Ventilator-associated pneumonia in patients on prolonged mechanical ventilation: description, risk factors for mortality, and performance of the SOFA score.

OBJECTIVE: Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation (MV). However, data on VAP in patients on prolonged MV (PMV) are scarce. We aimed to describe the characteristics of VAP patients on PMV and to identify factors associated with mortality. METHODS: This was a retrospective cohort study including VAP patients on PMV. We recorded baseline characteristics, as well as 30-day and 90-day mortality rates. Variables associated with mortality were determined by Kaplan-Meier survival analysis and Cox regression model. RESULTS: We identified 80 episodes of VAP in 62 subjects on PMV. The medians for age, Charlson Comorbidity Index, SOFA score, and days on MV were, respectively, 69.5 years, 5, 4, and 56 days. Episodes of VAP occurred between days 21 and 50 of MV in 28 patients (45.2%) and, by day 90 of MV, in 48 patients (77.4%). The 30-day and 90-day mortality rates were 30.0% and 63.7%, respectively. There were associations of 30-day mortality with the SOFA score (hazard ratio [HR] = 1.30; 95% CI: 1.12-1.52; p < 0.001) and use of vasoactive agents (HR = 4.0; 95% CI: 1.2-12.9; p = 0.02), whereas 90-day mortality was associated with age (HR = 1.03; 95% CI: 1.00-1.05; p = 0.003), SOFA score (HR = 1.20; 95% CI: 1.07-1.34; p = 0.001), use of vasoactive agents (HR = 4.07; 95% CI: 1.93-8.55; p < 0.001), and COPD (HR = 3.35; 95% CI: 1.71-6.60; p < 0.001). CONCLUSIONS: Mortality rates in VAP patients on PMV are considerably high. The onset of VAP can occur various days after MV initiation. The SOFA score is useful for predicting fatal outcomes. The factors associated with mortality could help guide therapeutic decisions and determine prognosis.

Ventilator-associated pneumonia in patients on prolonged mechanical ventilation: description, risk factors for mortality, and performance of the SOFA score / Pneumonia associada à ventilação mecânica em pacientes em ventilação mecânica prolongada: descrição, fatores de risco associados à mortalidade e desempenho do escore SOFA

ABSTRACT Objective: Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation (MV). However, data on VAP in patients on prolonged MV (PMV) are scarce. We aimed to describe the characteristics of VAP patients on PMV and to identify factors associated with mortality. Methods: This was a retrospective cohort study including VAP patients on PMV. We recorded baseline characteristics, as well as 30-day and 90-day mortality rates. Variables associated with mortality were determined by Kaplan-Meier survival analysis and Cox regression model. Results: We identified 80 episodes of VAP in 62 subjects on PMV. The medians for age, Charlson Comorbidity Index, SOFA score, and days on MV were, respectively, 69.5 years, 5, 4, and 56 days. Episodes of VAP occurred between days 21 and 50 of MV in 28 patients (45.2%) and, by day 90 of MV, in 48 patients (77.4%). The 30-day and 90-day mortality rates were 30.0% and 63.7%, respectively. There were associations of 30-day mortality with the SOFA score (hazard ratio [HR] = 1.30; 95% CI: 1.12-1.52; p < 0.001) and use of vasoactive agents (HR = 4.0; 95% CI: 1.2-12.9; p = 0.02), whereas 90-day mortality was associated with age (HR = 1.03; 95% CI: 1.00-1.05; p = 0.003), SOFA score (HR = 1.20; 95% CI: 1.07-1.34; p = 0.001), use of vasoactive agents (HR = 4.07; 95% CI: 1.93-8.55; p < 0.001), and COPD (HR = 3.35; 95% CI: 1.71-6.60; p < 0.001). Conclusions: Mortality rates in VAP patients on PMV are considerably high. The onset of VAP can occur various days after MV initiation. The SOFA score is useful for predicting fatal outcomes. The factors associated with mortality could help guide therapeutic decisions and determine prognosis.

RESUMO Objetivo: A pneumonia associada à ventilação mecânica (PAVM) é uma séria complicação da ventilação mecânica (VM). Entretanto, dados sobre PAVM em pacientes em VM prolongada (VMP) são escassos. Nosso objetivo foi descrever as características de pacientes com PAVM em VMP e identificar fatores associados à mortalidade. Métodos: Estudo de coorte retrospectivo incluindo pacientes com PAVM em VMP. Foram registradas características basais, bem como as taxas de mortalidade em 30 e 90 dias. As variáveis associadas à mortalidade foram determinadas por meio da análise de sobrevida de Kaplan-Meier e do modelo de regressão de Cox. Resultados: Foram identificados 80 episódios de PAVM em 62 indivíduos em VMP. As medianas de idade, índice de comorbidade de Charlson, pontuação no SOFA, e dias em VM foram, respectivamente, de 69,5 anos, 5, 4 e 56 dias. Os episódios de PAVM ocorreram entre o 21º e o 50º dia de VM em 28 pacientes (45,2%) e até o 90º dia de VM em 48 pacientes (77,4%). As taxas de mortalidade em 30 e 90 dias foram de 30,0% e 63,7%, respectivamente. A mortalidade em 30 dias associou-se a pontuação no SOFA (razão de risco [RR] = 1,30; IC95%: 1,12-1,52; p < 0,001) e uso de drogas vasoativas (RR = 4,0; IC95%: 1,2-12,9; p = 0,02), enquanto a mortalidade em 90 dias associou-se a idade (RR = 1,03; IC95%: 1,00-1,05; p = 0,003), pontuação no SOFA (RR = 1,20; IC95%: 1,07-1,34; p = 0,001), uso de drogas vasoativas (RR = 4,07; IC95%: 1,93-8,55; p < 0,001) e DPOC (RR = 3,35; IC95%: 1,71-6,60; p < 0,001). Conclusões: As taxas de mortalidade em pacientes com PAVM em VMP são consideravelmente altas. O início da PAVM pode ocorrer vários dias após a instituição da VM. O escore SOFA é útil para predição de desfechos fatais. Os fatores associados à mortalidade podem ajudar a orientar as decisões terapêuticas e a determinar o prognóstico.

Antibiotic Resistance in Community-Acquired Intra-Abdominal Infections: Diabetes Mellitus as a Risk Factor.

Background: Antimicrobial drug resistance in community-acquired (CA) infections is a growing problem. Knowing the local epidemiology is essential to design empirical antibiotic therapy. Therefore, we conducted this study to evaluate the resistance patterns of microorganisms isolated from surgical samples of community-acquired intra-abdominal infections (IAIs) and to determine the factors associated with resistance. Methods: We analyzed retrospectively the records of patients treated from January 2015 to June 2017 who had IAIs with positives aerobic cultures performed in the first 72 hours after admission. Surgical site infections, abdominal wall procedures, peritoneal dialysis catheters, and patients with admissions in the prior month were excluded. To identify the factors associated with resistance, we considered the resistance to the regimen recommended at our institution, ampicillin/sulbactam (AMS) plus ciprofloxacin (CIP). Results: There were 119 patients with 133 isolates, 59% women, and mean age 54 years. The main sources of infection were appendicitis (38%) and cholecystitis (20%), with 64 patients presenting a complicated IAI (cIAI), defined by the presence of peritonitis (55%). Resistance in Enterobacteriaceae was AMS 32% (6.4% intermediate resistance), CIP 31%, cefotaxime 9%, piperacillin/tazobactam (PTZ) 3%, trimethoprim/sulfamethoxazole 32%, gentamicin 9.5%, and amikacin 2%. Considering all patients, resistance to AMS + CIP was 16.8%. Factors associated with resistant to this regimen was, by univariable and multivariable analysis, the presence of diabetes mellitus (odds ratio [OR] 3.6; 95% confidence interval [CI] 1.1-11.6; p = 0.03). Female gender (OR 2.7; CI 0.9-8.4; p = 0.08) and complicated IAI (OR 2.0; CI 0.7-5.4; p = 0.17) were associated with resistance but did not reach statistical significance. Conclusion: High resistance to CIP and AMS was observed. Although the combination of AMS + CIP offers coverage for 84% of patients, PTZ should be considered as an option for patients with severe infections or diabetes mellitus. Finding factors associated with antibiotic resistance could help to select empirical therapy for CA IAIs better.

[Influenza and pneumococcal immunization in cardiovascular prevention]. / Inmunización para influenza y neumococo en prevención cardiovascular.

A group of interdisciplinary experts (cardiologists, clinicians, infectologists met with the purpose of analyzing the evidence revealed by the relationship between respiratory diseases caused by influenza, pneumococcal diseases and cardiovascular events, and the role played by immunization strategies applied in cardiovascular prevention. The present statement summarizes the conclusions reached by the expertise of the aforementioned professionals. Systematic revisions imply consistent evidence that influenza and pneumococcal infection lead to acute myocardial infarction and cardiovascular death. Studies published during the last 15 years suggest that vaccination against influenza and S. pneumoniae reduce the risk of acute coronary syndromes. With the current evidence, and considering cost-effectiveness, reducing operating expenses and safety profile of the vaccines, scientific societies, national and international government health agencies strongly recommend incorporating immunization programs in those patients with chronic cardiovascular disease.

Inmunización para influenza y neumococo en prevención cardiovascular / [Influenza and pneumococcal immunization in cardiovascular prevention]

A group of interdisciplinary experts (cardiologists, clinicians, infectologists met with the purpose of analyzing the evidence revealed by the relationship between respiratory diseases caused by influenza, pneumococcal diseases and cardiovascular events, and the role played by immunization strategies applied in cardiovascular prevention. The present statement summarizes the conclusions reached by the expertise of the aforementioned professionals. Systematic revisions imply consistent evidence that influenza and pneumococcal infection lead to acute myocardial infarction and cardiovascular death. Studies published during the last 15 years suggest that vaccination against influenza and S. pneumoniae reduce the risk of acute coronary syndromes. With the current evidence, and considering cost-effectiveness, reducing operating expenses and safety profile of the vaccines, scientific societies, national and international government health agencies strongly recommend incorporating immunization programs in those patients with chronic cardiovascular disease.

Inmunización para influenza y neumococo en prevención cardiovascular. / [Influenza and pneumococcal immunization in cardiovascular prevention].

A group of interdisciplinary experts (cardiologists, clinicians, infectologists met with the purpose of analyzing the evidence revealed by the relationship between respiratory diseases caused by influenza, pneumococcal diseases and cardiovascular events, and the role played by immunization strategies applied in cardiovascular prevention. The present statement summarizes the conclusions reached by the expertise of the aforementioned professionals. Systematic revisions imply consistent evidence that influenza and pneumococcal infection lead to acute myocardial infarction and cardiovascular death. Studies published during the last 15 years suggest that vaccination against influenza and S. pneumoniae reduce the risk of acute coronary syndromes. With the current evidence, and considering cost-effectiveness, reducing operating expenses and safety profile of the vaccines, scientific societies, national and international government health agencies strongly recommend incorporating immunization programs in those patients with chronic cardiovascular disease.