The Severity of ICU-Acquired Pneumonia

Factors Associated with Mortality in Immunocompetent Patients with Hospital-acquired Pneumonia

Aim

The aim of the study is to determine the factors associated with 28-day mortality in immunocompetent patients with hospital-acquired pneumonia (HAP).

Methods

This was a 42-month retrospective cohort study in Chiang Kham Hospital. Patients with HAP diagnosed between January 2013 and June 2016 who did not have an immunocompromised status were recruited into the study.

Statistical Analysis Used

Univariable and multivariable binary logistic regression analyses were performed to determine the factors associated with mortality in patients with HAP.

Results

A total of 181 HAP patients. The most causative pathogens were nonfermenting Gram-negative bacilli. Fifty-two (28.7%) patients had died within 28 days after HAP diagnosis. Multivariable analysis demonstrated that mechanical ventilation (MV) dependency (adjusted odds ratio [OR] = 3.58, 95% confidence interval [CI] 1.53-8.37, P = 0.003), antibiotic duration (adjusted OR = 0.79, 95% CI 0.70-0.88, P < 0.001), acute kidney injury (adjusted OR = 5.93, 95% CI 1.29-27.22, P = 0.022), and hematologic diseases (adjusted OR = 11.45, 95% CI 1.61-81.50, P = 0.015) were the significant factors associated with 28-day mortality.

Conclusions

The factors associated with mortality were MV dependency, HAP duration of treatment, acute kidney injury, and hematologic disease. Early recognition of these factors in immunocompetent patients with HAP and treatment with intensive care may improve the outcome.

Prevention of ventilator-associated pneumonia and ventilator-associated conditions: a randomized controlled trial with subglottic secretion suctioning

OBJECTIVES

Ventilator-associated pneumonia diagnosis remains a debatable topic. New definitions of ventilator-associated conditions involving worsening oxygenation have been recently proposed to make surveillance of events possibly linked to ventilator-associated pneumonia as objective as possible. The objective of the study was to confirm the effect of subglottic secretion suctioning on ventilator-associated pneumonia prevalence and to assess its concomitant impact on ventilator-associated conditions and antibiotic use.

DESIGN

Randomized controlled clinical trial conducted in five ICUs of the same hospital.

PATIENTS

Three hundred fifty-two adult patients intubated with a tracheal tube allowing subglottic secretion suctioning were randomly assigned to undergo suctioning (n = 170, group 1) or not (n = 182, group 2).

MAIN RESULTS

During ventilation, microbiologically confirmed ventilator-associated pneumonia occurred in 15 patients (8.8%) of group 1 and 32 patients (17.6%) of group 2 (p = 0.018). In terms of ventilatory days, ventilator-associated pneumonia rates were 9.6 of 1,000 ventilatory days and 19.8 of 1,000 ventilatory days, respectively (p = 0.0076). Ventilator-associated condition prevalence was 21.8% in group 1 and 22.5% in group 2 (p = 0.84). Among the 47 patients with ventilator-associated pneumonia, 25 (58.2%) experienced a ventilator-associated condition. Neither length of ICU stay nor mortality differed between groups; only ventilator-associated condition was associated with increased mortality. The total number of antibiotic days was 1,696 in group 1, representing 61.6% of the 2,754 ICU days, and 1,965 in group 2, representing 68.5% of the 2,868 ICU days (p < 0.0001).

CONCLUSIONS

Subglottic secretion suctioning resulted in a significant reduction of ventilator-associated pneumonia prevalence associated with a significant decrease in antibiotic use. By contrast, ventilator-associated condition occurrence did not differ between groups and appeared more related to other medical features than ventilator-associated pneumonia.

Prognostic factors associated with mortality of drug-resistant Acinetobacter baumannii ventilator-associated pneumonia

Background

Ventilator-associated pneumonia (VAP) caused by drug-resistant Acinetobacter baumannii is associated with high mortality in critically ill patients. We identified the prognostic factors of 30-day mortality in patients with VAP caused by drug-resistant A. baumannii and compared survival outcomes among multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) A. baumannii VAP.

Methods

A retrospective cohort study was conducted in the Medical Intensive Care Unit at Chiang Mai University Hospital, Thailand. All adult patients diagnosed with A. baumannii VAP between 2005 and 2011 were eligible. Univariable and multivariable Cox’s proportional hazards regression were performed to identify the prognostic factors of 30-day mortality.

Results

A total of 337 patients with microbiologically confirmed A. baumannii VAP were included. The proportion of drug-sensitive (DS), MDR, XDR, and PDR A. baumannii were 9.8%, 21.4%, 65.3%, and 3.6%, respectively. The 30-day mortality rates were 21.2%, 31.9%, 56.8%, and 66.7%, respectively. The independent prognostic factors were SOFA score >5 (hazard ratio (HR) = 3.33, 95% confidence interval (CI) 1.94–5.72, P < 0.001), presence of septic shock (HR = 2.66, 95% CI 1.71–4.12, P < 0.001), Simplified Acute Physiology Score (SAPS) II >45 (HR = 1.58, 95% CI 1.01–2.46, P = 0.045), and inappropriate initial antibiotic treatment (HR = 1.53, 95% CI 1.08–2.20, P = 0.016).

Conclusions

Drug-resistant A. baumannii, particularly XDR and PDR, was associated with a high mortality rate. Septic shock, high SAPS II, high SOFA score, and inappropriate initial antibiotic treatment were independent prognostic factors for 30-day mortality.

Ventilator-associated pneumonia: epidemiology and prognostic indicators of 30-day mortality

We conducted a retrospective cohort study in the medical intensive care unit of Chaing Mai University Hospital to describe the epidemiology of ventilator-associated pneumonia (VAP) and identify prognostic indicators of 30-day VAP mortality. A total of 621 patients diagnosed with VAP between January 2005 and December 2011 were included. The overall 30-day mortality rate was 44.4%. The major causative pathogens were Acinetobacter baumannii (54.3%), Pseudomonas aeruginosa (35.2%), and methicillin-resistant Staphylococcus aureus (15.1%). Most A. baumannii (90.2%) comprised drug-resistant strains. Identified prognostic indicators were co-morbid malignancy (hazard ratio [HR] = 1.60; 95% confidence interval [CI] 1.02-2.42; P = 0.040), septic shock (HR = 2.51; 95% CI, 1.60-4.00; P < 0.001), Simplified Acute Physiology Score II >45 (HR = 1.62; 95% CI, 1.03-2.56; P = 0.041), Sequential Organ Failure Assessment score >5 (HR = 3.40; 95% CI 2.00-5.81; P < 0.001), and delayed inappropriate empirical antibiotic treatment (HR = 2.23; 95% CI, 1.12-4.45; P = 0.022). VAP was associated with high mortality. The major causative pathogen was drug-resistant A. baumannii. Therefore, early detection of VAP by surveillance in mechanically ventilated patients leading to earlier treatment may improve patient outcomes. Guidelines for prescribing appropriate empirical antibiotics to cover drug-resistant bacteria could be established using local epidemiological data.