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A Comparison of the Mortality Risk Associated With Ventilator-Acquired Bacterial Pneumonia and Nonventilator ICU-Acquired Bacterial Pneumonia*

Ibn Saied, Wafa, MD1–3; Mourvillier, Bruno, MD1,4; Cohen, Yves, MD5,6; Ruckly, Stephane, MSc1,7; Reignier, Jean, MD, PhD8; Marcotte, Guillaume, MD9; Siami, Shidasp, MD, PhD10; Bouadma, Lila, MD, PhD1,4; Darmon, Michael, MD, PhD11,12; de Montmollin, Etienne, MD13; Argaud, Laurent, MD, PhD14; Kallel, Hatem, MD15; Garrouste-Orgeas, Maité, MD1,16,17; Soufir, Lilia, MD16,17; Schwebel, Carole, MD, PhD18; Souweine, Bertrand, MD, PhD19; Glodgran-Toledano, Dany, MD20; Papazian, Laurent, MD, PhD21; Timsit, Jean-François, MD, PhD1,4,7 on behalf of the OUTCOMEREA Study Group

doi: 10.1097/CCM.0000000000003553
Clinical Investigations
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Objectives: To investigate the respective impact of ventilator-associated pneumonia and ICU–hospital-acquired pneumonia on the 30-day mortality of ICU patients.

Design: Longitudinal prospective studies.

Setting: French ICUs.

Patients: Patients at risk of ventilator-associated pneumonia and ICU–hospital-acquired pneumonia.

Interventions: The first three episodes of ventilator-associated pneumonia or ICU–hospital-acquired pneumonia were handled as time-dependent covariates in Cox models. We adjusted using the case-mix, illness severity, Simplified Acute Physiology Score II score at admission, and procedures and therapeutics used during the first 48 hours before the risk period. Baseline characteristics of patients with regard to the adequacy of antibiotic treatment were analyzed, as well as the Sequential Organ Failure Assessment score variation in the 2 days before the occurrence of ventilator-associated pneumonia or ICU–hospital-acquired pneumonia. Mortality was also analyzed for Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species(ESKAPE) and P. aeruginosa pathogens.

Measurements and Main Results: Of 14,212 patients who were admitted to the ICUs and who stayed for more than 48 hours, 7,735 were at risk of ventilator-associated pneumonia and 9,747 were at risk of ICU–hospital-acquired pneumonia. Ventilator-associated pneumonia and ICU–hospital-acquired pneumonia occurred in 1,161 at-risk patients (15%) and 176 at-risk patients (2%), respectively. When adjusted on prognostic variables, ventilator-associated pneumonia (hazard ratio, 1.38 (1.24–1.52); p < 0.0001) and even more ICU–hospital-acquired pneumonia (hazard ratio, 1.82 [1.35–2.45]; p < 0.0001) were associated with increased 30-day mortality. The early antibiotic therapy adequacy was not associated with an improved prognosis, particularly for ICU–hospital-acquired pneumonia. The impact was similar for ventilator-associated pneumonia and ICU–hospital-acquired pneumonia mortality due to P. aeruginosa and the ESKAPE group.

Conclusions: In a large cohort of patients, we found that both ICU–hospital-acquired pneumonia and ventilator-associated pneumonia were associated with an 82% and a 38% increase in the risk of 30-day mortality, respectively. This study emphasized the importance of preventing ICU–hospital-acquired pneumonia in nonventilated patients.

1UMR 1137, IAME, Université Paris Diderot, Paris, France.

2Departement of Emergency, AP-HP, Henri Mondor Hospital, Paris, France.

3Emergency Department, Henri Mondor Hospital, Medicine University Paris-Est Créteil Val de Marne, France.

4Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France.

5Intensive Care Unit, AP-HP, Avicenne Hospital, Paris, France.

6Intensive Care Unit, Medicine University, Paris 13 University, Bobigny, France.

7Outcomerea Research Network, Aulnay sous Bois, France.

8Medical Intensive Care Unit and University Hospital Centre, Nantes, France.

9Surgical Intensive Care Unit and Lyon University Hospital, Lyon, France.

10Critical Care Medicine Unit, CH Etampes-Dourdan, Etampes, France.

11Medical Intensive Care Unit, Saint Etienne University Hospital, Saint-Etienne, France.

12Intensive Care Unit, Jacques Lisfranc Medicine University, Jean Monnet University, Saint-Etienne, France.

13CH de Saint-Denis – Hôpital Delafontaine Service de Réanimation Polyvalente, Saint-Denis, Cedex, France.

14Medical ICU, Edouard Herriot University Hospital, Lyon, France.

15Medical Surgical ICU, Centre Hospitalier de Cayenne, Cayenne, French Guiana.

16Intensive Care Unit, Saint Joseph Hospital Network, Paris, France.

17Intensive Care Unit, Medicine University, Paris Descartes University, Sorbonne Cite, Paris, France.

18Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, La Tronche, France.

19Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France.

20Medical-Surgical Intensive Care Unit, Le Raincy-Montfermeil General hospital, France.

21Respiratory and infectious diseases ICU, APHM Hôpital Nord, Aix Marseille University, Marseille, France.

*See also p. 472.

The members of the OUTCOMEREA Network are listed in the supplementary appendix (Supplemental Digital Content 6, http://links.lww.com/CCM/E185).

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).

The OUTCOMEREA research network entirely funded the study.

The authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: timsit@bch.aphp.fr

Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.