Emad Ibrahim - Academia.edu (original) (raw)

Papers by Emad Ibrahim

Research paper thumbnail of Laparoscopic Management of Adhesions Developed after Peritoneal Nonclosure in Primary Cesarean Section Delivery

Obstetrics and gynecology international, 2018

The aim of the current study was to laparoscopically investigate the effects of peritoneal nonclo... more The aim of the current study was to laparoscopically investigate the effects of peritoneal nonclosure on the sites, types, and degrees of adhesions developed after primary caesarean section (CS) in women complaining of secondary infertility after first CS delivery. This was a cross-sectional study, where 250 women suffering from secondary infertility after their first CS had been recruited. They had been classified into group I ( = 89), where both the visceral and parietal peritoneum had been left opened; group II ( = 75), where only the parietal peritoneum had been closed; and group III ( = 86), where both peritoneal layers had been closed. Laparoscopy had been used to classify those adhesions according to the location, severity, and their adverse impact on the reproductive capacity. Both adnexal and nonadnexal adhesions had been found significantly higher in group I, while adnexal types of adhesions were significantly higher after nonclosure of the visceral peritoneum in group II....

Research paper thumbnail of Hepatocyte growth factor and the risk of pulmonary embolism

Egyptian Journal of Chest Diseases and Tuberculosis, 2014

Background: Diagnosis of pulmonary embolism (PE) in early stages by conventional laboratory metho... more Background: Diagnosis of pulmonary embolism (PE) in early stages by conventional laboratory methods is difficult because the currently available tests lack sufficient sensitivity and specificity. Hepatocyte growth factor (HGF) was originally regarded as specific to hepatocytes, but has been found to be identical to the scatter factor affecting a wide range of tissues including the lungs. The aim of this work is to study the relationship between HGF and PE. Patients and methods: This study included 40 patients with PE, 40 stable angina (SA) patients, and 10 healthy controls. HGF and D-dimer were measured in all patients of this study. Results: Mean HGF was significantly higher in the PE group (788.8 ± 361.5 pg/ml) compared to the SA group (262.4 ± 158.1 pg/ml) and control group (215.5 ± 18.5 pg/ml) (P = 0.0001). The predictive values of D-dimer in the diagnosis of PE were as follows: 100% sensitivity and negative predictive value, 80% specificity, 83.3% positive predictive value and 90% accuracy, while those of HGF were: 97.5% sensitivity, 97.4% negative predictive value, 92.5% specificity, 92.9% positive predictive value and 95% accuracy. When used both D-dimer and HGF together the values improved to: 100% sensitivity and negative predictive value, 97.5% specificity, 97.6% positive predictive value and 98.8% accuracy.

Research paper thumbnail of Assessment of risk factors responsible for difficult weaning from mechanical ventilation in adults

Egyptian Journal of Chest Diseases and Tuberculosis, 2012

The aim of this work is to identify the most important risk factors responsible for difficult wea... more The aim of this work is to identify the most important risk factors responsible for difficult weaning from mechanical ventilation in adult patients. Design: A prospective cohort study. Setting: Respiratory Intensive care unit of Alexandria main University Hospitals. Patients: Thirty one patients requiring mechanical ventilation with difficult weaning according to Brochard's classification. Methods: After failure of weaning on PSV mode of mechanical ventilation, the patient is reevaluated to detect the risk factors responsible for difficult weaning. Results: Eighteen patients (58%) were successfully weaned and thirteen (42%) failed weaning trials and finally died. Of the thirty-one studied cases, 16 (52%) were males. Mean age of the studied patients was 57.7 ± 15 and mean BMI was 30 ± 7.9. Twenty-one patients (67.7%) required prolonged mechanical ventilation and ten (32%) required less than 14 days. Mean of Rapid Shallow Breathing Index measured during SBT was 56 ± 9 breaths/min per L among cases who were successfully weaned from MV and 122 ± 19 breaths/min per L among those who failed weaning trials. Mean CROP index value was 38.7 ± 11 ml/breath per min among cases who were successfully weaned and of significantly lower value 7.5 ± 2.6 ml/breath per min among those who failed weaning trials & finally died, (p = 0.00). In the present work; risk factors that found to be responsible for failure of weaning trials were recent infections (pulmonary and/or extra-pulmonary) that were detected in all the studied cases (100%), disturbances in the trace elements & electrolytes in 26 cases (83.8%

Research paper thumbnail of Emergency Percutaneous Tracheotomy in Failed Intubation

Research paper thumbnail of The Role of the Biomarker and the Genetic Polymorphism of Endothelin-1 in Pulmonary Arterial Hypertension Among Egyptians

Research paper thumbnail of A Comparative Analysis of Patients With Early-Onset vs Late-Onset Nosocomial Pneumonia in the ICU Setting

Chest, 2000

To compare the clinical outcomes of critically ill patients developing early-onset nosocomial pne... more To compare the clinical outcomes of critically ill patients developing early-onset nosocomial pneumonia (NP; ie, within 96 h of ICU admission) and late-onset NP (ie, occurring after 96 h of ICU admission). Design: Prospective cohort study. Setting: A medical ICU and a surgical ICU from a university-affiliated urban teaching hospital. Patients: Between July 1997 and November 1998, 3,668 patients were prospectively evaluated. Intervention: Prospective patient surveillance and data collection. Results: Four hundred twenty patients (11.5%) developed NP. Early-onset NP was observed in 235 patients (56.0%), whereas 185 patients (44.0%) developed late-onset NP. Among patients with early onset NP, 114 patients (48.5%) spent at least 24 h in the hospital prior to ICU admission, compared to 57 patients (30.8%) with late-onset NP (p ‫؍‬ 0.001). One hundred eighty-three patients (77.9%) with early-onset NP received antibiotics prior to the development of NP, as compared to 162 patients (87.6%) with late-onset NP (p ‫؍‬ 0.010). The most common pathogens associated with early-onset NP were Pseudomonas aeruginosa (25.1%), oxacillin-sensitive Staphylococcus aureus (OSSA; 17.9%), oxacillin-resistant S aureus (ORSA; 17.9%), and Enterobacter species (10.2%). P aeruginosa (38.4%), ORSA (21.1%), Stenotrophomonas maltophilia (11.4%), OSSA (10.8%), and Enterobacter species (10.3%) were the most common pathogens associated with late-onset NP. The ICU length of stay was significantly longer for patients with early-onset NP (10.3 ؎ 8.3 days; p < 0.001) and late-onset NP (21.0 ؎ 13.7 days; p < 0.001), as compared to patients without NP (3.5 ؎ 3.2 days). Hospital mortality was significantly greater for patients with early-onset NP (37.9%; p ‫؍‬ 0.001) and late-onset NP (41.1%; p ‫؍‬ 0.001) compared to patients without NP (13.1%). Conclusions: Both early-onset and late-onset NP are associated with increased hospital mortality rates and prolonged lengths of stay. The pathogens associated with NP were similar for both groups. This may be due, in part, to the prior hospitalization and use of antibiotics in many patients developing early-onset NP. These data suggest that P aeruginosa and ORSA can be important pathogens associated with early-onset NP in the ICU setting. Additionally, clinicians should be aware of the common microorganisms associated with both early-onset NP and late-onset NP in their hospitals in order to avoid the administration of inadequate antimicrobial treatment.

Research paper thumbnail of The Influence of Inadequate Antimicrobial Treatment of Bloodstream Infections on Patient Outcomes in the ICU Setting

Chest, 2000

To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infe... more To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission. Design: Prospective cohort study. Setting: A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital. Patients: Between July 1997 and July 1999, 492 patients were prospectively evaluated. Intervention: Prospective patient surveillance and data collection. Results: One hundred forty-seven patients (29.9%) received inadequate antimicrobial treatment for their bloodstream infections. The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment (61.9%) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment (28.4%; relative risk, 2.18; 95% confidence interval [CI], 1.77 to 2.69; p < 0.001). Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality (adjusted odds ratio [AOR], 6.86; 95% CI, 5.09 to 9.24; p < 0.001). The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n ‫؍‬ 17; 100%), Candida species (n ‫؍‬ 41; 95.1%), oxacillin-resistant Staphylococcus aureus (n ‫؍‬ 46; 32.6%), coagulase-negative staphylococci (n ‫؍‬ 96; 21.9%), and Pseudomonas aeruginosa (n ‫؍‬ 22; 10.0%). A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality (Spearman correlation coefficient ‫؍‬ 0.8287; p ‫؍‬ 0.006). Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to Candida species (AOR, 51.86; 95% CI, 24.57 to 109.49; p < 0.001), prior administration of antibiotics during the same hospitalization (AOR, 2.08; 95% CI, 1.58 to 2.74; p ‫؍‬ 0.008), decreasing serum albumin concentrations (1-g/dL decrements) (AOR, 1.37; 95% CI, 1.21 to 1.56; p ‫؍‬ 0.014), and increasing central catheter duration (1-day increments) (AOR, 1.03; 95% CI, 1.02 to 1.04; p ‫؍‬ 0.008) were independently associated with the administration of inadequate antimicrobial treatment. Conclusions: The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections. These data suggest that clinical efforts should be aimed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections, especially individuals infected with antibioticresistant bacteria and Candida species.

Research paper thumbnail of Sleep-Related Breathing Disorders in Patients With Schistosomal Cor Pulmonale

CHEST Journal, 2012

Schistosmiasis has long been an endemic disease in Egypt and an important cause of pulmonary hype... more Schistosmiasis has long been an endemic disease in Egypt and an important cause of pulmonary hypertension. Objectives: We aimed to investigate the clinical and polysomnographic features of sleep-related breathing disorders (SRBD) in patients with schistosomal cor-pulmonale and to evaluate their effects on pulmonary hemodynamics. Patients and methods: We studied 10 stable patients diagnosed with schistosomal pulmonary hypertension (7 males and 3 females their mean age was 43.7 ± 8.04) and 10 healthy volunteers matched for age, sex and BMI. Patients' exclusion criteria were: smoking, morbid obesity, other secondary causes of pulmonary hypertension, systemic hypertension, ischemic or rheumatic heart disease or left heart failure. All patients underwent overnight polysomnography or ambulatory cardiorespiratory sleep studies, spirometry, ECG and echocardiography. Daytime sleepiness was also assessed using the Epworth sleepiness scale (ESS). Results: The mean AHI in patients group was 20.0 ± 11.34/h while in the control group it was 2.3 ± 1.16/h. 80% of the patients were found to have an AHI > 10/h and 60% had moderate to severe sleep apnea (AHI P 15/h). In addition, the majority of the patients (80%) spent > 30% of the night with an arterial oxygen saturation <90%. SRBD were not correlated with anthropometric measures, spirometry nor with the typical symptoms of SA such as excessive sleepiness as assessed by ESS. More importantly, SRBD were significantly associated with measures of pulmonary hypertension severity, and patients with moderate to severe SA had more impaired cardiovas

Research paper thumbnail of The Occurrence of Ventilator-Associated Pneumonia in a Community Hospital

Chest, 2001

Study objectives: To prospectively identify the occurrence of ventilator-associated pneumonia (VA... more Study objectives: To prospectively identify the occurrence of ventilator-associated pneumonia (VAP) in a community hospital, and to determine the risk factors for VAP and the influence of VAP on patient outcomes in a nonteaching institution. Design: Prospective cohort study. Setting: A medical ICU and a surgical ICU in a 500-bed private community nonteaching hospital: Missouri Baptist Hospital. Patients: Between March 1998 and December 1999, all patients receiving mechanical ventilation who were admitted to the ICU setting were prospectively evaluated. Intervention: Prospective patient surveillance and data collection. Results: During a 22-month period, 3,171 patients were admitted to the medical and surgical ICUs. Eight hundred eighty patients (27.8%) received mechanical ventilation. VAP developed in 132 patients (15.0%) receiving mechanical ventilation. Three hundred one patients (34.2%) who received mechanical ventilation died during hospitalization. Logistic regression analysis demonstrated that tracheostomy (adjusted odds ratio [AOR], 6.71; 95% confidence interval [CI], 3.91 to 11.50; p < 0.001), multiple central venous line insertions (AOR, 4.20; 95% CI, 2.72 to 6.48; p < 0.001), reintubation (AOR, 2.88; 95% CI, 1.78 to 4.66; p < 0.001), and the use of antacids (AOR, 2.81; 95% CI, 1.19 to 6.64; p ‫؍‬ 0.019) were independently associated with the development of VAP. The hospital mortality of patients with VAP was significantly greater than the mortality of patients without VAP (45.5% vs 32.2%, respectively; p ‫؍‬ 0.004). The occurrence of bacteremia, compromised immune system, higher APACHE (acute physiology and chronic health evaluation) II scores, and older age were identified as independent predictors of hospital mortality. Conclusions: These data suggest that VAP is a common nosocomial infection in the community hospital setting. The risk factors for the development of VAP and risk factors for hospital mortality in a community hospital are similar to those identified from university-affiliated hospitals. These risk factors can potentially be employed to develop local strategies for the prevention of VAP. Clinical implications: ICU clinicians should be aware of the risk factors associated with the development of VAP and the impact of VAP on clinical outcomes. More importantly, they should cooperate in the development of local multidisciplinary strategies aimed at the prevention of VAP and other nosocomial infections.

Research paper thumbnail of Experience with a clinical guideline for the treatment of ventilator-associated pneumonia

Critical Care Medicine, 2001

Research paper thumbnail of The Impact of VAP Staff Education on VAP Morbidity and Mortality in Alexandria University

Background: Staff education had several success stories in reducing Ventilator-associated Pneumon... more Background: Staff education had several success stories in reducing Ventilator-associated Pneumonia (VAP) rate. However, the stability of supplies and the top management support were not addressed in most of these studies. In addition, both were considered essential in several reviews.
Aim: To determine the efficiency (VAP rate) and efficacy (mechanical ventilation morbidity and mortality) of VAP staff education with deficient supplies and lack of top management support.
Methods: Quasi-experimental study with before and after prospective cohort in two medical/surgical ICUs of Alexandria university affiliated hospitals during the period from September 2007 till May 2013. The intervention phase included the provision of supplementary supplies,
interactive education for physicians and nurses followed by a VAP campaign. All VAP episodes not only the first one was included.
Results: A total of 598 patients were enrolled in the study. The adherence to expanded VAP bundle significantly increased in the post-intervention phase as follows; head of bed elevation (from mean of 40 to 100% with p=0.001), oral care (from mean of 20 to 100% with p=0.001),
daily sedation vacation (from mean of 56.5 to 91% with p=0.001), daily assessment of weaning (from mean of 9 to 25% with p=0. 03), peptic ulcer prophylaxis (from mean of 83 to 100% with p=0.001), DVT prophylaxis (from mean of 82 to 100% and p=0.001), cuff pressure measurement (from mean of 9 to 60% with p=0.001), and hand hygiene (from mean of 8 to 28.5% with p=0.001).The VAP rate decreased significantly by 35% (from 66.5 to 43 per 1000 MV days) with p= 0.002 and CI 9.73-37.15 in spite of significant increase of the ventilator utilization ratio (p <0.001) in the post-intervention phase. The MV, antibiotic and ICU days did not change significantly in the post-intervention phase. The distribution of organisms did not differ significantly between both groups (p=0. 465). The sensitivity of most of carbapenems and β-lactam/β-lactamase inhibitors to Acinetobacter, Klebsiella andPseudomonas decreased significantly in the post intervention phase whereas the sensitivity of vancomyicin to Staphylococcus aureus remained the same.
Conclusions: In spite of the lack of top management support and fluctuating supplies, VAP staff education was still efficient in reducing VAP without affecting mortality or MV days or ICU length of stay.

Research paper thumbnail of Laparoscopic Management of Adhesions Developed after Peritoneal Nonclosure in Primary Cesarean Section Delivery

Obstetrics and gynecology international, 2018

The aim of the current study was to laparoscopically investigate the effects of peritoneal nonclo... more The aim of the current study was to laparoscopically investigate the effects of peritoneal nonclosure on the sites, types, and degrees of adhesions developed after primary caesarean section (CS) in women complaining of secondary infertility after first CS delivery. This was a cross-sectional study, where 250 women suffering from secondary infertility after their first CS had been recruited. They had been classified into group I ( = 89), where both the visceral and parietal peritoneum had been left opened; group II ( = 75), where only the parietal peritoneum had been closed; and group III ( = 86), where both peritoneal layers had been closed. Laparoscopy had been used to classify those adhesions according to the location, severity, and their adverse impact on the reproductive capacity. Both adnexal and nonadnexal adhesions had been found significantly higher in group I, while adnexal types of adhesions were significantly higher after nonclosure of the visceral peritoneum in group II....

Research paper thumbnail of Hepatocyte growth factor and the risk of pulmonary embolism

Egyptian Journal of Chest Diseases and Tuberculosis, 2014

Background: Diagnosis of pulmonary embolism (PE) in early stages by conventional laboratory metho... more Background: Diagnosis of pulmonary embolism (PE) in early stages by conventional laboratory methods is difficult because the currently available tests lack sufficient sensitivity and specificity. Hepatocyte growth factor (HGF) was originally regarded as specific to hepatocytes, but has been found to be identical to the scatter factor affecting a wide range of tissues including the lungs. The aim of this work is to study the relationship between HGF and PE. Patients and methods: This study included 40 patients with PE, 40 stable angina (SA) patients, and 10 healthy controls. HGF and D-dimer were measured in all patients of this study. Results: Mean HGF was significantly higher in the PE group (788.8 ± 361.5 pg/ml) compared to the SA group (262.4 ± 158.1 pg/ml) and control group (215.5 ± 18.5 pg/ml) (P = 0.0001). The predictive values of D-dimer in the diagnosis of PE were as follows: 100% sensitivity and negative predictive value, 80% specificity, 83.3% positive predictive value and 90% accuracy, while those of HGF were: 97.5% sensitivity, 97.4% negative predictive value, 92.5% specificity, 92.9% positive predictive value and 95% accuracy. When used both D-dimer and HGF together the values improved to: 100% sensitivity and negative predictive value, 97.5% specificity, 97.6% positive predictive value and 98.8% accuracy.

Research paper thumbnail of Assessment of risk factors responsible for difficult weaning from mechanical ventilation in adults

Egyptian Journal of Chest Diseases and Tuberculosis, 2012

The aim of this work is to identify the most important risk factors responsible for difficult wea... more The aim of this work is to identify the most important risk factors responsible for difficult weaning from mechanical ventilation in adult patients. Design: A prospective cohort study. Setting: Respiratory Intensive care unit of Alexandria main University Hospitals. Patients: Thirty one patients requiring mechanical ventilation with difficult weaning according to Brochard's classification. Methods: After failure of weaning on PSV mode of mechanical ventilation, the patient is reevaluated to detect the risk factors responsible for difficult weaning. Results: Eighteen patients (58%) were successfully weaned and thirteen (42%) failed weaning trials and finally died. Of the thirty-one studied cases, 16 (52%) were males. Mean age of the studied patients was 57.7 ± 15 and mean BMI was 30 ± 7.9. Twenty-one patients (67.7%) required prolonged mechanical ventilation and ten (32%) required less than 14 days. Mean of Rapid Shallow Breathing Index measured during SBT was 56 ± 9 breaths/min per L among cases who were successfully weaned from MV and 122 ± 19 breaths/min per L among those who failed weaning trials. Mean CROP index value was 38.7 ± 11 ml/breath per min among cases who were successfully weaned and of significantly lower value 7.5 ± 2.6 ml/breath per min among those who failed weaning trials & finally died, (p = 0.00). In the present work; risk factors that found to be responsible for failure of weaning trials were recent infections (pulmonary and/or extra-pulmonary) that were detected in all the studied cases (100%), disturbances in the trace elements & electrolytes in 26 cases (83.8%

Research paper thumbnail of Emergency Percutaneous Tracheotomy in Failed Intubation

Research paper thumbnail of The Role of the Biomarker and the Genetic Polymorphism of Endothelin-1 in Pulmonary Arterial Hypertension Among Egyptians

Research paper thumbnail of A Comparative Analysis of Patients With Early-Onset vs Late-Onset Nosocomial Pneumonia in the ICU Setting

Chest, 2000

To compare the clinical outcomes of critically ill patients developing early-onset nosocomial pne... more To compare the clinical outcomes of critically ill patients developing early-onset nosocomial pneumonia (NP; ie, within 96 h of ICU admission) and late-onset NP (ie, occurring after 96 h of ICU admission). Design: Prospective cohort study. Setting: A medical ICU and a surgical ICU from a university-affiliated urban teaching hospital. Patients: Between July 1997 and November 1998, 3,668 patients were prospectively evaluated. Intervention: Prospective patient surveillance and data collection. Results: Four hundred twenty patients (11.5%) developed NP. Early-onset NP was observed in 235 patients (56.0%), whereas 185 patients (44.0%) developed late-onset NP. Among patients with early onset NP, 114 patients (48.5%) spent at least 24 h in the hospital prior to ICU admission, compared to 57 patients (30.8%) with late-onset NP (p ‫؍‬ 0.001). One hundred eighty-three patients (77.9%) with early-onset NP received antibiotics prior to the development of NP, as compared to 162 patients (87.6%) with late-onset NP (p ‫؍‬ 0.010). The most common pathogens associated with early-onset NP were Pseudomonas aeruginosa (25.1%), oxacillin-sensitive Staphylococcus aureus (OSSA; 17.9%), oxacillin-resistant S aureus (ORSA; 17.9%), and Enterobacter species (10.2%). P aeruginosa (38.4%), ORSA (21.1%), Stenotrophomonas maltophilia (11.4%), OSSA (10.8%), and Enterobacter species (10.3%) were the most common pathogens associated with late-onset NP. The ICU length of stay was significantly longer for patients with early-onset NP (10.3 ؎ 8.3 days; p < 0.001) and late-onset NP (21.0 ؎ 13.7 days; p < 0.001), as compared to patients without NP (3.5 ؎ 3.2 days). Hospital mortality was significantly greater for patients with early-onset NP (37.9%; p ‫؍‬ 0.001) and late-onset NP (41.1%; p ‫؍‬ 0.001) compared to patients without NP (13.1%). Conclusions: Both early-onset and late-onset NP are associated with increased hospital mortality rates and prolonged lengths of stay. The pathogens associated with NP were similar for both groups. This may be due, in part, to the prior hospitalization and use of antibiotics in many patients developing early-onset NP. These data suggest that P aeruginosa and ORSA can be important pathogens associated with early-onset NP in the ICU setting. Additionally, clinicians should be aware of the common microorganisms associated with both early-onset NP and late-onset NP in their hospitals in order to avoid the administration of inadequate antimicrobial treatment.

Research paper thumbnail of The Influence of Inadequate Antimicrobial Treatment of Bloodstream Infections on Patient Outcomes in the ICU Setting

Chest, 2000

To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infe... more To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission. Design: Prospective cohort study. Setting: A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital. Patients: Between July 1997 and July 1999, 492 patients were prospectively evaluated. Intervention: Prospective patient surveillance and data collection. Results: One hundred forty-seven patients (29.9%) received inadequate antimicrobial treatment for their bloodstream infections. The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment (61.9%) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment (28.4%; relative risk, 2.18; 95% confidence interval [CI], 1.77 to 2.69; p < 0.001). Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality (adjusted odds ratio [AOR], 6.86; 95% CI, 5.09 to 9.24; p < 0.001). The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n ‫؍‬ 17; 100%), Candida species (n ‫؍‬ 41; 95.1%), oxacillin-resistant Staphylococcus aureus (n ‫؍‬ 46; 32.6%), coagulase-negative staphylococci (n ‫؍‬ 96; 21.9%), and Pseudomonas aeruginosa (n ‫؍‬ 22; 10.0%). A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality (Spearman correlation coefficient ‫؍‬ 0.8287; p ‫؍‬ 0.006). Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to Candida species (AOR, 51.86; 95% CI, 24.57 to 109.49; p < 0.001), prior administration of antibiotics during the same hospitalization (AOR, 2.08; 95% CI, 1.58 to 2.74; p ‫؍‬ 0.008), decreasing serum albumin concentrations (1-g/dL decrements) (AOR, 1.37; 95% CI, 1.21 to 1.56; p ‫؍‬ 0.014), and increasing central catheter duration (1-day increments) (AOR, 1.03; 95% CI, 1.02 to 1.04; p ‫؍‬ 0.008) were independently associated with the administration of inadequate antimicrobial treatment. Conclusions: The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections. These data suggest that clinical efforts should be aimed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections, especially individuals infected with antibioticresistant bacteria and Candida species.

Research paper thumbnail of Sleep-Related Breathing Disorders in Patients With Schistosomal Cor Pulmonale

CHEST Journal, 2012

Schistosmiasis has long been an endemic disease in Egypt and an important cause of pulmonary hype... more Schistosmiasis has long been an endemic disease in Egypt and an important cause of pulmonary hypertension. Objectives: We aimed to investigate the clinical and polysomnographic features of sleep-related breathing disorders (SRBD) in patients with schistosomal cor-pulmonale and to evaluate their effects on pulmonary hemodynamics. Patients and methods: We studied 10 stable patients diagnosed with schistosomal pulmonary hypertension (7 males and 3 females their mean age was 43.7 ± 8.04) and 10 healthy volunteers matched for age, sex and BMI. Patients' exclusion criteria were: smoking, morbid obesity, other secondary causes of pulmonary hypertension, systemic hypertension, ischemic or rheumatic heart disease or left heart failure. All patients underwent overnight polysomnography or ambulatory cardiorespiratory sleep studies, spirometry, ECG and echocardiography. Daytime sleepiness was also assessed using the Epworth sleepiness scale (ESS). Results: The mean AHI in patients group was 20.0 ± 11.34/h while in the control group it was 2.3 ± 1.16/h. 80% of the patients were found to have an AHI > 10/h and 60% had moderate to severe sleep apnea (AHI P 15/h). In addition, the majority of the patients (80%) spent > 30% of the night with an arterial oxygen saturation <90%. SRBD were not correlated with anthropometric measures, spirometry nor with the typical symptoms of SA such as excessive sleepiness as assessed by ESS. More importantly, SRBD were significantly associated with measures of pulmonary hypertension severity, and patients with moderate to severe SA had more impaired cardiovas

Research paper thumbnail of The Occurrence of Ventilator-Associated Pneumonia in a Community Hospital

Chest, 2001

Study objectives: To prospectively identify the occurrence of ventilator-associated pneumonia (VA... more Study objectives: To prospectively identify the occurrence of ventilator-associated pneumonia (VAP) in a community hospital, and to determine the risk factors for VAP and the influence of VAP on patient outcomes in a nonteaching institution. Design: Prospective cohort study. Setting: A medical ICU and a surgical ICU in a 500-bed private community nonteaching hospital: Missouri Baptist Hospital. Patients: Between March 1998 and December 1999, all patients receiving mechanical ventilation who were admitted to the ICU setting were prospectively evaluated. Intervention: Prospective patient surveillance and data collection. Results: During a 22-month period, 3,171 patients were admitted to the medical and surgical ICUs. Eight hundred eighty patients (27.8%) received mechanical ventilation. VAP developed in 132 patients (15.0%) receiving mechanical ventilation. Three hundred one patients (34.2%) who received mechanical ventilation died during hospitalization. Logistic regression analysis demonstrated that tracheostomy (adjusted odds ratio [AOR], 6.71; 95% confidence interval [CI], 3.91 to 11.50; p < 0.001), multiple central venous line insertions (AOR, 4.20; 95% CI, 2.72 to 6.48; p < 0.001), reintubation (AOR, 2.88; 95% CI, 1.78 to 4.66; p < 0.001), and the use of antacids (AOR, 2.81; 95% CI, 1.19 to 6.64; p ‫؍‬ 0.019) were independently associated with the development of VAP. The hospital mortality of patients with VAP was significantly greater than the mortality of patients without VAP (45.5% vs 32.2%, respectively; p ‫؍‬ 0.004). The occurrence of bacteremia, compromised immune system, higher APACHE (acute physiology and chronic health evaluation) II scores, and older age were identified as independent predictors of hospital mortality. Conclusions: These data suggest that VAP is a common nosocomial infection in the community hospital setting. The risk factors for the development of VAP and risk factors for hospital mortality in a community hospital are similar to those identified from university-affiliated hospitals. These risk factors can potentially be employed to develop local strategies for the prevention of VAP. Clinical implications: ICU clinicians should be aware of the risk factors associated with the development of VAP and the impact of VAP on clinical outcomes. More importantly, they should cooperate in the development of local multidisciplinary strategies aimed at the prevention of VAP and other nosocomial infections.

Research paper thumbnail of Experience with a clinical guideline for the treatment of ventilator-associated pneumonia

Critical Care Medicine, 2001

Research paper thumbnail of The Impact of VAP Staff Education on VAP Morbidity and Mortality in Alexandria University

Background: Staff education had several success stories in reducing Ventilator-associated Pneumon... more Background: Staff education had several success stories in reducing Ventilator-associated Pneumonia (VAP) rate. However, the stability of supplies and the top management support were not addressed in most of these studies. In addition, both were considered essential in several reviews.
Aim: To determine the efficiency (VAP rate) and efficacy (mechanical ventilation morbidity and mortality) of VAP staff education with deficient supplies and lack of top management support.
Methods: Quasi-experimental study with before and after prospective cohort in two medical/surgical ICUs of Alexandria university affiliated hospitals during the period from September 2007 till May 2013. The intervention phase included the provision of supplementary supplies,
interactive education for physicians and nurses followed by a VAP campaign. All VAP episodes not only the first one was included.
Results: A total of 598 patients were enrolled in the study. The adherence to expanded VAP bundle significantly increased in the post-intervention phase as follows; head of bed elevation (from mean of 40 to 100% with p=0.001), oral care (from mean of 20 to 100% with p=0.001),
daily sedation vacation (from mean of 56.5 to 91% with p=0.001), daily assessment of weaning (from mean of 9 to 25% with p=0. 03), peptic ulcer prophylaxis (from mean of 83 to 100% with p=0.001), DVT prophylaxis (from mean of 82 to 100% and p=0.001), cuff pressure measurement (from mean of 9 to 60% with p=0.001), and hand hygiene (from mean of 8 to 28.5% with p=0.001).The VAP rate decreased significantly by 35% (from 66.5 to 43 per 1000 MV days) with p= 0.002 and CI 9.73-37.15 in spite of significant increase of the ventilator utilization ratio (p <0.001) in the post-intervention phase. The MV, antibiotic and ICU days did not change significantly in the post-intervention phase. The distribution of organisms did not differ significantly between both groups (p=0. 465). The sensitivity of most of carbapenems and β-lactam/β-lactamase inhibitors to Acinetobacter, Klebsiella andPseudomonas decreased significantly in the post intervention phase whereas the sensitivity of vancomyicin to Staphylococcus aureus remained the same.
Conclusions: In spite of the lack of top management support and fluctuating supplies, VAP staff education was still efficient in reducing VAP without affecting mortality or MV days or ICU length of stay.