Healthcare associated pneumonia in intensive care patients – optimal choice of initial empirical antimicrobial therapy: Results of a multicenter, observational study

Czech version

Authors: T. Herkeľ ¹; R. Uvízl ¹; M. Kolář ²; M. Htoutou Sedláková ²; M. Adamus ¹; L. Doubravská ¹; T. Gabrhelík ³; V. Pudová ²; K. Langová ⁴; R. Zazula ⁵; T. Řezáč ⁵; M. Moravec ⁵; P. Čermák ⁶; P. Ševčík ^7,8; J. Stašek ⁹; A. Ševčíková ¹⁰; M. Hanslianová ¹⁰; Z. Turek ¹¹; V. Černý ^11,12; P. Paterová ¹³
Authors‘ workplace: Klinika anesteziologie, resuscitace a intenzivní medicíny, Fakultní nemocnice Olomouc a Lékařská fakulta Univerzity Palackého v Olomouci ¹; Ústav mikrobiologie, Fakultní nemocnice Olomouc a Lékařská fakulta Univerzity Palackého v Olomouci ²; Anesteziologicko-resuscitační oddělení, Krajská nemocnice Tomáše Bati ³; Ústav lékařské biofyziky, Lékařská fakulta Univerzity Palackého v Olomouci ⁴; Anesteziologicko-resuscitační klinika 1. lékařské fakulty Univerzity Karlovy v Praze a Thomayerovy nemocnice Praha ⁵; Oddělení klinické mikrobiologie, Thomayerova nemocnice Praha ⁶; Katedra intenzivní medicíny, urgentní medicíny a forenzních oborů, Lékařská fakulta Ostravské univerzity v Ostravě ⁷; Klinika anesteziologie, resuscitace a intenzivní medicíny, Fakultní nemocnice Ostrava ⁸; Klinika anesteziologie, resuscitace a intenzivní medicíny, Fakultní nemocnice Brno a Lékařská fakulta Masarykovy univerzity Brno ⁹; Mikrobiologický ústav, Fakultní nemocnice Brno a Lékařská fakulta Masarykovy univerzity Brno ¹⁰; Centrum pro výzkum a vývoj, Klinika anesteziologie, resuscitace a intenzivní medicíny, Fakultní nemocnice Hradec Králové a Lékařská fakulta Univerzity Karlovy v Hradci Králové ¹¹; Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Canada ¹²; Ústav klinické mikrobiologie, Fakultní nemocnice Hradec Králové a Lékařská fakulta Univerzity Karlovy v Hradci Králové ¹³
Published in: Anest. intenziv. Med., 28, 2017, č. 3, s. 154-162
Category: Intensive Care Medicine - Original Paper

Overview

Objective:
This study aimed to obtain recent epidemiological data on hospital-acquired pneumonia (HAP) in intensive care patients and to determine adequate empirical antimicrobial therapy.

Setting:
Department of Anaesthesiology, Resuscitation and Intensive Care Medicine.

Patients and methods:
The prospective, multicenter, observational study assessed the spectrum of detected bacterial pathogens and their resistance to antimicrobial agents. It was compared with a reference approach to initial antibiotic therapy in early- and late-onset HAP.

Results:
Total 317 patients were included in the study. The final patient sample comprised 201 subjects (159 males and 42 females) with a mean age of 59.9 years. Total 260 valid samples of lower respiratory tract secretions were obtained. Early- and late-onset HAP was detected in 26 (12.9%) and 175 (87.1%) patients, respectively. A total of 22 bacterial species were identified as etiological agents, with detection rates higher that 5% being noted in only 6 of them (Klebsiella pneumoniae 20.4%, Pseudomonas aeruginosa 20.0%, Escherichia coli 10.8%, Enterobacter spp. 8.1%, Staphylococcus aureus 6.2% and Burkholderia cepacia complex 5.8%). Gram-negative bacteria were most prevalent (86.1%). Patients with early-onset HAP had considerably higher prevalence of strains of Staphylococcus aureus (26.9%) and Haemophilus influenzae (15.4%). In late-onset HAP, most dominant were the strains of Pseudomonas aeruginosa (21.8%) and Klebsiella pneumoniae (21.4%). Most pathogens causing HAP (74.0%) were shown to have a unique restriction profile. Adequate initial empirical antibiotic therapy was noted in 59.7% of patients.

Conclusion:
The reference approach to initial empirical antibiotic therapy of early- and late-onset HAP was consistent with the spectrum of bacterial pathogens and their susceptibility to antimicrobial agents.

KEYWORDS:
nosocomial infections – hospital acquired pneumonia – initial empirical antibiotic therapy – epidemiology – pneumonia

Sources

1. Joseph NM, Sistla S, Dutta TK, et al. Ventilator-associated pneumonia: a review. Eur J Intern Med 2010;21:360–369.

2. Jones RN Microbial etiologies of hospital-acquired pneumonia and ventilator-associated bacterial pneumonia. Clin Index Dis 2010;51:81–87.

3. Rello J, Torres A, Ricart M, et al. Ventilator-associated pneumonia by Staphylococcus aureus. Comparison of methicillin-resistant and methicillin-sensitive episodes. Am J Respir Crit Care Med 1994;150:1645–1549.

4. http://ecdc.europa.eu/en/healthtopics/Healthcare-associated_infections/Pages/index.aspx

5. Vincent JL, Bihari DJ, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA 1995;23–30,274:639–644.

6. Uvizl R, Hanulik V, Husickova V, et al. Hospital-acquired pneumonia in ICU patients. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2011;155:373–378.

7. Guideline for prevention of nosocomial pneumonia. Centers for Disease Control and Prevention. Respir Care 1994;39:1191.

8. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388.

9. Craven DE, Palladino R, McQuillen DP. Healthcare-associated pneumonia in adults: management principles to improve outcomes. Infect Dis Clin North Am 2004;18:939.

10. Scheld WM. Developments in the pathogenesis, diagnosis and treatment of nosocomial pneumonia. Surg Gynecol Obstet 1991;172 Suppl:42.

11. Ibrahim EH, Ward S, Sherman G, et al. A comparative analysis of patients with early-onset vs late-onset nosocomial pneumonia in the ICU setting. Chest 2000;117:1434–1442.

12. Langer M, Cigada M, Mandelli M et al. Early onset pneumonia: a multicenter study in intensive care units. Intensive Care Med 1987;13:342–346.

13. The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 4.0, 2014. http://www.eucast.org.

14. Standard iniciální antibiotické terapie HAP ve FN Olomouc. https://altus.fnol.loc/Default.aspx?page=p831750607 Směrnice č. Sm-L034.

15. http://www.mzcr.cz/Verejne/obsah/program-prevence-a-kontroly-infekci-v-zdravotnickych-zarizenich_2917_5.html.

16. Esperatti M, Ferrer M, Theessen A, et al. Nosocomial pneumonia in the intensive care unit acquired by mechanically ventilated versus nonventilated patients. Am J Respir Crit Care Med 2010;182:1533-1539.

17. Burgmann H, Hiesmayr JM, Savey A, et al. Impact of nosocomial infections on clinical outcome and resource consumption in critically ill patients. Intensive Care Med 2010;36:1597–1601

18. Hortal J, Muñoz P, Cuerpo G, et al. Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe. The European Study Group of Nosocomial Infections, the European Work Group of Cardiothoracic Intensivists. Crit Care 2009;13:80.

19. Lambiase A, Rossano F, Piazza O, et al. Typing of Pseudomonas aeruginosa isolated from patients with VAP in an intensive care unit. New Microbiol 2009;32:277–283.

20. Pravin ChMV, Easow JM, Joseph NM, et al. Role of Appropriate Therapy in Combating Mortality among the Ventilated Patients. J Clin Diagn Res 2014;8:DC01–DC03.

21. Chung RD, Song JH, Kim SH, et al. High prevalence of multidrug-resistant nonfermenters in hospital-acquired pneumonia in Asia. American Journal of Respiratory and Critical Care Medicine 2011;184:1409–1417.

22. Forel JM, Voillet F, Pulina D, et al. Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy. Crit Care 2012;16:65.

23. Crouch Brewer S, Jones CB, Leeper KV, et al. Ventilator-associated pneumonia due to Pseudomonas aeruginosa. Chest 1996;109:1029.

24. Valle’s J, Martin-Loeches I, Torres A. Epidemiology, antibiotic therapy and clinical outcomes of healthcare-associated pneumonia in critically ill patients: a Spanish cohort study. Intensive Care Med 2014;40:572–581.

25. Ioanas M, Cavalcanti M, Ferrer M. Hospital-acquired pneumonia: coverage and treatment adequacy of current guidelines. Eur Respir J 2003;22:876–882.

26. Luna CM, Aruj P, Niederman MS, et al. Grupo Argentino de Estudio de la Pneumonia Asociada el Respirador group. Appropriateness and delay to initiate therapy in ventilator-associated pneumonia. Eur Respir J 2006;27:158–164.

27. Alvarez-Lerma F, Alvarez B, Luque P, et al. ADANN Study Group. Empiric broad-spectrum antibiotic therapy of nosocomial pneumonia in the intensive care unit: a prospective observational study. Crit Care 2006;10:78.

28. Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated Ppeumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016, in press.

29. American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416

30. Masterton RG, Galloway A, French G, et al. Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial chemotherapy J Antimicrob Chemother 2008.

31. Dalhoff K, Abele-Horn M, Andreas S, et al. Epidemiology, diagnosis and treatment of adult patients with nosocomial pneumonia. Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy. Pneumologie 2012;66:707–765.

Labels

Anaesthesiology, Resuscitation and Inten Intensive Care Medicine

Selected Aspects of Interdisciplinary Collaboration in the Delivery Room

Practical application of the results of clinical trials

Pulmonary trauma by energy load – ventilator-induced lung injury

Epidemiology of out-of-hospital cardiac arrest in the Czech Republic – national results of the EuReCa ONE trial

Statistics in biomedical research II

Anaesthesia in the Austro-Hungarian Empire during World War I and in the newly formed Czechoslovak Republic

Article was published in

Anaesthesiology and Intensive Care Medicine

2017 Issue 3