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* From the Washington University School of Medicine (Dr. Kollef), St. Louis, MO; the Department of Pulmonary and Critical Care Medicine (Dr. Morrow), Creighton University, Omaha, NE; the Department of Internal Medicine (Dr. Niederman), Winthrop University Hospital, Mineola, NY; the Department of Pulmonary and Critical Care Medicine (Dr. Leeper), Emory University, Atlanta, GA; the Department of Pulmonary and Critical Care Medicine (Dr. Anzueto), University of Texas Health Sciences Center, Houston, TX; and Rodino Healthcare (Drs. Bullard and Rodino), Millburn, NJ.
Correspondence to: Marin H. Kollef, MD, FCCP, Campus Box 8052, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO 63110; e-mail: mkollef{at}im.wustl.edu
Abstract
Study objectives: To evaluate clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia (VAP), including the implementation of and outcomes associated with deescalation therapy.
Design: Prospective, observational, cohort study.
Setting: Twenty ICUs throughout the United States.
Patients: A total of 398 ICU patients meeting predefined criteria for suspected VAP.
Interventions: Prospective, handheld, computer-based data collection regarding routine VAP management according to local institutional practices, including clinical and microbiological characteristics, treatment patterns, and outcomes.
Measurements and results: The most frequent ICU admission diagnoses in patients with VAP were postoperative care (15.6%), neurologic conditions (13.3%), sepsis (13.1%), and cardiac complications (10.8%). The mean (± SD) duration of mechanical ventilation prior to VAP diagnosis was 7.3 ± 6.9 days. Major pathogens were identified in 197 patients (49.5%) through either tracheal aspirate or BAL fluid and included primarily methicillin-resistant Staphylococcus aureus (14.8%), Pseudomonas aeruginosa (14.3%), and other Staphylococcus species (8.8%). More than 100 different antibiotic regimens were prescribed as initial VAP treatment, the majority of which included cefepime (30.4%) or a ureidopenicillin/monobactam combination (27.9%). The mean duration of therapy was 11.8 ± 5.9 days. In the majority of cases (61.6%), therapy was neither escalated nor deescalated. Escalation of therapy occurred in 15.3% of cases, and deescalation occurred in 22.1%. The overall mortality rate was 25.1%, with a mean time to death of 16.2 days (range, 0 to 49 days). The mortality rate was significantly lower among patients in whom therapy was deescalated (17.0%), compared with those experiencing therapy escalation (42.6%) and those in whom therapy was neither escalated nor deescalated (23.7%; 
2 = 13.25; p = 0.001).
Conclusions: Treatment patterns for VAP vary widely from institution to institution, and the overall mortality rate remains unacceptably high. The deescalation of therapy in VAP patients appears to be associated with a reduction in mortality, which is an association that warrants further clinical study.
Key Words: mortality • nosocomial infections • outcomes • pneumonia • treatment • ventilator
This article has been cited by other articles:
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  L. Vidaur, K. Planas, R. Sierra, G. Dimopoulos, A. Ramirez, T. Lisboa, and J. Rello Ventilator-Associated Pneumonia: Impact of Organisms on Clinical Resolution and Medical Resources Utilization Chest, March 1, 2008; 133(3): 625 - 632. [Abstract] [Full Text] [PDF]
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 VAP -- A "Real Life" View Journal Watch Infectious Diseases, June 9, 2006; 2006(609): 3 - 3. [Full Text]
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