.2 percent) of the 26 nonsurvivors (p = 0.57). On D0 and D4, the levels of all biomarkers (except CRP), as well as SOFA scores, were lower in eventual survivors than in eventual nonsurvivors. For D0 and D4, the area under the ROC curve was largest for procalcitonin. On D0, MR-proANP had the highest positive likelihood ratio (2.71) and positive predictive value (0.60), but procalcitonin had the highest negative predictive value (0.87). On D4, procalcitonin had the highest positive likelihood ratio (3.46), the highest positive predictive value (0.66), and the highest negative predictive value (0.93). CONCLUSIONS: The biomarkers procalcitonin, MR-proANP, and copeptin can predict mortality in VAP, as can the SOFA score. Procalcitonin alone has the greatest predictive power for such mortality.

Factores de riesgo para mortalidad en neumonía asociada a ventilación mecánica / Mortality risk factors in ventilator associated pneumonia

Objective: to identify lethality and mortality rates and, mortality risk factors in ventilator associated pneumonia (VAP) on 114 patients treated between 2000 and 2007. Method: Twenty five risk factors were analyzed, emphasizing age, gender, APACHE score, associated diseases, hypotension at intake, coma, hospitalization time, length of time of ventilation, emergeney intubation, reintubation, previous antibiotics, and resistant microrganisms. Results: Lethality was 25.4 percent, and mortality was 2.4 percent. Association between lethality, and APACHE score was found (p: 0.04). Critical APACHE valué was 22. Also, in early pneumonia, association between lethality and nasogastric tube (p: 0.01, I.C. 95 percent 1.39 - 6.35) was found. No association with late pneumonia was found among mortality and clinical practices. Death's RR (relative risk) increase in following valúes with: previous neurological disease 2.7 (p: 0.15, IC 95 percent 1.15 - 6.5), neurological comaRR2 (p: 0.2, IC 95 percent 0.54 - 7.53). Nevertheless, at multivariate analysis no mortality risk factors were identified. Fair association with time in ICU (p: 0.051 IC 95 percent 0.99 - 1.17) and, male sex (p: 0.051, IC 95 percent 0.99 - 6.72) was found. Conclusions: We observed múltiple factors associated to mortality in VAP: use of nasogastric catheter, longer stay in ICU and male sex.

Objetivo: Identificar la tasa de letalidad, mortalidad y factores de riesgo de mortalidad en neumonía asociada a ventilación mecánica (NAVM) en 114 pacientes de la cohorte 2000-2007. Se estudiaron 25 factores de riesgo del paciente y de las prácticas clínicas. Resultados: La tasa de letalidad fue 25,4 por ciento) y la tasa de mortalidad de 2,4 por ciento>. Se encontró asociación entre el puntaje APACHE al momento del diagnóstico de neumonía y mortalidad (p: 0,04). El valor crítico de APACHE de alto riesgo fue igual o mayor a 22. En neumonía precoz se identificó como factor de letalidad la presencia de sonda naso-gástrica (p: 0,01, IC 95 por ciento> 1,39-6,35). Para las variables categóricas no se encontró asociación significativa entre la exposición y mortalidad. El RR en presencia de enfermedad neurológica previa (accidente vascular encefálico) fue 2,7 (p: 0,15, IC 95 por ciento 1,15-6,5), coma al ingreso 2 (p: 0,2, IC 95 por ciento 0,54-7,53). En neumonía tardía, no se identificaron factores de riesgo asociados a la atención. El análisis multivariado de todas esas exposiciones no identificó factores significativos asociados a mortalidad. Identificamos una asociación débil con días de estada en UCI (p: 0,051 IC 95 por ciento 0,99-1,17) y sexo masculino (p: 0,051, IC 95 por ciento 0,99-6,72). Conclusiones: Los resultados muestran una relación multifactorial de prácticas clínicas y del paciente para fallecer por NAVM. Como factor de prácticas clínicas encontramos asociado a mortalidad el uso de sonda nasogástrica y mayor permanencia en UCI. Dependiente del paciente encontramos una débil asociación entre mortalidad y sexo masculino.

Eficacia de la tinción de Gram de muestras respiratorias para la predicción de la neumonía asociada al respirador y su utilidad en la selección de la terapéutica antibiótica empírica / Efficacy of the Gram stain in respiratory samples for the prediction of ventilation associated pneumonia and its utility in the selection of the initial empiric antibiotic therapy

Introducción: La neumonía asociada a la ventilación (NAV) es una complicación frecuente de la ventilación mecánica (VM) y se asocia a alta mortalidad. Su adecuado manejo se basa en detección precoz y terapia con antibióticos (ATB) empírica eficaz, siendo esenciales los métodos que permitan predecir la NAV y ayuden a seleccionar los ATB. Objetivo: valorar la eficacia del examen directo por tinción de Gram de muestras obtenidas del tracto respiratorio en la detección de NAV y como ayuda a la selección de ATB. Materiales y Métodos: Se incluyeron prospectivamente 95 episodios de sospecha de NAV en 69 pacientes, considerando sólo los casos sin modificación de los ATB por más de 48 hs o sin ATB. Las muestras fueron obtenidas por medio de Lavado bronquioloalveolar a través de Fibro- broncoscopia (BAL) o minibal por catéter envainado a ciegas (miniBal). La confirmación se efectuó por el análisis bacteriológico cuantitativo (> 10 elevado a la cuarta y > 10³ para el BAL y minibal respectivamente). Se calculó la sensibilidad (S), especificidad (E), valor predictivo positivo (VPP) y negativo (VPN) de la técnica de tinción directa de Gram, considerando como referencia el resultado microbiológico del cultivo del BAL o mini-BAL. Se comparó además la concordancia entre el tipo de germen observado en la tinción directa de Gram, bacilo Gram negativo (BGN) o coco Gram positivo (CGP) y el tipo de bacteria aislada en el cultivo. Se analizaron también las variables predictivas específicas o cualitativas, esto es la eficacia del Gram en predecir VAP por CGP o por BGN. Resultados: Se diagnosticó NAV en 52 casos. La S de la tinción de Gram fue de 60%, E: 100%, VPP Positivo: 100%, VPN: 67%. En cuanto a la eficacia para predecir VAP por BGN se observó: S: 52%, E: 100%, VPP: 100%, VPN: 72%. Para CGP: s: 91 %, E: 100%, VPP 100% y VPN: 99%. Conclusión: Si bien un examen bacteriológico directo por tinción de Gram predice presencia de VAP, su VPN es bajo por lo que un directo negativo...

Introduction: Ventilator Associated Pneumonia (VAP) is a frequent complication in mechanically ventilated patients, and is associated with a high mortality. Early diagnosis and appropriate use of empiric antibiotic therapy (ATB) is essential to its treatment. Tests that help to make an early diagnosis and select the initial ATB are useful. Objective: to evaluate the accuracy of the Gram stain examination of respiratory tract samples in the prediction of VAP and its potential role in the selection of empiric ATB. Materials and methods: prospective evaluation of 95 episodes in 69 patients with clinical suspicion of VAP who had not had any changes in the ATB for more than 48 hours or had not been treated with ATB. Samples were taken by bronchoalveolar lavage (BAL) through flexible bronchoscopy or blind mini bronchoalveolar lavage with protected catheter. VAP was confirmed when the quantitative cultures showed =10 to the fourth ufc/ml for BAL and =10³ ufc/ml for mini BAL. A comparison was made between the type of bacteria observed by the direct Gram staining (Gram negative bacteria or Gram positive bacteria) and the type of bacteria isolated by culture. Specific or qualitative predictive variables were analyzed to determine the value of Gram staining to predict a Gram-negative VAP or Gram-positive VAP. Results: VAP was confirmed in 52 cases. The sensitivity of the Gram stain for VAP was 60%, specificity 100%; positive predictive value: 100% and negative predictive value: 67%. The sensitivity of Gram negative bacteria for VAP was: 52%; specificity: 100%; positive predictive value: 100%; negative predictive value: 72%. The sensitivity of Gram positive bacteria for VAP was: 91 %; specificity: 100%; positive predictive value: 100%; negative predictive value: 99%. Conclusions: A positive finding in the Gram staining examination of respiratory tract samples was highly predictive of VAP but a negative result did not mean absence of VAP, because the negative...

Risk factors and evolution of Ventilator-associated pneumonia by Staphylococcus aureus sensitive or resistant to oxacillin in patients at the intensive care unit of a Brazilian University Hospital

This study investigated the participation and risk factors of VAP by resistant (ORSA) or sensitive (OSSA) S. aureus to oxacillin and evaluated the implications of adequate or inadequate empirical antimicrobial therapeutics in its evolution in patients interned in a mixing ICU of adults. A patient control-case study with PAVs by ORSA and OSSA was carried out from May 2005 to April 2007 involving 993 patients. VAP was defined based on clinical, radiological, and microbiological (> 106 CFU/mL count in the tracheal aspirate) criteria. Four hundred and seventy four (47.7 percent) patients were submitted to mechanical ventilation with 141 (29.7 percent) VAPs, with S. aureus as the most frequent agent (41.2 percent). The phenotype ORSA accounted for 47.5 percent and OSSA for 52.5 percent, predominant in late-onset VAPs with frequencies of 93.1 percent and 68.7 percent, respectively. Age > 60, use of corticoid and previous antibiotic therapy were related (p<0.05) with the development of VAP by ORSA. Mortality rate was higher (p>0.05) in the group with VAP by ORSA (37.9 percent). S. aureus was the main agent of VAPs, around half by ORSA, associated with age, late-onset VAP development and previous use of antibiotics and corticoids, but with no significant difference in mortality compared with VAP by OSSA.

Device-associated infection rates and mortality in intensive care units of Peruvian hospitals: findings of the International Nosocomial Infection Control Consortium / Tasas de infección asociadas a aparatos y mortalidad en unidades de cuidados intensivos de hospitales peruanos: datos del Consorcio Internacional para el Control de las Infecciones Nosocomiales

OBJECTIVES: To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, and attributable mortality in intensive care units (ICUs) in hospitals in Peru that are members of the International Nosocomial Infection Control Consortium (INICC). METHODS: Prospective cohort surveillance of DAIs was conducted in ICUs in four hospitals applying the definitions for nosocomial infections of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS) and National Healthcare Safety Network (NHSN). RESULTS: From September 2003 to October 2007 1 920 patients hospitalized in ICUs for an aggregate of 9 997 days acquired 249 DAIs, accounting for a rate of 13.0 percent and 24.9 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 31.3 per 1 000 ventilator-days; the central venous catheter-associated bloodstream infections (CVC-BSI) rate was 7.7 cases per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 5.1 cases per 1 000 catheter-days. Extra mortality for VAP was 24.5 percent (RR 2.07, P < 0.001); for CVC-BSI the rate was 15.0 percent (RR 2.75, P = 0.028). Methicillin-resistant strains accounted for 73.5 percent of all Staphylococcus aureus DAIs; 40.5 percent of the Enterobacteriaceae were resistant to ceftriaxone, 40.8 percent were resistant to ceftazidime, and 32.0 percent were resistant to piperacillin-tazobactam. Sixty-five percent of Pseudomonas aeruginosa isolates were resistant to ciprofloxacin, 62.0 percent were resistant to ceftazidime, 29.4 percent were resistant to piperacillin-tazobactam, and 36.1 percent were resistant to imipenem. CONCLUSIONS: The high rates of DAIs in the Peruvian hospitals in this study indicate the need for active infection control. Programs consisting of surveillance of DAIs and implementation of guidelines for infection prevention can ensure improved patient...

OBJETIVOS: Determinar las tasas de infecciones asociadas a aparatos (IAA), sus perfiles microbiológicos y la resistencia bacteriana, así como la mortalidad atribuible a estas infecciones en unidades de cuidados intensivos (UCI) de hospitales de Perú, miembros del Consorcio Internacional para el Control de las Infecciones Nosocomiales (INICC). MÉTODOS: Se hizo un seguimiento retrospectivo de cohorte de las IAA en las UCI de cuatro hospitales, según las definiciones de infección nosocomial del Sistema Nacional de Vigilancia de Infecciones Nosocomiales de los Centros para el Control y la Prevención de Enfermedades (CDC-NNIS) y de la Red Nacional de Seguridad Sanitaria (NHSN), de los Estados Unidos de América. RESULTADOS: De septiembre de 2003 a octubre de 2007, 1 920 pacientes hospitalizados en las UCI, con un total de 9 997 días, adquirieron 249 IAA, para una tasa de 13,0 por paciente (24,9 IAA por 1 000 días-UCI). La tasa de neumonía asociada a respiradores (NAR) fue de 31,3 casos por 1 000 días-ventilador; la tasa de infecciones circulatorias asociadas con cateterismo venoso central (IC-CVC) fue de 7,7 casos por 1 000 díascatéter; y la tasa de infecciones urinarias asociadas con el uso de catéteres (IUAC) fue de 5,1 casos por días-catéter. La mortalidad adicional por NAR fue de 24,5 por ciento (RR = 2,07; P < 0,001) y por IC-CVC fue de 15,0 por ciento (RR = 2,75; P = 0,028). De las IAA por Staphylococcus aureus, 73,5 por ciento se debían a cepas resistentes a la meticilina; de los aislamientos de Enterobacteriaceae, 40,5 por ciento eran resistentes a la ceftriaxona, 40,8 por ciento a la ceftazidima y 32,0 por ciento a la piperacilina-tazobactam. De los aislamientos de Pseudomonas aeruginosa, 65,0 por ciento eran resistentes a la ciprofloxacina; 62,0 por ciento a la ceftazidima; 36,1 por ciento al imipenem; y 29,4 por ciento a la piperacilina-tazobactam. CONCLUSIONES: Las elevadas tasas de IAA encontradas en los hospitales peruanos señalan...

Ventilator-associated pneumonia Part 1: epidemiology, pathogenesis and prevention

Ventilator-associated pneumonia [VAP] is the leading cause of morbidity and mortality in intensive care units [ICUs]. Intubation and mechanical ventilation [MV] is associated with a 7-fold to 21 -fold increase in the incidence of pneumonia and approximately one third of patients receiving mechanical ventilation will develop this complication. Prevention of VAP must be regarded as one of the most important issues in critical care. It is possible through the use of several evidence-based strategies intended to minimize intubation, the duration of mechanical ventilation, and the risk of aspiration of oropharyngeal pathogens. Important components of effective preventive strategies focus on basic infection control principles like hand washing, adequate ICU staff education, and optimal resource utilization. Measures to prevent VAP extend into all aspects of daily intensive care practice, including antibiotic selection and duration of use, preferred routes of intubation, limitation of sedation, protocolized weaning, optimal use of noninvasive mask ventilation, patient positioning, ventilator circuit management, transfusion practices, stress ulcer prophylaxis, and glycemic control. However, strategies to prevent VAP are likely to be successful only if based upon a sound understanding of pathogenesis and epidemiology. In the first part of this article we review the evidence on prevalence, pathogenesis, microbiology, and prevention of VAP. Evidence-based recommendations for prevention of VAP are provided. Diagnosis and treatment of this condition are discussed in part two

Epidemiological and microbiological analysis of ventilator-associated pneumonia patients in a public teaching hospital

Ventilator-associated pneumonia (VAP) is the most commonly-acquired infection in patients in intensive care units. We analyzed epidemiological and microbiological characteristics and the outcome, in a cohort of critically-ill patients with confirmed diagnosis of VAP. All patients who had been on mechanical ventilation (MV) for more than 48 hours were included in our study; material collection for microbiological analysis was done within the first 24 hours after beginning treatment or after changing antibiotics. There were 55/265 (20.7 percent) VAP cases diagnosed, at a rate of 21.6 episodes per 1,000 days of mechanical ventilation. Mean age of the patients was 66 years, with a mean APACHE II score of 26.7 + 7.0; male patients were more prevalent. The mortality rates in the intensive care unit (ICU) and during the hospital stay were 71 percent and 80 percent, respectively. MV duration in patients with VAP was 17 (range 3-43) days and among patients who had not developed VAP, 6 (2-32) days (p < 0.0001). 98.2 percent of the samples were positive, with a high prevalence of Gram-negative bacteria, mainly Acinetobacter calcoaceticus. Risk factors for death included age, MV duration and surgery. VAP incidence in this sample of critically-ill patients was high, with a high mortality rate. Control and prevention strategies based on continuing education of healthcare workers, developed by a multidisciplinary team, should be encouraged to minimize morbimortality of this infection.

Etiología de la neumonía asociada a ventilación mecánica en un hospital clínico: Asociación con co-morbilidad, uso previo de antimicrobianos y mortalidad / Etiology of ventilator-associated pneumonia in a university hospital: Association with comorbidity, previous use of antibiotics and mortality

Ventilator-associated pneumonia (VAP) is a complication with an increased risk of morbidity and mortality. Inadequate antibiotic treatment is a risk factor of mortality which can be improved. For this reason it is important to know the local etiology of VAP. During a one year-period we investigated the etiology of VAP in a teaching hospital. Forty eight VAP were included, of which 19 were women. The median age was 59.5 (range 17-91 years), twelve VAP were early onset. Methicillin resistant Staphylococcus aureus (MRSA) was the main microorganism isolated, regardless of timing of diagnosis of VAP, followed by polimicrobial etiology, Acinetobacter sp and P. aeruginosa. Etiology was not associated with comorbidity; however previous antibiotic use was related with MRSA and polymicrobial etiology. Mortality was 35 percent and was mainly associated with P. aeruginosa isolation. Conclusion: MRSA was the main cause of VAP regardless of the timing of its occurrence.

La neumonía asociada a la ventilación mecánica (NAVM) es una complicación relacionada con un aumento de morbilidad y mortalidad. Dentro de los factores de mal pronóstico, el tratamiento antimicrobiano inadecuado es una de las variables que puede corregirse. Para esto debe conocerse la etiología institucional de la NAVM. Durante un año se recopilaron las NAVM con documentación microbiológica en un hospital universitario. En total, 48 neumonías fueron incluidas, 19 en pacientes femeninas, la mediana de la edad fue de 59,5 años (rango 17-91), 12 de ellas precoces. Staphylococcus aureus meticilina resistente (MRSA) fue el principal agente involucrado, independiente del momento de su génesis, seguido por la etiología polimicrobiana, Acinetobacter sp y Pseudomonas aeruginosa, en ese orden. La etiología no se asoció con la existencia de co-morbilidad, el uso previo de antimicrobianos se asoció con la presencia de MRSA y etiología polimicrobiana. La letalidad fue de 35 por ciento y se relacionó, principalmente, con la presencia de P. aeruginosa. Conclusión: La principal causa de NAVM en esta experiencia fue SAMR, independiente del momento evolutivo de su ocurrencia.

Nosocomial pneumonia in mechanically ventilated patients

Ventilator associated pneumonia [VAP] is a disease caused by different microorganisms and is associated with high mortality. The objective of this study was to ascertain the causative organisms of VAP and the mortality associated with this disorder. It was a prospective comparative study of 100 patients who underwent ventilatory support at a tertiary care teaching hospital [Combined Military Hospital Rawalpindi] from 1st July, 2000 to 30th June 2001. Patients who developed clinical signs of pneumonia are investigated by bronchoalveolar lavage[BAL] and blood culture. In patients who were diagnosed as a case of VAP, microorganisms were identified by BAL [79%] and blood culture [21%]. Patients who developed VAP were followed as well as the controls that do not developed VAP. Mortality among both groups was recorded. Outcome of the study showed organisms including Pseudomonas aeruginosa [26%], Staphylococcus aureus [20%], Acinetobacter spp. [9%], Proteus spp. [6%], Haemophilus spp. [6%], Escherichia coli [6%], Klebsiella spp. [3%], Streptococcus pneumoniae [3%], Corynebacteria spp. [3%], and Polymicrobial flora [9%]. The mortality among the patients of VAP was 50% compared to 30% among the patients without VAP. But this difference is non-significant. In conclusion VAP is developed by diverse groups of microorganisms with Pseudomonas aeruginosa, Staphylococcus aureus and Acinetobacter spp amongst the commonest pathogens. VAP is associated with higher percentage of mortality