Background Legionella species are important causative organisms of severe pneumonia. However, data are limited on predictors of progression to severe Legionella pneumonia (LP). Therefore, the risk factors for LP progression from non-severe to the severe form were investigated in the present study. Methods: This was a retrospective cohort study that included adult LP patients admitted to a 2,700-bed referral center between January 2005 and December 2019. Results: A total of 155 patients were identified during the study period; 58 patients (37.4%) initially presented with severe pneumonia and 97 (62.6%) patients with non-severe pneumonia. Among the 97 patients, 28 (28.9%) developed severe pneumonia during hospitalization and 69 patients (71.1%) recovered without progression to severe pneumonia. Multivariate logistic regression analysis showed platelet count ≤150,000/mm3 (odds ratio [OR], 2.923; 95% confidence interval [CI], 1.100–8.105; P=0.034) and delayed antibiotic treatment >1 day (OR, 3.092; 95% CI, 1.167–8.727; P=0.026) were significant independent factors associated with progression to severe pneumonia. Conclusions: A low platelet count and delayed antibiotic treatment were significantly associated with the progression of non-severe LP to severe LP.
Background Studies on the effects of viral coinfection on bacterial pneumonia are still scarce in South Korea. This study investigates the frequency and seasonal distribution of virus infection and its impact on the prognosis in patients with community-acquired pneumonia (CAP). Methods: The medical records of CAP patients with definite etiology, such as viruses and bacteria, were retrospectively reviewed. Their epidemiologic and clinical characteristics, microbiologic test results, the severity of illness, and 30-day mortality were analyzed. Results: Among 150 study subjects, 68 patients (45.3%) had viral infection alone, 47 (31.3%) had bacterial infection alone, and 35 (23.3%) had viral-bacterial coinfection, respectively. Among 103 patients with viral infections, Influenza A virus (44%) was the most common virus, followed by rhinovirus (19%), influenza B (13%), and adenovirus (6%). The confusion-urea-respiratory rateblood pressure-age of 65 (CURB-65) score of the viral-bacterial coinfection was higher than that of the viral infection (median [interquartile range]: 2.0 [1.0–4.0] vs. 2.0 [0.3–3.0], P=0.029). The 30-day mortality of the viral infection alone group (2.9%) was significantly lower than that of bacterial infection alone (19.1%) and viral-bacterial coinfection (25.7%) groups (Bonferroni-corrected P<0.05). Viral-bacterial coinfection was the stronger predictor of 30-day mortality in CAP (odds ratio [OR], 18.9; 95% confidence interval [CI], 3.0–118.3; P=0.002) than bacterial infection alone (OR, 6.3; 95% CI, 1.1–36.4; P=0.041), compared to viral infection alone on the multivariate analysis. Conclusions: The etiology of viral infection in CAP is different according to regional characteristics. Viral-bacterial coinfection showed a worse prognosis than bacterial infection alone in patients with CAP.
Background Fiberoptic endoscopic evaluation of swallowing (FEES) has been recommended to assess aspiration in stroke. This study aimed to determine the diagnostic and prognostic roles of FEES in the early assessment of aspiration, intensive care unit (ICU) stay and mortality in acute stroke patients.
Methods Fifty-two patients with acute stroke admitted to the Alexandria Main University Hospital were included. Complete examinations and assessment of aspiration using the 8-point penetration-aspiration scale (PAS) with FEES protocol were performed.
Results The patients were classified into three groups: normal with no or low risk of aspiration (n=15, 27.3%; PAS level 1), low to moderate risk (n=8, 14.5%; PAS level 2–4), and high risk (n=32, 58.2%; PAS ≥5). There was high incidence of aspiration pneumonia, prolonged ICU stay, and mortality in both moderate- and high-risk groups (P=0.001, P<0.001, and P<0.001, respectively). The PAS score predicted aspiration pneumonia (hospital-acquired pneumonia) with sensitivity and specificity of 80.0% and 76.0%, respectively (negative predictive value [NPV], 76.0; positive predictive value [PPV], 80.0; 95% confidence interval [CI], 0.706–0.940) and mortality with sensitivity and specificity of 88.46% and 68.97% (NPV, 87.0; PPV, 71.9; 95% CI, 0.749–0.951). The PAS score could predict the length of ICU stay with sensitivity and specificity of 70.21% and 87.50, respectively (NPV, 33.3; PPV, 97.1; 95% CI, 0.605–0.906).
Conclusions The standard FEES protocol using PAS score is a useful tool to assess aspiration in acute stroke patients and could be used to predict length of ICU stay and mortality.
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The use of videofluoroscopy (VFS) and fibreoptic endoscopic evaluation of swallowing (FEES) in the investigation of oropharyngeal dysphagia in stroke patients: A narrative review K. Helliwell, V.J. Hughes, C.M. Bennion, A. Manning-Stanley Radiography.2023; 29(2): 284. CrossRef
Background Coronavirus disease 2019 (COVID-19) is one of the biggest pandemic causing acute respiratory failure (ARF) in the last century. Seasonal influenza carries high mortality, as well. The aim of this study was to compare features and outcomes of critically-ill COVID-19 and influenza patients with ARF.
Methods Patients with COVID-19 and influenza admitted to intensive care unit with ARF were retrospectively analyzed.
Results Fifty-four COVID-19 and 55 influenza patients with ARF were studied. Patients with COVID-19 had 32% of hospital mortality, while those with influenza had 47% (P=0.09). Patients with influenza had higher Eastern Cooperative Oncology Group, Clinical Frailty Scale, Acute Physiology and Chronic Health Evaluation II and admission Sequential Organ Failure Assessment (SOFA) scores than COVID-19 patients (P<0.01). Secondary bacterial infection, admission acute kidney injury, procalcitonin level above 0.2 ng/ml were the independent factors distinguishing influenza from COVID-19 while prone positioning differentiated COVID-19 from influenza. Invasive mechanical ventilation (odds ratio [OR], 42.16; 95% confidence interval [CI], 9.45–187.97), admission SOFA score more than 4 (OR, 5.92; 95% CI, 1.85–18.92), malignancy (OR, 4.95; 95% CI, 1.13–21.60), and age more than 65 years (OR, 3.31; 95% CI, 0.99–11.03) were found to be independent risk factors for hospital mortality.
Conclusions There were few differences in clinical features of critically-ill COVID-19 and influenza patients. Influenza cases had worse performance status and disease severity. There was no significant difference in hospital mortality rates between COVID-19 and influenza patients.
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Comparison of Clinical Features and Outcomes between SARS-CoV-2 and Non-SARS-CoV-2 Respiratory Viruses Associated Acute Respiratory Distress Syndrome: Retrospective Analysis Manbong Heo, Jong Hwan Jeong, Sunmi Ju, Seung Jun Lee, Yi Yeong Jeong, Jong Deog Lee, Jung-Wan Yoo Journal of Clinical Medicine.2022; 11(8): 2246. CrossRef
Background Mechanical ventilation is a lifesaving intervention for critically ill patients but can produce the major complication of ventilator-associated pneumonia (VAP). Inappropriately inflated endotracheal tubes cause potential harm due to high or low pressure; this can be prevented through monitoring protocols.
Methods A cross-sectional study of 348 cuff pressure readings was performed with intubated and mechanically ventilated patients to evaluate the exact proportion of patients in intensive care units (ICUs) where the cuff pressure is optimal and to identify the ICUs where device-based monitoring is available to produce a lower proportion of sub-optimal cuff pressure cases. Every three days, cuff pressure was assessed with a handheld cuff pressure manometer. The corresponding VAP rates of those ICUs were obtained from the hospital infection control department.
Results Cuff pressure of 40.2% was the lower cutoff for the high category, that of optimal was 35.3%, and the highest cutoff of sub-optimal was 24.4%. This study also showed ICUs that had cuff pressure monitoring devices and protocols. Active measurement protocols had a higher proportion of optimal cuff pressure (58.5%) and a lower proportion of sub-optimal and high cuff pressure (19.5% and 22.0%) compared to ICUs with no device-based monitoring protocols. Furthermore, the VAP rate of ICUs exhibited a weak positive correlation with sub-optimal cuff pressure.
Conclusions Device-based cuff pressure monitoring is essential in maintaining adequate cuff pressure but often is inadequate, resulting in high readings. Therefore, this study suggests that device-based cuff pressure monitoring be practiced.
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Efficacy of using an intravenous catheter to repair damaged expansion lines of endotracheal tubes and laryngeal masks Tingting Wang, Jiang Wang, Yao Lu, Xuesheng Liu, Shangui Chen BMC Anesthesiology.2022;[Epub] CrossRef
Background Care bundles for ventilator-associated pneumonia (VAP) have been shown to minimize the rate of VAP in critically ill patients. Standard care bundles may need to be modified in resource-constrained situations. The goal of this study was to see if our modified VAP-care bundles lowered the risk of VAP in neurosurgical patients.
Methods A prospective cohort study was conducted in mechanically ventilated neurosurgical patients. The VAP bundle was adjusted in the cohort group by increasing the frequency of intermittent endotracheal tube cuff pressure monitoring to six times a day while reducing oral care with 0.12% chlorhexidine to three times a day. The rate of VAP was compared to the historical control group.
Results A total of 146 and 145 patients were enrolled in control and cohort groups, respectively. The mean age of patients was 52±16 years in both groups (P=0.803). The admission Glasgow coma scores were 7.79±2.67 and 7.80±2.77 in control and cohort group, respectively (P=0.969). VAP was found in nine patients in control group but only one patient in cohort group. The occurrence rate of VAP was significantly reduced in cohort group compared to control group (0.88/1,000 vs. 6.84/1,000 ventilator days, P=0.036).
Conclusions The modified VAP bundle is effective in lowering the VAP rate in critically ill neurosurgical patients. It requires low budget and manpower and can be employed in resource-constrained settings.
Background The aim of the present study was to develop a prognostic model using demographic characteristics, comorbidities, and clinical variables measured on day 4 of mechanical ventilation (MV) for patients with prolonged acute mechanical ventilation (PAMV; MV for >96 hours).
Methods Data from 437 patients (70.9% male; median age, 68 years) were obtained over a period of 9 years. All patients were diagnosed with pneumonia. Binary logistic regression identified factors predicting mortality at 90 days after the start of MV. A PAMV prognosis score was calculating ß-coefficient values and assigning points to variables.
Results The overall 90-day mortality rate was 47.1%. Five factors (age ≥65 years, body mass index <18.5 kg/m2, hemato-oncologic diseases as comorbidities, requirement for vasopressors on day 4 of MV and requirement for neuromuscular blocking agents on day 4 of MV) were identified as prognostic indicators. Each factor was valued as +1 point, and used to develop a PAMV prognosis score. This score showed acceptable discrimination (area under the receiver operating characteristic curve of 0.695 for mortality, 95% confidence interval 0.650–0.738, p<0.001), and calibration (Hosmer–Lemeshow chi-square=6.331, with df 7 and p=0.502). The cutoff value for predicting mortality based on the maximum Youden index was ≤2 (sensitivity, 87.5%; specificity, 41.3%). For patients with PAMV scores ≤1, 2, 3 and ≥4, the 90-day mortality rates were 29.2%, 45.7%, 67.9%, and 90.9%, respectively (P<0.001).
Conclusions Our study developed a PAMV prognosis score for predicting 90-day mortality. Further research is needed to validate the utility of this score.
A 74-year-old man presented with recurrent vomiting and aspiration pneumonia in the left lower lobe. He entered the intensive care unit to manage the pneumonia and septic shock. Although a percutaneous endoscopic gastrostomy tube was implanted for recurrent vomiting, vomiting and aspiration recurred frequently during admission. Subsequently, he complained of neck pain when in an upright position. A videofluoroscopic swallowing study showed compression of the esophagus by cervical osteophytes and tracheal aspiration caused by an abnormality at the laryngeal inlet. Cervical spine X-rays and computed tomography showed anterior cervical osteophytes at the C3-6 levels. Surgical decompression was scheduled, but was cancelled due to his frailty. Unfortunately, further recurrent vomiting and aspiration resulted in respiratory arrest leading to hypoxic brain damage and death. Physicians should consider cervical spine disease, such as diffuse skeletal hyperostosis as an uncommon cause of recurrent aspiration pneumonia.
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An unusual presentation of thoracic diffuse idiopathic skeletal hyperostosis (DISH) and video-assisted thoracoscopic surgery (VATS) Suthipas Pongmanee, Borvornsake Rojdumrongrattana, Noparoot Kritworakarn, Peem Sarasombath, Wongthawat Liawrungrueang International Journal of Surgery Case Reports.2022; 93: 106993. CrossRef
Background Several antibiotics can be used to treat ventilator-associated pneumonia caused by carbapenem-resistant A. baumannii (CRAB-VAP) including high-dose sulbactam. However, the effectiveness of high-dose sulbactam therapy is not well known. We report our experience with high-dose sulbactam for treatment of CRAB-VAP.
Methods Medical records of patients with CRAB-VAP who were given high-dose sulbactam between May 2013 and June 2015 were reviewed.
Results Fifty-eight patients with CRAB-VAP were treated with high-dose sulbactam. The mean age was 72.0 ± 15.2 years, and the acute physiology and chronic health evaluation II (APACHE II) score was 15.1 ± 5.10 at the time of CRAB-VAP diagnosis. Early clinical improvement was observed in 65.5% of patients, and 30-day mortality was 29.3%. Early clinical failure (odds ratio [OR]: 8.720, confidence interval [CI]: 1.346-56.484; p = 0.023) and APACHE II score ≥ 14 at CRAB-VAP diagnosis (OR: 10.934, CI: 1.047-114.148; p = 0.046) were associated with 30-day mortality.
Conclusions High-dose sulbactam therapy may be effective for the treatment of CRAB-VAP. However, early clinical failure was observed in 35% of patients and was associated with poor outcome.
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A Randomized Controlled Trial of Colistin Combined with Sulbactam: 9 g per Day versus 12 g per Day in the Treatment of Extensively Drug-Resistant Acinetobacter baumannii Pneumonia: An Interim Analysis Chutchawan Ungthammakhun, Vasin Vasikasin, Dhitiwat Changpradub Antibiotics.2022; 11(8): 1112. CrossRef
Meropenem/colistin versus meropenem/ampicillin–sulbactam in the treatment of carbapenem-resistant pneumonia Hossein Khalili, Lida Shojaei, Mostafa Mohammadi, Mohammad-Taghi Beigmohammadi, Alireza Abdollahi, Mahsa Doomanlou Journal of Comparative Effectiveness Research.2018; 7(9): 901. CrossRef
A patient had undergone left pneumonectomy for lung cancer and had an increased risk of fatal complications such as pneumonia, including acute respiratory distress syndrome (ARDS). The treatment effects of veno-venous extracorporeal membrane oxygenation (VV-ECMO) for ARDS of postpneumonectomy patient are uncertain. A 74-year-old man with one lung experienced aspiration pneumonia while swallowing pills after the operation, and his condition progressed to ARDS within a day. He was successfully treated with VV-ECMO support and intensive care unit care.
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The Future of Research on Extracorporeal Membrane Oxygenation (ECMO) Ji Young Lee Korean Journal of Critical Care Medicine.2016; 31(2): 73. CrossRef
Background: Infectious complications frequently occur after cardiac arrest and may be even more frequent after therapeutic hypothermia. Pneumonia is the most common infectious complication associated with therapeutic hypothermia, and it is unclear whether prophylactic antibiotics administered during this intervention can decrease the development of early-onset pneumonia. We investigated the effect of antibiotic prophylaxis on the development of pneumonia in cardiac arrest patients treated with therapeutic hypothermia.
Methods We retrospectively reviewed the medical records of patients who were admitted for therapeutic hypothermia after resuscitation for out-of-hospital cardiac arrest between January 2010 and July 2015. Patients who died within the first 72 hours or presented with pneumonia at the time of admission were excluded. Early-onset pneumonia was defined as pneumonia that developed within 5 days of admission. Prophylactic antibiotic therapy was defined as the administration of any parenteral antibiotics within the first 24 hours without any evidence of infection.
Results Of the 128 patients admitted after cardiac arrest, 68 were analyzed and 48 (70.6%) were treated with prophylactic antibiotics within 24 hours. The frequency of early-onset pneumonia was not significantly different between the prophylactic antibiotic group and the control group (29.2% vs 30.0%, respectively, p = 0.945). The most commonly used antibiotic was third-generation cephalosporin, and the class of prophylactic antibiotics did not influence early-onset pneumonia.
Conclusion Antibiotic prophylaxis in cardiac arrest patients treated with therapeutic hypothermia did not reduce the frequency of pneumonia.
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Prophylactic antibiotic use following cardiac arrest: A systematic review and meta-analysis Keith Couper, Ryan Laloo, Richard Field, Gavin D. Perkins, Matthew Thomas, Joyce Yeung Resuscitation.2019; 141: 166. CrossRef
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Aspiration pneumonia rarely occurs during general anesthesia; however, it can result in fatal pulmonary complications. To reduce aspiration pneumonia, a preoperative fasting time of 8 hours is recommended. A 4-year-old boy with ankyloglossia was scheduled for frenotomy. He completed preoperative fasting time and had no digestive symptoms. Pulmonary aspiration due to unexpected massive vomiting occurred during anesthesia induction. The patient’s airway was immediately secured by endotracheal tube. The vomitus in the airway tract was removed by fiberoptic bronchoscopy. Abdomen radiograph taken after this event showed paralytic ileus which can cause aspiration of gastric contents. We describe a case of pneumonia caused by aspiration of gastric contents in a pediatric patient who followed fasting instructions and who was scheduled for outpatient surgery.
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Factors associated with bronchopulmonary aspiration: a national-based study Jaqueline Helena Tanner, Cristina Mara Zamarioli, Magda Machado de Miranda Costa, Heiko Thereza Santana, Ana Clara Ribeiro Bello dos Santos, Cleide Felicia de Mesquita Ribeiro, Fernanda Raphael Escobar Gimenes Revista Brasileira de Enfermagem.2022;[Epub] CrossRef
Background Pneumonia is the most common cause of death among patients with infectious disease in Korea. However, studies of pneumonia with septic shock in patients presenting to the emergency department are limited. The aim of this study was to investigate the prognostic factors associated with pneumonia with septic shock in patients presenting to the emergency department.
Methods From January 2008 to September 2014, patients with pneumonia with septic shock admitted through the emergency department were retrospectively examined.
Results Of the 561,845 patients who visited the emergency department, 398 were admitted for pneumonia with septic shock. The 28-day mortality rate in these patients was 36.4%. The independent prognostic factors were old age (>70 yrs) (odds ratio [OR], 2.42; 95%, confidence interval [CI], 1.35–4.32), Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 1.04; 95% CI, 1.01–1.08), leukopenia (OR, 3.63; 95% CI, 1.48–8.94), prolonged PT-INR (OR, 2.53; 95% CI, 1.41–4.54), and hypoxemia (OR, 2.88; 95% CI, 1.30–6.38).
Conclusions A poor prognosis of patients with pneumonia is associated with old age (>70 yrs), increased APACHE II score, leukopenia, prolonged PT-INR, and hypoxemia.
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Background Few reports have documented the clinical characteristics and treatment outcomes of adult patients with Elizabethkingia meningoseptica infection.
Methods Medical records of patients over 18 years of age and suspected of having an E. meningoseptica infection from March 1, 2006 to February 28, 2013 were reviewed retrospectively. Their clinical characteristics, antimicrobial susceptibility results, and treatment outcomes were analyzed.
Results E. meningoseptica was isolated from 30 patients. Median age was 68.5 years, and infections were more frequent in males (17, 56.7%). The most common isolation source was sputum (23, 76.7%), and pneumonia was the most common condition (21, 70%) after excluding two cases of colonization. This bacterium was most susceptible to minocycline (27, 90%) and fluoroquinolones, including levofloxacin (20, 66.7%) and ciprofloxacin (18, 60%). The mortality rate due directly to E. meningoseptica infection was 20% (6/30), and uncontrolled pneumonia was the only cause of death. After isolating E. meningoseptica, the numbers of patients with pneumonia (9/9, 100% vs. 12/21, 57.1%), history of hemodialysis (5/9, 55.6% vs. 3/21, 14.3%), tracheostomy (8/9, 88.9 vs. 10/21, 47.6%), and median Charlson comorbidity index score (6 [range, 3–9] vs. 4 [range, 0–9]) were significantly higher in non-survivors than those in survivors (p < 0.05, for each). However, only 12 (40%) patients received appropriate antibiotics.
Conclusions E. meningoseptica infection most commonly presented as pneumonia in adults with severe underlying diseases. Despite the high mortality rate, the rate of appropriate antibiotic use was notably low.
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In connective tissue diseases, autoantibodies cause pulmonary interstitial inflammation and fibrosis, and patients require treatment with an immunosuppressive agent such as a steroid. Dermatomyositis is an incurable, uncommon form of connective tissue disease that occasionally causes diffuse pulmonary inflammation leading to acute severe respiratory failure. In such cases, the prognosis is very poor despite treatment with high-dose steroid. In the present case, a 46-year-old man was admitted to our hospital with dyspnea. He was diagnosed with dermatomyositis combined with cryptogenic organizing pneumonia (COP) with respiratory failure and underwent treatment with steroid and an immunosuppressive agent, but the COP was not improved. However, the respiratory failure did improve after treatment with intravenous immunoglobulin, which therefore can be considered a treatment option in cases where steroids and immunosuppressive agents are ineffective.
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