Bacterièmia en la pneumònia nosocomial i pneumònia associada a ventilació mecànica en pacients traumàtics: resultats de l'eu-pneumonia survey 2005

La pneumonia nosocomial (PN) és la segona infecció nosocomial més freqüent en pacients hospitalitzats, sent la pneumonia asociada a ventilació mecànica (PAV) la infecció nosocomial líder a les UCIs i representa més del 80% de tots els episodis de PN. Els rangs de freqüència de la PN oscil.len entre cinc i deu casos per cada 1.000 ingressos hospitalaris, i augmenta de 6 a 20 vegades en pacients sotmesos a ventilació mecànica (VM). Donada la importància de la pneumònia que requereix VM respecte a la freqüència, la mortalitat, i els costos sanitaris, la literatura mèdica és plena de discussions sobre els mètodes que s'han d'utilitzar per diagnosticar la pneumònia en les UCIs. No obstant això, hi ha una gran desproporció entre el pes d'aquesta entitat i la poca informació sobre la pràctica real. Davant d'aquesta manca de informació en el nostre àmbit, es va dissenyar l'estudi EU-PNEUMONIA Survey 2005 per examinar de manera prospectiva el diagnòstic clínic de tots els tipus de pneumònia que requerien VM en una gran mostra de 27 UCIs de nou països europeus amb l'objectiu de definir millor la pràctica clínica real de la pneumònia en pacients ventilats. El fet de disposar de dades epidemiològiques, etiologia, factors de risc i outcomes d'una mostra tan àmplia de pacients, ens ha permès analitzar i extreure dades de múltiples subgrups que presenten característiques específiques i que els diferencien del grup en conjunt. Dins d'aquesta àmplia mostra de pacients recollits diagnosticats de pneumònia que van precisar de VM, existeixen dos grans subgrups de malalts que han estat objecte de múltiples estudis en quan a l'etiologia, epidemiologia, factors de risc i mortalitat. Aquests dos grans subgrups, que són els objectius d'anàlisi d'aquesta tesi i són: la PN bacterièmica i la PAV en pacients politraumàtics. Donat que en algunes UCIs no es realitzen hemocultius com a protocol de diagnòstic en pacients amb sospita de PN i que aquesta informació proporciona dades útils en la informació epidemiològica sobre el patogen causal de la PN i de la seva resistència, es va realitzar un segon anàlisi d'aquesta cohort multicèntrica de pacients amb PN. Per altra banda, una de les principals causes de morbiditat i mortalitat en els països industrialitzats són els pacients politraumàtics. Molts d'ells requereixen ingrés a UCI i precisen VM. En els pacients traumàtics sotmesos a VM la PAV és una de les complicacions principals amb una incidència aproximadament del 40 al 50%. Encara que, en les últimes dècades diversos estudis mostren que la mortalitat de la PAV en els pacients politraumàtics és del 8% al 59%, recentment en altres estudis, s'ha observat que la PAV no sembla augmentar la taxa de mortalitat en els pacients traumàtics severs . La PAV en els pacients traumàtics difereix de la PAV en els pacients no traumàtics pel fet que no es relaciona amb els dies de VM i s'associa freqüentment a patògens específics. Per analitzar les diferències en l'etiologia, factors de risc i outcomes d'aquest subgrup de malalts es va realizar un segon anàlisi d'aquesta cohort multicèntrica de pacients traumàtics amb PAV. Les conclusions d'ambdós subanàlisi foren: la bacterièmia és un factor de risc independent associat a un augment de la mortalitat en els pacients intubats amb PN. Per tant, el reconeixement dels factors de risc és rellevant per a una bona pràctica clínica. Les nostres troballes recolzen la necessitat de realitzar hemocultius en pacients hospitalitzats amb PN. La PAV s'associa a una menor mortalitat en els pacients traumàtics que en els pacients no traumàtics. Donada l'alta incidència de PAV en els pacients traumàtics, diferents estratègies de prevenció haurien d'estar dirigides per disminuir la seva incidència.Nosocomial pneumonia (NP) is the second most common nosocomial infection in hospitalized patients being ventilator-associated pneumonia (VAP), the leading nosocomial infection in Intensive Care Units (ICU) and represents over 80% of all episodes of NP. The frequency ranges of NP ranging between five and ten cases per 1,000 hospital admissions, and increases from 6 to 20 times in patients undergoing mechanical ventilation (MV). Due to the importance of pneumonia that requires VM with respect to the frequency, mortality and healthcare costs, medical literature is full of discussions about the methods to be used to diagnose pneumonia in ICU. However, there is a big difference between the importance of this entity and the limited information on actual practice. Given this lack of information in our field, we designed the study EU-PNEUMONIA Survey 2005 to examine prospectively the clinical diagnosis of all types of pneumonia requiring MV in a large sample from 27 ICUs of nine european countries in order to define the actual clinical practice of pneumonia in ventilated patients. The availability of epidemiological data, etiology, risk factors and outcomes of such a large sample of patients has allowed us to analyze and extract data from multiple subgroups that have specific characteristics that distinguish the group as a whole. Within this broad sample of patients diagnosed with pneumonia who require MV, there are two major subgroups of patients who have undergone multiple studies about the etiology, epidemiology, risk factors and mortality. These two subgroups, which are the objectives of this thesis and analysis are: bacteremic NP and VAP in trauma patients. Since in some UCIs blood cultures are not performed as a diagnostic protocol for patients suspected of NP and this information provides useful data on the epidemiological information on the causative pathogen of the NP and its resistance, a second analysis was conducted. On the other hand, a major cause of morbidity and mortality in industrialized countries are trauma patients. Many of them require admission to ICU and requiring MV. In trauma patients undergoing the MV, VAP is one of the major complications with an incidence of approximately 40 to 50%. Although, in recent decades several studies show that mortality of patients in the trauma VAP is 8% to 59%, in other recent studies we found that the VAP does not seem to increase mortality in trauma patients. The VAP in trauma patients differs from the VAP in patients non- trauma because it was not related to the days of MV and is frequently associated with specific pathogens. To examine differences in the etiology, risk factors and outcomes of this subgroup of patients was realize a second analysis of this multicenter cohort of VAP in trauma patients. The conclusions of both secondary analysis were: bacteremia is an independent risk factor associated with increased mortality in intubated patients with NP. Therefore, recognition of risk factors is important for good clinical practice. Our findings support the need for blood cultures in hospitalized patients with NP. The VAP is associated with lower mortality in trauma patients than in trauma patients. Given the high incidence of VAP in trauma patients, various prevention strategies should be directed to reduce its incidence

Bacterièmia en la pneumònia nosocomial i pneumònia associada a ventilació mecànica en pacients traumàtics : resultats de l'eu-pneumonia survey 2005 /

Nosocomial pneumonia (NP) is the second most common nosocomial infection in hospitalized patients being ventilator-associated pneumonia (VAP), the leading nosocomial infection in Intensive Care Units (ICU) and represents over 80% of all episodes of NP. The frequency ranges of NP ranging between five and ten cases per 1,000 hospital admissions, and increases from 6 to 20 times in patients undergoing mechanical ventilation (MV). Due to the importance of pneumonia that requires VM with respect to the frequency, mortality and healthcare costs, medical literature is full of discussions about the methods to be used to diagnose pneumonia in ICU. However, there is a big difference between the importance of this entity and the limited information on actual practice. Given this lack of information in our field, we designed the study EU-PNEUMONIA Survey 2005 to examine prospectively the clinical diagnosis of all types of pneumonia requiring MV in a large sample from 27 ICUs of nine european countries in order to define the actual clinical practice of pneumonia in ventilated patients. The availability of epidemiological data, etiology, risk factors and outcomes of such a large sample of patients has allowed us to analyze and extract data from multiple subgroups that have specific characteristics that distinguish the group as a whole. Within this broad sample of patients diagnosed with pneumonia who require MV, there are two major subgroups of patients who have undergone multiple studies about the etiology, epidemiology, risk factors and mortality. These two subgroups, which are the objectives of this thesis and analysis are: bacteremic NP and VAP in trauma patients. Since in some UCIs blood cultures are not performed as a diagnostic protocol for patients suspected of NP and this information provides useful data on the epidemiological information on the causative pathogen of the NP and its resistance, a second analysis was conducted. On the other hand, a major cause of morbidity and mortality in industrialized countries are trauma patients. Many of them require admission to ICU and requiring MV. In trauma patients undergoing the MV, VAP is one of the major complications with an incidence of approximately 40 to 50%. Although, in recent decades several studies show that mortality of patients in the trauma VAP is 8% to 59%, in other recent studies we found that the VAP does not seem to increase mortality in trauma patients. The VAP in trauma patients differs from the VAP in patients non- trauma because it was not related to the days of MV and is frequently associated with specific pathogens. To examine differences in the etiology, risk factors and outcomes of this subgroup of patients was realize a second analysis of this multicenter cohort of VAP in trauma patients. The conclusions of both secondary analysis were: bacteremia is an independent risk factor associated with increased mortality in intubated patients with NP. Therefore, recognition of risk factors is important for good clinical practice. Our findings support the need for blood cultures in hospitalized patients with NP. The VAP is associated with lower mortality in trauma patients than in trauma patients. Given the high incidence of VAP in trauma patients, various prevention strategies should be directed to reduce its incidence.La pneumonia nosocomial (PN) és la segona infecció nosocomial més freqüent en pacients hospitalitzats, sent la pneumonia asociada a ventilació mecànica (PAV) la infecció nosocomial líder a les UCIs i representa més del 80% de tots els episodis de PN. Els rangs de freqüència de la PN oscil·len entre cinc i deu casos per cada 1.000 ingressos hospitalaris, i augmenta de 6 a 20 vegades en pacients sotmesos a ventilació mecànica (VM). Donada la importància de la pneumònia que requereix VM respecte a la freqüència, la mortalitat, i els costos sanitaris, la literatura mèdica és plena de discussions sobre els mètodes que s'han d'utilitzar per diagnosticar la pneumònia en les UCIs. No obstant això, hi ha una gran desproporció entre el pes d'aquesta entitat i la poca informació sobre la pràctica real. Davant d'aquesta manca de informació en el nostre àmbit, es va dissenyar l'estudi EU-PNEUMONIA Survey 2005 per examinar de manera prospectiva el diagnòstic clínic de tots els tipus de pneumònia que requerien VM en una gran mostra de 27 UCIs de nou països europeus amb l'objectiu de definir millor la pràctica clínica real de la pneumònia en pacients ventilats. El fet de disposar de dades epidemiològiques, etiologia, factors de risc i outcomes d'una mostra tan àmplia de pacients, ens ha permès analitzar i extreure dades de múltiples subgrups que presenten característiques específiques i que els diferencien del grup en conjunt. Dins d'aquesta àmplia mostra de pacients recollits diagnosticats de pneumònia que van precisar de VM, existeixen dos grans subgrups de malalts que han estat objecte de múltiples estudis en quan a l'etiologia, epidemiologia, factors de risc i mortalitat. Aquests dos grans subgrups, que són els objectius d'anàlisi d'aquesta tesi i són: la PN bacterièmica i la PAV en pacients politraumàtics. Donat que en algunes UCIs no es realitzen hemocultius com a protocol de diagnòstic en pacients amb sospita de PN i que aquesta informació proporciona dades útils en la informació epidemiològica sobre el patogen causal de la PN i de la seva resistència, es va realitzar un segon anàlisi d'aquesta cohort multicèntrica de pacients amb PN. Per altra banda, una de les principals causes de morbiditat i mortalitat en els països industrialitzats són els pacients politraumàtics. Molts d'ells requereixen ingrés a UCI i precisen VM. En els pacients traumàtics sotmesos a VM la PAV és una de les complicacions principals amb una incidència aproximadament del 40 al 50%. Encara que, en les últimes dècades diversos estudis mostren que la mortalitat de la PAV en els pacients politraumàtics és del 8% al 59%, recentment en altres estudis, s'ha observat que la PAV no sembla augmentar la taxa de mortalitat en els pacients traumàtics severs . La PAV en els pacients traumàtics difereix de la PAV en els pacients no traumàtics pel fet que no es relaciona amb els dies de VM i s'associa freqüentment a patògens específics. Per analitzar les diferències en l'etiologia, factors de risc i outcomes d'aquest subgrup de malalts es va realizar un segon anàlisi d'aquesta cohort multicèntrica de pacients traumàtics amb PAV. Les conclusions d'ambdós subanàlisi foren: la bacterièmia és un factor de risc independent associat a un augment de la mortalitat en els pacients intubats amb PN. Per tant, el reconeixement dels factors de risc és rellevant per a una bona pràctica clínica. Les nostres troballes recolzen la necessitat de realitzar hemocultius en pacients hospitalitzats amb PN. La PAV s'associa a una menor mortalitat en els pacients traumàtics que en els pacients no traumàtics. Donada l'alta incidència de PAV en els pacients traumàtics, diferents estratègies de prevenció haurien d'estar dirigides per disminuir la seva incidència

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society