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Ventilator-associated pneumonia

Background Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia that occurs in patients who receive mechanical ventilation (MV). According to the International Nosocomial Infection Control Consortium (INICC), the overall rate of VAP is 13.6 per 1,000 ventilator days. The incidence varies according to the patient group and hospital setting. The incidence of VAP ranges from 13–51 per 1,000 ventilation days. Early diagnosis of VAP with appropriate antibiotic therapy can reduce the emergence of resistant organisms. Method The aim of this review was to provide an overview of the incidence, risk factors, aetiology, pathogenesis, treatment, and prevention of VAP. A literature search for VAP was done through the PUBMED/MEDLINE database. This review outlines VAP’s risk factors, diagnostic methods, associated organisms, and treatment modalities. Conclusion VAP is a common nosocomial infection associated with ventilated patients. The mortality associated with VAP is high. The organisms associated with VAP and their resistance pattern varies depending on the patient group and hospital setting. The diagnostic methods available for VAP are not universal; however, a proper infection control policy with appropriate antibiotic usage can reduce the mortality rate among ventilated patients.


Objectives
To find out Microbiological pattern of VAP in patients on ventilator along with Correlation of pathogen with duration of stay and mortality a) Inclusion Criteria Patients with VAP, more than 18yrs with consent were included b) Exclusion Criteria Patients having prior pneumonia and ARDS ,less than 18 yrs were excluded.

Methodology a) Source of Data
Patients admitted in the critical care areas of JSS Hospital

b) Method of Collection of Data
This was a prospective cohort study done over a period of 1 year. Total of 86 who met the criteria were included. VAP was diagnosed using clinical pulmonary infection score which was evaluated on day2, 4, 7, and 10. CPIS> 6 was used diagnostic. Early onset VAP within 4 days of ventilation and late onset VAP after 4 days of ventilation. Endotracheal aspirate was preferred over protected specimen brush (PSB) sampling and bronchi-alveolar lavage(BAL), as these techniques are more invasive without mortality benefit over endotracheal aspirate c) Endotracheal Aspirate: Endotracheal aspirate was obtained under aseptic precautions using a 22-inch Ramson's 12F suction catheter with a mucus extractor as per standard protocol. After this, 2ml of 0.9% saline was injected into ET to flush the exudates into sterile container and immediately taken to the laboratory.

Descriptives
The Descriptive procedure displays univariate summary statistics for several variables in a single table and calculates standardized values (z scores). Variables can be ordered by the size of their means (in ascending or descending order), alphabetically, or by the order in which you select the variables (the default).

Crosstabs (Contingency table analysis)
The Crosstabs procedure forms two-way and multi-way tables and provides a variety of tests and measures of association for two-way tables. The structure of the table and whether categories are ordered determine what test or measure to use.

Chi square test
The Chi-Square Test procedure tabulates a variable into categories and computes a chi-square statistic. This goodness-of-fit test compares the observed and expected frequencies in each category to test either that all categories

One way ANOVA and Scheffe's post hoc test
The One-Way ANOVA procedure produces a one-way analysis of variance for a quantitative dependent variable by a single factor (independent) variable. Analysis of variance is used to test the hypothesis that several means are equal. This technique is an extension of the two-sample t test.

Graph 1: Demographics
The maximum number of patients were in the age group 51-60, includes a total of 11 patients (36.7), followed by 5 (16.7%) in the age group 71-80 years. From the above table and graph we infer that there is no significant relation between the development of VAP and age groups

Discussion
The incidence of VAP in our study was 34.8%.this correlates with other studies in which the incidence of VAP was 15.5 to 47%, depending on the diagnostic criteria used. 48, 49, 50, and 51 There was no statistically significant association between the age of the patient and development of VAP, indicating that age is neither predisposing nor protective factor for the development of VAP. There was no statistically significant association between the gender of the patient and development of VAP, and both males and females are equally predisposed to VAP. 52 The most common organism isolated was Acinetobacter baumannii which was the common pathogen in study by Arindam Dey and Indira Bairy. 54 Out of 20 isolates, 14 were from patients with early onset VAP and 6 from late onset VAP.The next common organism was Klebsiella pneumoniae with total of 11isolates.Out of these 11 isolates, 7 isolates were in early onset VAP, followed by E.coli 5 isolates and pseudomonas with 5 isolates. The least common was of Coagulase positive Staphylococcus aureus with only 1. There is no significant association between the microbiological patterns of VAP in our hospital with duration of stay.
Analysis of antibiotic sensitivity pattern suggests that these organisms were highly resistant to commonly used antibiotics in our hospital. All 20(100%) isolates of Acinetobacter were sensitive to tigecycline, 11(55%) isolates were sensitive to imipenem 4(20%) to colistin. VAP due to multidrug resistant acetinobacter sensitive to tigecycline is common in our setting. 35,38,39,40,46,47 Out of 11 isolates of Klebsiella all 11(100%) were sensitive to tigecycline,7(63.63%) were sensitive to imipenem and 5(45.45%) to amikacin and 2 (18.18%) to ciprofloxacin and piperacillin and tazobactam, suggesting a high prevalence of extended spectrum beta-lactamase(ESBL) producing organisms in our setting.All the 5(100%) isolates of Pseudomonas aeruginosa were sensitive to colistin. 4(80%) out of 5 isolates E.coli was found sensitive to tigecycline and amikacin.3 isolates(60%) were sensitive to carbapenems This observation suggests that the organisms isolated in etiology of VAP in our hospital were resistant to commonly used antibiotics like fluoroquinolones, cephalosporins and aminoglycosides but showed variable sensitivity to tigecycline,colistin and carbapenems. Mortality of VAP group was 76.6% which is very high. A similar high mortality was found in other studies. 53

Conclusions and Summary
Thus , we conclude that most of the VAP cases in our setting were early onset VAP & majority of these are caused by highly resistant strains.VAP due to multidrug resistant acetinobacter sensitive to tigecycline is common in our setting. And local epidemiological data should be connected at all centres, as the information can help in guiding the initial empirical antibiotic therapy, which would be more rationale and help in decreasing mortality and morbidity. An effective empirical antibiotic therapy would also help in preventing development of more resistant strains.