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Patterns of Early and Late Ventilator-Associated Pneumonia Due to Methicillin-Resistant Staphylococcus aureus in a Trauma Population

Kashuk, Jeffry L. MD; Moore, Ernest E. MD; Price, Connie S. MD; Zaw-Mon, Christopher MD; Nino, Theresa RN; Haenel, James RRT; Biffl, Walter L. MD; Burlew, C. Cothren MD; Johnson, Jeffrey L. MD

The Journal of Trauma: Injury, Infection, and Critical Care: September 2010 - Volume 69 - Issue 3 - p 519-522
doi: 10.1097/TA.0b013e3181c4521c
Original Article

Background: Community-acquired methicillin-resistant Staphylococcal aureus (CA-MRSA) infection is approaching endemic proportions nationally, and it is a potential cause for early ventilator-associated pneumonia (VAP) in the acutely injured patient. We sought to determine the prevalence of early (≤4 days) and late (>4 days) MRSA pneumonia in ventilated multisystem trauma patients and to correlate findings with admission nasal swabs.

Methods: We performed a review of our prospective trauma and infectious disease data bases for all patients admitted to our surgical intensive care unit with early (≤4 days) and late (>4 days) VAP during a 4-year period. The diagnosis of pneumonia was established by clinical pulmonary infection score >6, bronchoalveolar lavage, and quantitative cultures showing >104 organisms. Nasal swabs for early identification of MRSA carriers were performed routinely at admission.

Results: One hundred seventy-six patients were identified with S. aureus VAP. Patients with MRSA were compared with those with methicillin-susceptible S. aureus (MSSA). There were 47 (27%) early MSSA VAP and only 4 (2.2%) with early MRSA VAP. One hundred twenty-five patients were diagnosed with late VAP. Forty patients (23%) had MRSA VAP and 85 patients (64%) had MSSA VAP. None of the four patients with an early MRSA VAP had positive nasal swabs at admission.

Conclusion: Despite an increase of MRSA nationally, we found a low incidence of early and late MRSA VAP in trauma patients, which was not identified by nasal swab screening. On the basis of our results, we question the efficacy of empiric vancomycin therapy in early (≤4 days) S. aureus VAP. Furthermore, nasal swabs were not helpful in identifying patients at risk for MRSA VAP.

From the Department of Surgery (J.L.K.), Division of Acute Care Surgery, Penn State Hershey Medical Center and College of Medicine, Hershey, PA; Departments of Surgery (E.E.M., C.Z.-M., J.H., W.L.B., C.C.B., J.L.J.), Medicine (Infectious Diseases) (C.S.P.), and Nursing (T.N.), Rocky Mountain Regional Trauma Center, Denver Health Medical Center, University of Colorado, Denver School of Medicine, Denver, Colorado.

Submitted for publication April 29, 2009.

Accepted for publication September 4, 2009.

Presented, in part, at the Society of Critical Care Medicine, 37th Congress, Honolulu, Hi, February 2–6, 2008.

Address for reprints: Jeffry L. Kashuk, MD, Department of Surgery, Division of Trauma, Acute Care, and Acute Care Surgery, Penn State Hershey Medical Center and College of Medicine, 500 University Dr, MC H075, Hershey, PA 17033; email:

© 2010 Lippincott Williams & Wilkins, Inc.