Low Efficacy of Antibiotics Against Staphylococcus aureus Airway Colonization in Ventilated Patients.

Background: Airway-colonization by Staphylococcus aureus predisposes to the development of ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP). Despite extensive antibiotic treatment of intensive care unit patients, limited data are available on the efficacy of antibiotics on bacterial airway colonization and/or prevention of infections. Therefore, microbiologic responses to antibiotic treatment were evaluated in ventilated patients.

Pre-emptive antibiotic therapy to reduce ventilator-associated pneumonia: "thinking outside the box".

Mechanically ventilated, intubated patients are at increased risk for tracheal colonization with bacterial pathogens that may progress to heavy bacterial colonization, ventilator-associated tracheobronchitis (VAT), and/or ventilator-associated pneumonia (VAP). Previous studies report that 10 to 30 % of patients with VAT progress to VAP, resulting in increased morbidity and significant acute and chronic healthcare costs. Several natural history studies, randomized, controlled trials, and a meta-analysis have reported antibiotic treatment for VAT can reduce VAP, ventilator days, length of intensive care unit (ICU) stay, and patient morbidity and mortality.

Lyme disease presenting as multiple ischaemic strokes.

A 46-year-old man presented with recurrent left hemiparesis and headache. MRI of brain showed an acute right pontine and subacute right thalamic infarcts and MR angiogram showed multiple intracranial arterial stenoses, suggesting cerebral vasculopathy. There was a cerebrospinal fluid lymphocytic pleocytosis with Borrelia burgdorferi antibodies.

Antibiotic therapy for ventilator-associated tracheobronchitis: a standard of care to reduce pneumonia, morbidity and costs?

Purpose Of Review: The present review draws our attention to ventilator-associated tracheobronchitis (VAT) as a distinct clinical entity that has been associated with progression to ventilator-associated pneumonia (VAP) and worse patient outcomes. In contrast to VAP, which has been extensively investigated for over the past 30 years, most VAT studies have been conducted in the past decade. There are ample data which demonstrate that VAT may progress to VAP, have more ventilator days, and have longer ICU stay that may translate into higher healthcare costs.

Ventilator-associated tracheobronchitis: pre-emptive, appropriate antibiotic therapy recommended.

Nseir and colleagues presented data from a large multicenter study of patients with ventilator-associated tracheobronchitis (VAT), demonstrating that appropriate antibiotic therapy for VAT was an independent predictor for reducing transition to pneumonia (ventilator-associated pneumonia, or VAP). These data added to the growing evidence supporting the use of appropriate antibiotic therapy for VAT as a standard of care to prevent VAP and improve patient outcomes.

α-Hemolysin activity of methicillin-susceptible Staphylococcus aureus predicts ventilator-associated pneumonia.

Rationale: Colonization of lower airways by Staphylococcus aureus is a risk factor for the development of ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP). However, little is known about the virulence factors of methicillin-sensitive and -resistant S. aureus (MSSA and MRSA) that may influence host colonization and progression to VAT and VAP.

Antibiotic treatment of ventilator-associated tracheobronchitis: to treat or not to treat?

Purpose Of Review: To evaluate the data on antimicrobial therapy for ventilator-associated tracheobronchitis (VAT) to prevent ventilator-associated pneumonia (VAP), and its impact on patient outcomes.

Recent Findings: Mechanically ventilated patients are at increased risk for tracheal colonization with bacterial pathogens that may progress to VAT and/or VAP. Previous studies suggest that 10-30% of patients with VAT progress to VAP, which results in increased morbidity but not mortality.

Incidence and outcomes of ventilator-associated tracheobronchitis and pneumonia.

Background: Prolonged intubation with mechanical ventilation carries a risk for ventilator-associated respiratory infections manifest as tracheobronchitis or pneumonia. This study analyzed natural history, incidence, and outcomes of patients developing ventilator-associated tracheobronchitis and pneumonia.

Methods: We studied 188 mixed intensive care unit (ICU) patients intubated ≥48 hours for the development of tracheobronchitis defined as quantitative endotracheal aspirate ≥10(5) cfu/mL plus at least 2 clinical criteria (fever, leukocytosis, or purulent sputum).

Diagnosis of ventilator-associated pneumonia: controversies and working toward a gold standard.

Purpose Of Review: The aim is to discuss the clinical, microbiologic, and radiological criteria used in the diagnosis of ventilator-associated pneumonia (VAP), distinguish between ventilator-associated tracheobronchitis (VAT) and VAP, and reconcile the proposed Centers for Disease Control surveillance criteria with clinical practice.

Recent Findings: Numerous ventilator-associated complications (VACs), including VAP and VAT, may occur in critically ill, intubated patients. A variety of definitions for identifying VAP have been proposed, but there is no diagnostic gold standard.

Management and prevention of ventilator-associated pneumonia caused by multidrug-resistant pathogens.

Ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) pathogens is a leading healthcare-associated infection in mechanically ventilated patients. The incidence of VAP due to MDR pathogens has increased significantly in the last decade. Risk factors for VAP due to MDR organisms include advanced age, immunosuppression, broad-spectrum antibiotic exposure, increased severity of illness, previous hospitalization or residence in a chronic care facility and prolonged duration of invasive mechanical ventilation.

Strategies for prevention of ventilator-associated pneumonia: bundles, devices, and medications for improved patient outcomes.

Ventilator-associated pneumonia is associated with significant patient morbidity, mortality, and increased health care costs. In the current economic climate, it is crucial to implement cost-effective prevention strategies that have proven efficacy. Multiple prevention measures have been proposed by various expert panels.

Diagnosis of ventilator-associated respiratory infections (VARI): microbiologic clues for tracheobronchitis (VAT) and pneumonia (VAP).

Intubated patients are at risk of bacterial colonization and ventilator-associated respiratory infection (VARI). VARI includes tracheobronchitis (VAT) or pneumonia (VAP). VAT and VAP caused by multidrug-resistant (MDR) pathogens are increasing in the United States and Europe.

Ventilator-associated tracheobronchitis and pneumonia: thinking outside the box.

Lower respiratory tract infections in intubated patients include ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP). These infections are increasingly caused by multidrug-resistant bacteria, which colonize the patient's oropharynx and enter the lower respiratory tract around the endotracheal tube cuff or through the lumen. Progression of colonization to VAT and, in some patients, to VAP is related to the quantity, types, and virulence of invading bacteria versus containment by host defenses.

Noninvasive markers of liver fibrosis are highly predictive of liver-related death in a cohort of HCV-infected individuals with and without HIV infection.

Objectives: Noninvasive markers of liver fibrosis correlate with the stage of liver fibrosis, but have not been widely applied to predict liver-related mortality.

Methods: We assessed the ability of two indices of liver fibrosis, aspartate aminotransferase (AST)-to-platelet ratio index (APRI) and Fib-4, and two markers of extracellular matrix metabolism, hyaluronic acid (HA) and YKL40, to predict liver mortality in a prospective cohort of hepatitis C virus (HCV)-infected individuals with and without HIV coinfection. These were compared with two established prognostic scores, the Child-Pugh-Turcotte (CPT) and model of end-stage liver disease (MELD) scores.

Association between a silver-coated endotracheal tube and reduced mortality in patients with ventilator-associated pneumonia.

Background: A silver-coated endotracheal tube (ETT) reduced the incidence of ventilator-associated pneumonia (VAP) compared with an uncoated ETT in the North American Silver-Coated Endotracheal Tube (NASCENT) study.

Methods: To evaluate the effect of an ETT and risk factors on mortality, we performed a retrospective cohort analysis in patients who developed VAP in the NASCENT study. We determined causes of death and VAP due to potentially multidrug-resistant bacteria (eg, Pseudomonas, Acinetobacter) and performed stepwise multivariate logistic regression with the following predefined variables: treatment group, Acute Physiology and Chronic Health Evaluation (APACHE) II score, continuous sedation, coma, COPD, emergency surgery/trauma, immunodeficiency, potentially multidrug-resistant bacteria, and inappropriate initial antibiotics.

Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.

These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them.

Predictors of treatment for hepatitis C virus (HCV) infection in drug users.

Documented treatment rates for Hepatitis C virus (HCV) infection are low. Within this cohort of HCV-infected patients (N = 373), participants who were not actively injecting drugs or not co-infected with HIV were most likely to initiate HCV treatment. Persons of white race and HIV-infected participants with a CD4 count above 200 were also more likely to have initiated HCV treatment.

Molecular typing of Mycobacterium chelonae isolates from a pseudo-outbreak involving an automated bronchoscope washer.

We describe a pseudo-outbreak of Mycobacterium chelonae infection in bronchoalveolar lavage fluid from 9 patients that was traced to contamination of an automated bronchoscope washer. Molecular typing using repetitive extragenic palindromic polymerase chain reaction was helpful in confirming epidemiologic and clinical findings.

Ventilator-associated tracheobronchitis: the impact of targeted antibiotic therapy on patient outcomes.

Nosocomial lower respiratory tract infections are a common cause of morbidity and mortality in ICU patients receiving mechanical ventilation. Many studies have investigated the management and prevention of ventilator-associated pneumonia (VAP), but few have focused on the role of ventilator-associated tracheobronchitis (VAT). The pathogenesis of lower respiratory tract infections often begins with tracheal colonization that may progress to VAT, and in selected patients to VAP.

Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial.

Context: Ventilator-associated pneumonia (VAP) causes substantial morbidity. A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation.

Objective: To determine whether a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP.

Ventilator-associated tracheobronchitis (VAT): questions, answers, and a new paradigm?

Nosocomial lower respiratory tract infections are a common cause of morbidity and mortality in intensive care unit (ICU) patients. Although many studies have investigated the management and prevention of ventilator-associated pneumonia (VAP), few have focused on ventilator-associated tracheobronchitis (VAT). In this issue of Critical Care, Nseir and coworkers present interesting data from a randomized controlled study of antimicrobial therapy for VAT.

Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes--proceedings of the HCAP Summit.

Increasingly, patients are receiving treatment at facilities other than hospitals, including long-term-health care facilities, assisted-living environments, rehabilitation facilities, and dialysis centers. As with hospital environments, nonhospital settings present their own unique risks of pneumonia. Traditionally, pneumonia in these facilities has been categorized as community-acquired pneumonia (CAP).