Chest
Volume 129, Issue 5, May 2006, Pages 1210-1218
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Original Research: Critical Care Medicine
Clinical Characteristics and Treatment Patterns Among Patients With Ventilator-Associated Pneumonia

https://doi.org/10.1378/chest.129.5.1210Get rights and content

Study objectives

To evaluate clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia (VAP), including the implementation of and outcomes associated with deescalation therapy.

Design

Prospective, observational, cohort study.

Setting

Twenty ICUs throughout the United States.

Patients

A total of 398 ICU patients meeting predefined criteria for suspected VAP.

Interventions

Prospective, handheld, computer-based data collection regarding routine VAP management according to local institutional practices, including clinical and microbiological characteristics, treatment patterns, and outcomes.

Measurements and results

The most frequent ICU admission diagnoses in patients with VAP were postoperative care (15.6%), neurologic conditions (13.3%), sepsis (13.1%), and cardiac complications (10.8%). The mean (± SD) duration of mechanical ventilation prior to VAP diagnosis was 7.3 ± 6.9 days. Major pathogens were identified in 197 patients (49.5%) through either tracheal aspirate or BAL fluid and included primarily methicillin-resistant Staphylococcus aureus (14.8%), Pseudomonas aeruginosa (14.3%), and other Staphylococcus species (8.8%). More than 100 different antibiotic regimens were prescribed as initial VAP treatment, the majority of which included cefepime (30.4%) or a ureidopenicillin/monobactam combination (27.9%). The mean duration of therapy was 11.8 ± 5.9 days. In the majority of cases (61.6%), therapy was neither escalated nor deescalated. Escalation of therapy occurred in 15.3% of cases, and deescalation occurred in 22.1%. The overall mortality rate was 25.1%, with a mean time to death of 16.2 days (range, 0 to 49 days). The mortality rate was significantly lower among patients in whom therapy was deescalated (17.0%), compared with those experiencing therapy escalation (42.6%) and those in whom therapy was neither escalated nor deescalated (23.7%; χ2 = 13.25; p = 0.001).

Conclusions

Treatment patterns for VAP vary widely from institution to institution, and the overall mortality rate remains unacceptably high. The deescalation of therapy in VAP patients appears to be associated with a reduction in mortality, which is an association that warrants further clinical study.

Section snippets

Materials and Methods

The Assessment of Local Antimicrobial Resistance Measures study was a prospective, observational, cohort study of outcomes variables for VAP. Investigators affiliated with 20 ICUs across the United States identified and enrolled eligible patients with VAP. The study was approved by the individual institutional review boards associated with the participating sites. As most of the eligible patients were sedated for mechanical ventilation and because of the purely observational nature of the

Results

A total of 398 eligible patients were identified among the 20 sites between May 2003 and December 2004. Two sites were responsible for 43% of all enrollments (111 and 62 patients, respectively). Nine sites enrolled between 19 and 30 patients, and the remaining nine sites enrolled ≤ 6 patients each.

Discussion

In this prospective observational study, we found that VAP remains a significant cause of mortality in the ICU setting, and that treatment patterns for this disease vary widely across institutions. The distribution of identified pathogens was similar to that observed in other VAP studies, including high frequencies of MRSA and P aeruginosa.

There were > 100 different antibiotic regimens prescribed as initial therapy among the patients that were studied. The majority of patients experienced no

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