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Anesthesiology:
Clinical Investigations

Risk Factors for Early-onset, Ventilator-associated Pneumonia in Critical Care Patients: Selected Multiresistant versus Nonresistant Bacteria

Akça, Ozan M.D.*; Koltka, Kemalettin M.D.†; Uzel, Serdar M.D.‡; Çakar, Nahit M.D.§; Pembeci, Kamil M.D.§; Sayan, Mehmet A. M.D.∥; Tütüncü, Ahmet S. M.D.§; Karakas, Serife Eti M.D.#; Çalangu, Semra M.D.**; Özkan, Tülay M.D.†; Esen, Figen M.D.§; Telci, Lütfi M.D.††; Sessler, Daniel I. M.D.‡‡; Akpir, Kutay M.D.§§

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Abstract

Background: Ventilator-associated pneumonia is the leading nosocomial infection in critically ill patients. The frequency of ventilator-associated pneumonia caused by multidrug-resistant bacteria has increased in recent years, and these pathogens cause most of the deaths attributable to pneumonia. The authors, therefore, evaluated factors associated with selected multidrug-resistant ventilator-associated pneumonia in critical care patients.
Methods: The authors prospectively recorded potential risk factors at the time of intensive care unit admission. An endotracheal aspirate was obtained in all patients who met clinical criteria for pneumonia. Patients were considered to have ventilator-associated pneumonia only when they met the clinical criteria and aspirate culture was positive for bacteria 48 h or more after initiation of mechanical ventilation. Pediatric patients were excluded. Adult patients with ventilator-associated pneumonia were first grouped as “early-onset” (< 5 days) and “late-onset,” determined by episodes of ventilator-associated pneumonia, and then, assigned to four groups based on the bacteria cultured from their tracheal aspirates:Pseudomonas aeruginosa, Acinetobacter baumanii, methicillin-resistant staphylococci, and all others. The first three bacteria were considered to be multidrug resistant, whereas the others were considered to be antibiotic susceptible. Potential risk factors were evaluated with use of univariate statistics and multivariate regression.
Results: Among 486 consecutive patients admitted during the study, 260 adults underwent mechanical ventilation for more than 48 h. Eighty-one patients (31%) experienced 99 episodes of ventilator-associated pneumonia, including Pseudomonas (33 episodes), methicillin-resistant staphylococci (17 episodes), Acinetobacter (9 episodes), and nonresistant bacteria (40 episodes). Sixty-six of these episodes were early onset and 33 episodes were late onset. Logistic regression analysis identified three factors significantly associated with early-onset ventilator-associated pneumonia caused by any one of the multidrug-resistant bacterial strains: emergency intubation (odds ratio, 6.4; 95% confidence interval, 2.0–20.2), aspiration (odds ratio, 12.7; 95% confidence interval, 2.4–64.6), and Glasgow coma score of 9 or less (odds ratio, 3.9; 95% confidence interval, 1.3–11.3). A. baumanii–related pneumonia cases were found to be significantly associated with two of these factors: aspiration (odds ratio, 14.2; 95% confidence interval, 1.5–133.8) and Glasgow coma score (odds ratio, 6.0; 95% confidence interval, 1.1–32.6).
Conclusions: The authors recommend that patients undergoing emergency intubation or aspiration or who have a Glasgow coma score of 9 or less be monitored especially closely for early-onset multidrug-resistant pneumonia. The occurrence of aspiration and a Glasgow coma score of 9 or less are especially associated with pneumonia caused by A. baumanii.
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PNEUMONIA is a frequent and serious complication in patients undergoing mechanical ventilation. Mechanical ventilation increases the incidence of pneumonia in patients in the hospital 6- to 20-fold. 1–3 A consensus statement from the American Thoracic Society identified an incidence of approximately 35 episodes per 1,000 patient-days. 4 Consequently, ventilator-associated pneumonia is the leading nosocomial infection in critical care patients. 5 Although, the cause of pneumonia is well-known and prevention guidelines have been established, treatment of these infections is challenging, and these infections account for a substantial mortality. 6,7
Distal airways are usually colonized by upper respiratory tract flora after a few days of mechanical ventilation. The flora are mostly endogenous bacterial strains from the gastrointestinal tract, although some result from inhaled contaminants or are transmitted from healthcare workers. 6 The specific epidemiology depends on numerous factors, including the patient’s underlying disease and previous antibiotic use. 8
The frequency of ventilator-associated pneumonia caused by multidrug-resistant bacteria has increased in recent years. 6,9,10 Among the most important multidrug-resistant bacteria are Pseudomonas aeruginosa, Acinetobacter baumanii, and methicillin-resistant staphylococci. These pathogens cause most of the deaths attributable to pneumonia. 9–11 Additionally, timing of the onset of pneumonia is an important factor in predicting causative organisms, complications, and prognosis of the illness. 9,12–14 Accordingly, we prospectively evaluated factors associated with selected multidrug-resistant, early-onset, ventilator-associated pneumonia in critical care patients.
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Methods

This study was conducted with approval from the Institutional Review Board at Istanbul University, Istanbul Medical Faculty; consent was waived because the protocol was observational. All 483 adult patients in this 18-bed multidisciplinary intensive care unit (ICU) who underwent mechanical ventilation between January and September of 1996 were prospectively enrolled in the study.
We did not use prophylactic systemic antibiotics or selective digestive decontamination. All patients were administered either sucralfate or ranitidine to reduce the risk of stress ulcer formation. Unless the position was contraindicated, all patients were kept semirecumbent.
All patients underwent mechanical ventilation with the ventilator set in either pressure-controlled or pressure-support mode. Mechanical ventilation nearly always initiated a fraction of inspired oxygen (Fio2) of 1.0, with complete muscular relaxation. Subsequently, muscular strength was allowed to return and the Fio2 was appropriately reduced unless acute respiratory distress syndrome (ARDS) developed in patients, in which case the patients were kept paralyzed and given a high Fio2. 15,16 (General management strategies are outlined in the Appendix.) Heat- and moisture-exchanging bacterial filters (Gibeck, Inc., Stockholm, Sweden) were inserted between the endotracheal tube and the ventilator circuit. The filters were changed daily and the breathing circuits were changed weekly, unless copious secretions mandated more frequent exchanges.
We prospectively recorded potential risk factors at the time of ICU admission. These included age, gender, admission source or type (medical or surgical); history of thorax trauma; need for emergency surgery; history of diabetes mellitus type II, chronic obstructive pulmonary disease (COPD), aspiration of oral or gastric content, renal failure, neurologic deficit, and antibiotic use within the seven preceding days; need for emergency intubation, acute physiology and chronic health evaluation (APACHE II) score;17 and Glasgow coma score. 18 Aspiration and need for emergency intubation were similarly recorded from the clinical notes of the initial caregivers. Emergency intubation was defined as the need for immediate intubation during the initial inspection of the patient. The need was defined as respiratory or cardiac arrest or decreased level of consciousness. Emergency intubations were performed by the responsible consultant anesthesiologist, who also determined whether the patients had aspirated. Renal failure was determined as having occurred if blood creatinine concentrations that exceeded 1.5 mg/dl for two consecutive measurements.
The clinical criteria for a suspected diagnosis of ventilator-associated pneumonia was a new or persistent opacity, seen during radiography, and any two of the following factors: (1) purulent endotracheal aspirate; (2) core temperature more than 38°C or less than 36°C); (3) leukocyte count more than 10,000 cells/mm3 or less than 4,000 cells/mm3; or (4) exudative pleural effusion. 2,9 An endotracheal aspirate was obtained in all patients who met clinical criteria for pneumonia. The aspirates were quantitatively cultured; those yielding more than 105 colony-forming units (cfu)/ml were considered to be positive for bacteria. Patients were considered to have ventilator-associated pneumonia only when they met the clinical criteria and if the aspirate culture was positive for bacteria 48 h after initiation of mechanical ventilation. 2,9
Patients with suspected ventilator-associated pneumonia were observed for development of ARDS. ARDS was diagnosed using the following criteria: partial pressure of arterial oxygen (Pao2)–Fio2 less than 200 mmHg (regardless of positive end-expiratory pressure [PEEP]), bilateral infiltrates seen on chest radiograph, a pulmonary artery occlusion pressure less than 18 mmHg (when available), and no clinical evidence of left atrial hypertension. 19 It was not always easy to determine whether ventilator-associated pneumonia developed as a result of ARDS or whether the syndrome facilitated development of pneumonia. Consequently, we did not consider ARDS to be a specific complication of pneumonia.
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Data Analysis
Patients with ventilator-associated pneumonia were compared with the remaining ICU population with use of unpaired, two-tailed t tests or a nonparametric analog of the t test (Kruskal-Wallis).
Patients with ventilator-associated pneumonia were first grouped as “early-onset” (< 5 days) and “late-onset,”13,14 and then assigned to four groups based on the bacteria cultured from their tracheal aspirates:P. aeruginosa, A. baumanii, methicillin-resistant staphylococci, and all others. The first three were considered to be multidrug-resistant, whereas the other bacteria were considered to be antibiotic susceptible. This decision was made prospectively in collaboration with the Infectious Diseases and Clinical Microbiology consultants and was based on clinical data collected during the previous year. 20,21 We used one-way analysis of variance, unpaired, two-tailed t or Kruskal-Wallis tests to compare patients infected with sensitive or resistant species.
The influence of potential risk factors on subsequent development of various types of ventilator-associated pneumonia was evaluated by one-way analysis of variance and with use of the Dunnett test, with nonresistant bacteria considered as the reference group. These univariate results are presented as the mean ± SD. Potential risk factors were further evaluated with use of multivariate regression. Logistic regression results are presented as odds ratios and 95% confidence intervals. In all cases, a two-tailed P < 0.05 was considered to be statistically significant.
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Results

Table 1
Table 1
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The ICU admitted 486 patients during the study period, and 260 adult patients underwent mechanical ventilation for more than 48 h. Most of the patients underwent elective surgical procedures and were admitted for planned postoperative care (47%; the remainder were medical multidisciplinary [31%] and trauma [22%] patients. There were many more men than women (166 vs. 94, table 1)
Among these patients, 81 (28%) experienced 99 episodes of ventilator-associated pneumonia. Overall, 33 episodes of P. aeruginosa, 17 episodes of methicillin-resistant staphylococci, and 9 episodes of Acinetobacter species were diagnosed, along with 40 episodes attributed to nonresistant bacteria. There were only two mixed infections according to the quantitative culture results. One was P. aeruginosa and Klebsiella, and the other was P. aeruginosa and A. baumanii. Patients with ventilator-associated pneumonia were younger (41 ± 21 yr) than the remaining ICU population (50 ± 20 yr, P < 0.001). Admission APACHE II scores of patients with ventilator-associated pneumonia were minimally higher than the patients without; the Glasgow coma score of patients with ventilator-associated pneumonia was minimally lower.
Table 2
Table 2
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Admission diagnosis of 33% of the patients with ventilator-associated pneumonia was thorax trauma. In contrast, thorax trauma was present in only 7% of the patients without ventilator-associated pneumonia (P < 0.001). The rate of COPD was higher in the patients with ventilator-associated pneumonia (20 vs. 13%), but this difference was not statistically significant. Emergency intubation, aspiration during intubation, and the need for emergency surgery were more common in patients with ventilator-associated pneumonia. Duration of ICU stay and mechanical ventilation were significantly longer in the patients with ventilator-associated pneumonia. Similarly, sepsis (26 vs. 11%) and ARDS (32 vs. 9%) were most common in patients with ventilator-associated pneumonia. A smaller percentage of patients with ventilator-associated pneumonia had been administered antibiotics during the first 48 h of admission than of patients without pneumonia (44 vs. 57%). Although, mortality rate was greater in the patients with ventilator-associated pneumonia than in the remaining critical care population (31 vs. 23%), this difference was not statistically significant (table 2).
Table 3
Table 3
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When patients with early-onset ventilator-associated pneumonia were compared with the patients without pneumonia, significant differences were observed regarding emergency intubation (44 vs. 12%), aspiration (33 vs. 3%), thorax trauma (33 vs. 7%), emergency surgery (9 vs. 1%), and renal failure (24 vs. 14%). Similar to the general pneumonia population, early-onset pneumonia developed in fewer patients (44 vs. 59%;table 3) administered antibiotics during the first 48 h.
Table 4
Table 4
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The subgroups of early-onset pneumonia were also compared with each other. Morphometric and demographic characteristics of the patients in each pathogen group were similar. Age and gender were also similar in each pathogen group, and there were no significant differences in APACHE II scores or the incidence of thorax trauma, diabetes mellitus, or acute renal failure. The types of procedures for which patients were admitted (medical vs. surgical) were also comparable among the groups. Aspiration was found to occur significantly less frequently in the nonresistant group, compared with A. baumanii and P. aeruginosa groups (8 vs. 83 and 47%, respectively). Emergency intubation rate was also significantly less in the nonresistant group compared with the A. baumanii group (21 vs. 75%). The P. aeruginosa group stayed in the ICU significantly longer than did the nonresistant group (23 ± 13 vs. 12 ± 7 days). The P. aeruginosa group experienced the highest rate of ARDS (41%); mortality rate was highest in the A. baumanii group (50%). However, these differences were not statistically significant (table 4).
Table 5
Table 5
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When all patients with resistant bacteria were compared with those with nonresistant bacteria by use of logistic regression, emergency intubation (odds ratio, 6.42; confidence interval, 2.04–20.22), aspiration (odds ratio, 12.69; confidence interval, 2.49–64.58), and Glasgow coma score of 9 or less (odds ratio, 3.86; confidence interval, 1.31–11.34) were found to be statistically significant risk factors. Finally, a Glasgow coma score of 9 or less correlated significantly with early-onset pneumonia caused by A. baumanii (odds ratio, 6.00; confidence interval, 1.10–32.60), whereas it was not a significant predictor for the other two resistant strains (table 5).
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Discussion

Our aim was to identify specific risk factors associated with early-onset ventilator-associated pneumonia caused by bacteria that are typically multidrug-resistant. The reason for performing this risk analysis was that approximately 60% of ventilator-associated pneumonia is caused by multidrug-resistant bacteria. 6,9,10 More importantly, ventilator-associated pneumonia caused by resistant bacteria is associated with a more serious clinical course and a higher mortality rate. Our results identify three independent risk factors for early-onset ventilator-associated pneumonia caused by resistant bacteria: emergency intubation, aspiration, and a Glasgow coma score of 9 or less. The latter two of these factors were also found to be independent risks for the A. baumanii subgroup of early-onset ventilator-associated pneumonia.
There is considerable regional variability in critical care populations and treatment strategies. The specific relative risks we identify must therefore be applied with considerable caution to other populations. Nonetheless, factors related to patient health and preadmission history should be considered seriously when planning clinical treatment and assessing individual risk. For example, intensivists started to develop predictive models for nosocomial pneumonia more than a decade ago and were able to identify numerous risk factors. 22–24 The risks determined in these studies improved clinical practice by identifying treatments that have since become routine for critical care. These include maintaining patients in a semirecumbent position and use of drugs that protect the gastric–mucosal barrier.
More recently, investigators have focused on specific risk factors for multidrug-resistant bacteria. 9–11 These studies mostly identified P. aeruginosa, A. baumanii, methicillin-resistant staphylococci, and Stenotrophomonas maltophilia as multidrug-resistant bacteria. In a prospective study of 135 episodes of ventilator-associated pneumonia, Talon et al.10 found that duration of hospital stay, duration of mechanical ventilation exceeding 7 days, previous use of third-generation cephalosporins with poor effectiveness against P. aeruginosa, and COPD significantly increased the risk of ventilator-associated pneumonia caused by P. aeruginosa. Additionally, Celis et al.,23Talon et al.,10 and Rello et al.25 identified preexisting COPD as one of the most important predictors of infection by P. aeruginosa.10,23,25 Consistent with the findings of Talon et al.,10 we observed that P. aeruginosa was more frequently observed as a late-onset episode. Although only 26% of early-onset ventilator-associated pneumonia episodes are associated with P. aeruginosa, in the late-onset group, this rate was 48%. However, we were not able to identify other specific risk factors for P. aeruginosa. Unlike in our results, in a recent report by Rello et al., it was shown that aspiration was a specific risk for early pneumonia (< 48 h) in patients who underwent mechanical ventilation. 26
The conclusions of recently published studies by Trouillet et al.9 and Rello et al differ. 26 In the report of Trouillet et al.,9 previous use of broad-spectrum antibiotics was found to be an independent risk factor for ventilator-associated pneumonia. However, in a study published a year later, Rello et al.26 showed previous antimicrobial use to be an independent protective factor. Our results are most consistent with those of Rello et al.26 because prior antibiotic use was observed in 44% of the patients with ventilator-associated pneumonia versus in 57% of those without ventilator-associated pneumonia.
Data are not sufficient to suggest firm conclusions about prophylactic antibiotic use. It is likely that well-developed antibiotic-use policy within a unit based on experience and known patterns of resistance will reduce infection rates, whereas haphazard choice may increase risk. Rello et al.26 makes the same point, suggesting that instead of following general recommendations, antimicrobial prescribing practices for ventilator-associated pneumonia should be based on up-to-date information of the pattern of multiresistant isolates from each institution. 12Acinetobacter baumanii pneumonia has been described as having epidemiologic characteristics similar to P. aeruginosa and the Enterobacteriaceae family. In previous publications, for example, preexisting illness, including COPD, and duration of mechanical ventilation were not found to be associated with ventilator-associated pneumonia caused by A. baumanii. The important risk factors for this agent appear to be head trauma, neurosurgery, ARDS, and large-volume aspiration. 11 Our results are consistent in identifying a Glasgow coma score of 9 or less and aspiration as significant risk factors.
A limitation of our study is that we cultured endotracheal aspirates rather than samples obtained from bronchoalveolar lavage. The role of invasive versus noninvasive culture sampling is controversial. 27–31,32 However, there has yet to be a study showing that mortality, morbidity, or any other outcome in patients with ventilator-associated pneumonia can be improved by invasive culture methods. 31,33,34 Cultures from endotracheal aspirates are routine and have been used in numerous recent studies.
In summary, we identify aspiration, emergency intubation, and a Glasgow coma score of 9 or less as specific risk factors for early-onset ventilator-associated pneumonia caused by resistant organisms. Additionally, aspiration and a Glasgow coma score of 9 or less were significant risk factors for early-onset ventilator-associated pneumonia caused by A. baumanii. We recommend that patients with these risk factors be closely monitored for development of pneumonia caused by multidrug-resistant bacteria.
The authors thank the personnel of the Multidisciplinary Critical Care Unit at the University of Istanbul for support and generous assistance and Vildan Vural, Department of Anesthesiology, University of Istanbul, and Halit Ozsut, M.D., Department of Infectious Diseases, University of Istanbul, for assistance.
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References

1. Craven DE, Steger KA, Barber TW: Preventing nosocomial pneumonia: State of the art and perspectives for the 1990s. Am J Med 1991; 91: 44S–53S

2. Torres A, Aznar R, Gatell JM, Jimenez P, Gonzalez J, Ferrer A, Celis R, Rodriguez-Roisin R: Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 1990; 142: 523–8

3. A consensus statement from the American Thoracic Society: Hospital-acquired pneumonia in adults: Diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies. Am J Respir Crit Care Med 1996; 153: 1711–25

4. Valles J, Rello J: [Prevention of respiratory infections in the intubated patient] (Spanish) (editorial). Enferm Infecc Microbiol Clin 1994; 12: 231–4

5. Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M: The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA 1995; 274: 639–44

6. Rello J, Torres A: Microbial causes of ventilator-associated pneumonia. Semin Respir Infect 1996; 11: 24–31

7. Girou E, Stephan F, Novara A, Safar M, Fagon JY: Risk factors and outcome of nosocomial infections: Results of a matched case-control study of ICU patients. Am J Respir Crit Care Med 1998; 157: 1151–8

8. Fagon JY, Chastre J, Domart Y, Trouillet JL, Pierre J, Darne C, Gibert C: Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis 1989; 139: 877–84

9. Trouillet JL, Chastre J, Vuagnat A, Joly-Guillou ML, Combaux D, Dombret MC, Gibert C: Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med 1998; 157: 531–9

10. Talon D, Mulin B, Rouget C, Bailly P, Thouverez M, Viel JF: Risks and routes for ventilator-associated pneumonia with Pseudomonas aeruginosa. Am J Respir Crit Care Med 1998; 157: 978–84

11. Baraibar J, Correa H, Mariscal D, Gallego M, Valles J, Rello J: Risk factors for infection by Acinetobacter baumannii in intubated patients with nosocomial pneumonia. Chest 1997; 112: 1050–4

12. Rello J, Sa-Borges M, Correa H, Leal SR, Baraibar J: Variations in etiology of ventilator-associated pneumonia across four treatment sites: Implications for antimicrobial prescribing practices. Am J Respir Crit Care Med 1999; 160: 608–13

13. Antonelli M, Moro ML, Capelli O, De Blasi RA, D’Errico RR, Conti G, Bufi M, Gasparetto A: Risk factors for early onset pneumonia in trauma patients. Chest 1994; 105: 224–8

14. Kollef MH, Silver P, Murphy DM, Trovillion E: The effect of late-onset ventilator-associated pneumonia in determining patient mortality. Chest 1995; 108: 1655–62

15. Tutuncu AS, Cakar N, Esen F, Kesecioglu J, Telci L, Akpir K: Titrating PEEP therapy in patients with acute respiratory failure. Adv Exp Med Biol 1996; 388: 575–7

16. Nelson LD, Civetta JM, Hudson-Civetta J: Titrating positive end expiratory pressure therapy in patients with early, moderate arterial hypoxemia. Crit Care Med 1987; 15: 14–9

17. Knaus WA, Draper EA, Wagner DP, Zimmerman JE: APACHE II: A severity of disease classification system. Crit Care Med 1985; 13: 818–29

18. Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2: 81–4

19. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R: The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149: 818–24

20. Gunseren F, Mamikoglu L, Ozturk S, Yucesoy M, Biberoglu K, Yulug N, Doganay M, Sumerkan B, Kocagoz S, Unal S, Cetin S, Calangu S, Koksal I, Leblebicioglu H, Gunaydin M: A surveillance study of antimicrobial resistance of Gram negative bacteria isolated from intensive care units in eight hospitals in Turkey. J Antimicrobial Chemotherapy 1999; 43: 373–8

21. Uzel S, Akca O, Cakar N, Esen F, Ozsut H, Eraksoy H, Dilmener M, Akpir K, Calangu S: Clinical efficacy and safety of imipenem in an intensive care unit. Klimik Derg 1994; 7: 149–52

22. Kollef MH: Ventilator-associated pneumonia. A multivariate analysis. JAMA 1993; 270: 1965–70

23. Celis R, Torres A, Gatell JM, Almela M, Rodriguez-Roisin R, Agusti-Vidal A: Nosocomial pneumonia. A multivariate analysis of risk and prognosis. Chest 1988; 93: 318–24

24. Craven DE, Kunches LM, Kilinsky V, Lichtenberg DA, Make BJ, McCabe WR: Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 1986; 133: 792–6

25. Rello J, Ausina V, Ricart M, Puzo C, Quintana E, Net A, Prats G: Risk factors for infection by Pseudomonas aeruginosa in patients with ventilator-associated pneumonia. Intensive Care Med 1994; 20: 193–8

26. Rello J, Diaz E, Roque M, Valles J: Risk factors for developing pneumonia within 48 hours of intubation. Am J Respir Crit Care Med 1999; 159: 1742–6

27. Papazian L, Martin C, Meric B, Dumon JF, Gouin F: A reappraisal of blind bronchial sampling in the microbiologic diagnosis of nosocomial bronchopneumonia. A comparative study in ventilated patients. Chest 1993; 103: 236–42

28. Papazian L, Thomas P, Garbe L, Guignon I, Thirion X, Charrel J, Bollet C, Fuentes P, Gouin F: Bronchoscopic or blind sampling techniques for the diagnosis of ventilator-associated pneumonia. Am J Respir Crit Care Med 1995; 152: 1982–91

29. Niederman MS: Diagnosing nosocomial pneumonia: To brush or not to brush (editorial). J Intensive Care Med 1991; 6: 151–2

30. Bergmans DC, Bonten MJ, De Leeuw PW, Stobberingh EE: Reproducibility of quantitative cultures of endotracheal aspirates from mechanically ventilated patients. J Clin Microbiol 1997; 35: 796–8

31. Subcommittee of the Scientific Assembly: Hospital-acquired pneumonia in adults: Diagnosis, assessment of severity, initial antimicrobial therapy, and preventive strategies. Am J Respir Crit Care Med 1995; 153: 1711–25

32. Niederman MS, Torres A, Summer W: Invasive diagnostic testing is not needed routinely to manage suspected ventilator-associated pneumonia. Am J Respir Crit Care Med 1994; 150: 565–9

33. Bregeon F, Papazian L, Visconti A, Gregoire R, Thirion X, Gouin F: Relationship of microbiologic diagnostic criteria to morbidity and mortality in patients with ventilator-associated pneumonia. JAMA 1997; 277: 655–62

34. Sanchez-Nieto JM, Torres A, Garcia-Cordoba F, El-Ebiary M, Carrillo A, Ruiz J, Nunez ML, Niederman M: Impact of invasive and noninvasive quantitative culture sampling on outcome of ventilator-associated pneumonia: A pilot study. Am J Respir Crit Care Med 1998; 157: 371–6

35. Tutuncu AS, Cakar N, Camci E, Esen F, Telci L, Akpir K: Comparison of pressure- and flow-triggered pressure-support ventilation on weaning parameters in patients recovering from acute respiratory failure. Crit Care Med 1997; 25: 756–60

36. Kiliccioglu BT, Esen F, Telci L, Cakar N, Tutuncu A, Denkel T, Akpir K: Evaluation of the effects of prone position on respiratory and hemodynamic parameters in patients with ARDS. Turk Anest ve Rean Cem Mecmuasi 1994; 22: 185–9

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Keywords:
Anesthesia; antibiotic resistance; infection; intensive care; nosocomial.

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