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Validation of Predictors of Adverse Outcomes in Hospital-Acquired Pneumonia in the ICU*

Esperatti, Mariano MD1,2; Ferrer, Miquel PhD1,2; Giunta, Valeria MD1,3; Ranzani, Otavio Tavares MD4; Saucedo, Lina Maria MD1; Li Bassi, Gianluigi MD1,2; Blasi, Francesco PhD3; Rello, Jordi PhD2,5; Niederman, Michael S. PhD6; Torres, Antoni MD, PhD1,2

doi: 10.1097/CCM.0b013e31828a674a
Clinical Investigations

Objective: To validate a set of predictors of adverse outcomes in patients with ICU-acquired pneumonia in relation to clinically relevant assessment at 28 days.

Design: Prospective, observational study.

Setting: Six medical and surgical ICUs of a university hospital.

Patients: Three hundred thirty-five patients with ICU-acquired pneumonia.

Interventions: None.

Measurements and Main Results: Development of predictors of adverse outcomes was defined when at least one of the following criteria was present at an evaluation made 72–96 hours after starting treatment: no improvement of PaO2/FIO2, need for intubation due to pneumonia, persistence of fever or hypothermia with purulent respiratory secretions, greater than or equal to 50% increase in radiographic infiltrates, or occurrence of septic shock or multiple organ dysfunction syndrome. We also assessed the inflammatory response by different serum biomarkers. The presence of predictors of adverse outcomes was related to mortality and ventilator-free days at day 28. Sequential Organ Failure Assessment score was evaluated and related to mortality at day 28.

One hundred eighty-four (55%) patients had at least one predictor of adverse outcomes. The 28-day mortality was higher for those with versus those without predictors of adverse outcomes (45% vs 19%, p < 0.001), and ventilator-free days were lower (median [interquartile range], 0 [0–17] vs 22 [0–28]) for patients with versus patients without predictors of adverse outcomes (p < 0.001). The lack of improvement of PaO2/FIO2 and lack of improvement in Sequential Organ Failure Assessment score from day 1 to day 5 were independently associated with 28-day mortality and fewer ventilator-free days. The marginal structural analysis showed an odds ratio of death 2.042 (95% CI, 1.01–4.13; p = 0.047) in patients with predictors of adverse outcomes. Patients with predictors of adverse outcomes had higher serum inflammatory response accordingly to biomarkers evaluated.

Conclusions: The presence of any predictors of adverse outcomes was associated with mortality and decreased ventilator-free days at day 28. The lack of improvement in the PaO2/FIO2 and Sequential Organ Failure Assessment score was independently associated with mortality in the multivariate analysis.

1Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.

2Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes)-Instituto de Salud Carlos III-Ministerio de Ciencia e Innovación, Spain.

3Istituto Malattie Respiratorio, University of Milan, Istituto di Ricerca e Cura a Carattere Scientifico, Policlinico, Milan, Italy.

4Respiratory Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

5Hospital Universitari Vall D´Hebron, Barcelona, Spain.

6Winthrop, University Hospital, Mineola New York and SUNY at Stony Brook School of Medicine, Mineola, NY.

* See also p. 2235.

Drs. Esperatti, Ferrer, and Torres conceived and designed the study. Drs. Esperatti, Saucedo, and Giunta acquired the data. Drs. Esperatti, Ferrer, Tavares Ranzani, Torres, Li Bassi, Niederman, Rello, and Torres analyzed and interpreted the data. Drs. Esperatti, Ferrer, Giunta, Tavares Ranzani, Saucedo, Li Bassi, Blasi, Rello, Niederman, Rello, and Torres drafted or revised the manuscript for important intellectual content.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported by, in part, CibeRes (CB06/06/0028)-ISCiii, 2009 SGR 911, ERS Fellowship, and IDIBAPS.

Dr. Esperatti received grant support from the European Respiratory Society (long-term research fellowship). Dr. Saucedo was a research fellow from Universidad de la Sabana, Bogotá, Colombia. Dr. Li Bassi lectured for Covidien; received royalties from the National Institutes of Health; and received support for travel from Covidien. Dr. Blasi served as a board member for Pfizer, GSK, and AstraZeneca; consulted for AstraZeneca; received grant support from Pfizer and Zambon; and lectured for Pfizer, Zambon, Chiesi, and AstraZeneca. Dr. Niederman has received honoraria as consultant from Pfizer and Merck company and research funding from Bayer and Sanofi; consulted for Pfizer and Merck; received grant support from Cubist and Bayer; lectured for Pfizer and Merck; received support for development of educational presentations from CME companies on behalf of Cubist. Dr. Torres has received honoraria as speaker from Covidien, AstraZeneca, and Astellas Company and Advisory board from Covidien, Astellas, and Pfizer; and received grant support from Covidien, Toray, Pfizer, and Astellas. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: atorres@clinic.ub.es

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins