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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
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: Methods

processing....

Methods

Study Design and Patients

During January 2018–August 2019, we conducted a prospective cohort study at 3 adult ICUs in 2 hospitals in Shandong Province, China: Qilu Hospital of Shandong University in Jinan and Qingdao Branch of Qilu Hospital in Qingdao. We enrolled patients on their first day of invasive mechanical ventilation in the ICU and obtained written informed consent for all patients. We divided the patients into 3 groups on the basis of their treatment: no aerosol inhalation therapy, glucocorticoid aerosol therapy, and aerosol inhalation without glucocorticoid. Within 48 hours of patient enrollment, we collected secretion samples from the lower respiratory tract by transtracheal aspiration for microbial culture; thereafter, we collected samples 3 times per week until we obtained an A. baumannii–positive culture. We followed patients for 30 days after enrollment. If the patient was hospitalized for >3 weeks, we reduced the culture frequency to once a week. We excluded patients who received invasive mechanical ventilation for <48 hours; received aerosol inhalation or glucocorticoid aerosol for <48 hours after enrollment and before A. baumannii–positive culture; were <18 years of age; were assumed to have A. baumannii infection or colonization at baseline because they were A. baumannii–positive before enrollment or within the first 48 hours of enrollment; or had been exposed to ≥1 of the following A. baumannii risk factors before enrollment: antimicrobial drugs for ≥7 days, invasive mechanical ventilation for ≥5 days, or vasopressor for ≥3 days. We also excluded patients who lacked follow-up data or had incomplete information. The Institutional Ethics Committee of Qilu Hospital of Shandong University approved our study.

Microbiology

We performed microbial cultures according to standard procedures. In brief, we incubated respiratory samples on MacConkey agar plates at 5% CO2 and 35°C for 48 h. We identified A. baumannii, a gram-negative, nonfermentative, and oxidase-negative coccobacillus, by using the VITEK 2 compact system and GN ID card (bioMérieux, https://www.biomerieux.com). We used Escherichia coli (ATCC accession no. 25922) and Pseudomonas aeruginosa (ATCC accession no. 27853) as quality controls.

Definitions and Data Collection

We defined no aerosol inhalation as patients who did not receive aerosolized medications during the study. We defined glucocorticoid aerosol therapy as patients who received aerosolized glucocorticoids for ≥48 hours after enrollment and before A. baumannii isolation, with or without nonglucocorticoid aerosolized medications for any duration. We defined aerosol inhalation without glucocorticoid as patients who received only aerosolized nonglucocorticoid medications, such as bronchodilators and expectorants, for ≥48 hours after enrollment and before A. baumannii isolation. We excluded all other conditions.

The primary endpoint was A. baumannii isolation, which we defined as A. baumannii–positive culture from the lower respiratory tract samples collected during the ICU stay. Negative outcomes were no A. baumannii isolation before death, ICU discharge, or end of follow-up period. We recorded the time-to-event, which we defined as number of days from enrollment to A. baumannii isolation.

We collected baseline information at ICU admission, including age, sex, history of smoking and surgeries, underlying conditions, past inhaled steroids for chronic conditions, and Charlson comorbidity index. We used the Acute Physiology and Chronic Health Evaluation II (APACHE II) score to assess illness severity. We also recorded other possible A. baumannii risk factors, such as use of broad-spectrum antimicrobial drugs, invasive mechanical ventilation, urethral catheter placement, vasopressor treatment, renal dialysis, and length of ICU stay. In addition, we recorded indications for glucocorticoid aerosol therapy by reviewing patients’ medical records. We reviewed patients’ clinical data to determine A. baumannii isolation status as infection, colonization, or undefined.

Statistical Analyses

We expressed continuous variables as median and interquartile range (IQR) or mean and SD and categorical variables as number and percentage. We used univariate and multivariate Cox proportional hazards regression and hazard ratio (HR) and 95% CI to assess risk factors for A. baumannii isolation and 30-day mortality. We performed propensity score matching analysis to reduce the imbalance between the glucocorticoid aerosol therapy and nonglucocorticoid groups. We included all possible covariables (i.e., demographics, background history, underlying conditions, and disease severity) in the propensity score matching. We calculated propensity scores by using a logistic regression model. We applied a 1:1 nearest neighbor matching algorithm with a caliper of 0.02 and without replacement. We assessed balance of variables in both groups by standardized differences. We analyzed A. baumannii isolation in complete cases and the propensity-matched cohort. We used Kaplan-Meier curves to visually compare cumulative hazards for A. baumannii isolation among the 3 groups, which we evaluated by using a log-rank test. To assess the consistency of glucocorticoid therapy in terms of its effect on A. baumannii isolation from prespecified subgroups with different characteristics, we applied Cox proportional hazards model with Efron’s method for handling ties and used forest plots for HRs and 95% CIs. We assessed heterogeneity of efficacy of glucocorticoid therapy on A. baumannii isolation in subgroups by using an interaction test, expressed p values for interaction, and considered p<0.05 statistically significant. We performed all analyses by using SPSS Statistics 16.0 (IBM, https://www.ibm.com) and R version 3.0 (R Foundation for Statistical Computing, https://www.r-project.org).