Treatment of multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia (VAP) with intravenous colistin: a comparison with imipenem-susceptible VAP. Nosocomial pneumonia in mechanically ventilated patients, a prospective randomised evaluation of the Stericath closed suctioning system Incidence and risk factor for ventilator-associated pneumonia in Kathmandu University Hospital. Incidence and risk factors of pneumonia acquired in intensive care units. Results from a multicenter prospective study on 996 patients. European Cooperative Group on Nosocomial Pneumonia. Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia. Tracheal suction by closed system without daily change versus open system A prospective, randomized study of ventilator-associated pneumonia in patients using a closed vs. open suction system. Oral Care Reduces Incidence of Ventilator-Associated Pneumonia in ICU Populations Incidence of colonization, nosocomial pneumonia, and mortality in critically ill patients using a Trach Care™ closed‐suction system versus an open‐suction system: Prospective, randomized study Can nurses safely assess the need for endotracheal suction in short-term ventilated patients, instead of using routine techniques? Ventilator-associated pneumonia using a closed versus an open tracheal suction system Closed versus open endotracheal suctioning: Costs and physiologic consequences Mechanical ventilation with or without daily changes of in-line suction catheters.
We prospect ively evaluated the efficacy and toxicity of intravenously administered colistin in 35 episodes of ventilator-associated pneumonia ( VAP ) due to multidrug-resistant Acinetobacter baumannii . Microbiological diagnosis was performed with use of quantitative culture . In 21 patients , the episodes were caused by a strain susceptible exclusively to colistin ( the CO group ) and were all treated with this antimicrobial intravenously . In 14 patients , the episodes were caused by strains that remained susceptible to imipenem and were treated with imipenem-cilastatin ( the IM group ) . Acute Physiology and Chronic Health Evaluation II scores at the time of admission and Sequential Organ Failure Assessment scores at time of diagnosis were similar in both groups . VAP was considered clinical ly cured in 57 % of cases in both groups . In-hospital mortality rates were 61.9 % in the CO group and 64.2 % in the IM group , and the VAP-related mortality rates were 38 % and 35.7 % , respectively . Four patients in the CO group and 6 in the IM group developed renal failure . Neurophysiological evaluation was performed during 12 episodes in the CO group , but it revealed no signs of neuromuscular blockade . Intravenous colistin appears to be a safe and effective alternative to imipenem for the management of VAP due to carbapenem-resistant strains of A. baumannii Objective : To compare the ventilator-associated pneumonia ( VAP ) incidence rates in mechanically ventilated patients according to the type of endotracheal suctioning ( closed versus open ) . Setting : The Neurosurgery Intensive Care Unit of the Grenoble University Hospital , France . Design : A prospect i ve r and omised study performed after a 6-month period of nursing personnel training . Patients : One hundred four consecutive patients needing mechanical ventilation for more than 48 h were r and omised into two groups . To be eligible , patients had to have no active infection or respiratory affection in their passes . In the Stericath group ( S + , n = 54 ) , patients were not disconnected from the ventilator during suctioning . The others were routinely managed ( S– , n = 50 ) . In both groups patterns of frequency and duration of suctioning were performed according to a st and ardised protocol .¶ Measurements : The non-adjusted incidence rate of VAP was lower for S + than for S– ( 7.32 versus15.89 per 1000 patient-days , p = 0.07 ) . Multivariate analysis performed using the Cox model showed an adjusted risk of VAP 3.5 times higher in S– ( 95 % Cl : 11.00–12.33 ) . The risk being 4.3 higher in patients receiving gastric acid secretion inhibitors ( 1.08–16.82 ) . In non-censored cases ( n = 76 ) length of ICU stay increased by an average of 16.8 days when VAP was present ( p = 0.0008 ) . No adverse effect due to Stericath use was noted and volume of tracheal aspirate was similar between groups ( p = 0.178 ) . Conclusion : The use of Stericath  reduced the incidence rate of VAP without demonstrating any adverse effect BACKGROUND Ventilator associated pneumonia is a major cause of morbidity in the intensive care unit . Difficulties in identification of the risk factors , in diagnosing and in prevention , have intensified the problem . OBJECTIVES To measure the incidence of ventilator associated pneumonia in intensive care unit and to identify the risk factors associated . METHODS A prospect i ve observational cohort study was done in which we evaluated 69 patients who were mechanically ventilated for more than 48 hours to find out the development of nosocomial pneumonia and presence or absence of risk factors . Data were subjected to univariate analysis using chi-square and t-test . Level of significance was set at 0.05 . RESULTS Twenty two ( 31.88 % ) out of 69 patients developed ventilator associated pneumonia , majority of them between four days to 14 days . Reintubation , invasive lines , H2 blockers and low PaO2/FiO2 were identified as major risk factors in our study . Enteral feeding via nasogastric tube and use of steroids was not associated with development of ventilator associated pneumonia . The patients with ventilator associated pneumonia had significantly longer duration of mechanical ventilation ( 18.88+/-7.7 days vs 7.36+/-4.19 days ) and stay ( 29+/-17.8 days vs 9.22+/-5.14 days ) . The morality was similar for both the groups with or without ventilator associated pneumonia . CONCLUSION The incidence of ventilator pneumonia is high . Patients requiring prolonged ventilation , re-intubation , more invasive lines and H2 blockers , are at high risk and need special attention towards prevention OBJECTIVE To estimate the incidence of pneumonia acquired in the intensive care unit ( ICU ) , and to define risk factors for developing such an event . DESIGN European prospect i ve survey , in which all patients admitted to the participating ICU from January , 17 to 23 , 1990 , were followed until ICU discharge . SETTING 107 general ICUs from 18 countries . PATIENTS Of 1078 admitted to the ICUs , 996 patients without pneumonia at admission were studied . MEASUREMENTS Pneumonia was diagnosed by the staff physician on the basis of clinical , radiological and microbiological criteria , secondly vali date d by an expert committee who review ed all the forms and even recontacted ICU physicians .  Crude incidence and time to occurrence of pneumonia were estimated , then both used as end-points for prognosis analysis . RESULTS 89 pneumoniae were observed : crude incidence was estimated at 8.9 % 7-day and 14-day pneumonia rates at 15.8 % and 23.4 % , respectively . The risk of developing pneumonia increased when either coma , trauma , respiratory support , Apache II > 16 and /or imparied air-way reflexes were present at ICU admission . To predict time to occurrence of pneumonia , only two variables remained significant : the presence of impaired airway reflexes at admission and the use of mechanical ventilation during ICU course . CONCLUSIONS The role of the injury to the respiratory system-with the subsequent need for respiratory support -- appears central in determining the risk to acquire pneumonia in ICU . In the future , the predictive value of severity scores during ICU course should be otherwise assessed The aim of this study was to compare the effect of closed versus open endotracheal suction systems on the development of  ventilator-associated pneumonia ( VAP ) . A prospect i ve , r and omized , controlled trial was performed in a medical intensive care unit ( MICU ) of a university hospital in patients who received mechanical ventilation for more than 48 h. Patients were r and omized to receive endotracheal suction with either closed catheters ( closed suction group ; N-41 ) or single-use catheters ( open suction group ; N=37 ) . Cultures were taken from the ventilator tubing of 42 patients to determine the rate of colonization . There was no difference between the groups in terms of the frequency of development of VAP , mortality in the MICU , length of MICU stay and duration of mechanical ventilation .  Thirteen patients in the open suction group and 16 patients in the closed suction group became colonized ( P=0.14 ) . The colonization rates by Acinetobacter spp . and Pseudomonas aeruginosa were more frequent in the closed suction group than in the open suction group ( P<0.01 and P=0.04 , respectively ) . In conclusion , closed endotracheal suction result ed in increased colonization rates of ventilator tubing with multi drug-resistant micro-organisms but did not increase the development of VAP and MICU outcome compared with open endotracheal suction Background Tracheal suctioning costs are higher with a closed tracheal suction system ( CTSS ) than with an open system ( OTSS ) , due to the need for complete daily change as recommended by the manufacturer . However , is it necessary to change the closed system daily ? Objective To evaluate the tracheal suctioning costs and incidence of ventilator-associated pneumonia ( VAP ) using closed system without daily change vs OTSS . Design Prospect i ve and r and omised study . Setting An Intensive Care Unit in a university hospital . Patients Patients requiring mechanical ventilation . Interventions Patients were r and omly assigned to CTSS without daily change or OTSS . We used a CTSS that allowed partial or complete change . Measurements and results There were no significant differences between both groups of patients ( 236 with CTSS and 221 with OTSS ) in gender , age , diagnosis ,  APACHE-II score , mortality , number of aspirations per day , percentage of patients who developed VAP ( 13.9 vs 14.1 % ) or the number of ventilator-associated pneumonia per 1000 days of mechanical ventilation ( 14.1 vs 14.6 ) . There were not significant differences in tracheal suctioning costs per patient/day between CTSS vs OTSS ( 2.3 ± 3.7 vs 2.4 ± 0.5 Euros ; p = 0.96 ) ; however , when length of mechanical ventilation was lower than 4 days , the cost was higher with CTSS than with OTSS ( 7.2 ± 4.7 vs 1.9 ± 0.6 Euros ; p < 0.001 ) ; and when length of mechanical ventilation was higher than 4 days , the cost was lower with CTSS than with OTSS ( 1.6 ± 2.8 vs 2.5 ± 0.5 Euros ; p < 0.001 ) . Conclusion CTSS without daily change is the optimal option for patients needing tracheal suction longer than 4 days The objective of this study was to verify the incidence of nosocomial pneumonia in intubated and extended mechanically ventilated patients having endotracheal suctioning by an open vs. closed suction method aim ing to decrease nosocomial pneumonia .  Twenty-four ( 51.1 % ) patients received open-tracheal suction and 23 ( 48.9 % ) received closed-tracheal suction .  The inclusion criteria were : surgical and medical patients older than 13 years , undergoing mechanical ventilation for more than 48 hours . Additional data were gathered using the Acute Physiology and Chronic Health Evaluation II , and details on smoking , alcoholism , diabetes mellitus , renal failure , previous lung disease , and previous use of antibiotics , steroids , H2 antagonists and antacids . Among the 24 patients having open-tracheal suction , 11 developed nosocomial pneumonia while of the 23 patients undergoing closed-tracheal suction , seven developed infection ( P = 0.278 ) . Risk factors for nosocomial pneumonia were not significantly different between the two groups . In the final logistical regression model the following variables remained : groups ( open and closed ) [ odds ratio ( OR ) = 0.014 ; confidence interval ( CI ) = 0.001 - 0.416 ; P = 0.014 ] and use of prior antibiotics ( OR = 2.297 ; CI = 1.244 - 4.242 ; P = 0.008 ) . Use of a closed suction system did not decrease the incidence of nosocomial pneumonia when compared with the open system . The exogenous risk factors were the most important for acquiring this infection Objective To examine whether oral care contributes to preventing  ventilator-associated pneumonia ( VAP ) in ICU patients . Design Nonr and omized trial with historical controls . Setting A medical-surgical ICU in a university hospital . Patients 1,666 mechanically ventilated patients admitted to the ICU.InterventionOral  care was provided to 1,252 patients who were admitted to the ICU during period between January 1997 and December 2002 ( oral care group ) , while 414 patients who were admitted to the ICU during period between January1995 and December 1996 and who did not receive oral care served as historical controls ( non-oral care group ) . Measurements and results Incidence of VAP(episodes of pneumonia per 1000 ventilator days ) in the oral care group was significantly lower than that in the non-oral care group ( 3.9 vs 10.4 ) . The relative risk of VAP in the oral care group compared to that in the non-oral care group was 0.37 , with an attributable risk of −3.96 % . Furthermore , length of stay in ICU before onset of VAP was greater in the oral care than in the non-oral care group ( 8.5 ± 4.6 vs 6.3 ± 7.5 days ) . However , no significant difference was observed in either duration of mechanical ventilation or length of stay between the groups ( 5.9 ± 10.8 vs 6.0 ± 8.8 days and 7.5 ± 11.5 vs 7.2 ± 9.5 days , respectively ) . Pseudomonoas aeruginosa was the most frequently detected bacteria in both groups . Number of potentially pathogenic bacteria in oral cavity was significantly reduced by single oral care procedure . Conclusion Oral care decreased the incidence of VAP in ICU patients .DescriptorPulmonary nosocomial Eighty-four intubated , mechanically ventilated patients were prospect ively evaluated for incidences of colonization and nosocomial pneumonias dependent on whether they received  endotracheal suctioning by an “ open ” suction method vs. “ closed ” suction ( Trach Care ™ Closed Suction System ) method . Results show that closed suctioning is associated with a significant ( 67 % vs. 39 % p < .02 ) increase in colonization compared with open suctioning . However , difference in the incidence of nosocomial pneumonia was not significantly ( 26 % vs. 29 % ) different between closed and open suctioning . Differences in severity of illness ( Acute Physiology and Chronic Health Evaluation II and Therapeutic Intervention Scoring System ) , age , sex , presence of NG tubes , use of H2 antagonists or antacids , use of antibiotics , and history of smoking were all nonsignificant . Survival analysis demonstrated that the probability of survival without developing nosocomial pneumonia was greater among closed-suctioning patients vs. open-suctioned patients ( p < .03 ) . This study shows that suctioning performed via the Trach Care closed-suction system  increases the incidence of colonization but not the incidence of nosocomial pneumonia , and may actually decrease mortality when compared with open-suction systems Most literature describes endotracheal suction as a hazardous procedure associated with numerous complications and proposes that it should only be performed as necessary to minimize these complications . Other authors suggest endotracheal suction only after assessment predisposes patients to a number of different complications . This article describes a controlled study to compare and contrast the differences in endotracheal suction outcomes in patients who received ritualized 2 hourly suctioning and those who received it following assessment .  A group of qualified nurses in an Intensive Care Unit were taught auscultation skills to assess a patient 's needs for suctioning and all the nurses received educational training regarding endotracheal suctioning .  Short-term ventilated patients were allocated to receive endotracheal suctioning either when the need for it was determined by assessment only or routinely , using a st and ardized suctioning technique . The results demonstrated a clear increase in nurses ' knowledge regarding endotracheal suctioning . The assessed group of patients demonstrated significantly better outcomes and less complications than the controlled group in relation to changes in peak airway pressures , heart rate and mean arterial pressure pre- and post-endotracheal suctioning , and the amount of secretions obtained on suctioning . Although only preliminary , these results do provide support for the view that  endotracheal suction  only in response to assessment is better practice for short-term ventilated patients Objective : The aim of this study was to analyze the prevalence of ventilator-associated pneumonia ( VAP ) using a closed-tracheal suction system vs. an open system . Design : Prospect i ve and r and omized study , from October 1 , 2002 , to December 31 , 2003 . Setting : A 24-bed medical-surgical intensive care unit in a 650-bed tertiary hospital . Patients : Patients requiring mechanical ventilation for > 24 hrs . Interventions : Patients were r and omized into two groups ; one group was suctioned with the closed-tracheal suctioning system and another group with the open system . Measurements : Throat swabs were taken at admission and twice a week until discharge to classify pneumonia in endogenous and exogenous . Main Results : A total of 443 patients ( 210 with closed-tracheal suction system and 233 with the open system ) were included . There were no significant differences between groups of patients in age , sex , diagnosis groups , mortality , number of aspirations per day , and Acute Physiology and Chronic Health Evaluation II score . No significant differences were found in either the percentage of patients who developed VAP ( 20.47 % vs. 18.02 % ) or in the number of VAP cases per 1000 mechanical ventilation-days ( 17.59 vs. 15.84 ) . There were also no differences in the VAP incidence by mechanical ventilation duration . At the same time , we did not find any differences in the incidence of exogenous VAP . Likewise , there were also no differences in the microorganisms responsible for pneumonia . Patient cost per day for the closed suction was more expensive than the open suction system ( $ 11.11 ± $ 2.25 vs. $ 2.50 ± $ 1.12 , p < .001 ) . Conclusion : We conclude that in our study , the closed-tracheal suction system did not reduce VAP incidence , even for exogenous pneumonia Objective To examine the physiologic consequences and costs associated with two methods of endotracheal suctioning : closed vs. open . Design A prospect i ve , r and omized , controlled study . Setting An eight-bed trauma intensive care unit ( ICU ) in a 460-bed level I trauma center . Patients The study included 35 trauma/general surgery patients ( 16 in the open suction group , 19 in the closed suction group ) who were treated with a total of 276 suctioning procedures ( 127 open , 149 closed ) . Measurements and Main Results Physiologic data collected after hyperoxygenation , immediately after suctioning , and 30 sees after suctioning , were compared with baseline values . Open endotracheal suctioning result ed in significant increases in mean arterial pressure throughout the suctioning procedure . Both methods result ed in increased mean heart rates . However , 30 sees after the procedure , the open-suction method was associated with a significantly higher mean heart rate than was the closed method . Closed suctioning was associated with significantly fewer dysrhythmias . Arterial oxygen saturation and systemic venous oxygen saturation decreased with open suctioning . In contrast , arterial oxygen saturation and systemic venous oxygen saturation increased with the closed suction method . There was no difference between the two methods in the occurrence of nosocomial pneumonia .  Open endotracheal suctioning  cost 1.88 more per patient per day and required more nursing time . Conclusions The closed suction method result ed in significantly fewer physiologic disturbances .  Closed suctioning appears to be an effective and cost-efficient method of endotracheal suctioning that is associated with fewer suction-induced complications . ( Crit Care Med 1994 ; 22:658–666 The purpose of this study was to determine the safety and cost-effectiveness of not routinely changing in-line suction catheters for patients requiring mechanical ventilation . Patients were r and omly assigned to receive either no routine in-line suction catheter changes ( n = 258 ) or in-line suction catheter changes every 24 h ( n = 263 ) . The main outcome measure was the incidence of ventilator-associated pneumonia . Other outcomes evaluated included hospital mortality , acquired organ system derangements , duration of mechanical ventilation , lengths of intensive care and hospital stay , and the cost for in-line suction catheters . Ventilator-associated pneumonia was seen in 38 patients ( 14.7 % ) receiving no routine in-line suction catheter changes and in 39 patients ( 14.8 % ) receiving in-line suction catheter changes every 24 h ( relative risk , 0.99 ; 95 % CI , 0.66 to 1.50 ) . No statistically significant differences for hospital mortality , lengths of stay , the number of acquired organ system derangements , death in patients with ventilator-associated pneumonia , or mortality directly attributed to ventilator-associated pneumonia were found between the two treatment groups . Patients receiving in-line suction catheter changes every 24 h had 1,224 catheter changes costing a total of $ 11,016 ; patients receiving no routine in-line suction catheter changes had a total of 93 catheter changes costing $ 837 . Our findings suggest that the elimination of routine in-line suction catheter changes is safe and can reduce the costs associated with providing mechanical ventilation
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