Effect of hospital-acquired ventilator-associated pneumonia on mortality of severe community-acquired pneumonia

doi:10.1016/S0883-9441(99)90003-5

Journal of Critical Care

Volume 14, Issue 1, March 1999, Pages 12-19

https://doi.org/10.1016/S0883-9441(99)90003-5 Get rights and content

Abstract

$Purpose:$ The purpose of this article is to evaluate, using two pairwise case-control studies, attributable mortality linked to hospital-acquired ventilator-associated pneumonia (HA-VAP) complicating the intensive care unit (ICU) stay of patients exhibiting severe community-acquired pneumonia (CAP).

$Materials and Methods:$ Over an 11-year period, 498 patients with severe CAP were collected. Among them, 43 exhibited HA-VAP. In a first case-control study, these patients were matched with control on the basis of six confounding variables known to be general ICU prognosis factors. In a second case-control study, six variables specifically linked to CAP prognosis were used for matching.

$Results:$ In the two case-control studies, each case patient was matched with one control patient. In the first analysis, success of matching was achieved in 198 of 258 (77%) variables used for matching. In the second analysis, matching was successful for 242 of 258 (94%) confounding variables used. Eighteen patients died, compared with, respectively, 6 (P = .003) and 7 (P = .01) controls. Attributable mortality of HA-VAP was similar in the two pairwise analyses, respectively, 28% (risk ratio = 3.0; 95% confidence interval, 1.32 to 6.82) and 26% (risk ratio = 2.57; 95% confidence interval, 1.2 to 5.52).

$Conclusion:$ When confounding factors were controlled, HA-VAP appeared to increase mortality of severe CAP requiring ICU admission.

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The impact of ventilator-associated pneumonia on the Canadian health care system
2008, Journal of Critical Care
Citation Excerpt :
Previous reported estimates of the cost of VAP have ranged from US$5365 (CAN$6278) to US$50 000 (CAN$58 505) per case, with the variability attributable to the methodology used [28-30]. The attributable mortality of VAP has been reported to be between 0% and 40% and is related to the adequacy of initial therapy and the population studied [31-35]. We used the attributable mortality reported by Heyland et al [22] of 5.8% as that was derived in a Canadian setting.
Ventilator-associated pneumonia (VAP) is a cause of morbidity and mortality in critically ill patients. It is associated with increased health care costs and duration of mechanical ventilation. Using published data and information from public health care providers, we sought to determine the impact of VAP on the Canadian health care system.
Ventilator-associated pneumonia incidence, attributable mortality, and intensive care unit (ICU) utilization/resource data were obtained through Canadian published and institutional data. Ontario case cost methodology was used for the cost of a critical care bed which is CAN$2396 per day, excluding treatment costs. Antibiotic acquisition costs for Ontario were used. Physician reimbursement rates were obtained from the provincial ministries of health. Ventilator-associated pneumonia data, ICU resource data, and costs were combined to determine the impact of VAP.
For the Canadian health care system; ICU utilization is 217 episodes per 100 000 population and 1150 days of mechanical ventilation per 100 000. The incidence of VAP is 10.6 cases per 1000 ventilator days (95% CI, 5.1-16.1). Ventilator-associated pneumonia increases ICU length of stay 4.3 days (95% CI, 1.5-7.0 days) per episode. The attributable mortality of VAP is 5.8% (95% CI, −2.4 to 14). The number of cases of VAP is estimated to be approximately 4000 cases per year (95% CI, 1900-6100). This results in 230 deaths per year with the lower and upper confidence intervals ranging from 0 to 580. Ventilator-associated pneumonia accounts for approximately 17 000 ICU days per year or around 2% of all ICU days in Canada. The cost to the health care system is CAN$46 million (possible range, $10 million to 82 million) per year.
The impact of VAP on the Canadian health care system is considerable. Eradication of this preventable nosocomial infection would save lives and conserve scarce health care resources.
Hospital-acquired pneumonia risk factors for antimicrobial-resistant causative pathogens in critically III patients
2003, Chest
To determine factors associated with antimicrobial-resistant hospital-acquired pneumonia (AR-HAP), to build an algorithm evaluating the risk for such a pneumonia, and to test this algorithm.
Combined observational and validation cohorts over two periods: January 1994 to December 1999, and January 2000 to March 2001.
One ICU from a university-affiliated urban teaching hospital.
One hundred twenty-four patients in the observational cohort and 26 patients in the validation cohort exhibiting bacteriologically documented hospital-acquired pneumonia (HAP).
Prospective data collection and multivariate analysis using the χ² automatic interaction and detection technique.
In the observational cohort, 39 antimicrobial-resistant bacteria were incriminated in 37 patients (30%). Multivariate analysis identified four independent variables allowing a binary stratification of risk. According to the presence or absence of prior antimicrobial treatment, neurologic disturbances on ICU admission, aspiration on ICU admission, and time elapsed between ICU admission and the onset of pneumonia, we were able to identify and separate patients at high, low, or even no risk for acquiring AR-HAP. In the validation cohort, nine antimicrobial-resistant bacteria were incriminated in nine patients (34.6%). In this cohort, the algorithm performed well allowing the identification of null risk categories: the absence of prior antimicrobial treatment, the presence of prior antimicrobial treatment with neurologic disturbances on ICU admission and an early-onset pneumonia, and the presence of prior antimicrobial treatment without neurologic disturbances but with aspiration on ICU admission were always associated with antimicrobial-susceptible HAP.
We developed and tested a binary algorithm allowing the identification of patients at low risk for acquiring AR-HAP. An antibiotic strategy including an initial antimicrobial treatment guided by such an algorithm, followed, if possible, by a de-escalation when antimicrobial data are available, could increase the administration of adequate initial antimicrobial treatment and help prevent the emergence of antibiotic resistance in the ICU.
Mortality due to ventilator-associated pneumonia: Impact of medical versus surgical ICU admittance status
2001, Journal of Critical Care
Purpose: The purpose of this study was to compare the prognosis of medical versus surgical patients developing ventilator-associated pneumonia (VAP). Materials and Methods: An observational cohort study included 125 consecutive patients exhibiting VAP. Incidence of death occurred at two different times: during intensive care unit (ICU) stay and during hospital stay. Results: Eighty-seven patients were included in the medical group and 38 in the surgical group. On ICU admission and at the time of VAP onset, most collected data, such as demographic parameters, severity of underlying diseases, and current illness, risk factors forVAP development andVAP characteristics were similar in the two groups. Mortality rates during ICU and hospital stays were not significantly different in medical (49%, 56%) and surgical (55%, 61%) groups. In multivariate logistic regression model adjusting for main factors of VAP mortality, surgical admittance status demonstrated no significant impact on mortality assessed during ICU stay (AOR = 1.6; 0.6 – 4.3 CI) and during hospital stay (AOR = 1.6; 0.6 – 4.2 CI). Conclusions: In this series, after adjustment for mortality confounding factors, medical versus surgical admittance status was not a significant determinant of VAP mortality. Copyright © 2001 by W.B. Saunders Company
British Thoracic Society guidelines for the management of community acquired pneumonia in adults: Update 2009
2009, Thorax
Attributable mortality of ventilator-associated pneumonia
2011, Current Opinion in Critical Care
Attributable mortality of ventilator-associated pneumonia: A meta-analysis
2011, International Journal of Tuberculosis and Lung Disease

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Original investigationEffect of hospital-acquired ventilator-associated pneumonia on mortality of severe community-acquired pneumonia

Abstract

Am J Med

Am J Med

Lancet

Chest

Am J Infect Control

Chest

Chest

Effect of ventilator-associated pneumonia on mortality and morbidity

Am J Respir Crit Care Med

Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients

Am Rev Respir Dis

Nosocomial pneumonia in patients receiving continuous mechanical ventilation

Am Rev Respir Dis

Ventilator-associated pneumonia: A multivariate analysis

JAMA

Hospital-acquired pneumonia in adults: Diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies

Am J Respir Crit Care Med

Pneumonia in intubated trauma patients

Am J Respir Crit Care Med

A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit

Int Care Med

Severe communityacquired pneumonia in ICUs: Prospective validation of a prognostic score

Int Care Med

Original investigation
Effect of hospital-acquired ventilator-associated pneumonia on mortality of severe community-acquired pneumonia