Ventilator-associated pneumonia is an important healthcare-associated infection. Interventions for the prevention of ventilator-associated pneumonia are often used within bundles of care. Recent evidence has challenged widespread practices mandating a review of subject. This article outlines guidance for ventilator-associated pneumonia prevention.

Hospital acquired pneumonia (HAP) is often fatal in older patients. The mouth is the main reservoir of infection and studies have suggested that oral hygiene interventions may prevent HAP. The aim of this study was to investigate associations between HAP and preceding a) heavy dental plaque and b) oral carriage of potential respiratory pathogens in older patients with lower limb fracture to determine the target for intervention studies.MethodsWe obtained a time series of tongue/throat swabs from 90 patients with lower limb fracture, aged 65-101 in a general hospital in the North East of England between April 2009-July 2010. We used novel real-time multiplex PCR assays to detect S. aureus, MRSA, E. coli, P. aeruginosa, S. pneumoniae, H. influenza and Acinetobacter spp. We collected data on dental/denture plaque (modified Quigley-Hein index) and outcomes of clinician-diagnosed HAP.ResultsThe crude incidence of HAP was 10% (n = 90), with mortality of 80% at 90 days post discharge. 50% of cases occurred within the first 25 days. HAP was not associated with being dentate, tooth number, or heavy dental/denture plaque. HAP was associated with prior oral carriage with E. coli/S. aureus/P.aeruginosa/MRSA (p = 0.002, OR 9.48 95% CI 2.28-38.78). The incidence of HAP in those with carriage was 35% (4% without), with relative risk 6.44 (95% CI 2.04-20.34, p = 0.002). HAP was associated with increased length of stay (Fishers exact test, p=0.01), with mean 30 excess days (range -11.5-115). Target organisms were first detected within 72 hours of admission in 90% participants, but HAP was significantly associated with S. aureus/MRSA/P. aeruginosa/E. coli being detected at days 5 (OR 4.39, 95%CI1.73-11.16) or 14 (OR 6.69, 95%CI 2.40-18.60).ConclusionsPatients with lower limb fracture who were colonised orally with E. coli/ S. aureus/MRSA/P. aeruginosa after 5 days in hospital were at significantly greater risk of HAP (p = 0.002).

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Sustaining change requires (a) a continued team-based, collaborative approach, (b) ongoing stakeholder and executive leadership engagement,

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Respiratory tract infections are the commonest nosocomial infections, and occur predominantly in frailer, older patients with multiple comorbidities. The oropharyngeal microbiota is the major reservoir of infection. This study explored the relative contributions of time in hospital and patient demographics to the community structure of the oropharyngeal microbiota in older patients with lower limb fracture. We collected 167 throat swabs from 53 patients (mean age 83) over 14 days after hospitalization, and analyzed these using 16S rRNA gene sequencing. We calculated frailty/comorbidity indices, undertook dental examinations and collected data on respiratory tract infections. We analyzed microbial community composition using correspondence (CA) and canonical correspondence analysis. Ten patients were treated for respiratory tract infection. Microbial community structure was related to frailty, number of teeth and comorbidity on admission, with comorbidity exerting the largest effect. Time in hospital neither significantly changed alpha (t = −0.910, p = 0.365) nor beta diversity (CA1 t = 0.022, p = 0.982; CA2 t = −0.513, p = 0.609) of microbial communities in patient samples. Incidence of respiratory pathogens were not associated with time in hospital (t = −0.207, p = 0.837), nor with alpha diversity of the oral microbiota (t = −1.599, p = 0.113). Patient characteristics at admission, rather than time in hospital, influenced the community structure of the oral microbiota.

Background: Frailty refers to the reduction in homeostatic reserve resulting from an accumulation of physiological deficits over a lifetime. Frailty is common in older patients undergoing surgery and is an independent risk factor for post-operative mortality, morbidity and increased length of hospital stay. In frail individuals, stressors, such as surgery, can precipitate an acute deterioration in health, manifesting as delirium, falls, reduction in mobility or continence, rendering these individuals at an increased risk of adverse perioperative outcomes. However, little is known about how frailty affects the patient experience, functional ability and quality of life (QoL) after surgery. In addition, the distribution of frailty in this population is unknown. Methods: We will conduct a multi-centre observational trial to investigate the relationship between patient reported outcome measures and preoperative frailty. We aim to recruit approximately two-hundred patients with operable, potentially curative colorectal cancer. Eligible patients will be identified at three hospital sites. QoL and functional ability (measured using EORTC QLQ-C30 and WHO-DAS 2.0 respectively) will be recorded at the preoperative assessment clinic, and at 6 and 12 weeks postoperatively. Frailty scores including the Edmonton Frail Scale (EFS) and Rockwood clinical frailty scale (CFS) will be calculated both preoperatively, and at 12 weeks postoperatively. Secondary outcome measures including post-operative morbidity and mortality will be measured using Clavien Dindo classification and 90-day mortality. Discussion: This observational feasibility study seeks to define the prevalence of frailty in older (> 65 years) colorectal cancer patients and understand how frailty impacts on patient reported outcome measures. This information will help to inform larger studies relating to treatment decision algorithms and promote shared decision making in this population.