Characterization of post-surgical critical patients with infections associated with healthcare after prolonged perfusion of remifentanil

SUMMARY INTRODUCTION Healthcare associated infections (HAI) are the most frequent complication of hospitalized patients. The aim of this study was to describe the clinical and epidemiological characteristics of critically ill post-surgical patients with a diagnosis of healthcare associated infections, after a pattern of sedoanalgesia of at least 4 days. METHODS All patients over 18 years of age with a unit admission of more than 4 days were consecutively selected. The study population was the one affected by surgical pathology where sedation was based as analgesic the opioid remifentanil for at least 96 hours in continuous perfusion. Patients who died during admission to the unit and those with combined analgesia (peripheral or neuroaxial blocks) were excluded. Data analysis was performed using the statistical package Stata version 7.0. RESULTS The patients admitted to the Post-Surgical Critical Care Unit (PCU) during study were 1789 and the population eligible was comprised of 102 patients. 56.86% of patients suffered IACS. The most frequent IACS was pneumonia associated with mechanical ventilation (30.96 per 1000 days of mechanical ventilation), Pseudomonas aeruginosa being the most frequently isolated germ. The germs with the greatest involvement in multiple drug resistance (MDROs) were enterobacteria, mainly Klebsiella pneumoniae resistant to extended-spectrum beta-lactamases (ESBL). CONCLUSIONS Pneumonia associated with mechanical ventilation is the most prevalent HAI and Pseudomonas aeruginosa is the main etiological agent. The groups of antibiotics most frequently used were cephalosporin and aminoglycosides. It is necessary to implement the prevention strategies of the different HAI, since most of them are avoidable.

RESUMO INTRODUCCIÓN Las infecciones asociadas a cuidados de salud (IACS) constituyen la complicación más frecuente de los pacientes hospitalizados. El objetivo de este estudio es describir las características clínicas y epidemiológicas de los pacientes críticos postquirúrgicos con diagnóstico de infección asociada a cuidados de salud, tras una pauta de sedoanalegia de al menos 4 días. MÉTODOS Se seleccionaron de manera consecutiva todos los pacientes mayores de 18 años con un ingreso en la Unidad de Reanimación Postquirúrgica (URP) superior a 4 días. La población de estudio fue aquella afectada por patología quirúrgica de cualquier origen donde la sedación se basó en cualquier hipnótico y como analgésico el opioide remifentanilo durante al menos 96 horas en perfusión continua. Se excluyeron los pacientes que fallecieron durante su ingreso en la unidad y aquellos pacientes con analgesia combinada (bloqueos periféricos o neuroaxiales). El análisis de los datos se realizó con paquete estadístico Stata versión 7.0. RESULTADOS El número de pacientes que ingresaron en la URP durante el periodo de estudio fueron de 1789. Tras aplicar los criterios de inclusión y exclusión, la población elegible quedó constituida por 102 pacientes. Un 56,86% de pacientes padecieron IACS. La IACS más frecuente fue la neumonía asociada a ventilación mecánica (30,96 por 1000 días de ventilación mecánica) siendo Pseudomona aeruginosa el germen más frecuentemente aislado. Los gérmenes con mayor implicación en las multirresistencias (MDROs) fueron las enterobacterias, principalmente Klebsiella pneumoniae resistente a betalactamasas de espectro extendido (BLEE). CONCLUSIONES La neumonía asociada a ventilación mecánica es la IACS más prevalente y Pseudomona aeruginosa es el principal agente etiológico. Los grupos de antibióticos más frecuentemente empleados fueron cefalosporinas y aminoglucósidos. Es necesario implementar las estrategias de prevención de las distintas IACS, ya que la mayoría de ellas son evitables.

Risk factors for early-onset ventilator-associated pneumonia in aneurysmal subarachnoid hemorrhage patients

This study aimed to investigate the risk factors related to ventilator-acquired pneumonia (VAP) in aneurysmal subarachnoid hemorrhage (SAH) patients. From January 2011 to December 2015, a single-center retrospective study including 200 SAH patients requiring mechanical ventilation (MV) ≥48 h was performed. The clinical data of these patients were collected and analyzed. The age range of the patients were 41-63 and 72 (36%) were male. The Glasgow coma scale score range was 5-15 and the Simplified Acute Physiology Score II range was 31-52. One hundred and forty-eight (74%) patients had a World Federation of Neurosurgeons (WNFS) score ≥III. Aneurysm was secured with an endovascular coiling procedure in 168 (84%) patients and 94 (47%) patients presented VAP. Male gender (OR=2.25, 95%CI=1.15-4.45), use of mannitol (OR=3.02, 95%CI=1.53-5.94) and enteral feeding above 20 kcal·kg−1·day−1 (OR=2.90, 95%CI=1.26-6.67) after day 7 were independent factors for VAP. Patients with early-onset VAP had a longer duration of sedation (P=0.03), MV (P=0.001) and ICU length of stay (P=0.003) and a worse Glasgow Outcome Scale score (P<0.001), but did not have a higher death rate.

Risk factors for mortality in patients with ventilator-associated pneumonia caused by carbapenem-resistant Enterobacteriaceae

Abstract Background: The ideal therapeutic option for ventilator associated pneumonia caused by carbapenem-resistant Enterobacteriaceae is not defined. The aim of this study was to assess mortality-associated risk factors in patients with VAP by CRE and determine the outcome of several treatment options. Methods: This was a retrospective study performed in two tertiary hospitals involving patients with VAP caused by CRE between January 2010 and August 2014. The outcomes were mortality within 30 days of VAP diagnosis and overall mortality during hospital admission. Risk factors for mortality were assessed by comparing variables of survivors and non-survivors. Results: One hundred and twelve patients with CRE-VAP were included, 73 (65%) male, median age 56 years. The 30-day mortality was 57.1% and the overall hospital mortality was 67%. In the binary logistic regression analysis, only age >50 years was independently associated to increased mortality. Polymyxin was the most used drug (47.5%), followed by tigecycline (29.2%) and aminoglycosides (2.4%). Combined therapy with two active drugs was used by 17 patients (20.8%). No therapeutic option was independently associated to survival. However, combined therapy with two active drugs was superior to the therapy with a single active drug when inappropriate therapy was the comparator (p = 0.044). The addition of carbapenem was not associated with increased survival. Conclusion: The best therapeutic option for VAP by CRE is still not completely defined, but the therapy with at least two active drugs was superior in this study.

Pneumonia associada à ventilação mecânica: epidemiologia e impacto na evolução clínica de pacientes em uma unidade de terapia intensiva / Ventilator-associated pneumonia: epidemiology and impact on the clinical evolution of ICU patients

OBJETIVO: Apesar de representar uma das principais causas de infecção nosocomial, o papel da pneumonia associada à ventilação mecânica (PAVM) no prognóstico ainda permanece indefinido. O objetivo deste estudo foi avaliar o impacto dessa doença na evolução clínica dos pacientes. MÉTODOS: Estabeleceu-se uma coorte prospectiva de 233 pacientes sob ventilação mecânica (grupo PAV, n = 64; grupo controle, n = 169). Os desfechos primários foram tempo de ventilação mecânica (TVM), tempo de permanência na UTI (TUTI), tempo de permanência hospitalar (TH) e mortalidade na UTI. Os desfechos secundários foram mortalidade hospitalar, perfil microbiológico, uso prévio de antibióticos e fatores de risco para PAVM. RESULTADOS: Os desfechos dos grupos controle e PAVM foram, respectivamente, os seguintes: mediana do TVM (dias), 9 (intervalo interquartílico [II]: 5-15) e 23 (II: 15-37; p < 0,0001); mediana do TUTI (dias), 12 (II: 8-21) e 27 (II: 17-42; p < 0,0001); mediana do TH (dias), 33 (II: 18-64) e 46 (II: 25-90; p = 0,02); e mortalidade na UTI, 38 por cento (IC95 por cento: 31-45) e 55 por cento (IC95 por cento: 42-67; p = 0,02). A PAVM foi um preditor de mortalidade na UTI (OR = 3,40; IC95 por cento: 1,54-1,78). O TVM (OR = 2,27; IC95 por cento: 1,05-4,87) e o uso prévio de antibióticos (OR = 1,07; IC95 por cento: 1,04-1,10) foram fatores de risco para PAVM. A PAVM não afetou a mortalidade hospitalar. Acinetobacter spp. foi o isolado mais frequente (28 por cento). Antibioticoterapia empírica inadequada foi administrada em 48 por cento dos casos. CONCLUSÕES: No presente estudo, houve uma alta incidência de bactérias resistentes e de antibioticoterapia inicial inadequada. TVM longo e o uso prévio de antibióticos são fatores de risco para PAVM.

OBJECTIVE: Although ventilator-associated pneumonia (VAP) is a major cause of nosocomial infection, its role in the prognosis of patients remains undefined. The objective of this study was to evaluate the impact of VAP on the clinical evolution of patients. METHODS: This was a prospective cohort study involving 233 patients on mechanical ventilation (VAP group, n = 64; control group, n = 169). Primary outcomes were time on mechanical ventilation (TMV), time in ICU (TICU), overall length of hospital stay (LHS) and in-ICU mortality. Secondary outcomes were in-hospital mortality, microbiological profile, prior use of antibiotics and risk factors for VAP acquisition. RESULTS: Control and VAP group outcomes were, respectively, as follows: median TMV (days), 9 (interquartile range [IQR]: 5-15) and 23 (IQR: 15-37; p < 0.0001); median TICU (days), 12 (IQR: 8-21) and 27 (IQR: 17-42; p < 0.0001); median LHS (days), 33 (IQR: 18-64) and 46 (IQR: 25-90; p = 0.05); and in-ICU mortality, 38 percent (95 percent CI: 31-45) and 55 percent (95 percent CI: 42-67; p = 0.02). VAP was a predictor of in-ICU mortality (OR = 3.40; 95 percent CI: 1.54-7.48). TMV (OR = 2.27; 95 percent CI: 1.05-4.87) and prior use of antibiotics (OR = 1.07; 95 percent CI: 1.04-1.10) were risk factors for VAP. VAP did not affect in-hospital mortality. Acinetobacter spp. was the most common isolate (28 percent). Inappropriate empirical antibiotic therapy was administered in 48 percent of cases. CONCLUSIONS: In this study, there was a high incidence of infection with resistant bacteria and inappropriate initial antibiotic therapy. Long TMV and prior use of antibiotics are risk factors for VAP.

Ventilator-associated pneumonia in an adult clinical-surgical intensive care unit of a Brazilian university hospital: incidence, risk factors, etiology, and antibiotic resistance

The objective of this study was to evaluate clinical characteristics, etiology, and resistance to antimicrobial agents, among patients with ventilator-associated pneumonia (VAP). A case study vs. patients control under mechanical ventilation and hospitalized into clinical-surgical adults ICU of HC-UFU was performed from March/2005 to March/2006. Patients under ventilation for over 48 h were included in the study including 84 with diagnosis of VAP, and 191 without VAP (control group). Laboratory diagnosis was carried out through quantitative microbiological evaluation of tracheal aspirate. The identification of pathogens was performed by classical microbiological tests, and the antibiotics sensitivity spectrum was determined through the CLSI technique. VAP incidence rate over 1,000 days of ventilation was 24.59. The mean (± SD) duration of mechanical ventilation prior to VAP diagnosis was 23.2 ± 17.2 days. By multivariate analysis the risk factors predisposing for VAP were: mechanical ventilation time and mechanical ventilation > seven days, tracheostomy and use of > three antibiotics. Mortality rate was high (32.1 percent) but lower than that of the control group (46.5 percent). Major pathogens were identified in most of patients (95.2 percent) and included: Pseudomonas aeruginosa (29 percent), Staphylococcus aureus (26 percent), Enterobacter/Klebsiella/Serratia (19 percent) and Acinetobacter spp. (18 percent), with expressive frequencies of P. aeruginosa (52 percent), S. aureus (65.4 percent) and Enterobacteriaceae (43.7 percent) resistant to imipenem, oxacillin and 3/4 generation cephalosporins, respectively. In conclusion, our observation showed VAPs caused by multiresistant microorganisms, the prescription of > three antibiotics, and mortality with unacceptably high rates. The practice of de-escalation therapy appears to be urgently needed in order to improve the situation.

Epidemiological and microbiological analysis of ventilator-associated pneumonia patients in a public teaching hospital

Ventilator-associated pneumonia (VAP) is the most commonly-acquired infection in patients in intensive care units. We analyzed epidemiological and microbiological characteristics and the outcome, in a cohort of critically-ill patients with confirmed diagnosis of VAP. All patients who had been on mechanical ventilation (MV) for more than 48 hours were included in our study; material collection for microbiological analysis was done within the first 24 hours after beginning treatment or after changing antibiotics. There were 55/265 (20.7 percent) VAP cases diagnosed, at a rate of 21.6 episodes per 1,000 days of mechanical ventilation. Mean age of the patients was 66 years, with a mean APACHE II score of 26.7 + 7.0; male patients were more prevalent. The mortality rates in the intensive care unit (ICU) and during the hospital stay were 71 percent and 80 percent, respectively. MV duration in patients with VAP was 17 (range 3-43) days and among patients who had not developed VAP, 6 (2-32) days (p < 0.0001). 98.2 percent of the samples were positive, with a high prevalence of Gram-negative bacteria, mainly Acinetobacter calcoaceticus. Risk factors for death included age, MV duration and surgery. VAP incidence in this sample of critically-ill patients was high, with a high mortality rate. Control and prevention strategies based on continuing education of healthcare workers, developed by a multidisciplinary team, should be encouraged to minimize morbimortality of this infection.

Etiología de la neumonía asociada a ventilación mecánica en un hospital clínico: Asociación con co-morbilidad, uso previo de antimicrobianos y mortalidad / Etiology of ventilator-associated pneumonia in a university hospital: Association with comorbidity, previous use of antibiotics and mortality

Ventilator-associated pneumonia (VAP) is a complication with an increased risk of morbidity and mortality. Inadequate antibiotic treatment is a risk factor of mortality which can be improved. For this reason it is important to know the local etiology of VAP. During a one year-period we investigated the etiology of VAP in a teaching hospital. Forty eight VAP were included, of which 19 were women. The median age was 59.5 (range 17-91 years), twelve VAP were early onset. Methicillin resistant Staphylococcus aureus (MRSA) was the main microorganism isolated, regardless of timing of diagnosis of VAP, followed by polimicrobial etiology, Acinetobacter sp and P. aeruginosa. Etiology was not associated with comorbidity; however previous antibiotic use was related with MRSA and polymicrobial etiology. Mortality was 35 percent and was mainly associated with P. aeruginosa isolation. Conclusion: MRSA was the main cause of VAP regardless of the timing of its occurrence.

La neumonía asociada a la ventilación mecánica (NAVM) es una complicación relacionada con un aumento de morbilidad y mortalidad. Dentro de los factores de mal pronóstico, el tratamiento antimicrobiano inadecuado es una de las variables que puede corregirse. Para esto debe conocerse la etiología institucional de la NAVM. Durante un año se recopilaron las NAVM con documentación microbiológica en un hospital universitario. En total, 48 neumonías fueron incluidas, 19 en pacientes femeninas, la mediana de la edad fue de 59,5 años (rango 17-91), 12 de ellas precoces. Staphylococcus aureus meticilina resistente (MRSA) fue el principal agente involucrado, independiente del momento de su génesis, seguido por la etiología polimicrobiana, Acinetobacter sp y Pseudomonas aeruginosa, en ese orden. La etiología no se asoció con la existencia de co-morbilidad, el uso previo de antimicrobianos se asoció con la presencia de MRSA y etiología polimicrobiana. La letalidad fue de 35 por ciento y se relacionó, principalmente, con la presencia de P. aeruginosa. Conclusión: La principal causa de NAVM en esta experiencia fue SAMR, independiente del momento evolutivo de su ocurrencia.

Prevalência e prognóstico dos pacientes com pneumonia associada à ventilação mecânica em um hospital universitário / Prevalence of ventilator-associated pneumonia in a university hospital and prognosis for the patients affected

OBJETIVO: Determinar prevalência de pneumonia associada à ventilação mecânica em unidade de terapia intensiva, fatores associados e evolução. MÉTODOS: Foram avaliados 278 pacientes sob ventilação mecânica por mais de 24 horas prospectivamente em hospital universitário. RESULTADOS: Desenvolveram a doença 38,1 por cento dos pacientes, 35,7 casos/1.000 dias de ventilação mecânica: 45,3 por cento por bacilos gram negativos, Pseudomonas aeruginosa (22 por cento) o mais comum e 43,4 por cento por germes multi-resistentes. O grupo com pneumonia associada à ventilação mecânica teve maiores tempos de ventilação mecânica, desmame, permanência no hospital e na unidade de terapia intensiva (p < 0,001); atelectasia, síndrome do desconforto respiratório agudo, pneumotórax, sinusite, traqueobronquite e infecção multirresistente foram mais comuns (p < 0,05). Letalidades na unidade de terapia intensiva e no hospital foram semelhantes. Fatores associados à doença (razão de chances; intervalo de confiança 95 por cento): sinusite aguda (38,8; 3,4 - 441), ventilação mecânica >10 dias (7,7; 4,1 - 14,2), imunodepressão (4,3; 1,3 - 14,3), síndrome do desconforto respiratório agudo (3,5; 1,4 - 9,0), atelectasia (3,0; 1,2 - 7,3), parada cardiorrespiratória (0,18; 0,05 - 0,66) e hemorragia digestiva alta (0,07; 0,009 - 0,62]. Fatores associados ao óbito hospitalar: insuficiência renal crônica (26,1; 1,9 - 350,7), admissão prévia na unidade de terapia intensiva (15,6; 1,6 - 152,0), simplified acute physiologic score II > 50 pontos (11,9; 3,4 - 42,0) e idade > 55 anos (4,4; 1,6 - 12,3). CONCLUSÃO: A pneumonia associada à ventilação mecânica aumentou tempos de ventilação mecânica, permanência na unidade de terapia intensiva e no hospital, número de complicações, mas não a letalidade.

OBJECTIVE: To determine the prevalence of ventilator-associated pneumonia in an intensive care unit, as well as to identify related factors and characterize patient evolution. METHODS: This study evaluated 278 patients on mechanical ventilation for more than 24 hours in a university hospital. RESULTS: Ventilator-associated pneumonia developed in 38.1 percent of the patients, translating to 35.7 cases/1000 ventilator-days: 45.3 percent were caused by gram-negative agents (Pseudomonas aeruginosa accounting for 22 percent); and multidrug resistant organisms were identified in 43.4 percent. In the ventilator-associated pneumonia group, time on mechanical ventilation, time to mechanical ventilation weaning, hospital stays and intensive care unit stays were all longer (p < 0.001). In addition, atelectasis, acute respiratory distress syndrome, pneumothorax, sinusitis, tracheobronchitis and infection with multidrug resistant organisms were more common in the ventilator-associated pneumonia group (p < 0.05). Mortality rates in the intensive care unit were comparable to those observed in the hospital infirmary. Associations between ventilator-associated pneumonia and various factors are expressed as odds ratios and 95 percent confidence intervals: acute sinusitis (38.8; 3.4-441); > 10 days on mechanical ventilation (7.7; 4.1-14.2); immunosuppression (4.3; 1.3-14.3); acute respiratory distress syndrome (3.5; 1.4-9.0); atelectasis (3.0; 1.2-7.3); cardiac arrest (0.18; 0.05-0.66); and upper gastrointestinal tract bleeding (0.07; 0.009-0.62). The variables found to be associated with in-hospital death were as follows: chronic renal failure (26.1; 1.9-350.7); previous intensive care unit admission (15.6; 1.6-152.0); simplified acute physiologic score II > 50 (11.9; 3.4-42.0); and age > 55 years (4.4; 1.6-12.3). CONCLUSION: Ventilator-associated pneumonia increased the time on mechanical ventilation and the number of complications, as well as the length...