Internally coated endotracheal tubes with silver sulfadiazine in polyurethane to prevent bacterial colonization: a clinical trial

Berra, Lorenzo; Kolobow, Theodor; Laquerrière, Patrice; Pitts, Betsey; Bramati, Simone; Pohlmann, Joshua R.; Marelli, Chiara; Panzeri, Miriam; Brambillasca, Pietro; Villa, Federico; Baccarelli, Andrea; Bouthors, Sylvie; Stelfox, Henry T.; Bigatello, Luca M.; Moss, Joel; Pesenti, Antonio

doi:10.1007/s00134-008-1100-1

Cited by 62 publications

(52 citation statements)

References 33 publications

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“…This could explain the difference of thickness between the measurements in our study (500 or 2.5 m) and between the thickness described in precedent studies. 17,30,31,33 Indeed, we demonstrate that a part of biofilm still covers ETT despite rinsing.…”

Section: Discussionmentioning

confidence: 61%

“…11 Berra and co-workers 15,30 studied ETT biofilm from animals ventilated for 24 h, and found 750 m of thickness using electron microscopy and 65 m with confocal microscopy. In a clinical trial using confocal microscopy, the same authors demonstrated an accumulation of biological material within the ETT, ranging from 0 to 700 m. 31 We Except for subject 21, the same microorganisms were found in both sites. observed a global covering of the internal side of the ETT with optical microscopy and AFM.…”

Section: Discussionmentioning

confidence: 63%

“…13 These results were confirmed experimentally with tubes covered with silver sulfadiazine and chlorhexidine, 13 or silver-coated ETT. 48 Berra et al 31 have concluded that silver-coated ETT in ICU patients decreased overall bacterial colonization. The North American Silver-Coated Endotracheal Tube (NASCENT) study included 2,003 subjects intubated with either a standard tube or a silver-coated ETT, 17 showing a decrease in the VAP rate from 7.5% to 4.8% without effect on mechanical ventilation duration or mortality.…”

Section: Discussionmentioning

confidence: 99%

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Description and Microbiology of Endotracheal Tube Biofilm in Mechanically Ventilated Subjects

Danin¹,

Girou²,

Legrand³

et al. 2014

Respir Care

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BACKGROUND: A biofilm is found on the inner side of endotracheal tubes (ETT) in mechanically ventilated patients, but its features and role in pneumonia remain unclear. METHODS: This prospective, observational, monocentric study included critically ill ventilated subjects. Measurement of the ETT inner volume was first performed before extubation using the acoustic reflection method. After extubation, the biofilm was studied by means of optical and atomic force microscopy. Bacteriological analysis was then performed and compared with clinical documentation. RESULTS: Twenty-four subjects were included. Duration of intubation lasted from 2 to 79 d (mean ؎ SD: 11 ؎ 15 d). The mean percentage of ETT volume loss evaluated in situ (n ‫؍‬ 21) was 7.1% and was not linked with the duration of intubation. Analyses with atomic force microscopy (n ‫؍‬ 6) showed a full coverage of the inner part of the tube with biofilm, even after saline rinse. Its thickness ranged from 0.8 to 5 m. Bacteriological cultures of the biofilm (n ‫؍‬ 22) often showed the same bacteria as in tracheal secretions, especially for pathogenic organisms. Pseudomonas aeruginosa and Candida albicans were among the most frequent microorganisms. In subjects who had experienced a successfully treated episode of ventilator-associated pneumonia (n ‫؍‬ 5), the responsible bacteria were still present in the biofilm. CONCLUSIONS: ETT biofilm is always present in intubated patients whatever the duration of intubation and appears quickly after intubation. Even after soft rinse, a small but measurable part of biofilm remains always present, and seems strongly adherent to the ETT lumen. It contains potentially pathogenic bacteria for the lung.

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Section: Discussionmentioning

confidence: 61%

Section: Discussionmentioning

confidence: 63%

Section: Discussionmentioning

confidence: 99%

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Description and Microbiology of Endotracheal Tube Biofilm in Mechanically Ventilated Subjects

Danin¹,

Girou²,

Legrand³

et al. 2014

Respir Care

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“…4 Several new ETT technologies have tested the incorporation of antibiotics into biomaterials, showing a possible decrease in lung colonization by pathogenic bacteria. [42][43][44][45][46][47] Although long-term use of antimicrobialimpregnated central venous catheters has shown no selection of bacterial resistance, 48 biofi lm formation has been associated with antibiotic-resistant pathogens and lack of antimicrobial penetrability into the biofi lm of the ETT. 41,49,50 Recently, an in vitro model evaluated the role of antimicrobial photodynamic therapy in the reduction of ETT biofi lm.…”

Section: Cuff Pressurementioning

confidence: 99%

“…45 Most recently, a large, randomized, multicenter study demonstrated a decrease in microbiologically proven VAP incidence in patients intubated with the silver-coated ETT, when compared with a standard ETT. 24 The study performed at 54 centers in the United States in 1,509 patients who required MV for more than 24 h showed a lower rate of microbiologically confi rmed VAP of 4.8% (37 of 766 patients) in the group randomized to the silver-coated ETT compared with 7.5% (56 of 743 patients) in the group randomized to an uncoated ETT ( P 5 .03, number needed to treat 5 37).…”

Section: Acknowledgmentsmentioning

confidence: 99%

Technologic Advances in Endotracheal Tubes for Prevention of Ventilator-Associated Pneumonia

Fernandez

Levine

Restrepo

2012

Chest

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231V entilator-associated pneumonia (VAP) is a common complication in patients on mechanical ventilation (MV). Depending on the surveillance methods used for the diagnosis of VAP, the risk of this complication ranges from 1.2 to 8.5 cases per 1,000 ventilatordays (0.6%-4%). 1 VAP is associated with increased hospital length of stay, mortality, infections due to multidrug-resistant pathogens, and an attributable hospital cost of approximately $10,000 to $25,000. 2,3 Therefore, preventive measures that could impact the incidence of VAP in the ICU setting must be considered a priority, because they could improve the safety of patients in the ICU. Multiple interventions are used to prevent VAP; however, there is a growing interest in those interventions related to the endotracheal tube (ETT) as one of the main targets linked to VAP. 2,4 An ETT tube is considered one of the major risk factors for VAP, acting both as a reservoir for potential infecting microorganisms and as a bridge between the oropharyngeal environment and the sterile bronchoalveolar space by bypassing host defenses. 5,6 Moreover, the ETT alters the ability of the host to clear secretions by coughing, and keeps the epiglottis open, allowing the passage of secretions and fluids into the airways.The two most important mechanisms implicated in the development of VAP are microaspiration and biofi lm formation. Microaspiration occurs when there is distal migration of microorganisms present in the secretions accumulated above the ETT cuff. 7 Biofi lm

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Silver-Coated Endotracheal Tubes and Patient Outcomes in Ventilator-Associated Pneumonia

Klompas

2008

JAMA

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1 concluded that silver-coated endotracheal tubes reduced the incidence of ventilatorassociated pneumonia (VAP) by 36% compared with uncoated tubes. The evidence they present, however, is more suggestive of an effect on endobronchial colonization than on clinically meaningful invasive disease.First, the authors defined VAP as 10 4 colony-forming units/mL or greater on quantitative culture of bronchoalveolar lavage (BAL) fluid. Although this definition has the advantage of being objective, it does not necessarily translate into histological VAP or clinically important disease. 2 The reported sensitivity of quantitative BAL culture is only 50% to 77% and the specificity is 58% to 95% relative to autopsy-confirmed VAP. 3,4 Second, 28 of 93 positive BALs (30%) yielded organisms that are typically considered nonpathogenic colonizers. These included coagulase-negative staphylococci, enterococci, yeast, and normal flora. Excluding these nonpathogenic organisms, 28 of 968 patients (2.9%) in the silver-coated endotracheal tube group developed VAP vs 37 of 964 patients (3.8%) in the uncoated endotracheal group. This difference is not statistically significant (P = .26 by Fisher exact test, SAS version 9.1; SAS Institute Inc, Cary, North Carolina). Limiting the analysis to patients ventilated for more than 24 hours yields a similar result (3.7% vs 5.0%; P=.25).Third, although the study was not specifically powered to assess differences in clinical outcomes, with 2003 enrolled patients nonstatistically significant but clinically meaningful differences might have been expected. However, there were no differences between patients receiving silvercoated and uncoated tubes in the proportion that aroused physician suspicion for VAP (26% vs 31%; P = .39) or who met a clinical definition of VAP (presence of radiographic infiltrate and Ն2 of abnormal white blood cell count, abnormal temperature, or purulent secretions; 53% vs 56%; P =.74). There were no differences in the important clinical parameters of duration of mechanical ventilation, length of stay in the intensive care unit (ICU), length of stay in hospital, or mortality.Introducing silver-coated endotracheal tubes into practice should require evidence of a clinically meaningful effect on patient outcomes. Consideration should also be given to the magnitude of the benefit, the kinds of patients who stand to benefit, and the cost of achieving benefit in comparison with other interventions. The NASCENT trial demonstrated that silver coating reduces colonization of the lower airway and therefore merits additional evaluation but does not provide evidence that silver coating benefits patients.

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Internally coated endotracheal tubes with silver sulfadiazine in polyurethane to prevent bacterial colonization: a clinical trial

Abstract: SSD-ETT can be safely used in preventing bacterial colonization and narrowing of the ETT in patients intubated for up to 24 h (mean intubation time 16 h).

Cited by 62 publications

References 33 publications

Description and Microbiology of Endotracheal Tube Biofilm in Mechanically Ventilated Subjects

Description and Microbiology of Endotracheal Tube Biofilm in Mechanically Ventilated Subjects

Technologic Advances in Endotracheal Tubes for Prevention of Ventilator-Associated Pneumonia

Silver-Coated Endotracheal Tubes and Patient Outcomes in Ventilator-Associated Pneumonia

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