الفهرس 
Ventilator Associated Tracheobronchitis
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Abstract
The aim of the current study was to assess VAT and to
study the effect of aerosolized antibiotics (ceftazidime and
amikacin) as an adjuvant therapy to systemic antibiotics on
outcome of these patients during the course of eighteen months
started from December 2013, in respiratory intensive care unit
(RICU) Ain Shams University Hospital. The present study
included 104 mechanically ventilated patients of different ages
and gender.
Thirty patients out of 104 were excluded from the start of
the study due to presence of infection as a cause of admission.
Seventy four patients were subjected to mini-BAL sampling of
the lower respiratory tract secretions (thirty nine patients out of
74 were subjected to mini-BAL sampling once and did not
continue the serial survey).Thirty five patients out of 74 were
subjected to serial mini-BAL samples of the lower respiratory
tract secretions, quantitative culture, and drug sensitivity twice
a week. Two patients out of 35 patients showed no growth of
any bacteria till extubation and 33 patients showed positive
cultures. Twenty three patients out of 33 were diagnosed as
VAT and 10 patients were diagnosed as early VAP.
In the current study for diagnosis of VAT we used both
clinical criteria (temperature >380 C or <360 C, Leukocytosis >
12,000 /mm3 and Sputum production; increase amount and
change color to yellow, greenish or pus) and microbiological
criteria (positive culture obtained by mini-BAL catheter with
colony count <103 as cut off value for positive culture suggesting VAT) following the criteria recommended by Horan
et al., (2008) and Craven et al., (2011). For diagnosis of VAP
we used the same criteria for diagnosis of VAT with the
development of CXR shadows suggesting pneumonia, which
equal to CPIS score > 6 and we used 103 as cut off value of
colony count for VAP following.
Patients diagnosed as VAT were 23 patients out of 104
mechanically ventilated patients with incidence 22.1%. The
mean age ± SD in this study was (55.2 ± 19.11) years old. 43.
47% of them were males and 56.52% were females and the
causes of admission were chronic obstructive airway disease
(COPD) and interstitial lung disease (ILD) 30.43% for each.
Obese hypoventilation and obstructive sleep apnea,
bronchogenic carcinoma, 8.6% for each, bronchial asthma,
mesothelioma with pleural effusion, post-mechanical
ventilation tracheal stenosis, post- operative and drug toxicity
ARDS 4.3% for each of them.
The most common co-morbidities were renal impairment
and hypertension(26%) for each followed by diabetes mellitus
(21.7%), cardiac diseases, cerebrovascular accidents and
chronic liver diseases (13%) for each of them.
The incidence of VAT was found to be 22.1%.
During stage 2 of the study 33 patients showing positive
cultures were classified into 3 groups. group I: diagnosed as
VAT received systemic antibiotics and aerosolized antibiotic:
13 patients (three of them did not continue receiving
AA).group II: diagnosed as VAT received only systemic antibiotics: 10 patients and group III diagnosed as early VAP:
10 patients.
Total patients diagnosed as VAP were 18 patients. Ten
patients got early VAP with incidence 9.6% and 8 patients
diagnosed as late VAP (7patients progressed from group II and
only 1 patient progressed from group I). Chest x-ray suggesting
VAP was positive in 100% of patients, CPIS was > 6 in 100 %
of patients, the mini-BAL quantitative culture for diagnosis of
early VAP was 103in 2 patients (20%) , 104 in 1 patient (10%) ,
and ≥ 105 in 7 patients (70%).
The microbiological pattern of VAT patients was; 4
patients out of 23 patients (13%) had positive culture with
colony count<103, 19 patients out of 23 patients (82.6%) had
positive culture with colony count ≥ 103, Gram negative
organisms were the most frequent cause of VAT,(47.8%) of
them were klebsiella and mixed infections were (34.6%).
The microbiological pattern of the early onset VAP
patients was; Klebsiella pneumoniae (90( and the infection was
polymicrobial in (10%) of cases.
Thirty two patients during Stage II of the study were
divided into three group; group I (VAT patients received AA
plus systemic antibiotics), group II (VAT patients received
systemic antibiotics only) and group III (early VAP patients
received systemic antibiotics only).
At day 1 there were no significant differences in
comparing group I by group II or by group III as regards temperature, (p= 0.239, 0.272 respectively), leukocytic count,
(p= 0.484, 0.665respectively) or mean PaO2/FIO2 ratio (p= >
0.05, > 0.05 ( respectively.
During stage II of our study 23 patients diagnosed as
VAT were assigned 1:1 for treatment with aerosolized amikacin
400mg /12 hours and ceftazidime 500 mg/12 hours as adjuvant
therapy to the used systemic antibiotics. Data from 3 VAT
patients from group I were not analyzed because one patient
got severe bronchospasm, 2 patients died in the second day of
AA, one because of hematemesis and one due to cardiac arrest.
The clinical outcome (at day 5) regarding decrease
secretion amount, group I showed statistical significant
difference between day 1 and day 5 (p=0.001), in group II and
group III there was no statistical significant difference
between day 1 and day 5 (p= 0 .371, 0 .952respectively). Group
I showed significant decrease in secretion amount in
comparison to group III (p=.050) and non-significant decrease
in comparison to group II (p =0.329). Regarding secretion
color there was no statistical significant difference between day
1 and day 5 in group I, group II or group III.
Regarding temperature, group I showed high
significant decrease in temperature at day 5 (p=0.005) than day
1 but group II and group III showed no statistical significant
difference between day 1 and day 5 (p=0.618, p=0.834) and
there was no statistical significant difference between group I
and group II (p =0.178) or between group I and group III
(p=0.361). Regarding total leukocytic count, group I showed
significant decrease in leukocytic count in comparison to day 1
(p=0.018) but group II and group III showed no significant
difference between day I and day 5 (p=o.604, o.397). There was
also significant decrease in leukocytic count in group I in
comparison to group III (p=0.025) and non-significant
decrease in comparison to group II (p=0.160).
Regarding the mean PaO2/FIO2 ratio, group I showed
statistical significant increase in PaO2/FIO2 ratio at day 5 in
comparison to day 1 (p=0.021) but group II and group III
showed no statistical significant differences between day 1 and
day 5 (p=0.071, 0.834). Also group I showed significant
increase in PaO2/FIO2 ratio in comparison to group II (p
=<0.001) and also in comparison to group III (p=<0.001).
As regards microbiological outcome bacteriological
clearance was in group I 50%, in group II and there was no
statistical significant difference between group I and group II
as regards clearance (p=0.913), resistance (p=0.894) or
superinfection (p=1.491).
Note: we did not follow group III bacteriologically.
As regards progression to VAP there was significant
decrease in group 1 in comparison to group II (P < .001).
The average systemic antibiotics days , group I was
(13±9) days, group II was (20.7±14.9) days, group III was
(21.8±13.2) days and there was significant decrease in
antibiotics days in group I in comparison to group III (p = .039) and insignificant decrease in comparison to group II
(p=0 .178).
Regarding the frequency of need to change systemic
antibiotics, group I its mean was (1.3±1.2), group II was (
2±2) group III was (3.1 ± 1.8)and there was significant
decrease in frequency of change systemic antibiotics in group I
in comparison to group III (p value = .017) but no significant
difference between group I and group II p= 0.355).
As ventilation regards total mechanical (MV) days, the
average days for group I was (9.40±4.06) days, for group II
was (19.80±13.83) days, for group III was (16.30±5.21) days
and there was significant decrease in MV days in group I in
comparison to group III (p=0.035) and non-significant
decrease in MV days in comparison to group II (p =140).
As regards total ICU stay days, the average ICU stay
days for group I was (13±9) days, for group II was (20±4.9)
days, and for group III was (21.8±13.2) days and there was
statistically significant decrease in ICU stay days in group I in
comparison to group III (p=.039) and non-significant decrease
in ICU stay days in comparison to group II (p=.178).
As regards mortality there was no statistically
significant difference between group I and group II (p value =
1.000), or between group I and group III (p = .639)
The causes of death in group I, were cardiac arrest 20%,
Cerebral infarction, ARDS, renal failure, metabolic acidosis
10% for each of them, for group II, septic shock, ARDS (20%).