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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Comparison between the Clinical Pulmonary Infection Score and Modified Centre for Disease Control Criteria for Diagnosis of Ventilator-associated Pneumonia: A Cross-sectional Study
Correspondence Address :
Sumit Roy Tapadar,
12/10, Bireswar Dhole Lane, Kolkata-700035, West Bengal, India.
E-mail: sumittapadar@gmail.com
Introduction: Ventilator-Associated Pneumonia (VAP) is a frequent complication of Mechanical Ventilation (MV). The incidence of VAP is not precisely known and ranges from 13 to 51 per 1,000 ventilator days. A uniform surveillance definition for VAP is not available. The Centre for Disease Control (CDC)/ National Healthcare Safety Network (NHSN) and the Clinical Pulmonary Infection Score (CPIS) algorithms are widely used.
Aim: To compare the modified CDC criteria and the CPIS algorithm for VAP.
Materials and Methods: A cross-sectional study was conducted at the respiratory care unit of the Department of Respiratory Medicine at RG Kar Medical College and Hospital in Kolkata, West Bengal, India, over a period of 18 months, from January 2021 to June 2022. A total of 60 adult patients on MV for more than 48 hours, with a high index of suspicion for VAP, clinically and radiologically, were included in this study. The microbiological (bacteriological quantitative culture) and radiological profiles {CXR parenchymal opacities, Ultrasonography (USG) and Contrast-Enhanced Computed Tomography (CECT) thorax} of VAP infections were assessed and compared. Statistical analysis was conducted after entering the data into a Microsoft Excel spreadsheet.
Results: Among the 60 patients, most were male (76.67%) and aged between 51 and 60 years (40%). A total of 48 (80%) patients had a positive CPIS score, while 42 (70%) had positive modified CDC criteria. A fair degree of concordance was found between the two algorithms. Pseudomonas was the most common organism identified in both early and late-onset VAP. Among all antibiotics, Polymyxin B was found to be sensitive to all the organisms.
Conclusion: The VAP is the most frequent infection associated with Intensive Care Unit (ICU) admissions. Polymicrobial aetiology and MDR strains were found in a significant number of cases. In the present study, the CPIS criteria demonstrated a fair concordance with the modified CDC criteria and slightly better sensitivity than the modified CDC criteria in diagnosing VAP.
Intensive care unit infection, Lung infection score, Pseudomonas
The VAP impacts 10-20% of patients requiring MV and nearly doubles the risk of mortality in critically ill patients (1). Consequently, the prevention and early diagnosis of VAP have emerged as high priorities. However, the prevention of VAP is hindered by challenges related to its definitions and diagnosis. In particular, surveillance definitions for VAP pose significant problems due to interobserver variability and a lack of specificity and sensitivity (2). There is no gold standard for the surveillance of VAP, but the most widely used method is the CDC/NHSN algorithm, which facilitates clinical and microbiological diagnosis of VAP (3). However, this algorithm is also prone to interobserver variability.
The CPIS is another useful tool with an easy scoring system but requires microbiological data that may not be immediately available (4). There is a lack of sufficient data comparing the CDC and CPIS algorithms, particularly from India. This absence of updated national studies is creating a knowledge gap in the prevention and treatment of VAP. The present study aimed to evaluate the degree of agreement between the modified CDC criteria and the CPIS criteria. Additionally, the microbiological (bacteriological quantitative culture) and radiological profiles (CXR parenchymal opacities, USG and CECT thorax) of VAP infections were assessed and compared.
A cross-sectional study was conducted in the respiratory care unit of the Department of Respiratory Medicine at RG Kar Medical College and Hospital in Kolkata, West Bengal, India, over a period of 18 months, from January 2021 to June 2022. After obtaining approval from the review committee and the Institutional Ethics Committee (IEC No. RKC/344, Date: 15.02.2021), patients admitted to the respiratory care unit who fulfilled the inclusion criteria were considered for the study.
Sample size calculation: The sample size was calculated to be 60, based on a prevalence of VAP of 25% (5). The sample size calculation was carried out with the assistance of a statistician.
Inclusion criteria: All patients who had been mechanically ventilated for more than 48 hours and those in whom VAP was clinically suspected were included.
Exclusion criteria: Patients who had pneumonia before or within 48 hours of intubation, patients below 18 years of age and patients unwilling to provide consent were excluded.
Study Procedure
Early VAP is defined as an infection occurring within four days of hospitalisation and MV, while late VAP is designated for infections that occur five days or more post-admission (6). Respiratory failure is conventionally defined by an arterial oxygen tension (PaO2) of <8.0 kPa (60 mmHg), an arterial carbon dioxide tension (PaCO2) of >6.0 kPa (45 mmHg), or both. Additionally, failure of oxygenation is classified as hypoxaemic (Type 1) and failure of ventilation is defined as hypercapnic (Type 2) (7).
History taking and clinical examinations were performed, followed by laboratory investigations including chest X-ray (Table/Fig 1),(Table/Fig 2),(Table/Fig 3),(Table/Fig 4),(Table/Fig 5), Arterial Blood Gas (ABG) analysis, thoracic USG, contrast-enhanced CT scan of the thorax, endotracheal aspirates and fibreoptic bronchoscopy with bronchoalveolar lavage as required. Culture sensitivity tests of the collected specimens were conducted.
Evaluation was carried out using the modified CDC criteria (8),(9), which include assessments like chest X-ray results, total leucocyte count, fever and clinical parameters like mental status, respiratory secretions, oxygenation status, respiratory rate and the presence of rhonchi and crepitations. The CPIS criteria (6), which encompass temperature, chest X-ray, total leucocyte count, respiratory secretion (including quantity, nature and bacteriology) and oxygenation, were applied in all cases. The concordance between the two criteria was then estimated.
Statistical Analysis
Statistical analysis was conducted after entering the data into a Microsoft Excel spreadsheet. Quantitative variables were expressed as mean±SD. A p-value of <0.05 was considered statistically significant. Confounding factors were addressed using appropriate methods of adjustment. The correlation between the CDC and CPIS algorithms was measured using Cohen’s Kappa statistic (κ). κ is a robust tool for measuring observational correlation, accounting for variation due to chance. The standard error for κ was calculated using the original equation developed by Cohen (10). A κ value of <0.20 indicates poor agreement, 0.21-0.40 indicates fair agreement, 0.41-0.60 indicates moderate agreement and values of 0.61-0.80 and 0.81-1.00 indicate very good agreement (11).
A total of 60 patients were included in the study, with a predominance of males and the most common age group was 51-60 years. Regarding co-morbidities, the majority of patients had chronic Obstructive Airway Disease (OAD) (68%), while 45% had Diabetes Mellitus (DM) and hypertension (Table/Fig 6).
Most patients experienced early onset VAP and leucocytosis was most common in those with late onset VAP (Table/Fig 7). Type 2 respiratory failure was observed in 51.7% of patients, with mean ages of >60 for both females (60.3%) and males (62%) (Table/Fig 8).
Among the 60 patients, 51 had chest X-ray infiltrates, of which 42 exhibited new purulent sputum or a change in sputum character, along with worsening symptoms. Consequently, 42 patients (70%) had positive modified CDC criteria (Table/Fig 9). Elderly patients predominated according to the modified CDC criteria, accounting for 71.5% of the age group 51-70 years (Table/Fig 10).
According to the CPIS, most patients were male (72.9%) (Table/Fig 11). Late onset VAP was more common according to both the CDC and CPIS algorithms, with patients exceeding 50%. The CPIS demonstrated better sensitivity compared to the modified CDC criteria, at 80% versus 70%. There was a fair degree of agreement between the CPIS and modified CDC criteria, with Cohen’s k 0.34 (Table/Fig 12).
The most commonly identified organisms were Pseudomonas i.e., 16 (26.6%) isolates, closely followed by Acinetobacter and Klebsiella, with a similar distribution in both early and late onset VAP cases (Table/Fig 13).
Regarding antibiotic susceptibility, Pseudomonas aeruginosa exhibited 100% resistance to amoxiclav, ceftazidime and vancomycin but showed significant sensitivity to Polymyxin B (93.8%) (12), piperacillin-tazobactam (87.5%) (13) and meropenem (81.3%) (14). Acinetobacter baumannii was also 100% resistant to amoxiclav, ceftazidime, vancomycin and cotrimoxazole, but demonstrated sensitivity to Polymyxin B (91.7%) (11), amikacin (83.3%) (10) and imipenem (75%) (6). Among all antibiotics tested, Polymyxin B was found to be effective against all the organisms (Table/Fig 14).
Suspicion and clinical criteria continue to serve as the foundation for VAP diagnosis, however, the criteria used for diagnosis vary widely (15). Historically, the diagnosis of VAP has relied on two or three components: 1) systemic signs of infection; 2) new or worsening infiltrates observed on chest imaging; and 3) microbiological evidence of pulmonary parenchymal infection when available (11). Various diagnostic algorithms have been proposed to standardise the diagnosis, but discrepancies remain regarding which one is the most effective.
In the present study, the most common age group was 51-60 years (40%), with a predominant male gender (76.67%). In the study conducted by Dey A and Indira B the most affected age group for VAP was found to be 46-60 years (14). Similarly, in the study by Apostolopoulou E et al., 71% of patients were male and 29% were female (13).
Risk factors like diabetes mellitus and oxygenation status were studied. In the present study, 45% of patients had diabetes, with a higher proportion of male patients. Martins M et al., found the burden of diabetes to be around 35.5% (12). Additionally, 68% of patients in our study had a history of obstructive airway disease and Type 2 respiratory failure was more prevalent (51.7%). The mean age for males with Type 2 failure was 62 years, while for females it was 60.3 years. Thus, elderly patients with a history of obstructive airway disease predominated, with a significant number of them being diabetic. In this study, 51.66% (n=31) experienced early onset VAP, whereas 48.33% (n=29) had late onset VAP. Golia S et al., reported that out of 52 VAP cases in a tertiary care hospital in India, 23 (44.23%) were early onset and 29 (55.77%) were late onset (16).
Regarding organisms identified in the present study, the most common were Pseudomonas aeruginosa and Acinetobacter baumannii (both 25.81%) in cases of early onset VAP. For late onset VAP, the predominant organisms were Pseudomonas aeruginosa (24.14%) and Klebsiella pneumoniae (20.69%). Similar results were noted in a study by Dey A and Indira B conducted in Manipal, where the most common organism causing both early and late onset VAP was Acinetobacter (48.94%), followed by Pseudomonas aeruginosa (25.53%) (14). ESKAPE organisms (Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas and Enterobacter spp.) accounted for 80% of VAP episodes, according to a study conducted by Joseph NM et al., in a tertiary care hospital in India (17).
In the present study, 48 (80%) of patients were positive for VAP according to CPIS criteria, compared to 42 (70%) as per the modified CDC criteria (17). In a study by Safdar N et al., in the USA, out of 73 ventilated patients, 36 (49.31%) met CDC criteria for VAP; 35 (47.94%) were classified as high likelihood for the original CPIS, while 14 (19.17%) were high likelihood for the modified CPIS (11). A study from JIPMER, Puducherry, India, conducted by Gunalan A et al., showed that 93 (34.1%) of patients had VAP according to CPIS criteria, compared to 33 (12.1%) as per NHSN/CDC criteria (18). Safdar N et al., found that the original CPIS exhibited a high degree of concordance with CDC criteria, with Cohen’s kappa statistic of 0.81 (11). The modified CPIS showed a fair to moderate concordance with kof 0.39. Patients who met CDC criteria had a mean CPIS score of 7.9 and a mean modified CPIS score of 6.3. Rahimbashar F et al., from Iran showed that using Hospital in Europe Link for Infection Control through Surveillance (HELICS) as the reference standard, the sensitivity and specificity for each of the assessed diagnostic algorithms were as follows: CDC/NHSN (sensitivity 54.2%; specificity 100%) and CPIS (sensitivity 68.75%; specificity 95.23%) (15). The present study indicated a fair degree of agreement between the CPIS and modified CDC criteria, with Cohen’s kappa value of 0.34. The CPIS criteria showed a sensitivity of 80%, while the modified CDC had a sensitivity of 70%. The mean CPIS score in patients diagnosed according to the CDC criteria was 7.7.
In the present study, the production of Extended-Spectrum Beta-Lactamases (ESBL) and Metallo-Beta-Lactamases (MBL) was observed quite commonly in infections caused by Pseudomonas, Acinetobacter and Klebsiella. Ahmed W et al., from Pakistan elucidated that Klebsiella pneumoniae was 100% resistant to piperacillin, vancomycin and meropenem (19). A study by Sarkar MD et al., from Bangladesh revealed that Acinetobacter baumannii was 30% sensitive to tigecycline (20).
Limitation(s)
The present study employed a cross-sectional design and there was no provision for blinding. The study was conducted during the Coronavirus Disease 2019 (COVID-19) pandemic, which posed certain limitations.
Polymicrobial aetiology and MDR strains were found in a significant number of cases. Late onset VAP was more common according to both the CDC and CPIS. ESBL producing MDR organisms, such as Pseudomonas aeruginosa and Acinetobacter, were the most prevalent. The CPIS criteria demonstrated good concordance with the modified CDC criteria and slightly better sensitivity than the modified CDC criteria in diagnosing VAP.
DOI: 10.7860/JCDR/2025/74334.21103
Date of Submission: Aug 05, 2024
Date of Peer Review: Oct 10, 2024
Date of Acceptance: Jan 29, 2025
Date of Publishing: Jun 01, 2025
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 07, 2024
• Manual Googling: Jan 25, 2025
• iThenticate Software: Jan 27, 2025 (15%)
ETYMOLOGY: Author Origin
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