• Journal of Korean Critical Care Nursing
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• v.10 no.2
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• pp.14-23
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• 2017

Purpose: The purpose of this study was to evaluate the effectiveness of a ventilator-associated pneumonia (VAP) bundle. Methods: This was a retrospective study that was carried out between June 2010 and October 2015. In this study, 3,224 intubated patients were included. The VAP bundle which was applied to Group 1 patients (n=470) included head-of-bed elevation to 30 degrees, cuff pressure monitorization, prophylaxis of peptic ulcer, and prophylaxis of deep vein thrombosis. The VAP bundle for Group 2 patients (n=1,914) included all the elements of the VAP bundle for Group 1 patients and one additional element which was oral care with 0.12% chlorhexidine. The VAP bundle for Group 3 patients (n=870) added sedative interruption and assessment of readiness to extubate to the VAP bundle for Group 2. Results: The numbers and incidences of VAP were significantly different among the three groups. Moreover, there were significant differences among groups in ICU length of stay and mortality. Conclusion: Three different VAP prevention bundles made different effects in patient outcomes.

• Tuberculosis and Respiratory Diseases
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• v.70 no.3
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• pp.191-198
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• 2011

Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in the intensive care unit (ICU), with an incidence ranging from 8% to 38%. Patients who acquire VAP have higher mortality rates and longer ICU and hospital stays. Because there are other potential causes of fever, leukocytosis, and pulmonary infiltrates, clinical diagnosis of VAP is overly sensitive. The only alternative approach to the clinical diagnosis of VAP is the Clinical Pulmonary Infection Score (CPIS). Employing quantitative cultures of respiratory secretions in the diagnosis of VAP leads to less antibiotic use and probably to lower mortality. With respect to microbiologic diagnosis, however, it is not clear that the use of invasive sampling using bronchoscopy is associated with better outcomes. Delayed administration of antibiotic therapy is associated with an increased mortality, and inadequate antibiotic therapy is also associated with higher mortality. Therefore, prompt initiation of adequate antibiotic therapy is a cornerstone of the treatment of VAP. The initial antibiotic therapy should be based on the most common organisms in each hospital and the most likely pathogens for that specific patient. When final cultures and susceptibilities are available, de-escalation to less broad spectrum antibiotics should be done. Since clinical improvement usually takes 2 to 3 days, clinical responses to the initial empirical therapy should be evaluated by day 3. A short course of antibiotic therapy appears to be equivalent to a traditional course of more than 14 days, except when treating non-fermenting gram-negative organisms. If patients receive initially adequate antibiotic therapy, efforts should be made to shorten the duration of therapy to as short as 7 days, provided that the etiologic pathogen is not a non-fermenting gram-negative organism.

• Annals of Clinical Neurophysiology
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• v.22 no.2
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• pp.61-66
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• 2020

Critical illness neuromyopathy (CINM) is a common but frequently underdiagnosed condition in critically ill patients that contributes to ventilator weaning failure and limb weakness in intensive care unit (ICU). CINM is subdivided into critical illness polyneuropathy and critical illness myopathy, and the occurrence of these conditions in the ICU is associated with multiple organ failure due to sepsis or certain medications. CINM survivors might have persistent functional disabilities and a poor quality of life. This situation demonstrates the need for efforts to minimize or prevent CINM in critically ill patients. This article provides a current overview of CINM and the associated clinical strategies.

• Korean Journal of Clinical Pharmacy
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• v.27 no.4
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• pp.207-213
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• 2017

Background: It is recommended to use aerosolized (AS) colistin in patients undergoing mechanical ventilation therapy as an adjunctive in the latest guidelines, in spite of high nephrotoxicity and limited studies. In this study, systematic reviews and meta-analyzes were conducted to evaluate the safety and efficacy of AS colistin in patients with ventilator-associated pneumonia Methods: Two authors independently searched related literature published from Pubmed and EMBASE until July 2016 and included a study comparing adjunctive AS colistin with intravenous (IV) colistin monotherapy. The primary outcome was the clinical response rate, the secondary outcome was the overall mortality, and nephrotoxicity. The publication bias was evaluated using the Egger's test. Results: Of the total 279 articles, nine were finally included in the final analysis. There was a significant difference between the adjunctive AS colistin group and the IV colistin monotherapy group for the treatment-response rate (odds ratio (OR), 1.56; 95% CI, 1.14-2.14; p = 0.005; $I^2=36%$), although there was no significant difference in overall mortality (OR, 0.77; 95% CI, 0.57-1.04; p = 0.09; $I^2=20%$). However, there was no significant difference between the two groups in nephrotoxicity (OR, 1.13; 95% CI, 0.74-1.74; p = 0.57; $I^2=4%$). Conclusion: The addition of aerosolized colistin to IV colistin monotherapy showed better results in terms of efficacy than IV colistin monotherapy and did not show any significant difference in terms of total mortality and nephrotoxicity. Additional large-scale studies of this need to be verified.

• Korean Journal of Adult Nursing
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• v.28 no.6
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• pp.628-636
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• 2016

Purpose: This study examined the effects of a program designed to prevent ventilator-associated pneumonia (VAP) on VAP rate and endotracheal colonization. The program focused on aspiration prevention and oral care. Methods: A nonequivalent control group post-test only design was utilized. One hundred patients admitted to a medical intensive care unit (MICU) or coronary care unit (CCU) were assigned to either a experimental group (n=50) or a control group (n=50). The participants were selected 48 hours following an endotracheal intubation. VAP prevention program given to the experimental group includes keeping the head of the bed to $30^{\circ}{\sim}45^{\circ}$ high, maintaining continuous endotracheal cuff pressure at 25 cm $H_2O$, performing endotracheal suction before change position, and providing oral care with 0.1% chlorhexidine every four hours. The control group received usual care. Data were analyzed using t-test, $x^2$ test, Mantel-Haenszel $x^2$ and Cox proportional harzard regression model. Results: The experimental group showed a lower VAP rate than the control group although the difference was not statistically significant ($x^2=0.79$, p=.375). The experimental group showed lower colonization in tracheal secretion than the control group ($x^2=14.59$, p<.001). Conclusion: Results showed that a VAP prevention program is effective in reducing colonization of tracheal secretion. Therefore, VAP prevention programs are recommended as an ICU nursing intervention.

• Journal of Trauma and Injury
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• v.26 no.4
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• pp.291-296
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• 2013

Purpose: Prolonged ventilation leads to a higher incidence of ventilator-associated pneumonia (VAP), resulting in weaning failure and increased medical costs. The aim of this study was to analyze clinical results and prognostic factors of VAP in patients with blunt chest trauma. Methods: From 2007 to 2011, one hundred patients undergoing mechanical ventilation for more than 48 hours were divided into two groups: a VAP-negative group, (32 patients, mean age; 53 years, M:F=25:7) and a VAP- positive group, (68 patients, mean age; 60 years, M:F=56:12). VAP was diagnosed using clinical symptoms, radiologic findings and microorganisms. The injury severity score (ISS), shock, combined injuries, computerized tomographic pulmonary findings, transfusion, chronic obstructive lung disease (COPD), ventilation time, stay in intensive care unit (ICU) and hospital stays, complications such as sepsis or disseminated intravascular coagulation (DIC) and microorganisms were analyzed. Chi square, t-test, Mann-Whitney U test and logistic regression analysies were used with SPSS 18 software. Results: Age, sex, ISS, shock and combined injuries showed no differences between the VAP - negative group and - positive group (p>0.05), but ventilation time, ICU and hospital stays, blood transfusion and complications such as sepsis or DIC showed significant differencies (p<0.05). Four patients(13%) showed no clinical symptoms eventhough blood cultures were positive. Regardless of VAP, mortality-related factors were shock (p=0.036), transfusion (p=0.042), COPD (p=0.029), mechanical ventilation time (p=0.011), ICU stay (p=0.032), and sepsis (p=0.000). Microorgnisms were MRSA(43%), pseudomonas(24%), acinetobacter(16%), streptococcus(9%), klebsiela(4%), staphillococus aureus(4%). However there was no difference in mortality between the two groups. Conclusion: VAP itself was not related with mortality. Consideration of mortality-related factors for VAP and its aggressive treatment play important roles in improving patient outcomes.

• Tuberculosis and Respiratory Diseases
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• v.72 no.1
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• pp.30-36
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• 2012

Background: Patients with ventilator-associated pneumonia (VAP) in intensive care unit (ICU) have a high mortality rate. The routine surveillance cultures obtained previously or an ATS guideline for hospital-acquired pneumonia was used in selecting initial antimicrobials. The object of this study was to compare the respiratory samples before VAP and bronchoalveolar lavage (BAL) culture. Methods: 54 patients underwent fiberoptic bronchoscopy to obtain BAL samples. We reviewed microbiologic specimen results of prior respiratory specimens (pre-VAP) and BAL. Results: Among 51 patients with 54 VAP episodes, 52 microorganisms of pre-VAP and 56 BAL samples were isolated. Pre-VAP included 21.2% of MRSA, and 32.6% of multidrug resistant-Acinetobacter baumannii (MDR-AB). BAL samples comprised 25.0% of MRSA, 26.7% of MDR-AB, 14.3% of Stenotrophomonas maltophilia and 3.6% of Klebsiella pneumonia in order. In pre-VAP samples compared to BAL samples, only 35.2% were identical. In BAL samples compared to pre-VAP samples obtained in 5 days before the onset of VAP, only 43.6% were identical. However, among BAL samples compared to pre-VAP samples obtained after more than 5 days, 13.3% were identical (p=0.037). Conclusion: Based on these data, pre-VAP samples obtained prior to 5 day onset of VAP may help to predict the causative microorganisms and to select appropriate initial antimicrobials.

• Tuberculosis and Respiratory Diseases
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• v.73 no.1
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• pp.32-37
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• 2012

Background: This study evaluates the bacterial pathogens of Ventilator-associated pneumonia (VAP) in a tertiary referral hospital. Methods: A total of 109 bacterial pathogens from 91 adult patients with VAP, who were admitted to the medical intensive care unit from January 2008 to December 2009, were examined. Clinical characteristics, bacterial pathogens, and resistance profiles were analyzed. Results: Staphylococcus aureus (44%) was the most frequently isolated. Acinetobacter baumanii (30%), Pseudomonas aeruginosa (12%), Stenotrophomonas maltophilia (7%), Klebsiella pneumoniae (6%), and Serratia marcescens (2%) were isolated from the transtracheal aspirates or bronchoalveolar lavage in patients with VAP. There was no significant difference of bacterial pathogens between early and late onset VAP. All isolated S. aureus were methicillin resistant S. aureus; the imipenem resistance rate of A. baumanii was 69%. Conclusion: The two most frequent pathogens of VAP were S. aureus and A. baumanii. There were no pathogenic differences between early and late onset VAP.

• Pediatric Infection and Vaccine
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• v.27 no.1
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• pp.45-52
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• 2020

Purpose: This pilot study aimed to evaluate the efficacy of high dose ampicillin-sulbactam and colistin combination therapy for ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii (CRAB) in the pediatric intensive care unit of Pusan National University Children's Hospital. Methods: We retrospectively reviewed 17 pediatric patients with VAP caused by CRAB from June 2017 to August 2018. Ten (58.8%) patients were treated with high dose ampicillin-sulbactam and colistin combination therapy (combination therapy group), whereas 7 were treated with colistin only or with various combinations with or without colistin (other antibiotics group). Clinical and bacteriological outcomes were compared between the groups. Results: The mean duration of fever after antibiotic use was 1.30±1.70 days in the combination therapy group and 1.71±1.49 days in the other antibiotics group. The mean duration of days for negative conversion of endotracheal aspirate bacterial culture after antibiotic therapy was 3.40±1.71 days in the combination therapy group and 11.80±8.86 days in the other antibiotics group. The mortality rate within 30 days of antibiotic therapy was 1/10 (10%) in the combination therapy group and 3/7 (42.9%) in the other antibiotics group. Conclusions: High dose ampicillin-sulbactam and colistin combination therapy as early antibiotic treatment in VAP caused by CRAB in children could improve clinical outcomes.

• Tuberculosis and Respiratory Diseases
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• v.67 no.3
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• pp.212-220
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• 2009

Background: Ventilator-associated pneumonia caused by multi-drug resistant Acinetobacter baumannii has been increasing and growing as a threat in intensive care units. Limited therapeutic options have forced clinicians to choose colistin with or without combination of other antibiotics. We tried to compare the effectiveness between colistin monotherapy and combination therapy based on in vitro synergistic tests. Methods: From January 2006 to December 2007 in medical ICU of a tertiary care hospital in Korea, We reviewed the medical records of patients treated with intravenous colistin due to ventilator-associated pneumonia caused by multi-drug resistant Acinetobacter baumannii. Results: A total of 41 patients were analyzed. 22 patients had been treated with colistin monotherapy and 19 patients with colistin and combination antibiotics that were found to have in vitro synergistic effects. Baseline characteristics were similar in both groups but the mean duration of colistin administration was significantly longer in the combination group (19.1${\pm}$11.2 days vs. 12.3${\pm}$6.8 days, p=0.042). There were no significant differences in outcome variables between the two groups. Conclusion: Combination treatment based on the in vitro antimicrobial synergy test did not show better outcomes compared with colistin monotherapy in VAP caused by multi-drug resistant A. baumannii.