Early- and late-onset ventilator-associated pneumonia acquired in the intensive care unit: comparison of risk factors

Giard, Marine; Lepape, Alain; Allaouchiche, Bernard; Guérin, Claude; Lehot, Jean‐Jacques; Robert, M; Fournier, G.; Jacques, Didier; Chassard, D.; Gueugniaud, Pierre‐Yves; Artru, F; Petit, Paul; Robert, Dominique; Mohammedi, I.; Girard, R.; Cêtre, J.-C.; Nicolle, Marie-Christine; Grando, J.; Fabry, J.; Vanhems, Philippe

doi:10.1016/j.jcrc.2007.08.005

Cited by 63 publications

(47 citation statements)

References 18 publications

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“…24 In unselected populations of mixed ICU patients, an incidence of early-onset pneumonia between 5% and 25% has usually been reported. [25][26][27][28][29] Our rate of 15.5% among liver recipients agrees with previously reported rates of pneumonia after LT ranging from 5% to 34%. [4][5][6][7][8][9][10]30 Two recent studies showed a rate of pneumonia of 21.1% in liver recipients receiving a 3-day prophylactic regimen of CTX and ampicillin and a rate of 18% in living donor-related recipients receiving selective digestive decontamination.…”

Section: Discussionsupporting

confidence: 92%

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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: Discussionsupporting

confidence: 92%

“…An association between surgical events and early pneumonia has already been suggested in unselected surgical ICU patients. 26 Overall, our results indicate that the risk of E-HAP can probably be significantly influenced by inflammation or prothrombotic disorders induced by the surgery.…”

Section: Discussionmentioning

confidence: 62%

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

Weiss¹,

Dahmani²,

Bert³

et al. 2010

Liver Transpl

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“…Paradoxically, this could lead to a situation in which VAP incidence increases due to prolonged ventilatory times and VAE incidence decreases because of fewer failed extubations. 57 …”

Section: Vaes Can Sometimes Be Triggered By Improvements In Carementioning

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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“…61 It accounts for 62-73% of all cases, with the highest daily hazard rates of 2-4% reported to occur between days 6 and 8. [61][62][63] Whether VAP can be eradicated requires discussion of both VAP pathophysiology and ETT design limitations. To begin with, terms such as VAP and VAE are unfortunate misnomers.…”

Section: Pathophysiology Of Ventilator-associated Pneumoniamentioning

confidence: 99%

“…Late-onset VAP accounts for both the majority of cases and the greatest associated morbidity and mortality, 61 with the highest risk occurring between days 6 and 8 of mechanical ventilation. [61][62][63] In the early 1990s, the average duration of mechanical ventilation was 7-12 d, with an additional average of 3-5 d for weaning using various techniques driven by protocols. 99 In a contemporaneous survey of clinicians, the average duration of weaning ranged from 5 to 18 d, with the longest duration associated with synchronized intermittent mandatory ventilation combined with pressure support ventilation.…”

Section: Weaning and Sedation Strategiesmentioning

confidence: 99%

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

Kallet

2015

Respir Care

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SummaryVentilator-associated pneumonia (VAP) is an acquired infection related primarily to the consequences of prolonged endotracheal intubation. It is considered the most important infectious challenge in the critical care setting. Preventable complications of hospital care are considered an important source of wasted health-care costs believed to consume up to 47% of annual expenditures in the United States. Whether VAP is preventable has become a highly contentious debate since public reporting commenced a decade ago. This selective review focuses on specific aspects of this debate, including the inherent vagaries in the diagnosis of VAP and the marked disparities between VAP rates based on clinical diagnosis versus surveillance data. Also discussed is how this debate has impacted public policy, leading to the new paradigm of ventilator-associated events. The limited ability of artificial airways to prevent microaspiration and biofilm build-up, as well as non-modifiable conditions increasing the risk of VAP, is described in detail. In addition, the origins of the mistaken but widely embraced notion that zero VAP is a realistic achievement are examined.

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Early- and late-onset ventilator-associated pneumonia acquired in the intensive care unit: comparison of risk factors

Cited by 63 publications

References 18 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?

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

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