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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Prophylactic use of the probiotic strain Lactobacillus casei rhamnosus as part of a triple anti-infective regimen in very preterm infants during neonatal intensive care


Background. Probiotics are increasingly used in neonatal intensive care and prove to reduce rates of necrotizing enterocolitis (NEC), sepsis and all-cause mortality by meta-analyses.

Objective. Aim of the study was to analyze the prophylactic use of the probiotic Lactobacillus casei rhamnosus (LCR) as part of a triple anti-infective treatment regimen in very preterm neonates in respect to complications and possible side effects.

Setting. This was a study on 1169 very preterm infants of 32 weeks of gestational age and less born between 2005 and 2015 who were admitted within the first 24 hours of life to the neonatal intensive care unit (NICU) and hospitalized for at least 7 days.

Design. Retrospective observational STROBE compliant single-center cohort study

Intervention. All infants received a standardized prophylactic anti-infective treatment regimen with enteral probiotics (LCR), antifungal agents, and oral gentamycin over the study time starting at the first day of life.

Outcome measures. Perinatal and neonatal data were collected for descriptive analysis. Complications possibly avoided by the anti-infective regimen included NEC, late-onset sepsis (LOS), late-onset multiple organ dysfunction syndrome (MODS), and ventilator associated pneumonia (VAP).

Main results. Eleven of 1169 infants 11 (0.9%) had diagnosis of NEC ≥ IIa, 141 (12.1%) exhibited at least one episode of LOS, 31 (2.7%) a VAP, and 44 (3.8%) a MODS. Those infants with complications were of younger gestational age (p<0.001), had lower birth weight (p<0.001), lower Apgar scores at 1/5/10 minutes (p<0.001), were more common SGA (p=0.007), had longer courses of mechanical ventilation and longer hospital stays and for longer time parenteral antibiotics (all p<0.001). Mortality rate was increased in infants having experienced complications (6.9 vs. 1.7%, p<0.001).

Conclusions. Over an 11-year period, the use of the probiotic LCR as part of an anti-infective regimen was safe and resulted in low rates of NEC, LOS, VAP, and MODS compared to the literature. Those infants with complications had higher mortality rates.

Key words: very preterm infant, probiotics, Lactobacillus casei rhamnosus, necrotizing enterocolitis, multiple organ dysfunction syndrome, neonatal intensive care, ventilator associated pneumonia, late-onset sepsis, antibiotic-associated diarrhea 

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Microbial colonization of the lower airways after insertion of a cuffed endotracheal tube in pediatric patient


Background. Ventilator-associated pneumonia (VAP) still remains a common device-associated hospital acquired infection in pediatric and adult intensive care units. The aim of our study was to determine ways of microbial transmission to the lower airways in intubated patients admitted to a single tertiary-care pediatric intensive care unit.

Methods. This was a prospective observational study. A total of 284 sample sets (oropharyngeal swabs, swabs from the lumen of the proximal tip of an endotracheal tube, and bronchoalveolar lavage samples) were collected from 62 consecutive pediatric patients intubated for > 24 hours. Pulsed-field gel electrophoresis was performed on all isolated pathogens, which were later identified by MALDI biotyper (MALDI-TOF mass spectrometry).

Results. Overall colonization rates were high and did not differ significantly at different time points in the oropharynx (75%–100%) and the lower airways (50%–76.5%). The endotracheal tube was colonized at lower rates: on day 1–3 (28.8%), on day 4–6 (52.7%), on day 7–9 (61.8%) and on day 10-12 (52.9%) (P < 0.001). A total of 191 matched sample sets from the lower airways and at least one site above were collected from 46 (74.2%) patients. In the oropharynx-lower airways group, Candida spp. (76.9%) and upper airway bacteria (63.2%); in the endotracheal tube-lower airway group, S. aureus (15.7%) and upper airway bacteria (21.1%); in the oropharynx-endotracheal tube-lower airway group, Enterobacteriaceae (70.8%) prevailed (P < 0.001). The mean survival (entrance) time to lower airways for the Acinetobacter/Pseudomonas/Stenotrophomonas group was 8.28 ± 0.81 days; for the Enterobacteriaceae group, 5.63 ± 0.41; and for Candida spp. group, 3.00 ± 0.82 days (P < 0.005).

Conclusions. Oropharyngeal contamination of the lower airways is the most important route of colonization. Different pathogens enter the lower airways at different time intervals from the insertion of an endotracheal tube.

Key words: colonization, airway, intubation, mechanical ventilation, bronchoalveolar lavage, ventilator-associated pneumonia

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The impact of early percutaneous tracheotomy on reduction of the incidence of ventilator associated pneumonia and the course and outcome of ICU patients


The aim of the study. The primary objective of this study was to determine the differences in the incidence of respiratory infections and septic episodes in patients who underwent early percutaneous tracheotomy (ET) and in patients who underwent translaryngeal intubation i.e late tracheotomy (LT). Secondary objectives were to determine the differences in the early mortality of patients, duration of mechanical ventilation and length of Intensive care unit (ICU) stay.

Materials and methods. The study included 72 surgical and trauma patients older than 18 years of age, treated at the ICU of the University Clinical Hospital Mostar who had undergone translaryngeal intubation and were mechanically ventilated for at least 48 hours. The basic criterion for inclusion in the study was expected duration of mechanical ventilation of at least 14 days. Forty-eight hours after enrollment, patients were randomly divided into two groups. The first group of patients underwent ET after 2-4 days of mechanical ventilation; the second group underwent LT if they exhibited longer episodes of hypoxemia after 15 days.

Results. The ET group of patients spent less time in mechanical ventilation and ICU. The ET group had a lower rate of VAS pneumonia (p=0.137), sepsis episodes (p=0.029) and mortality rate (p=0.056).

Conclusion. The results of our study support ET being performed 2–4 days from the start of mechanical ventilation. Despite a lack of power, we found significant benefits of ET regarding the incidence of pneumonia, sepsis, hospital mortality, duration of mechanical ventilation and length of ICU stay

Key words: tracheotomy, mechanical ventilation, intensive care unit, ventilator-associated pneumonia, treatment outcome, complications

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Evaluation of a clinical pulmonary infection score in the diagnosis of ventilator-associated pneumonia


The most important dilemma in the diagnosis of ventilator-associated pneumonia (VAP) based on only clinical findings is overdiagnosis. The aim of the study is to prospectively evaluate the Clinical Pulmonary Infection Score (CPIS) in relation to VAP diagnosis.

Design. Prospective, in a cohort of mechanically ventilated patients.

Setting. The intensive care unit of a university hospital.

Patients. Fifty patients, on mechanical ventilation therapy for more than 48 hours, suspected of having VAP were enrolled in the study and bacteriologic confirmation was done by bronchoalveolar lavage (BAL) culture.

Interventions. Bronchoscopy with BAL fluid culture after establishing a clinical suspicion of VAP in patients having no prior antibiotic therapy or no change in current antibiotic therapy within last three days before BAL.

CPIS scores during diagnosis were 6±2 (3-9) (median±QR, maximum-minimum) and it was 7±2 (2-9) at the 72nd hour, in 41 cases with a diagnosis of VAP. In cases with no diagnosis of VAP, the CPIS scores were found to be 6±2 (4-8) and 5±3 (2-7), respectively. There was no significant difference between the VAP group and the non-VAP group at diagnosis, but was significant at 72nd hour (respectively, p=0.551 and p=0.025).

CPIS scores during diagnosis were 6±3 (4-8) (median± QR, maximum-minimum) and 7±4 (2-8) at the 72nd hour, in 14 cases with a diagnosis of early-onset VAP. In cases with a diagnosis of late-onset VAP, the CPIS scores were found to be 6±2 (3-9) and 7±2 (3-9), respectively. There was no significant difference between the early-onset VAP group and the late-onset VAP group. In conclusion, the CPIS results should be evaluated carefully in the clinical setting during the diagnosis.

Key words: ventilator associated pneumonia, CPIS, VAP diagnosis

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