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Spectrum of practice in the diagnosis of nosocomial pneumonia in patients requiring mechanical ventilation in European intensive care units

Koulenti, Despoina MD; Lisboa, Thiago MD; Brun-Buisson, Christian MD, PhD; Krueger, Wolfgang MD, PhD; Macor, Antonio MD; Sole-Violan, Jordi MD, PhD; Diaz, Emili MD, PhD; Topeli, Arzu MD; DeWaele, Jan MD, PhD; Carneiro, Antonio MD; Martin-Loeches, Ignacio MD, PhD; Armaganidis, Apostolos MD, PhD; Rello, Jordi MD, PhD for the EU-VAP/CAP Study Group

doi: 10.1097/CCM.0b013e3181a037ac
Clinical Investigations
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Objectives: Information on clinical practice regarding the diagnosis of pneumonia in European intensive care units is limited. The aim of this study was to describe the spectrum of actual diagnostic practices in a large sample of European intensive care units.

Design: Prospective, observational, multicenter study.

Setting: Twenty-seven intensive care units of nine European countries.

Patients: Consecutive patients requiring invasive mechanical ventilation for an admission diagnosis of pneumonia or receiving mechanical ventilation for >48 hrs irrespective of admission diagnosis.

Interventions: None.

Measurements and Main Results: A total of 2,436 patients were evaluated; 827 were admitted with or developed nosocomial pneumonia (hospital-acquired pneumonia [HAP], 27.1%; ventilator-associated pneumonia [VAP], 56.2%; very early onset VAP, 16.7%). Mean age was 59.4 ± 18.1 yrs, 65.0% were men, and mean admission Simplified Acute Physiology Score II was 46.7 ± 17.1. Worsening oxygenation (76.8%), purulent/changing respiratory secretions (72.1%), and new temperature elevation (69.2%) were the most frequent clinical signs of nosocomial pneumonia. Etiological diagnosis was based on noninvasive respiratory specimens in 74.8% of episodes. Bronchoscopy was performed in 23.3% of episodes. Bronchoscopy performance, after adjustment by severity of illness, age, and type of hospital, were predicted by worsening oxygenation (odds ratio 2.03; 95% confidence interval, 1.27–3.24) and male sex (odds ratio 1.77; 95% confidence interval, 1.19–2.65). Definite cause was documented in 69.5% of nosocomial pneumonia cases. The most common isolates were Staphylococcus aureus (16.3% methicillin-sensitive S. aureus and 16.0% methicillin-resistant S. aureus), Pseudomonas aeruginosa (23.1%), and Acinetobacter baumannii (19.1%). Presence of nosocomial pneumonia significantly prolonged mean length of mechanical ventilation (10.3 days, p < .05) and mean intensive care unit length of stay (12.2 days, p < .05) in intensive care unit survivors. Mortality rate was 37.7% for nosocomial pneumonia vs. 31.6% for patients without pneumonia (p < .05).

Conclusions: Etiological diagnosis of nosocomial pneumonia in a large sample of European intensive care units was based mainly on noninvasive techniques. However, there was high variability in bronchoscopy use between the participating intensive care units.

From the Critical Care Department (DK, AA), Attikon University Hospital, Athens, Greece; Rovira i Virgili University (DK, TL, JR), Tarragona, Spain; Critical Care Department (TL, ED, JR), Joan XXIII University Hospital–Pere Virgili Health Institut and CIBER Enfermedades Respiratorias (CIBERES), Tarragona, Spain; Critical Care Department (CBB), Henri Mondor University Hospital, Paris, France; Department of Anaesthesiology and Intensive Care Medicine (WK), Tuebingen University Hospital, Tuebingen and Constance Hospital, Constance, Germany; Department of Infectious Risk Prevention (AM), Amedeo di Savoia Hospital, Torino, Italy; Critical Care Department (JSV), Dr Negrin University Hospital, Gran Canaria, Spain; Critical Care Department (AT), Hacettepe University Hospital, Ankara, Turkey; Critical Care Department (JD), Ghent University Hospital, Ghent, Belgium; Critical Care Department (AC), Santo Antonio Hospital, Porto, Portugal; and Critical Care Department (IML), Mater Misericordiae University Hospital, Dublin, Ireland. Members of the EU-VAP/CAP Study Group are listed in Appendix 1 (Collaborators).

Supported, in part, by Generalitat de Catalunya grant SGR 05/920, by CIBER Enfermedades Respiratorias (CIBERES), and by Carlos III Health Institute grants PI05/2410 and AI/07/90031.

Presented, in part, at the American Thoracic Society International Conference, Toronto, Ontario, May 16–21, 2008, and at the European Society of Intensive Care Medicine Congress, Lisbon, Portugal, September 21–24, 2008.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal's Web site (www.ccmjournal.org).

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: jrello.hj23.ics@gencat.cat

© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins