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HĂŠctor H. Cubides Z. Internal Medicine


BIOFILM


INTRODUCTION BIOFILM (Pathophysiological) : • Microorganisms attach synthetic surfaces • Microorganisms multiply • Extracellular polymeric substance (Matrix) BIOFILM (Problem) • Associated device-related infections • Bacterial antibiotic resistance


INTRODUCTION ENDOTRAQUEAL TUBE (ETT): Impairs mucocilliary clearance Disrupts cough reflex Inoculate bacteria low airway Produce injury airway PROMOTE

BIOFILM VAP VAP


INTRODUCTION • Biofilm be universally on surface ETT • High concordance between microorganisms: – Colonization oropharyngeal-ETT (biofilm)-VAP

• ETT biofilm promote survival bacterial • Microbial persistence airways implicated: – Lack response A/B (RESISTANCE-FAILURE TTO) – Relapse VAP


OBJETIVE INVESTIGATE THE ROLE OF ETT BIOFILM IN VAP PATHOGENESIS, RESPONSE TO TREATMENT AND RELAPSE


MATERIALS AND METHODS • Prospective observational study single center • Follow-up period 7 month • Protocol reviewed, approved X Institutional Review Board

• Patients (relatives) provided informed consent • Inclusion criteria: – All patients required MV for at least 24 hours


MATERIALS AND METHODS STATISTICAL ANALYZES (SPSS 16.0): • Results continuous variables expressed: – Mean/Median (Interquartile range) for and the

• Results dichotomous variables expressed: – # (Percentage)

• Risk factors analyzed by univariate analysis – chi-square test/ANOVA (Dichotomous variables) – Mann-Whitney U test (Continuous variables)

• P <0.05


MATERIALS AND METHODS DATA RECORDED: • Age - Sex • APACHE II Score • Cause and duration mechanical ventilation • Maneuvers to prevent VAP • Occurrence or not of nosocomial pneumonia • Pathogen isolated (respiratory samples ETT biofilm)

• Antibiotic therapy and sensitivity patterns


MATERIALS AND METHODS RESPIRATORY SAMPLES surveillance sampling TIME TIMEINTUBATION INTUBATION

(analysis (analysismicrobiology microbiologylaboratory) laboratory)

TWICE TWICEXXWEEK WEEK

(analysis (analysismicrobiology microbiologylaboratory) laboratory)

BAL BALBEFORE BEFORETO TOSTART STARTA/B A/B (Suspected (SuspectedVAP) VAP)


MATERIALS AND METHODS PROCESSING ETT AFTER EXTUBATION ETT (1CM) WAS COLLECTED ELECTRON ELECTRONMICROSCOPY MICROSCOPY

QUANTIFY QUANTIFY BIOFILM BIOFILM

IDENTIFY IDENTIFY MICROORGANISMS MICROORGANISMS

BACTERIAL BACTERIALCULTURES CULTURES


OPERATIONAL DEFINITIONS VAP: – New infiltrates > 48 hours after intubation – 2 or more: Fever, / WBC, Purulent secretions – Microbiological confirmation by BAL (> 1.000 UFC/ml)

– Management based ATS/IDSA guidelines

VAP-EARLY: – Pneumonia initiated 4 days/less intubation


OPERATIONAL DEFINITIONS MICROBIAL PERSISTENCE: • Persistence causative microorganism VAP least 2 successive respiratory samples, despite 72 H A/B

VAP RELAPSE: • • • • •

New clinical at least 72 H after clinical resolution Culture (+) for previously isolated strain New infiltrate on the chest X-ray IRSS Absence extrapulmonary source of infection


OPERATIONAL DEFINITIONS TREATMENT FAILURE: Least one, 72 H after initiation A/B – Failure to improve PaO2/FiO2 – Fever/hypothermia + purulent secretions – Worsening pulmonary infiltrates (> 50%) – Septic shock/Multiple organ dysfunction not present at the onset of pneumonia


RESULTS 81 PATIENTS THAT REQUIRED IMV 2:2:LOSS LOSSOF OFETT ETTAFTER AFTEREXTUBATION EXTUBATION 4:4:INAPPROPRIATE INAPPROPRIATEFIXATION FIXATIONTECHNIQUE TECHNIQUE

75 PATIENTS INCLUDED ANALYSIS ALL ALLMULTIDRUGMULTIDRUGRESISTANT RESISTANT


RESULTS


RESULTS - SURVEILLANCE CULTURES • Bacterial growth cultures (+) 65 patients (87%) • ETA sampled, 252/151 (60%) grew (+) microorganisms • Latency time 2.1 ± 0.4 days

ALL ALLMULTIDRUG-RESISTANT MULTIDRUG-RESISTANT


RESULTS - BIOFILM FORMATION • Biofilm was present 71 (95%) ETTs: – Scarce biofilm (18%) – Dispersed clusters biofilm (37%) – Confluent abundant biofilm (41%)

• Biofilm formation was not associated: – Duration stay ETT – Selective digestive decontamination – Systemic antibiotics – Grade immunosuppression


RESULTS - VAP

EARLY EARLYONSET ONSET


RESULTS - VAP Days intubation Previous airway colonization Associated Associated(+) (+)

LATE-ONSET VAP

P. Aeurginosa (OR) 10.2; 95% CI, 2.11- 49.3; P = 0.005

A. Baumannii (OR) 4.9, 1.18-20.3; P = 0.03


RESULTS - VAP Age - Gender APACHE II Grade Immunosuppression Diabetes Cause of ICU admission Cause of intubation A/B previo to intubation Biofilm extension Not NotAssociated Associated

DEVELOPMENT VAP


CONCLUSIONS • A. baumannii-P. aeruginosa most frequently implicated microbial persistence • Bacterial survival on biofilm was associated to microbial persistence (100% vs 29%; P = 0.021) • All TTO failure/relapse related A. baumannii - P. aeruginosa


BACTERIAL BACTERIAL SURVIVAL SURVIVAL

BACTERIAL SURVIVAL SURVIVAL BACTERIAL

CONCLUSIONS


CONCLUSIONS TENDENCY (57% vs 14%; P = 0.133): TTO failure was more frequent when causal bacteria remained biofilm despite appropriate TTO

Biofilm formation and airway colonization were necessary but not sufficient for VAP development

BIOFILM Y NAV  

Evaluacion de presencia y biofilm en la aparicion de NAV

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