Ventilator-associated pneumonia in critically-ill patients with COVID-19 in a setting of selective decontamination of the digestive tract,Critical Care

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Ventilator-associated pneumonia in critically-ill patients with COVID-19 in a setting of selective decontamination of the digestive tract
Critical Care ( IF 15.1 ) Pub Date : 2021-12-20 , DOI: 10.1186/s13054-021-03869-y
Sinta B van der Meer ₁ , Grace Figaroa ₁ , Peter H J van der Voort ₁ , Maarten W Nijsten ₁ , Janesh Pillay _{1,

2}

Affiliation

To the editor,

In mechanically ventilated patients with COVID-19 high incidences of ventilator-associated pneumonia (VAP) have been reported ranging from 40 to 58% [1, 2]. This occurred despite judicious use of systemic antibiotics at ICU-admission, preventive measures and in healthcare systems with more than adequate staffing resources [3].

In the Netherlands, most patients admitted to an ICU receive a regimen of selective decontamination of the digestive tract (SDD), aimed at eradication of pathogenic flora and preservation of protective anaerobic bacteria [4]. This consists of a 3rd generation cephalosporin for 4 days intravenously, topical and enteral nonabsorbable antibiotics (polymyxin, tobramycin, amphotericin B) during their entire ICU stay [4]. SDD has reduced nosocomial infections and mortality in patient populations with an overall shorter duration of mechanical ventilation and ICU stay (8–9 days) compared to the current patients infected with SARS-CoV-2 [5].

We assessed our practice of care, including SDD, and the associated incidence of VAP in patients infected with SARS-COV-2 and compared it to current literature. We performed a single center retrospective observational study in the University Medical Center of Groningen (UMCG), The Netherlands. All adult patients consecutively admitted to our ICU between March 2020 and February 2021 with PCR-confirmed COVID-19 were included. This resulted in inclusion of 212 mechanically ventilated patients. Standard care with SDD included microbiological surveillance of respiratory samples, throat and rectal swabs at admission, and twice weekly thereafter. All patients were retrospectively reviewed for presence of VAP. VAP was defined accordingly by the presence of clinical suspicion (fever and/or decline in ventilation or oxygenation), laboratory parameters (leukocyte count and CRP), new or progressive radiographic infiltrates and positive microbiological cultures from lower respiratory tract specimens (surveillance and obtained additionally when VAP was suspected).

Twenty-two patients (10%) had confirmed VAP and the median time to diagnosis was 12 (IQR 7–17) days (Table 1). The observed low VAP incidence of 10%, occurred despite the fact that 96% of the patients were mechanically ventilated for more than 5 days. This incidence is in contrast with aforementioned high rates of 40–58% [1]. 62% of patients received steroids during ICU admission, the percentage of VAP was not higher compared to patients not receiving steroids (11% vs 9.6%).

Table 1 Characteristics of patients with and without VAP

Full size table

We recognize the limitations and risk of bias and underdiagnosis when retrospectively identifying VAP, however there was a 90% agreement between clinically (by the treating intensivist) and retrospectively identified VAP. The observed low incidence of VAP could be attributed to underdiagnosis, although routine microbiological surveillance would likely have resulted in an overestimation of VAP. Additionally, judicious use of antibiotics could have artificially reduced rate of VAP using microbiological confirmation, however apart from the 4-day course of cephalosporins, use of antibiotics was limited (44% of all patients after hospital admission) compared to rates > 80% reported elsewhere[2].

The main limitation of this single center observational study is the lack of a control group receiving no SDD, therefore a causal relationship between the use of SDD and the incidence of VAP cannot be established. Demographics, treatments and outcomes between patients described in this report and previous literature are similar, however major differences are the use of SDD and the incidence of VAP [1,2,3]. In support of our data, a recently published observational study, suggests a strong mortality benefit of SDD, although the incidence of VAP was not reported [6].

Therefore, although no causal relationship can be established from this report, our practice of care including the use of SDD appears to be associated with a reduced incidence of VAP in critically-ill patients infected with SARS-COV-2 as reported in other critically-ill patients [5].

Not applicable.

1.
Martínez-Martínez M, Plata-Menchaca EP, Nuvials FX, Roca O, Ferrer R. Risk factors and outcomes of ventilator-associated pneumonia in COVID-19 patients: a propensity score matched analysis. Crit Care. 2021;25(1):235. https://doi.org/10.1186/s13054-021-03654-x.
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Author notes

Sinta B. van der Meer and Grace Figaroa have contributed equally to this work

Affiliations

Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
Sinta B. van der Meer, Grace Figaroa, Peter H. J. van der Voort, Maarten W. Nijsten & Janesh Pillay
Department of Pathology and Medical Biology, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
Janesh Pillay

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Grace FigaroaView author publications
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Maarten W. NijstenView author publications
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Contributions

J.P. conceived and designed the study, S.v.d.M., G.F., J.P., M.N., collected and reviewed the data. All authors contributed to drafting the manuscript.

Corresponding author

Correspondence to Janesh Pillay.

Ethical approval and consent to participate

The need for individual informed consent and formal evaluation according to the Dutch Law on Scientific Medical Research with Humans was waived by our institutional ethics committee (METc 2020/254).

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Yes.

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The authors declare that there are no conflicts of interests.

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van der Meer, S.B., Figaroa, G., van der Voort, P.H.J. et al. Ventilator-associated pneumonia in critically-ill patients with COVID-19 in a setting of selective decontamination of the digestive tract. Crit Care 25, 445 (2021). https://doi.org/10.1186/s13054-021-03869-y

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Received: 14 October 2021
Accepted: 15 December 2021
Published: 20 December 2021
DOI: https://doi.org/10.1186/s13054-021-03869-y

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中文翻译：

COVID-19危重患者呼吸机相关性肺炎在消化道选择性净化的情况下

致编辑，

据报道，在接受机械通气的 COVID-19 患者中，呼吸机相关肺炎 (VAP) 的发生率高达 40% 至 58% [1, 2]。尽管在 ICU 入院、采取预防措施以及在人力资源充足的医疗保健系统中明智地使用了全身抗生素 [3]，这种情况还是发生了。

在荷兰，大多数入住 ICU 的患者接受消化道选择性净化 (SDD) 方案，旨在根除病原菌群并保留保护性厌氧菌 [4]。这包括在整个 ICU 住院期间静脉注射 4 天的第三代头孢菌素、局部和肠内不可吸收的抗生素（多粘菌素、妥布霉素、两性霉素 B）[4]。与目前感染 SARS-CoV-2 的患者相比，SDD 降低了患者群体的医院感染和死亡率，机械通气和 ICU 住院时间总体较短（8-9 天）[5]。

我们评估了我们的护理实践，包括 SDD，以及感染 SARS-COV-2 的患者中 VAP 的相关发病率，并将其与当前文献进行了比较。我们在荷兰格罗宁根大学医学中心 (UMCG) 进行了一项单中心回顾性观察研究。包括在 2020 年 3 月至 2021 年 2 月期间连续入住我们 ICU 且经 PCR 确认为 COVID-19 的所有成年患者。结果纳入了 212 名机械通气患者。SDD 的标准护理包括入院时呼吸道样本、喉咙和直肠拭子的微生物监测，此后每周两次。对所有患者进行回顾性检查以了解 VAP 的存在。VAP 相应地通过临床怀疑（发烧和/或通气或氧合下降）的存在来定义，

22 名患者 (10%) 确诊为 VAP，诊断的中位时间为 12 (IQR 7-17) 天（表 1）。尽管 96% 的患者机械通气超过 5 天，但观察到的低 VAP 发生率为 10%。这一发生率与上述 40-58% 的高发生率形成鲜明对比 [1]。62% 的患者在入住 ICU 期间接受了类固醇治疗，与未接受类固醇治疗的患者相比，VAP 的百分比并不高（11% 对 9.6%）。

表 1 有无 VAP 患者的特征

全尺寸表

我们认识到在回顾性识别 VAP 时存在偏倚和漏诊的局限性和风险，但是临床上（由治疗重症医师）和回顾性识别的 VAP 之间存在 90% 的一致性。观察到的 VAP 发生率低可归因于诊断不足，尽管常规微生物监测可能会导致对 VAP 的高估。此外，通过微生物学确认，明智地使用抗生素可以人为地降低 VAP 的发生率，但是，除了 4 天的头孢菌素疗程外，与报告的比率 > 80% 相比，抗生素的使用是有限的（入院后所有患者的 44%）其他地方[2]。

这项单中心观察性研究的主要限制是缺乏未接受 SDD 的对照组，因此无法确定使用 SDD 与 VAP 发生率之间的因果关系。本报告中描述的患者的人口统计学、治疗和结果与之前的文献相似，但主要差异在于 SDD 的使用和 VAP 的发生率 [1,2,3]。为支持我们的数据，最近发表的一项观察性研究表明，SDD 具有很强的死亡率益处，但未报告 VAP 的发生率 [6]。

因此，尽管无法从该报告中建立因果关系，但我们的护理实践（包括使用 SDD）似乎与感染 SARS-COV-2 的危重患者的 VAP 发生率降低有关，正如其他危重患者所报道的那样。患者[5]。

不适用。

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作者笔记

Sinta B. van der Meer 和 Grace Figaroa 对这项工作做出了同等贡献

隶属关系

格罗宁根大学医学中心重症监护系，格罗宁根大学，Hanzeplein 1, 9713 GZ，格罗宁根，荷兰
Sinta B. van der Meer、Grace Figaroa、Peter HJ van der Voort、Maarten W. Nijsten 和 Janesh Pillay
病理学和医学生物学系，格罗宁根哮喘和慢阻肺研究所，格罗宁根大学医学中心，格罗宁根大学，格罗宁根，荷兰
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van der Meer, SB, Figaroa, G., van der Voort, PHJ等。COVID-19 重症患者呼吸机相关性肺炎在消化道选择性净化的情况下。暴击护理 25, 445 (2021)。https://doi.org/10.1186/s13054-021-03869-y

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