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Increased mortality of ventilated patients with endotracheal Pseudomonas aeruginosa without clinical signs of infection*

Zhuo, Hanjing MD, MPH; Yang, Katherine PharmD, MPH; Lynch, Susan V. PhD; Dotson, Rachel H. MD; Glidden, David V. PhD; Singh, Gaurav MD; Webb, W Richard MD; Elicker, Brett M. MD; Garcia, Oscar RT; Brown, Ronald; Sawa, Yoriko RN; Misset, Benoît MD; Wiener-Kronish, Jeanine P. MD

doi: 10.1097/CCM.0b013e318183f3f8
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Objective: To investigate the frequency and outcomes of ventilated patients with newly acquired large burdens of Pseudomonas aeruginosa and to test the hypothesis that large quantities of bacteria are associated with adverse patient outcomes.

Design: A prospective, single-center, observational, cohort study.

Setting: Medical-surgical intensive care units in a tertiary care university hospital.

Patients: All adult patients requiring ≥48 hrs of mechanical ventilation and identified as having newly acquired P. aeruginosa in their lower respiratory tracts between October 2002 and April 2006.

Interventions: None.

Measurements and Main Results: Daily surveillance cultures of endotracheal aspirates were performed on patients intubated ≥48 hrs; 69 patients with newly acquired P. aeruginosa were enrolled. Daily P. aeruginosa quantification of endotracheal aspirates was performed; clinical signs of infection were noted. Of 45 patients with high P. aeruginosa burdens (≥1,000,000 colony-forming units/mL in endotracheal aspirates; ≥10,000 colony-forming units/mL in bronchoalveolar-lavage), 17 (37.8%) patients did not meet clinical criteria for ventilator-associated pneumonia and had a statistically significant higher risk of death (adjusted hazard ratio, 37.53; 95% confidence interval, 3.79–371.96; p = 0.002) when compared with the patients who had P. aeruginosa ventilator-associated pneumonia. When excluding the ten patients who had ventilator-associated pneumonia attributed to bacteria other than P. aeruginosa or attributed to multiple bacteria including P. aeruginosa, the risk of death remained statistically significant (adjusted hazard ratio, 23.98; 95% confidence interval: 2.49–230.53; p = 0.006). Furthermore, more patients with high P. aeruginosa burdens secreted the type III secretion facilitator protein, PcrV (p = 0.01).

Conclusions: A group of patients with large burdens of P. aeruginosa who did not meet clinical criteria for ventilator-associated pneumonia had an increased risk of death when compared with patients who had high P. aeruginosa burdens and met ventilator-associated pneumonia criteria. Patients with high P. aeruginosa burden seemed to possess more virulent strains.

From the Cardiovascular Research Institute (HZ, SVL, YS), and Departments of Clinical Pharmacy (KY), Medicine (RHD), Epidemiology and Biostatistics (DVG), Anesthesia and Perioperative Care (GS, OG, RB, JPwK), Radiology (WRW, BME), University of California San Francisco, CA; Department of Medical-Surgical Intensive Care (BM), Saint-Joseph Hospital, and Faculty of Medicine, University of Paris Descartes, Paris, France; and Department of Anesthesia and Critical Care (JPW-K), Massachusetts General Hospital, Boston, MA.

Supported, in part, by NIH HL74005, HL 69809 and KL2 RR024130.

The authors have not disclosed any potential conflicts of interest.

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© 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins