Descriptive Epidemiology and Outcomes of Nonventilated Hospital-Acquired, Ventilated Hospital-Acquired, and Ventilator-Associated Bacterial Pneumonia in the United States, 2012-2019.

OBJECTIVES: Multiple randomized controlled trials exploring the outcomes of patients with ventilator-associated bacterial pneumonia and hospital-acquired bacterial pneumonia have noted that hospital-acquired bacterial pneumonia patients who require subsequent ventilated hospital-acquired bacterial pneumonia suffered higher mortality than either those who did not (nonventilated hospital-acquired bacterial pneumonia) or had ventilator-associated bacterial pneumonia. We examined the epidemiology and outcomes of all three conditions in a large U.S. database. DESIGN: Retrospective cohort. SETTING: Two hundred fifty-three acute-care hospitals, United States, contributing data (including microbiology) to Premier database, 2012-2019. PATIENTS: Patients with hospital-acquired bacterial pneumonia or ventilator-associated bacterial pneumonia identified based on a slightly modified previously published International Classification of Diseases, 9th Edition/International Classification of Diseases, 10th Edition-Clinical Modification algorithm. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 17,819 patients who met enrollment criteria, 26.5% had nonventilated hospital-acquired bacterial pneumonia, 25.6% vHAPB, and 47.9% ventilator-associated bacterial pneumonia. Ventilator-associated bacterial pneumonia predominated in the Northeastern United States and in large urban teaching hospitals. Patients with nonventilated hospital-acquired bacterial pneumonia were oldest (mean 66.7 ± 15.1 yr) and most likely White (76.9%), whereas those with ventilator-associated bacterial pneumonia were youngest (59.7 ± 16.6 yr) and least likely White (70.3%). Ventilated hospital-acquired bacterial pneumonia was associated with the highest comorbidity burden (mean Charlson score 4.1 ± 2.8) and ventilator-associated bacterial pneumonia with the lowest (3.2 ± 2.5). Similarly, hospital mortality was highest among patients with ventilated hospital-acquired bacterial pneumonia (29.2%) and lowest in nonventilated hospital-acquired bacterial pneumonia (11.7%), with ventilator-associated bacterial pneumonia in-between (21.3%). Among survivors, 24.5% of nonventilated hospital-acquired bacterial pneumonia required a rehospitalization within 30 days of discharge, compared with 22.5% among ventilated hospital-acquired bacterial pneumonia and 18.8% ventilator-associated bacterial pneumonia. Unadjusted hospital length of stay after infection onset was longest among ventilator-associated bacterial pneumonia and shortest among nonventilated hospital-acquired bacterial pneumonia patients. Median total hospital costs mirrored length of stay: ventilator-associated bacterial pneumonia $77,657, ventilated hospital-acquired bacterial pneumonia $62,464, and nonventilated hospital-acquired bacterial pneumonia $39,911. CONCLUSIONS: Both hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia remain associated with significant mortality and cost in the United States. Our analyses confirm that of all three conditions, ventilated hospital-acquired bacterial pneumonia carries the highest risk of death. In contrast, ventilator-associated bacterial pneumonia remains most costly. Nonventilated hospital-acquired bacterial pneumonia survivors were most likely to require a readmission within 30 days of discharge.

A Minority of Patients on Mechanical Ventilation Consume Disproportionate Resources: A Retrospective Cohort Study.

BACKGROUND: The Pareto principle states that the majority of any effect comes from a minority of the causes. This property is widely used in quality improvement science. RESEARCH QUESTION: Among patients requiring mechanical ventilation (MV), are there subgroups according to MV duration that may serve as potential nodes for high-value interventions aimed at reducing costs without compromising quality? STUDY DESIGN AND METHODS: This multicenter retrospective cohort study included approximately 780 hospitals in the Premier Research Database (2014-2018). Patients receiving MV were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, codes. They were then divided into quintiles according to MV duration; their hospital costs, post-MV onset length of stay (LOS), ICU LOS, and cumulative post-MV onset hospital days per quintile were compared. RESULTS: A total of 691,961 patients were included in the analysis. Median [interquartile range] duration of MV in days by quintile was as follows: quintile 1 (Q1), 1 [1, 1]; Q2, 2 [2, 2]; Q3, 3 [3, 3]; Q4, 6 [6, 7]; and Q5, 13 [10, 19]. Median [interquartile range] post-MV onset LOS (Q1, 2 [0, 5]; Q5, 17 [12, 26]) and hospital costs (Q1, $15,671 [$9,180, $27,901]; Q5, $70,133 [$47,136, $108,032]) rose from Q1 through Q5. Patients in Q5 consumed 47.7% of all post-MV initiation hospital days among all patients requiring MV, and the mean per-patient hospital costs in Q5 exceeded the sum of costs incurred by Q1 to Q3. Adjusted marginal mean (95% CI) hospital costs rose exponentially from Q1 through Q5: Q2 vs Q1, $3,976 ($3,354, $4,598); Q3 vs Q2, $5,532 ($5,103, $5,961); Q4 vs Q3, $11,705 ($11,071, $12,339); and Q5 vs Q4, $26,416 ($25,215, $27,616). INTERPRETATION: Patients undergoing MV in the highest quintiles according to duration of MV consume a disproportionate amount of resources, as evidenced by MV duration, hospital LOS, and costs, making them a potential target for streamlining MV care.

Device associated -health care associated infections monitoring, prevention and cost assessment at intensive care unit of University Hospital in Poland (2015-2017).

BACKGROUND: Device-associated health care-associated infections (DA-HAIs) in intensive care unit (ICU) patients constitute a major therapeutic issue complicating the regular hospitalisation process and having influence on patients' condition, length of hospitalisation, mortality and therapy cost. METHODS: The study involved all patients treated > 48 h at ICU of the Medical University Teaching Hospital (Poland) from 1.01.2015 to 31.12.2017. The study showed the surveillance and prevention of DA-HAIs on International Nosocomial Infection Control Consortium (INICC) Surveillance Online System (ISOS) 3 online platform according to methodology of the INICC multidimensional approach (IMA). RESULTS: During study period 252 HAIs were found in 1353 (549F/804M) patients and 14,700 patient-days of hospitalisation. The crude infections rate and incidence density of DA-HAIs was 18.69% and 17.49 ± 2.56 /1000 patient-days. Incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI) and catheter-associated urinary tract infection (CA-UTI) per 1000 device-days were 12.63 ± 1.49, 1.83 ± 0.65 and 6.5 ± 1.2, respectively. VAP(137) constituted 54.4% of HAIs, whereas CA-UTI(91) 36%, CLA-BSI(24) 9.6%.The most common pathogens in VAP and CA-UTI was multidrug-resistant (MDR) Acinetobacter baumannii (57 and 31%), and methicillin-resistant Staphylococcus epidermidis (MRSE) in CLA-BSI (45%). MDR Gram negative bacteria (GNB) 159 were responsible for 63.09% of HAIs. The length of hospitalisation of patients with a single DA-HAI at ICU was 21(14-33) days, while without infections it was 6.0 (3-11) days; p = 0.0001. The mortality rates in the hospital-acquired infection group and no infection group were 26.1% vs 26.9%; p = 0.838; OR 0.9633;95% CI (0.6733-1.3782). Extra cost of therapy caused by one ICU acquired HAI was US$ 11,475/Euro 10,035. Hand hygiene standards compliance rate was 64.7%, while VAP, CLA-BSI bundles compliance ranges were 96.2-76.8 and 29-100, respectively. CONCLUSIONS: DA-HAIs was diagnosed at nearly 1/5 of patients. They were more frequent than in European Centre Disease Control report (except for CLA-BSI), more frequent than the USA CDC report, yet less frequent than in limited-resource countries (except for CA-UTI). They prolonged the hospitalisation period at ICU and generated substantial additional costs of treatment with no influence on mortality. The Acinetobacter baumannii MDR infections were the most problematic therapeutic issue. DA-HAIs preventive methods compliance rate needs improvement.

Cost-drivers of medical expenses in burn care management.

BACKGROUND: Profound differences exist in the cost of burn care globally, thus we aim to investigate the affected factors and to delineate a strategy to improve the cost-effectiveness of burn management. METHODS: A retrospective analysis of 66 patients suffering from acute burns was conducted from 2013 to 2015. The average age was 26.7 years old and TBSA was 42.1% (±25.9%). We compared the relationship between cost and clinical characteristics. RESULTS: The estimated cost of acute burn care with the following formula (10,000 TWD) = -19.80 + (2.67 × percentage of TBSA) + (124.29 × status of inhalation injury) + (147.63 × status of bacteremia) + (130.32 × status of respiratory tract infection). CONCLUSION: The majority of the cost were associated with the use of antibiotics and burns care. Consequently, it is crucial to prevent nosocomial infection in order to promote healthcare quality and reduce in-hospital costs.

Network meta-analysis and pharmacoeconomic evaluation of antibiotics for the treatment of patients infected with complicated skin and soft structure infection and hospital-acquired or ventilator-associated penumonia.

Background: Infections due to methicillin-resistant Staphylococcus aureus (MRSA) cause serious health risks and significant economic burdens and the preferred drugs are still controversial. Methods: We performed a network meta-analysis (NMA) to compare the efficacy and safety of antibiotics used to treat inpatients with complicated skin and soft structure infections (cSSSI) or hospital-acquired or ventilator-associated pneumonia (HAP/VAP). We also developed a decision tree model to assess the cost-effectiveness of antibiotics. Results: Forty-nine randomized controlled trials met the inclusion criteria (34 for cSSSI, 15 for HAP/VAP) and compared the efficacy and safety of 16 antibiotics. For cSSSI, NMA indicated that for clinical cure, linezolid was superior than vancomycin (odds ratio (OR) 1.55, 95% confidence interval (CI) 1.19-2.02), while tedizolid (OR 1.39, CI 0.70-2.76) was similar to vancomycin. In terms of safety, there were no significant differences between any two interventions on total adverse events. Based on drug and hospital costs in America, the incremental cost-effectiveness ratios (ICERs) per life-year saved for linezolid and tedizolid compared with vancomycin were US$2833 and US$5523. For HAP/VAP, there were no significant effects either for clinical cure or for safety endpoints between linezolid and vancomycin in NMA. ICERs per life-year saved for linezolid compared with vancomycin were US$2185. Conclusion: In these clinical trials, considering efficacy, safety, and cost-effectivenes, linezolid and tedizolid showed their superiority in MRSA cSSSI; while linezolid might be recommended to treat MRSA pneumonia. Although vancomycin was not cost-effective in pharmacoeconomic evaluation, it is still the first-line treatment for MRSA infection in the clinical practice. This study might provide new insights of therapeutic choices for patients with MRSA infections whilst awaiting the arrival of higher quality evidence.

Incidence and costs of ventilator-associated pneumonia in the adult intensive care unit of a tertiary referral hospital in Mexico.

BACKGROUND: Ventilator-associated pneumonia (VAP) is defined as pneumonia that occurs after 48 hours of endotracheal intubation and initiation of mechanical ventilation. The aim of this work was to use a micro-costing method to calculate the costs generated in 2017 for the care of patients with VAP at the Hospital Juárez de México. METHODS: We performed a cross-sectional, retrospective, analytical, and observational study of the databases of the registry of health care-associated infections (HAIs) in 2017, in addition to a micro-costing study. RESULTS: We studied 48 VAP cases in an adult intensive care unit (AICU). In this period, 1668 ventilator days were identified, with an incidence rate of 28.8 per 1000 days. All cases were caused by multidrug-resistant (MDR) bacteria and the costs of their care exceeded the average costs for the use of antimicrobials. By calculating the profit on return as an association measure, we found that VAP caused by MDR bacteria confers 9 times the risk of increasing the costs of care above the expected average. CONCLUSIONS: The cost for a case of VAP in the AICU is high and has an impact on the institutional budget. Control measures to prevent the spread of bacteria, particularly MDR bacteria, must be put into place in order to avoid increases in hospital stay costs and mortality.

A Novel Algorithm to Analyze Epidemiology and Outcomes of Carbapenem Resistance Among Patients With Hospital-Acquired and Ventilator-Associated Pneumonia: A Retrospective Cohort Study.

BACKGROUND: Carbapenem resistance is a growing concern. Applying a novel algorithm, we examined epidemiology and outcomes of carbapenem resistance among gram-negative pathogens in hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). METHODS: In a retrospective cohort design within the Premier Research database (2009-2016), all hospitalized adult patients with a gram-negative organism in a respiratory or blood culture specimen who fit criteria for HAP/VAP based on International Classification of Diseases, Ninth Revision, Clinical Modification, codes were included in the study. RESULTS: Among 8,969 patients with HAP/VAP, 1,059 isolates (11.8%) were carbapenem-resistant (CR) organisms. Patients with CR organisms were more likely female (41.4% vs 33.2%; P < .001) and medical admissions (33.8% vs 27.4%, P < .001) than those with carbapenem-susceptible (CS) organisms. Patients with carbapenem resistance had higher comorbidity burden than those with carbapenem susceptibility (median [interquartile range] Charlson Comorbidity Index score, 3 [1-4] vs 2 [1-4]; P < .001). Pseudomonas aeruginosa was the most common gram-negative pathogen overall (24.9%) and among CS organisms (23.5%), and was second to Stenotrophomonas maltophilia (44.0%) among CR organisms (35.3%). Acinetobacter baumannii accounted for 11.8% of CR organisms and 2.5% of CS organisms (P < .001). Patients with carbapenem resistance were more likely than those with carbapenem susceptibility to receive inappropriate empiric therapy (25.8% vs 10.0%; P < .001). Carbapenem resistance did not affect adjusted mortality (22.9% CR vs 21.6% CS) or postinfection length of stay (except among survivors of VAP), but it was associated with excess costs ($8,921; 95% CI, 3,864-13,977). CONCLUSIONS: Using administrative data, our novel algorithm identified patients with pneumonia at high risk for death, consistent with HAP/VAP. Among them, carbapenem resistance occurred in 12% of all cases and was associated with substantial excess in hospital costs.

Epidemiology of ICU-acquired pneumonia.

PURPOSE OF REVIEW: Review of the epidemiology of ICU-acquired pneumonia, including both ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP) in nonventilated ICU patients, with critical review of the most recent literature in this setting. RECENT FINDINGS: The incidence of ICU-acquired pneumonia, mainly VAP has decrease significantly in recent years possibly due to the generalized implementation of preventive bundles. However, the exact incidence of VAP is difficult to establish due to the diagnostic limitations and the methods employed to report rates. Incidence rates greatly vary based on the studied populations. Data in the literature strongly support the relevance of intubation, not ventilatory support, in the development of HAP in ICU patients, but also that the incidence of HAP in nonintubated patients is not negligible. Despite the fact of a high crude mortality associated with the development of VAP, the overall attributable mortality of this complication was estimated in 13%, with higher mortality rates in surgical patients and those with mid-range severity scores at admission. Mortality is consistently greatest in patients with HAP who require intubation, slightly less in VAP, and least for nonventilated HAP. The economic burden of ICU acquired pneumonia, particularly VAP, is important. The increased costs are mainly related to the longer periods of ventilatory assistance and ICU and hospital stays required by these patients. However, the different impact of VAP on economic burden among countries is largely dependent on the different costs associated with heath care. SUMMARY: VAP has significant impact on mortality mainly in surgical patients and those with mid-range severity scores at admission. The economic burden on ICU-acquired pneumonia depends mainly on the increased length of stay of these patients.

Cost assessment of a new oral care program in the intensive care unit to prevent ventilator-associated pneumonia.

OBJECTIVES: Ventilator-associated pneumonia (VAP) is the most frequent hospital-acquired infections in intensive care units (ICU). In the bundle of care to prevent the VAP, the oral care is very important strategies, to decrease the oropharyngeal bacterial colonization and presence of causative bacteria of VAP. In view of the paucity of medical economics studies, our objective was to determine the cost of implementing this oral care program for preventing VAP. MATERIALS AND METHODS: In five ICUs, during period 1, caregivers used a foam stick for oral care and, during period 2, a stick and tooth brushing with aspiration. Budgetary effect of the new program from the hospital's point of view was analyzed for both periods. The costs avoided were calculated from the incidence density of VAP (cases per 1000 days of intubation). The cost study included device cost, benefit lost, and ICU cost (medication, employer and employee contributions, blood sample analysis…). RESULTS: A total of 2030 intubated patients admitted to the ICUs benefited from oral care. The cost of implementing the study protocol was estimated to be €11,500 per year. VAP rates decreased significantly between the two periods (p1 = 12.8% and p2 = 8.5%, p = 0.002). The VAP revenue was ranged from €28,000 to €45,000 and the average cost from €39,906 to €42,332. The total cost assessment calculated was thus around €1.9 million in favor of the new oral care program. CONCLUSION AND CLINICAL RELEVANCE: Our study showed that the implementation of a simple strategy improved the quality of patient care is economically viable. TRIAL REGISTRATION: NCT02400294.

Cost Drivers of a Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia Phase 3 Clinical Trial.

Background: Studies indicate that the prevalence of multidrug-resistant infections, including hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (HABP/VABP), has been rising. There are many challenges associated with these disease conditions and the ability to develop new treatments. Additionally, HABP/VABP clinical trials are very costly to conduct given their complex protocol designs and the difficulty in recruiting and retaining patients. Methods: With input from clinicians, representatives from industry, and the US Food and Drug Administration, we conducted a study to (1) evaluate the drivers of HABP/VABP phase 3 direct and indirect clinical trial costs; (2) to identify opportunities to lower these costs; and (3) to compare (1) and (2) to endocrine and oncology clinical trials. Benchmark data were gathered from proprietary and commercial databases and used to create a model that calculates the fully loaded (direct and indirect) cost of typical phase 3 HABP/VABP endocrine and oncology clinical trials. Results: Results indicate that the cost per patient for a 200-site, 1000-patient phase 3 HABP/VABP study is $89600 per patient. The cost of screen failures and screen failure rates are the main cost drivers. Conclusions: Results indicate that biopharmaceutical companies and regulatory agencies should consider strategies to improve screening and recruitment to decrease HABP/VABP clinical trial costs.

Costo de las neumonías asociadas a la ventilación mecánica en pacientes adultos en un hospital general en Chile / Cost evaluation of ventilator-associated pneumonia in adult patients in a general hospital in Chile

Resumen Introducción: La neumonía asociada a la ventilación mecánica (NAVM) es un evento adverso que aumenta la morbi-mortalidad y costos. Genera días adicionales de hospitalización y de procedimientos diagnósticos y terapéuticos para su tratamiento. No existen datos actualizados nacionales respecto al exceso de costos por NAVM. Objetivo: Dimensionar el costo de las NAVM en un hospital general de la Región Metropolitana. Pacientes y Métodos: Aplicación del protocolo caso-control de costos de infecciones intrahospitalarias de la Organización Panamericana de la Salud (OPS) y cálculo directo de gasto en exceso por evento de NAVM. Se comparó el exceso de días de hospitalización, de antimicrobianos en dosis diaria definida (DDD) y de cultivos. Resultados: Se recolectaron 18 casos de NAVM entre los años 2012 y 2015 en pacientes adultos. Se seleccionaron 18 controles pareados por edad y género. Se observó una mayor estadía promedio de 6,1 días en los casos (p < 0,05), una mayor prescripción de antimicrobianos (diferencia promedio de 11,7 DDD, sin significancia estadística) y un exceso de solicitud de cultivos con una diferencia promedio de 3,2 (p < 0,05). El costo unitario por NAVM fue de 4.475 USD. Conclusiones: Los eventos de NAVM generan una mayor estadía hospitalaria, consumo de recursos diagnósticos y terapéuticos.

Background: Ventilator-associated pneumonia (VAP) is an adverse event that increases morbidity, mortality and costs due to a prolonged stay and requirement of microbiological studies and antimicrobial therapy. There is not recent data of VAP costs in Chile. Aim: To evaluate additional costs in adult patients with VAP compared to controls in a general hospital in the Metropolitan Area. Patients and Methods: Use of the PAHO paired casecontrol protocol for cost evaluation associated to nosocomial infections and estimation of cost in excess per VAP event. Length of stay (LOS) in excess, antimicrobial consumption in daily-defined doses (DDD), and number of microbiological studies were compared between both groups. Results: From 2012 to 2015, 18 patients with VAP events were identified with their respective controls. LOS exceeded 6.1 days on average among patients with VAP respect to controls (p < 0.05). DDD was higher among patients with VAP (difference 11.7 DDD) as well as number of cultures (3.2 higher on average, p < 0.05). Cost in excess per VAP event reached 4,475 USD. Conclusions: In our Centre, VAP events are associated to a higher LOS, antimicrobial consumption and microbiological studies.

Management of ventilator associated pneumonia with a new antibiotic adjuvant entity (ceftriaxone+sulbactam+disodium edetate) - A novel approach to spare carbapenems.

BACKGROUND: Ventilator associated pneumonia (VAP) is one of the most serious nosocomial infections in Intensive Care Unit (ICU). The aim of this study was to evaluate a new approach to spare the carbapenems for the management of patients diagnosed with VAP due to Acinetobacter baumannii (A. baumannii). METHOD: This retrospective study was conducted on VAP patients presenting for treatment at tertiary care centre between May 2014 and March 2016. The case sheets of patients who have been treated for VAP with meropenem, antibiotic adjuvant entity (AAE) and colistin were analysed. RESULTS: Out of 113 patients analysed, 24 (21.3%) patients were having VAP due to MDR A. baumannii. Microbial sensitivity has shown that 87.5% of patients were sensitive to AAE and colistin whereas all of them were resistant to meropenem, imipenem and gentamycin. The mean treatment durations were 12.4±2.1, 13.2±2.4 and 14.3±2.1days for AAE, meropenem+colistin and AAE+colistin treatment groups. In AAE susceptible patients, the mean treatment duration and cost could be reduced by 23-24% and 43-53% if AAE is used empirically. In AAE-resistant patients, the mean treatment duration and cost could be reduced by 21% and 26% if AAE+colistin regime is used empirically instead of meropenem followed by AAE+colistin. CONCLUSIONS: Clinical assessment with microbial eradication and pharmaco-economic evaluation clearly shows benefits in using AAE empirically in the management of A. baumannii infected VAP cases.

[Cost evaluation of ventilator-associated pneumonia in adult patients in a general hospital in Chile]. / Costo de las neumonías asociadas a la ventilación mecánica en pacientes adultos en un hospital general en Chile.

BACKGROUND: Ventilator-associated pneumonia (VAP) is an adverse event that increases morbidity, mortality and costs due to a prolonged stay and requirement of microbiological studies and antimicrobial therapy. There is not recent data of VAP costs in Chile. AIM: To evaluate additional costs in adult patients with VAP compared to controls in a general hospital in the Metropolitan Area. PATIENTS AND METHODS: Use of the PAHO paired casecontrol protocol for cost evaluation associated to nosocomial infections and estimation of cost in excess per VAP event. Length of stay (LOS) in excess, antimicrobial consumption in daily-defined doses (DDD), and number of microbiological studies were compared between both groups. RESULTS: From 2012 to 2015, 18 patients with VAP events were identified with their respective controls. LOS exceeded 6.1 days on average among patients with VAP respect to controls (p < 0.05). DDD was higher among patients with VAP (difference 11.7 DDD) as well as number of cultures (3.2 higher on average, p < 0.05). Cost in excess per VAP event reached 4,475 USD. CONCLUSIONS: In our Centre, VAP events are associated to a higher LOS, antimicrobial consumption and microbiological studies.

Determining impacts and factors in ventilator-associated pneumonia bundle. / Impactos e fatores determinantes no bundle de pneumonia associada à ventilação mecânica.

OBJECTIVE:: Assessing the determining impacts and factors in ventilator-associated pneumonia (VAP) bundle. METHOD:: descriptive retrospective longitudinal study, with quantitative approach, held at a public teaching hospital. Collection held between May 2014 and April 2015. Patients of the ICU with VAP participated in the research. For organizing data, the Microsoft Excel 2010 program was used. A critical analysis between the data collected and infection rates was performed. The survey was approved under no. 566,136. RESULTS:: an increase in the incidence of VAP after implementing the bundle was observed; the prevalent pathogens were gram-negative bacteria. Deaths were equal to or greater than 50%. Changes of professionals and lack of supplies were determining factors. CONCLUSION:: in this context, the need for permanent qualification of the team is emphasized, with the purpose of promoting the adherence to the protocol and preventing VAP.

Impactos e fatores determinantes no bundle de pneumonia associada à ventilação mecânica / Impactos y factores determinantes en cumplimiento del bundle de neumonía asociada a la ventilación mecánica / Determining impacts and factors in ventilator-associated pneumonia bundle

RESUMO Objetivo: avaliar os impactos e fatores determinantes no cumprimento do bundle para redução da pneumonia associada à ventilação mecânica. Método: estudo longitudinal retrospectivo, descritivo, com abordagem quantitativa, realizado no Hospital público de ensino. Coleta realizada entre maio de 2014 e abril de 2015. Participaram da pesquisa, os pacientes da UTI, notificados com PAV. Para a organização dos dados foi utilizado o programa Microsoft Excel 2010. Estabeleceu-se uma análise crítica entre os dados levantados e as taxas de infecção. A pesquisa obteve parecer favorável, sob o n° 566.136. Resultados: observou-se aumento na incidência de PAV após implementação do bundle; os patógenos prevalentes foram bactérias gram-negativas. Os óbitos foram iguais ou maiores a 50%. As mudanças de profissionais e a falta de insumos foram fatores determinantes. Conclusão: nesse contexto, ressalta-se a necessidade de qualificação permanente da equipe, com o propósito de favorecer a adesão ao protocolo e prevenir a PAV.

RESUMEN Objetivo: evaluar los impactos y factores determinantes en el cumplimiento del bundle para reducir la neumonía asociada a la ventilación mecánica (NAV). Método: se trata de un estudio descriptivo retrospectivo longitudinal con un enfoque cuantitativo, realizado en el hospital público universitario. La recolección de datos se ha llevado a cabo entre mayo de 2014 y abril de 2015. Los participantes fueron los pacientes de la UCI reportados con NAV. Para la organización de los datos se utilizó el programa Microsoft Excel 2010. Se estableció un análisis crítico de los datos recogidos y las tasas de infección. La investigación fue aprobada bajo el número de registro 566.136. Resultados: hubo un aumento en la incidencia de NAV después de la implementación del bundle; los patógenos prevalentes fueron las bacterias gramnegativas. Las muertes eran igual o superior al 50%. Cambios profesionales y la falta de insumos fueron factores determinantes. Conclusión: en este contexto, se destaca la necesidad de una formación continua del personal, con el fin de promover la adhesión al protocolo y prevenir la NAV.

ABSTRACT Objective: Assessing the determining impacts and factors in ventilator-associated pneumonia (VAP) bundle. Method: descriptive retrospective longitudinal study, with quantitative approach, held at a public teaching hospital. Collection held between May 2014 and April 2015. Patients of the ICU with VAP participated in the research. For organizing data, the Microsoft Excel 2010 program was used. A critical analysis between the data collected and infection rates was performed. The survey was approved under no. 566,136. Results: an increase in the incidence of VAP after implementing the bundle was observed; the prevalent pathogens were gram-negative bacteria. Deaths were equal to or greater than 50%. Changes of professionals and lack of supplies were determining factors. Conclusion: in this context, the need for permanent qualification of the team is emphasized, with the purpose of promoting the adherence to the protocol and preventing VAP.

Healthcare associated infections in Paediatric Intensive Care Unit of a tertiary care hospital in India: Hospital stay & extra costs.

BACKGROUND & OBJECTIVES: Healthcare associated infections (HAIs) increase the length of stay in the hospital and consequently costs as reported from studies done in developed countries. The current study was undertaken to evaluate the impact of HAIs on length of stay and costs of health care in children admitted to Paediatric Intensive Care Unit (PICU) of a tertiary care hospital in north India. METHODS: This prospective study was done in the seven bedded PICU of a large multi-specialty tertiary care hospital in New Delhi, India. A total of 20 children with HAI (cases) and 35 children without HAI (controls), admitted to the PICU during the study period (January 2012 to June 2012), were matched for gender, age, and average severity of illness score. Each patient's length of stay was obtained prospectively. Costs of healthcare were estimated according to traditional and time driven activity based costing methods approach. RESULTS: The median extra length of PICU stay for children with HAI (cases), compared with children with no HAI (controls), was seven days (IQR 3-16). The mean total costs of patients with and without HAI were ' 2,04,787 (US$ 3,413) and ' 56,587 (US$ 943), respectively and the mean difference in the total cost between cases and controls was ' 1,48,200 (95% CI 55,716 to 2,40,685, p<0.01). INTERPRETATION & CONCLUSIONS: This study highlights the effect of HAI on costs for PICU patients, especially costs due to prolongation of hospital stay, and suggests the need to develop effective strategies for prevention of HAI to reduce costs of health care.

The effectiveness of a bundle in the prevention of ventilator-associated pneumonia

Abstract Objectives The aim of this study was to evaluate the impact of a bundle called FAST HUG in ventilator-associated pneumonia, weigh the healthcare costs of ventilator-associated pneumonia patients in the intensive care unit, and hospital mortality due to ventilator-associated pneumonia. Material and methods The study was performed in a private hospital that has an 8-bed intensive care unit. It was divided into two phases: before implementing FAST HUG, from August 2011 to August 2012 and after the implementation of FAST HUG, from September 2012 to December 2013. An individual form for each patient in the study was filled out by using information taken electronically from the hospital medical records. The following data was obtained from each patient: age, gender, reason for hospitalization, use of three or more antibiotics, length of stay, intubation time, and outcome. Results After the implementation of FAST HUG, there was an observable decrease in the occurrence of ventilator-associated pneumonia (p < 0.01), as well as a reduction in mortality rates (p < 0.01). In addition, the intervention resulted in a significant reduction in intensive care unit hospital costs (p < 0.05). Conclusion The implementation of FAST HUG reduced the number of ventilator-associated pneumonia cases. Thus, decreasing costs, reducing mortality rates and length of stay, which therefore resulted in an improvement to the overall quality of care.

Clarithromycin Leads to Long-Term Survival and Cost Benefit in Ventilator-Associated Pneumonia and Sepsis.

Increasing numbers of admissions for sepsis impose a heavy burden on health care systems worldwide, while novel therapies have proven both expensive and ineffective. We explored the long-term mortality and hospitalization costs after adjunctive therapy with intravenous clarithromycin in ventilator-associated pneumonia (VAP). Two hundred patients with sepsis and VAP were enrolled in a published randomized clinical trial; 100 were allocated to blind treatment with a placebo and another 100 to clarithromycin at 1 g daily for three consecutive days. Long-term mortality was recorded. The hospitalization cost was calculated by direct quantitation of imaging tests, medical interventions, laboratory tests, nonantibiotic drugs and antibiotics, intravenous fluids, and parenteral and enteral nutrition. Quantities were priced by the respective prices defined by the Greek government in 2002. The primary endpoint was 90-day mortality; cumulative hospitalization cost was the secondary endpoint. All-cause mortality rates on day 90 were 60% in the placebo arm and 43% in the clarithromycin arm (P = 0.023); 141 patients were alive on day 28, and mortality rates between days 29 and 90 were 44.4% and 17.4%, respectively (P = 0.001). The mean cumulative costs on day 25 in the placebo group and in the clarithromycin group were €14,701.10 and €13,100.50 per patient staying alive, respectively (P = 0.048). Respective values on day 45 were €26,249.50 and €19,303.10 per patient staying alive (P = 0.011); this was associated with the savings from drugs other than antimicrobials. It is concluded that intravenous clarithromycin for three consecutive days as an adjunctive treatment in VAP and sepsis offers long-term survival benefit along with a considerable reduction in the hospitalization cost. (This study has been registered at ClinicalTrials.gov under registration no. NCT00297674.).

The effectiveness of a bundle in the prevention of ventilator-associated pneumonia.

OBJECTIVES: The aim of this study was to evaluate the impact of a bundle called FAST HUG in ventilator-associated pneumonia, weigh the healthcare costs of ventilator-associated pneumonia patients in the intensive care unit, and hospital mortality due to ventilator-associated pneumonia. MATERIAL AND METHODS: The study was performed in a private hospital that has an 8-bed intensive care unit. It was divided into two phases: before implementing FAST HUG, from August 2011 to August 2012 and after the implementation of FAST HUG, from September 2012 to December 2013. An individual form for each patient in the study was filled out by using information taken electronically from the hospital medical records. The following data was obtained from each patient: age, gender, reason for hospitalization, use of three or more antibiotics, length of stay, intubation time, and outcome. RESULTS: After the implementation of FAST HUG, there was an observable decrease in the occurrence of ventilator-associated pneumonia (p<0.01), as well as a reduction in mortality rates (p<0.01). In addition, the intervention resulted in a significant reduction in intensive care unit hospital costs (p<0.05). CONCLUSION: The implementation of FAST HUG reduced the number of ventilator-associated pneumonia cases. Thus, decreasing costs, reducing mortality rates and length of stay, which therefore resulted in an improvement to the overall quality of care.

Potential Cost-effectiveness of Early Identification of Hospital-acquired Infection in Critically Ill Patients.

RATIONALE: Limitations in methods for the rapid diagnosis of hospital-acquired infections often delay initiation of effective antimicrobial therapy. New diagnostic approaches offer potential clinical and cost-related improvements in the management of these infections. OBJECTIVES: We developed a decision modeling framework to assess the potential cost-effectiveness of a rapid biomarker assay to identify hospital-acquired infection in high-risk patients earlier than standard diagnostic testing. METHODS: The framework includes parameters representing rates of infection, rates of delayed appropriate therapy, and impact of delayed therapy on mortality, along with assumptions about diagnostic test characteristics and their impact on delayed therapy and length of stay. Parameter estimates were based on contemporary, published studies and supplemented with data from a four-site, observational, clinical study. Extensive sensitivity analyses were performed. The base-case analysis assumed 17.6% of ventilated patients and 11.2% of nonventilated patients develop hospital-acquired infection and that 28.7% of patients with hospital-acquired infection experience delays in appropriate antibiotic therapy with standard care. We assumed this percentage decreased by 50% (to 14.4%) among patients with true-positive results and increased by 50% (to 43.1%) among patients with false-negative results using a hypothetical biomarker assay. Cost of testing was set at $110/d. MEASUREMENTS AND MAIN RESULTS: In the base-case analysis, among ventilated patients, daily diagnostic testing starting on admission reduced inpatient mortality from 12.3 to 11.9% and increased mean costs by $1,640 per patient, resulting in an incremental cost-effectiveness ratio of $21,389 per life-year saved. Among nonventilated patients, inpatient mortality decreased from 7.3 to 7.1% and costs increased by $1,381 with diagnostic testing. The resulting incremental cost-effectiveness ratio was $42,325 per life-year saved. Threshold analyses revealed the probabilities of developing hospital-acquired infection in ventilated and nonventilated patients could be as low as 8.4 and 9.8%, respectively, to maintain incremental cost-effectiveness ratios less than $50,000 per life-year saved. CONCLUSIONS: Development and use of serial diagnostic testing that reduces the proportion of patients with delays in appropriate antibiotic therapy for hospital-acquired infections could reduce inpatient mortality. The model presented here offers a cost-effectiveness framework for future test development.