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Research Article | DOI: https://doi.org/10.31579/2690-1919/067
1 "Guillermo Dominguez Lopez”, Las Tunas, Cuba
*Corresponding Author: Dixan Negreira Ochoa, “Guillermo Dominguez Lopez”, Las Tunas, Cuba.
Citation: Dixan Negreira Ochoa, Characterization of hospital-acquired pneumonia in Intensive Care Unit. General Hospital. J Clinical Research and Reports, 4(3); DOI:10.31579/2690-1919/067
Copyright: © 2020 Dixan Negreira Ochoa. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 10 March 2020 | Accepted: 28 April 2020 | Published: 12 May 2020
Keywords: hospital-acquired pneumonia; mechanical ventilation; mortality; germs; antibiotics
Objective: characterize the hospital-acquired pneumonia (HAN) in the Intensive Care Unit(ICU) of the
Methods: a descriptive and cross-sectional study was carried out to characterize the hospital-acquired pneumonia in admitted patient in ICU of the General Hospital “Guillermo Domínguez López” in Puerto Padre, Las Tunas since June, 2018 to May, 2019. The population was all the patients who acquired the infection during the admission. The information was taken from de patient`s clinic file. It was created graphics and charts to pick the information. Dates was described, analyzed and compared with others national and international studies.
Result: the prevalent age group was 60 -79 to 59%. Asisted mechanical ventilation was not realed with the HAN due to the procedure was only performing in 9 patients to 25%. The most frequent isolated germ was citrobacter. The deseases which was most related with (HAN) was neurological deseases. The mortality was high, 20 patients die to 58%.
Conclusion: clinic and epidemiologic characterisctics of NIH was described in the ICU of the General Hospital “Guillermo Domínguez López”.
Durante siglos la humanidad se ha enfrentado a diversas problemáticas de salud, las enfermedades infecciosas que muchos atribuían a influencias sobrenaturales, en la edad de piedra, fueron de las que más azotaron al hombre hasta su posterior evolución intelectual (1).
Las infecciones respiratorias y en particular las neumonías, tan frecuentes en tiempos de guerra y catástrofes, tuvieron gran participación en la necesidad del hombre por buscar una solución. Se sabe que las muertes masivas, por contagio y ausencia de sustancias que pudieran ayudar a sanar al enfermo, eran abrumadoras. No fue hasta la era de los antibióticos que pudo tener un mayor conocimiento del tema (2).
Hoy en día el hombre no muere por una infección respiratoria, gracias a la gran variedad de antibióticos sintetizados, pero de forma inversa y contradictoria, se sabe que los servicios médicos tiene protagonismo en el aumento de la frecuencia de neumonías causadas por otros gérmenes diferentes a los que comúnmente se adquieren en la comunidad, las que se debe poner mayor énfasis y control con antibióticos de mayor potencia, las llamadas neumonías intrahospitalaria(NIH) o asociadas a los servicios de médicos(NASM)(3).
En países del primer mundo constituye una de las principales causas de sepsis intrahospitalarias, en España y México ocupan el tercer lugar,(2) mientras que en Estados Unidos solo fueron precedidas por la infecciones urinarias(3).
La mortalidad de la NN en estos pacientes asciende desde un 30% hasta un 70%, aunque se debe tener en cuenta que este porcentaje depende de muchos factores y es muy difícil atribuir la mortalidad a la NN en concreto (4).
La mortalidad atribuible por neumonía asociada a ventilación mecánica (NAVM) se ha definido como el porcentaje de muertes que no hubieran ocurrido en ausencia de la infección. Numerosos estudios y controles de casos (5) han estimado que entre un 33% y un 50% de todas las muertes relacionadas con la NAVM suceden como resultado directo de la infección, con una mortalidad más alta en pacientes infectados por Pseudomona aeruginosa o Acinetobacterspp y asociados a bacteriemia(6).
En Cuba se aprecia un comportamiento similar y ocupa el foco principal de sepsis en las salas de terapia intensiva y contribuye a aumentar las pérdidas humanas y elevar los costos hospitalarios (7-8).
Nuestro país no queda aislado de esta problemática, estudios revelan que la mortalidad haciende a más del 50% de los pacientes con NIH (9). Se considera la misma una causa de muerte evitable dentro de las enfermedades transmisibles donde existen una serie de factores de riesgos que se pueden modificar en vida del paciente para una mejor atención (8).
En la provincia Las Tunas se determinó que de cada 10 pacientes ingresados en UCI, 6 se complicaban con NIH y 2 morían, cantidad significativa que demandaba una mayor atención (9).
En nuestro hospital la neumonía nosocomial en pacientes ingresados en la UCI es común, datos estadísticos muestran que en el año 2016 la mortalidad fue de más del 50% de los pacientes complicados por NIH, además de las incontables pérdidas materiales que le ocasionan al hospital y a la familia. Para nuestro servicio, una de las metas más importantes es disminuir las neumonías nosocomiales, ya que inciden en un gran porcentaje de morbilidad y mortalidad. Esto nos ha motivado a realizar un estudio con el objetivo de caracterizar la neumonía en la población crítica en el HG Guillermo Domínguez López, así como entenderla en términos de: grupo de edad mayor afectado, relación de la ventilación mecánica en la aparición de NIH, momento del diagnóstico, patrones microbianos de la institución y mortalidad por la afección.
The total number of NIH episodes in the ICU in the period studied was 34 patients as shown in Table 1. The most affected age group was 70-79 years with 20 patients for 59% and the sex most affected was the male with 21 patients for 64%.
When calculating the mean from the formula above:
X=(Mc×fA)n
X= 244334
= 71,852… ≈ 71,9
We found that the average age of all infected patients was 71 years. As you can see, the mean value is within the age group of the most affected patients.
Grupos de edades (años) | Masculino | Femenino | Total |
N % | N % | N % | |
19-29 | 0 0 | 0 0 | 0 0 |
30-49 | 2 7 | 0 0 | 2 6 |
50-59 | 1 3 | 0 0 | 1 3 |
60-69 | 4 15 | 2 7 | 6 17 |
70-79 | 11 29 | 9 24 | 20 59 |
80-89 | 2 7 | 2 7 | 4 12 |
90 y más | 1 3 | 0 0 | 1 3 |
Total | 21 62 | 13 38 | 34 100 |
Table 1. Distribution of cases according to age groups and sex.
At the Ernesto Guevara hospital in Las Tunas, they found that the age group most affected was over 60 years with 71 patients for 41%, followed by those between 50 and 59 years (10).
According to José Gundián Gozalez-Piñeira, in a study carried out at the Hermanos Ameijeiras hospital, he obtained as a result that the age group over 50 years was the one that predominated the most (11), which is similar to our result. In this same study, a female predominance was reported with 58%.
On her side, Carmen Alicia San José Arribas, in her doctoral thesis, found a predominance of males and patients older than 60 years (12).
However, in another study carried out in the Granma provincial hospital, a different figure was found, with a predominance in those under 60 years of age. In relation to sex, it was more frequent in males; 72.0% of affected patients were men (13).
In the opinion of this author at an older age, the immune system becomes depressed, providing susceptibility to serious infections, in addition to the association with chronic diseases is more likely. Extreme ages are considered to be an important risk factor in the incidence of these infections.
This researcher found differences with respect to the results obtained by Yoniel Milanés González at the Bayamo provincial hospital, which reported a higher incidence in children under 60 years of age (13), I believe that it could be related to a predominance of income of young adults in relation to with complex surgical and multiple trauma.
In the opinion of this author, the predominance of the male sex could be related to smoking, which is an important risk factor in atherogenic diseases. These diseases, as demonstrated in this study, are one of the main causes of admissions in our unit.
Table 2 correlates the number of diseases for which the studied patients were admitted associated with greater frequency with the development of NIH, where a predominance of neurological followed by cardiovascular was found with 13 and 12 patients respectively (44 and 35% ).
Enfermedades | Nro % |
Neurológicas | 13 44 |
Cardiovasculares | 12 35 |
Respiratorias | 5 9 |
Quirúrgicas | 2 6 |
Otras | 2 6 |
Total | 34 100 |
Table 2. Distribution of cases according to underlying disease.
The presence of coma or the alteration of the reflexes of the upper airways, which usually accompany these diseases, have been identified as important risk factors, especially in early-onset pneumonia. There is no doubt that the state of health prior to admission and the condition that causes said admission, plays an important role in the development of nosocomial pneumonia since the alterations caused by the morbid process itself can alter the host's defense mechanisms (14) .
In the research by César León-Chahua et al. reported neurological diseases as the main causes related to NIH, reaching 26% of the studied population (15).
For their part, Liudmila Carnesoltas et al, found a relationship of neurological diseases with NIH in 21 patients of the studied population for 34.4% (16).
However, in a study carried out in the provincial hospital of Pinar del Rio, respiratory diseases were in the first place as the main cause of admission of patients who later presented the complication. It was followed in second place by cardiovascular diseases (17).
It is the author's criterion that neurological diseases generally take first place, and more particularly cerebrovascular diseases, followed by cardiovascular diseases, results that are similar to other studies. The high incidence of these conditions in the population of Puerto Padre contributes to an increase in patients requiring admission to the ICU. There is a high risk for patients admitted for these conditions to present NN in the first days after admission. It is vitally important that the medical and nursing staff take this as a reference to pay more attention to the signs that may appear and that suggest the presentation of the infection. In addition to taking into account the measures that must be taken in these services in order to avoid the appearance of respiratory infections such as frequent aspiration of bronchial secretions in intubated patients and the mobilization of the patient from bed to chair as soon as possible.
Table 3 shows the distribution of patients according to the time of diagnosis, it was found that 25 patients were diagnosed between two and four days and nine patients at five days or more for 73.5% and 26.6% respectively.
Momento del diagnostico (días) | Nro. % | |
2-4 | 25 73.5 | |
≥ 5 | 9 26.5 | |
Total | 34 100 |
|
Table 3. Distribution of cases according to time of diagnosis.
NN develops in hospitalized patients 48 to 72 hours after admission or 7 days after discharge (17).
According to Langer et al. In a multicenter study in intensive care units, they were the first to classify NN as early onset (developed in the first 4 days after hospitalization) and late onset (after 5 days or more) (18). However, there are no appropriately designed studies to support these time thresholds.
According to the American Thoracic Society, from day five of hospitalization, the nosocomial flora replaces the normal bacterial flora of the patients; Following this criterion, day five is established as a point of separation between one and the other (19).
According to Cortinas Saenz et al, reported that in early pneumonia the most frequently isolated pathogens were Staphylococcus aureus, in late pneumonia cases the genus Pseudomonas stands out (20).
The American Thoracic Society published guidelines for the diagnosis and treatment of adult patients with NN, in which it is considered that the two main factors that determine the type of antibiotics to be administered are the length of time the patient has been admitted to the hospital, which It allows classifying pneumonia into early (<5>
For the author, it is of great importance that the medical personnel in charge of dealing with this complication be able to define, classify the infection according to these time periods and provide an empirical therapy according to the most frequent germs according to the days of made the diagnosis. This, in addition to alerting us about the rapid installation of the infection, helps us to understand that we should not ignore any symptoms that guide us to reach an early diagnosis and provide immediate therapy avoiding the appearance of other complications or the prolonged stage .
Table 4 relates the nosocomial infection with mechanical ventilation, it was found that 25 patients for 75% were not associated with this procedure, while 9 patients for 25% were related.
Ventilación mecánica | Nro. % |
No | 25 75 |
Si | 9 25 |
Total | 34 100 |
Table 4. Distribution of cases according to mechanical ventilation.
According to Pérez Estrada et al. In a study carried out in 2014 on nosocomial infections in the ICU, they reported an incidence of nosocomial pneumonia in ventilated patients of 43.8% (34), a figure that does not resemble ours.
In their publication on the incidence of risk factors for VAP in critically ill patients, Cook et al (22) have estimated that the risk of NN is 1
Durante el periodo estudiado se determinó que el grupo de edad en que más frecuentemente se produce las NIH es el de 70 a 79 años. La aparición de los primeros síntomas de la infección generalmente es en los primeros días. La asociación de la ventilación mecánica con el desarrollo de la enfermedad no es semejante a otros estudios.
Se le indicaron cultivo al 90% de los pacientes, quedando un 10% sin un tratamiento específico, debido al déficit de materiales necesarios para su realización. El citrobacter fue el microorganismo etológico responsable del desarrollo de la mayoría de las NIH en el periodo estudio, además de poseer una gran resistencia antibiótica.
Uno de los antibióticos que se demostró ha perdido efectividad frente a las bacterias aisladas es la cefotaxima mientras que otros como el meropenem continua demostrando su espectro antimicrobiano frente a estos patógenos. Las afecciones que llevaron al paciente a ingresar en nuestro servicio y que más se asociaron al desarrollo de la infección fueron las enfermedades neurológicas. La mortalidad es alta, llegando alcanzar más del 50% de los pacientes aquejados de la infección.
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