Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is ...associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative.
Antibiotics for Sepsis-Finding the Equilibrium Klompas, Michael; Calandra, Thierry; Singer, Mervyn
JAMA : the journal of the American Medical Association,
2018-Oct-09, Letnik:
320, Številka:
14
Journal Article
The increasing number of hospitals reporting ventilator-associated pneumonia (VAP) rates at or close to zero begs the question of whether zero should become the national benchmark for VAP. This ...article explores the significance of very low VAP rates, reviews differences in surveillance and clinical rates, proposes reasons for their discrepancies, and suggests possible objective alternatives for surveillance.
Surveillance rates of VAP are decreasing, whereas clinical diagnoses and antibiotic prescribing remain prevalent. This growing discrepancy reflects the lack of objective and definitive signs to diagnose VAP. External reporting pressures may be encouraging stricter interpretation of subjective signs and other surveillance initiatives that can artifactually lower rates. It is impossible to disentangle the relative contribution of care improvements versus surveillance effects to currently observed low VAP rates.
The increasing mismatch between surveillance rates and clinical diagnoses limits the utility of official VAP rates to estimate disease burden and guide quality improvement. Advocates are advised to consider objective alternatives such as average duration of mechanical ventilation, length of stay, mortality, and antibiotic prescribing. Emerging surveillance definitions that use more objective criteria may better reflect and inform future clinical practice.
Background Reports that septic shock incidence is rising and mortality rates declining may be confounded by improving recognition of sepsis and changing coding practices. We compared trends in septic ...shock incidence and mortality in academic hospitals using clinical vs claims data. Methods We identified all patients with concurrent blood cultures, antibiotics, and vasopressors for ≥ two consecutive days, and all patients with International Classification of Diseases , 9th edition (ICD-9) codes for septic shock, at 27 academic hospitals from 2005 to 2014. We compared annual incidence and mortality trends. We reviewed 967 records from three hospitals to estimate the accuracy of each method. Results Of 6.5 million adult hospitalizations, 99,312 (1.5%) were flagged by clinical criteria, 82,350 (1.3%) by ICD-9 codes, and 44,651 (0.7%) by both. Sensitivity for clinical criteria was higher than claims (74.8% vs 48.3%; P < .01), whereas positive predictive value was comparable (83% vs 89%; P = .23). Septic shock incidence, based on clinical criteria, rose from 12.8 to 18.6 cases per 1,000 hospitalizations (average, 4.9% increase/y; 95% CI, 4.0%-5.9%), while mortality declined from 54.9% to 50.7% (average, 0.6% decline/y; 95% CI, 0.4%-0.8%). In contrast, septic shock incidence, based on ICD-9 codes, increased from 6.7 to 19.3 per 1,000 hospitalizations (19.8% increase/y; 95% CI, 16.6%-20.9%), while mortality decreased from 48.3% to 39.3% (1.2% decline/y; 95% CI, 0.9%-1.6%). Conclusions A clinical surveillance definition based on concurrent vasopressors, blood cultures, and antibiotics accurately identifies septic shock hospitalizations and suggests that the incidence of patients receiving treatment for septic shock has risen and mortality rates have fallen, but less dramatically than estimated on the basis of ICD-9 codes.
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