A systematic approach for developing a ventilator-associated pneumonia prevention bundle.

BACKGROUND: Ventilator-associated pneumonia (VAP) is among the most common type of health care-associated infection in the intensive care unit and is associated with significant morbidity and mortality. Existing VAP prevention intervention bundles vary widely on the interventions included and in the approaches used to develop these bundles. The objective of this study was to develop a new VAP prevention bundle using a systematic approach that elicits clinician perceptions on which interventions are most important and feasible to implement. METHODS: We identified potential interventions to include through a review of current guidelines and literature. We implemented a 2-step modified Delphi method to gain consensus on the final list of interventions. An interdisciplinary group of clinical experts participated in the Delphi process, which was guided by a technical expert panel. RESULTS: We identified 65 possible interventions. Through the Delphi method, we narrowed that list to 19 interventions that included 5 process and 14 structural measures. CONCLUSIONS: We described a structured approach for developing a new VAP prevention bundle. Obtaining clinician input on what interventions to include increases the likelihood that providers will adhere to the bundle.

Regulation of high-affinity iron acquisition homologues in the tsetse fly symbiont Sodalis glossinidius.

Sodalis glossinidius is a facultative intracellular bacterium that is a secondary symbiont of the tsetse fly (Diptera: Glossinidae). Since studies with other facultative intracellular bacteria have shown that high-affinity iron acquisition genes are upregulated in vivo, we investigated the regulation of several Sodalis genes that encode putative iron acquisition systems. These genes, SG1538 (hemT) and SG1516 (sitA), are homologous to genes encoding periplasmic heme and iron/manganese transporters, respectively. hemT promoter- and sitA promoter-gfp fusions were constructed, and in both Escherichia coli and Sodalis backgrounds, expression levels of these fusions were higher when the bacteria were grown in iron-limiting media than when the bacteria were grown in iron-replete media. The Sodalis promoters were tested for iron regulation in an E. coli strain that lacks the fur gene, which encodes the iron-responsive transcriptional repressor Fur. Expression of the promoter-gfp fusions in the E. coli fur mutant was constitutively high in both iron-replete and iron-deplete media, and addition of either Shigella flexneri fur or Sodalis fur to a plasmid restored normal regulation. A Sodalis fur mutant was constructed by intron mutagenesis, and semiquantitative reverse transcription-PCR (RT-PCR) showed that iron repression of sitA expression was also abolished in this strain. In vivo expression analysis showed that hemT and sitA are expressed when Sodalis is within tsetse fly hosts, suggesting a biological role for these genes when Sodalis is within the tsetse fly.