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      Lower neutrophil-to-lymphocyte ratio predicts high risk of multidrug-resistant Pseudomonas aeruginosa infection in patients with hospital-acquired pneumonia

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          Abstract

          Background and purpose

          Hospital-acquired pneumonia (HAP) remains an important cause of morbidity and mortality despite advances in antimicrobial therapy. The emergence of multidrug resistant (MDR) Pseudomonas aeruginosa (PA) is of major concern. Our aim was to evaluate the risk factors and prognosis of HAP due to MDR-PA infection.

          Patients and methods

          In a retrospective observational study, we collected data on all episodes of HAP caused by PA (PA-HAP) occurring from January 2013 to December 2016. Characteristics of patients with drug-sensitive PA were compared with those with MDR-PA. Data of demographic, underlying conditions, peripheral neutrophil-to-lymphocyte ratio (NLR), and clinical outcomes were collected and analyzed.

          Results

          One hundred fifty-seven patients with PA-HAP were included, of which 69 (43.9%) patients were diagnosed with MDR-PA infection. There were significant differences between MDR-PA group and non-MDR-PA group on the following variables: initial inappropriate antibiotic therapy ( P<0.001, OR 0.103, 95% CI 0.044–0.244), admission in more than two departments in previous 30 days ( P<0.001, OR 0.186, 95% CI 0.072–0.476), and NLR level ( P=0.020, OR 0.911, 95% CI 0.843–0.985). The effect of antibiotic treatment was significantly different ( P<0.001, OR 4.263, 95% CI 2.142–8.483). The 30-day mortality was higher in MDR-PA group than that in non-MDR-PA group ( P<0.001).

          Conclusion

          We have shown that lower NLR level was identified as a clinical predictor of MDR-PA infection in HAP patients. Even with goal-directed therapy, MDR-PA infection implicates poor outcomes in patients with HPA.

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          Most cited references 21

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          The European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and antimicrobial use.

          A standardised methodology for a combined point prevalence survey (PPS) on healthcare-associated infections (HAIs) and antimicrobial use in European acute care hospitals developed by the European Centre for Disease Prevention and Control was piloted across Europe. Variables were collected at national, hospital and patient level in 66 hospitals from 23 countries. A patient-based and a unit-based protocol were available. Feasibility was assessed via national and hospital questionnaires. Of 19,888 surveyed patients, 7.1% had an HAI and 34.6% were receiving at least one antimicrobial agent. Prevalence results were highest in intensive care units, with 28.1% patients with HAI, and 61.4% patients with antimicrobial use. Pneumonia and other lower respiratory tract infections (2.0% of patients; 95% confidence interval (CI): 1.8–2.2%) represented the most common type (25.7%) of HAI. Surgical prophylaxis was the indication for 17.3% of used antimicrobials and exceeded one day in 60.7% of cases. Risk factors in the patient-based protocol were provided for 98% or more of the included patients and all were independently associated with both presence of HAI and receiving an antimicrobial agent. The patient-based protocol required more work than the unit-based protocol, but allowed collecting detailed data and analysis of risk factors for HAI and antimicrobial use.
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            Hospital-acquired pneumonia and ventilator-associated pneumonia: recent advances in epidemiology and management.

            The recent evidence is reviewed on clinical epidemiology, trends in bacterial resistance, diagnostic tools and therapeutic options in hospital-acquired pneumonia (HAP), with a special focus on ventilator-associated pneumonia (VAP). The current incidence of VAP ranges from two to 16 episodes for 1000 ventilator-days, with an attributable mortality of 3-17%. Staphylococcus aureus (with 50-80% of methicillin-resistant strains), Pseudomonas aeruginosa and Enterobacteriaceae represent the most frequent pathogens in HAP/VAP. The prevalence of carbapenemase-producing Gram-negative bacilli (GNB) and the emergence of colistin resistance are alarming. Procalcitonin seems to have a good value to monitor the response to treatment. Rapid molecular tests for the optimization of empirical therapy will be available soon. Recent studies support the use of a high-dosing regimen of colistin in HAP/VAP caused by extensively drug-resistant GNB. Linezolid may probably be preferred to vancomycin for a subset of methicillin-resistant S. aureus HAP/VAP. Given the scarcity of novel antimicrobial drugs, different approaches such as bacteriophage therapy or immunotherapy warrant further clinical evaluations. HAP/VAP is a major cause of deaths, morbidity and resources utilization, notably in patients with severe underlying conditions. The development of new diagnostic tools and therapeutic weapons is urgently needed to face the epidemic of multidrug-resistant pathogens.
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              An international multicenter retrospective study of Pseudomonas aeruginosa nosocomial pneumonia: impact of multidrug resistance

              Introduction Pseudomonas aeruginosa nosocomial pneumonia (Pa-NP) is associated with considerable morbidity, prolonged hospitalization, increased costs, and mortality. Methods We conducted a retrospective cohort study of adult patients with Pa-NP to determine 1) risk factors for multidrug-resistant (MDR) strains and 2) whether MDR increases the risk for hospital death. Twelve hospitals in 5 countries (United States, n = 3; France, n = 2; Germany, n = 2; Italy, n = 2; and Spain, n = 3) participated. We compared characteristics of patients who had MDR strains to those who did not and derived regression models to identify predictors of MDR and hospital mortality. Results Of 740 patients with Pa-NP, 226 patients (30.5%) were infected with MDR strains. In multivariable analyses, independent predictors of multidrug-resistance included decreasing age (adjusted odds ratio [AOR] 0.91, 95% confidence interval [CI] 0.96-0.98), diabetes mellitus (AOR 1.90, 95% CI 1.21-3.00) and ICU admission (AOR 1.73, 95% CI 1.06-2.81). Multidrug-resistance, heart failure, increasing age, mechanical ventilation, and bacteremia were independently associated with in-hospital mortality in the Cox Proportional Hazards Model analysis. Conclusions Among patients with Pa-NP the presence of infection with a MDR strain is associated with increased in-hospital mortality. Identification of patients at risk of MDR Pa-NP could facilitate appropriate empiric antibiotic decisions that in turn could lead to improved hospital survival.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2018
                02 October 2018
                : 14
                : 1863-1869
                Affiliations
                [1 ]Institute of Respiratory Diseases of Sun Yat-Sen University, Guangzhou, Guangdong, China, chenzhuanggui@ 123456126.com , zhtituli@ 123456163.com
                [2 ]Department of Internal Medicine, Division of Respiratory Diseases, Guangzhou, Guangdong, China, zhtituli@ 123456163.com
                [3 ]Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China, chenzhuanggui@ 123456126.com
                Author notes
                Correspondence: Zhuang-Gui Chen, Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road #600, Guangzhou 510630, Guangdong Province, China, Tel +86 136 0000 9221, Fax +86 20 8525 2241, Email chenzhuanggui@ 123456126.com
                Tian-Tuo Zhang, Institute of Respiratory Diseases of Sun Yat-Sen University, Tianhe Road #600, Guangzhou 510630, Guangdong Province, China, Tel +86 189 2210 2729, Fax +86 20 8525 2241, Email zhtituli@ 123456163.com
                [*]

                These authors contributed equally to this work

                Article
                tcrm-14-1863
                10.2147/TCRM.S179181
                6174305
                © 2018 Zhou et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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