Impact of appropriate antimicrobial treatment on transition from ventilator-associated tracheobronchitis to ventilator-associated pneumonia

Critical Care, Jun 2014

Introduction Two small randomized controlled trials have suggested beneficial effects of antibiotic treatment in patients with ventilator-associated tracheobronchitis (VAT). The primary aim of this study is to determine the impact of appropriate antibiotic treatment on transition from VAT to ventilator-associated pneumonia (VAP) in critically ill patients. The secondary objective was to determine the incidence of VAP in patients with VAT. Methods This was a prospective observational multicenter study. All patients with a first episode of VAT were eligible. Patients with tracheostomy at intensive care unit (ICU) admission, and those with VAP prior to VAT were excluded. VAT was defined using all the following criteria: fever > 38°C with no other cause, purulent tracheal secretions, positive tracheal aspirate (≥105 cfu/mL), and absence of new infiltrate on chest X ray. Only VAP episodes diagnosed during the 96 h following VAT, and caused by the same bacteria, were taken into account. Antibiotic treatment was at the discretion of attending physicians. Risk factors for transition from VAT to VAP were determined using univariate and multivariate analysis. All variables from univariate analysis with P values <0.1 were incorporated in the multivariate logistic regression analysis. Results One thousand seven hundred and ten patients were screened for this study. Eighty-six, and 123 patients were excluded for tracheostomy at ICU admission, and VAP prior to VAT; respectively. One hundred and twenty two (7.1%) patients were included. 17 (13.9%) patients developed a subsequent VAP. The most common microorganisms in VAT patients were Pseudomonas aeruginosa (30%), Staphylococcus aureus (18%), and Acinetobacter baumannii (10%). Seventy-four (60%) patients received antimicrobial treatment, including 58 (47.5%) patients who received appropriate antimicrobial treatment. Appropriate antibiotic treatment was the only factor independently associated with reduced risk for transition from VAT to VAP (OR [95% CI] 0.12[0.02-0.59], P = 0.009). The number of patients with VAT needed to treat to prevent one episode of VAP, or one episode of VAP related to P. aeruginosa was 5, and 34; respectively. Conclusions Appropriate antibiotic treatment is independently associated with reduced risk for transition from VAT to VAP.

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Impact of appropriate antimicrobial treatment on transition from ventilator-associated tracheobronchitis to ventilator-associated pneumonia

Saad Nseir 0 1 3 Ignacio Martin-Loeches 0 3 Demosthenes Makris 2 Emmanuelle Jaillette 1 Marios Karvouniaris 2 Jordi Valles 0 3 Epaminondas Zakynthinos 2 Antonio Artigas 0 3 0 Critical Care Center, Sabadell Hospital, CIBER de Enfermedades Respiratorias, Corporacio Sanitaria Universitaria Parc Tauli, Universitat Autonoma de Barcelona , Sabadell , Spain 1 Critical Care Department, R. Salengro Hospital, University Hospital of Lille, Rue Emile Laine , 59037 Lille, Cedex , France 2 Intensive Care Unit, University Hospital of Larisa, University of Thessaly , Biopolis Street, 41110 Larisa , Greece 3 Critical Care Center, Sabadell Hospital, CIBER de Enfermedades Respiratorias, Corporacio Sanitaria Universitaria Parc Tauli, Universitat Autonoma de Barcelona , Sabadell , Spain Introduction: Two small randomized controlled trials have suggested beneficial effects of antibiotic treatment in patients with ventilator-associated tracheobronchitis (VAT). The primary aim of this study is to determine the impact of appropriate antibiotic treatment on transition from VAT to ventilator-associated pneumonia (VAP) in critically ill patients. The secondary objective was to determine the incidence of VAP in patients with VAT. Methods: This was a prospective observational multicenter study. All patients with a first episode of VAT were eligible. Patients with tracheostomy at intensive care unit (ICU) admission, and those with VAP prior to VAT were excluded. VAT was defined using all the following criteria: fever > 38C with no other cause, purulent tracheal secretions, positive tracheal aspirate (105 cfu/mL), and absence of new infiltrate on chest X ray. Only VAP episodes diagnosed during the 96 h following VAT, and caused by the same bacteria, were taken into account. Antibiotic treatment was at the discretion of attending physicians. Risk factors for transition from VAT to VAP were determined using univariate and multivariate analysis. All variables from univariate analysis with P values <0.1 were incorporated in the multivariate logistic regression analysis. Results: One thousand seven hundred and ten patients were screened for this study. Eighty-six, and 123 patients were excluded for tracheostomy at ICU admission, and VAP prior to VAT; respectively. One hundred and twenty two (7.1%) patients were included. 17 (13.9%) patients developed a subsequent VAP. The most common microorganisms in VAT patients were Pseudomonas aeruginosa (30%), Staphylococcus aureus (18%), and Acinetobacter baumannii (10%). Seventy-four (60%) patients received antimicrobial treatment, including 58 (47.5%) patients who received appropriate antimicrobial treatment. Appropriate antibiotic treatment was the only factor independently associated with reduced risk for transition from VAT to VAP (OR [95% CI] 0.12[0.02-0.59], P = 0.009). The number of patients with VAT needed to treat to prevent one episode of VAP, or one episode of VAP related to P. aeruginosa was 5, and 34; respectively. Conclusions: Appropriate antibiotic treatment is independently associated with reduced risk for transition from VAT to VAP. - Introduction Ventilator-associated tracheobronchitis (VAT) is common in intubated critically ill patients. This infection represents an intermediate process between colonization of lower respiratory tract and ventilator-associated pneumonia (VAP). VAT is characterized by increased purulent sputum production and lower respiratory tract inflammation resulting in difficult weaning and prolonged duration of mechanical ventilation [1-3]. Two recent randomized trials reported beneficial effects of antibiotic treatment in patients with VAT. In a randomized blinded placebo-controlled trial, aerosolized antibiotics significantly reduced the incidence of subsequent VAP [4]. Further, aerosolized antibiotics increased weaning from mechanical ventilation, reduced usage of systemic antibiotics and antibiotic resistance. The impact of systemic antibiotics on outcomes of VAT patients was evaluated in a randomized unblinded controlled study [5]. Antibiotic treatment increased mechanical-ventilationfree days, and reduced the incidence of subsequent VAP and ICU-mortality. However, these studies had some limitations precluding definite conclusions. The beneficial effects of antibiotic treatment in VAT patients should be confirmed by future large multicenter studies. Inappropriate antibiotic treatment was repeatedly identified as a major risk factor for worse outcome in patients with severe sepsis and VAP [6]. To our knowledge, no data are available on the impact of appropriate antibiotic treatment on outcome in patients with VAT. Therefore, we planned this prospective observational study to determine the impact of appropriate antibiotic treatment on the transition from VAT to VAP. Our hypothesis is that appropriate antibiotic treatment would be associated with reduced risk for transition from VAT to VAP. Methods This prospective observational study was performed in thr (...truncated)


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Saad Nseir, Ignacio Martin-Loeches, Demosthenes Makris, Emmanuelle Jaillette, Marios Karvouniaris, Jordi Valles, Epaminondas Zakynthinos, Antonio Artigas. Impact of appropriate antimicrobial treatment on transition from ventilator-associated tracheobronchitis to ventilator-associated pneumonia, Critical Care, 2014, pp. R129, 18, DOI: 10.1186/cc13940