Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study

Abstract

We report on intensive care nosocomial pneumonia (NP) in Europe through a review of EU-VAP/CAP manuscripts: a prospective observational study, enrolling patients from 27 ICUs in nine European countries. From 2,436 eligible ICU patients, 827 cases presented NP, with 18.3 episodes of VAP per 1000 ventilator-days. Most common findings were worsening oxygenation, purulent respiratory secretions and temperature increase. At least three criteria from Clinical Pulmonary Infection score (CPIS) were present in 77.9 % of episodes, but only 0.2 % met six CPIS criteria. Diagnosis was confirmed mainly noninvasively (74.8 %), with half qualitative and quantitative cultures. The dominant isolate was S. aureus in Spain, France, Belgium and Ireland, P. aeruginosa in Italy and Portugal, Acinetobacter in Greece and Turkey, but Escherichia coli in Germany. NP resulted in 6 % higher mortality, longer ICU stay and duration of mechanical ventilation (12 and 10 days). COPD and age ≥45 years were not associated with higher VAP incidence but did correlate with increased mortality. Trauma had higher VAP incidence but lower mortality. Bacteremia (led by MRSA and Acinetobacter baumannii) was documented in 14.6 %, being associated with extra ICU stay and mortality. Vasopressors and ICUs with above 25 % prevalence of Potential Resistant Organisms (PRM) were independently associated with PRM, being documented in 50.7 % of patients with early-onset VAP without known risk factors. Most patients initially received combination therapy. Delay in appropriate antimicrobial choice significantly increased mortality, and LOS in survivors was six days longer (p < 0.05). In conclusion, NP management in Europe presents local differences and major shifts when compared to reports from North America, outcomes of randomized trials and general guidelines.

Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns

“…The recent article published by Koulenti et al [63] on data from 27 ICUs in Europe from the EU-VAP/CAP study analyzed 2436 patients. Among NP cases, HAP occurred in 20.6%, VAP in 42.7% and very early-onset VAP (VE-VAP) in 12.7% of cases.…”

“…Pneumonia caused by more than two pathogenic microorganism is defined as polymicrobial and approximately 30%–70% of VAP cases are considered to have polymicrobial origen [63,68,69]. The study by Combes et al [69] found no differences regarding epidemiology data or clinical outcomes between monomicrobial cases or polymicrobial cases.…”

Emerging strategies for the noninvasive diagnosis of nosocomial pneumonia

“…The most common gram-positive bacteria are methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-intermediate S. aureus. The most common gram-negative bacteria are Pseudomonas aeruginosa, Acinetobacter species, and Enterobacteriaceae which may be either extended-spectrum βlactamase (ESBL)-producing or carbapenem-resistant, including Klebsiella pneumoniae carbapenemase (KPC)-producing variants [3,5]. Interest has increased in gram-negative pathogens over recent years because they are associated with a higher mortality [6,7].…”

“…Moreover, patients treated in intensive care units (ICUs) with an MDR pathogen prevalence of >25% have an increased risk of developing MDR VAP, regardless of other risk factors [7][8][9]. For this reason, determining the frequency of MDR pathogens in ICUs is essential [3,5].…”

Metabolomics in Sepsis and Its Impact on Public Health

“…The role of metabolomics in this case is illustrated by the following examples. Streptococcus pneumoniae is the most frequent infectious agent across the whole spectrum of patients with CAP (outpatients, hospitalized, ICU) [85], whereas Staphylococcus aureus is, together with Pseudomonas aeruginosa , the most frequent isolate in cases of hospital-acquired pneumonia (HAP) in ICU [86]. Quantitative metabolomics with the use of NMR in urine samples of patients with CAP have revealed a distinct metabolic profile for pneumococcal pneumonia as compared to viruses and other bacterial agents [87].…”