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Published on: March 17, 2014
Pseudomonas aeruginosa ventilator-associated pneumonia. predictive factors of treatment failure
Benjamin Planquette1, Jean-Francois Timsit, Benoit Y Misset
1André Mignot Hospital, Versailles-Le Chesnay, France. benjamin.planquette@gmail.com
Rationale:
The predictive factors of treatment failure for ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa (PA) remain uncertain.
Objectives:
To describe PA-VAP recurrence prognosis and to identify associated risk factors in a large cohort of intensive care unit patients with PA-VAP.
Methods:
From the multicenter OUTCOMEREA database (1997-2011), PA-VAP onset and recurrence were recorded. All suspected cases of VAP were confirmed by a positive quantitative culture of a respiratory sample. Multidrug-resistant PA strains were defined by the resistance to two antibiotics among piperacillin, ceftazidime, imipenem, colistine, and fluoroquinolones (FQ). An extensively resistant PA was defined by resistance to piperacillin, ceftazidime, imipenem, and FQ. A treatment failure was defined as a PA-VAP recurrence or by the death occurrence.
Measurements And Main Results:
A total of 314 patients presented 393 PA-VAP. Failure occurred for 112 of them, including 79 recurrences. Susceptible, multidrug resistant, and extensively resistant PA represented 53.7%, 32%, and 14.3% of the samples, respectively. Factors associated with treatment failure were age (P = 0.02); presence of at least one chronic illness (P = 0.02); limitation of life support (P = 0.0004); a high Sepsis-Related Organ Failure Assessment score (P < 0.0001); PA bacteremia (P = 0.003); and previous use of FQ before the first PA-VAP (P = 0.0007). The failure risk was not influenced by the strain resistance profile or by the biantibiotic treatment, but decreased in case of VAP treatment that includes FQ (subdistribution hazard ratio, 0.5 [0.3-0.7]; P = 0.0006). However, the strain resistance profile slowed down the intensive care unit discharge hazard (subdistribution hazard ratio, 0.6 [0.4-1.0]; P = 0.048).
Conclusions:
Neither resistance profile nor biantibiotic therapy decreased the risk of PA-VAP treatment failure. However, the profile of PA resistance prolonged the length of stay. Better evaluation of the potential benefit of an initial treatment containing FQ requires further randomized trials.
Insights
Treatment failure in Pseudomonas aeruginosa ventilator-associated pneumonia (PA-VAP) is linked to patient factors, not resistance profiles. Fluoroquinolone (FQ) treatment may reduce failure risk, but PA resistance prolongs hospital stays.
Area of Science:
- Critical Care Medicine
- Infectious Diseases
- Respiratory Medicine
Background:
- Ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa (PA) presents uncertain treatment failure predictors.
- Understanding PA-VAP recurrence and risk factors is crucial for improving patient outcomes in intensive care units (ICUs).
Purpose of the Study:
- To determine the prognosis of PA-VAP recurrence.
- To identify risk factors associated with PA-VAP treatment failure in a large ICU patient cohort.
Main Methods:
- Retrospective analysis of the multicenter OUTCOMEREA database (1997-2011).
- Recording of PA-VAP onset and recurrence, with VAP confirmed by positive respiratory sample culture.
- Defining multidrug-resistant (MDR) and extensively drug-resistant (XDR) PA strains based on antibiotic resistance patterns.
Main Results:
- Factors associated with PA-VAP treatment failure included older age, chronic illness, limited life support, high SOFA score, PA bacteremia, and prior fluoroquinolone (FQ) use.
- Treatment failure risk was not influenced by PA strain resistance or biantibiotic therapy.
- Initial treatment including FQ decreased PA-VAP failure risk (SHR 0.5 [0.3–0.7]; P = 0.0006).
- PA resistance profiles prolonged ICU length of stay (SHR 0.6 [0.4–1.0]; P = 0.048).
Conclusions:
- Neither PA resistance profile nor biantibiotic therapy impacted PA-VAP treatment failure risk.
- PA resistance profiles were associated with prolonged ICU stays.
- Further randomized trials are needed to evaluate the benefit of initial FQ-containing VAP treatment.
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