An observational study of Pseudomonas aeruginosa in adult long-term ventilation.

Introduction: Pseudomonas aeruginosa increases morbidity and mortality in respiratory disease. To date the long-term ventilation population does not have clear guidelines regarding its management. Method: We undertook a retrospective observational study in a regional long-term ventilation population (837 patients). We defined the primary outcome as P. aeruginosa isolation. In addition positive cultures for copathogens (Serratia, Proteus species, Stenotrophomonas, Burkholderia cepacia complex and nontuberculous mycobacteria) were recorded. Logistic regression and odds ratios were calculated. Results: 17.6% of the cohort isolated P. aeruginosa, and this pathogen was cultured more frequently in patients with a tracheostomy (logistic regression coefficient 2.90, p≤0.0001) and cystic fibrosis/bronchiectasis (logistic regression coefficient 2.48, p≤0.0001). 6.3% of patients were ventilated via tracheostomy. In the P. aeruginosa positive cohort 46.9% of patients were treated with a long-term macrolide, 36.7% received a nebulised antibiotic and 21.1% received both. Tracheostomised P. aeruginosa positive patients received a nebulised antibiotic more frequently (OR 2.63, 95% CI 1.23-5.64, p=0.013). Copathogens were isolated in 33.3% of the P. aeruginosa cohort. In this cohort patients with a tracheostomy grew a copathogen more frequently than those without (OR 2.75, 95% CI 1.28-5.90). Conclusions: P. aeruginosa isolation is common within the adult long-term ventilation population and is significantly associated with tracheostomy, cystic fibrosis and bronchiectasis. Further research and international guidelines are needed to establish the prognostic impact of P. aeruginosa and to guide on antimicrobial management. The increased risk of P. aeruginosa should be considered when contemplating long-term ventilation via tracheostomy.

Respiratory outpatient clinics during and post COVID-19: the use of patient satisfaction and preference data to redesign service delivery.

We used a survey to evaluate patient satisfaction with a remote system for the delivery of respiratory clinics and to capture future preferences. 98% of responders were satisfied with their current appointment being held remotely in order to reduce the risks from COVID-19. Regarding future preferences beyond the pandemic, 41% of respondents preferred a face-to-face appointment, 35% preferred a remote appointment and 24% had no preference of one modality over another. Additional qualitative data suggest that a flexible system allowing patients to choose the mode of attendance shortly before the appointment would be welcomed.

Intracolonic Administration of Vancomycin in Intensive Care Unit Patients with Severe Clostridium Difficile Colitis.

BACKGROUND: Clostridium difficile infection (CDI) is a major cause of antibiotic-associated diarrhea worldwide. The incidence of sepsis has been shown to be increasing due to severe or fulminant colitis. Oral vancomycin is the treatment of choice for CDI, but it is often ineffective in patients in the intensive care unit (ICU) due to poor intestinal motility. We present a review of eight cases with severe to fulminant CDI treated with adjunctive intracolonic vancomycin (ICV) administration. METHODS: A retrospective chart review identified patients in sepsis with severe colitis and positive Clostridium difficile toxin A or B. Patients who had failed standard therapy for CDI were given adjunctive ICV through an enteric tube, which was inserted via colonoscopy. To indicate the severity of patients, the patients selected had required vasopressor support. RESULTS: Eight patients (37.5% females) received this adjunctive treatment; the mean age was 73.25. The average Acute Physiology and Chronic Health Evaluation (APACHE) 2 score at the time of the procedure was 39. The median length of stay was 5.5 days, with in-hospital mortality of 37.5% and an average time to death of 1.33 days from the day of colonoscopy.  Conclusion: Colonoscopic decompression and administration of vancomycin for fulminant CDI using an enteric tube can have favorable outcomes in severely ill patients whose surgical options carry a high risk of mortality. Further larger randomized controlled trials are needed to evaluate its efficacy.

Cough and bronchiectasis.

Bronchiectasis is a chronic lung disease with permanent airway dilatation, mucus retention and recurrent lower respiratory tract infections. Bronchiectasis is increasing in prevalence and has a significant morbidity and an excess mortality rate over age matched controls. It is increasingly identified during investigations into chronic cough and is evident high resolution CT scanning. There remain significant knowledge gaps in our understanding of the epidemiology, pathophysiology, prognosis and optimal treatments in bronchiectasis. This article reviews current concepts in bronchiectasis and focusses on the complex aspects of chronic cough in this setting. Cough is important in bronchiectasis as it is one of the most common presenting symptoms, it affects a patients' quality of life and in conjunction with cough hypersensitivity and airway hyper responsiveness may limit the successful uptake of treatment modalities such as inhaled antibiotics and/or inhaled mucoactive therapies. Effective coughing often assisted by physiotherapy is a cornerstone of bronchial toileting in bronchiectasis. Some patients however have ongoing non-productive cough symptoms suggesting a cough sensitisation syndrome. Post nasal drip and gastro-oesophageal reflux may complicate bronchiectasis and further lead to intractable cough syndromes. There may be multiple cough syndromes within an individual at interplay and careful assessment and multidisciplinary working is needed to optimize symptom control. This article also highlights the many unknowns in chronic cough in bronchiectasis.