Comparison of piperacillin/tazobactam and imipenem/cilastatin, both in combination with tobramycin, administered every 6 h for treatment of nosocomial pneumonia.
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This randomized, double-blind, multicenter study compared the efficacy and safety of piperacillin/tazobactam (P/T) and imipenem/cilastatin (IMP), both in combination with an aminoglycoside, in hospitalized patients with acute nosocomial pneumonia (NP). Patients with acute NP, defined as pneumonia with symptoms > or = 48 h after admission or < or =7 days after hospital discharge, received infusions of 4 g/500 mg P/T or 500 mg/500 mg IMP every 6 h. Endpoints were clinical cure and microbiological response rates; pathogen eradication rates; length of hospital stay; hospital readmissions; and adverse events (AEs). Of 437 patients in the intent-to-treat population, 197 were efficacy evaluable. At test-of-cure, response rates were similar between groups. Within the efficacy evaluable population, 68% of P/T patients and 61% of IMP patients were clinically cured (P = 0.256). Microbiological responses for P/T and IMP patients were: eradication, 64% versus 59%; persistence, 29% versus 21%; relapse, 0% versus 5%; and superinfection, 7% versus 15%, respectively. Gram-positive isolates were eradicated in 83% of P/T patients and 75% of IMP patients; Gram-negative pathogens were eradicated in 72% of P/T patients and 77% of IMP patients. Treatment groups had similar number of mean hospital days, readmission rates, and frequency of AEs. This study showed that P/T administered four times per day was as safe and efficacious as IMP in treating hospitalized patients with NP. (+info)
Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change.
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BACKGROUND: Nosocomial infections occur in approximately 10% of patients in intensive care units (ICUs). Several studies have shown that a quality improvement initiative can reduce nosocomial infections, mortality, and cost. CONTEXT: Our hospital is located in Northern Mississippi and has a 28 bed Medical-Surgical ICU unit with 95% occupancy. We joined the ICU collaborative with the IMPACT initiative of the Institute of Healthcare Improvement (IHI) in October 2002. A preliminary prospective before (fiscal year (FY) 2001-2) and after (FY 2003) hypothesis generating study was conducted of outcomes resulting from small tests of change in the management of ICU patients. KEY MEASURES FOR IMPROVEMENT: Nosocomial infection rates, adverse events per ICU day, average length of stay, and average cost per ICU episode. STRATEGY FOR CHANGE: Four changes were implemented: (1) physician led multidisciplinary rounds; (2) daily "flow" meeting to assess bed availability; (3) "bundles" (sets of evidence based best practices); and (4) culture changes with a focus on the team decision making process. EFFECTS OF CHANGE: Between baseline and re-measurement periods, nosocomial infection rates declined for ventilator associated pneumonia (from 7.5 to 3.2 per 1000 ventilator days, p = 0.04) and bloodstream infections (from 5.9 to 3.1 per 1000 line days, p = 0.03), with a downward trend in the rate of urinary tract infections (from 3.8 to 2.4 per 1000 catheter days, p = 0.17). There was a strong downward trend in the rates of adverse events in the ICU as well as the average length of stay per episode. From FY 2002 to FY 2003 the cost per ICU episode fell from $3406 to $2973. LESSONS LEARNED: A systematic approach through collaboration with IHI's IMPACT initiative may have contributed to significant improvements in care in the ICU setting. Multidisciplinary teams appeared to improve communication, and bundles provided consistency of evidence based practices. The flow meetings allowed for rapid prioritization of activity and a new decision making culture empowered team members. The impact of these changes needs to be assessed more widely using rigorous study designs. (+info)
Oral health status and development of ventilator-associated pneumonia: a descriptive study.
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BACKGROUND: Ventilator-associated pneumonia is a significant cause of morbidity and mortality and may be influenced by oral health. OBJECTIVE: To describe the relationship between ventilator-associated pneumonia and oral health status, changes in oral health status during the first 7 days after intubation, and microbial colonization of the oropharynx and trachea. METHODS: A total of 66 patients were enrolled within 24 hours of intubation and were followed up for up to 7 days. Data on oral health measures and the Clinical Pulmonary Infection Score (CPIS) were collected at baseline, day 4 (n = 37), and day 7 (n = 21). A regression model was used to predict risk of pneumonia at day 4. RESULTS: Dental plaque and oral organisms increased over time. Correlations were significant for baseline and day 4 dental plaque (P < .001), baseline salivary lactoferrin and day 4 plaque (P = .01), and lower salivary volume and higher day 4 CPIS (P = .02). Potential pathogens were identified in oral cultures for 6 patients before or at the same time as the appearance of the organisms in tracheal aspirates. Correlations were significant with day 4 CPIS for score on the Acute Physiology and Chronic Health Evaluation (APACHE) II (P = .007), day 4 salivary volume (P = .02), interaction of APACHE II score and day 1 CPIS (P<.001), and interaction of day 1 CPIS and plaque (P=.01). CONCLUSIONS: Higher dental plaque scores confer greater risk for ventilator-associated pneumonia, particularly for patients with greater severity of illness. Salivary volume and lactoferrin may affect the risk. (+info)
Pneumonia in nonambulatory patients. The role of oral bacteria and oral hygiene.
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BACKGROUND: Considerable evidence exists to support a relationship between poor oral health, the oral microflora and bacterial pneumonia, especially ventilator-associated pneumonia in institutionalized patients. Teeth or dentures have nonshedding surfaces on which oral biofilms (that is, dental plaque) form that are susceptible to colonization by respiratory pathogens. Subsequent aspiration of respiratory pathogens shed from oral biofilms into the lower airway increases the risk of developing a lung infection. In addition, patients may aspirate inflammatory products from inflamed periodontal tissues into the lower airway, contributing to lung insult. TYPES OF STUDIES REVIEWED: The author reviewed laboratory studies, clinical trials and review articles. CONCLUSIONS: A number of studies have shown that the mouth can be colonized by respiratory pathogens and serve as a reservoir for these organisms. Other studies have demonstrated that oral interventions aimed at controlling or reducing oral biofilms can reduce the risk of pneumonia in high-risk populations. Taken together, the evidence is substantial that improved oral hygiene may prevent pneumonia in vulnerable patients. CLINICAL IMPLICATIONS: Institution of rigorous oral hygiene regimens for hospitalized patients and long-term-care residents may reduce the risk of developing pneumonia. (+info)
Incidence and risk factors for ventilator-associated pneumonia in a developing country: where is the difference?
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BACKGROUND: Latin America exhibits a wide range of differences, compared to developed nations, in genetic background, health services, and clinical research development. It is valid to hypothesize that the incidence and risk factors for ventilator-associated pneumonia (VAP) in our setting may be substantially different of those reported elsewhere. We conducted a study to determine the incidence and risk factors for VAP in a University Hospital from Medellin, Colombia. METHODS: Prospective cohort study in three intensive care units (ICU) (surgical/trauma, medical, cardiovascular) in a 550-bed University Hospital. Critically ill patients (n=270) who required at least 48 h of mechanical ventilation (MV) between June 2002 and October 2003 were followed until ICU discharge, VAP diagnosis or death. RESULTS: Sixty patients (22.2%) developed VAP 5.9+/-3.6 days after admission. The overall incidence of VAP was 29 cases per 1000 ventilator-days. The daily hazard for developing VAP increased until day 8, and then decreased over the duration of stay in the ICU. The only statistically significant factor after multivariable analysis was gender, with being female reducing 57% the risk of pneumonia (hazard ratios (HR): 0.43; 95% confidence intervals (CI): 0.19-0.96). CONCLUSIONS: The epidemiologic profile of VAP in terms of incidence, length of stay and clinical course resembles the general pattern described everywhere. Surprisingly, we could not identify any potentially modifiable risk factor for VAP. A comprehensive multicenter study is warranted. It should provide deep insight about the specific microbiological, genetic and clinic features of VAP in our setting. (+info)
Using evidence and process improvement strategies to enhance healthcare outcomes for the critically ill: a pilot project.
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BACKGROUND: Although the value of evidence-based practice may seem obvious, the process needed to produce more effective delivery of evidence-based healthcare is not obvious. Furthermore, the continuing escalation of healthcare costs fuels the desire of providers and consumers to undertake only those treatments that have benefit. One way to effect necessary changes in healthcare organizations is through focused, interdisciplinary, collaborative projects related to evidence-based practice. OBJECTIVES: To reduce rates of ventilator-associated pneumonia and catheter-related bloodstream infection in patients in the medical intensive care unit of a large, urban tertiary referral hospital in the Southwest. METHODS: The theory of planned behavior served as the basis for providing staff members with research-based, easily controllable strategies that "fit" with the usual methods of care delivery. Implementation of the strategies and data collection were accomplished through routine rounds on patients and regular reporting of objective information. RESULTS: During a 15-month period, use of the selected strategies resulted in a 54% reduction in ventilator-associated pneumonia, a 78% reduction in catheter-related bloodstream infections, and a 18% reduction in mean length of stay in the unit. Use of a multidisciplinary, environmentally tailored approach to concerns about patients' care resulted in estimated cost savings of 1.0 million US dollars to 2.3 million US dollars. CONCLUSIONS: Early, consistent communication about the project's rationale, expected behavior, and outcomes enhanced the manageability and effectiveness of this change in an adult intensive care unit. (+info)
Nurses' knowledge and application of evidence-based guidelines for preventing ventilator-associated pneumonia.
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AIM: The aim of the study was to evaluate the nurses' knowledge and to highlight the causes that hinder guidelines implementation. METHODS: EXPERIMENTAL DESIGN: descriptive study. SETTING AND PARTICIPANTS: 106 nurses working in the ICUs of a major Italian hospital of national importance. INTERVENTION: administration of a questionnaire listing 21 non-pharmacological strategies considered the most useful in the literature. RESULTS: Eighty-four nurses responded to the questionnaire. Only 19 (22.6%) declared that their knowledge of ventilation associated pneumonia (VAP) and the strategies used to prevent it were satisfactory, whereas 46 (54.8%) declared that they were poorly informed; 68 nurses (80.9%) said that they applied one or more strategies, and 15 (17.9%) that they applied none. The reasons given for not applying the strategies were: method not foreseen in Department protocols (31.5%), lack of the necessary resources (14.3%), disagreement with the method (3.2%), high costs (2.6%), the possibility of causing discomfort (1%) or side effects (0.6%). CONCLUSIONS: In our experience, VAP preventive strategies are widely applied by nurses, but not in a responsible and informed manner. It is important to ensure that nurses receive continuous training and are involved in drawing up and updating Departmental protocols and guidelines for care and behaviour. (+info)
Mechanical ventilation in patients with Guillain-Barre syndrome.
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BACKGROUND: Patients with Guillain-Barre syndrome are commonly exposed to prolonged mechanical ventilation. Specific data on ventilatory management of these patients have been limited. OBJECTIVE: To describe the practice of mechanical ventilation in patients with Guillain-Barre syndrome and evaluate risk factors for morbidity and mortality. METHODS: We describe a historical cohort of mechanically ventilated patients with Guillain-Barre syndrome in a tertiary-care center. We extracted database information on demographics, severity of illness, pulmonary function, and ventilatory management for the period 1976 to 1996. Primary outcomes were development of pulmonary complications, duration of ventilatory support, and mortality. RESULTS: Fifty-four patients met the inclusion criteria. After 1990, lower tidal volume (p = 0.031) and higher positive end-expiratory pressure (p = 0.003) were used than during the 1976 to 1990. Outcomes did not change significantly during the studied period. Forty-six patients (85%) survived to hospital discharge, and 39 (72%) were alive at 1-year follow-up. Ventilator-associated pneumonia was the most frequent complication (56%) and was associated with prolonged mechanical ventilation (p < 0.01). Atelectasis developed in 49%, and acute lung injury in 13%. All but 6 patients (89%) received tracheostomy. In 14 patients (30%) tracheostomy was placed > or = 14 days after intubation. When adjusted for atelectasis and severity of illness in a stepwise logistic regression analysis, delayed tracheostomy was associated with the development of ventilator-associated pneumonia (odds ratio 8.2, p = 0.029). CONCLUSIONS: Changes in ventilator practice did not affect outcomes of mechanically ventilated patients with Guillain-Barre syndrome. The majority of patients received tracheostomy, which should be considered early in the course of respiratory failure. (+info)