Is ventilated hospital-acquired pneumonia a worse entity than ventilator-associated pneumonia?

IntroductionNosocomial pneumonia develops after ≥48 h of hospitalisation and is classified as ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP); the latter may require mechanical ventilation (V-HAP) or not (NV-HAP).Main findingsVAP and HAP affect a significant proportion of hospitalised patients and are characterised by poor clinical outcomes. Among them, V-HAP has the greatest 28-day mortality rate followed by VAP and NV-HAP (27.8% versus 18% versus 14.5%, respectively). However, no differences in terms of pathophysiology, underlying microbiological pathways and subsequent therapy have been identified. International guidelines suggest specific flow charts to help clinicians in the therapeutic management of such diseases; however, there are no specific recommendations beyond VAP and HAP classification. HAP subtypes are scarcely considered as different entities and the lack of data from the clinical scenario limits any final conclusion. Hopefully, recent understanding of the pathophysiology of such diseases, as well as the discovery of new therapies, will improve the outcome associated with such pulmonary infections.ConclusionNosocomial pneumonia is a multifaced disease with features of pivotal interest in critical care medicine. Due to the worrisome data on mortality of patients with nosocomial pneumonia, further prospective studies focused on this topic are urgently needed

Double carbapenem as a rescue strategy for the treatment of severe carbapenemase-producing Klebsiella pneumoniae infections: A two-center, matched case-control study

Background: Recent reports have suggested the efficacy of a double carbapenem (DC) combination, including ertapenem, for the treatment of carbapenem-resistant Klebsiella pneumoniae (CR-Kp) infections. We aimed to evaluate the clinical impact of such a regimen in critically ill patients. Methods: This case-control (1:2), observational, two-center study involved critically ill adults with a microbiologically documented CR-Kp invasive infection treated with the DC regimen matched with those receiving a standard treatment (ST) (i.e., colistin, tigecycline, or gentamicin). Results: The primary end point was 28-day mortality. Secondary outcomes were clinical cure, microbiological eradication, duration of mechanical ventilation and of vasopressors, and 90-day mortality. Forty-eight patients treated with DC were matched with 96 controls. Occurrence of septic shock at infection and high procalcitonin levels were significantly more frequent in patients receiving DC treatment (p < 0.01). The 28-day mortality was significantly higher in patients receiving ST compared with the DC group (47.9% vs 29.2%, p = 0.04). Similarly, clinical cure and microbiological eradication were significantly higher when DC was used in patients infected with CR-Kp strains resistant to colistin (13/20 (65%) vs 10/32 (31.3%), p = 0.03 and 11/19 (57.9%) vs 7/27 (25.9%), p = 0.04, respectively). In the logistic regression and multivariate Cox-regression models, the DC regimen was associated with a reduction in 28-day mortality (OR 0.33, 95% CI 0.13-0.87 and OR 0.43, 95% CI 0.23-0.79, respectively). Conclusions: Improved 28-day mortality was associated with the DC regimen compared with ST for severe CR-Kp infections. A randomized trial is needed to confirm these observational results. Trial registration: ClinicalTrials.gov NCT03094494. Registered 28 March 2017

Risk factors for mortality in elderly and very elderly critically ill patients with sepsis: a prospective, observational, multicenter cohort study

Elderly; ICU; SepsisAncià; UCI; SèpsiaAnciano; UCI; SepsisBACKGROUND: Age has been traditionally considered a risk factor for mortality in elderly patients admitted to intensive care units. The aim of this prospective, observational, multicenter cohort study is to determine the risk factors for mortality in elderly and very elderly critically ill patients with sepsis. RESULTS: A total of 1490 patients with ≥ 65 years of age were included in the study; most of them 1231 (82.6%) had a cardiovascular failure. The mean age (± SD) was 74.5 (± 5.6) years, and 876 (58.8%) were male. The patients were divided into two cohorts: (1) elderly: 65-79 years and (2) very elderly: ≥ 80 years. The overall hospital mortality was 48.8% (n = 727) and was significantly higher in very elderly compared to elderly patients (54.2% vs. 47.4%; p = 0.02). Factors independently associated with mortality were APACHE II score of the disease, patient location at sepsis diagnosis, development of acute kidney injury, and thrombocytopenia in the group of elderly patients. On the other hand, in the group of very elderly patients, predictors of hospital mortality were age, APACHE II score, and prompt adherence of the resuscitation bundle. CONCLUSION: This prospective multicenter study found that patients aged 80 or over had higher hospital mortality compared to patients between 65 and 79 years. Age was found to be an independent risk factor only in the very elderly group, and prompt therapy provided within the first 6 h of resuscitation was associated with a reduction in hospital mortality in the very elderly patients

Risk factors for mortality in elderly and very elderly critically ill patients with sepsis: a prospective, observational, multicenter cohort study

Abstract Background Age has been traditionally considered a risk factor for mortality in elderly patients admitted to intensive care units. The aim of this prospective, observational, multicenter cohort study is to determine the risk factors for mortality in elderly and very elderly critically ill patients with sepsis. Results A total of 1490 patients with ≥ 65 years of age were included in the study; most of them 1231 (82.6%) had a cardiovascular failure. The mean age (± SD) was 74.5 (± 5.6) years, and 876 (58.8%) were male. The patients were divided into two cohorts: (1) elderly: 65–79 years and (2) very elderly: ≥ 80 years. The overall hospital mortality was 48.8% (n = 727) and was significantly higher in very elderly compared to elderly patients (54.2% vs. 47.4%; p = 0.02). Factors independently associated with mortality were APACHE II score of the disease, patient location at sepsis diagnosis, development of acute kidney injury, and thrombocytopenia in the group of elderly patients. On the other hand, in the group of very elderly patients, predictors of hospital mortality were age, APACHE II score, and prompt adherence of the resuscitation bundle. Conclusion This prospective multicenter study found that patients aged 80 or over had higher hospital mortality compared to patients between 65 and 79 years. Age was found to be an independent risk factor only in the very elderly group, and prompt therapy provided within the first 6 h of resuscitation was associated with a reduction in hospital mortality in the very elderly patients

Correction to: Risk factors for mortality in elderly and very elderly critically ill patients with sepsis: a prospective, observational, multicenter cohort study

Following the publication of the original article [1], the author reported a mistake in Fig. 1

CO₂ driven endotracheal tube cuff control in critically ill patients: A randomized controlled study

<div><p>Background</p><p>To determine the safety and clinical efficacy of an innovative integrated airway system (AnapnoGuard^™ 100 system) that continuously monitors and controls the cuff pressure (P_cuff), while facilitating the aspiration of subglottic secretions (SS).</p><p>Methods</p><p>This was a prospective, single centre, open-label, randomized, controlled feasibility and safety trial. The primary endpoint of the study was the rate of device related adverse events (AE) and serious AE (SAE) as a result of using AnapnoGuard (AG) 100 during mechanical ventilation. Secondary endpoints were: (1) mechanical complications rate (2) ICU staff satisfaction; (3) VAP occurrence; (4) length of mechanical ventilation; (5) length of Intensive Care Unit stay and mortality; (6) volume of evacuated subglottic secretions.</p><p>Sixty patients were randomized to be intubated with the AG endotracheal-tube (ETT) and connected to the AG 100 system allowing P_cuff adjustment and SS aspiration; or with an ETT combined with SS drainage and P_cuff controlled manually.</p><p>Results</p><p>No difference in adverse events rate was identified between the groups. The use of AG system was associated with a significantly higher incidence of P_cuff determinations in the safety range (97.3% vs. 71%; <i>p</i><0.01) and a trend to a greater volume of aspirated SS secretions: (192.0[64–413] ml vs. 150[50–200], <i>p</i> = 0.19 (total)); (57.8[20–88.7] ml vs. 50[18.7–62] ml, <i>p</i> = 0.11 (daily)). No inter-group difference was detected using AG system vs. controls in terms of post-extubation throat pain level (0 [0–2] vs. 0 [0–3]; <i>p</i> = 0.7), hoarseness (42.9% vs. 75%; p = 0.55) and tracheal mucosa oedema (16.7% vs. 10%; <i>p</i> = 0.65).</p><p>Patients enrolled in the AG group had a trend to reduced VAP risk of ventilator-associated pneumonia(VAP) (14.8% vs. 40%; <i>p</i> = 0.06), which were more frequently monomicrobial (25% vs. 70%; <i>p</i> = 0.03).</p><p>No statistically significant difference was observed in duration of mechanical ventilation, ICU stay, and mortality.</p><p>Conclusions</p><p>The use AG 100 system and AG tube in critically ill intubated patients is safe and effective in P_cuff control and SS drainage. Its protective role against VAP needs to be confirmed in a larger randomized trial.</p><p>Trial registration</p><p>ClinicalTrials.gov <a href="https://clinicaltrials.gov/ct2/show/NCT01550978" target="_blank">NCT01550978</a>. Date of registration: February 21, 2012.</p></div

Automatic endotracheal tube cuff pressure closed loop adjustment.

<p>Automatic endotracheal tube cuff pressure closed loop adjustment.</p

Baseline patient characteristics.

<p>Baseline patient characteristics.</p

Comparison between AG group and control group according to total SS drained.

<p>Comparison between AG group and control group according to total SS drained.</p

Flow chart of study inclusion process.

<p><i>ED</i>, Emergency Department; <i>BMI</i>, Body Mass Index *Patients connected to either AG 110 system or subglottic suction system after 6 hours from tracheal intubation **The reasons for excluding patients at admission were: suspicion of pneumonia and lung contusion on chest X ray (n = 375); mechanical ventilation during previous three months (n = 58); facial, oropharingeal and neck trauma (n = 123); difficult intubation (n = 28); BMI >40 (n = 16).</p