The Burden of Viruses in Pneumonia Associated With Acute Respiratory Failure: An Underappreciated Issue. (Freeman)

Shorr AF, et al. The Burden of Viruses in Pneumonia Associated With Acute Respiratory Failure: An Underappreciated Issue. Chest. 2018 Jul; 154(1):84-90.

BACKGROUND: Pneumonia associated with mechanical ventilation (MV) results in substantial mortality and represents a leading reason for the use of antibiotics. The role of viruses in this setting is unclear. Identifying a viral cause in such instances could facilitate antibiotic stewardship.

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An Evaluation of Various Ventilator-Associated Infection Criteria in a PICU. (Coleman)

Beardsley AL, et al. An Evaluation of Various Ventilator-Associated Infection Criteria in a PICU. Pediatr Crit Care Med. 2016 Jan;17(1):73-80.

OBJECTIVE: To describe characteristics and overlap associated with various ventilator-associated infection criteria in the PICU.

DESIGN: Retrospective observational study.

SETTING: A quaternary care children’s hospital PICU.

PATIENTS: Children ventilated more than 48 hours, excluding patients with tracheostomy.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Ventilator-associated infection, including pneumonia, infection-related ventilator-associated condition, tracheobronchitis, and lower respiratory tract infection were defined according to criteria from the Centers for Disease Control and Prevention or medical literature. Clinical data were abstracted to assign diagnoses of each ventilator-associated infection. In 300 episodes of mechanical ventilation, there were 30 individual episodes of ventilator-associated infection. Nine episodes met more than one definition. Rates per 1,000 ventilator days were 2.60 for ventilator-associated pneumonia, 2.16 for infection-related ventilator-associated condition, 5.19 for ventilator-associated tracheobronchitis, and 6.92 for lower respiratory tract infection. The rate of any ventilator-associated infection was 12.98 per 1,000 ventilator days. Individual criteria had similar risk factors and outcomes. Risk factors for development of any ventilator-associated infection included older age (p = 0.003) and trauma (p = 0.007), while less cardiac surgery patients developed ventilator-associated infection (p = 0.015). On multivariate analysis, trauma was the only independent risk factor (adjusted odds ratio, 3.10; 95% CI, 1.15-8.38). Developing any ventilator-associated infection was associated with longer duration of mechanical ventilation (p < 0.001) and longer PICU length of stay (p < 0.001) but not PICU mortality (p = 0.523).

CONCLUSIONS: There is little overlap in diagnosis of various ventilator-associated infection. However, the risk factors and outcomes associated with individual criteria are similar, indicating that they may have validity in identifying true pathology. Ventilator-associated infection in general is likely a larger problem than indicated by low hospital-reported rates of ventilator-associated pneumonia. There is clinical confusion due to the presence of several diagnostic criteria for ventilator-associated infection. Developing a more inclusive and clinically relevant criterion for diagnosing ventilator-associated infection is warranted to accurately assess their impact and improve guidance for clinicians in evaluating and treating ventilator-associated infection.

Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis. (Singh)

O’Horo JC, Maki DG, Krupp AE, Safdar N. Arterial catheters as a source of
bloodstream infection: a systematic review and meta-analysis*. Crit Care Med.
2014 Jun;42(6):1334-9.

OBJECTIVE: Catheter-related bloodstream infections are associated with significant costs and adverse consequences. Arterial catheters are commonly used in the critical care setting and are among the most heavily manipulated vascular access devices. We sought to evaluate the prevalence of arterial catheter-related bloodstream infection.

DATA SOURCES: PubMed, CinAHL, EMBASE, and Web of Science.

STUDY SELECTION: Included studies reported prevalence rate of catheter-related bloodstream infection for arterial catheters used for critical illness or postoperative monitoring. For the purposes of this study, catheter-related bloodstream infection was defined as positive blood culture collected from an arterial catheter and from the periphery with the same organism in a patient demonstrating systemic signs of sepsis.

DATA EXTRACTION: The study population, site of insertion, antiseptic preparation, catheter days, and prevalence of catheter-related bloodstream infection were abstracted. When data were not available, authors were contacted for further information.

DATA SYNTHESIS: Forty-nine studies met criteria including 222 cases of arterial catheter-related bloodstream infection in 30,841 catheters. Pooled incidence was 3.40/1,000 catheters or 0.96/1,000 catheter days. Prevalence was considerably higher in the subgroup of studies that cultured all catheters (1.26/1,000 catheter days) compared with those studies that cultured only when the arterial catheter was suspected as the source for the catheter-related bloodstream infection (0.70/1,000 catheter days). Pooled data also found a significantly increased risk of infection for femoral site of insertion compared with radial artery for arterial catheter placement (relative risk, 1.93; 95% CI, 1.32-2.84; p = 0.001)

CONCLUSIONS:: Arterial catheters are an underrecognized cause of catheter-related bloodstream infection. Pooled incidence when catheters were systematically cultured and correlated to blood culture results indicated a substantial burden of arterial catheter-related bloodstream infection. Selection of a radial site over a femoral site will help reduce the risk of arterial catheter-related bloodstream infection. Future studies should evaluate technologies applied to preventing central venous catheter-related bloodstream infection to arterial catheters as well.

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Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. (Teppa)

Ricard JD, Salomon L, Boyer A, et al. Central or Peripheral Catheters for Initial Venous Access of ICU Patients: A Randomized Controlled Trial. Crit Care Med. 2013 Sep;41(9):2108-2115.

OBJECTIVES: The vast majority of ICU patients require some form of venous access. There are no evidenced-based guidelines concerning the use of either central or peripheral venous catheters, despite very different complications. It remains unknown which to insert in ICU patients. We investigated the rate of catheter-related insertion or maintenance complications in two strategies: one favoring the central venous catheters and the other peripheral venous catheters.

DESIGN: Multicenter, controlled, parallel-group, open-label randomized trial.

SETTING: Three French ICUs.

PATIENTS: Adult ICU patients with equal central or peripheral venous access requirement.

INTERVENTION: Patients were randomized to receive central venous catheters or peripheral venous catheters as initial venous access.

MEASUREMENTS AND RESULTS: The primary endpoint was the rate of major catheter-related complications within 28 days. Secondary endpoints were the rate of minor catheter-related complications and a composite score-assessing staff utilization and time spent to manage catheter insertions. Analysis was intention to treat. We randomly assigned 135 patients to receive a central venous catheter and 128 patients to receive a peripheral venous catheter. Major catheter-related complications were greater in the peripheral venous catheter than in the central venous catheter group (133 vs 87, respectively, p = 0.02) although none of those was life threatening. Minor catheter-related complications were 201 with central venous catheters and 248 with peripheral venous catheters (p = 0.06). 46% (60/128) patients were managed throughout their ICU stay with peripheral venous catheters only. There were significantly more peripheral venous catheter-related complications per patient in patients managed solely with peripheral venous catheter than in patients that received peripheral venous catheter and at least one central venous catheter: 1.92 (121/63) versus 1.13 (226/200), p < 0.005. There was no difference in central venous catheter-related complications per patient between patients initially randomized to peripheral venous catheters but subsequently crossed-over to central venous catheter and patients randomized to the central venous catheter group. Kaplan-Meier estimates of survival probability did not differ between the two groups.

CONCLUSION: In ICU patients with equal central or peripheral venous access requirement, central venous catheters should preferably be inserted: a strategy associated with less major complications.

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