الفهرس 
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Abstract
Hospital-Acquired Pneumonia (HAP) acts as a big concern for an intensivist. Detailed Information on Non-Ventilated Hospital-Acquired Pneumonia (NV-HAP), and Ventilated-Acquired Pneumonia (VAP) is vital for prevention as well as appropriate strategy. Hence, enhancing quality Intensive Care Unit (ICU) care.
Our main objectives were quantifying the incidence of HAP as well as determining predictors of HAP, reporting HAP-microbiological resistance, calculating HAP-related mortality risk ratios, and identifying the different risk factors contributing to mortality.
It was a prospective longitudinal study, conducted at Damanhur Medical National Institute (DMNI)’s general ICUs, over 12 months. from 356 patients, 133 patients developed VAP (aged 18-93 years; median 60 years (43-71); 75 males), 76 patients with NV-HAP (aged 19-90 years; median 58 (43.5-67.5); 38 males), and 147 patients did not develop HAP (aged 18-86 years; median 60 (47-70); 73 males).
➢ Inclusion Criteria: Patients aged 18 years or older (males as well as females), and length of stay should be at least 72 hours before signs appear to ensure infection was acquired after admission to ICU.
➢ Exclusion Criteria: Patients with proved pneumonia on admission or within the first two days following entrance to ICU.
Data on patient characteristics, APACHE II scores, HAP, and mortality outcomes were analyzed. We also studied the causative organisms, antibiotic susceptibility, and resistance patterns of these patients. We utilized logistic regression for mortality outcome, cox regression for HAP outcome, and relative risk (RR) model for multi-drug resistance (MDR) to determine the corresponding predictors. Statistical analyses were performed using SPSS software (version 23) and R software.
Summary, Conclu sion, & Recommendations
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HAP showed a high incidence of 28 cases of HAP per 1000 person-days, and the mortality rate was 74 per 100 days (mortality rate ratio= 6.81). The incidence rate of MDR was 1.48 per 100 person-days, while the Attributable Risk Percentage (ARP) was 85% (Population Attributable Risk (PAR) percentage= 37%). Although Acinetobacter baumannii (28, 21.1%), Klebsiella pneumoniae (54, 40.6%), Pseudomonas aeruginosa (25, 18.8%) were the most isolated bacteria among VAP patients, only Klebsiella pneumoniae (32. 42.1%), and Pseudomonas aeruginosa (18, 23.7%) were the most predominant organisms detached from NV-HAP. A. baumannii showed maximum resistance to Ciprofloxacin (100%) and Amoxicillin with Clavulanic acid (96.4%), K. pneumoniae displayed the greatest resistance to Second-generation Cephalosporins (100%), and Amoxicillin and Clavulanic acid (96.5%), while P. aeruginosa revealed maximum resistance to Amoxicillin and Clavulanic acid (100%), and Linezolid (97.7%).
Overall resistance was high for Second-generation Cephalosporins (Cefuroxime 100%, Cefoxitin 99%), Monobactams (Aztreonam 99%), followed by Sulfonamides Derivatives (Cotrimoxazole 97.1%), and high sensitivity for Polymyxin E (Colistin 40.7%), Carbapenem (Imipenem 40.2%, Meropenem 34.9%) followed by β-lactamase Inhibitors (Piperacillin and Tazobactam 33.5%).
The high mortality was explained by independent variables as HAP outcome (OR=6.49, P=0.001), neurological diseases (OR=2.20, P=0.03), diabetes mellitus (OR= 2.98, P=0.004), duration in ICU ≥ 5 days (OR=7.29, P=0.02), APACHE II ≥ 17 (OR=2.76, P=0.004), and reintubation (OR=8.99, P<0.001). The most common predictors for HAP are APACHE II ≥ 17 (HR=1.54, P=0.04), tracheostomy (HR=1.72, P=0.04), K. pneumoniae (HR=1.81, P=0.003), and P. aeruginosa (HR=2.27, P<0.001), in contrast to the A. baumannii. For the Multidrug Resistance (MDR), A. baumannii (RR= 3.71, P=0.014), K. pneumoniae (RR= 2.78, P<0.001), P. aruginosa (RR=2.66, P=0.002), and duration in ICU (RR=0.99, P=0.001) are the most predominant predictors.
Conclusions
The high incidence rate of HAP was due to APACHE II ≥ 17, and tracheostomy, while the high mortality rate was because of HAP outcome, duration in ICU ≥ 5 days, neurological disorders, diabetes mellitus, APACHE II ≥ 17, and reintubation. Multi-drug
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Resistance (MDR) predictors were A. baumannii, K. pneumoniae, and P. aeruginosa, however duration in ICU does not alter MDR.
Recommendations
• Avoid unnecessarily prolonged duration in ICU as the extended length of stay independently anticipates the mortality.
• Avoid heavy use of acid suppression, as heavy use of acid suppression causes bacterial colonization in the lungs.
• Appropriate care for reintubated patients as reintubation independently predicts mortality for ICU patients.
• Precise precaution for patients with APACHE II ≥ 17, as in our study, they were liable to develop HAP and die.
• Special attention for patients with diabetes mellitus, as the diabetes mellitus is an independent predictor for developing HAP.
• Peculiar consideration for patients who are tracheostomized, as in our study, tracheostomy is an independent predictor for HAP.
• Avoid unnecessary prescriptions for Second-generation Cephalosporins, Monobactams, and Sulfonamides Derivatives, specifically for high resistance.
• Meticulous precaution of the selection of antibiotics for Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa contributing to the highest Multi-drug Resistance (MDR), to avoid likely resistance later.
• Further research should reexamine the impact of HAP in private ICU hospital settings, investigate risk factors for both its occurrence and outcome, and the latest antibiotics evidence would deliver us a broader perspective.