Early, single chlorhexidine application reduces ventilator-associated pneumonia in trauma patients

Background

Ventilator-associated pneumonia (VAP) is an important complication of mechanical ventilation and is particularly common in trauma, burn, and surgical patients. Interventions that kill bacteria in the oropharynx reduce the pool of viable organisms available for translocation to the lung and thereby lessen the likelihood of developing VAP. Repeated administration of chlorhexidine (CHX) to the mouth and oropharynx has been shown to reduce the incidence of VAP, but use of a single dose has not been studied. This randomized, controlled clinical trial tested an early (within 12 hours of intubation) application of CHX by swab versus control (no swab) on oral microbial flora and VAP.

Methods

A total of 145 trauma patients requiring endotracheal intubation were randomly assigned to the intervention (5 mL CHX) or control group. VAP (Clinical Pulmonary Infection Score [CPIS] ≥ 6) was evaluated on study admission and at 48 and 72 hours after intubation.

Results

A total of 145 patients were enrolled; 71 and 74 patients were randomized to intervention and control groups, respectively. Seventy percent of the patients were male, and 60% were white; their mean age was 42.4 years (±18.2). A significant treatment effect was found on CPIS both from admission to 48 hours (P = .020) and to 72 hours (P = .027). In those subjects without pneumonia at baseline (CPIS < 6), 55.6% of the control patients (10/18) had developed VAP by 48 or 72 hours versus only 33.3% of the intervention patients (7/21).

Conclusion

an early, single application of CHX to the oral cavity significantly reduces CPIS and thus VAP in trauma patients.     

Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia

RATIONALE: Ventilator-associated pneumonia (VAP) is the most frequently occurring nosocomial infection associated with increased morbidity and mortality. Although oral decontamination with antibiotics reduces incidences of VAP, it is not recommended because of potential selection of antibiotic-resistant pathogens. We hypothesized that oral decontamination with either chlorhexidine (CHX, 2%) or CHX/colistin (CHX/COL, 2%/2%) would reduce and postpone development of VAP, and oral and endotracheal colonization. OBJECTIVES: To determine the effect of oral decontamination with CHX or CHX/COL on VAP incidence and time to development of VAP. METHODS: Consecutive patients needing mechanical ventilation for 48 h or more were enrolled in a randomized, double-blind, placebo-controlled trial with three arms: CHX, CHX/COL, and placebo (PLAC). Trial medication was applied every 6 h into the buccal cavity. Oropharyngeal swabs were obtained daily and quantitatively analyzed for gram-positive and gram-negative microorganisms. Endotracheal colonization was monitored twice weekly. RESULTS: Of 385 patients included, 130 received PLAC, 127 CHX and 128 CHX/COL. Baseline characteristics were comparable. The daily risk of VAP was reduced in both treatment groups compared with PLAC: 65% (hazard ratio [HR]=0.352; 95% confidence interval [CI], 0.160, 0. 791; p=0.012) for CHX and 55% (HR=0.454; 95% CI, 0.224, 0. 925; p=0.030) for CHX/COL. CHX/COL provided significant reduction in oropharyngeal colonization with both gram-negative and gram-positive microorganisms, whereas CHX mostly affected gram-positive microorganisms. Endotracheal colonization was reduced for CHX/COL patients and to a lesser extent for CHX patients. No differences in duration of mechanical ventilation, intensive care unit stay, or intensive care unit survival could be demonstrated. CONCLUSIONS: Topical oral decontamination with CHX or CHX/COL reduces the incidence of VAP.     

Treatment failure in patients with ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is one of the most important infectious diseases in the intensive care unit (ICU). In some series the attributable mortality of VAP may reach 30%, and the adequacy of the initial empirical treatment greatly influences the prognosis. Treatment failure can be anticipated in approximately 30 to 40% of patients developing pneumonia during mechanical ventilation and this situation is associated with an adverse outcome in terms of morbidity. For these reasons, the lack of response to empirical antibiotic treatment should be recognized early in the course of VAP, and a clear strategy for clarifying the causes of failure should be implemented. Resolution of VAP depends not only on the accuracy of microbial diagnosis but also on comorbidities, the response of the host to the infection, concomitant infections, and the correct clinical diagnosis. Treatment failure can be defined by the pattern of resolution of VAP, which is clearly established in the literature.     

Treatment failures in patients with ventilator-associated pneumonia

Treatment failures in patients with VAP are a complex issue and form a major challenge for clinicians. The following key elements inherent to a rational approach to treatment failures have been elucidated: (1) the presence of treatment failure must be thoroughly defined and assessed; (2) the many causes behind treatment failures must be realized, particularly the possibility of pneumonia-related and extrapulmonary reasons; (3) the recognition of different patterns of treatment failures as a useful framework for decisions about modalities and intensity of diagnostic reassessment; and (4) the establishment of a protocol for the search of pulmonary and extrapulmonary sites of infection and noninfectious causes of nonresponse. Only such a rational approach precludes the adverse effects of blind empiricism, which always implies a dangerous and costly overtreatment. Many issues related to treatment failures remain unsettled, and efforts will have to be made in the future to improve current clinical attitudes to treatment failures in VAP.     

血清降钙素原在呼吸机相关性肺炎的应用

呼吸机相关性肺炎（VAP）是ICU患者进行机械通气后病情加重甚至死亡的原因之一。传统预测感染的指标对VAP的诊断敏感性、特异性不高,其预测价值有限。血清降钙素原（PCT）检测在VAP预测中较传统的炎性指标具有较高的灵敏性和特异性。国外研究发现,当人体发生细菌感染以及发生脓毒症时血清PCT浓度升高,具有一定的诊断价值。监测PCT的变化可能有助于VAP的早期诊断以及及时调整抗生素的使用。本文就VAP的诊断、治疗及预后几方面,综述PCT在VAP患者中的应用。     

老年呼吸机相关性肺炎的临床分析

目的探讨老年呼吸机相关肺炎（VAP）的预防与治疗。方法选取我科重症监护室（ICU）收治的34例行气管插管或气管切开机械通气老年患者,记录其治疗阶段的症状、体征变化。结果发生呼吸机相关肺炎者11例,占总人数的32.35%,其中4例经积极治疗痊愈,2例症状缓解,5例死亡,其死亡率为45.45%。老年呼吸机相关性肺炎最常见的致病菌分别为绿脓杆菌、鲍曼不动杆菌、肺炎克雷伯氏菌、大肠埃希菌、金黄色葡萄球菌。结论老龄患者极易发生呼吸机相关肺炎,临床中必须积极做好预防和综合治疗。     

Predictors of long-term mortality in patients with ventilator-associated pneumonia

Purpose

To determine the long-term outcome of ventilator-associated pneumonia (VAP) and identify factors associated with increased mortality.

Methods

We retrospectively studied 671 patients with VAP admitted to an intensive care unit between 1994 and 2000. We determined long-term and out-of-hospital mortality for these patients.

Results

The in-hospital mortality was 42.3%; 19.8% of patients had concomitant bacteremia, the mortality was 59.7% versus 38.0% for those without bacteremia (P <.001). The factors associated with increased hospital mortality by univariable analysis were: diagnosis on admission, the need of vasopressors during the stay in the intensive care unit, not undergoing a tracheostomy, the absence of fever, the presence of concomitant bacteremia, and renal failure or the need for dialysis. Patients transferred from an outside hospital and patients with normal serum bicarbonate, serum total bilirubin <2 mg/dL, and platelets >120 × 4> 10³/μL had a lower in-hospital mortality. All of these factors except bilirubin level, platelet count, transfer from outside hospital, and serum bicarbonate remained significant on multivariable analysis. The estimated mortality at 1, 3 and 5 years is 25.9% (95% confidence interval [CI], 20.2-30.1%), 33.6% (95% CI, 27.4-39.2%) and 44.7% (95% CI, 38.1-50.6%), respectively.

Conclusions

VAP is associated with a high rate of hospital and long-term mortality. The presence of bacteremia is associated with a high mortality. The 5-year estimated mortality of the survivors is less than 50%.     

ICU呼吸机相关肺炎性141例调查分析

目的探讨某院呼吸机相关肺炎性（VAP）的流行病学特点及危险因素,指导临床医生采取预防和控制措施。方法对2010年9月至2011年2月重症监护病房（ICU）907例患者中发生VAP感染的141例进行回顾性调查分析。结果该院ICU呼吸机相关性医院感染肺炎的感染率为27.60‰,呼吸机使用率为61.18%。多种侵入性操作及肺部疾病患者呼吸机相关肺炎发生率较高。主要致病菌为革兰阴性杆菌（85.03%）,以鲍曼不动杆菌、铜绿假单胞菌和肺炎克雷伯菌为主。革兰阳性球菌占3.23%,主要为金黄色葡萄球菌。真菌占11.68%,主要为白色念珠菌和曲霉菌。结论该院ICU呼吸机相关的医院感染肺炎的感染率较高,这与呼吸机使用时间、使用呼吸机方式及基础疾病等多种危险因素相关。     

Impact of ventilator-associated pneumonia on outcome in patients with COPD

PURPOSES: The aim of this study was to determine the impact of ventilator-associated pneumonia (VAP) on outcome in patients with COPD. METHODS: Prospective, observational, case-control study conducted in a 30-bed ICU during a 5-year period. All COPD patients who required intubation and mechanical ventilation (MV) for > 48 h were eligible. VAP diagnosis was based on clinical, radiographic, and quantitative microbiologic criteria. Patients with unconfirmed VAP were excluded, as well as patients with ventilator-associated tracheobronchitis without subsequent VAP. Matching (1:1) criteria included MV duration before VAP occurrence, age +/- 5 years, simplified acute physiology score II on ICU admission +/- 5, and ICU admission category. Variables associated with ICU mortality were determined using univariate and multivariate analyses. RESULTS: A total of 1,241 patients were eligible; 181 patients (14%) were excluded, including 133 patients for VAT and 48 patients for unconfirmed VAP. VAP developed in 77 patients (6%), and all were successfully matched. Pseudomonas aeruginosa was the most frequently isolated bacteria (31%). ICU mortality rate (64% vs 28%), duration of MV (24 +/- 15 d vs 13 +/- 11 d [+/- SD]), and ICU stay (26 +/- 17 d vs 15 +/- 13 d) were significantly (< 0.001) higher in case patients than in control patients. VAP was the only variable independently associated with ICU mortality (odds ratio [OR], 7.7; 95% confidence interval [CI], 3.2 to 18.6; p < 0.001). In VAP patients who received corticosteroids during their ICU stay compared with those who did not receive corticosteroids, mortality rate (50% vs 82%; OR, 1.8; 95% CI, 1.2 to 2.7; p = 0.002), duration of MV (21 +/- 14 d vs 27 +/- 16 d, p = 0.043), and ICU stay (22 +/- 16 d vs 31 +/- 18 d, p = 0.006) were significantly lower. CONCLUSION: VAP is associated with increased mortality rates and longer duration of MV and ICU stay in COPD patients.     

呼吸机相关性肺炎的病原菌及耐药性分析

目的研究重症监护病房（ICU）内呼吸机相关性肺炎（VAP）的病原菌分布及其耐药性,为临床用药提供参考。方法以我院2007年12月～2008年12月ICU内行有创机械通气患者为研究对象,从中筛选出符合VAP临床诊断标准的病例,回顾性分析VAP的病原菌分布和耐药情况。结果36例VAP患者共培养出病原菌175株,其中G^-杆菌154株,占88％,G^＋球菌15株,占8．6％,真菌6株,占3．4％。位于前5位的病原菌依次为铜绿假单胞菌、嗜麦芽窄食单胞菌、鲍曼不动杆菌、洋葱伯克霍尔德菌、金黄色葡萄球菌。产超广谱β-内酰胺酶（ESBLs）细菌分离率为33．3％。G^-杆菌对常用抗菌药已表现出较高的耐药率,金黄色葡萄球菌耐药现象严重,耐甲氧西林金黄色葡萄球菌（MRSA）占66．7％,但对万古霉素、替考拉宁敏感。结论VAP主要病原菌为G^-杆菌且存在严重的耐药现象,对机械通气患者应严密监测病原菌,合理选用抗生素,加强管理,综合防治VAP。     

肺结核并发呼吸机相关性肺炎病原菌特点及临床分析

目的 了解肺结核患者呼吸机相关性肺炎（VAP）病原菌菌谱构成和药敏情况,为临床经验性治疗提供参考。方法 选择2007年1月至2011年1月入住重症监护病房（ICU）接受机械通气治疗,确诊为VAP 的58例患者,采用一次性呼吸道吸引导管Ⅱ型或纤维支气管镜直接经气管插管或气管切开套管留取患者深部痰标本,镜检合格标本接种至培养基分离培养,普通细菌培养基采用血琼脂和麦康凯琼脂,真菌培养采用沙保罗培养基,培养后采用VITEK32全自动微生物分析仪进行细菌鉴定和药敏试验。分析并发VAP的肺结核患者的临床特点、病原菌分布、耐药情况和治疗结果。 结果 58例发生VAP肺结核患者共分离104株病原菌,其中革兰阴性(G^-)杆菌71株［占68.3%（71/104）］、革兰阳性(G⁺)球菌8株［占7.7%（8/104）］、真菌25株［占24.0%（25/104）］。肺结核并发VAP的主要病原菌为鲍曼不动杆菌［占26.0%（27/104）］、铜绿假单胞菌［占21.2%（22/104）］、白色念珠菌［占14.4%（15/104）］。2种及2种以上病原菌混合感染患者26例［占44.8%（26/58）］。结论 肺结核并发VAP的主要病原菌为G^-杆菌和真菌,混合感染率较高。     

Long-term outcome of percutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke.

OBJECTIVE: investigation of length of survival, complications, level of dependence and recovery of swallow in patients who received percutaneous endoscopic gastrostomy (PEG) feeding for dysphagia due to stroke. DESIGN: a retrospective case note analysis of patients treated between 1991 and 1995 and telephone survey of modified Barthel index in October 1996. SETTING: Cardiff Royal Infirmary and the University Hospital of Wales in Cardiff. SUBJECTS: 126 patients who had PEG inserted after dysphagic stroke. MAIN OUTCOME MEASURES: complications of PEG, length of survival, duration of PEG feeding, recovery of swallow and modified Barthel index score. RESULTS: median length of follow-up was 31 months (range 4-71). Median duration of PEG use was 127 days (range 1-1372). For patients with PEG inserted within 2 weeks the median duration was 52 days (range 2-1478). At follow up 36 (29%) had had PEG removed, 72 (57%) had died with PEG in use, 10 (8%) still had PEG and were nil by mouth and five (4%) had PEG in use with swallow recovered. The median survival was 305 days. Thirty-five (28%) patients died in hospital. Aspiration pneumonia was the commonest complication. Thirty-three patients were alive in October 1996. The modified Barthel index for nursing home patients was 4 (range 0-13) and for patients at home 11 (range 2-20). CONCLUSION: PEG feeding is safe and well tolerated in patients with dysphagic stroke. Early PEG placement (within 2 weeks) is worthwhile with many going on to have long-term feeding. Although overall mortality is high, some patients have a long-term survival and a few attain a reasonable level of function in daily living activities. Late recovery of swallow occurs and patients should have follow-up swallowing assessment.     

老年人呼吸机相关肺炎的诊断

呼吸机相关肺炎(Ventilator—associated pneu—monia，VAP)是ICU内常见感染，也是导致院内感染死亡、住院日延长及治疗费用增加的主要原因。正确的诊断是明确危险因素，制定预防策略及采取适当治疗的前提。目前，在VAP诊断中仍有一定困难和争论，如确定可常规应用的理想取材技术、定量培养     

Strategies in the prevention of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) remains a significant problem in the hospital setting, with very high morbidity, mortality, and cost. We performed an evidence-based review of the literature focusing on clinically relevant pharmacological and nonpharmacological interventions to prevent VAP. Owing to the importance of this condition the implementation of preventive measures is paramount in the care of mechanically ventilated patients. There is evidence that these measures decrease the incidence of VAP and improve outcomes in the intensive care unit. A multidisciplinary approach, continued education, and ventilator protocols ensure the implementation of these measures. Future research will continue to investigate cost/benefit relationships, antibiotic resistance, as well as newer technologies to prevent contamination and aspiration in mechanically ventilated patients.     

Effects of nasogastric and percutaneous endoscopic gastrostomy tube feeding on the susceptibility of pulmonary infection in long-term coma patients with stroke or traumatic brain injury

<正>Objective To investigate the effects of nasogastric tube (NGT) and percutaneous endoscopic gastrostomy(PEG) tube feeding on the susceptibility of pulmonary infection in long-term coma patients with stroke or traumatic brain injury. Methods A total of 295 candidates who were in long-term coma after stroke or traumatic     

Aspiration pneumonia in nursing home patients fed via gastrostomy tubes

Aspiration pneumonia is among the most serious complication of gastrostomy tube feedings. However, few data are available from the nursing home setting where tube feedings are used for extended periods. We reviewed 109 nursing facility charts in order to determine the incidence of, and risk factors for, aspiration pneumonia: 22.9% of gastrostomy tube-fed patients aspirated. A history of recent previous pneumonia was found in 40.7% of those who subsequently developed aspiration pneumonia. This was the only risk factor related (p less than 0.05) to subsequent aspiration pneumonia. No association was found with age, mental status, or the method of enteral formula administration (continuous vs. intermittent infusion). We conclude that patients with a previous history of pneumonia are a high risk group in which alternative forms of enteral alimentation (i.e., jejunostomy feedings) should be explored.     

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%) 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% and 80%, 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% 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.