Clinical and economic consequences of ventilator-associated pneumonia: a systematic review.
ABSTRACT Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in critically ill patients. The clinical and economic consequences of VAP are unclear, with a broad range of values reported in the literature
To perform a systematic review to determine the incidence of VAP and its attributable mortality rate, length of stay, and costs.
Computerized PUBMED and MEDLINE search supplemented by manual searches for relevant articles, limited to articles published after 1990.
English-language observational studies and randomized trials that provided data on the incidence of VAP were included. Matched cohort studies were included for calculation of attributable mortality rate and length of stay.
Data were extracted on patient population, diagnostic criteria for VAP, incidence, outcome, type of intensive care unit, and study design.
The cumulative incidence of VAP was calculated by combining the results of several studies using standard formulas for combining proportions, in which the weighted average and variance are calculated. Results from studies comparing intensive care unit and hospital mortality due to VAP, additional length of stay, and additional days of mechanical ventilation were pooled using a random effects model, with assessment of heterogeneity.
Our findings indicate a) between 10% and 20% of patients receiving >48 hrs of mechanical ventilation will develop VAP; b) critically ill patients who develop VAP appear to be twice as likely to die compared with similar patients without VAP (pooled odds ratio, 2.03; 95% confidence interval, 1.16-3.56); c) patients with VAP have significantly longer intensive care unit lengths of stay (mean = 6.10 days; 95% confidence interval, 5.32-6.87 days); and d) patients who develop VAP incur > or = USD $10,019 in additional hospital costs.
Ventilator-associated pneumonia occurs in a considerable proportion of patients undergoing mechanical ventilation and is associated with substantial morbidity, a two-fold mortality rate, and excess cost. Given these findings, strategies that effectively prevent VAP are urgently needed.
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ABSTRACT: Il est généralement admis que les pneumonies acquises sous ventilation mécanique (PAVM) nécessitent un traitement antibiotique dès leur suspicion, afin de ne pas compromettre le pronostic des patients. Cette antibiothérapie initiale peut être administrée selon deux stratégies. La première, basée sur des recommandations comme celles de l’American Thoracique Society, consiste à administrer une antibiothérapie à très large spectre puis à l’adapter en fonction des résultats des prélèvements microbiologiques. Cette méthode a pour inconvénient de promouvoir l’utilisation des antibiotiques à large spectre pouvant ainsi favoriser l’émergence de bactéries multirésistantes. C’est pourquoi il a été proposé une seconde stratégie qui vise à surveiller de façon routinière, systématique, les cultures des aspirations trachéales chez les patients sous ventilation mécanique. Lorsqu’une PAVM est suspectée, le traitement antibiotique peut alors être immédiatement ciblé sur les bactéries retrouvées dans les prélèvements trachéaux systématiques. Notre analyse de la littérature confirme que ces cultures trachéales systématiques permettent de prédire la bactérie responsable de la PAVM avec une bonne précision, d’adapter au mieux l’antibiothérapie initiale et de limiter considérablement l’utilisation des antibiotiques de très large spectre en réanimation. Abstract Ventilator-associated pneumonia (VAP) requires early and appropriate antibiotic treatment in order not to compromise patients’ outcome. Initial antibiotic treatment can be based upon two strategies. The first one, based on guidelines such as those delivered by the American Thoracic Society, is to administer broad spectrum antibiotics and to adapt the treatment when results of the microbiological cultures are available. This method has the disadvantage of encouraging the extensive use of broad spectrum antibiotics and promotes multiresistant bacteria emergence. Therefore, an alternative strategy was suggested, aiming to perform routine systematic cultures of tracheal aspirates in patients requiring mechanical ventilation. When VAP is suspected, initial antibiotic treatment can be adapted immediately to bacteria found in the systematic cultures of tracheal aspirates. Our analysis of the literature suggests that these tracheal aspirate cultures, performed twice a week, predict the responsible bacteria in most cases and allow adapting antibiotics and limiting broad spectrum antibiotic use in the intensive care unit.Réanimation 05/2014; 23(3):263-270.
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ABSTRACT: Background: Infectious diseases of the airways are a major health care problem world wide. New treatment strategies focus on employing the body's immune system to enhance its protective capacities during airway disease. One source for immune-competent cells is the pleural space, however, its immune-physiological function remains poorly understood. The aim of this study was to develop an experimental technique in rodents that allows for an in vivo analysis of pleural space immune cells participating in the host defense during airway disease. Methods: I developed an easy and reliable technique that I named the " InterCostal Approach of the Pleural Space " (ICAPS) model that allows for in vivo analysis of pleural space immune cells in rodents. By injection of immune cell altering fluids into or flushing of the pleural space the immune response to airway infections can be manipulated. Results: The results reveal that (i) the pleural space cellular environment can be altered partially or completely as well as temporarily or permanently, (ii) depletion of pleural space cells leads to increased airway inflammation during pulmonary infection, (iii) the pleural space contributes immune competent B cells during airway inflammation and (iv) inhibition of B cell function results in reduced bacterial clearance during pneumonia. Conclusion: As the importance for in-depth knowledge of participating immune cells during health and disease evolves, the presented technique opens new possibilities to experimentally elucidate immune cell function, trafficking and contribution of pleural space cells during airway diseases.BMC Pulmonary Medicine 02/2015; 15(14). · 2.49 Impact Factor
- Revista Brasileira de Terapia Intensiva 12/2014; 26(4):367-372.