COPD patients with ventilator-associated pneumonia: implications for management

Abstract

Data on the occurrence and outcome of patients with chronic obstructive pulmonary disease (COPD) and ventilator-associated pneumonia (VAP) are quite limited. The aim of this study was to determine if COPD intensive care unit (ICU) patients have a higher rate of VAP development, different microbiological aetiology or have worse outcomes than other patients without VAP. A secondary analysis of a large prospective, observational study conducted in 27 European ICUs was carried out. Trauma patients were excluded. Of 2082 intubated patients included in the study, 397 (19.1%) had COPD; 79 (19.9%) patients with COPD and 332 (19.7%) patients without COPD developed VAP. ICU mortality increased by 17% (p < 0.05) when COPD patients developed VAP, remaining an independent predictor of mortality [odds ratio (OR) 2.28; 95% confidence interval (CI) 1.35-3.87]. The development of VAP in COPD patients was associated with a median increase of 12 days in the duration of mechanical ventilation and >13 days in ICU stay (p < 0.05). Pseudomonas aeruginosa was more common in VAP when COPD was present (29.1% vs. 18.7%, p = 0.04) and was the most frequent isolate in COPD patients with early-onset VAP, with a frequency 2.5 times higher than in patients without early-onset VAP (33.3% vs. 13.3%, p = 0.03). COPD patients are not more predisposed to VAP than other ICU patients, but if COPD patients develop VAP, they have a worse outcome. Antibiotic coverage for non-fermenters needs to be included in the empiric therapy of all COPD patients, even in early-onset VAP.

Impact of Chronic Obstructive Pulmonary Disease on Incidence, Microbiology and Outcome of Ventilator-Associated Lower Respiratory Tract Infections

“…However, antibiotic treatment is well-known risk factor for late-onset ICU-acquired infections, and MDR bacteria emergence [22]. Our results contradict several earlier studies that identified COPD as an independent risk factor for VAP [7,8], but are in line with data from a recent retrospective analysis of a large prospective observational study conducted in 27 European ICUs and including 2082 intubated patients, which reported a similar 20% incidence of VAP among COPD and non COPD patients [9].…”

“…Among intubated COPD patients, VAP incidence widely ranges, from 6 to 34% [7][8][9]11], possibly because of different VAP diagnostic criteria used in these studies. The relatively low rate of VAP among COPD patients, together with the lack of significant difference with non-COPD patients, may be due to the significantly higher previous exposure to antibiotics in COPD patients.…”

“…Several studies have identified COPD as independently associated to VAP occurrence [7,8], but more recent data suggest that COPD patients may not be at higher risk for VAP [9]. However, VAP is associated with prolonged MV and intensive care unit (ICU) stay, and higher mortality among critically ill patients [5,10], including COPD population [9,11], although mortality attributable to VAP is still a matter for debate [12].…”

Infections Due to Acinetobacter baumannii in the ICU: Treatment Options

“…ABC is a common cause of ICU-acquired pneumonia, accounting for 8 to 14% of VAP in the United States 50 and Europe, 51 but much higher rates (19% to >50%) in Asia, 48,52 Latin America, 53 and some Middle Eastern 54 countries. In the United States, rates of VAP due to ABC increased from 4% in 1986 to 7.0% in 2003; no increase was observed for any other gram-negative bacilli.…”

“…50 In a study of 411 cases of VAP from nine European countries, A. baumannii was implicated in 13.9% of cases. 51 In a cohort of 827 cases of VAP in 27 ICUs in Europe, A. baumannii was implicated in 11% of early-onset and 26.5% of late-onset VAP. 56 In Greece and Turkey, ABC was the most common cause of VAP.…”