An antibiotic stewardship exercise in the ICU: building a treatment algorithm for the management of ventilator-associated pneumonia based on local epidemiology and the 2016 Infectious Diseases Society of America/American Thoracic Society guidelines (original) (raw)
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PubMed, 2015
Ventilator-associated pneumonia (VAP) is very common in many intensive care Units, but there are still many uncertainties about VAP, especially about the choice of initial empiric antibiotics. The incidence of specific pathogens with different susceptibility patterns causing VAP varies from hospital to hospital. This is the reason why empiric initial antibiotic treatment for VAP should be based not only on general guidelines (that recommend therapy according to the presence of risk factors for multidrug-resistant bacteria), but also on up-to-date information on local epidemiology. The aim of this study was to determine the microbial profile of pathogens causing VAP and their antibiotic susceptibility patterns. The study was conducted in the 15-bed surgical and neurosurgical Intensive Care Unit, Department of Anesthesiology and Intensive Care, Sestre milosrdnice University Hospital Center, Zagreb, Croatia. Retrospective data were collected from September 2009 to March 2013. All patients that developed VAP during the study period were eligible for the study. According to study results, the incidence of VAP was 29.4%. The most commonly isolated bacterium was Staphylococcus aureus (21.1%), followed by Pseudomonas aeruginosa (19.0%) and Acinetobacter species (13.6%). All Staphylococcus aureus isolates were susceptible to vancomycin and linezolid. Pseudomonas aeruginosa showed 100% susceptibility to cefepime and very high susceptibility to pip'eracillin-tazobactam (96%), ceftazidime (93%) and ciprofloxacin (89%). Ampicillin-sulbactam was highly effective for Acinetobacter species, showing resistance in only 8% of isolates. In conclusion, according to study data, appropriate empiric antibiotic therapy for patients with VAP without risk factors for multidrug-resistant bacteria is ceftriaxone and for patients with risk factors for multidrug-resistant bacteria ampicillin-sulbactam plus cefepime plus vancomycin or linezolid.
Eurasian Journal of Medical Investigation, 2019
H ealthcare-related infections (HCRI) are among the most important health problems affecting hospitalized patients that increase morbidity and mortality, treatment costs and prolong hospital stay in our country as in the rest of the world. These infections occur 5-10 times more frequently in intensive care units (ICU). Factors such as age, immune status, underlying diseases and nutritional status of the patient as well as the number of patients, ar-Objectives: This study aimed to determine how ventilator-associated pneumonia (VAP) frequency, and antibiotic susceptibilities are affected by the changes in the intensive care unit (ICU) conditions in adult patients. Methods: In this retrospective study, 457 VAP patients diagnosed in the ICUs of a training hospital between 2008 and 2017 were analyzed. Alterations in VAP rates during this period were evaluated. Results: Our results indicated that the improvement of physical conditions, and VAP prevention measures yielded a remarkable decline in the rates of VAP. VAP rates (cases per 1000 ventilator-days) decreased significantly between before 2013 and 2013-2017 periods (from 16.1 to 7.1; p<0.0000001). A total of 504 VAP episodes developed and 569 microorganisms were identified. The most frequent microorganisms were Acinetobacter baumanii (33.7%), Pseudomonas aeruginosa (31.6%), Klebsiella pneumonia (12%). The resistances against sulbactam-ampicillin, imipenem, and meropenem were increased significantly after 2013. (p=0.002, p<0.001, p=0.001; respectively.) There was a noteworthy surge in resistances against colistin (p=0.010) in Gram-negative bacteria and teicoplanin in Gram-positive bacteria (p=0.044). Conclusion: The study shows that the rates of VAP can be decreased with collaboration with other disciplines, adherence to preventative measures and continue education of healthcare workers.
International Journal of Research in Medical Sciences, 2014
Ventilator associated pneumonia (VAP) is the most common infection diagnosed in intensive care units (ICUs). VAP is defined as pneumonia that occurs 48 hours or more after endotracheal intubation or tracheostomy, caused by infectious agents not present or incubating at the time mechanical ventilation was started. 1 It can be of two types. Early-onset VAP, defined as occurring within the first 4 days of mechanical ventilation, usually carries a better prognosis, and is more likely to be caused by antibiotic sensitive bacteria. Late onset VAP occuring 5 days or more after mechanical ventilation is more likely to be caused by multidrug resistant (MDR) pathogens, and is associated with increased patient mortality and morbidity. 2 The specific microbial causes of VAP are many and varied. Gram negative bacteria, including Pseudomonas aeruginosa, Acinetobacter spp and enteric gram negative rods are implicated in 55-85% of VAP cases. High rates of ABSTRACT Background: Ventilator-associated pneumonia (VAP) is the most common infection diagnosed in intensive care units (ICUs). The causative organisms of VAP vary among different populations and are increasingly associated with resistance against various antimicrobial agents. Objective of current study was to determine the bacteriological etiology of VAP, antimicrobial susceptibility pattern of the isolates and detect the presence of extended-spectrum lactamases (ESBL), metallo β-lactamases (MBL) and AmpC -lactamases in multidrug resistant isolates causing VAP in the medical ICU. Methods: A prospective study was carried out over a year to know the various etiological agents of VAP and their drug susceptibility patterns. ESBL, MBL and AmpC -lactamases were detected in various isolates by combination disk method, imipenem-EDTA combined disk method and AmpC disk method respectively. Results: The majority of bacterial isolates causing VAP were found to be gram negative bacilli. Acinetobacter spp accounted for 34.28% of VAP cases followed by Pseudomonas aeruginosa which was responsible for 25.71% cases. Other gram negative bacilli isolated were Klebsiella pneumoniae, Citrobacter freundii, Enterobacter spp, and Escherichia coli. Out of the total 70 isolates, 67 (95.7%) were multidrug resistant and not even a single isolate was sensitive to all the drugs tested. Conclusions: Most of the pathogens causing VAP in our institute were multidrug resistant and in many isolates this resistance was due to production of ESBL, MBL, and AmpC β-latamases. Polymixin-B and colistin were found to be highly effective against multidrug resistant Acinetobacter spp and P. aeruginosa.
Japanese journal of infectious diseases, 2008
The identification of microorganisms causing ventilator-associated pneumonia (VAP) is important for formulating appropriate therapies. In this study, we report the incidence, etiology, and antibiotic resistance patterns of Gram-negative microorganisms isolated from patients diagnosed with VAP in our medical-surgical intensive care unit (ICU) during the years 2004-2006. VAP was diagnosed by using the clinical criteria of the Centers for Disease Control and Prevention. Antibiotic resistance patterns of isolated microorganisms were defined by standard methods. The VAP incidence rate was 22.6/1,000 ventilator days. The most frequently isolated pathogens were Acinetobacter spp., methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa. Ninety percent of Acinetobacter spp. isolates were resistant to ceftazidime, 64% to imipenem, and 80% to ciprofloxacin. Fifty-nine percent of P. aeruginosa isolates were resistant to ceftazidime, 32% to imipenem, and 62% to ciprofloxacin. Ce...
Indian Journal of Critical Care Medicine, 2011
Background: The initial empirical therapy of Ventilator Associated Pneumonia (VAP) modified based on the knowledge of local microbiological data is associated with decreased morbidity and mortality. The objective was to find the incidence and risk factors associated with VAP, the implicated pathogens and their susceptibility pattern as well as to assess the final clinical outcome in VAP. Materials and Methods: This was a prospective cohort study of 107 patients taken on ventilatory support for two or more days and those not suffering from pneumonia prior were to be taken on ventilator. The study was done over a period of one year. VAP was diagnosed using clinical pulmonary infection score of >6. The mortality, incidence of VAP, frequency of different pathogens isolated, their antibiotic sensitivity pattern, duration of mechanical ventilation and duration of hospital stay were assessed. Statistical Analysis: Univariate analysis, χ 2 test and paired t-test. Results: The incidence of VAP was 28.04%. Mortality in VAP group was 46.67%, while in the non-VAP group was 27.28%. High APACHE II score was associated with a high mortality rate as well as increased incidence of VAP. The most common organisms isolated from endotracheal aspirate of patients who developed VAP were Pseudomonas aeruginosa, Methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae and Acinetobacter baumannii. Most strains of Pseudomonas (55.56%) were resistant to commonly used beta-lactam antibiotics known to be effective against Pseudomonas. All strains of Staphylococcus aureus were MRSA and most isolates of K. pneumoniae (85.71%) were extended-spectrum beta-lactamase producing. About 50% isolates of Acinetobacter were resistant to carbapenems. Mortality was highest for infections caused by A. baumannii (83.33%) and K. pneumoniae (71.42%). Conclusions: APACHE II score can be used to stratify the risk of development of VAP and overall risk of mortality. Drug-resistant strains of various organisms are an important cause of VAP in our setting.
Revista da Sociedade Brasileira de Medicina Tropical, 2013
Introduction: Antimicrobial resistance is an increasing threat in hospitalized patients, and inappropriate empirical antimicrobial therapy is known to adversely affect outcomes in ventilator-associated pneumonia (VAP). The aim of this study was to evaluate antimicrobial usage, incidence, etiology, and antimicrobial resistance trends for prominent nosocomial pathogens causing ventilatorassociated pneumonia in a clinical-surgical intensive care unit (ICU). Methods: Gram-negative bacilli and Staphylococcus aureus causing VAP, as well as their antimicrobial resistance patterns and data on consumption (defined daily dose [DDD] per 1,000 patient days) of glycopeptides, extended-spectrum cephalosporins, and carbapenems in the unit were evaluated in two different periods (A and B). Results: Antimicrobial use was high, mainly of broad-spectrum cephalosporins, with a significant increase in the consumption of glycopeptides (p < 0.0001) and carbapenems (p < 0.007) in period B. For Acinetobacter baumannii and members of the Enterobacteriaceae family, 5.27-and 3.06-fold increases in VAPs, respectively, were noted, and a significant increase in resistance rates was found for imipenem-resistant A. baumannii (p = 0.003) and third-generation cephalosporinsresistant Enterobacteriaceae (p = 0.01) isolates in this same period. Conclusions: Our results suggest that there is a link between antibiotics usage at institutional levels and resistant bacteria. The use of carbapenems was related to the high rate of resistance in A. baumannii and therefore a high consumption of imipenem/meropenem could play a major role in selective pressure exerted by antibiotics in A. baumannii strains.
Vojnosanitetski pregled, 2016
Background/Aim. Ventilator-associated pneumonia (VAP) incidence, causative pathogens, and resistance patterns are different among countries and intensive care units (ICUs). In Europe, resistant organisms have progressively increased in the last decade. However, there is a lack of data from Serbian ICUs. The aims of this study were to evaluate etiology and antimicrobial resistance for pathogens causing VAP in ICU patients, to examine whether there were differences among pathogens in early-onset and late-onset VAP and to identify mortality in patients with VAP after 30 and 60 days of hospitalization. Methods. A retrospective cohort study was conducted in the respiratory ICU and all adult patients diagnosed with VAP from 2009 to 2014 were included. Results. Gram negative organisms were the major pathogens (80.3%). The most commonly isolated was Acinetobacter spp (59.8%). There was a statistically significant increase in the incidence of infection with Klebsiella pneumoniae (8.9% vs 25....
Journals International Journal of Pharmacy and Pharmaceutical Sciences, 2024
Objective: This study was conducted to investigate the antibiotic usage, risk factors and mortality associated with the development of VAP (Ventilator Associated Pneumonia). Methods: An open-labelled, prospective, observational (case-control) study was carried out for 6 mo in the Department of Critical Care Medicine. Initial screening was done based on inclusion and exclusion criteria and 58 patients were found eligible. The statistical analysis was done using the Chi-Square test and t-test. Results: The incidence of VAP in our study was 6.07%. Prolonged hospitalisation (p=0.00) and ICU stay (p=0.00) showed a statistically significant association with the development of VAP and they possessed a high risk of carbapenem-resistant organisms in the age group more than 60 years. Colistin therapy alone and/or combined with tigecycline therapy showed 100% survival. SOFA (Sequential Organ Failure Assessment) scoring done before and after VAP diagnosis showed a significant difference (p<0.005). Our study revealed that mortality was high in patients with SOFA score range of 7-9. Conclusion: The lower incidence of VAP points out the good infection control practices in the ICU (Intensive Care Unit). Late-onset VAP was more prevalent with Acinetobacter baumannii. Prolonged hospitalization and ICU stay were the significant risk factors. Colistin therapy alone and/or in combination with tigecycline was the most effective treatment.
Journal of Evolution of Medical and Dental Sciences
BACKGROUND Ventilator Associated Pneumonia (VAP) is an important infection most often encountered in mechanical ventilation (MV) patients in intensive care units in hospital. VAP occurs in approximately 9-27% of patients who are intubated. The morbidity and mortality associated with VAP is more inspite of recent advances in diagnosis and accurate management. Emergence of multidrug resistance among the pathogens causing VAP is also contributing to the outcome. We wanted to isolate the bacterial pathogens, study the antibiotic susceptibility pattern of the isolates and detect the presence of drug resistance in various pathogens. METHODS This is a retrospective, cross sectional study done on samples received between 2016 to 2018 among patients on MV for >/= 48 hours. Endotracheal aspirates were collected from 85 patients with assumed VAP, clinical pulmonary infection score (CPIS) was noted and aerobic quantitative cultures were performed on all samples. VAP was diagnosed by count of pathogenic organisms isolated >/= 10 5 cfu/mL. Identification and antibiotic susceptibility of the isolates were done as per the standard laboratory procedures. Patients with characteristic features i.e. clinical and radiological signs of pneumonia on admission were excluded from the study. RESULTS 50 cases were diagnosed as VAP by CPIS. Gender ratio was 30:20 (male to female) higher incidence 42% of VAP was seen in the age group of 46-60 years. Majority were Gram negative bacilli; 96%-Klebsiella 36%, Acinetobacter 26% E. coli 16%, Pseudomonas 14%, and Citrobacter 4% along with coagulase positive Staphylococcus in 4%. Of the 50 VAP patients, single organism was isolated in 92% and polymicrobial in 8%. Most of the isolates showed resistance to Amoxiclav, Cefepime, Cefixime and Meropenem. CONCLUSIONS Good compliance with VAP bundle adopted in critical care areas by the health care workers will reduce the incidence of VAP. Early and accurate diagnosis, appropriate empirical and specific antimicrobial use may significantly improve patient outcome.
IP Innovative Publication Pvt. Ltd., 2017
Introduction: Ventilator Associated Pneumonia (VAP) is the most commonly encountered health care associated infection among mechanically ventilated patients, which in turn contributed for raised morbidity, mortality and prolonged hospital stay. Early onset VAP is more common in comparison to late onset VAP. Materials and Method: This study was conducted in a tertiary care teaching hospital for a period of one and half year ranging from January 2013 to June 2014. Clinical Pulmonary Infection score (CPIS) of more than six was used for the clinical diagnosis of VAP and only culture proven cases, out of clinically suspected were further evaluated. Results: Overall rate of VAP was 19.87 per 1000 device days with (0.40) device utilization ratio. Among Gram negative bacterial isolates from VAP, Pseudomonas aeruginosa (50%) was the leading isolate followed by Acinetobacter baumanii (17.64%) and E. coli (14.70%). Pseudomonas aeruginosa exhibited (47.05%) resistance to ciprofloxacin and gentamicin followed by (41.17%) to cefepime, (35.29%) to piperacillin (17.64%) to Amikacin. Acinetobacter baumanii exhibited (100%) resistance to amoxycillin+clavulanic, piperacillin, piperacillin+ Tazobactum, followed by (83.33%) to amikacin. Conclusion: Continuous surveillance data of Ventilator Associated Pneumonia will be helpful in reducing the number of cases of VAP and thus in reducing the associated adverse outcomes.