Hospital-acquired pneumonia (HAP) is pneumonia that occurs ≥48 h after hospital admission; it is the most common hospital-acquired infection contributing to death. Ventilator-associated pneumonia ...(VAP) arises ≥48–72 h after intubation. Opinions differ on whether VAP is a subset of HAP; the same pathogens predominate in both. Compared with VAP-free controls, patients developing VAP are twice as likely to die and have significantly longer stays in intensive care units. Guidelines recommend that microbiological cultures should guide antibiotic treatment, but these lack sensitivity and take 48–72 h to process, meaning that initial therapy must be empiric, generally with broad-spectrum agents. Given increasing pressure to improve both antibiotic stewardship and patient outcomes, the National Institute for Health and Care Excellence and the Infectious Diseases Society of America recommend research into rapid molecular diagnostic tests to identify causative organisms and their antibiotic resistances. Ideally, these would supersede culture, being quicker and more sensitive. In the UK, the INHALE research programme, funded by the National Institute for Health Research, is exploring rapid molecular diagnostics to inform treatment of HAP/VAP and, given resource implications, incorporates a health economic component.
To identify previous economic modelling of HAP/VAP costs to inform this component.
Literature review of HAP/VAP studies with economic modelling identified from three databases.
Twenty studies were identified. Only one study specifically evaluated strategies to improve diagnosis; the remaining 19 studies omitted this important aspect.
HAP/VAP modelling would be improved by better awareness of long-term outcomes and treatment complexity. To the authors' knowledge, no similar literature reviews of economic modelling for HAP/VAP have been published.
Acinetobacter baumannii is a Gram-negative saprophytic rod inhabiting both moist niches and dry surfaces. The wide spread of the microbe in the environment by means of minimal nutritional ...requirements and exceptional survival capabilities give the opportunities to occupy hospital niches, and thus to create threats for hospitalized patients. This bacterium may be a part of the human microbiota as an opportunistic pathogen which upon the host’s weakening, causes less or more serious diseases. A. baumannii is an etiological factor of ventilator-associated pneumonia, which is especially dangerous for patients in intensive care units (in Poland every fifth patient suffers from such infection). Due to the increasing multidrug resistance of A. baumannii, this bacterium belongs to the group of priority pathogens. Fighting such dangerous bacteria is difficult due to their natural resistance as well as acquired resistance mechanisms in response to environmental threats. The unique ability of A. baumannii to cause diseases and acquire resistance to numerous antibiotics, make it necessary to control and prevent these infections.
Ventilator-associated pneumonia (VAP) is a common nosocomial infection in patients admitted to
intensive care units (ICU), leading to prolonged stay in the ICU, increased hospital costs, and ...mortality.
This study aimed to compare the effect of using normal saline with eucalyptus in endotracheal
suctioning on the rate of ventilator-dependent pneumonia. For this purpose, a randomized clinical trial
study was performed on 120 patients under a ventilator in the hospital ICU. Patients were randomly
divided into control and intervention groups. The control group consisted of 60 patients who used 0.9%
normal saline to dilute endotracheal secretions. The intervention group also included 60 patients treated
with 0.9% normal saline with 5% eucalyptus to dilute endotracheal secretions. The sensitivity of
isolated microbes was determined by the diffusion susceptibility test Kirby-Bauer disk protocol. The
CDC protocol was used to diagnose VAP. 100 CFU/ml of endotracheal aspiration was considered the
differentiation number between the microbe responsible for VAP and colonization. Whenever a VAP
guess was made, a blood culture was done. Finally, the incidence of ventilator-associated pneumonia in
the two groups was compared. The results showed that the incidence of VAP during using normal saline
and normal saline with eucalyptus as a diluent for pulmonary secretions was different between the two
groups (P = 0.042). Also, among infected patients with VAP, there was a difference between the types
of microorganisms in the two groups (P = 0.019). Seven cases of Klebsiella pneumonia were observed
in the control group, while no case of this bacterium was observed in the intervention group. In terms of
the prevalence of Pseudomonas (two cases), both groups had a similar situation. These findings can
reassure nurses and the treatment team that they can use normal saline solution with 5% eucalyptus
during suction to dilute pulmonary secretions.
Carbapenem-resistant Acinetobacter baumannii (CRAB) has gained global notoriety as a critically important nosocomial pathogen. It mostly affects debilitated patients, causing pneumonia and ...bloodstream infections with high mortality rates. Difficulties in treating CRAB infections stem from a formidable resistance profile that leaves available only a few antibiotics of uncertain efficacy such as colistin and tigecycline. Despite the relentless attempts to improve therapeutic approaches (as depicted in colistin-oriented randomized clinical trials and the numerous observational studies), progress is still limited.
We aim (a) to assist physicians to adapt therapeutic approaches in CRAB infections by considering all potentially available antimicrobials, and (b) to present directions for future investigations that emerge through treatment efforts in endemic settings.
Articles and reviews from PubMed and Scopus databases; studies from ClinicalTrials.gov; presentations from ECCMID congresses and IDWeek meetings.
The review provides a succinct overview of the important pharmacokinetic/pharmocodynamic parameters of relevant antimicrobial agents, a critical appraisal of randomized control trials and observational studies, suggestions for increasing the strength of observational studies and directions facilitating the choice of therapeutic regimens by severity of infection and status of the host.
The lack of an optimal therapeutic regimen for CRAB thus far, as shown in this review, suggests the need to thoroughly investigate alternative approaches through carefully designed trials that should include all relevant drugs. Some of these alternative directions are indicated in the present review.
A voice assistant (VA), a type of voice-enabled artificial intelligence, is no longer just a character in science fiction movies. Currently, voice is embedded in a variety of products such as ...smartphones (mobile applications) and smart speakers in consumers' homes. Furthermore, voice assistants are becoming integral to our daily lives. While human personalities shape the way we interact with the world, voice assistant personalities can also impact everyday interactions with our environment. This study identifies seven voice assistant personality traits (VAP) of three commonly used mobile applications: Microsoft's Cortana, Google's Assistant, and Amazon's Alexa. To examine the effect of VAP on consumer experience, this study applies and extends flow theory to uncover why VAP has the effects it has and what facets of VAP drive the voice interaction flow experience that can influence consumers' attitudes and behavioral intentions. Our study shows that voice interaction with a VA that incorporates functional intelligence, sincerity, and creativity empowers consumers to take control of their voice interactions with the VA, focus on their voice interaction, and engage in exploratory behavior. Consumers' exploratory behavior leads to consumer satisfaction and consumers' willingness to continue using voice assistant.
Previous meta-analyses suggested that treating hospital-acquired pneumonia (HAP), including ventilator-associated pneumonia (VAP), with empiric carbapenems was associated with lower mortality rates ...but higher rates of clinical failure for pseudomonal pneumonia. This study was an updated meta-analysis with sensitivity analyses and meta-regression to better understand the impact of carbapenem use in HAP/VAP.
What is the efficacy of carbapenems for empiric treatment of nosocomial pneumonia?
Databases were searched for randomized controlled studies evaluating empiric treatment for HAP and/or VAP, and studies were included comparing carbapenem- vs non-carbapenem-containing regimens. The primary outcome was all-cause mortality. Secondary outcomes included subgroup stratification and resistance development.
Of 9,140 references, 20 trials enrolling 5,489 patients met inclusion criteria. For mortality, carbapenem use had a risk ratio (RR) of 0.84 (95% CI, 0.74-0.96; P = .01). Stratified according to VAP proportion (< 33%, 33%-66%, and > 66%), RRs were 0.95 (95% CI, 0.77-1.17; P = .66), 0.78 (95% CI, 0.57-1.07; P = .13), and 0.81 (95% CI, 0.65-0.99; P = .04), respectively. Stratified according to severity, only groups with Acute Physiology and Chronic Health Evaluation II scores < 14 and between 14 and 17 showed mortality benefit (RRs of 0.64 95% CI, 0.45-0.92; P = .01 and 0.77 95% CI, 0.61-0.97; P = .03). Meta-regression did not show an association between Pseudomonas prevalence and mortality (P = .44). Carbapenem use showed a trend toward developing resistance (RR, 1.40; 95% CI, 0.95-2.06; P = .09) and a 96% probability of resistance emergence.
Carbapenem-based empiric regimens were associated with lower mortality rates compared with non-carbapenems, largely driven by trials of VAP. The mortality effect was not observed in trials with high disease severity and was not associated with Pseudomonas. The mortality difference was observed mainly in studies that used ceftazidime as control. There was a trend toward increasing resistance associated with carbapenems.
International Prospective Register of Systematic Reviews; No. CRD42018093602; URL: https://www.crd.york.ac.uk/prospero/.
Abstract Background Prolonged intubation with mechanical ventilation carries a risk for ventilator-associated respiratory infections manifest as tracheobronchitis or pneumonia. This study analyzed ...natural history, incidence, and outcomes of patients developing ventilator-associated tracheobronchitis and pneumonia. Methods We studied 188 mixed intensive care unit (ICU) patients intubated ≥48 hours for the development of tracheobronchitis defined as quantitative endotracheal aspirate ≥105 cfu/mL plus at least 2 clinical criteria (fever, leukocytosis, or purulent sputum). Pneumonia was defined as microbiologic criteria for tracheobronchitis and a new and persistent infiltrate on chest radiograph. Results Airways of 41 (22%) patients became heavily colonized with a bacterial pathogen(s) at a concentration of ≥105 cfu/mL. Tracheobronchitis developed in 21 (11%) study patients, of which 6 (29%) later progressed to pneumonia. Including these 6 patients, 28 (15%) study patients developed pneumonia. Multidrug-resistant pathogens were isolated in 39% of pneumonia patients. Patients with tracheobronchitis and pneumonia had significantly more ventilator days and longer stays in the ICU ( P ≤.02). Conclusions Approximately one third of tracheobronchitis patients later developed pneumonia. Patients with tracheobronchitis or pneumonia experienced significantly more ventilator days and longer ICU stays, but had no difference in mortality. Better patient outcomes and reduced health care costs may be achieved by earlier treatment of ventilator-associated respiratory infections, manifest as tracheobronchitis or pneumonia.
BACKGROUNDCardiovascular failure (CVF) may complicate intensive care unit-acquired pneumonia (ICUAP) and radically alters the empirical treatment of this condition. The aim of this study was to ...determine the impact of CVF on outcome in patients with ICUAP. METHODSA prospective, single-center, observational study was conducted in six medical and surgical ICUs at a University Hospital. CVS was defined as a score of 3 or more on the cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score. At the onset of ICUAP, CVF was reported as absent, transient (if lasting ≤ 3 days) or persistent (>3 days). The primary outcome was 90-day mortality modelled through a Cox regression analysis. Secondary outcomes were 28-day mortality, hospital mortality, ICU length of stay (LOS) and hospital LOS. RESULTS358 patients were enrolled: 203 (57%) without CVF, 82 (23%) with transient CVF, and 73 (20%) with persistent CVF. Patients with transient and persistent CVF were more severely ill and presented higher inflammatory response than those without CVF. Despite having similar severity and aetiology, the persistent CVF group more frequently received inadequate initial antibiotic treatment and presented more treatment failures than the transient CVF group. In the persistent CVF group, at day 3, a bacterial superinfection was more frequently detected. The 90-day mortality was significantly higher in the persistent CVF group (62%). The 28-day mortality rates for patients without CVF, with transient and with persistent CVF were 19, 35 and 41% respectively and ICU mortality was 60, 38 and 19% respectively. In the multivariate analysis chronic pulmonary conditions, lack of Pa02/FiO2 improvement at day 3, pulmonary superinfection at day 3 and persistent CVF were independently associated with 90-day mortality in ICUAP patients. Conclusions: Persistent CVF has a significant impact on the outcome of patients with ICUAP. Patients at risk from persistent CVF should be promptly recognized to optimize treatment and outcomes.
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