Aetiological agents of ventilator-associated pneumonia and its resistance pattern – a threat for treatment

Background

Ventilator-associated pneumonia (VAP) is a common type of nosocomial pneumonia encountered in intensive care units. There are several aetiological agents which make treatment challenging. Improper antibiotic treatment of ventilated patients may lead to the emergence of multidrug resistant (MDR) pathogens.

Method

A prospective study was performed over a period of 20 months. Our study had two arms: the first, ‘Incidence and risk factors of VAP in a tertiary care hospital’ was the subject of an earlier publication; we therefore present the second investigative arm in this work. The aetiological agents of patients on mechanical ventilation (MV) were identified by standard bacteriological method. The susceptibility pattern was evaluated by Kirby-Bauer disc diffusion method. Extended spectrum beta lactamase (ESBL) testing was performed by combination disc method, and metallo-beta lactamase (MBL) testing was performed by EDTA disk synergy test (EDS).

Results

Late-onset VAP was associated with Pseudomonas aeruginosa, Klebsiella pneumoniae and Escherichia coli, while early-onset VAP was commonly caused by members of Enterobacteriaceae, Candida albicans and Staphylococcus aureus. 72.2 per cent of VAP patients had monomicrobial and 27.8 per cent had polymicrobial infection. Out of the 24 isolates obtained from patients with VAP, seven (29.2 per cent) were MDR pathogens. ESBL and MBL production was detected in 40 per cent and 20 per cent of Klebsiella pneumoniae isolated in our study. Around 50 per cent of isolates associated with late-onset VAP were MDR, while 22.2 per cent isolates obtained from patients with earlyonset VAP were MDR.

Conclusion

VAP is a nosocomial pneumonia that is common among ventilated patients. The aetiological agents vary from common organisms to MDR pathogens that are difficult to treat. A proper knowledge of MDR pathogens and early isolation followed by prevention of prolonged antibiotic therapy can reduce the mortality of late onset VAP.     

Outcome of ventilator-associated pneumonia: Impact of antibiotic therapy and other factors

Background

Ventilator-associated pneumonia (VAP) is the most frequent infection in patients intubated for longer than 48 hours. There is a great interest in determining the factors influencing the outcome of VAP, as it may help in reducing the associated morbidity and mortality. This study aimed to determine the impact of appropriate antibiotic therapy based on endotracheal aspirate cultures on the outcome of VAP. We have also studied the other factors that may influence the outcome of VAP.

Method

A cohort study was conducted in the intensive care units of a tertiary care hospital in South India over a period of 15 months.The outcome of VAP was assessed by prolongation of the duration of mechanical ventilation and/or death of the patient.

Results

The duration of mechanical ventilation was significantly prolonged in patients with VAP (16.61 ± 8.2 d vs. 8.21 ± 5.9 d, P < 0.0001). VAP patients receiving partially or totally inappropriate therapy (defined as lack of coverage of one or all the significant VAP pathogens) were at significantly high risk for death (Relative risk, 2.00; 95% confidence interval, 1.14 to 3.52; P 0.0008). A delay of > 2 days in administering the first dose of appropriate antibiotic therapy significantly prolonged the duration of ventilation (P < 0.0001). Infection by multi-drug resistant pathogens, polymicrobial infection and time of onset of VAP did not have significant impact on the outcome of VAP.

Conclusion

Early administration of appropriate antibiotic therapy, based on the antibiogram of the VAP pathogens identified by quantitative culture of endotracheal aspirate, could lead to an improved outcome of patients with ventilator-associated pneumonia.     

Treatment of ventilator-associated pneumonia and ventilator-associated tracheobronchitis in the intensive care unit: A national survey of clinicians and pharmacists in Saudi Arabia

Objectives:

To assess current practices of different healthcare providers for treating extensively drug-resistant (XDR) Acinetobacter baumannii (AB) infections in tertiary-care centers in Saudi Arabia.

Methods:

This cross-sectional study was performed in tertiary-care centers of Saudi Arabia between March and June 2014. A questionnaire consisting of 3 parts (respondent characteristics; case scenarios on ventilator-associated pneumonia [VAP] and tracheobronchitis [VAT], and antibiotic choices in each scenario) was developed and sent electronically to participants in 34 centers across Saudi Arabia.

Results:

One-hundred and eighty-three respondents completed the survey. Most of the respondents (54.6%) preferred to use colistin-based combination therapy to treat VAP caused by XDR AB, and 62.8% chose to continue treatment for 2 weeks. Most of the participants (80%) chose to treat VAT caused by XDR AB with intravenous antibiotics. A significant percentage of intensive care unit (ICU) fellows (41.3%) and clinical pharmacists (35%) opted for 2 million units (mu) of colistin every 8 hours without a loading dose, whereas 60% of infectious disease consultants, 45.8% of ICU consultants, and 44.4% of infectious disease fellows preferred a 9 mu loading dose followed by 9 mu daily in divided doses. The responses for the scenarios were different among healthcare providers (p<0.0001).

Conclusion:

Most of the respondents in our survey preferred to use colistin-based combination therapy and intravenous antibiotics to treat VAP and VAT caused by XDR AB. However, colistin dose and duration varied among the healthcare providers.Mechanical ventilation is commonly used as a therapeutic option when caring for critically ill patients in the intensive care unit (ICU). Although mechanical ventilation may be lifesaving, it is associated with an increased risk of infections, including ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). Ventilator-associated pneumonia has an estimated incidences of 10-25% and VAT has 1.4-11% with an estimated all-cause mortality of 25-50% for VAP, and 39% for VAT.1-3 Late-onset VAP (occurring after 5 days) is usually caused by multidrug-resistant (MDR) organisms and is associated with an increase in morbidity and mortality.1,2 The increased incidence of infections with these MDR pathogens is a major concern to health care providers worldwide and in particular Acinetobacter species, which were recognized as a cause of infection in critically ill patients in the past decade. With an increase in the use of broad-spectrum antibiotics, MDR and extensively drug-resistant (XDR) Acinetobacter baumannii (AB) have emerged as common pathogens causing late-onset VAP in the Middle East and Europe.4-6 The attributable mortality for ICU infected with AB was 10-43%, and for in-hospital patients (those who did not require ICU) was 8-23%.7 These high rates are likely related to the limited number of drugs available to treat XDR strains, as AB has an exceptional pathogenicity and capability to develop inherent and acquired resistance. The current knowledge on its treatment is insufficient as the quality of evidence, and the clinical practice guidelines are lacking. There are many controversies regarding different treatment options such as the superiority of combination therapy over monotherapy and the optimal dose of colistin, which is usually the only antibiotic to which XDR AB is susceptible.8,9 These have led to a variation in practice. The objective of this study was to investigate the current practices of clinicians and clinical pharmacists (CPs) caring for patients with XDR AB infections in Saudi Arabia. A survey was conducted to find answers to the following questions: Is combination therapy superior to monotherapy? Is there any role for colistin nebulization? What is the optimal dose of colistin?.     

Impact of infection control training for interns on PICU-acquired bloodstream infections in a middle-income country

INTRODUCTION

The present study aimed to determine the impact of an extended infection control training programme, which was conducted for all interns posted to the Department of Paediatrics, on the incidence of paediatric intensive care unit (PICU)-acquired bloodstream infections (BSIs) in University Malaya Medical Centre, Malaysia.

METHODS

The development of nosocomial BSIs during the baseline period (1 January–31 October 2008) and intervention period (1 November–31 December 2009) was monitored. During the intervention period, all paediatric interns underwent training in hand hygiene and aseptic techniques for accessing vascular catheters.

RESULTS

A total of 25 patients had PICU-acquired BSIs during the baseline period, while 18 patients had PICU-acquired BSIs during the intervention period (i.e. infection rate of 88 per 1,000 and 41 per 1,000 admissions, respectively). The infections were related to central venous catheters (CVCs) in 22 of the 25 patients who had PICU-acquired BSIs during the baseline period and 11 of the 18 patients who had PICU-acquired BSIs during the intervention period. Thus, the incidence rates of catheter-related BSIs were 25.2 per 1,000 CVC-days and 9.3 per 1,000 CVC-days, respectively (p < 0.05). The Paediatric Risk of Standardised Mortality III score was an independent risk factor for PICU-acquired BSIs and the intervention significantly reduced this risk.

CONCLUSION

The education of medical interns on infection control, a relatively low-cost intervention, resulted in a substantial reduction in the incidence of PICU-acquired BSIs.     

Healthcare-associated Pneumonia: Clinical Features and Retrospective Analysis Over 10 Years

Background:

Healthcare-associated pneumonia (HCAP) is associated with drug-resistant pathogens and high mortality, and there is no clear evidence that this is due to inappropriate antibiotic therapy. This study was to elucidate the clinical features, pathogens, therapy, and outcomes of HCAP, and to clarify the risk factors for drug-resistant pathogens and prognosis.

Methods:

Retrospective observational study among hospitalized patients with HCAP over 10 years. The primary outcome was 30-day all-cause hospital mortality after admission. Demographics (age, gender, clinical features, and comorbidities), dates of admission, discharge and/or death, hospitalization costs, microbiological results, chest imaging studies, and CURB-65 were analyzed. Antibiotics, admission to Intensive Care Unit (ICU), mechanical ventilation, and pneumonia prognosis were recorded. Patients were dichotomized based on CURB-65 (low- vs. high-risk).

Results:

Among 612 patients (mean age of 70.7 years), 88.4% had at least one comorbidity. Commonly detected pathogens were Acinetobacter baumannii, Pseudomonas aeruginosa, and coagulase-negative staphylococci. Initial monotherapy with β-lactam antibiotics was the most common initial therapy (50%). Mean age, length of stay, hospitalization expenses, ICU admission, mechanical ventilation use, malignancies, and detection rate for P. aeruginosa, and Staphylococcus aureus were higher in the high-risk group compared with the low-risk group. CURB-65 ≥3, malignancies, and mechanical ventilation were associated with an increased mortality. Logistic regression analysis showed that cerebrovascular diseases and being bedridden were independent risk factors for HCAP.

Conclusion:

Initial treatment of HCAP with broad-spectrum antibiotics could be an appropriate approach. CURB-65 ≥3, malignancies, and mechanical ventilation may result in an increased mortality.     

Immunosuppressant dose reduction and long-term rejection risk in renal transplant recipients with severe bacterial pneumonia

INTRODUCTION

Due to lifelong immunosuppression, renal transplant recipients (RTRs) are at risk of infectious complications such as pneumonia. Severe pneumonia results in respiratory failure and is life-threatening. We aimed to examine the influence of immunosuppressant dose reduction on RTRs with bacterial pneumonia and respiratory failure.

METHODS

From January 2001 to January 2011, 33 of 1,146 RTRs at a single centre developed bacterial pneumonia with respiratory failure. All patients were treated using mechanical ventilation and aggressive therapies in the intensive care unit.

RESULTS

Average time from kidney transplantation to pneumonia with respiratory failure was 6.8 years. In-hospital mortality rate was 45.5% despite intensive care and aggressive therapies. Logistic regression analysis indicated that a high serum creatinine level at the time of admission to the intensive care unit (odds ratio 1.77 per mg/dL, 95% confidence interval 1.01–3.09; p = 0.045) was a mortality determinant. Out of the 33 patients, immunosuppressive agents were reduced in 17 (51.5%). We found that although immunosuppressant dose reduction tended to improve in-hospital mortality, this was not statistically significant. Nevertheless, during a mean follow-up period of two years, none of the survivors (n = 18) developed acute rejection or allograft necrosis.

CONCLUSION

In RTRs with bacterial pneumonia and respiratory failure, higher serum creatinine levels were a mortality determinant. Although temporary immunosuppressant dose reduction might not reduce mortality, it was associated with a minimal risk of acute rejection during the two-year follow-up. Our results suggest that early immunosuppressant reduction in RTRs with severe pneumonia of indeterminate microbiology may be safe even when pathogens are bacterial in nature.     

Spectrum of bacteria associated with diabetic foot ulcer and biofilm formation: A prospective study

Background

India has the world’s largest number of diabetics. Non-traumatic lower limb amputation is the most common devastating complication of diabetes, primarily due to diabetic foot ulcers (DFU) and diabetic foot infections (DFI). In India, the incidence of foot ulcers ranges from 8–17 per cent. DFIs are predominantly polymicrobial and multidrug-resistant (MDR) with the ability to form biofilm, which is an important virulence factor and results in treatment failure.

Aims

The main objectives of the study are to identify the spectrum of multidrug-resistant bacteria associated with these infections, their antibiotic sensitivity pattern, and to detect the biofilm formation.

Methods

This was a prospective study at a tertiary care hospital. One hundred patients over the age of 18, having chronic diabetic foot ulcer, and attending the surgery outpatient department were included. Samples of pus were collected from deep wounds and processed using standard techniques for culture and sensitivity. Biofilm detection was done. Results were compiled and statistically analysed.

Results

One hundred samples were processed and 82 yielded positive cultures. Staphylococcus aureus was the predominant organism, followed by Pseudomonas aeruginosa. Biofilm formation was seen in 38 (46.34 per cent) of the organisms. Biofilms were formed predominantly by Staphylococcus aureus (20 per cent).

Conclusion

The organisms causing chronic diabetic foot ulcers were commonly multidrug-resistant; this was also observed among biofilm formers. Therefore, screening for biofilm formation, along with the usual antibiogram, needs to be performed as a routine procedure in chronic diabetic ulcers to formulate effective treatment strategies for these patients.     

A study of the effect of nasal modes of ventilation on the incidence of gastro-oesophageal reflux in preterm neonates

Background

Nasal modes of respiratory support cause variable amounts of gastric dilatation which may increase gastro-oesophageal reflux (GER) in preterms. To compare the incidence of GER in nasally ventilated, preterm babies with controls (babies not on ventilation). Type of study: A prospective, observational comparative study.

Method

Twenty-three preterm babies of gestational age 28–36 weeks and weight ranging between 1,000 g and < 2,500 g on either nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure venti-lation (nIPPV) were assessed for GER. They were compared with controls not on ventilation some of who were test babies when off ventilation (subgroup A) and some were unrelated babies not on ventilator but matched for gestational age and weight with test babies (subgroup B). All babies were subjected to continuous, oesophageal pH monitoring with dual sensor (upper and lower oesophageal) catheters. Reflux index (RI) was calculated as the percentage of study time the lower oesophageal pH was < 4. Primary outcome was the RI in the test and controls groups. Secondary outcome was the temporal relation of the reflux with symptoms if any. Numerical data were shown as mean with standard deviation and statistical comparisons were done using the χ²-test, Fischer test, and t-test wherever applicable.

Results

The RI was higher in ventilated babies as compared to the control group, particularly in the subgroup A, where test babies formed their own controls. Grade IV reflux (7 cases) was seen only in the ventilated babies. There was no difference in the incidence of GER in babies on nCPAP as compared with nIPPV. Grade IV reflux could not be reliably predicted by RI alone. No definite temporal relation between episodes of reflux and symptoms could be determined in this study.

Conclusion

There is an increase in GER in preterms on nasal modes of ventilation. A combination of upper (pharyngeal) and lower oesophageal sensors are preferred to a single lower oesophageal sensor when assessing GER by oesophageal pHmetry in neonates.Key Words: CPAP, gastro-oesophageal reflux, nasal ventilation, preterm     

Incidence of healthcare associated infection in the surgical ICU of a tertiary care hospital

Background

Healthcare associated infections (HAI) have taken on a new dimension with outbreaks of increasingly resistant organisms becoming common. Protocol-based infection control practices in the intensive care unit (ICU) are extremely important. Moreover, baseline information of the incidence of HAI helps in planning-specific interventions at infection control.

Methods

This hospital-based observational study was carried out from Dec 2009 to May 2010 in the 10-bedded surgical intensive care unit of a tertiary care hospital. CDC HAI definitions were used to diagnose HAI.

Results

A total of 293 patients were admitted in the ICU. 204 of these were included in the study. 36 of these patients developed HAI with a frequency of 17.6%. The incidence rate (IR) of catheter-related blood stream infections (CRBSI) was 16/1000 Central Venous Catheter (CVC) days [95% C.I. 9–26]. Catheter-associated urinary tract infections (CAUTI) 9/1000 urinary catheter days [95% C.I. 4–18] and ventilator-associated pneumonias (VAP) 32/1000 ventilator days [95% confidence interval 22–45].

Conclusion

The HAI rates in our ICU are less than other hospitals in developing countries. The incidence of VAP is comparable to other studies. Institution of an independent formal infection control monitoring and surveillance team to monitor & undertake infection control practices is an inescapable need in service hospitals.     

Multidrug-resistant acinetobacter infection and their susceptibility patterns in a tertiary care hospital

Background:

Antibiotic-resistant Acinetobacter nosocomial infection is a leading problem. It acts as an opportunistic pathogen to cause a wide spectrum of infection including nosocomial pneumonia, meningitis, endocarditis, skin and soft tissue infections, urinary tract infection, conjunctivitis, burn wound infection and bacteremia. Multidrug-resistant Acinetobacter infection creates a great problem in hospital setting.

Materials and Methods:

The clinical specimens obtained from ICU and different surgical and medical wards were investigated using standard microbiological techniques to know the distribution of and their resistant profile. Antimicrobial resistance was studied using the modified Kirby Bauer disk diffusion technique following the CLSI protocol.

Results:

Major infections found in different medical wards, surgical wards and ICU were due to Acinetobacter baumannii (74.02%), A. lowfii (14.2%), A. haemolyticus (7.79%), A. junii (3.8%) among Acinetobacter spices. Acinetobacter showed increased resistant against majority of commercially available drugs imipenem (5.2%), meropenem (9.75%), piperacillin-tazobactum (18.2%), netilmicin (16.24%), amikacin (14.29%), ceftazidime (74.1%), gentamicin (70.13%), ofloxacin (42.21%).

Conclusion:

A. baumannii was found to be associated with UTI, RTI, septicemia, bacteremia, and meningitis and wound infection. A. baumannii displayed higher resistance to more number of antibiotics than other nosocomial pathogens from ICU.     

Mesenchymal Stem Cell Attenuates Neutrophil-predominant Inflammation and Acute Lung Injury in an In Vivo Rat Model of Ventilator-induced Lung Injury

Background:Subsequent neutrophil (polymorphonuclear neutrophil [PMN])-predominant inflammatory response is a predominant feature of ventilator-induced lung injury (VILI),and mesenchymal stem cell (MSC)...     

I-ROAD could be efficient in predicting severity of community-acquired pneumonia or healthcare-associated pneumonia

INTRODUCTION

The ability to predict the prognosis of patients with pneumonia is critical, especially when making decisions regarding treatment regimens and sites of care. However, prognostic guidelines for healthcare-associated pneumonia (HCAP) have yet to be established. I-ROAD is the prognostic guideline of the Japanese Respiratory Society for hospital-acquired pneumonia (HAP). This study compared available prognostic guidelines to determine the usefulness of I-ROAD as a prognostic tool for patients with HCAP.

METHODS

We conducted a retrospective review of all patients with pneumonia admitted to Kameda Medical Center, Japan, from January 2006 to September 2009. Patients were categorised into two groups, namely those with community-acquired pneumonia (CAP) and those with HCAP. We compared the baseline characteristics, laboratory findings, identified pathogens, antibiotic regimens, clinical outcomes, pneumonic severity and prognostic accuracy of each guideline between the two patient groups. The severity of each disease was assessed on admission using the A-DROP, CURB-65, PSI and I-ROAD guidelines.

RESULTS

Of the 302 patients evaluated, 228 (75.5%) were diagnosed with CAP and 74 (24.5%) with HCAP. Patients with HCAP were older and had a higher performance status than patients with CAP. The mortality rate in the CAP group tended to rise with increasing severity scores of prognostic guidelines. Although the severity scores of all prognostic guidelines could predict 30-day mortality in patients with CAP, I-ROAD exhibited a higher discriminatory power for patients with HCAP based on analysis of receiver-operating characteristic curves.

CONCLUSION

I-ROAD could be more accurate than other prognostic guidelines for evaluating the severity of HCAP.     

Add-on effect of Qinbei Qingfei Yiqi granules for ventilator-associated pneumonia in intensive care units: a randomized controlled trial

Objective

To evaluate the add-on effect of Qinbei Qingfei Yiqi (QBQFYQ) granules for ventilator-associated pneumonia (VAP) in non-infectious critically ill patients.

Multi-drug resistant Acinetobacter species from various clinical samples in a tertiary care hospital from South India

Background

Acinetobacter species are gram-negative coccobacilli belonging to the group of Non-Fermenting Gram-Negative Bacilli, which are ubiquitous in nature. They cause outbreaks in intensive care units and healthcare settings, and are becoming increasingly drug resistant.

Aims

To determine the prevalence of multi-drug resistant Acinetobacter species from various clinical samples.

Method

Clinical samples were processed as per standard microbiological techniques. Antibiotic susceptibility testing was carried out on all the Acinetobacter isolates by Kirby- Bauer disc diffusion method as per CLSI guidelines.

Results

A total of 122 Acinetobacter spp. were isolated. 110 (90.16 per cent) were from inpatients, and 12 (9.83 per cent) were from outpatients. Out of 122 isolates, 44 (36.06 per cent) were from the ICU. The majority of the isolates, 47 (38.52 per cent), were from pus samples followed by 25 (20.49 per cent) from endotracheal tube aspirate. Out of 122 isolates, 87 (71.31 per cent) were multi-drug resistant of which 15 (12.29 per cent) were resistant to all drugs tested.

Conclusion

Acinetobacter infections associated with multi-drug resistant and pan-resistant strains have emerged as important nosocomial pathogens in our setting.     

Nosocomial methicillin resistant Staphylococcus aureus pneumonia - epidemiology and trends based on data of a network of 586 German ICUs (2005-2009)

The epidemiology of MRSA pneumonia varies across countries. One of the most import risk factors for the development of nosocomial MRSA pneumonia is mechanical ventilation. Methicillin resistance in S. aureus ventilator associated pneumonia (VAP) ranged between 37 % in German, 54 % in the US American and 78 % in Asian and Latin American ICUs. In 2009, the incidence density of nosocomial VAP caused by MRSA was 0.28 per 1000 ventilation days in a network of 586 German ICUs. Incidences peaked in neurological and neurosurgical ICUs. Crude hospital mortality in studies performed after 2005 lay between 27 % and 59 % and attributable MRSA pneumonia mortality at 40 %. Since 2005, US American and German data indicate decreasing trends for MRSA pneumonia. Measures to reduce MRSA pneumonia or to control the spread of MRSA include hand hygiene, standard and contact precautions, oral contamination with chlorhexidine, skin decontamination with antiseptics, screening, and (possibly) patient isolation in a single room.     

Preterm delivery and low maternal serum cholesterol level: Any correlation?

Background:

The study assessed whether low maternal serum cholesterol during early pregnancy is associated with preterm delivery.

Patients and Methods:

It was a prospective observational cohort study involving pregnant women at gestational age of 14-20 weeks over a period of 12 months. Blood samples were obtained to measure total serum cholesterol concentrations and the sera were then analysed enzymatically by the cholesterol oxidase: p-aminophenazone (CHOD PAP) method.

Results:

The study showed an incidence of 5.0% for preterm delivery in the low risk study patients. Preterm birth was 4.83-times more common with low total maternal cholesterol than with midrange total cholesterol (11.8% versus 2.2%, P = 0.024).

Conclusion:

Low maternal serum cholesterol (hypocholesterolaemia) is associated with preterm delivery. Optimal maternal serum cholesterol during pregnancy may have merit, therefore pregnant women should be encouraged to follow a healthy, balanced diet.     

Factors associated with inter-institutional variations in sepsis rates of very-low-birth-weight infants in 34 Malaysian neonatal intensive care units

INTRODUCTION

This study aimed to determine whether patient loads, infant status on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis rates in very-low-birth-weight (VLBW) infants in the Malaysian National Neonatal Registry (MNNR).

METHODS

This was a retrospective study of 3,880 VLBW (≤ 1,500 g) infants admitted to 34 neonatal intensive care units (NICUs) in the MNNR. Sepsis was diagnosed in symptomatic infants with positive blood culture.

RESULTS

Sepsis developed in 623 (16.1%) infants; 61 (9.8%) had early-onset sepsis (EOS) and 562 (90.2%) had late-onset sepsis (LOS). The median EOS rate of all NICUs was 1.0% (interquartile range [IQR] 0%, 2.0%). Compared with NICUs reporting no EOS (n = 14), NICUs reporting EOS (n = 20) had significantly higher patient loads (total live births, admissions, VLBW infants, outborns); more mothers with a history of abortions, and antenatal steroids and intrapartum antibiotic use; more infants requiring resuscitation procedures at birth; higher rates of surfactant therapy, pneumonia and insertion of central venous catheters. The median LOS rate of all NICUs was 14.5% (IQR 7.8%, 19.2%). Compared with NICUs with LOS rates below the first quartile (n = 8), those above the third quartile (n = 8) used less intrapartum antibiotics, and had significantly bigger and more mature infants, more outborns, as well as a higher number of sick infants requiring ventilator support and total parenteral nutrition.

CONCLUSION

Patient loads, resuscitation at birth, status of infants on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis.     

Ventilator-associated pneumonia in patients using HME filters and heated humidifiers

Background

Ventilator-associated pneumonia (VAP) is a clinical form of hospital-associated pneumonia, which may develop within 48 h in patients on mechanical ventilation who had no pre-existing pneumonia at the time of intubation.

Objective

The objective of this study was to compare the incidence of VAP among patients who started receiving treatment with heat and moisture exchanger (HME) filters and heated humidifiers (HHs) for mechanical ventilation.

Methods

Patients who were on the first day of intubation, did not have pre-intubation pneumonia, presented to the healthcare centre with no infections at the time of presentation, were not on antibiotic treatment for pulmonary infections and did not have evidence of infiltration with chest radiography were included in the study. Data were evaluated using Fischer’s exact, Mann–Whitney’s U and t tests.

Results

The patients in the HME filter and HHs groups had a mean age of 47.9 ± 2.2 and 44.5 ± 2.1 years, respectively. Infiltration on chest radiography was identified on day 6.33 for the patients in the HME filter group and on day 5.8 in the HHs group. Patients using HME filters and HHs did not differ significantly with regard to the day of mechanical ventilation and number of days hospitalized (p > 0.5). Comparison of the two groups with regard to presence of fever during the first 24 h, however, demonstrated higher than expected values for the patients using HHs, with a significant difference (p = 0.001).

Conclusion

There were no significant differences between the groups on HME filters and heated humidifiers in terms of infection development; although pulmonary radiography showed delayed average days to infiltration development for subjects using HME filters.     

A comparative drug utilisation study of the treatment of diabetes in Malaysia and Australia

Background

Once a disease of developed countries, type 2 diabetes mellitus (T2DM) has become widespread worldwide. For people with T2DM, achievement of therapeutic outcomes demands the rational and quality use of medicine.

Aims

The primary aim of this study was to examine the prevalence of diabetes and prescribing patterns of anti-diabetic medications in Australia and Malaysia.

Methods

The most recent, publicly available, statistical reports (2004–2008) on the use of medicines published in Australia and in Malaysia were evaluated. Defined daily doses (DDDs/1,000 population/day) were derived from the reports and used to rank and compare individual drug use.

Results

There was an increasing trend in the prevalence of diabetes in Australia, although there is a greater predicted increase in prevalence for Malaysia. While drugs used for the treatment of diabetes were not the most highly used drugs in Australia, their use increased during the study period, from 42.64 to 48.61 DDD/1,000/day. Anti-diabetic drugs were the most frequently dispensed class of drugs in Malaysia. Although the total consumption of anti-diabetic drugs in Malaysia decreased between 2006 and 2007 (from 40.30 to 39.72), this was followed by a marked increase to 46.69 in 2008. There was a marked reduction in the dispensing of insulin in Malaysia from 2004 to 2007 (7.77 to 3.23).

Conclusion

The use of drugs to treat diabetes does not reflect the usage patterns found in Australia. Effective drug use reviews are required to ensure impartial access in middle- and low-income countries.