Seminars in respiratory and critical care medicine
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Seminal studies have demonstrated that tracheally intubated, mechanically ventilated patients, positioned in supine horizontal position, are at a high risk of developing ventilator-associated pneumonia, through aspiration of gastric pathogens. In the 1990s, innovative clinical findings promoted a radical change in practice, through the use of the semirecumbent position in all mechanically ventilated patients. ⋯ Our review will span from preclinical experimental insights to clinical evidence, and we will discuss potential controversies on the use of the semirecumbent position as the standard of care. We will also detail potential alternatives to ultimately improve outcomes of tracheally intubated and mechanically ventilated patients.
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Semin Respir Crit Care Med · Jun 2017
ReviewVentilator-Associated Pneumonia: The Role of Emerging Diagnostic Technologies.
Antibiotic resistance has emerged as a key determinant of outcome in patients with serious infections along with the virulence of the underlying pathogen. Within the intensive care unit (ICU) setting, ventilator-associated pneumonia (VAP) is a common nosocomial infection that is frequently caused by multidrug-resistant bacteria. Antimicrobial resistance is a growing challenge in the care of critically ill patients. ⋯ The challenge to ICU clinicians is how to most effectively utilize these agents to maximize patient benefits while minimizing further emergence of resistance. Use of rapid diagnostics may hold the key for achieving this important balance. There is an urgent need for integrating the administration of new and existing antibiotics with the emerging rapid diagnostic technologies in a way that is both cost-effective and sustainable for the long run.
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Semin Respir Crit Care Med · Jun 2017
ReviewHow Should We Treat HAP/VAP Caused by Carbapenemase-Producing Enterobacteriaceae?
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) represent a common problem in hospital setting worldwide. Infections caused by carbapenem-resistant Enterobacteriaceae (CRE) are an emergent problem due to the lack of therapeutic options available, leading to significant increases in morbidity and mortality. ⋯ This review focuses on the current epidemiology of CRE, with a specific focus on HAP/VAP. Moreover, we will suggest a possible strategy for the empiric and targeted treatment of HAP and VAP in which the involvement of CRE is suspected or is confirmed.
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Semin Respir Crit Care Med · Jun 2017
ReviewNew Strategies Targeting Virulence Factors of Staphylococcus aureus and Pseudomonas aeruginosa.
Morbidity, mortality, and economic burden of nosocomial pneumonia caused by Staphylococcus aureus and Pseudomonas aeruginosa remain high in mechanically ventilated and hospitalized patients despite the use of empirical antibiotic therapy or antibiotics against specific classes of pathogens and procedures to reduce nosocomial infections in hospital settings. Newer agents that neutralize or inhibit specific S. aureus or P. aeruginosa virulence factors may eliminate or reduce the risk for developing pneumonia before or during mechanical ventilation and may improve patient outcomes through mechanisms that differ from those of antibiotics. In this article, we review the types, mechanisms of action, potential advantages, and stage of development of antivirulence agents (AVAs) that hold promise as alternative preventive or interventional therapies against S. aureus– and P. aeruginosa–associated nosocomial pneumonias. We also present and discuss challenges to the effective utilization of AVAs separately from or in addition to antibiotics and the design of clinical trials and meaningful study end points.
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Semin Respir Crit Care Med · Jun 2017
ReviewEmergence of Antimicrobial Resistance among Pseudomonas aeruginosa: Implications for Therapy.
Pseudomonas aeruginosa (PA), a nonlactose fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of bloodstream, urinary tract, intra-abdominal, wounds/skin/soft tissue. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). ⋯ Over the past three decades, antimicrobial resistance among PA has escalated globally, via dissemination of several international multidrug-resistant “epidemic” clones. We review the emergence of antimicrobial resistance to this pathogen, and discuss approaches to therapy (both empirical and definitive).