Ventilator-associated respiratory infection in a resource-restricted setting: impact and etiology

Abstract

BackgroundVentilator-associated respiratory infection (VARI) is a significant problem in resource-restricted intensive care units (ICUs), but differences in casemix and etiology means VARI in resource-restricted ICUs may be different from that found in resource-rich units. Data from these settings are vital to plan preventative interventions and assess their cost-effectiveness, but few are available.MethodsWe conducted a prospective observational study in four Vietnamese ICUs to assess the incidence and impact of VARI. Patients ≥ 16 years old and expected to be mechanically ventilated > 48 h were enrolled in the study and followed daily for 28 days following ICU admission.ResultsFour hundred fifty eligible patients were enrolled over 24 months, and after exclusions, 374 patients’ data were analyzed. A total of 92/374 cases of VARI (21.7/1000 ventilator days) were diagnosed; 37 (9.9%) of these met ventilator-associated pneumonia (VAP) criteria (8.7/1000 ventilator days). Patients with any VARI, VAP, or VARI without VAP experienced increased hospital and ICU stay, ICU cost, and antibiotic use (p < 0.01 for all). This was also true for all VARI (p < 0.01 for all) with/without tetanus. There was no increased risk of in-hospital death in patients with VARI compared to those without (VAP HR 1.58, 95% CI 0.75–3.33, p = 0.23; VARI without VAP HR 0.40, 95% CI 0.14–1.17, p = 0.09). In patients with positive endotracheal aspirate cultures, most VARI was caused by Gram-negative organisms; the most frequent were Acinetobacter baumannii (32/73, 43.8%) Klebsiella pneumoniae (26/73, 35.6%), and Pseudomonas aeruginosa (24/73, 32.9%). 40/68 (58.8%) patients with positive cultures for these had carbapenem-resistant isolates. Patients with carbapenem-resistant VARI had significantly greater ICU costs than patients with carbapenem-susceptible isolates (6053 USD (IQR 3806–7824) vs 3131 USD (IQR 2108–7551), p = 0.04) and after correction for adequacy of initial antibiotics and APACHE II score, showed a trend towards increased risk of in-hospital death (HR 2.82, 95% CI 0.75–6.75, p = 0.15).ConclusionsVARI in a resource-restricted setting has limited impact on mortality, but shows significant association with increased patient costs, length of stay, and antibiotic use, particularly when caused by carbapenem-resistant bacteria. Evidence-based interventions to reduce VARI in these settings are urgently needed.Electronic supplementary materialThe online version of this article (10.1186/s40560-017-0266-4) contains supplementary material, which is available to authorized users.

Excess direct hospital cost of treating adult patients with ventilator associated respiratory infection (VARI) in Vietnam

“…We did not distinguish between VAP and VAT as the pathogenesis and bacterial aetiology of the two entities are essentially the same and both are treated for a similar duration in Vietnam. A Vietnamese study analysing the costs of VAP and other VARI found little difference when similar patient groups were looked at [ 15 ]. All direct medical costs were estimated as the product of number of services and their unit cost.…”

“…Because the antimicrobial therapy de-escalation rate was not reported in Vietnam, we varied this rate by the values from the prospective study of 24 intensive care units in Spain [ 22 ]. Varying the incidence density of VARI was performed with the additional analysis of data from a previous prospective observational study in 4 CCUs in Vietnam [ 15 ]. The extra duration of antimicrobial therapy was varied between 7–14 days to cover 2 common antimicrobials regimens of 7–8 days and 10–14 days [ 25 ].…”

“…Although in Vietnam, HAI is an increasing concern, little is known about its economic impact. High levels of antibiotic resistance [ 13 ] and infection control programmes which are often inadequate means this is increasingly important, and VARI has been shown to be a particular problem [ 14 , 15 ]. This study aims to estimate the total annual excess cost associated with VARI in critical care units in Vietnam.…”

Bacterial Contamination of Circuit Inner Surfaces After High-Flow Oxygen Therapy

“…Mechanical ventilation with an endotracheal tube has been identified as a primary risk factor for ventilator-associated pneumonia (VAP). 1,2 Despite current efforts to control VAP and hospital-acquired pneumonia, 3 even in patients who have not received mechanical ventilation, it remains a matter of concern. Many studies have focused on managing risk factors to prevent VAP and a few more recent publications have addressed the epidemiology of hospital-acquired pneumonia in subjects who were not mechanically ventilated.…”

Risk of pneumonia in patients with burn injury: a population-based cohort study

“…Moreover, HAP occurs 48 hours or more after hospitalization and does not present on admission. For hospitalized patients, HAP can be divided into ventilator hospital-acquired pneumonia (V-HAP), in which pneumonia develops after endotracheal intubation over 48–72 hours, and nonventilator hospital-acquired pneumonia (NV-HAP) 7,8. A similar pathogenesis may exist in patients with burn injury.…”