RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES by b7CWM77

VIEWS: 4 PAGES: 7

									    RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE
                         KARNATAKA



     PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION



1.Name of the Candidate and Address :

       DR. SHAIK MOHAMMED USMAN
       #88, 2ND MAIN, 9TH A CROSS,
       KENGERI SATELLITE TOWN,
       BANGALORE-60



2.Name of Institution :

       KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES,
       BANGALORE-560070.
.


3.Course of the study and subject :

        M.D. MICROBIOLOGY



4.Date of admission to the course :

       3rd MAY 2010



5.Title of the Dissertation :

       Characterization and antibiogram of aerobic bacterial isolates using
       quantitative endotracheal aspirate culture as a means for microbiological
       confirmation in the diagnosis of ventilator associated pneumonia.
6.    BRIEF RESUME OF THE INTENDED WORK



6.1   NEED FOR THE STUDY
      Ventilator associated pneumonia(VAP) is the most common ICU infection and the
risk of pneumonia in mechanically ventilated patients increases by 6 to 20 folds1.Rapid
diagnosis and initiation of appropriate antimicrobial agent is of immense importance, as
many studies have correlated this delay with rise in mortality. Frequency of specific
bacterial pathogens causing VAP may vary by hospital, patient population, and changes over
time, emphasizing the need for timely local surveillance data. Bronchoscopy and BAL, being
invasive, are not uncommonly associated with complications, this has paved the way for less
invasive and less expensive tests with almost equivalent results such as endotracheal
aspiration(ETA) and quantitative ETA cultures with a threshold of 10 5 or more cfu/ml,
considered optimal for microbiological confirmation of VAP2.




6.2 REVIEW OF LITERATURE
       Ventilator associated pneumonia (VAP), an important form of hospital acquired
pneumonia refers to pneumonia developing in a mechanically ventilated patient more
than 48 hrs after tracheal intubation or tracheostomy. It has been categorized as early
onset VAP, occurring within 96 hrs of mechanical ventilation and late onset VAP,
occurring after 96 hrs of mechanical ventilation. This helps in predicting the implicated
pathogens and guides us in the initial empiric therapy. The attributable mortality of VAP,
the most common and lethal form of nosocomial pneumonia, is in the range of 6 to 14%3.




MICROBIOLOGY
       VAP may be caused by a spectrum of bacterial pathogens which may be
polymicrobial and rarely due to anaerobic bacteria, viruses or fungi. Common pathogens
include aerobic Gram negative bacilli such as Psuedomonas aeruginosa, Acinetobacter
species, Escherichia coli and Klebsiella pneumoniae (are the common agents of late onset
VAP), while Early onset VAP is commonly caused by Streptococcus pneumoniae,
Haemophilus influenzae and Methicillin sensitive Staphylococcus aureus1.
EPIDEMIOLOGY
         Intubation with mechanical ventilation is the strongest risk factor for nosocomial
pneumonia. Nosocomial pneumonia accounts for 9-27% in all intubated-mechanically
ventilated patients1. VAP is associated with crude mortality rate of 20-70%. In some studies
the incidence increases with duration of mechanical ventilation (7% at 10 days and 19% at 20
days) 4, but others have proved that the risk is more during the early period (risk increases by
3%/day during 5-10 days of ventilation and after 10 days it increases by 1% each day) 5.Data
from the Asian countries suggest an incidence varying from 3.5 to 46 per 1000 ventilator
days6. In an Indian study Nosocomial pneumonia in ICUs was found to have a 9% incidence
using radiological and microbiological criteria7. The incidence of Nososcomial pneumonia in
the ICU ranges from 9 to 24% in our country7. In a recent PGI Chandigarh study, VAP was
found to be 30.7% per 1000 ventilator days. Trivedi et al7 reported an incidence of 9.38% of
Nosocomial pneumonia and 38% had VAP which was associated with total mortality of
21.3%.




PATHOGENESIS
    Major sources of infection are the health care devices, environment, and health care
provider8. The organism/s may gain access to the lungs through many routes, out of which
microaspiration of oropharyngeal secretions is the most common. Aspiration of gastric
secretions (especially after antacids), hematogenous spread, exogenous penetration after
direct inoculation (pleural space) are the other causes.




6.3 OBJECTIVE OF THE STUDY
        Confirmation of VAP by quantitative ETA cultures and identification of bacterial
         pathogen.
        Evaluating the antimicrobial susceptibility of the pathogens isolated and helping the
         clinicians to choose appropriate antibiotics, thereby avoiding the injudicious use of
         antibiotics.
        To provide a local data of VAP associated bacterial pathogens.
7. MATERIALS AND METHODS


7.1 SOURCE OF DATA
         A prospective study done enrolling patients(as per inclusion criteria), from the
multidisciplinary ICUs of our tertiary care hospital(KIMS).
PERIOD OF STUDY: 1 year 6 months
SAMPLE SIZE: approximately 100


INCLUSION CRITERIA
      Intubated patients(irrespective of age) who are mechanically ventilated for more than
       48 hrs, with a clinical suspicion of pneumonia (CDC/ACCP criteria) which is new,
       progressive or persistent(>24 hrs) radiographic infiltrate on chest radiograph with one
       of the following: fever >380c, leukocytosis(>12000/mm3)or leukopenia(<4000/mm3)
       and/or purulent tracheobronchial secretions.


EXCLUSION CRITERIA :
      Patients with pre existing pneumonia.
      Patients who refuse the consent.


SAMPLE DESIGN
       Purposive sampling.


METHODOLOGY
       The data for the study will be collected from all those who fulfill the inclusion and
exclusion criteria by purposive sampling.


STATISTICAL ANALYSIS
       Data collected will be analyzed statistically by computing percentage, mean and
standard deviation. Appropriate tests will be employed for categorical, parametric or non
parametric data. Wherever necessary the results will be depicted in the form of graphs and
percentages.
7.2 METHOD OF COLLECTION OF DATA


SPECIMEN COLLECTION
       Endotracheal aspirates will be collected under aseptic precautions using sterile
   suction catheters and containers.
       .
PROCEDURE
       Endotracheal aspirate will be subjected to Gram staining(microscopy); inoculation
   on blood agar, chocolate agar, MacConkey agar (after dilution to 1 in 100 or 1 in 1000)
   and then incubation at 370c upto 72hrs and cfu/ml will be calculated.


   The grown pathogen will be characterised by colony morphology, Gram staining, and
biochemical tests. Antibiotic sensitivity testing will be done on Mueller Hinton Agar plates
by Kirby-Bauer’s disc diffusion method.


7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS
TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?IF
SO,PLEASE DISCRIBE BRIEFLY.
     The study involves investigating endotracheal aspirate, as a part of their routine
diagnostic workup. The study does not involve animal experiments.


7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITTION IN CASE OF 7.3?
      Yes.




8. LIST OF REFERENCES (ABOUT 4-6)
   1) Chastre J, Fagon JY. Ventilator associated pneumonia. Am J Respir Crit Care Med
       2002; 165:867-903.
   2) Jourdain B, Novara A, Joly-Guillou ML, Dombret MC, Calvat S, Trouillet JL, et al.
       Role of quantitative cultures of endotracheal aspirates in the diagnosis of Nosocomial
       pneumonia. Am J Respir Crit Care Med 1995; 152:241-6.
   3) Robert A Weinstein, Hospital acquired infections. Harrisons principles of internal
       medicine, 16th edition; 116:777
  4)    Fagon JY, Chastre J. Nosocomial pneumonia in text book of critical care. 4 th ed.
       WB Saunders Co; 2000. P.1572-98.
  5) Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, et al. Incidence and
       risk factors for ventilator associated pneumonia in critically ill patients. Ann Intern
       Med 1998; 129:433-40.
  6) Rakshit P, Nagar VS, Deshpande AK. Incidence, clinical outcome, and risk
       stratification of VAP, a prospective cohort study. Indian J crit care medicine,2005;
       9(4): 211-216.
  7) Trivdi TH, Shejala SB, Yeolekar ME. Nosocomial pneumonia for medical ICU. J
       Assoc Physicians India 2000;48: 1070-3.


  8) Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Healthcare Infection
       Control Practises Advisory Committee, Centers for Disease Control and Prevention.
       MMWR Recomm Rep 2004; 53(RR-3): 1-36.




9. SIGNATURE OF CANDIDATE              :


10. REMARKS OF GUIDE                   :




11. NAME AND DESIGNATION OF
  (In block letters)
   11.1 GUIDE                           : DR. PRATIBHA MALINI. J,
                                           PROFESSOR,
                                           DEPARTMENT OF MICROBIOLOGY,
                                           KEMPEGOWDA INSTITUTE OF MEDICAL
                                           SCIENCES, BENGALURU.
       SIGNATURE                       :
   11.2 CO GUIDE           : DR. K. C. CHANNAPPA,
                               ASSOCIATE PROFESSOR,
                               DEPARTMENT OF MEDICINE,
                               KEMPEGOWDA INSTITUTE OF MEDICAL
                               SCIENCES, BENGALURU.
     SIGNATURE             :




   11.3 HEAD OF DEPARTMENT : DR.K.L.RAVIKUMAR,
                               PROFESSOR& HEAD,
                               DEPARTMENT OF MICROBIOLOGY,
                               KEMPEGOWDA INSTITUTE OF MEDICAL
                               SCIENCES, BENGALURU.
     SIGNATURE             :




12. REMARKS OF CHAIRMAN AND PRINCIPAL:




     SIGNATURE                               :

								
To top