Safdar N, Dezfulian C, Collard HR, Saint SClinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 33:2184-2193
Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, 600 Highland Avenue, Madison, WI 53792, USA. Critical Care Medicine
(Impact Factor: 6.31).
10/2005; 33(10):2184-93. DOI: 10.1097/01.CCM.0000181731.53912.D9
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.
Available from: Olivier Barraud
- "VAP is traditionally reported as the most frequent nosocomial infection in critically ill patients and is associated with significant morbidity and mortality (Barbier et al., 2013; Melsen et al., 2013). VAP prolongs the duration of ventilation, the duration of ICU and hospital stays, and results in additional hospital costs (Restrepo et al., 2010; Safdar et al., 2005). "
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ABSTRACT: Major concern for intubated patients is ventilator-associated pneumonia (VAP). Early detection of VAP and its causative microorganism(s) is a key challenge for clinicians. Diagnosis is based on clinical, radiological, and microbiological elements, the latter being provided 24-48h after sampling. According to practices, clinicians can sample endotracheal aspirates (ETAs) so as to check for patient colonization or perform ETA in case of VAP suspicion. In this proof-of-concept study, we report the evaluation of a semiautomated molecular method to rapidly quantify Staphylococcus aureus, one of the most involved microorganisms in VAP, directly from raw ETA samples. After evaluation using artificial ETA samples, our method was applied on 40 clinical ETA samples. All S. aureus-positive samples were successfully detected and quantified. Our method can provide an efficient sample preparation protocol for all raw ETA samples, combined with an accurate quantification of the bacterial load, in less than 3h 30min.
Copyright © 2015. Published by Elsevier Inc.
Available from: Tom Coenye
- "About 40 % of the nosocomial S. aureus isolates in the USA are resistant to methicillin and in central and Southern Europe, more than 25 % of bacteraemia cases are caused by MRSA (Haddadin et al. 2002 ; Moellering 2012 ). S. aureus is the most common cause of nosocomial pneumonia and plays a prominent role in the development of VAP (American Thoracic Society 2005 ; Park 2005 ; Bahrani-Mougeot et al. 2007 ; Weber et al. 2007 ; Dickson et al. 2008 ; Hidron et al. 2008 ; Jones 2010 ; Joseph et al. 2010 ; Becker and von Eiff 2012 ; Park et al. 2012 ). S. aureus is frequently isolated from ET biofi lms by cultivation (Inglis et al. 1995 ; Adair et al. 1999 ; Feldman et al. 1999 ; Berra et al. 2012 ; Vandecandelaere et al. 2012 ; Liu et al. 2013 ) and also, the use of culture independent methods resulted in the identifi cation of S. aureus in ET biofi lms (Perkins et al. 2010 ; Cairns et al. 2011 ; Vandecandelaere et al. 2012 ). As S. aureus is part of the human nasal fl ora (Becker and von Eiff 2012 ), it can be assumed that S. aureus in ET biofi lms originate from nasopharyngeal secretions (Feldman et al. 1999 ; Safdar et al. 2005 ; Perkins et al. 2010 ). Subsequently, parts of the ET biofi lm (containing S. aureus ) can be dispersed to the lungs and this causes VAP (Otto 2013b ). "
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ABSTRACT: In critically ill patients, breathing is impaired and mechanical ventilation, using an endotracheal tube (ET) connected to a ventilator, is necessary. Although mechanical ventilation is a life-saving procedure, it is not without risk. Because of several reasons, a biofilm often forms at the distal end of the ET and this biofilm is a persistent source of bacteria which can infect the lungs, causing ventilator-associated pneumonia (VAP). There is a link between the microbial flora of ET biofilms and the microorganisms involved in the onset of VAP. Culture dependent and independent techniques were already used to identify the microbial flora of ET biofilms and also, the antibiotic resistance of microorganisms obtained from ET biofilms was determined. The ESKAPE pathogens play a dominant role in the onset of VAP and these organisms were frequently identified in ET biofilms. Also, antibiotic resistant microorganisms were frequently present in ET biofilms. Members of the normal oral flora were also identified in ET biofilms but it is thought that these organisms initiate ET biofilm formation and are not directly involved in the development of VAP.
Available from: PubMed Central
- "Although advances have been made in the diagnosis, prevention and treatment strategies of VAP in recent years, VAP remains a serious problem in ICU patients, with reported incidence rates of 10% to 65% , , , , –. The influence of ET on VAP had been reported; however, these studies present inconclusive results. "
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ABSTRACT: To compare important outcomes between early tracheostomy (ET) and late tracheostomy (LT) or prolonged intubation (PI) for critically ill patients receiving long-term ventilation during their treatment.
We performed computerized searches for relevant articles on PubMed, EMBASE, and the Cochrane register of controlled trials (up to July 2013). We contacted international experts and manufacturers. We included in the study randomized controlled trials (RCTs) that compared ET (performed within 10 days after initiation of laryngeal intubation) and LT (after 10 days of laryngeal intubation) or PI in critically ill adult patients admitted to intensive care units (ICUs). Two investigators evaluated the articles; divergent opinions were resolved by consensus.
A meta-analysis was evaluated from nine randomized clinical trials with 2,072 participants. Compared to LT/PI, ET did not significantly reduce short-term mortality [relative risks (RR) = 0.91; 95% confidence intervals (CIs) = 0.81-1.03; p = 0.14] or long-term mortality (RR = 0.90; 95% CI = 0.76-1.08; p = 0.27). Additionally, ET was not associated with a markedly reduced length of ICU stay [weighted mean difference (WMD) = -4.41 days; 95% CI = -13.44-4.63 days; p = 0.34], ventilator-associated pneumonia (VAP) (RR = 0.88; 95% CI = 0.71-1.10; p = 0.27) or duration of mechanical ventilation (MV) (WMD = - 2.91 days; 95% CI = -7.21-1.40 days; p = 0.19).
Among the patients requiring prolonged MV, ET showed no significant difference in clinical outcomes compared to that of the LT/PI group. But more rigorously designed and adequately powered RCTs are required to confirm it in future.
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