Ventilator-associated pneumonia (VAP), viewed as an inevitable consequence of critical illness, is increasingly accepted as an avoidable adverse health care incident. Whereas morbidity and mortality from VAP is well-documented in adults, it is poorly studied in children.This investigation was conducted to determine characteristics and possible risk factors for VAP, in critically ill neonates admitted to the neonatal intensive care unit (NICU). According to clinical pulmonary infection score (CPIS), 33 neonates were selected as having VAP and 24 neonates who did not develop VAP were assigned as non-VAP group. All neonates were subjected to case history, clinical examination, ABG, chest X-ray, and laboratory investigations (CBC, serum albumin, serum CRP, and blood culture). Neonates with VAP were subjected to broncheo-alveolar lavage (BAL) sampling. The BAL samples were subjected to macroscopic and microscopic examination, as well as quantitative cultures. Obtained results revealed that indications for mechanical ventilation (MV) included respiratory distress syndrome (RDS), congenital pneumonia, meconium aspiration syndrome (MAS), and hypoxic ischemic encephalopathy (HIE), with nonsignificant differences between VAP group and non-VAP group. VAP rates were significantly increased with decreased body weight and gestational age and with increased duration of NICU admission, duration of MV and use of invasive maneuvers. VAP was significantly associated with hypothermia, mucopurulent endotracheal tube (ETT) secretions, and radiological findings. The use of inotrops and corticosteroids was significantly noted among neonates with VAP than that among non-VAP neonates. Raised serum C-reactive protein (CRP), hypoalbuminemia and positive blood cultures were significantly associated with increased VAP rates. Cultures of BAL samples revealed Klebsiella pneumoniae (in 33%), Pseudomonas aeruginosa (in 21%), Staphylococcus aureus (in 15%), Escherichia coli (in 15%), Pneumococci (in 6%) and Candida albicans (in 9%). There was nonsignificant similarity in the type of organisms cultivated from either blood or BAL. In conclusion risk factors for the development of VAP include; 1) decreased body weight and gestational age, 2) increased duration of NICU admission, MV, and use of invasive maneuvers, 3) hypothermia, mucopurulent ETT secretions and the use of inotrops/ corticosteroids, 4) raised serum CRP, hypoalbuminemia and positive blood cultures and 5) nosocomial infection by Klebsiella, Pseudomonas, Staph aureus, E coli and Candida. (Mona Afify, Salha AI-Zahrani and Maha A Nouh. Risk Factors for the Development of Ventilator - Associated Pneumonia in Critically-Ill Neonates. Journal of American Science 2012; 8(1):461-466). (ISSN: 1545-1003). http://www.americanscience.org . 64

Risk Factors for the Development of Ventilator - Associated Pneumonia in Critically-Ill Neonates

status, repeatedintubations (more than 1), prolonged ventilation, prolonged duration of hospitalization and level III stay were found to significant risk factors for VAP by univariate analysis. Factors that retained significance in multivariate logistic regression model were unstable initial cardio pulmonary assessment (p value=0.010, adjusted OR: 0.2, 95% CI: 0.0,0.6) and repeated intubations (p value, 0.001, adjusted OR: 34.3, 95 % CI: 8.3,142.4). The mortality rates for the neonates with VAP was 50% and for those without VAP was 69.5 % (p value=0.030). VAP is a serious nosocomial infection. Preventable risk factors should be addressed in all neonatal units. Further research is necessary to formulate the guidelines for diagnosis of VAP in neonates.

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Ventilator Associated Pneumonia (VAP) in Neonatal Intensive Care Unit — An Emerging Problem

We read with great interest the article by Gozal et al. on ventriculostomy-associated infection (VAI) [1]. The authors propose that a standardized definition for VAI should be a CSF microbiological culture that is positive for microorganism and associated with fever or low CSF glucose. While the authors should be commended on their attempt to define VAI with unifying nomenclature and classification in the literature, there is a problem regarding neuroICU patients with ventriculostomy and neurogenic fever: Prone patients such as subarachnoid hemorrhage (SAH) and/or intraventricular hemorrhage (IVH) patients with ventricular catheters who have a CSF microbial contaminant that is not found on repeat CSF testing should be excluded from this definition. The other nosocomial organisms that the authors report, such as MRSA and Pseudomonas, are rarely contaminants, similar to Candida and various fungal species. Further, SAH/IVH patients may develop a sterile inflammatory response that causes central fever and CSF hypoglycorrhachia, the latter being a nonspecific finding which does not represent microbe glucose consumption but, rather, impaired glucose transport [2]. Repeat CSF sampling and clinical experience may reveal this to be a pathogen or contaminant instead of a true CSF infection. Many clinicians also incorporate CSF lactate level into the decision of whether to treat for VAI. Additionally, highrisk patients for false positive CSF results are those who receive frequent intraventricularly-injected medications such as TPA [3] for IVH or nicardipine for SAH-related vasospasm. The main concern with the authors’ proposed definition is interpretation by arbitrary or third-party payers in health care who deem these as inpatient quality metrics—unless there is the ability for physician or medical interpretation to override such criteria. Recently, The Joint Commission pre-publication guidelines for comprehensive stroke centers announced that it allows for clinical correction of such positive microbiological CSF samples under standard DSPM.3 section A.4a: ‘‘CSF infection is defined as the presence of a positive CSF culture in a patient with a CSF pressure monitoring device or external ventricular drain (EVD) if there is no documentation in the medical record stating that the culture results are thought to be the result of a contaminant or some other process, such as preexisting infection or infection resulting from another surgical procedure’’ [4]. Therefore the VAI definition matters and consequences to non-validated administrative data sets [5, 6] have been reported, requiring further research. The same comprehensive stroke center guideline also requires tracking of CSF infections as a quality metric in patients with ventriculostomy and invasive neuromonitoring probes [4]. Therefore, we again acknowledge the W. D. Freeman (&) Departments of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA e-mail: freeman.william1@mayo.edu

Ventriculostomy-Associated Infection (VAI): In Search of a Definition.

Objective: Ventilator associated pneumonia (VAP) is a frequent complication of mechanical ventilation (MV) and it is a leading cause of death in MV patients. The development of VAP has been demonstrated as being due to aspiration of oropharyngeal secretion, ventilator tubing condensate, or gastric contents that are colonized with pathogenic microorganisms. The aim of the present study is to isolate and identify bacteria that cause VAP and to study antibiotic susceptibility. Material and Methods : This study was carried out on 95 patients who fulfilled the diagnostic criteria for VAP. Quantitative cultures of endotracheal aspirates (EA) using a cut-off point of 10 [6] cfu/ml was done. Results : The microbiological results revealed that gram negative bacilli were the most common bacterial agents responsible for VAP and accounted for 78.8% of all the causative agents. The most common isolated organisms were Klebsiella pnemouniae (30.9 %) followed by Pseudomonas aeruginosa (22.5%), Staphylococcus aureus (21.2%), Eschericia coli (12.8 %), Proteus spp. (9.8%), and Citrobacter spp. (2.8%). Blood cultures were positive in 25.9% of patients with Klebsiella pnemouniae in about 33.3%. Conclusion : From this study, it can be concluded that VAP is an important nosocomial infection. EA is a simple procedure to obtain respiratory samples and perform sensitivity testing in patients with VAP. Also, the commonest cause of VAP is gram negative bacilli.

Antibiotic susceptibility patterns of different bacteria isolated from patients with ventilator associated pneumonia (vap).

Introduccion: los estudios que describen factores de riesgo para neumonia asociada a ventilador (NAV) en recien nacidos difieren con relacion al tipo de unidad hospitalaria y la poblacion incluida. El objetivo del estudio fue identificar factores de riesgo para desarrollar NAV en una unidad de cuidados intensivos neonatales. Metodos: Diseno de casos y controles. Se incluyeron pacientes que desarrollaron NAV (casos) para comparar los factores de riesgo y se seleccionaron dos controles por caso con misma edad gestacional, peso y diagnostico de ingreso similar. Se hizo un analisis de estadistica descriptiva e inferencial: prueba de chi-cuadrada, t de Student, razon de momios (RM), intervalo de confianza (IC) al 95 % y analisis multivariado de regresion logistica. Resultados: se incluyeron 45 casos y 90 controles. Los factores de riesgo estadisticamente significativos en el analisis univariado fueron: sepsis previa, reitubacion, malformacion de la via aerea, alimentacion parenteral exclusiva y dias de ventilacion mecanica. En el analisis multivariado: reintubacion (RM 41.26, IC 95 % 11.9-158.4, p = 0.001), malformacion de la via aerea (RM 19.5, IC 95 % 1.34-282.3, p = 0.029) y dias de ventilacion (RM 8.9, IC 95 % 1.9-40.8, p = 0.005). Conclusion: de los factores de riesgo encontrados se puede incidir en los eventos de reintubacion si se asegura una fijacion adecuada de la canula, se extreman cuidados al movilizar al paciente y se evalua diariamente a este para disminuir los dias de ventilacion

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Neumonía asociada a ventilación en una unidad de cuidados intensivos neonatales

Objective To explore pathogens and drug resistance in ventilator-associated pneumonia (VAP), and to provide the corresponding clinical prevention strategies. Method We analyzed 154 VAP patients' clinical data, pathogens distribution and resistance rate of bacilli. Results The incidence of VAP was 36.5%, the aged accounted for 61%. Among all the pathogens caused VAP, 77.93% of sputum culture results were gram-negative bacilli, most of which were Pseudomonas aeruginosa, Acinetobacter baumanii, Chryseobacterium, Pseudomonas maltophilia and Staphylococcus aureus. Most of gram-negative bacilli showed high resistance rate to common used antibiotics. Conclusions Extensive and dynamic monitoring of VAP pathogens and rational use of antibiotics were advocated for controlling VAP effectively.

LI Li-bin

Papers

Ventilator-associated pneumonia in intensive-care unit