Korean Guidelines for the Management and Antibiotic Therapy in Adult Patients with Hospital-Acquired Pneumonia.

BACKGROUND: Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are correlated with high morbidity and mortality rates. Guidelines that consider local epidemiologic data are fundamental for identifying optimal treatment strategies. However, Korea has no HAP/VAP guidelines. METHODS: This study was conducted by a committee of nine experts from the Korean Academy of Tuberculosis and Respiratory Diseases Respiratory Infection Study Group using the results of Korean HAP/VAP epidemiologic studies. Eleven key questions for HAP/VAP diagnosis and treatment were addressed. The Convergence of Opinion on Suggestions and Evidence (CORE) process was used to derive suggestions, and evidence levels and recommendation grades were in accordance with the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. RESULTS: Suggestions were made for the 11 key questions pertinent to diagnosis, biomarkers, antibiotics, and treatment strategies for adult patients with HAP/VAP. CONCLUSION: Using the CORE process and GRADE methodology, the committee generated a series of recommendations for HAP/VAP diagnosis and treatment in the Korean context.

Predicting nosocomial pneumonia risk in level-1 trauma patients: An external validation study using the trauma quality improvement program.

BACKGROUND: Early identification of patients at risk of nosocomial pneumonia enables the opportunity for preventative measures, which may improve survival and reduce costs. Therefore, this study aimed to externally validate an existing prediction model (issued by Croce et al.) to predict nosocomial pneumonia in patients admitted to US level-1 trauma centers. METHODS: A retrospective cohort study including patients admitted to level-1 trauma centers and registered in the TQIP, a US nationwide trauma registry, admitted between 2013-2015 and 2017-2019. The main outcome was total nosocomial pneumonia for the first period and ventilator-associated pneumonia (VAP) for the second. Model discrimination and calibration were assessed before and after recalibration. RESULTS: The study comprised 902,231 trauma patients (N2013-2015 â€‹= â€‹180,601; N2017-2019 â€‹= â€‹721,630), with a median age of 52 in both periods, 64-65 â€‹% male, and approximately 90 â€‹% sustaining blunt traumatic injury. The median Injury Severity Scores were 13 (2013-2015) versus 9 (2017-2019); median Glasgow Coma Scale scores were 15. Nosocomial pneumonia incidence was 4.4 â€‹%, VAP incidence was 0.7 â€‹%. The original model demonstrated good to excellent discrimination for both periods (c-statistic2013-2015 0.84, 95%CI 0.83-0.84; c-statistic2017-2019 0.92, 95%CI 0.91-0.92). After recalibration, discriminatory capacity and calibration for the lower predicted probabilities improved. CONCLUSIONS: The Croce model can identify patients admitted to US level-1 trauma centers at risk of total nosocomial pneumonia and VAP. Implementing (modified) Croce models in route trauma clinical practice could guide judicious use of preventative measures and prescription of additional non-invasive preventative measures (e.g., increased monitoring, pulmonary physiotherapy) to decrease the occurrence of nosocomial pneumonia in at-risk patients.

Intravenous combined with aerosolised polymyxins versus intravenous polymyxins monotherapy for ventilator-associated pneumonia: a systematic review and meta-analysis.

Polymyxins was applied to treat ventilator associated pneumonia (VAP) caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) via different administration routes. The potential benefits of aerosolised polymyxins as adjunctive treatment for patients still were contradictory. This review assessed the safety and efficacy of intravenous combined with aerosolised polymyxins versus intravenous polymyxins monotherapy in patients with VAP caused by CR-GNB. Two reviewers independently evaluated and extracted date from Pubmed, Embase, Cochrane library and Web of science. The primary outcome was all-cause mortality and secondary outcomes included clinical cure rate, clinical improvement rate, microbiological eradication and nephrotoxicity. Differences for dichotomous outcomes were expressed as odds ratios (OR) with 95% confidence intervals (CI). Eleven eligible studies were included. The results showed that compared with intravenous polymyxins monotherapy, intravenous plus aerosolised polymyxins therapy significantly reduced all-cause mortality rate (OR = 0.75, 95% CI 0.57 - 0.99, P = 0.045) and improved clinical improvement rate (OR = 1.62, 95% CI 1.02 - 2.60, P = 0.043) and microbial eradication rate (OR = 2.07, 95% CI 1.40 - 3.05, P = 0.000). However, there were no significant difference in terms of clinical cure rate (OR = 1.59, 95% CI 0.96 - 2.63, P = 0.072) and nephrotoxicity (OR = 1.14, 95% CI 0.80 - 1.63, P = 0.467) for intravenous plus aerosolised polymyxins therapy. Subgroup analysis revealed that the clinical improvement rate was improved significantly in case-control studies. Aerosolised polymyxins maybe a useful adjunct to intravenous polymyxins for CR-GNB VAP patients.

Droplet Digital PCR for Acinetobacter baumannii Diagnosis in Bronchoalveolar Lavage Samples from Patients with Ventilator-Associated Pneumonia.

Advanced diagnostic technologies have made accurate and precise diagnosis of pathogens easy. Herein, we present a new diagnostic method, droplet digital PCR (ddPCR), to detect and quantify Acinetobacter baumannii in mini bronchoalveolar lavage (mini-BAL) samples. A. baumannii causes ventilator-associated pneumonia (VAP), a severe healthcare infection affecting patients' lungs. VAP carries a high risk of morbidity and mortality, making its timely diagnosis crucial for prompt and effective management. Methodology. The assay performance was evaluated by comparing colonization data, quantitative culture results, and different generations of PCR (traditional PCR and Real-Time PCR-qPCR Taqman® and SYBR® Green). The ddPCR and qPCR Taqman® prove to be more sensitive than other molecular techniques. Reasonable analytical specificity was obtained with ddPCR, qPCR TaqMan®, and conventional PCR. However, qPCR SYBR® Green technology presented a low specificity, making the results questionable in clinical samples. DdPCR detected/quantified A. baumanni in more clinical samples than other methods (38.64% of the total samples). This emerging ddPCR technology offers promising advantages such as detection by more patients and direct quantification of pathogens without calibration curves.

An overview of sulbactam-durlobactam approval and implications in advancing therapeutics for hospital-acquired and ventilator-associated pneumonia by acinetobacter baumannii-calcoaceticus complex: A narrative review.

Purpose: Infections caused by Acinetobacter baumannii, particularly those resistant to antibiotics such as carbapenem, have become a global health crisis with a significant mortality rate. Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) resulting from the A. baumannii-calcoaceticus (ABC) complex represent a major clinical challenge. This review aimed to understand the approval process, mechanism of action, therapeutic potential, and future implications of sulbactam-durlobactam therapy (SUL-DUR). Methods: PubMed, Web of Science, EMBASE, Clinical trials. gov, ICTRP, and CENTRAL were searched for studies on SUL-DUR for the treatment of hospital-acquired pneumonia and ventilator-associated pneumonia. Also, World Health Organization, U.S. Food and Drug Administration, and Centers for Disease Control and Prevention websites were searched for relevant information. Results: SUL-DUR, marketed as Xacduro, is a novel pharmaceutical combination that functions as a narrow-spectrum parenterally administered antibiotic. Sulbactam acts as a ß-lactamase inhibitor, whereas durlobactam protects against degradation by A. baumannii enzymes. A phase 1 trial successfully established the safety and tolerability of SUL-DUR in patients with normal and mild renal impairment. A phase 2 trial demonstrated the safety and tolerability of SUL-DUR in a larger population with urinary tract infections. A phase 3 trial showed that SUL-DUR was non-inferior to colistin in terms of mortality in A. baumannii-related VAP, HAP, and bacteremia. Conclusion: The combination of sulbactam and durlobactam is a promising treatment option for HAP and VAP caused by ABC complex.

Comprehensive airway management of ventilator-associated pneumonia in ICU populations.

OBJECTIVE: To evaluate the validity of comprehensive airway management intervention on ventilator-associated pneumonia (VAP) in ICU patients requiring mechanical ventilation. METHODS: In this retrospective observational study, the clinical data from 120 patients undergoing mechanical ventilation in the ICU of Hebei Chest Hospital from May 2020 to July 2022 were surveyed. Finally, 50 cases of VAP were identified and placed into an observation (n=25) and a control group (n=25) according to the nursing model they received. The control group was treated with routine nursing intervention, and the observation group was given comprehensive airway management intervention based on the control group. After 3 weeks of intervention, the clinical symptom recovery time, treatment-related indexes, nursing quality and nursing satisfaction score, and blood gas indexes and vital signs of the patients in the two groups were examined. The multivariate Logistic regression analysis was performed to identify the risk factors related to the death of critically ill patients. RESULTS: The observation group showed a significant reduction in the recovery time of heart failure, wheezing cough, and lung rales compared with that in the control group. The duration of mechanical ventilation, hospitalization, and antibiotic use in the observation group were appreciably shorter compared with those in the control group (all P<0.05). Additionally, nursing satisfaction and nursing quality scores were higher in the observation group compared to the control group (P<0.05). The contrast of blood gas indexes and vital signs between the two groups before ventilation and 1 hour after evacuation ventilation showed that a statistical significance existed in the interaction between groups (P<0.05). The risk factors related to the death of critically ill patients included D-dimer (OR=1.051, 95% CI: 1.006-1.08, P<0.05) and lactic acid (OR=0.894, 95% CI: 0.923-1.031, P<0.05). CONCLUSION: Comprehensive airway management mode can reduce the occurrence of VAP in ICU patients requiring mechanical ventilation.

Adult intensive care unit nurses' knowledge of and compliance barriers to evidence-based guidelines for prevention of ventilator-associated pneumonia: A cross-sectional survey.

BACKGROUND: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICUs) and is a common cause of morbidity and mortality in intensive care patients. Previous studies show that insufficient knowledge and compliance barriers among nurses affect pneumonia. There have been no investigations into intensive care nurses' knowledge and compliance barriers to evidence-based guidelines (EBGs) for VAP prevention in county-level hospitals in China. AIMS: To explore adult ICU nurses' knowledge and compliance barriers to EBGs for preventing VAP in county-level hospitals in Hunan Province, China, examine the correlation between knowledge and compliance barriers, and analyse associated factors. STUDY DESIGN: A cross-sectional electronic survey was conducted to focus on nurses' knowledge of and compliance barriers to EBGs for preventing VAP. RESULTS: A total of 386 valid questionnaires were collected, with a response rate of 97.47% (386/396 = 97.47%). The median scores for nurses' knowledge (out of 9) and compliance barriers (out of 8) to EBGs for preventing VAP were 7 (interquartile range: 5-8) and 3 (interquartile range: 2-4), respectively. Knowledge was negatively associated with compliance barriers (r = -0.437, p < .01). The results of the multiple linear regression analysis showed that hospital level, age, nurses' attendance at VAP training and years of experience in ICUs were related to the level of knowledge. Nurses' attendance at VAP training, age and years of experience in ICUs were associated with the level of compliance barriers. CONCLUSIONS: Intensive care nurses have satisfactory knowledge of EBGs for preventing VAP, but compliance barriers can be reduced. Better knowledge helps reduce the barriers to compliance among nurses. RELEVANCE TO CLINICAL PRACTICE: Nurse managers and nurse educators are suggested to examine nurses' knowledge and compliance barriers to EBGs for preventing VAP, develop personalized training plans, promote continuous education based on the latest EBGs and raise the nurse-patient ratio reasonably.

Bacterial co-infection in COVID-19: a call to stay vigilant.

Co-infection with diverse bacteria is commonly seen in patients infected with the novel coronavirus, SARS-CoV-2. This type of co-infection significantly impacts the occurrence and development of novel coronavirus infection. Bacterial co-pathogens are typically identified in the respiratory system and blood culture, which complicates the diagnosis, treatment, and prognosis of COVID-19, and even exacerbates the severity of disease symptoms and increases mortality rates. However, the status and impact of bacterial co-infections during the COVID-19 pandemic have not been properly studied. Recently, the amount of literature on the co-infection of SARS-CoV-2 and bacteria has gradually increased, enabling a comprehensive discussion on this type of co-infection. In this study, we focus on bacterial infections in the respiratory system and blood of patients with COVID-19 because these infection types significantly affect the severity and mortality of COVID-19. Furthermore, the progression of COVID-19 has markedly elevated the antimicrobial resistance among specific bacteria, such as Klebsiella pneumoniae, in clinical settings including intensive care units (ICUs). Grasping these resistance patterns is pivotal for the optimal utilization and stewardship of antibiotics, including fluoroquinolones. Our study offers insights into these aspects and serves as a fundamental basis for devising effective therapeutic strategies. We primarily sourced our articles from PubMed, ScienceDirect, Scopus, and Google Scholar. We queried these databases using specific search terms related to COVID-19 and its co-infections with bacteria or fungi, and selectively chose relevant articles for inclusion in our review.

Prevalence and etiology of ventilator-associated pneumonia during the COVID-19 pandemic in Denmark: Wave-dependent lessons learned from a mixed-ICU.

BACKGROUND: Ventilator-associated pneumonia (VAP) may be a particular concern in patients with severe coronavirus disease 2019 (COVID-19). We aimed to determine the prevalence and etiology of VAP in critically ill COVID-19 patients in a Danish intensive care unit (ICU) during the first three waves of the COVID-19 pandemic and to study associations between dexamethasone (DXM) use and development of VAP. METHODS: In an observational single-center study patients were retrospectively screened for VAP including causative pathogens, use of DXM and commonly used antibiotics. Diagnosis of VAP required invasive mechanical ventilation (IMV) >48 h with presence of a new bacterial agent and clinical signs of infection. For analysis, common descriptive statistics were applied. Cox proportional hazards models were used to analyze the association between DXM use and VAP. RESULTS: VAP was detected in 53/119 (44.5%) mechanically ventilated patients across all three COVID-19 waves. Median length of IMV for VAP patients was 24 [15-41] days, and 3 out of 4 were males. VAP was most prevalent (47.0%) during the second wave. Common pathogens included Klebsiella pneumoniae (24.5%), Enterobacter aerogenes (17.0%) and Pseudomonas aeruginosa (13.2%), Staphylococcus aureus (13.2%), and Escherichia coli (13.2%). A change from Gram-negative bacteria only to a combination of Gram-positive and Gram-negative bacteria was observed in the second wave compared to first. Use of DXM was not associated with VAP (adjusted hazard ratio 1.63 95% CI: 0.84-3.17). CONCLUSION: The prevalence of VAP was high across all three COVID-19 waves and showed a different distribution of pathogens between the first and second wave. Use of DXM was not associated with VAP development. Further and larger studies are needed to understand the risk factors associated with VAP in patients with COVID-19.

Predictive values of serum amyloid A, toll-like receptor 4, and sTREM-1 for ventilator-associated pneumonia in elderly patients undergoing abdominal surgery with tracheal intubation and general anesthesia.

OBJECTIVES: This study aimed to conduct a retrospective study to identify inflammatory biomarkers for predicting ventilator-associated pneumonia in elderly patients. METHODS: Our retrospective study included 265 elderly patients (age ≥60 years) undergoing abdominal surgery with tracheal intubation and general anesthesia, with 93 experiencing varying degrees of ventilator-associated pneumonia during hospitalization, and 172 without. Serum concentrations of serum amyloid A (SAA), toll-like receptor 4 (TLR4), and soluble myeloid triggering receptor 1 (sTREM-1) were measured at 24 h post-operation using enzyme-linked immunosorbent assay. Comparisons of SAA, TLR4, and sTREM-1 and other risk factors at 24 h post-operation between elderly patients with and without ventilator-associated pneumonia were performed. RESULTS: The study revealed a 35.1% incidence of postoperative ventilator-associated pneumonia among elderly patients. Upregulations of SAA, TLR4, and sTREM-1 were observed in patients with ventilator-associated pneumonia. Chronic obstructive pulmonary disease, smoking, and tracheal intubation were identified as independent risk factors. The joint prediction model was demonstrated with superior predictive accuracy (area under the curve = 0.89) compared to individual biomarkers. Correlations with procalcitonin further supported the predictive potential of SAA, TLR4, and sTREM-1 in an inflammatory response. CONCLUSIONS: SAA, TLR4, and sTREM-1, particularly when combined, serve as valuable prognostic indicators for postoperative ventilator-associated pneumonia in elderly patients undergoing abdominal surgery with tracheal intubation and general anesthesia. The joint prediction model offered a promising tool for early risk assessment.

Specialized nursing intervention on critically ill patient in the prevention of intubation-associated pneumonia: an integrative literature review.

Healthcare-associated infections are adverse events that affect people in critical condition, especially when hospitalized in an intensive care unit. The most prevalent is intubation-associated pneumonia (IAP), a nursing-care-sensitive area. This review aims to identify and analyze nursing interventions for preventing IAP. An integrative literature review was done using the Medline, CINAHL, Scopus and PubMed databases. After checking the eligibility of the studies and using Rayyan software, ten final documents were obtained for extraction and analysis. The results obtained suggest that the nursing interventions identified for the prevention of IAP are elevating the headboard to 30º; washing the teeth, mouth and mucous membranes with a toothbrush and then instilling chlorohexidine 0.12%-0.2% every 8/8 hr; monitoring the cuff pressure of the endotracheal tube (ETT) between 20-30 mm Hg; daily assessment of the need for sedation and ventilatory weaning and the use of ETT with drainage of subglottic secretions. The multimodal nursing interventions identified enable health gains to be made in preventing or reducing IAP. This area is sensitive to nursing care, positively impacting the patient, family, and organizations. Future research is suggested into the effectiveness of chlorohexidine compared to other oral hygiene products, as well as studies into the mortality rate associated with IAP, with and without ETT for subglottic aspiration.

Comparative analysis of open and closed tracheal suction systems on mechanical ventilation efficiency in adults: A systematic review and meta-analysis.

BACKGROUND: There are two types of suction methods used clinically: closed tracheal suction system (CTSS) and open tracheal suction system (OTSS). However, the safety and efficacy of these two suction systems for patients remain to be analysed. OBJECTIVE: The objective of this study was to assess the safety and efficacy of OTSSs and CTSSs in adult mechanical ventilation. METHODS: Computer searches were conducted on PubMed, Web of science, MEDLINE, CINAHL, and Cochrane Library databases. The search spanned from the inception of each database to December 2023. Two researchers independently reviewed and extracted data from the literature. Quality assessment was performed using the Cochrane Manual of Systematic Reviews, and meta-analysis was conducted using RevMan 5.3 software. RESULTS: A total of 13 articles, involving 2822 patients, were included in the analysis. The meta-analysis showed that the CTSS could reduce the incidence of ventilator-associated pneumonia (odds ratio [OR] = 0.77, 95% confidence interval [CI]: [0.61, 0.98], P = 0.03). However, no significant difference existed in the microbial colonisation rate in the respiratory tract (OR = 1.40, 95% CI: [0.91, 2.15], P = 0.13), mechanical ventilation time (mean difference = -0.33, 95% CI: [-1.43, 0.78], P = 0.56), length of intensive care unit stay (mean difference = 0.23, 95% CI: [-0.90, 1.35], P = 0.69), and mortality (OR = 1.01, 95% CI: [0.84, 1.22], P = 0.89). CONCLUSION: In comparison to the OTSS, the CTSS proves effective in reducing the incidence of ventilator-associated pneumonia. However, additional high-quality evidence is needed to evaluate respiratory microbial colonisation rates, the duration of mechanical ventilation, length of intensive care unit stay, and mortality.

'Effectiveness of various sulbactam-based combination antibiotic therapy in the management of ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii in a tertiary care Health centre'.

OBJECTIVE: Carbapenem-resistant Acinetobacter baumannii (CRAB) is a common cause of ventilator-associated pneumonia (VAP). Some in vitro data favour various combination antibiotic therapy. However, there is a need for more in vivo studies for the management of VAP caused by CRAB. This retrospective study was done to evaluate the effectiveness of various combination antibiotic therapy including sulbactam on outcomes of VAP caused by CRAB. METHODS: Adult patients (age ≥18 years) diagnosed with VAP caused by CRAB were included. Patients with polymicrobial infections were excluded from the study. Patients with CRAB associated VAP who were given sulbactam based antibiotic combinations were observed for outcomes. The primary outcome was 28-day mortality after diagnosis of VAP caused by CRAB. Reduction in serum HsCRP (High sensitivity C-reactive protein) during treatment and requirement of inotropes were the secondary outcomes. Outcomes were compared between various sulbactam based antibiotic combination therapies. RESULTS: A total of 103 patients were included. A total of 44 (42.7 %) patients received sulbactam and minocycline or sulbactam and polymyxin B dual antibiotic combination, and 59 (57.3 %) patients received sulbactam, polymyxin B and minocycline triple antibiotic combination. The percentage difference in 28 days mortality was 27.51 % (95 % CI 8.03 %-44.06 %; p = 0.005) in dual vs triple sulbactam based antibiotic combination therapy. The percentage difference in requirement of inotropes during therapy and HsCRP reduction after 7 days of therapy was 23.65 % (95 % CI 6.43 %-38.3 %; p = 0.007) and 25.1 % (95%CI 10.1 %-38.2 %; p < 0.001) respectively when compared between dual vs triple sulbactam based antibiotic combination therapy. CONCLUSION: Treatment with sulbactam, polymyxin B and minocycline combination antibiotic therapy was associated with significantly lower 28-day mortality. Moreover, the lower requirement of inotropes during treatment and a significant reduction in HsCRP level favours this combination antibiotic therapy in VAP caused by CRAB.

Prevention of ventilator-associated pneumonia by metal-coated endotracheal tubes: a meta-analysis.

PURPOSE: This study aimed to evaluate whether endotracheal tubes (ETTs) with a metal coating reduce the incidence of ventilator-associated pneumonia (VAP) compared to uncoated ETTs. METHODS: An extensive literature review was conducted to find studies that compared metal-coated ETT with uncoated ETT across four databases: PubMed, Embase, Cochrane Library, and Web of Science. The search parameters were set from the inception of each database until June 2024. The primary outcome measures were the rates of VAP and hospital mortality. Two independent researchers carried out the literature selection, data extraction, and quality evaluation. Data analysis was performed with RevMan 5.4.1. Furthermore, a Deeks funnel plot was used to evaluate potential publication bias in the studies included. RESULTS: Following the screening process, five randomized controlled trials (RCTs) encompassing a total of 2157 patients were identified. In terms of the primary outcome, the VAP incidence was found to be lower in the group utilizing metal-coated ETT compared to those with uncoated ETT, demonstrating a statistically significant difference [RR = 0.71, 95% CI (0.54-0.95), P = 0.02]. No notable difference in mortality rates was observed between the two groups [RR = 1.05, 95% CI (0.86-1.27), P = 0.65]. Concerning secondary outcomes, two studies were evaluated to compare the mechanical ventilation duration (RR = 0.60, 95% CI (- 0.52, 1.72), P = 0.29, I2 = 97%) and intensive care unit (ICU) stay for both patient groups (RR = 0.47, 95% CI (- 1.02, 1.95), P = 0.54, I2 = 50%). Due to the marked heterogeneity, a comparison of mechanical ventilation length between the two patient groups was not feasible. However, both studies suggested no significant difference in ventilation duration between patients using metal-coated ETT and those with uncoated ETT. CONCLUSIONS: Metal-coated ETT show a lower occurrence of VAP compared to the uncoated ETT. Nevertheless, they do not considerably decrease the length of mechanical ventilation, the duration of ICU admission, nor do they reduce hospital mortality rates. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/prospero/ , identifier CRD42024560618.

The preventive effect of inhaled antibiotic against ventilator-associated pneumonia: A systematic review and meta-analysis.

BACKGROUND: Ventilator-associated pneumonia (VAP) constitutes a considerable challenge for patients in intensive care units (ICUs) and necessitates the development of effective preventive strategies. This study aimed to evaluate the clinical efficacy of inhaled antibiotics for preventing VAP. METHODS: PubMed, Embase, and ClinicalTrials.gov were searched until 21 January 2024. Randomized controlled trials investigating the clinical efficacy of inhaled antibiotics for VAP prevention were included. RESULTS: Seven randomized controlled trials, involving 1465 patients, of whom 734 were classified as the study group receiving inhaled antibiotics and 731 as the control group receiving placebo were included in this meta-analysis. Overall, the occurrence of VAP was significantly lower in the study group than in the control group (risk ratio, 0.69; 95% confidence interval [CI], 0.51-0.92). However, there were no significant differences in mortality (risk ratio, 0.90; 95% CI, 0.74-1.09), length of stay in ICU (mean difference [MD], 0.10 d; 95% CI, -0.91 to 1.1), and hospital (MD, 0.30 d; 95% CI, -1.82 to 2.43), and mechanical ventilation duration (MD, 0.45 d; 95% CI, -0.45 to 1.35) between groups. CONCLUSIONS: Inhaled antibiotics hold promise for mitigating the risk of VAP among critically ill patients. However, their impact on mortality, length of stay in ICU and hospital, and mechanical ventilation duration was not statistically significant.

Metagenomics in the Diagnosis of Pneumonia: Protocol for a Systematic Review.

BACKGROUND: Causative pathogens are currently identified in only a minority of pneumonia cases, which affects antimicrobial stewardship. Metagenomic next-generation sequencing (mNGS) has potential to enhance pathogen detection due to its sensitivity and broad applicability. However, while studies have shown improved sensitivity compared with conventional microbiological methods for pneumonia diagnosis, it remains unclear whether this can translate into clinical benefit. Most existing studies focus on patients who are ventilated, readily allowing for analysis of bronchoalveolar lavage fluid (BALF). The impact of sample type on the use of metagenomic analysis remains poorly defined. Similarly, previous studies rarely differentiate between the types of pneumonia involved-community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), or ventilator-associated pneumonia (VAP)-which have different clinical profiles. OBJECTIVE: This study aims to determine the clinical use of mNGS in CAP, HAP, and VAP, compared with traditional microbiological methods. METHODS: We aim to review all studies (excluding case reports of a series of fewer than 10 people) of adult patients with suspected or confirmed pneumonia that compare metagenomic analysis with traditional microbiology techniques, including culture, antigen-based testing, and polymerase chain reaction-based assays. Relevant studies will be identified through systematic searches of the Embase, MEDLINE, Scopus, and Cochrane CENTRAL databases. Screening of titles, abstracts, and subsequent review of eligible full texts will be done by 2 separate reviewers (SQ and 1 of AL, CJ, or CH), with a third clinician (ES) providing adjudication in case of disagreement. Our focus is on the clinical use of metagenomics for patients with CAP, HAP, and VAP. Data extracted will focus on clinically important outcomes-pathogen positivity rate, laboratory turnaround time, impact on clinical decision-making, length of stay, and 30-day mortality. Subgroup analyses will be performed based on the type of pneumonia (CAP, HAP, or VAP) and sample type used. The risk of bias will be assessed using the QUADAS-2 tool for diagnostic accuracy studies. Outcome data will be combined in a random-effects meta-analysis, and where this is not possible, a narrative synthesis will be undertaken. RESULTS: The searches were completed with the assistance of a medical librarian on January 13, 2024, returning 5750 records. Screening and data extraction are anticipated to be completed by September 2024. CONCLUSIONS: Despite significant promise, the impact of metagenomic analysis on clinical pathways remains unclear. Furthermore, it is unclear whether the use of this technique will alter depending on whether the pneumonia is a CAP, HAP, or VAP or the sample type that is collected. This systematic review will assess the current evidence base to support the benefit of clinical outcomes for metagenomic analysis, depending on the setting of pneumonia diagnosis or specimen type used. It will identify areas where further research is needed to advance this methodology into routine care. TRIAL REGISTRATION: PROSPERO CRD42023488096; https://tinyurl.com/3suy7cma. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57334.

Impact of head-of-bed elevation angle on the development of pressure ulcers and pneumonia in patients on mechanical ventilation: a systematic review and meta-analysis.

BACKGROUND: Mechanical ventilation is crucial for patient management in intensive care units, but it comes with complications such as pressure ulcers and ventilator-associated pneumonia (VAP). The impact of head-of-bed elevation angles on these complications remains a critical area for investigation. METHODS: This systematic review and meta-analysis followed PRISMA guidelines and involved searches across PubMed, Embase, Web of Science, and Cochrane Library, conducted on September 19, 2023, with no date or language restrictions. We included randomized controlled trials that compared different head-of-bed elevation angles in adult ICU patients on mechanical ventilation. Data were extracted on study characteristics, quality assessed using the Cochrane risk of bias tool, and statistical analyses performed using chi-square tests for heterogeneity and fixed or random-effects models based on heterogeneity results. RESULTS: Six studies met inclusion criteria out of an initial 601 articles. These studies showed minimal heterogeneity (I2 = 0.0% for pressure ulcers, p = 0.930; and for VAP, p = 0.797), supporting the use of fixed-effect models. Results indicated that a higher elevation angle (45°) significantly increased the risk of pressure ulcers (OR = 1.95, 95% CI: 1.12-3.37, p < 0.05) and decreased the incidence of VAP compared to a lower angle (30°) (OR = 0.51, 95% CI: 0.31-0.84, p < 0.05). CONCLUSIONS: While higher head-of-bed elevation can reduce the risk of VAP in mechanically ventilated patients, it may increase the risk of pressure ulcers. Clinical strategies should carefully balance these outcomes to optimize patient care in ICU settings. REGISTRATION: PROSPERO 2024 CRD42024570232.

Principais intervenções de enfermagem na prevenção da pneumonia associada à ventilação mecânica: revisão integrativa / Main nursing interventions in the prevention of ventilador-associated pneumonia: integrative review / Principales intervenciones de enfermería en la prevención de la neumonía asociada a ventilación mecánica: revisión integrativa

Introdução: a Pneumonia Associada à Ventilação Mecânica é a mais importante e comum infecção que acomete os pacientes em ventilação mecânica. Além disso, é considerada um grave problema de saúde hospitalar, com preocupantestaxas de morbimortalidade.Objetivo: investigar na literatura quais as principais ações de enfermagem para a prevenção da Pneumonia Associada à Ventilação Mecânica. Metodologia:trata-se de um estudo do tipo revisão integrativa da literatura. Após utilizar a estratégia PICO, definiu-se a seguinte pergunta norteadora: "Quais as principais intervenções de enfermagem para a prevenção da Pneumonia Associada à Ventilação Mecânica?". Com a leitura e aplicação dos critérios de seleção, foram utilizados nove artigos. Resultados:as principais intervenções de enfermagem descritas foram elevação da cabeceira entre 30-45 graus, manter pressão do cuff entre 20 e 30 cmH2O, higienização oral com clorexidina 0,12%, higienização das mãos, aspiração de secreções e interrupção diária da sedação. Com relação à adesão dos profissionais, a maioria das intervenções atingiram de 50% a 70% de adesão.Conclusão:as principais medidas preventivas constantes na literatura são utilizadas na prática clínica pelos enfermeiros, e estes demonstram boa adesão sobre os cuidados imprescindíveis para a prevenção da Pneumonia Associada à Ventilação Mecânica (AU).

Introduction:Ventilator-AssociatedPneumoniais the most important and common infection that affects patients on mechanical ventilation. Furthermore, it is considered a serious hospital health problem,with worrying morbidity and mortality rates.Objective:to investigate in the literature which are the main nursing actions for the prevention of Ventilator-Associated Pneumonia. Methodology:this is an integrative literature review study. After using the PICO strategy, the following guiding questionwas defined: "What are the main nursing interventions for preventingVentilator-Associated Pneumonia?". After reading and applying the selection criteria, nine articles were used. Results:the main nursing interventions described were elevation of the headboardbetween 30-45 degrees, maintaining cuff pressure between 20 and 30 cmH2O, oral hygiene with 0.12%chlorhexidine, hand hygiene, suctionof secretions and daily interruption of sedation. Regarding professional adherence, most interventions reached 50% to 70% adherence. Conclusion:the main preventive measures listed in the literature are used in clinical practice by nurses,and they demonstrate good adherence to essential care for the prevention of Ventilator-Associated Pneumonia (AU).

Introducción:la Neumonía Asociada a Ventilación Mecánica es la infección más importante y común que afecta a los pacientes que recibenventilación mecánica. Asimismo, se considera un grave problema de salud hospitalaria,con preocupantes tasas de morbimortalidad.Objetivo: investigar en la literatura cuáles son las principales acciones de enfermería para la prevención de la Neumonía Asociada a Ventilación Mecánica. Metodología:se trata de un estudio de revisión integrativade la literatura. Después de utilizar la estrategia PICO, se definió la siguiente pregunta orientadora: "¿Cuáles son las principales intervenciones de enfermería para la prevención de la Neumonía Asociada a Ventilación Mecánica?".Luegode la lectura y aplicación de los criterios de selección, se utilizaron nueve artículos. Resultados:las principales intervenciones de enfermería descritas fueron elevarla cabeceraentre 30-45 grados, mantenerla presión del manguito entre 20 y 30 cmH2O, higiene bucal conclorhexidina al 0,12%, higiene de manos, aspiración de secreciones e interrupción diaria de la sedación.En cuanto a la adherencia profesional, la mayoría de las intervenciones alcanzaron entre un 50% y un70% de adherencia. Conclusión:las principales medidas preventivas contenidas en la literatura son utilizadas en la práctica clínica por los enfermeros,y muestran una buena adherencia a los cuidados esenciales para la prevención de la Neumonía Asociada a Ventilación Mecánica (AU).

Role of bronchoscopy in the management of patients with suspected or suffering from ventilator-associated pneumonia: A meta-analysis.

Background: The utility of bronchoscopy in the treatment of patients with ventilator-associated pneumonia (VAP) has been proposed, although prior research has yielded inconclusive findings. This systematic review and meta-analysis were conducted to examine the impact of bronchoscopy on mortality rates, duration of mechanical ventilation (MV), and length of stay in the intensive care unit (ICU) among patients with VAP. Methods: Relevant randomized controlled trials (RCTs) and cohort studies were acquired by conducting a comprehensive search in the PubMed, Embase, and Cochrane Library databases. To account for the potential heterogeneity, a random-effects model was utilized to combine the findings and incorporate its potential influence. Results: Eight RCTs and three cohort studies, including 3907 patients with highly suspected or clinically diagnosed VAP, were included. Compared to the controls, bronchoscopy use was not associated with a significant effect on all-cause mortality (relative risk [RR]: 0.81, 95 % confidence interval [CI]: 0.62 to 1.05, p = 0.12; I2 = 57 %). Subgroup analysis showed that bronchoscopy used for the microbiological diagnosis of VAP was not associated with reduced mortality (RR: 0.92, 95 % CI: 0.75 to 1.13), while therapeutic bronchoscopy use was associated with significantly reduced mortality (RR: 0.53, 95 % CI: 0.35 to 0.81). The duration of MV or length of ICU stay was not significantly different between groups. Conclusions: Bronchoscopy use for the purpose of the microbiological diagnosis of VAP did not reduce short-term mortality compared to diagnosis without bronchoscopy use, while therapeutic bronchoscopy use was associated with reduced mortality in these patients.