Can optimal management prevent mortality in ventilator-associated pneumonia?

Impact of ventilator-associated pneumonia in patients with severe head injury

BACKGROUND

The impact of ventilator-associated pneumonia (VAP) on outcome seems to vary depending on the critically ill patients we analyze. Our objective, therefore, has been to evaluate the influence of VAP on the mortality and morbidity in patients with severe head injury (Glasgow Coma Scale score </= 8).

METHODS

A prospective, matched, case-control study was conducted in our intensive care unit (ICU) for a 3-year period (1998-2000). Seventy-two patients with severe head injury (HI) who developed VAP were matched with 72 patients with severe HI without VAP. The matching criteria were as follows: age (+/- 5 years); category of HI based on computed tomographic scanning; Acute Physiology and Chronic Health Evaluation II (+/- 4 points) score; Injury Severity Score (+/- 4 points); and duration of mechanical ventilation. VAP was diagnosed on the basis of quantitative microbiologic criteria.

RESULTS

Mortality did not differ significantly between cases and matched control subjects (15 [20.8%] vs. 11 [15.3%], p = 0.54). However, patients with VAP had a significantly longer duration of mechanical ventilation (median, 14 vs. 10 days; p = 0.015) and ICU stay (median, 21 vs. 15.5 days; p = 0.008). The occurrence of multiple organ failure was also significantly more frequent among the case group (33.3% vs. 12.5%, p = 0.004) during the overall ICU stay.

CONCLUSION

VAP does not seem to be associated with a significantly increased risk of death in patients with severe HI, but it may be associated with greater morbidity during the ICU stay.

Impact of ventilator-associated pneumonia on outcome in patients with COPD

PURPOSES

The aim of this study was to determine the impact of ventilator-associated pneumonia (VAP) on outcome in patients with COPD.

METHODS

Prospective, observational, case-control study conducted in a 30-bed ICU during a 5-year period. All COPD patients who required intubation and mechanical ventilation (MV) for > 48 h were eligible. VAP diagnosis was based on clinical, radiographic, and quantitative microbiologic criteria. Patients with unconfirmed VAP were excluded, as well as patients with ventilator-associated tracheobronchitis without subsequent VAP. Matching (1:1) criteria included MV duration before VAP occurrence, age +/- 5 years, simplified acute physiology score II on ICU admission +/- 5, and ICU admission category. Variables associated with ICU mortality were determined using univariate and multivariate analyses.

RESULTS

A total of 1,241 patients were eligible; 181 patients (14%) were excluded, including 133 patients for VAT and 48 patients for unconfirmed VAP. VAP developed in 77 patients (6%), and all were successfully matched. Pseudomonas aeruginosa was the most frequently isolated bacteria (31%). ICU mortality rate (64% vs 28%), duration of MV (24 +/- 15 d vs 13 +/- 11 d [+/- SD]), and ICU stay (26 +/- 17 d vs 15 +/- 13 d) were significantly (< 0.001) higher in case patients than in control patients. VAP was the only variable independently associated with ICU mortality (odds ratio [OR], 7.7; 95% confidence interval [CI], 3.2 to 18.6; p < 0.001). In VAP patients who received corticosteroids during their ICU stay compared with those who did not receive corticosteroids, mortality rate (50% vs 82%; OR, 1.8; 95% CI, 1.2 to 2.7; p = 0.002), duration of MV (21 +/- 14 d vs 27 +/- 16 d, p = 0.043), and ICU stay (22 +/- 16 d vs 31 +/- 18 d, p = 0.006) were significantly lower.

CONCLUSION

VAP is associated with increased mortality rates and longer duration of MV and ICU stay in COPD patients.