Respective impact of implementation of prevention strategies, colonization with multiresistant bacteria and antimicrobial use on the risk of early- and late-onset VAP: An analysis of the OUTCOMEREA network

Abstract

RationaleThe impact of prevention strategies and risk factors for early-onset (EOP) versus late-onset (LOP) ventilator-associated pneumonia (VAP) are still debated.ObjectivesTo evaluate, in a multicenter cohort, the risk factors for EOP and LOP, as the evolution of prevention strategies.Methods7,784 patients with mechanical ventilation (MV) for at least 48 hours were selected into the multicenter prospective OUTCOMEREA database (1997–2016). VAP occurring between the 3rd and 6th day of MV defined EOP, while those occurring after defined LOPs. We used a Fine and Gray subdistribution model to take the successful extubation into account as a competing event.Measurements and main resultsOverall, 1,234 included patients developed VAP (EOP: 445 (36%); LOP: 789 (64%)). Male gender was a risk factor for both EOP and LOP. Factors specifically associated with EOP were admission for respiratory distress, previous colonization with multidrug-resistant Pseudomonas aeruginosa, chest tube and enteral feeding within the first 2 days of MV. Antimicrobials administrated within the first 2 days of MV were all protective of EOP. ICU admission for COPD exacerbation or pneumonia were early risk factors for LOP, while imidazole and vancomycin use within the first 2 days of MV were protective factors. Late risk factors (between the 3rd and the 6th day of MV) were the intra-hospital transport, PAO2-FIO2<200 mmHg, vasopressor use, and known colonization with methicillin-resistant Staphylococcus aureus. Among the antimicrobials administered between the 3rd and the 6th day, fluoroquinolones were the solely protective one.Contrarily to LOP, the risk of EOP decreased across the study time periods, concomitantly with an increase in the compliance with bundle of prevention measures.ConclusionVAP risk factors are mostly different according to the pneumonia time of onset, which should lead to differentiated prevention strategies.

Impact of bronchial colonization with Candida spp. on the risk of bacterial ventilator-associated pneumonia in the ICU: the FUNGIBACT prospective cohort study

“…E1). The VAP prevention policy was similar between ICUs and is described elsewhere [23]. Subglottic aspiration was not used as routine practice.…”

Good practices for preventing ventilator-associated pneumonia in the emergency department

“…Peptic ulcer prophylaxis was the most performed measure in this study in 85.2% of the observations. Studies have found the non-use (24) and adhesions to this measure between 56.0% (19) and 100% (22) . This measure can be challenged in practice, since the risks and benefits of its application to the patient should be weighed.…”

“…This finding corroborates national studies in which the VAP prevalence was 23.2% (14) and 31.8% (15) . International studies have shown that VAP incidence varies from 8.0% to 25.0%, reaching 31.0% in the United States (19)(20) . The difference in these findings can be attributed to the diagnostic criteria for VAP, which may under or overestimate this condition (21) .…”

Non-Pharmacological Interventions to Prevent Ventilator-Associated Pneumonia: A Literature Review

“…[14][15][16] Whereas VAP bundles appear effective in reducing early-onset VAP (occurring within 5-7 d), late-onset VAP seems associated with patient severity and is thus more difficult to prevent. 17 The occurrence of VAP has been associated with several pathophysiological mechanisms, but a simplified paradigm is based on the presence of pathogens penetrating the lungs from within the ETT and around the ETT cuff, mainly from the digestive tract. 18 Preventive measures are usually based on the reduction of pathogen burden from one or both of the two reservoirs.…”