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Vibrio cholerae, a natural inhabitant of the marine environment, is capable of evolving from a strictly environmental to a pathogenic lifestyle. Upon this transition, the bacterium may cause the severe diarrheal disease cholera. To cause disease, ingested V. cholerae must survive a number of host defenses. Similarly, within the marine, V. cholerae is subject to various ecological pressures; these pressures may prompt the bacterium to develop adaptations that increase their survival in the environment as well as in response to host defenses. In the marine, V. cholerae can be found in different fractions: in sediment, in association with cyanobacteria, or in water. It is possible that different pressures found in each of these fractions may lead to specific host-associated phenotypes that increase the potential of V. cholerae to emerge as a pathogen. V. cholerae that do evolve into pathogens comprise a phylogenetically confined subset within the species that encode allelic variations of core genes, such as ompU, that confer virulence adaptations. In this study, we examined whether environmental V. cholerae isolated from different marine fractions exhibit distinct host-associated phenotypes and encode virulence associated alleles. We found that V. cholerae we isolated from different marine fractions did not show differences among the host-associated phenotypes tested, nor did fraction appear to select for and enrich a given virulence associated allele. Nevertheless, this study provides insight on the role of environmental conditions on the pathogenic potential of environmental V. cholerae.

Healthcare-Associated Infections (HAIs) continue to be an epidemiological issue burdening patients and public health systems worldwide. The purpose of this study was to determine if specific healthcare facility types (Acute Care Hospitals, Long Term Acute Care Hospitals, and Inpatient Rehabilitation Facilities) were associated with particular categories of HAIs: Ventilator-Associated Pneumonias (VAPs), Central Line-Associated Bloodstream Infections (CLABSIs), and Catheter-Associated Urinary Tract Infections (CAUTIs). The theoretical framework for this study was the environmental determinants of infectious disease framework. A single research question focused on whether an association existed among the specified health care facility types and HAIs. Three independent categorical variables were used, including Acute Care Hospitals, Long Term Acute Care Hospitals, and Inpatient Rehabilitation Facilities, and 3 dependent variables were used, comprising of VAPs, CAUTIs, and CLABSIs. A quantitative design engaged the chi-square test of association, using a 2012 population-level report of archival data collected by the Centers for Disease Control and Prevention's National Healthcare Safety Network. Seven groups of HAIs and facility types were tested, and the results revealed that 6 groups had statistically significant differences. This study may contribute to positive social change by helping to identify whether healthcare facility types are associated with HAIs and to supply evidence to stakeholders to support standardization of best practices across all facility types, thus contributing to the reduction of HAIs in the United States.

Bakgrund: På intensivvårdsavdelningar finns olika rutiner kring huruvida endotrakealtubens position hos intuberade skall skiftas eller bibehållas i samma mungipa, då sidbyten kan leda till allvarliga komplikationer. Rutinen vid CIVA har varit att byta endotrakealtubens position på alla intuberade patienter en gång per dygn. Varken rutinen med skifte samt bibehållen position har utvärderats. Syftet med studien är att undersöka oralt intuberade patienters munhälsa vid bibehållen position av endotrakealtub under vårdtiden. Metod: Studien är en kvantitativ deskriptiv tvärsnittsstudie. Ett protokoll utformades för att undersöka hur stor andel av patienterna som får tryckskador i munnen med bibehållen tublägesposition. Resultat: Av totalt 85 oralt intuberade patienter utvecklade 10 rodnad och 7 sår medan 68 hade helt intakt slemhinna. Flest nyupptäckta sår uppkom efter 3-4 dagars intubering medan rodnader var jämnt fördelat. Slutsats: Endast ett fåtal patienter utvecklade tryckskador. Rutinen att bibehålla endotrakealtuben i samma position lämpar sig på patientkategorin på CIVA eftersom medelvårdtiden för intuberade är 3,2 dagar och flertalet extuberas under de 3 första dagarna. Klinisk betydelse: Studien ligger till grund för CIVA:s ändrade rutin att bibehålla endotrakealtubspositionen i samma mungipa och skulle på sikt kunna bidra till att minska samhällskostnaderna genom att reducera förekomsten av VAP och därmed patientvårdtiden / Background: Intensive care units have different routines whether the endotracheal tube position should be shifted or maintained in the same corner of the mouth. Repositioning of the tube can lead to serious complications. The routine at CIVA has been to change the endotracheal tube position in all intubated patients once per day. None of the routines have been evaluated. The objective of this study is to examine the oral health of intubated patients with maintained tube position. Method: The study is a quantitative descriptive cross-sectional study. A protocol was designed to examine the proportion of patients receiving pressure sores in the mouth. Results: Of a total of 85 orally intubated patients, 10 developed redness and 7 wounds while 68 had intact mucosa. The majority of the newly discovered sores occurred after 3-4 days of intubation. Conclusion: Only a few patients developed pressure sores. The routine to maintain the endotracheal tube in the same position is suitable for the patient category at CIVA since the average length of stay for intubated is 3.2 days and the majority were extubated during the first 3 days . Clinical significance: This study is the basis for CIVA's changed routine to maintain the endotracheal tube position in the same corner of the mouth and could eventually help to reduce the costs for society by reducing the incidence of VAP and thus patient care period.

Background: Ventilator-associated pneumonia is a major cause of morbidity and mortality for patients in an intensive care unit. Once present, ventilator-associated pneumonia is known to increase the duration of mechanical ventilation, time in the intensive care unit, and length of hospital stay. Patients with acquired brain injury are commonly admitted to the intensive care unit and considered to be at a high risk for the development of respiratory complications such as ventilator-associated pneumonia, which could potentially impact on the intensive care unit costs and outcomes. Respiratory physiotherapy is often provided to prevent and/or treat ventilator-associated pneumonia in patients with acquired brain injury. The theoretical rationale of the respiratory physiotherapy is to improve airway clearance and enhance ventilation which may reduce the incidence of pulmonary infections and thus ventilator-associated pneumonia, and may in turn decrease the duration of mechanical ventilation, prevent the need for tracheostomy and hence result in reduced costs and shorter hospital stay. Although respiratory physiotherapy may be beneficial in reversing or preventing ventilator-associated pneumonia, to date there are no data concerning the effectiveness of respiratory physiotherapy in patients with acquired brain injury. Hence from an evidence-based perspective, at present there is no justification for the role of respiratory physiotherapy in the management of patients with acquired brain injury in the intensive care unit. Aim: This two-part, prospective randomised controlled trial aimed to investigate the effect of regular prophylactic respiratory physiotherapy on the incidence of ventilator-associated pneumonia, duration of mechanical ventilation, and length of intensive care unit stay in adults with acquired brain injury, as compared to a control group (Part A). / The second part of the study (Part B) randomised those subjects from Part A who developed a ventilatorassociated pneumonia into a treatment or control group to establish if the provision of a regimen of regular respiratory physiotherapy influenced the outcome of ventilator-associated pneumonia. Additionally, this study also aimed to provide the first description of the financial costs of respiratory physiotherapy time in providing interventions to patients with acquired brain injury in the intensive care unit and investigated the cost effectiveness of respiratory physiotherapy interventions in decreasing the incidence of ventilator-associated pneumonia, duration of mechanical ventilation and length of intensive care unit stay. Subjects: 144 adult patients with acquired brain injury admitted with a Glasgow Coma Scale of nine or less, requiring intracranial pressure monitoring, and invasive ventilatory support for greater than 24 hours, were randomised to a treatment group or a control group. Methods: For subjects randomised to the treatment groups, the regimen of respiratory physiotherapy treatment was repeated six times per 24-hour period and continued until the subject was weaned from mechanical ventilatory support. Each respiratory physiotherapy intervention of 30 minute duration comprised a regimen of positioning, manual hyperinflation and suctioning. In both Parts A and B, the control group received standard nursing and medical care but no respiratory physiotherapy interventions. Results: Consent was obtained for 144 subjects, with 72 randomised for treatment in Part A. Part A groups were comparable with respect to demographic variables, with the exception of body mass index and gender distribution. / Using intention to treat philosophy, there were no significant differences for incidence of ventilator-associated pneumonia [Treatment Group 14/72 (19.4%) vs. Control 19/72 (26.4%); p = 0.32], duration of mechanical ventilation (hr) [172.8 vs. 206.3); p = 0.18], or length of intensive care unit stay (hr) [224.2 vs. 256.4; p = 0.22]. For subjects with acquired brain injury receiving this prophylactic regimen of respiratory physiotherapy in the intensive care unit, in an attempt to prevent ventilator-associated pneumonia, the cost of physiotherapy was $487 per subject. Comparatively the intensive care unit mechanical ventilation bed day cost was $33,380 per subject. The cost of Part A respiratory physiotherapy time for Treatment Group 1 was 1.7 per cent of the cost of subject's intensive care unit mechanical ventilation bed days. Thirty-three subjects (22.9%) from Part A developed ventilator-associated pneumonia, and were transferred to Part B and re-randomised, 17 to the Treatment Group 3. Part B groups were comparable with respect to demographic variables. No significant differences were detected in the dependent variables for Part B of the study, with similar duration of mechanical ventilation (hr) [342.0 vs. 351.0); p = 0. 89], and length of ICU stay (hr) [384.7 vs. 397.9; p = 0.84] noted. In those subjects with acquired brain injury in whom ventilator-associated pneumonia developed, the regimen of respiratory physiotherapy for the remaining duration of mechanical ventilation following diagnosis of ventilator-associated pneumonia costed an average of $788. Comparatively the intensive care unit bed day cost for the period of mechanical ventilation was $43,865. The cost of Part B respiratory physiotherapy time for Treatment Group 3 was 1.8 per cent of the cost of their intensive care unit mechanical ventilation bed days. / Subjects with a ventilator-associated pneumonia were significantly younger, were admitted with a lower Glasgow coma scale, and more likely to have been admitted with a chest injury than subjects without a ventilator-associated pneumonia. Duration of mechanical ventilation and length of intensive care unit stay were significantly increased in subjects with ventilatorassociated pneumonia, but length of hospital stay was not significantly different. Significant differences in the costs of respiratory physiotherapy and intensive care unit mechanical ventilation bed day costs were evident between those subjects with ventilator-associated pneumonia as compared to those without ventilator-associated pneumonia. For subjects with ventilator-associated pneumonia, the respiratory physiotherapy time cost was $1,029 per subject, compared to $510 for subjects without ventilator-associated pneumonia. The intensive care unit mechanical ventilation bed day cost for subjects with ventilator-associated pneumonia was $61,092 per subject, and $25,142 for those without a ventilator-associated pneumonia, giving an incremental health cost of $35,950 per episode of ventilatorassociated pneumonia. No significant differences were evident in the cost of respiratory physiotherapy as a per cent of the cost of their intensive care unit mechanical ventilation bed days, with findings of 1.4 per cent in those with ventilator-associated pneumonia and 1.1 per cent in those without ventilator-associated pneumonia. / Conclusion: Use of a regular prophylactic respiratory physiotherapy regimen comprising of positioning, manual hyperinflation and suctioning, in addition to routine medical and nursing care, did not appear to prevent ventilator-associated pneumonia, reduce length of ventilation or intensive care unit stay in adults with acquired brain injury. Furthermore, in those acquired brain injury subjects with ventilator-associated pneumonia, regular respiratory physiotherapy did not appear to expedite recovery in terms of reducing length of ventilation or intensive care unit stay. It can be concluded from the findings of this study that the presence of ventilator-associated pneumonia has a significant influence on morbidity and costs in subjects with acquired brain injury. Whilst statistically significant results were not found with clinical variables, it is suggested that the provision of a prophylactic respiratory physiotherapy regimen costing $487 per subject is a worthwhile investment in attempts to avoid the incremental health cost of $35,950 per episode of ventilator-associated pneumonia. In subjects with ventilator-associated pneumonia it is concluded that the cost of respiratory physiotherapy would not appear to be justified in attempts to reduce the duration of mechanical ventilation.

Syftet med litteraturstudien var att beskriva förebyggande omvårdnadsåtgärder vid ventilatorassocierad pneumoni (VAP), vilket är en form av pneumoni som är sjukhusförärvad och relaterad till att patienten är intuberad, så kallad nosokomial infektion. Längre vårdtid, ökad kostnad samt mortalitet ses vid VAP. Resultatet som framkom var att personal ska ha god handhygien vilket var en av viktigaste åtgärden för att förebygga VAP. Andra förebyggande omvårdnadsåtgärder är att vårdpersonal ska hjälpa patienten som vårdas i respirator med munvården och använda hjälpmedel för detta. Personal ska även hjälpa patienten med lämplig höjning på huvudgärden då detta också minskar riken för VAP, även sugning och befuktning av luftvägar är en åtgärd som patienten behöver hjälp med.

SAMMANFATTNING Munvård är en förutsättning för optimal munhälsa och en viktig indikator för den vård en patient får. En välfungerande munvård har stor betydelse för patienter som vårdas på en intensivvårdsavdelning vid kritisk sjukdom. Intensivvårdspatienterna, speciellt de intuberade, har särskilda behov när det gäller munhygien. Ett av dessa speciella behov är att minska risken för infektion. Munfloran hos friska individer håller sig stabil över tiden, men förändras snabbt vid kritisk sjukdom och sjukhusinläggning till att bli en mer virulent bakterieflora i munhålan. Den förändringen inkluderar kolonisering av respiratoriska patogener i munnen och oropharynx som kan orsaka ventilatorassocierad pneumoni (VAP). Kritiskt sjuka patienters munhälsa kan riskeras på en intensivvårdsavdelning (IVA) av själva intensivvårdsutrustningen, intensivvårdspatientens medicinska tillstånd eller behandlingar och patientens oförmåga att ta hand om sin egen munvård. Detta visar behovet av ansträngningar i form av ökad kunskap om effekten av munvårdsåtgärder som kan förbygga VAP hos intensivvårds-patienten. Syftet är att belysa effekten av munvårdsåtgärder för att förebygga ventilatorassocierad pneumoni (VAP) hos intensivvårdspatienten. Den här systematiska litteraturstudien bygger på randomiserade kontrollerade studier (RKS) med systematisk sökning, urval, granskning och analys av data inhämtade från databaserna PubMed och CINAHL. De munvårdsåtgärder som visade sig ha förebyggande effekt på VAP var manuell tandborstning med barntandborste och tandläkarvård i kombination med klorhexidinmunsköljning i två olika koncentrationer, manuell tandborstning med låg-antibakteriell gel, manuell tandborstning med barn- och interdentaltandborste kombinerad med klorhexidin, elektrisk tandborstning med klorhexidin och elektrisk och manuell tandborstning i kombination med renat vatten. De munvårdsåtgärder som kan tillämpas för att förebygga VAP hos intensivvårdspatienter behöver inte vara omfattande eller tidskrävande. Billiga redskap som manuella tandborstar kan vara lika effektiva som elektriska tandborstar och kan kombineras med lättillgängliga medel som klorhexidin och förebygga VAP. Själva munvårdsåtgärderna bör vara i proportion till munnens status och behov av munvård.

Intensivvårdspatienter som vårdas i respirator riskerar att utveckla ventilatorassocierad pneumoni (VAP) vilket är en vårdrelaterad infektion. För att minska risken utförs munvård regelbundet och det är vanligt att patienterna får munvårdsmedel med klorhexidin för att reducera bakterietillväxten i munnen. Klorhexidin är dock smärtsamt för patienterna och kan öka mortaliteten. Syftet var att undersöka om regelbunden munvård med oral klorhexidinlösning jämfört med annan munvård förebygger uppkomst av VAP hos patienter inom intensivvården som vårdas i respirator. Metoden som användes var systematisk litteraturstudie med kvantitativ ansats. Databaserna Cinahl, Medline, Scopus och Web of Science genomsöktes och genererade 13 artiklar med RCT-design för inklusion. Fyra studier undersökte vuxen population och tre undersökte pediatrisk population med placebokontrollerad studiedesign. Övriga munvårdsmetoder som jämfördes med klorhexidin var tandborstning (n=1), ozoniserat vatten (n=2), miswakpinnar (n=1), munskölj med persica (n=1) och kryddnejlika (n=1). Tre studier påvisade evidens för att oral klorhexidin reducerar risken att patienter utvecklar VAP. Klorhexidin var enbart överlägset tandborstning. Ozoniserat vatten och munskölj med kryddnejlikaextrakt förhindrade VAP mer effektivt än klorhexidin. Evidensen för att munvård med klorhexidin förhindrar VAP bedömdes som låg. På grund av de risker och lidande klorhexidin föranleder patienten bör det omvärderas huruvida klorhexidin ska ingå i munvårdsrutiner inom intensivvården. Ozoniserat vatten eller munskölj med kryddnejlikaextrakt kan eventuellt ersätta klorhexidin, men behöver studeras vidare. Munvård inom intensivvården bör främst utföras för patientens munhälsa eftersom evidensen för att munvård effektivt förebygger VAP är svag.

Patients who require mechanical ventilation (MV) are at risk for developing ventilator associated pneumonia (VAP). Nurses’ adherence to sedation vacations (SVs) has a direct impact on the development of VAP, because SVs have been shown to reduce patients’ average duration of MV and length of stay (LOS) in the intensive care unit (ICU). The purposes of this study guided by Donabedian’s (1966) model were to quantify nurses’ level of adherence to SVs, in relation to the health outcomes of critically ill patients, and identify the barriers and facilitators to performing SVs. A correlational design was used. The design included three components: abstraction of patient data from the electronic medical record (EMR) (n=79 with VAP and n=79 without VAP), administration of surveys to ICU nurses (N =34), and vignettes related to SVs. Analyses included descriptive statistics, t-tests, correlations, and analyses of covariance. Most nurses held a Bachelors degree (70.6%), had < 9 years of ICU experience (52.9%), worked in a medical ICU (47.1%), and reported high confidence in managing SVs (M =8.88, SD =1.25). The majority of patients (N =158) were Black (58.2%), males (56.3%), and on average middle-aged (M =61.5, SD =14.91), with a long ICU LOS (M =15.5, SD =11.84), extended duration of MV (M =9.5, SD =8.47), and high acuity (APACHE III) (M =70.2, SD =25.42). The nurses’ education, advanced certification, and ICU experience were not associated with the appropriate implementation of SVs in the vignettes. On average nurses’ had low scores on the vignettes (M =6.97, SD =2.21; possible range =0-14). The adherence rate of nurses’ implementation of SVs, determined using EMR data, was also low (M =24%; SD =23%). There were higher rates of SV adherence in patients without VAP (p (p < .01), and a duration of MV < 6 days (p =.04). These findings indicate that even with established protocols, nurses may not consistently implement the evidenced-based interventions that have been shown to prevent nosocomial infections. Future research is needed to improve nursing practice and the quality of care in this patient population.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This study evaluated molecular characteristic of Rhodococcus equi isolates obtained from horses and standardized by PCR multiplex assay, which amplifies the vap gene family (vapA, B, C, D, E, F, G e H). One hundred eighty Rhodococcus equi isolates from different sources: healthy horse s feces (112), soil (12), stalls (23) and clinical isolates (33) of horsebreeding farms, were studied. The technique was standardized and confirmed by sequencing of amplified vap gene family controls. Thirty-two (17.8%) R. equi isolates evaluated were positive for vapA gene and carried at least three another vap genes associated. All 147 isolates from equine feces, stalls and soil from horse-breeding farms did not demonstrate any virulence-associated proteins genes. Thirty-two (97.0%) out of 33 clinical equines isolates were positive to multiplex PCR assay for vap gene family and demonstrated six molecular profile, 100% with vapA, vapD and vapG genes, 86.6% vapF, 76,6% vapH, 43.3% vapC, 36.6% vapE and none vapB. The most frequent molecular profile was vap A, D, F, G and H present in 37.5% of strains. Morever, there was no molecular epidemiological pattern for R. equi isolates from each horse-breeding farm studied. Thus this technique allows the identification of eight vap genes family (vapA, B, C, D, E, F, G e H), it is a practical an efficient method of conducting clinical and epidemiological studies on R. equi isolates. / O presente estudo tem por objetivo a caracterização molecular de isolados de Rhodococcus equi de eqüinos pela padronização de uma técnica de PCR multiplex para detecção dos genes da família vap (vapA, B, C, D, E, F, G e H). Foram analisadas 180 amostras de Rhodococcus equi de diferentes origens: fezes (112), solo (12) instalações (23) e isolados clínicos (33). A técnica foi padronizada e confirmada pelo sequenciamento da cepa padrão de R. equi (ATCC 33701), e de uma amostra de paciente humano contendo o gene vapB. Trinta e dois (17,8%) foram positivos para vapA e carregavam no mínimo 4 genes vap associados. Os 147 isolados oriundos de fezes, instalações e sola não apresentavam genes vap. Trinta e dois (97.0%) dos isolados clinicos foram positivos na PCR multiplex e demonstraram seis padrões moleculares, 100% com vapA, vapD and vapG, 86.6% vapF, 76,6% vapH, 43.3% vapC, 36.6% vapE e nenhum com vapB. O perfil molecular mais freqüente foi vap A, D, F, G eH presente em 37.5% das cepas. foram obtidos, sendo que os genes vapA, vapD e vapG estavam presentes em todas as amostras. Não foi obtido nenhum padrão molecular para cada propriedade estudada. Esta nova técnica constitui-se um método prático e eficaz para condução de estudos clínicos e epidemiológicos, bem como, por relevar os aspectos moleculares da infecção.