Inadequate treatment of ventilator-associated pneumonia: risk factors and impact on outcomes
Introduction
Ventilator-associated pneumonia (VAP) is a common complication in patients requiring mechanical ventilation. Its incidence varies widely depending on the type of population studied and the diagnostic methods and it occurs at rate of 1–3% per day of mechanical ventilation.1, 2, 3, 4, 5, 6, 7, 8 Prolonged intensive care unit (ICU) stay and prolonged mechanical ventilation increase the risk of death.7, 9, 10, 11, 12, 13, 14, 15 Due to the clear association between ventilation and risk of pneumonia, antimicrobial agents are widely prescribed for ventilated patients, and, in more than 50% of the cases, for patients with presumed or diagnosed respiratory tract infections.16 Nevertheless, the use of these drugs in the ICU encourage the increasing incidence of infections caused by multidrug-resistant pathogens and establish a vicious cycle that increases morbidity–mortality rates.17, 18, 19, 20, 21, 22, 23, 24 Using multiple logistic regression, Torres et al. demonstrated that the worsening of respiratory failure, an ultimately or rapidly fatal underlying condition, septic shock and inadequate antibiotic therapy were factors that negatively affected the prognosis of VAP.4 Other authors have also showed that the selection of initial antibiotic therapy is an important determinant of mortality.25, 26, 27, 28, 29, 30
We studied patients with a clinical diagnosis of VAP to identify possible risk factors for inadequate treatment and its subsequent impact on mortality.
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Materials and methods
During 40 months, all patients admitted to one of the five medical or surgical intensive care units (70 beds in oncology, respiratory, cardiology, neurology and general ICUs) of Santa Casa Hospital (1700 beds) with a presumed diagnosis of VAP were eligible for this investigation. This study was approved by the Ethics in Human Studies Committee.
A retrospective cohort study design was used. Primary outcome was antimicrobial adequacy. Secondary outcomes were duration of mechanical ventilation,
Results
Sixty-nine (45.7%) of the 151 patients with a clinical diagnosis of VAP received inadequate antimicrobial treatment for VAP initially, with eighty-two (54.3%) patients receiving appropriate antimicrobial agents. Age, sex, immunological status, co-morbidities, prior surgical procedure or MODS were not significantly different between these two groups. Higher APACHE II score was significantly associated with inadequate treatment (P = 0.02). The indications for mechanical ventilation are listed in
Discussion
The presence of unexpected or resistant bacteria may reduce the adequacy of empirical antimicrobial treatment. We identified multidrug-resistant bacteria, polymicrobial VAP and late-onset VAP as independent risk factors for inadequate treatment, which itself was associated with increased in-hospital mortality. Trouillet et al. reported that resistant bacteria caused 57% of episodes of VAP.34 Their results showed that mechanical ventilation for more than seven days, prior antibiotic use and
Acknowledgements
We would like to thank Carlos Luna for critical revision of this paper.
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