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Methicillin-resistant Staphylococcus aureus prolongs intensive care unit stay in ventilator-associated pneumonia,
Andrew F Shorr1, Alain Combes, Marin H Kollef
1Pulmonary and Critical Care Medicine, Washington Hospital Center, Washington, DC, USA.
Objective:
To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) on length of stay in the intensive care unit (ICU) for patients with ventilator-associated pneumonia (VAP) and to control for the effect of initially inappropriate antibiotic treatment on outcomes by focusing only on persons who were given appropriate antibiotic therapy for their infection.
Design:
Retrospective analysis of pooled, patient-level data from multiple clinical trials in VAP.
Setting:
Multiple ICUs in France.
Subjects:
Persons with bronchoscopically confirmed VAP due to either MRSA or methicillin-susceptible S. aureus (MSSA) and who received initially appropriate antibiotic treatment. All persons with MRSA VAP received vancomycin (15 mg/kg intravenously, twice daily).
Interventions:
None.
Measurements And Main Results:
We compared patients with MRSA VAP to persons with MSSA VAP. ICU length of stay represented the primary end point and ICU-free days served as a secondary end point. We recorded information regarding multiple confounders, including demographics, reasons for ICU admission and mechanical ventilation (MV), severity of illness at both ICU admission and time of diagnosis of VAP, and duration of mechanical ventilation before and following the onset of VAP. The final cohort included 107 patients, and one third of cases were due to MRSA. Despite receiving initially appropriate antibiotic treatment, median ICU length of stay was significantly longer for persons with MRSA infection (33 days vs. 22 days; p=.047). The median number of ICU-free days was concomitantly lower in MRSA VAP (0 days vs. 5 days; p=.011). Survival analysis employing a Cox proportional hazards model identified several predictors of remaining in the ICU: Pao2/Fio2 ratio at diagnosis of VAP, duration of MV before VAP, duration of MV after diagnosis of VAP, and reason for MV. Additionally, infection with MRSA as opposed MSSA doubled the probability of needing continued ICU care (hazard ratio, 2.08; 95% confidence interval, 1.09-3.95; p=.025).
Conclusions:
MRSA VAP independently prolongs the duration of ICU hospitalization, and in turn, increases overall costs, even for patients initially given appropriate antibiotic treatment. Confronting the adverse impact of MRSA will require efforts that address more than the initial antibiotic prescription.
Insights
Methicillin-resistant Staphylococcus aureus (MRSA) ventilator-associated pneumonia (VAP) significantly increases intensive care unit (ICU) length of stay, even with appropriate antibiotics. This MRSA VAP outcome highlights the need for strategies beyond initial antibiotic selection.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Hospital Epidemiology
Background:
- Ventilator-associated pneumonia (VAP) is a significant complication in intensive care units (ICUs).
- Methicillin-resistant Staphylococcus aureus (MRSA) is a common pathogen causing VAP, with potentially worse outcomes compared to methicillin-susceptible S. aureus (MSSA).
- The impact of MRSA on VAP outcomes, particularly length of stay, needs further clarification, especially when controlling for appropriate initial antibiotic therapy.
Purpose of the Study:
- To determine the impact of MRSA on ICU length of stay for patients with VAP.
- To assess the effect of MRSA on ICU-free days as a secondary outcome.
- To control for the influence of initially appropriate antibiotic treatment on these outcomes.
Main Methods:
- Retrospective analysis of pooled patient-level data from multiple clinical trials on VAP.
- Inclusion of patients with bronchoscopically confirmed VAP due to MRSA or MSSA who received appropriate initial antibiotic therapy.
- Comparison of ICU length of stay and ICU-free days between MRSA VAP and MSSA VAP cohorts, adjusting for confounders.
Main Results:
- Patients with MRSA VAP had a significantly longer median ICU length of stay (33 days) compared to MSSA VAP (22 days) (p=.047).
- MRSA VAP patients experienced fewer median ICU-free days (0 days vs. 5 days; p=.011).
- MRSA infection was independently associated with a doubled probability of continued ICU care (Hazard Ratio, 2.08; p=.025), even after appropriate antibiotic treatment.
Conclusions:
- MRSA VAP independently prolongs ICU hospitalization duration.
- The increased length of stay associated with MRSA VAP contributes to higher overall healthcare costs.
- Effective management of MRSA VAP necessitates strategies that extend beyond initial antibiotic selection.
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