Executive Summary Introduction Methodology Used to Prepare the Guideline Epidemiology Incidence Etiology Major Epidemiologic Points Pathogenesis Major Points for Pathogenesis Modifiable Risk Factors Intubation and Mechanical Ventilation Aspiration, Body Position, and Enteral Feeding Modulation of Colonization: Oral Antiseptics and Antibiotics Stress Bleeding Prophylaxis, Transfusion, and Glucose Control Major Points and Recommendations for Modifiable Risk Factors Diagnostic Testing Major Points and Recommendations for Diagnosis Diagnostic Strategies and Approaches Clinical Strategy Bacteriologic Strategy Recommended Diagnostic Strategy Major Points and Recommendations for Comparing Diagnostic Strategies Antibiotic Treatment of Hospital-acquired Pneumonia General Approach Initial Empiric Antibiotic Therapy Appropriate Antibiotic Selection and Adequate Dosing Local Instillation and Aerosolized Antibiotics Combination versus Monotherapy Duration of Therapy Major Points and Recommendations for Optimal Antibiotic Therapy Specific Antibiotic Regimens Antibiotic Heterogeneity and Antibiotic Cycling Response to Therapy Modification of Empiric Antibiotic Regimens Defining the Normal Pattern of Resolution Reasons for Deterioration or Nonresolution Evaluation of the Nonresponding Patient Major Points and Recommendations for Assessing Response to Therapy Suggested Performance Indicators

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia the official statement of the American Thoracic Society and the Infectious Disease Society of America (特集 救急診療ガイドライン) -- (海外のガイドライン)

The purpose of the study was to examine risk factors for nosocomial pneumonia in the surgical and medical/respiratory intensive care unit (ICU) populations. In a public teaching hospital, all cases of nosocomial pneumonia in the surgical and medical/respiratory ICUs (n = 20, respectively) were identified by prospective surveillance during a 5-yr period from 1987-1991. Each group of ICU cases was compared with 40 ICU control patients who did not acquire pneumonia, and analyzed for 25 potential risk factors. Surgical ICU patients were found to have consistently higher rates of nosocomial pneumonia than medical ICU patients (RR = 2.2). The strongest predictor for nosocomial pneumonia in both the surgical and medical/respiratory ICU groups was found to be prolonged mechanical ventilation (> 1 d) resulting in a 12-fold increase in risk over nonventilated patients. APACHE III score was found to be predictive of nosocomial pneumonia in the surgical ICU population, but not in the medical/respiratory ICU population. We conclude that certain groups deserve special attention for infection control intervention. Surgical ICU patients with high APACHE scores and receiving prolonged mechanical ventilation may be at the greatest risk of acquiring nosocomial pneumonia of all hospitalized patients.

Risk factors for nosocomial pneumonia comparing adult critical-care populations

Objective: To determine the short-term mortality rate of patients on mechanical ventilation in a tertiary care center in Sialkot, Pakistan.Study Design: Descriptive cross sectional study.Place and Duration of Study: This study was conducted jointly by the departments of Anesthesiology, Surgery and Gynecology & Obstetrics at Combined Military Hospital Sialkot Cantonment, from Jul 2013 to Jun 2015.Material and Methods: A total of 112 patients placed on mechanical ventilation were included in this study. The patients’ age, gender, disease on admission, duration of ventilation, indication for ventilation, outcomes and complications were noted. SPSS 21 was used for data analysis.Results: Fifty-eight (51.78%) patients expired while 54 (48.21%) were weaned off successfully. In the former group of expired patients, the major factors contributing towards the mortality were multi-organ failure (37.9%), VAP/ventilator-associated pneumonia (32.7%), coagulopathy (29.3%) and sepsis (27.5%). However, in the survivor patients group5 patient (9.25%) developed VAP, 3 (5.55%) developed pneumothorax while 3 others(5.55%) developed a fever of unknown etiology.Conclusion: The short-term mortality rate of patients who receive mechanical ventilation in an intensive care unit (ICU) in Sialkot, Pakistan is significantly higher than that of developed countries.Keywords: , , , , pneumonia.

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Short-term outcomes in patients undergoing mechanical ventilation in a tertiary care centre in sialkot

Objective: To evaluate the spectrum of ventilator-associated pneumonia (VAP) and relation of length of intensive care unit (ICU) stay, patient’s age and gender on the likelihood of being discharged from the ICU.Study Design: A cross sectional study.Place and Duration of Study: Shifa International Hospital, Islamabad, Pakistan over a period of 12 months extending, from Apr 2015 to Apr 2016.Material and Methods: We included 470 patients out of whom only 106 patients were diagnosed with VAP while on mechanical ventilation in ICU for >48 hours. A positive culture of tracheo-bronchial secretions, with any one of these; >48-h infiltrate on chest radiograph, fever of >38.3°C, leukocytosis of >12 × 109/ml and increase in tracheo-bronchial secretions established the diagnosis of VAP.Results: The mean age of the male and female patients was 49.8 ± 18 years and 50.6 ± 21.4 years respectively with 16.6 ± 13 days as the mean duration of ICU stay. About 30.2% VAP patients had Acinetoba cterbaumanni with 96.8% sensitivity to colistin, 27.4% patients had Klebsiella pneumonia with 72% and 62% sensitivity to colistin and carbapenems respectively and 15.1% patients had methicillin-resistant Staphylococcus aureus with 100% sensitivity to vancomycin. There was an increased incidence 60.4% of late-onset VAP compared to 39.6% early onset VAP. The overall mortality in VAP patients was 28.6%.Conclusion: We recommend the empirical combination therapy of colistin, carbapenem, and vancomycin in VAP. No statistical significant association was found between length of ICU stay and patient’s mortality. The odds of getting discharged were found to be 3.2 times greater for male participants as opposed to female patients. Decreasing age was associated with an increased likelihood of being discharged., , .

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Tauqeer Sulehria

Papers

Spectrum of ventilator associated pneumonia with effect on intensive care unit’s patient outcome