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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