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Review
. 2020 Dec;46(12):2168-2183.
doi: 10.1007/s00134-020-06292-z. Epub 2020 Nov 11.

Pulmonary infections complicating ARDS

Charles-Edouard Luyt  1   2 , Lila Bouadma  3   4 , Andrew Conway Morris  5   6 , Jayesh A Dhanani  7   8 , Marin Kollef  9 , Jeffrey Lipman  7   8 , Ignacio Martin-Loeches  10   11 , Saad Nseir  12   13 , Otavio T Ranzani  14   15 , Antoine Roquilly  16   17 , Matthieu Schmidt  18   19 , Antoni Torres  20 , Jean-François Timsit  3   4
Affiliations
Review

Pulmonary infections complicating ARDS

Charles-Edouard Luyt et al. Intensive Care Med. 2020 Dec.

Abstract

Pulmonary infection is one of the main complications occurring in patients suffering from acute respiratory distress syndrome (ARDS). Besides traditional risk factors, dysregulation of lung immune defenses and microbiota may play an important role in ARDS patients. Prone positioning does not seem to be associated with a higher risk of pulmonary infection. Although bacteria associated with ventilator-associated pneumonia (VAP) in ARDS patients are similar to those in patients without ARDS, atypical pathogens (Aspergillus, herpes simplex virus and cytomegalovirus) may also be responsible for infection in ARDS patients. Diagnosing pulmonary infection in ARDS patients is challenging, and requires a combination of clinical, biological and microbiological criteria. The role of modern tools (e.g., molecular methods, metagenomic sequencing, etc.) remains to be evaluated in this setting. One of the challenges of antimicrobial treatment is antibiotics diffusion into the lungs. Although targeted delivery of antibiotics using nebulization may be interesting, their place in ARDS patients remains to be explored. The use of extracorporeal membrane oxygenation in the most severe patients is associated with a high rate of infection and raises several challenges, diagnostic issues and pharmacokinetics/pharmacodynamics changes being at the top. Prevention of pulmonary infection is a key issue in ARDS patients, but there is no specific measure for these high-risk patients. Reinforcing preventive measures using bundles seems to be the best option.

Keywords: Acute respiratory distress syndrome; Microbiota; Nebulization; Prevention; Ventilator-associated pneumonia.

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Conflict of interest statement

C-EL reports personal fees from Merck Sharp and Dohme, Thermo Fisher Brahms, Biomérieux, Carmat, Bayer Healthcare, Aerogen and grants from Bayer Healthcare, outside the scope of the submitted work. ACM is supported by a Clinical Research Career Development Fellowship from the Wellcome Trust (WT 2055214/Z/16/Z). MK is supported by the Barnes-Jewish Hospital Foundation. IM-L received lecture fees from Gilead and Merck. SN reports personal fees from Merck Sharp and Dohme, Gilead, Pfizer, Biomérieux, and Bio Rad, outside the scope of the submitted work. OTR declares no competing interests. He is funded through a Sara Borrell grant from the Instituto de Salud Carlos III (CD19/00110). MS reports lecture fees from Maquet, Getinge and Fresenius, outside the scope of the submitted work. AT reports personal fees from Arsanis, Aridis, Bayer, Roche, Polyphor, GSK and Pfizer outside the submitted work. J-FT declares participation in adboard for MSD, Pfizer, Gilead, Paratek, Bayer, Medimune, and Nabriva; lectures for MSD, Pfizer, Biomerieux and research grants to his research team from MSD, Pfizer, Thermofisher, outside the submitted work. J-FT is the PI of academic research project MULTICAP (PHRC N 16-0595 NCT 03452826) on molecular methods for diagnosing severe pneumonia and is PI of an academic research comparing antimicrobial regimens in severe sepsis (BICCS PHRC-N 18-0316 not yet recruiting), both outside the submitted work. Other authors declare that they have no conflicts of interest to declare in relation with the current manuscript.

Figures

Fig. 1
Fig. 1
Mechanisms which lead to altered microbiota in lungs and hence infection. ETT endotracheal tube, TNF tumor necrosis factor, IL interleukin
Fig. 2
Fig. 2
Mechanisms for the relationship between hyperoxia and ventilator-associated pneumonia. VAP ventilator-associated pneumonia, HALI hyperoxic acute lung injury
Fig. 3
Fig. 3
Graphical representation of the combined assessment of clinical, radiological, and laboratory evaluation of host response and microbiological data for the diagnosis of pneumonia as a proxy for histopathological examination
Fig. 4
Fig. 4
Annual Epidemiological Report for 2016 Healthcare-associated infections in intensive care units [https://www.ecdc.europa.eu/sites/default/files/documents/AER_for_2016-HAI_0.pdf (accessed 21 February 2020)] and the PROSEVA Trial [4]. Bar graphs depicting the percentages of the most frequently isolated microorganisms in ICU-acquired pneumonia episodes for 2016 (red bars) and for patients with acute respiratory distress syndrome (ARDS) (blue bars). Total number of isolates 16, 869 and 112, respectively
Fig. 5
Fig. 5
Venn diagram showing the relationship and overlap for ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT) with acute respiratory distress syndrome (ARDS). Respiratory microbiome dysbiosis is also demonstrated as a prerequisite for most cases of VAP and VT
Fig. 6
Fig. 6
Prevention of pulmonary infections in ARDS patients: from highly recommended preventive measures to a cautious or even a not recommended use
See this image and copyright information in PMC

References

    1. Thompson BT, Chambers RC, Liu KD. Acute respiratory distress syndrome. N Engl J Med. 2017;377:562–572. doi: 10.1056/NEJMra1608077. - DOI - PubMed
    1. Magill SS, O’Leary E, Janelle SJ, et al. Changes in prevalence of health care-associated infections in US Hospitals. N Engl J Med. 2018;379:1732–1744. doi: 10.1056/NEJMoa1801550. - DOI - PMC - PubMed
    1. Forel J-M, Voillet F, Pulina D, et al. Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy. Crit Care. 2012;16:R65. doi: 10.1186/cc11312. - DOI - PMC - PubMed
    1. Ayzac L, Girard R, Baboi L, et al. Ventilator-associated pneumonia in ARDS patients: the impact of prone positioning. A secondary analysis of the PROSEVA trial. Intensive Care Med. 2016;42:871–878. doi: 10.1007/s00134-015-4167-5. - DOI - PubMed
    1. Papazian L, Klompas M, Luyt C-E. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med. 2020 doi: 10.1007/s00134-020-05980-0. - DOI - PMC - PubMed

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