Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models

Nguilé-Makao, Molière; Zahar, Jean‐Ralph; Français, Adrien; Tabah, Alexis; Garrouste-Orgeas, Maïté; Allaouchiche, Bernard; Goldgran-Tolédano, Dany; Azoulay, Élie; Adrie, Christophe; Jamali, Samir; Clec’h, Christophe; Souweine, Bertrand; Timsit, Jean‐François

doi:10.1007/s00134-010-1824-6

Cited by 170 publications

(115 citation statements)

References 35 publications

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“…However, in an unselected ICU population, it has been suggested that late-onset pneumonia and not early-onset pneumonia can be associated with excessive mortality. 27,31,32 The SAPS II score, serum lactatemia, and vasopressor requirements on ICU admission were significantly higher in patients who developed E-HAP. They also required immediate postoperative mechanical ventilation exceeding 2 days more frequently.…”

Section: Discussionmentioning

confidence: 99%

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Weiss¹,

Dahmani²,

Bert³

et al. 2010

Liver Transpl

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Early-onset hospital-acquired pneumonia (E-HAP) is one of the leading causes of sepsis and mortality after liver transplantation (LT). The appropriate antimicrobial therapy is crucially important for surviving sepsis in this context. The aim of this study was to analyze microbiological findings, associated factors, and optimal antibiotic regimens for E-HAP after LT. Patients demonstrating E-HAP in a single-center cohort of 148 LT recipients were prospectively detected. The diagnosis of pneumonia relied on a combination of supportive clinical findings and a positive culture of a lower respiratory tract sample. E-HAP was considered present if pneumonia occurred within 6 days of intensive care unit (ICU) admission after LT. Twenty-three patients (15.5%) developed E-HAP, which were caused by 36 pathogens (61.1% were gram-negative bacilli, and 33.3% were classified as hospital-acquired). For patients who developed E-HAP, the duration of mechanical ventilation and the ICU stay were significantly longer. Despite a trend toward higher mortality at any time in the E-HAP group, there was no significant difference in mortality between patients with E-HAP and patients without E-HAP. Lactatemia, vasopressor requirements, Simplified Acute Physiology Score II (SAPS II) score on ICU admission, and mechanical ventilation lasting more than 48 hours after LT were associated with E-HAP. Combinations of broad-spectrum b-lactams and aminoglycosides were active against more than 91% of the encountered pathogens. However, antibiotic de-escalation was possible in more than one-third of cases after identification of the pathogens. In conclusion, E-HAP after LT is a severe condition that appears to be influenced by physiological derangements induced by the surgery, such as lactatemia, vasopressor requirements, and mechanical ventilation requirements, as well as the postoperative SAPS II score. At the time of treatment initiation, an antimicrobial regimen usually proposed for late-onset pneumonia should be followed. Orthotopic liver transplantation (LT) is a widely accepted treatment for patients with end-stage liver disease. Despite global improvements in survival over the last few decades, sepsis remains the leading cause of early postoperative mortality. 1,2 Lower respiratory tract infections are a major concern in this context.

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Section: Discussionmentioning

confidence: 99%

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Weiss¹,

Dahmani²,

Bert³

et al. 2010

Liver Transpl

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“…Subsequent analyses that attempted to match subjects with VAP to similar subjects without VAP, to adjust for important comorbidities, and/or to employ novel statistical strategies to overcome these sources of bias generated much lower estimates of the attributable mortality of VAP. [10][11][12] Furthermore, if VAP is only responsible for a small fraction of ICU mortality, this begs the question of whether focusing quality improvement efforts on VAP detection and prevention alone is the best way to improve outcomes for ventilated populations. 13 What about all of the other common and morbid conditions that can develop in ventilated patients, such as ARDS, pulmonary edema, severe sepsis, thromboembolic disease, and others?…”

Section: Limitations Of Vap As a Quality Metric For Ventilated Patientsmentioning

confidence: 99%

Should Ventilator-Associated Events become a Quality Indicator for ICUs?

Klompas,

Berra

2016

Respir Care

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in 2013. Controversy abounds as to whether VAE definitions are potentially suitable to serve as quality indicators for ICUs. On the pro side, VAE definitions overcome many of the weaknesses of traditional VAP surveillance. VAE definitions are objective, reproducible, electronically computable, and strongly predict poor outcomes for patients. There is an increasing amount of data on clinical correlates, risk factors, and approaches to prevent VAEs. Potential strategies to prevent VAEs are highly aligned with accepted best practices in critical care. VAE surveillance therefore has the potential to catalyze better care and to help hospitals track outcomes in ventilated patients more rigorously and more efficiently. On the con side, the complete VAE definition set with subtiers is complicated, neither sensitive nor specific for VAP, non-physiological compared with other ICU metrics, susceptible to gaming, and may bring about changes in clinician behavior that could paradoxically end up harming patients.

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“…The originality of the present study lies in the description of OD/F over the entire ICU course using a score developed for that purpose [12]. Thus, it differs from recent studies on severity of sepsis or VAP that measured SOFA score [18], a new score called VAP-PIRO [19], or the LOD score [20] from the day of infection. In our study, we found that delta SOFA related to ICUAP explained only 10.3% of the SOFAmax which was by far lower than the contribution of SOFApreICUAP (the sum of SOFA-D1 and deltapreICUAP), which accounted for 87.5% of SOFAmax (Fig.…”

Section: Discussionmentioning

confidence: 99%

Severity of ICU-acquired pneumonia according to infectious microorganisms

et al. 2011

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Purpose: To assess the severity of intensive care unit (ICU)-acquired pneumonia (ICUAP) according to the bacteria involved, classified into seven groups: thirdgeneration cephalosporin-resistant non-fermenting Gram-negative bacilli (resistant C3NF); sensitive C3NF; methicillin-resistant Staphylococcus aureus; methicillin-sensitive Staphylococcus aureus; extended-spectrum beta-lactamase-producing Enterobacteriaceae; Enterobacteriaceae not producing extended-spectrum betalactamase; Haemophilus influenzae and Streptococcus pneumoniae. Methods: Over a 4-year period, sequential organ failure assessment (SOFA) score was prospectively measured daily in 453 adult patients with ICUAP. ICUAP severity was evaluated by the severity of sepsis and by the occurrence of new organ dysfunctions or failures (OD/F) during ICUAP. Results: Septic shock occurred in 21% of all cases of ICUAP. The occurrence of new OD/F during ICUAP was similar regardless of the identified microorganism.These new OD/F represented less than 11% of SOFAmax, defined as the sum of all OD/F occurring at any time during the ICU stay. There was a significant association between SOFApreICUAP, defined as the sum of all the OD/F occurring before ICUAP, and ICUAP severity. In the multivariate analysis, the type of bacteria was not a risk factor (RF) for occurrence of septic shock and mortality. Age and SOFApreICUAP were RF for the sepsis severity. The ICUAP severity was an RF for ICU mortality. Conclusions: ICUAP was responsible for a minor proportion of OD/F occurring during the ICU stay. Severity of ICUAP was related to clinical status prior to ICUAP, but not to the type of bacteria. ICU mortality depended on the severity of ICUAP.

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Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models

Cited by 170 publications

References 35 publications

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Should Ventilator-Associated Events become a Quality Indicator for ICUs?

Severity of ICU-acquired pneumonia according to infectious microorganisms

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