Prevention of ventilator-associated pneumonia with inhaled antibiotics

The direct delivery of inhaled antibiotics to the respiratory tract has been a subject of enduring interest among medical practitioners and researchers due to the associated favorable pharmacokinetics.This interest has been particularly pronounced in the context of critically illpatients,wherehealthcare-associatedpulmonary infections represent a significant challenge,driving continued exploration of inhaled antibiotics for intubated patients.Recent high-level evidence has shown a very promising application in the field of ventilator-associated pneumonia (VAP) prevention.^([1]).

Causative bacteria of ventilator-associated pneumonia in intensive care unit in Bahrain:Prevalence and antibiotics susceptibility pattern

BACKGROUND Ventilator-associated pneumonia(VAP)is defined as pneumonia that occurs two calendar days following endotracheal intubation or after that.It is the most common infection encountered among intubated patients.VAP incidence showed wide variability between countries.AIM To define the VAP incidence in the intensive care unit(ICU)in the central gove-rnment hospital in Bahrain and review the risk factors and the predominant bacterial pathogens with their antimicrobial susceptibility pattern.METHODS The research was a prospective cross-sectional observational study over six months from November 2019 to June 2020.It included adult and adolescent patients(>14 years old)admitted to the ICU and required intubation and mechanical ventilation.VAP was diagnosed when it occurred after 48 h after endotracheal intubation using the clinical pulmonary infection score,which considers the clinical,laboratory,microbiological,and radiographic evidence.RESULTS The total number of adult patients admitted to the ICU who required intubation and mechanical ventilation during the study period was 155.Forty-six patients developed VAP during their ICU stay(29.7%).The calculated VAP rate was 22.14 events per 1000 ventilator days during the study period,with a mean age of 52 years±20.Most VAP cases had late-onset VAP with a mean number of ICU days before the development of VAP of 9.96±6.55.Gram-negative contributed to most VAP cases in our unit,with multidrug-resistant Acinetobacter being the most identified pathogen.CONCLUSION The reported VAP rate in our ICU was relatively high compared to the international benchmark,which should trigger a vital action plan for reinforcing the implementation of the VAP prevention bundle.

Comparison of the Use of Conventional and Antibiotic-Coated Tracheal Tubes and EVAC on the Incidence of Ventilator-Associated Pneumonia (VAP)

Ventilator-associated pneumonia (VAP) is one of the most important hospital infections in hospitalized patients, which is associated with increased mortality and patient costs. The tracheal tube itself seems to be a major risk factor for VAP. Contaminated secretions pass through the endotracheal tube and reach the lungs. Also, bacteria form a bacterial biofilm on the tracheal tube and are transferred from there to the lungs. Different tracheal tube designs have been produced to overcome these cases. The purpose of this study is to investigate the effect of an Evac tracheal tube covered with antibiotics and normal on the incidence of pneumonia caused by the ventilator. Research method: 180 patients were randomly intubated in three groups of 60 people with three types of tracheal tubes, Evac and Bactiguard. Clinical examinations, endotracheal tube aspiration culture, and chest radiography were obtained from the patients and the incidence of VAP was calculated based on the CPIS standard. The relationship between the type of endotracheal tube and the incidence of VAP and the length of stay in the intensive care unit (ICU) and being discharged alive from the ICU were investigated. Findings and conclusions: The average incidence of VAP for the group of patients intubated with a conventional tracheal tube was 50%, EVAC was 45% and Bactiguard was 40%. The results showed that there is no significant relationship between the incidence of ventilator-induced pneumonia and the type of tracheal tube. The incidence of ventilator-induced pneumonia was not significantly reduced by suctioning subglottic secretions and Bactiguard tracheal tubes. It seems that using one method alone is not effective in reducing ventilator-induced pneumonia.

Distribution and antibiotic resistance of pathogens isolated from ventilator-associated pneumonia patients in pediatric intensive care unit

BACKGROUND： With mechanical ventilation widely used in intensive care unit, the ventilator associated pneumonia （VAP） has become a common and serious complication in critically ill patients. Compared with adults, the incidence of VAP and the mortality are higher in children in pediatric intensive care unit （PICU） because of immune deficiency, severe basic diseases, and increased use of artificial airway or mechanical ventilation. Hence it is of significance to study the epidemiology and changes of antibacterial susceptibility in order to reduce the incidence and mortality of VAP in children.METHODS： From January 2008 to June 2010, 2758 children were treated in PICU of Wuhan Children＇s Hospital. Among them, 171 received mechanical ventilation over 48 hours in PICU, and 46 developed VAP. The distribution and drug-resistance pattern of the pathogenic bacteria isolated from lower respiratory tract aspirations were analyzed. RESULTS：A total of 119 pathogenic microbial strains were isolated. Gram-negative bacilli （G-） were the most （65.55%）, followed by fungi （21.01%） and gram-positive cocci （G~, 13.45%）. Among them, the most common pathogens were Acinetobacter baummannii, Escherichia coli, Klebsiella pneumoniae, candida albicans and coagulase-negative staphylococci. Antibiotic susceptibility tests indicated that the multiple drug-resistances of G- and G＋to antibiotics were serious. Most of G- was sensitive to ciprofloxacin, amikacin, imipenem, meropenem, cefoperazone-sulbactam and piperacillin-tazobactam. The susceptibility of G＋ to vancomycin, teicoplanin and linezolid were 100%. Fungi were almost sensitive to all the antifungal agents. The primary pathogens of VAP were G-, and their multiple drug-resistances were serious. CONCLUSION： In clinical practice we should choose the most sensitive drug for VAP according to pathogenic test.

Effect of traditional Chinese preparation Xuebijing on inflammatory markers in patients with ventilator-associated pneumonia

Objective:To observe the effect of Xuebijing,a complex traditional Chinese preparation,on inflammation and prognosis of patients with pneumonia.Methods:The patients with ventilator-associated pneumonia in the intensive care unit(ICU)were randomly divided into the control group and the treatment group with 35 cases in each group.Both groups were given routine treatment such as anti-inflammatory drugs,rehydration,expectorant,and nutritional support,while the treatment group was additionally given Xuebijing injection.Serum C-reactive protein(CRP),clinical pulmonary infection score(CPIS),acute physiology,and chronic health scoreⅡ(APACHEⅡ)were recorded before treatment,the 3rd and 7th day after treatment.The duration of antibiotic use,mechanical ventilation,ICU stay,and mortality during 28 days was recorded.Results:There was no significant difference in CRP,CPIS,and APACHEⅡbetween the two groups before treatment(P>0.05).The improvement of CRP,CPIS,and APACHEⅡin the treatment group was better than those in the control group on the 3 and 7 days after treatment,and the differences were statistically significant(P<0.05).The duration of antibiotic use,mechanical ventilation,and ICU stay in the treatment group were less than those in the control group(P<0.05).The 28-day mortality of the treatment group was lower than that of the control group,but the difference was not statistically significant(P>0.05).Conclusions:Xuebijing injection can improve the inflammatory indexes of patients with ventilator-associated pneumonia,and can partly improve the prognosis.

Ventilator-associated pneumonia in patients with cancer: Impact of multidrug resistant bacteria

BACKGROUND Patients with cancer have several risk factors for developing respiratory failure requiring mechanical ventilation(MV).The emergence of multidrug resistant bacteria(MDRB)has become a public health problem,creating a new burden on medical care in hospitals,particularly for patients admitted to the intensive care unit(ICU).AIM To describe risk factors for ventilator-acquired pneumonia(VAP)in patients with cancer and to evaluate the impact of MDRB.METHODS A retrospective study was performed from January 2016 to December 2018 at a cancer referral center in Mexico City,which included all patients who were admitted to the ICU and required MV≥48 h.They were classified as those who developed VAP versus those who did not;pathogens isolated,including MDRB.Clinical evolution at 60-d was assessed.Descriptive analysis was carried out;comparison was performed between VAP vs non-VAP and MDRB vs non-MDRB.RESULTS Two hundred sixty-three patients were included in the study;mean age was 51.9 years;52.1%were male;68.4%had solid tumors.There were 32 episodes of VAP with a rate of 12.2%;11.5 episodes/1000 ventilation-days.The most frequent bacteria isolated were the following:Klebsiella spp.[n=9,four were Extended-Spectrum Beta-Lactamase(ESBL)producers,one was Carbapenem-resistant(CR)];Escherichia coli(n=5,one was ESBL),and Pseudomonas aeruginosa(n=8,two were CR).One Methicillin-susceptible Staphylococcus aureus was identified.In multivariate analysis,the sole risk factor associated for VAP was length of ICU stay(OR=1.1;95%CI:1.03-1.17;P=0.003).Sixty-day mortality was 53%in VAP and 43%without VAP(P=0.342).There was not higher mortality in those patients with MDRB.CONCLUSION This study highlights the high percentage of Gram-negative bacteria,which allows the initiation of empiric antibiotic coverage for these pathogens.In this retrospective,single center,observational study,MDRB VAP was not directly linked to increased mortality at 60 days.

Respiratory mechanics,ventilator-associated pneumonia and outcomes in intensive care unit

AIM To evaluate the predictive capability of respiratory mechanics for the development of ventilator-associated pneumonia (VAP) and mortality in the intensive care unit(ICU) of a hospital in southern Brazil. METHODS A cohort study was conducted between, involving a sample of 120 individuals. Static measurements of compliance and resistance of the respiratory system in pressure-controlled ventilation (PCV) and volumecontrolled ventilation(VCV) modes in the 1 st and 5 th days of hospitalization were performed to monitor respiratory mechanics. The severity of the patients' illness was quantified by the Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ). The diagnosis of VAP was made based on clinical, radiological and laboratory parameters.RESULTS The significant associations found for the development of VAP were APACHE Ⅱ scores above the average(P = 0.016), duration of MV (P = 0.001) and ICU length of stay above the average(P = 0.003), male gender(P = 0.004), and worsening of respiratory resistance in PCV mode(P = 0.010). Age above the average(P < 0.001), low level of oxygenation on day 1(P = 0.003) and day 5 (P = 0.004) and low lung compliance during VCV on day 1 (P = 0.032) were associated with death as the outcome.CONCLUSION The worsening of airway resistance in PCV mode indicated the possibility of early diagnosis of VAP. Low lung compliance during VCV and low oxygenation index were death-related prognostic indicators.

Risk factors for ventilator-associated pneumonia in trauma patients:A descriptive analysis

BACKGROUND:We sought to evaluate the risk factors for developing ventilator-associated pneumonia(VAP)and whether the location of intubation posed a risk in trauma patients.METHODS:Data were retrospectively reviewed for adult trauma patients requiring intubation for>48 hours,admitted between 2010 and 2013.Patients’demographics,clinical presentations and outcomes were compared according to intubation location(prehospital intubation[PHI]vs.trauma room[TRI])and presence vs.absence of VAP.Multivariate regression analysis was performed to identify predictors of VAP.RESULTS:Of 471 intubated patients,332 patients met the inclusion criteria(124 had PHI and208 had TRI)with a mean age of 30.7±14.8 years.PHI group had lower GCS(P=0.001),respiratory rate(P=0.001),and higher frequency of head(P=0.02)and chest injuries(P=0.04).The rate of VAP in PHI group was comparable to the TRI group(P=0.60).Patients who developed VAP were 6 years older,had significantly lower GCS and higher ISS,head AIS,and higher rates of polytrauma.The overall mortality was 7.5%,and was not associated with intubation location or pneumonia rates.In the early-VAP group,gram-positive pathogens were more common,while gram-negative microorganisms were more frequently encountered in the late VAP group.Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models.CONCLUSION:In trauma,the risk of developing VAP is multifactorial.However,the location of intubation and presence of chest injury could play an important role.

Antimicrobial resistance pattern in ventilator-associated pneumonia in an intensive care unit of Babol, northern Iran

Objective:To investigate antibiotic resistance pattern of ventilator-assiated pneumonia (VAP) generating microorganisms,and quantitative culture and determining antibiotic sensitivity.Methods:This cross sectional study was performed on 50 patients suffering from VAP in intensive care unit of Ayatollah Rouhani Hospital,Babol,Iran during 2014-2015.VAP was probable for them based on clinical signs and the criteria of Clinical Pulmonary Infection Score standards.Lower respiratory samples were given under bronchoalveolar lavage and quantitative culture was done on them.Afterwards by microdilution method,minimal inhibitory concentration based on respective microorganisms,considering clinical pulmonary infection score were determined.Results:From 50 investigated samples in this study,the most common microorganisms were Acinetobacter baumannii (A.baumannii) (70%) then Pseudomonas aeruginosa (12%),Staphylococcus aureus (8%) and Klebsiella pneumonia (3%).In our study A.baummannii showed approximate 100% resistance to all antibiotics,in a way that A.baumannii resistance to imipenem and meropenem and piperacillin/tazobactam each was 97.1%.The most resistance of Pseudomonas aeruginosa was 66.7% to each cefepime and ceftazidime and clavulanate/ticarcillin.Staphylococcus aureus showed 75% resistance to nafcillin,cloxacillin and resistance in case of vancomycin was not seen.Conclusion:In current study,A.baumannii had the most prevalence among VAP and this species is resistant to most of antibiotics.Using ceftazidime,cefepime and clavulanate/ticarcillin,in treatment of the patients suffering VAP is not reasonable.

Prevention of ventilator-associated pneumonia through care bundles:A systematic review and meta-analysis

Background Ventilator-associated pneumonia(VAP)represents a common hospital-acquired infection among mechanically ventilated patients.We summarized evidence concerning ventilator care bundles to prevent VAP.Methods A systematic review and meta-analysis were performed.Randomized controlled trials and controlled observational studies of adults undergoing mechanical ventilation(MV)for at least 48 h were considered for inclusion.Outcomes of interest were the number of VAP episodes,duration of MV,hospital and intensive care unit(ICU)length of stay,and mortality.A systematic search was conducted in the MEDLINE,the Cochrane Library,and the Web of Science between 1985 and 2022.Results are reported as odds ratio(OR)or mean difference(MD)with 95%confidence intervals(CI).The PROSPERO registration number is CRD42022341780.Results Thirty-six studies including 116,873 MV participants met the inclusion criteria.A total of 84,031 participants underwent care bundles for VAP prevention.The most reported component of the ventilator bundle was head-of-bed elevation(n=83,146),followed by oral care(n=80,787).A reduction in the number of VAP episodes was observed among those receiving ventilator care bundles,compared with the non-care bundle group(OR=0.42,95%CI:0.33,0.54).Additionally,the implementation of care bundles decreased the duration of MV(MD=−0.59,95%CI:−1.03,−0.15)and hospital length of stay(MD=−1.24,95%CI:−2.30,−0.18)in studies where educational activities were part of the bundle.Data regarding mortality were inconclusive.Conclusions The implementation of ventilator care bundles reduced the number of VAP episodes and the duration of MV in adult ICUs.Their application in combination with educational activities seemed to improve clinical outcomes.

Antibiotics De-Escalation in the Treatment of Ventilator-Associated Pneumonia in Trauma Patients： A Retrospective Study on Propensity Score Matching Method

Background： Antimicrobial de-escalation refers to starting the antimicrobial treatment with broad-spectrum antibiotics, followed by narrowing the drug spectrum according to culture results. The present study evaluated the effect of de-escalation on ventilator-associated pneumonia （VAP） in trauma patients. Methods： This retrospective study was conducted on trauma patients with VAP, who received de-escalation therapy （de-escalation group） or non-de-escalation therapy （non-de-escalation group）. Propensity score matching method was used to balance the baseline characteristics between both groups. The 28-day mortality, length of hospitalization and Intensive Care Unit stay, and expense of antibiotics and hospitalization between both groups were compared. Multivariable analysis explored the factors that influenced the 28-day mortality and implementation of de-escalation. Results： Among the 156 patients, 62 patients received de-escalation therapy and 94 patients received non-de-escalation therapy. No significant difference was observed in 28-day mortality between both groups （28.6% vs. 23.8%, P = 0.620）. The duration of antibiotics treatment in the de-escalation group was shorter than that in the non-de-escalation group （11 [8-13] vs. 14 [8-19] days, P = 0.045）. The expenses of antibiotics and hospitalization in de-escalation group were significantly lower than that in the non-de-escalation group （6430 ± 2730 vs. 7618 ± 2568 RMB Yuan, P = 0.043 and 19,173 ± 16,861 vs. 24,184 ± 12,039 RMB Yuan, P = 0.024, respectively）. Multivariate analysis showed that high Acute Physiology and Chronic Health Evaluation Ⅱ （APACHE Ⅱ） score, high injury severity score, multi-drug resistant （MDR） infection, and inappropriate initial antibiotics were associated with patients＇ 28-day mortality, while high APACHEⅡ score, MDR infection and inappropriate initial antibiotics were independent factors that prevented the implementation of de-escalation. Conclusions： De-escalation strategy in the treatment of trauma patients with VAP could reduce the duration of antibiotics treatments and expense of hospitalization, without increasing the 28-day mortality and MDR infection.

Microscopic examination of intracellular organisms in bronchoalveolar lavage fluid for the diagnosis of ventilator-associated pneumonia：a prospective multi-center study

Background The presence of intracellular organisms （ICOs） in polymorphonuclear leukocytes obtained from bronchoalveolar lavage fluid （BALF） is a possible method for rapid diagnosis of ventilator-associated pneumonia （VAP）.However,the validity of this diagnostic method remains controversial and the diagnostic thresholds reported by investigators were different.Our objective was to evaluate the accuracy of quantification of ICOs in BALF for the diagnosis of VAP,and to detect the best cutoff percentage of PMNs containing ICOs （PIC） in the microscopic examination of BALF for the diagnosis of VAP.Methods This was a prospective multi-center study conducted in 4 ICUs in Wuhan,China,which involved 181 patients suspected of first episode of VAP.BALF was obtained from all enrolled patients.The BALF samples underwent quantitative culture,cytological and bacteriological analysis to detect the culture results,PIC values and the morphological features of microorganisms.Definite diagnosis of VAP was based on pre-set criteria.The receiver-operating characteristic curve was used to detect the best cutoff point for PIG to diagnose VAP,and the diagnostic accuracy was calculated.Moreover,quantitative culture and Gram＇s stain of BALF were adopted to diagnose VAP,and their diagnostic accuracy was evaluated as well.Results There were 102 patients definitely diagnosed with VAP （VAP group）,and 60 patients definitely diagnosed without VAP （no VAP group）.We found that ICOs were present in 96.08％ （98 out of 102） of VAP patients and 20.00％ （12 out of 60） of no VAP patients.The PICs were significantly higher （（9.53±6.65）％ vs.（0.52±1.33）％,P＜0.01） in VAP group.In our study,the best cutoff point for PIC to diagnose VAP was 1.5％,which had a sensitivity of 94.12％,a specificity of 88.33％,a positive predictive value （PPV） of 93.20％ and a negative predictive value （NPV） of 89.83％.The area under the receiveroperating characteristic curve was 0.956 （95％ confidence interval,0.925-0.986; P＜0.01）.When the positive quantitative culture results of BALF were used to diagnose VAP,the sensitivity,specificity,PPV and NPV were 65.69％,95.00％,95.71％ and 61.96％,respectively.Whereas they were 70.59％,76.67％,83.72％ and 60.53％,respectively,when the positive Gram＇s stain results of BALF were used to diagnose VAP.The concordance between the results of Gram＇s stain and quantitative cultures was poor,only 32.10％ （52 out of 162） was totally right,and 17.28％ （28 out of 162） was partially right.Conclusions PIC＞1.5％ has good diagnostic performance in the microscopic examination of BALF for the diagnosis of VAP.However,Gram＇s stain is not reliable for the early application of antibiotic therapy,due to the poor bacteriological predictive value.

Risk factors for ventilator-associated pneumonia among patients undergoing major oncological surgery for head and neck cancer

Patients undergoing major oncological surgery for head and neck cancer （SHNC） have a particularly high risk of nosocomial infections. We aimed to identify risk factors for ventilator-associated pneumonia （VAP） in patients undergoing SHNC. The study included 465 patients who underwent SHNC between June 2011 and June 2014. The rate of VAP, risk factors for VAP, and biological aspects of VAP were retrospectively evaluated. The incidence of VAP was 19.6~0 （n = 95） in patients who required more than 48 h of mechanical ventilation. Staphylococcus （37.7%）, Enterobacteriaceae （32.1%）, Pseudomonas （20.8%）, and Haemophilus （16.9~） were the major bacterial species that caused VAP. The independent risk factors for VAP were advanced age, current smoking status, chronic obstructive pulmonary disease, and a higher simplified acute physiology score system II upon admission. Tracheostomy was an independent protective factor for VAP. The median length of stay in the ICU for patients who did or did not develop VAP was 8.0 and 6.5 days, respectively （P = 0.006）. Mortality among patients who did or did not develop VAP was 16.8% and 8.4%, respectively （P 〈 0.001）. The potential economic impact of VAP was high because of the significantly extended duration of ventilation. A predictive regression model was developed with a sensitivity of 95.3% and a specificity of 69.4%. VAP is common in patients who are undergoing SHNC and who require more than 48 h of mechanical ventilation. Therefore, innovative preventive measures should be developed and applied in this high-risk population.

Interpretation for practice guidelines for prevention, diagnosis, and treatment of ventilator-associated pneumonia in burn patients by american burn association

"American Burn Association Practice Guidelines for Prevention,Diagnosis,and Treatment of Ventilator-Associated Pneumonia in Burn Patients"was published to provide recommendation for the prevention,diagnosis,and treatment of ventilator-associated pneumonia in burn patients.This article makes interpretations and conclusions for prevention,diagnosis and treatment from this guideline in the combination of domestic burn patients.

Outcomes and risk factors of ventilator-associated pneumonia in neonates

Background:Ventilator-associated pneumonia (VAP) in neonates has been associated with high mortality and poor outcome.This study aimed to compare the incidence,risk factors,and outcomes of VAP and nonVAP conditions in neonates.Methods:We performed a prospective cohort study in a neonatal intensive care unit (NICU) in Thailand from January 2014 to December 2014.All neonatal patients who were ventilated more than 48 hours were enrolled.Results:There were 128 enrolled patients.The median (inter quartile range) gestational age and birthweight were 35 (30.2,37.8) weeks and 2380 (1323.8,3020.0) g.There were 17 VAP patients (19 episodes) and 111 non-VAP ones.The VAP rate was 13.3% or 10.1 per 1000 ventilator days.According to the multivariate analysis,a birthweight less than 750 g [adjusted odds ratio (aOR)=10.75,95% confidence interval (CI)=2.35-49.16;P=0.002] and sedative medication use (aOR=4.00,95% CI=1.23-12.50;P=0.021)were independent risk factors for VAP.Compared with the non-VAP group,the median difference in the VAP group yielded a significantly longer duration of NICU stay (18 days,P=0.001),total length of hospital stay (16 days,P=0.002) and higher hospital costs ($5113,P=0.001).The inhospital mortality rate in the VAP and non-VAP groups was 17.6% and 15.3% (P=0.73),respectively.Conclusions:A neonatal birthweight less than 750 g and sedative medication use were independent risk factors for VAP.Our VAP patients experienced a longer duration of both NICU and hospital stay,and incurred higher hospitalization costs.

Aerosolized Amikacin as Adjunctive Therapy of Ventilator-associated Pneumonia Caused by Multidrug-resistant Gram-negative Bacteria： A Single-center Randomized Controlled Trial

Background： Aerosolized amikacin （AA） is a current option for the management of ventilator-associated pneumonia （VAP） caused by multidrug-resistant Gram-negative bacteria （MDR-GNB）, as it is reported that AA could increase the alveolar level of the drug without increasing systemic toxicity. This study aimed to evaluate the efficacy and safety of AA as an adjunctive therapy for VAP caused by MDR-GNB. Methods： In this single-center, double-blind study conducted in a 36-bed general Intensive Care Unit （ICU） in a tertiary hospital from June 2014 to June 2016, 52 ICU patients with confirmed MDR-GNB VAP were randomized to two groups （AA group, n - 27 and placebo group, n = 25）. Amikacin （400 rag, q8h） or saline placebo （4 ml, q8h） was aerosolized for 7 days. The attending physician determined the administration of systemic antibiotics for VAP. Patients were tbllowed up for 28 days. Bacteriological eradication, clinical pulmonary infection score （CP1S）, and serum creatinine were assessed on day 7 of therapy. New resistance to amikacin, cure rate of VAP, weaning rate, and mortality were assessed on day 28. Results： The baseline characteristics of patients in both groups were similar. At the end of the treatment, 13 of the 32 initially detected bacterial isolates were eradicated in AA group, compared to 4 of 28 in placebo group （41% vs. 14%, P - 0.024）. As for patients, 11 of 27 patients treated with AA and 4 of 25 patients treated with placebo have eradication （41% vs. 16%, P = 0.049）. The adjunction of AA reduced CPIS （4.2 ± 1.6 vs. 5.8 ± 2.1, P = 0.007）. New drug resistance to amikacin and the change in serum creatinine were not detected in AA group. No significant differences in the clinical cure rate in survivors （48% vs. 35%, P = 0.444）, weaning rate （48% vs. 32%, P = 0.236）, and mortality （22% vs. 32%, P = 0.427） were detected between the two groups on day 28. Conclusions： As an adjunctive therapy of MDR-GNB VAP, AA successfully eradicated existing MDR organisms without inducing new resistance to amikacin or change in serum creatinine. However, the improvement of mortality was not found.

Add-on effect of Qinbei Qingfei Yiqi granules for ventilator-associated pneumonia in intensive care units:a randomized controlled trial

OBJECTIVE:To evaluate the add-on effect of Qinbei Qingfei Yiqi(QBQFYQ) granules for ventilator-associated pneumonia(VAP) in non-infectious critically ill patients.METHODS:In this randomized controlled trial, 80non-infectious critically ill patients undergoing mechanical ventilation in the intensive care unit(ICU)were randomly divided into two groups:those receiving QBQFYQ granules plus usual treatment(experimental group, n = 50) and those receiving only the usual treatment(control group, n = 30).The main outcome measures were VAP rate, time of VAP occurrence, duration of mechanical ventilation,and length of ICU stay.Interleukin-6(IL-6), C-reactive protein(CRP), and T-lymphocyte(CD4+, CD8+,and CD4+/CD8+ ratio) serum levels were also evaluated before and after treatment.RESULTS:Compared with the control group treatment, QBQFYQ administration significantly reduced the duration of mechanical ventilation [(9.58± 3.14) vs(12.52 ± 4.33) days] and length of ICU stay [(14.57 ± 3.72) vs(17.82 ± 5.24) days] and delayed VAP occurrence [(4.31 ± 0.86) vs(2.43 ± 0.27)days].Additionally, CRP and IL-6 serum levels and CD4+/CD8+ ratio were significantly lower in the experimental group(P < 0.05) than in the control group.However, there were no significant differences in hospital mortality rate(30.0% vs 33.3%) and adverse events(4.0% vs 6.7%).CONCLUSION:QBQFYQ delays the time of VAP occurrence and shortens the duration of mechanical ventilation in non-infectious critically ill patients,possibly through anti-inflammatory and immunomodulatory mechanisms.

Predictive value of C-reactive protein and the Pediatric Risk of Mortality Ⅲ Score for occurrence of postoperative ventilator-associated pneumonia in pediatric patients with congenital heart disease

Importance:Ventilator-associated pneumonia (VAP) is one of the most common complications after cardiac surgery in children with congenital heart disease (CHD).Early prediction of the incidence of VAP is important for clinical prevention and treatment.Objective:To determine the value of serum C-reactive protein (CRP) levels and the Pediatric Risk of Mortality Ⅲ (PRISM Ⅲ) score in predicting the risk of postoperative VAP in pediatric patients with CHD.Methods:We performed a retrospective review of clinical data of 481 pediatric patients with CHD who were admitted to our pediatric intensive care unit.These patients received mechanical ventilation for 48 hours or longer after corrective Surgery.On the basis of their clinical manifestations and laboratory results,patients were separated into two groups of those with VAP and those without VAP.CRP levels were measured and PRISM Ⅲ scores were collected within 12 hours of admission to the pediatric intensive care unit.The Pearson correlation coefficient was used to evaluate the association of CRP levels and the PRISM score with the occurrence of postoperative VAP.A linear regression model was constructed to obtain a joint function and receiver operating curves were used to assess the predictive value.Results:CRP levels and the PRISM Ⅲ score in the VAP group were significantly higher than those in the non-VAP group (P < 0.05).Receiver operating curves suggested that using CRP + the PRISM Ⅲ score to predict the incidence of VAP after congenial heart surgery was more accurate than using either of them alone (CRP + the PRISM Ⅲ score:sensitivity:53.2%,specificity:85.7%).When CRP + the PRISM Ⅲ score was greater than 45.460,patients were more likely to have VAP.Interpretation:Although using CRP levels plus the PRISM Ⅲ score to predict the incidence of VAP after congenial heart surgery is more accurate than using either of them alone,its predictive value is still limited.

Klebsiella pneumoniae infections after liver transplantation:Drug resistance and distribution of pathogens,risk factors,and influence on outcomes

BACKGROUND Liver transplantation(LT)is the only curative treatment for end-stage liver disease.However,LT recipients are susceptible to infection,which is the leading cause of early mortality after LT.Klebsiella pneumoniae infections(KPIs)in the bloodstream are common in LT recipients.We hypothesized that KPIs and carbapenemresistant Klebsiella pneumoniae(CRKP)infections may affect the outcomes of LT recipients.AIM To assess KPI incidence,timing,distribution,drug resistance,and risk factors following LT and its association with outcomes.METHODS This retrospective study included 406 patients undergoing LT at The Third Xiangya Hospital of Central South University,a tertiary hospital,from January 2015 to January 2023.We investigated the risk factors for KPIs and assessed the impact of KPIs and CRKP infections on the prognosis of LT recipients using logistic regression analysis.RESULTS KPI incidence was 7.9%(n=32),with lung/thoracic cavity the most frequent site of infection;the median time from LT to KPI onset was 7.5 d.Of 44 Klebsiella pneumoniae isolates,43(97.7%)and 34(77.3%)were susceptible to polymyxin B or ceftazidime/avibactam and tigecycline,respectively;>70%were resistant to piperacillin/tazobactam,ceftazidime,cefepime,aztreonam,meropenem,and levofloxacin.Female sex[odds ratio(OR)=2.827,95%confidence interval(CI):1.256-6.364;P=0.012],pre-LT diabetes(OR=2.794,95%CI:1.070-7.294;P=0.036),day 1 post-LT alanine aminotransferase(ALT)levels≥1500 U/L(OR=3.645,95%CI:1.671-7.950;P=0.001),and post-LT urethral catheter duration over 4 d(OR=2.266,95%CI:1.016-5.054;P=0.046)were risk factors for KPI.CRKP infections,but not KPIs,were risk factors for 6-month all-cause mortality post-LT.CONCLUSION KPIs occur frequently and rapidly after LT.Risk factors include female sex,pre-LT diabetes,increased post-LT ALT levels,and urethral catheter duration.CRKP infections,and not KPIs,affect mortality.

Clinical analysis of colistin sulfate in the treatment of pneumonia caused by carbapenem-resistant Gram-negative bacteria

BACKGROUND Multidrug-resistant Gram-negative bacteria,exacerbated by excessive use of antimicrobials and immunosuppressants,are a major health threat.AIM To study the clinical efficacy and safety of colistin sulfate in the treatment of carbapenem-resistant Gram-negative bacilli-induced pneumonia,and to provide theoretical reference for clinical diagnosis and treatment.METHODS This retrospective analysis involved 54 patients with Gram-negative bacilli pneumonia admitted to intensive care unit of The General Hospital of the Northern Theater Command of the People's Liberation Army of China from August 2020 to June 2022.After bacteriological culture,the patients'airway secretions were collected to confirm the presence of Gram-negative bacilli.The patients were divided into the experimental and control groups according to the medication used.The research group consisted of 28 patients who received polymyxin sulfate combined with other drugs through intravenous,nebulization,or intravenous combined with nebulization,with a daily dosage of 1.5–3.0 million units.The control group consisted of 26 patients who received standard dosages of other antibiotics(including sulbactam sodium for injection,cefoperazone sodium sulbactam for injection,tigecycline,meropenem,or vaborbactam).RESULTS Of the 28 patients included in the research group,26 patients showed improvement,treatment was ineffective for two patients,and one patient died,with the treatment efficacy rate of 92.82%.Of the 26 patients in the control group,18 patients improved,treatment was ineffective for eight patients,and two patients died,with the treatment efficacy rate of 54.9%;significant difference was observed between the two groups(P<0.05).The levels of white blood cell(WBC),procalcitonin(PCT),and C-reactive protein(CRP)in both groups were significantly lower after treatment than before treatment(P<0.05),and the levels of WBC,PCT,and CRP in the research group were significantly lower than those in the control group(P<0.05).Compared with before treatment,there were no significant changes in aspartate aminotransferase,creatinine,and glomerular filtration rate in both groups,while total bilirubin and alanine aminotransferase decreased after treatment(P<0.05)with no difference between the groups.In patients with good clinical outcomes,the sequential organ failure assessment(SOFA)score was low when treated with inhaled polymyxin sulfate,and specific antibiotic treatment did not improve the outcome.Sepsis and septic shock as well as a low SOFA score were independent factors associated with good clinical outcomes.CONCLUSION Polymyxin sulfate has a significant effect on the treatment of patients with multiple drug-resistant Gram-negative bacilli pneumonia and other infections in the lungs and is safe and reliable.Moreover,the administration route of low-dose intravenous injection combined with nebulization shows better therapeutic effects and lower adverse reactions,providing new ideas for clinical administration.