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Factors predicting ventilator-associated pneumonia recurrence

Combes, Alain MD, PhD; Figliolini, Corinne MD; Trouillet, Jean-Louis MD; Kassis, Najibi MD; Dombret, Marie-Christine MD; Wolff, Michel MD; Gibert, Claude MD; Chastre, Jean MD

doi: 10.1097/01.CCM.0000059313.31477.2C
Clinical Investigations

Objective To determine the factors associated with ventilator-associated pneumonia recurrence in patients alive after 8 days of treatment for a first episode.

Design A 16-month, prospective, observational cohort study of patients diagnosed with a first ventilator-associated pneumonia episode. Predictors of recurrence were assessed by logistic regression analysis.

Setting Two intensive care units in a university hospital.

Patients Bronchoscopy was performed in 124 patients with clinically or radiologically suspected ventilator-associated pneumonia. Ventilator-associated pneumonia was confirmed by the presence of at least two of the following criteria: ≥2% of cells with intracellular bacteria found on direct examination of bronchoalveolar lavage fluid, protected specimen brush sample culture ≥103 colony-forming units/mL, or bronchoalveolar lavage culture ≥104 colony-forming units/mL. Ventilator-associated pneumonia recurrence was confirmed using the same microbiological criteria. Antibiotic treatment for ventilator-associated pneumonia lasted 14 days.

Measurements and Main Results Clinical, radiologic, and biological data at intensive care unit admission, on the day of bronchoscopy (D1) and on D8, and outcome variables were prospectively recorded. Ventilator-associated pneumonia recurred in 28 patients (all of them still on mechanical ventilation on D8), 21 ± 9 days after the first episode (82% after D14). Factors significantly associated with recurrence were: acute respiratory failure as initial reason for mechanical ventilation, D1 radiologic score >7, D8 radiologic score >8, adult respiratory distress syndrome on D8, mechanical ventilation persistence on D8, D8 temperature >38°C, and D8 temperature >D1 temperature, but not disease-severity scores at inclusion and D8, or first-episode pathogen(s). Multivariate analysis identified D1 radiologic score >7 (odds ratio = 3.9; 95% confidence interval, 1.3–11.6), D8 temperature >38°C (odds ratio = 4.4; 95% confidence interval, 1.4–13.4), and adult respiratory distress syndrome on D8 (odds ratio = 14.6; 95% confidence interval, 1.5–143.5) as predictors of recurrence.

Conclusions Factors of ventilator-associated pneumonia recurrence evaluated on D8 of a 14-day course of antibiotics are linked to the severity of lung injury and persistence of fever, but not to first-episode pathogen(s).

From the Service de Réanimation Médicale, Hôpital Pitié-Salpêtrière (AC, CF, JLT, MCD,CG, JC); Service de Réanimation Infectieuse (MW), and Service de Microbiologie (NK), Hôpital Bichat, Paris, France.

Shortening the duration of antibiotic treatment for ventilator-associated pneumonia would undoubtedly reduce antibiotic-associated complications and costs.

© 2003 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins