Shah, Aditya

Extracorporeal membrane oxygenation (ECMO) provides life support for severe respiratory and cardiac failure, including failure from severe infection such as sepsis and acute respiratory distress syndrome. Additionally, ECMO-acquired infections are frequent and associated with prolonged hospitalization, increased healthcare utilization, and higher mortality. This review summarizes current evidence regarding the epidemiology, pathophysiology, diagnosis, prevention, and management of infectious adverse events during ECMO. Future work should aim to refine ECMO-related infectious adverse event definitions, improve harmonized multicenter data collection, and to invest in high-quality, well-designed studies.

In this retrospective cohort study at a quaternary referral hospital, 829 adult patients supported by extracorporeal membrane oxygenation (ECMO) between January 1, 2014, and October 31, 2024, were screened for ventilator-associated pneumonia (VAP). The incidence of VAP in ECMO-supported patients was 17.7 per 1,000 ECMO days (venoarterial [VA] ECMO, 22.1 per 1,000 ECMO days; venovenous [VV] ECMO, 13.8 per 1,000 ECMO days). Median time from ECMO cannulation to diagnosis of VAP was 4 (interquartile range [IQR], 3–8; range 1–84) days. Gram-negative bacteria comprised most respiratory pathogens. A significant increase in minimum ECMO sweep was noted from 2 days before to 1 day after VAP diagnosis (0.79 L/min increase, p = 0.004). Only 38 of 153 patients (24.8%) met National Healthcare Safety Network (NHSN) VAP definitions. After creating a modified VAP definition, which included an ECMO sweep increase of 0.5 L/min as evidence of worsening respiratory status, 78 (51.0%) met the modified definition. Those who met the modified VAP definition had worse in-hospital (60.3% vs. 28.0%, p < 0.001), 30 day (33.3% vs. 17.3%, p = 0.023), and 90 day (53.8% vs. 25.3%, p < 0.001) mortality compared with those who did not meet the modified VAP definition. The incorporation of ECMO parameters into diagnostic criteria may improve detection sensitivity, but further validation is necessary before implementation.

Background Chlorhexidine is commonly used in prevention bundles for ventilator-associated pneumonia. Results for use of chlorhexidine in critically ill patients requiring mechanical ventilation via an endotracheal tube are mixed, and data for patients using a tracheostomy are lacking. Objectives To assess the risk for ventilator-associated pneumonia according to chlorhexidine exposure in patients requiring a new tracheostomy for mechanical ventilation. Methods This single-center, retrospective cohort study compared the development of ventilator-associated pneumonia according to chlorhexidine exposure in adult intensive care unit patients requiring new tracheostomy at a large academic medical center. Adults who received a new tracheostomy and required ventilator support for at least 48 hours were included. Patients treated for pneumonia at the time of tracheostomy or who met additional exclusion criteria were excluded. Results Of 235 patients who met the inclusion criteria, 203 received chlorhexidine and 32 did not. The cohort was predominantly White, male, and admitted to a surgical intensive care unit. Incidence of ventilator-associated pneumonia did not differ significantly between patients exposed or not to chlorhexidine (by 30 days, 32.5% vs 35.7%, P = .87). Time to development of ventilator-associated pneumonia also did not differ significantly between patients exposed or not (9 vs 12 days, respectively, P = .34). Conclusions Chlorhexidine exposure was not associated with a difference in the incidence of or time to ventilator-associated pneumonia after new tracheostomy. Further study is needed on the role of chlorhexidine in preventing ventilator-associated pneumonia after a new tracheostomy.

Background: Candidemia is a serious complication after gastrointestinal (GI) perforation and/or ischemia, yet most evidence pools candidemia with intra-abdominal candidiasis (IAC). We sought candidemia-specific risk factors after GI perforation and/or ischemia and evaluated associated outcomes. Methods: We conducted a single-center, retrospective matched case–control study of adults undergoing emergency surgical procedure for GI perforation and/or ischemia and admitted to a surgical intensive care unit. Cases with candidemia during index admission were matched 4:1 to controls by age, Charlson Comorbidity Index, and surgical procedure year. Conditional logistic regression assessed pre-specified risk factors, and exploratory outcomes included mortality, length of stay, and days on invasive ventilation. Results: Twenty-four cases were matched to 99 controls. Factors identified to be independently associated with candidemia include the presence of IAC (adjusted OR [aOR]: 5.51, 95% CI: 1.61, 18.89; p = 0.007), upper GI injury (aOR: 4.28, 95% CI: 1.52–12.08; p = 0.006), and diffuse intra-abdominal contamination, compared with contained/none (aOR: 3.21, 95% CI: 1.06–9.74; p = 0.040). Among candidemia cases, species distribution was Candida albicans 41.7%, C. glabrata 33.3%, C. parapsilosis 12.5%, with single cases of C. tropicalis, C. krusei , and C. dubliniensis . Candidemia was associated with a longer hospital length of stay (+13.97 d; 95% CI: 0.90–27.04; p = 0.036), without significant differences in ICU stay, duration of invasive ventilation, or mortality. Conclusions: After GI perforation and/or ischemia, the risk of candidemia is highest in patients with upper GI injury and diffuse contamination, independent of IAC. These readily identifiable operative features may guide targeted surveillance and selective early antifungal strategies. Prospective validation is warranted.