For a long time, the monitoring of ventilator-associated pneumonia (VAP) has many drawbacks, such as complex diagnostic criteria, high subjectivity, low comparability, low attributable mortality, and difficulty in automated monitoring. The U.S. Center for Disease Control and Prevention proposed a new monitoring definition of ventilator-associated event (VAE) in January 2013 to address the existing problems of VAP. VAE monitoring can better predict the adverse prognosis of patients, adopt objective diagnostic criteria, and realize automatic monitoring. However, VAE surveillance also has some shortcomings: poor identification of VAP patients, lack of sufficient evidence of preventive strategies so far, inconclusive application in neonates and children groups, as easy to be interfered with as VAP. The applicability of VAE in China, its risk factors and preventive strategies need to be further studied.
Objective To evaluate the effects of inhalation combined intravenous antibiotics for the treatment of ventilator-associated pneumonia. Methods A computerized search was performed through Cochrane library, Joanna Briggs Institute Library, PubMed, MEDLINE, CINAHL, CBM, CNKI and Wangfang medical network about inhalation combined intravenous antibiotics therapy in ventilator-associated pneumonia in the literatures. The data extracting and quality assessment were performed by three researchers. The meta-analysis was performed by RevMan 5.3 software. Results Thirteen studies was included for analysis. The results showed that the cure rate was higher in the experimental group compared with the control group with significant difference (RR=1.16, 95%CI 1.07 to 1.56,P=0.000 5). There were no significant differences in the mortality (RR=1.04, 95%CI 0.82 to 1.32,P=0.74) or the incidence of kidney damage (RR=0.79, 95%CI 0.51 to 1.22,P=0.29). The difference in pathogenic bacteria removal was statistically significant (RR=1.38, 95%CI 1.09 to 1.74,P=0.007). The negative conversion rate of respiratory secretions was higher in the experimental group. Conclusion Inhalation combined intravenous antibiotics can improve the cure rate of patients with ventilator-associated pneumonia, clear pathogenic bacteria effectively, and is worthy of recommendation for clinical use.
ObjectiveTo investigate the prognostic value of high mobility group protein 1 (HMGB1) in patients with ventilator-associated pneumonia (VAP). MethodsA total 118 VAP patients admitted between March 2013 and March 2015 were recruited in the study. The patients were divided into a death group and a survival group according to 28-day death. Baseline data, HMGB1, C-reactive protein (CRP), clinical pulmonary infection score (CPIS), acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) and sepsis-related organ failure assessment (SOFA) scores were collected on 1st day (d1), 4th day (d4), and 7th day (d7) after VAP diagnosis. The possible prognostic factors were analyzed by univariate and logistic multivariate analysis. ResultsThere were 87 cases in the survival group and 31 cases in the death group. Age, female proportion, body mass index, HMGB1 (d1, d4, d7), APACHEⅡ (d1, d4, d7) and SOFA (d1, d4, d7) scores were all higher in the death group than those in the survival group (all P < 0.05). HMGB1 (d4, P=0.031), APACHEⅡ (d4, P=0.018), SOFA (d4, P=0.048), HMGB1(d7, P=0.087), APACHEⅡ(d7, P=0.073) and SOFA (d7, P=0.049) were closely correlated with 28-day mortality caused by VAP. Multivariate analysis revealed that HMGB1 (d4, HR=1.43, 95%CI 1.07 to 1.78, P=0.021), SOFA (d4, HR=1.15, 95%CI 1.06 to 1.21, P=0.019) and HMGB1 (d7, HR=1.27, 95%CI 1.18 to 1.40, P=0.003) were independent predictors of death in the VAP patients. ROC curve revealed HMGB1 (d4, d7) and SOFA (d4) with area under ROC curve of 0.951, 0.867 and 0.699. ConclusionIndividual HMGB1 level can be used as a good predictor of the short-outcomes of VAP.
ObjectiveTo systematically evaluate the efficacy and safety of probiotics for prevention of ventilator-associated pneumonia (VAP).MethodsThe Web of Science, Pubmed, OVID, Cochrane Library, CNKI, EMbase, Sciencedirect, Chinese biomedical database, and Wanfang database before August 2017 were searched, and the relevant data resources were also searched by hand to collect randomized controlled trials (RCTs) of probiotics for prevention of VAP. The quality of the included studies was evaluated using a modified version of the Jadad scale. Meta-analysis was performed with RevMan 5.3 software.ResultsA total of 16 RCTs were included. The use of probiotics can reduce the incidence of VAP [RR=0.71, 95%CI (0.62, 0.80), P<0.000 01], ICU days [MD=–3.28, 95%CI (–6.15, –0.41), P=0.03] and total duration of antibiotics [MD=–2.47, 95%CI (–4.89, –0.04), P=0.05], but can not reduce the mortality of ICU [RR=0.99, 95%CI (0.74, 1.32), P=0.94], hospital mortality [RR=0.77, 95%CI (0.58, 1.01), P=0.06], 28-day mortality [RR=1.01, 95%CI (0.69, 1.47), P=0.97], 90-day mortality [RR=1.00, 95%CI (0.72, 1.37), P=0.99], hospital stays [MD=–0.68, 95%CI (–3.88, 2.52), P=0.68], duration of mechanical ventilation [MD=–2.17, 95%CI (–4.78, 0.44), P=0.10], or the incidence of diarrhea [RR=0.96, 95%CI (0.80, 1.14), P=0.62]. No serious adverse events were reported in all included RCTs.ConclusionsThe use of probiotics can reduce the incidence of VAP, but it has no effect on the mortality, hospital stay, duration of mechanical ventilation or the incidence of diarrhea. However, considering the heterogeneity of research designs, we need more rigorous, large sample randomized controlled studies to increase the strength of evidence.
ObjectiveTo compare and evaluate the diagnostic value of procalcitonin(PCT) and soluble triggering receptor expressed on myeloid cells-1(sTREM-1) for ventilator-associated pneumonia(VAP). MethodsThe related studies were systematically searched in PubMed, OvidSP (EMBASE), Cochrane Library, clinicaltrials.gov, EBSCO, CBM, CNKI and Wanfang database and the methodological quality of all eligible studies were assessed using the Quality Assessment for Studies of Diagnostic Accuracy (QUADAS) tool. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio (DOR), and areas under the summary receiver operating characteristic (sROC) curve of PCT and sTREM-1 were pooled by Meta-disc software, respectively. Area under the sROC curve (AUC) was compared using Z-test. In addition, Bayes's theorem was used to calculate the probability of VAP, conditioned by the likelihood ratio as a function of the pretest probability. ResultsIn total, 31 studies were included (20 studies on PCT and 11 studies on sTREM-1). The combined sensitivity, specificity, DOR and AUC of diagnosing VAP by PCT was 0.78, 0.74, 15.21, and 0.868, respectively. And the combined sensitivity, specificity, DOR and AUC of diagnosing VAP by sTREM-1 was 0.88, 0.80, 30.28, and 0.919, respectively. There was no statistical difference between two areas under the sROC curve (P=0.25). ConclusionsTREM-1 is superior to PCT in diagnosing VAP, however, neither can confirm nor exclude VAP alone.
Objective To evaluate the diagnostic accuracy of procalcitonin (PCT) for ventilator-associated pneumonia (VAP). Methods We searched MEDLINE, EMbase, The Cochrane Library, CBM, BIOSIS to identify all diagnostic tests which evaluated the diagnostic value of PCT in patients with VAP. QUADAS items were used to evaluate the quality of the included studies. Pooled sensitivity, specificity, positive likelihood ratio (+LR), negative likelihood ratio (-LR), summary receiver operating characteristic (SROC) curve, and the heterogeneity of the included studies were calculated by using the Meta-disk software. Results Five studies which were identified from 103 references met the inclusion criteria. The summary sensitivity, specificity, +LR, and –LR values were 0.70 (95%CI 0.62 to 0.77), 0.76 (95%CI 0.69 to 0.82), 5.651 (95%CI 1.237 to 25.810), and 0.349 (95%CI 0.155 to 0.784), respectively. Overall area under the curve (AUC) of SROC curve was 0.884 (DOR=19.416, 95%CI 2.473 to 152.47), demonstrating significant heterogeneity (I2gt;50%). Conclusion The use of PCT for VAP diagnosis has only a moderate sensitivity and specificity. Although the overall accuracy of VAP diagnosis is relatively high, there is significant heterogeneity between the studies, so more high-quality studies are needed. Besides, using PCT alone to diagnose VAP is not sufficient, and a combination with other clinical evaluations is necessary.
Objective To investigate the relationship between the gastrointestinal function and ventilator-associated pneumonia (VAP) in critically ill patients who underwent invasive mechanical ventilation. Methods One-hundred and fifty-three cases of critically ill patients receiving mechanically ventilation were recruited in the study. After 5 days of ventilation, the gastrointestinal function score and the C-reactive protein (CRP) of each patient were recorded. The incidence of VAP was recorded during hospitalization. According to the incidence of VAP, all patients were divided intoaVAP group and a non-VAP group. The relationship between gastrointestinal function score and the incidence of VAP was analyzed. The relationship between CRP level and severity degree of VAP was also analyzed. Results VAP occurred in 42 cases with the incidence of 27.45%. The gastrointestinal function score (1.9±1.0 vs. 0.8±1.0, P < 0.05) and CRP level [(52.38±12.06) mg/L vs. (36.69±11.08)mg/L, P < 0.05] were both higher in the VAP group than those in the non-VAP group. At gastrointestinal function score of 0 - 3, the CRP levels were all higher in the VAP group than those in the non-VAP group (P < 0.05). The incidence of VAP was 8.33%, 23.68%, 45.45%, and 59.09% at gastrointestinal function score of 0, 1, 2 and 3, respectively, with significant differences between each other(P < 0.05). Conclusion For critically ill patients receiving invasive mechanical ventilation, the more severe the damage of gastrointestinal function is, the higher the incidence of VAP is, and the more serious the disease is.
Objective To determine the effect of closed tracheal suction system versus open tracheal suction system on the rate of ventilator-associated pneumonia in adults. Methods We searched The Cochrane Library (Issue 1, 2007), PubMed (1966 to 2006) and CBM (1980 to 2007), and also hand searched relevant journals. Randomized controlled trials involving closed tracheal suction system versus open tracheal suction system for ventilator-associated pneumonia in adults were included. Data were extracted and the quality of trials was critical assessed by two reviewers independently. The Cochrane Collaboration’s RevMan 4.2.8 software was used for data analyses. Result Five randomized controlled trials involving 739 patients were included. Results of meta-analyses showed that compared to open tracheal suction system, closed tracheal suction system did not increase the rate of ventilator-associated pneumonia (RR 0.83, 95%CI 0.50 to 1.37) or case fatality (RR 1.05, 95%CI 0.85 to 1.31). No significant differences were observed between open tracheal suction system and closed tracheal suction system in the total number of bacteria (RR 0.83, 95%CI 0.50 to 1.37), the number of SPP colony (RR 2.87, 95%CI 0.94 to 8.74) and the number of PSE colony (RR 1.46, 95%CI 0.76 to 2.77). There was no significant difference between the two groups in the duration of ventilation and length of hospital stay. Conclusion Open or closed tracheal suction systems have similar effects on the rate of ventilator-associated pneumonia, case fatality, the number of SPP and PSE colonies, duration of ventilation and length of hospital stay. However, due to the differences in interventions and statistical power among studies included in this systematic review, further studies are needed to determine the effect of closed or open tracheal suction systems on these outcomes.
Objective To evaluate the clinical effects and safety of polymyxin B on ventilator-associated pneumonia caused by pandrug-resistant Acinetobacter baumannii (PDR-AB) in patients with chronic obstructive pulmonary disease (COPD). Methods COPD patients who were diagnosed as ventilator-associated pneumonia caused by PDR-AB and treated with polymyxin B between January 2015 and August 2016 in this hospital were included in this retrospective study. The patients’ symptoms, vital signs, and the results of laboratory examinations were recorded before and after treatment. The clinical cure rates, microbiological eradication rates, mortality and safety were also measured. Results A total of 11 cases were included in this study. Mean time of therapy was 10 days, ranged 8-13 days. After treatment with polymyxin B, most of the patients’ clinical symptoms, signs, and results of laboratory tests as well as imaging examinations were significantly improved. Seven cases had clinical response, and the clinical efficacy rate was 63.6%; 8 cases achieved bacteriological eradication, with the bacteriological eradication rate of 72.7%. Four patients died, and the overall mortality was 36.4%. Only 1 case discontinued treatment with polymyxin B because of the drug fever. Conclusions Polymyxin B might be an alternative option for COPD patients with ventilator-associated pneumonia caused by PDR-AB, who is non-responder to prior antimicrobial therapy. However, this method should be evaluated cautiously in prospective well-controlled studies.
ObjectiveTo investigate the clinical value of serum proadrenomedullin (pro-ADM) for diagnosis of ventilator-associated pneumonia(VAP). MethodsA prospective study was carried out in eighty-nine patients with clinically suspected diagnosis of VAP who underwent invasive mechanical ventilation between June 2014 and July 2015.The patients were divided into a VAP group (n=52) and a non-VAP group (n=37) according to clinical and microbiological culture results.The levels of serum pro-ADM were measured by sandwich ELISA on 1st, 3rd and 5th day of VAP suspicion.The diagnostic value of pro-ADM for VAP was assessed by receiver operating characteristic (ROC) curve analysis. ResultsOn 1st day, 3rd day and 5th day, the pro-ADM levels [3.10(2.21, 4.61) nmol/L, 3.01(2.04, 4.75)nmol/L and 1.85(1.12, 3.54)nmol/L, respectively] in the VAP group were significantly higher than those in the non-VAP group [1.53(1.07, 2.24)nmol/L, 1.52(1.05, 2.17) nmol/L and 1.26(1.02, 2.17) nmol/L, respectively] (all P < 0.05).For diagnosis of VAP, the area under the ROC curve (AUC) for pro-ADM on 1st, 3rd and 5th were 0.896 (95%CI 0.799-0.940), 0.863(95%CI 0.791-0.935) and 0.651 (95%CI 0.538-0.765), respectively.When using 2.53 nmol/L as the best cutoff on 1st day, pro-ADM had 84.6% sensitivity and 86.5% specificity.When using 2.40 nmol/L as the best cutoff on 3rd day, pro-ADM had 82.7% sensitivity and 83.8% specificity. ConclusionSerum level of pro-ADM in the diagnosis of VAP has good sensitivity and specificity, which may be used as a marker to diagnose VAP early.