Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study

Martín‐Loeches, Ignacio; Póvoa, Pedro; Rodríguez, Alejandro; Curcio, Daniel; Suarez, David L.; Mira, Jean‐Paul; Cordero, Maria Lourdes; Lepecq, Raphaël; Girault, Christophe; Candeias, C.; Séguin, Philippe; Paulino, Carolina; Messika, Jonathan; Castro, A. González; Vallès, Jordi; Coelho, Luís; Rabello, Lígia Sarmet Cunha Farah; Lisboa, Thiago; Collins, Daniel; Torres, Antônio; Salluh, Jorge I.; Nseir, Saad

doi:10.1016/s2213-2600(15)00326-4

Cited by 160 publications

(185 citation statements)

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“…It can hit 10% to 25% of all ICU patients (4,5), being associated with longer duration of mechanical ventilation, longer ICU and hospital stays, increased healthcare costs and increased morbidity and mortality (6,7). VAP mortality rates range from 20% to 70% with healthcare costs of $20,000 to $40,000 per patient (4,8), making it a primary focus for risk-reduction strategies (9).…”

Section: Introductionmentioning

confidence: 99%

Antibiotic consumption and ventilator-associated pneumonia rates, some parallelism but some discrepancies

Nora¹,

Póvoa²

2017

Ann. Transl. Med.

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Ventilator-associated pneumonia (VAP) is a common infection in intensive care units (ICUs) but its clinical definition is neither sensitive nor specific and lacks accuracy and objectivity. New defining criteria were proposed in 2013 by the National Healthcare Safety Network (NHSN) in order to more accurately conduct surveillance and track prevention progress. Although there is a consistent trend towards a decrease in VAP incidence during the last decade, significant differences in VAP rates have been reported and are persistently lower in NHSN and other American reports (0.0 to 4.4 VAP per 1,000 ventilator-days in 2012) compared to the European Centre for Disease Prevention and Control (ECDC) data (10 VAP per 1,000 ventilator-days in 2014). In the United States, VAP has been proposed as an indicator of quality of care in public reporting, and the threat of financial penalties for this diagnosis has put pressure on hospitals to minimize VAP rates that may lead to artificial lower values, independently of patient care. Although prevention bundles may contribute for encouraging reductions in VAP incidence, both pathophysiologic and epidemiologic factors preclude a zero-VAP rate. It would be expected from the trend of reduction of VAP incidence that the consumption of antibiotics would also decrease in particular in those hospitals with lowest VAP rates. However, ICU reports show a steadily use of antibiotics for nosocomial pneumonia in 15% of patients and both ECDC and NHSN data on antibiotic consumption showed no significant trend. Knowledge of bacterial epidemiology and resistance profiles for each ICU has great relevance in order to understand trends of antibiotic use. The new NHSN criteria provide a more objective and quantitative data based VAP definition, including an antibiotic administration criterion, allowing, in theory, a more comprehensive assessment and a reportable benchmark of the observed VAP and antibiotic consumption variability.

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Section: Introductionmentioning

confidence: 99%

Antibiotic consumption and ventilator-associated pneumonia rates, some parallelism but some discrepancies

Nora¹,

Póvoa²

2017

Ann. Transl. Med.

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“…In a study of mechanically ventilated patients with VAP, patients showed a relative depression of genes involved in calcium signaling pathways, the complement system and cyclic adenosine monophosphate (Martin-Loeches I, 2012). Patients with VAP exhibit increased inflammation and worse outcomes than those with VAT, and this may be related to an immunosuppressed state (Martin-Loeches I, 2015). As a result, is important to ensure measures are in place to reduce the risk of VAT progressing to VAP.…”

Section: Bodymentioning

confidence: 99%

“…There is no gold standard definition of VAT, and this makes an accurate assessment of its prevalence difficult, though it is estimated to be between 0 and 15% in intubated mechanically ventilated patients. (Malacarne P, 2008;Martin-Loeches I, 2015). VAT has been defined differently in recent years.…”

Section: Introductionmentioning

confidence: 99%

23rd International Symposium on Infections in the Critically Ill Patient

et al. 2018

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IntroductionThis 23rd International Symposium on Infections in the Critically Ill Patient aims to review current concepts, technology and present advances in infections in critically ill patient.Sepsis, Pulmonary Infections and their therapeutic and preventive strategies will be the topics presented by international experts who will review and update sepsis as a global international problem. New guidelines of Surviving Sepsis campaign, fluid therapy and vassopressors, a balance view between personalization and protocol treatment and new recommendations for the design of future randomized control trials are provided. The immune response and the emerging methods to personalize sepsis care including new biomarkers and immunomonitoring of patients with sepsis represent a new complementary view to treat patients with severe infections and organ failure in addition to early antibiotic and the control of source of infection.New ways to treat pulmonary infections including the new global guidelines and the international actions against multiresistant microorganisms and the development of new antibiotics represent key factors to improve the outcome of severe infections. antibiotics, fluid resuscitation, blood pressure targets and so forth fails to account for the individualized needs of the patient. Sepsis is not a specific disease entity but an umbrella syndrome covering a range of biological phenotypes. Therapies should thus be selected and dose-adjusted accordingly, taking into account the individual host's phenotype, underlying comorbidities, and the site and source of infection. A one-size-fits-all, brain-stem, heavily protocolized approach will suit the lowest common denominator. Surely we should seek loftier ambitions based on education, an increased depth of understanding, enhanced monitoring and diagnostics, and a personalized approach incorporating evidence and clinical expertise. This concept of EBID (evidence-based individualized decision-making) is not new; indeed, it was enshrined by none other than David Sackett, a pioneer of evidence-based medicine who railed against rigid adoption of evidence: "Clinicians who fear top down cookbooks will find the advocates of evidence -based medicine joining them at the barricades". Ignacio Do We Need New Clinical Design for RCT? Jean-Louis VincentDepartment of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, BelgiumAbstract: The prospective randomized controlled trial (RCT) has been widely promoted as the only effective means of definitively proving the superiority of one intervention over another. However, in the intensive care unit (ICU) population, RCTs can be challenging to conduct, and results have rarely demonstrated beneficial effects of the intervention under investigation on outcomes. The main reason for this lack of success is the heterogeneous nature of the critically ill populations included in these studies. Ethical issues can also be a problem in the ICU as patients are frequently not able to give consent and surrogates may not be ...

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Ventilator-associated pneumonia prevention: one good turn does not always deserve another

2017

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Ventilator-associated pneumonia (VAP) is a frequent complication of patients undergoing invasive mechanical ventilation and its occurrence is associated with considerable morbidity and mortality [1][2][3]. The key factor in the pathogenesis of VAP is the endotracheal tube (ETT) [4]. Its presence compromises the natural anatomical barriers (larynx) and functional mechanisms (mucus clearance and cough), and it expedites the formation of biofilm as well as macro-and microaspiration of oropharyngeal secretions. As a result, several strategies have been successfully implemented, namely subglottic secretion drainage or cuff pressure control [3,4].One of the current recommendations for VAP prevention is elevation of the head of bed to 30-45° to prevent the reflux of colonized gastric contents that has a potential role in VAP pathogenesis. This strategy has been evaluated in three randomized controlled trials (RCT) enrolling 337 patients, one positive and two negatives [5][6][7], and in a meta-analysis pooling these three studies that found a significant impact on prevention [8]. However, the quality of evidence is low, being considered a basic practice because of its simplicity, ubiquity, low cost, and potential benefit [3].Simultaneously, we can conceive that in a patient with an ETT, any position above horizontal increases the gravitational forces exerted by subglottic secretions above the cuff and, consequently, the risk of aspiration [9]. The results of several experimental studies challenged the recommendation of the semirecumbent position in VAP prevention. In animal models, the Trendelenburg position showed an increase in mucus clearance, decreasing aspiration and consequently VAP rates [9,10]. With this rationale an RCT was designed to evaluate this hypothesis.In the GRAVITY-VAP trial, recently published in Intensive Care Medicine, Li Bassi, Panigada, and co-workers performed a multicenter, multinational RCT to assess the impact of the lateral Trendelenburg position (LTP) vs. semi-recumbent position (SRP) in VAP incidence [11]. A total of 395 patients (N = 194 LTP; N = 201 SRP) were included. The trial was prematurely ended because of low incidence of VAP, lack of benefit in secondary outcomes, and serious adverse events (SAE). The incidence of microbiologically confirmed VAP was 0.5% in LTP and 4.0% in the SRP patients (P = 0.04); however, the rate of SAE was significantly higher in the LTP group, namely transient oxygen desaturation and hemodynamic instability. In addition, mortality (ICU, hospital, and day 28) was non-significantly higher in the LTP group, ranging from an absolute difference of 6.5% in ICU mortality to 4.5% in day 28 mortality. Moreover, in spite of the risk difference of −7.6% (P = 0.02) in microbiologically confirmed VAP in the LTP group, antibiotic consumption was similar in both groups. This may be due to the higher incidence of clinically suspected VAP in LTP patients with pulmonary infiltrates at the time of enrollment, encouraging BAL assessments, and empirical antibiotic prescription...

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Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study

Cited by 160 publications

References 34 publications

Antibiotic consumption and ventilator-associated pneumonia rates, some parallelism but some discrepancies

Antibiotic consumption and ventilator-associated pneumonia rates, some parallelism but some discrepancies

23rd International Symposium on Infections in the Critically Ill Patient

Ventilator-associated pneumonia prevention: one good turn does not always deserve another

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