Combes Alain, Luyt Charles-Edouard, Fagon Jean-Yves, Wolff Michel, Trouillet Jean-Louis, Chastre Jean
Service de Réanimation Médicale, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris 6, France.
Crit Care Med. 2007 Jan;35(1):146-54. doi: 10.1097/01.CCM.0000249826.81273.E4.
Early recognition of predictors of unfavorable evolution of ventilator-associated pneumonia (VAP) might prompt therapeutic measures that might improve outcome. The objective of this study was to describe resolution of VAP variables and to determine early predictors of VAP recurrence and death.
Description of the natural course of VAP resolution and multivariable analyses of predictors of VAP recurrence and death by day 28 after VAP onset based on the 401 patients included in the PNEUMA trial, a multiple-center, randomized study comparing 8 vs. 15 days of antibiotics for microbiologically proven VAP. Every patient included in that trial had received appropriate empirical antibiotics.
By day 28 after VAP onset, 27% of patients had VAP recurrence and 18% had died. On day 8 after VAP onset, predictors of VAP recurrence included intensive care unit admission Simplified Acute Physiology Score II (odds ratio [OR], 1.02), radiologic score (OR, 1.17), temperature (OR, 1.34), nonfermenting Gram-negative bacilli (OR, 2.00) or methicillin-resistant Staphylococcus aureus (OR, 2.50) as pathogens responsible for VAP, and mechanical ventilation dependency (OR, 2.08). Day 8 predictors of 28-day death were age (OR, 1.06), female sex (OR, 2.30), Sepsis-Related Organ Failure Assessment score (OR, 1.26), and nonfermenting Gram-negative bacilli (OR, 2.83) as pathogens responsible for VAP. However, the duration of antimicrobial therapy (8 vs. 15 days) was not associated with any of the studied adverse outcomes.
For patients benefiting from appropriate empirical antibiotics for VAP, early predictors of infection recurrence or death included demographic characteristics, such as age or female sex, disease severity at VAP onset, nonfermenting Gram-negative bacilli or methicillin-resistant S. aureus as VAP-causative pathogens, prolonged mechanical ventilation dependency, persistent fever, and severity of lung injury. Future studies should attempt to determine whether specific diagnostic or therapeutic strategies could markedly improve VAP outcomes when early criteria for treatment failure are present.
早期识别呼吸机相关性肺炎（VAP）不良进展的预测因素可能会促使采取改善预后的治疗措施。本研究的目的是描述VAP各项指标的缓解情况，并确定VAP复发和死亡的早期预测因素。
基于PNEUMA试验纳入的401例患者，描述VAP缓解的自然病程，并对VAP发作后第28天VAP复发和死亡的预测因素进行多变量分析。PNEUMA试验是一项多中心随机研究，比较针对微生物学确诊的VAP使用8天与15天抗生素治疗的效果。该试验纳入的每位患者均接受了适当的经验性抗生素治疗。
在VAP发作后第28天，27%的患者出现VAP复发，18%的患者死亡。在VAP发作后第8天，VAP复发的预测因素包括重症监护病房入院时的简化急性生理学评分II（比值比[OR]，1.02）、放射学评分（OR，1.17）、体温（OR，1.34）、作为VAP致病病原体的非发酵革兰阴性杆菌（OR，2.00）或耐甲氧西林金黄色葡萄球菌（OR，2.50），以及机械通气依赖（OR，2.08）。第8天预测28天死亡的因素包括年龄（OR，1.06）、女性（OR，2.30）、脓毒症相关器官功能衰竭评估评分（OR，1.26），以及作为VAP致病病原体的非发酵革兰阴性杆菌（OR，2.83）。然而，抗菌治疗的持续时间（8天与15天）与任何一项研究的不良结局均无关联。
对于受益于适当的VAP经验性抗生素治疗的患者，感染复发或死亡的早期预测因素包括人口统计学特征，如年龄或女性，VAP发作时的疾病严重程度，作为VAP致病病原体的非发酵革兰阴性杆菌或耐甲氧西林金黄色葡萄球菌，机械通气依赖时间延长，持续发热，以及肺损伤的严重程度。未来的研究应尝试确定当存在治疗失败的早期标准时，特定的诊断或治疗策略是否能显著改善VAP的预后。
