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Table 1.  

Variables Overall, n = 497 Acinetobacter baumannii isolated p value Hazard ratio (95% CI)
Yes, n = 159 No, n = 338
Median age, y (IQR) 60.1 (49–73) 61 (50–74) 59.6 (49–73) 0.444 1.004 (0.994–1.013)
Sex, no. (%)          
   F 160 (32.2) 44 (27.7) 116 (34.3) Referent  
   M 337 (67.8) 115 (72.3) 222 (65.7) 0.139 0.769 (0.544–1.089)
Mean Charlson comorbidity index, (SD) 4.26 (2.12) 4.40 (2.14) 4.20 (2.11) 0.293 1.038 (0.968–1.113)
Underlying conditions, no. (%)          
   Cardiovascular diseases 200 (40.2) 79 (49.7) 121 (358) 0.003 1.596 (1.169–2.178)
   Chronic renal insufficiency 179 (36.0) 71 (44.7) 108 (32.0) 0.011 1.504 (1.200–2.056)
   COPD and asthma 176 (35.4) 71 (44.7) 105 (31.1) 0.005 1.570 (1.148–2.146)
   Type 2 diabetes mellitus 116 (23.3) 46 (28.9) 70 (20.7) 0.057 1.395 (0.990–1.965)
   Solid tumor 100 (20.1) 36 (22.6) 64 (18.9) 0.363 1.188 (0.820–1.723)
   Hematologic malignancy 31 (6.2) 8 (5.0) 23 (6.8) 0.497 0.781 (0.384–1.591)
   Past inhaled steroids use for chronic conditions 47 (9.5) 17 (10.7) 30 (8.9) 0.450 1.214 (0.734–2.007)
   Current or former smoker 187 (37.6) 74 (46.5) 113 (33.4) 0.005 1.565 (1.146–2.138)
   Postoperative admission 142 (28.6) 38 (23.9) 104 (30.8) 0.134 0.757 (0.526–1.090)
Treatment, no. (%)          
   No aerosol inhalation 137 (27.6) 33 (20.8) 104 (30.8) Referent  
   Glucocorticoid aerosol inhalation 262 (52.7) 107 (67.3) 155 (45.9) 0.002 1.860 (1.264–2.738)
   Aerosol inhalation without glucocorticoid 98 (19.7) 19 (11.9) 79 (23.4) 0.337 0.760 (0.433–1.332)
   Broad-spectrum antimicrobial drugs, ≥7 d 417 (83.9) 157 (98.7) 260 (76.9) <0.001 9.539 (4.595–18.795)
   Invasive mechanical ventilation, ≥5 d 221 (44.5) 112 (70.4) 109 (32.2) <0.001 3.452 (2.453–4.858)
   Urethral catheter placement, ≥3 d 493 (99.2) 158 (99.4) 335 (99.1) 0.875 1.171 (0.164–8.361)
   Vasopressor treatment, ≥3 d 75 (15.1) 42 (26.4) 33 (9.8) <0.001 2.634 (1.850–3.750)
   Renal dialysis, ≥3 d 84 (16.9) 34 (21.4) 50 (14.8) 0.063 1.432 (0.980–2.093)
APACHE II score, mean (SD) 18.18 (6.03) 18.98 (6.44) 17.80 (5.80) 0.053 1.026 (1.000–1.053)
Median length of ICU stay, d (IQR) 15 (7–23) 20 (10–28) 13 (6–20) 0.057 1.005 (1.000–1.010)

Table 1. Univariate analysis of risk factors for Acinetobacter baumannii among patients during invasive mechanical ventilation, China*

*APACHE II, Acute Physiology and Chronic Health Evaluation II; COPD, chronic obstructive pulmonary disease; ICU, intensive care unit; IQR, interquartile range.

Table 2.  

Variables p value Hazard ratio (95% CI)
Underlying conditions    
   Cardiovascular diseases 0.054 1.394 (0.994–1.955)
   Chronic renal insufficiency 0.730 0.937 (0.648–1.356)
   COPD and asthma 0.132 1.299 (0.924–1.825)
   Type 2 diabetes mellitus 0.325 1.197 (0.837–1.714)
   Current or former smoker 0.098 1.307 (0.951–1.797)
Treatment    
     No aerosol inhalation Referent  
     Glucocorticoid aerosol inhalation 0.038 1.528 (1.024–2.278)
     Aerosol inhalation without glucocorticoid 0.524 0.829 (0.467–1.475)
   Broad-spectrum antimicrobial drugs, ≥7 d 0.001 7.238 (2.758–15.788)
   Invasive mechanical ventilation, ≥5 d 0.001 2.381 (1.664–3.405)
   Vasopressor treatment, ≥3 d <0.001 2.060 (1.402–3.028)
   Renal dialysis, ≥3 d 0.841 1.046 (0.675–1.620)
APACHE II score 0.586 0.992 (0.965–1.020)

Table 2. Multivariate analysis of risk factors for Acinetobacter baumannii among patients during invasive mechanical ventilation, China*

*Results are from model 2; only variables with p<0.1 in univariate analysis were included. APACHE II, Acute Physiology and Chronic Health Evaluation II; COPD, chronic obstructive pulmonary disease.

Table 3.  

Variables p value Hazard ratio (95% CI)
Underlying conditions    
   Cardiovascular diseases 0.117 1.361 (0.926–2.001)
   Chronic renal insufficiency 0.800 1.052 (0.712–1.554)
   Type 2 diabetes mellitus 0.243 1.271 (0.850–1.899)
   Current or former smoker 0.051 1.442 (0.998–2.083)
Treatment    
     Glucocorticoid aerosol inhalation 0.032 1.489 (1.036–2.141)
   Broad-spectrum antimicrobial drugs, ≥7 d 0.004 6.315 (2.543–13.921)
   Invasive mechanical ventilation, ≥5 d <0.001 2.388 (1.614–3.534)
   Vasopressor treatment, ≥3 d 0.501 1.188 (0.719–1.963)
APACHE II score 0.363 1.014 (0.984–1.045)

Table 3. Multivariate analysis of risk factors for Acinetobacter baumannii among propensity-matched patient cohort during invasive mechanical ventilation, China*

*Only variables with p<0.1 in univariate analysis of the propensity-matched cohort were included. APACHE II, Acute Physiology and Chronic Health Evaluation II; COPD, chronic obstructive pulmonary disease.

CME / ABIM MOC

Acinetobacter baumannii Among Patients Receiving Glucocorticoid Aerosol Therapy During Invasive Mechanical Ventilation, China

  • Authors: Wenchao Zhang, MD, PhD; Mei Yin, MD, PhD; Wei Li, MD, PhD; Nana Xu, MD; Haining Lu, MD; Weidong Qin, MD, PhD; Hui Han, MD; Chen Li, MD; Dawei Wu, MD; Hao Wang, MD, PhD
  • CME / ABIM MOC Released: 11/17/2022
  • Valid for credit through: 11/17/2023, 11:59 PM EST
Start Activity

  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 1.00 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, infectious disease specialists, critical care specialists, and other physicians who care for patients receiving invasive mechanical ventilation (IMV).

The goal of this activity is for learners to be better able to discuss how aerosol treatments may affect the risk for infection with Acinetobacter baumannii (AB).

Upon completion of this activity, participants will:

  1. Distinguish the percentage of patients receiving invasive mechanical ventilation (IMV) who had a positive culture for Acinetobacter baumannii (AB)
  2. Assess the role of aerosol inhalation in the isolation of AB in the current study
  3. Analyze risk factors for the isolation of AB in the current study
  4. Evaluate the effects of aerosol inhalation and AB on the risk for mortality among patients receiving IMV


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Faculty

  • Wenchao Zhang, MD, PhD

    Qilu Hospital of Shandong University
    Jinan, China

  • Mei Yin, MD, PhD

    Qilu Hospital of Shandong University
    Jinan, China

  • Wei Li, MD, PhD

    Qilu Hospital of Shandong University
    Jinan, China

  • Nana Xu, MD

    Qilu Hospital of Shandong University
    Jinan, China

  • Haining Lu, MD

    Qingdao Branch Qilu Hospital of Shandong University Qingdao, China

  • Weidong Qin, MD, PhD

    Qilu Hospital of Shandong University
    Jinan, China

  • Hui Han, MD

    Qilu Hospital of Shandong University
    Jinan, China

  • Chen Li, MD

    Qilu Hospital of Shandong University
    Jinan, China

  • Dawei Wu, MD

    Qingdao Branch
    Qilu Hospital of Shandong University
    Qingdao, China

  • Hao Wang, MD, PhD

    Qilu Hospital of Shandong University
    Jinan, China

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor

  • Amy J. Guinn, BA, MA

    Copyeditor 
    Emerging Infectious Diseases

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.


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CME / ABIM MOC

Acinetobacter baumannii Among Patients Receiving Glucocorticoid Aerosol Therapy During Invasive Mechanical Ventilation, China

Authors: Wenchao Zhang, MD, PhD; Mei Yin, MD, PhD; Wei Li, MD, PhD; Nana Xu, MD; Haining Lu, MD; Weidong Qin, MD, PhD; Hui Han, MD; Chen Li, MD; Dawei Wu, MD; Hao Wang, MD, PhDFaculty and Disclosures

CME / ABIM MOC Released: 11/17/2022

Valid for credit through: 11/17/2023, 11:59 PM EST

processing....

Abstract and Introduction

Abstract

Acinetobacter baumannii is a nosocomial pathogen associated with severe illness and death. Glucocorticoid aerosol is a common inhalation therapy in patients receiving invasive mechanical ventilation. We conducted a prospective cohort study to analyze the association between glucocorticoid aerosol therapy and A. baumannii isolation from ventilator patients in China. Of 497 enrolled patients, 262 (52.7%) received glucocorticoid aerosol, and A. baumannii was isolated from 159 (32.0%). Glucocorticoid aerosol therapy was an independent risk factor for A. baumannii isolation (hazard ratio 1.5, 95% CI 1.02–2.28; p = 0.038). Patients receiving glucocorticoid aerosol had a higher cumulative hazard for A. baumannii isolation and analysis showed that glucocorticoid aerosol therapy increased A. baumannii isolation in most subpopulations. Glucocorticoid aerosol was not a direct risk factor for 30-day mortality, but A. baumannii isolation was independently associated with 30-day mortality in ventilator patients. Physicians should consider potential A. baumannii infection when prescribing glucocorticoid aerosol therapy.

Introduction

Acinetobacter baumannii, a gram-negative coccobacillus, is a major nosocomial pathogen worldwide. A. baumannii is particularly challenging in intensive care units (ICUs). According to the Extended Prevalence of Infection in Intensive Care study, aimed at providing information on the prevalence of infection in ICUs worldwide, Acinetobacter spp. constituted 8.8% of all culture-positive ICU infections in 2007[1], which increased to 11.4% in 2017[2]. However, infection rates differed markedly, ranging from 1.0% in North America to 25.6% in Asia and the Middle East and 22.9% in eastern Europe[2]. Patients on invasive mechanical ventilation are particularly vulnerable to A. baumannii infection and colonization due to airway barrier destruction and bacterial virulence factors such as motility, epithelial adherence, and biofilm formation that enable A. baumannii colonization in the airways[3,4]. A. baumannii in patient airways is associated with longer hospitalization, higher medical expenses, and increased mortality rates[5–7]. Identifying risk factors for A. baumannii infection is crucial for implementing preventive measures and decreasing overall illness and death.

Aerosol inhalation is widely used in patients requiring mechanical ventilation. Glucocorticoids are frequently administered during aerosol therapy, especially in China[8–10]. Compared with systemic application, aerosol therapy has several advantages, including targeted delivery to the lungs, faster response, and fewer systemic side effects[11,12]. However, the aerosols and droplets generated during aerosol inhalation can become sources of respiratory pathogens[13], and inhaled glucocorticoids might suppress pulmonary immunity[14], which could increase the opportunity for nosocomial acquisition. Inhaled corticosteroids are associated with an increased risk for pneumonia in patients with chronic obstructive pulmonary disease (COPD)[15]. However, the effects of glucocorticoid aerosol inhalation on nosocomial infection risk has not been clearly elucidated.

Glucocorticoid aerosol therapy is mainly indicated for patients with asthma, COPD[16], acute respiratory distress syndrome (ARDS)[17], and some pathophysiological conditions, such as airway hyperresponsiveness[18], hyperinflammation, and mucosal edema[19]. In the past decade, use of glucocorticoid aerosol therapy has increased in hospitals in China; on average, >40% of patients on mechanical ventilation receive this therapy[9]. In addition, a market analysis determined that aerosolized glucocorticoid sales in China were almost 3-fold higher in 2018 than in 2012[20].

Although epidemiology has demonstrated a slow increase in A. baumannii infection globally over the past decade[1,2], the increase in A. baumannii incidence in China appears to have outpaced increases in other regions worldwide[21–23]. According to the China Antimicrobial Surveillance Network (CHINET), a national surveillance of the trends of bacterial strains isolated from the major hospitals in China, the number of Acinetobacter spp. strains increased by 2.7-fold in 2018 compared with 2012[23,24]. Previously, we reported a marked increase in the incidence of A. baumannii–related bloodstream infections and incidence of pneumonia-related A. baumannii infections in ICUs in China that were 3.2-fold higher during 2017–2018 than during 2011–2012[25]. A. baumannii was the most frequent bacterial isolate in ventilator-associated pneumonia in China, and rates were 35.7%–52.7%[26,27]. Furthermore, the incidence of the drug-resistant phenotype of A. baumannii is high. According to CHINET reports, carbapenem-resistant A. baumannii strains increased from 31% in 2005 to 66.7% in 2014[28], then to ≈80% in 2018[29]. We previously reported that carbapenem resistance rates in ICUs in China increased from 25% during 2011–2012 to 95.7% during 2017–2018[25]. A multicenter study of ICUs in China reported that multidrug-resistant (MDR) A. baumannii was detected in 40% of all cases[30].

We hypothesized that increased use of glucocorticoid aerosol therapy might contribute to increased A. baumannii incidence. Therefore, we performed a prospective cohort study of critically ill patients receiving invasive mechanical ventilation in China to determine whether use of aerosolized glucocorticoid increased the risk for A. baumannii isolation.