Kollef M H, Silver P, Murphy D M, Trovillion E
Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
Chest. 1995 Dec;108(6):1655-62. doi: 10.1378/chest.108.6.1655.
To determine whether the development of late-onset ventilator-associated pneumonia (VAP) is associated with an increased risk of hospital mortality.
Prospective cohort study.
ICUs of two university-affiliated teaching hospitals.
Three hundred fourteen patients admitted to an ICU who required mechanical ventilation for greater than 5 days.
Prospective patient surveillance and data collection.
The primary outcome measures were the development of late-onset VAP (ie, occurring > 96 h after intubation) and hospital mortality.
Late-onset VAP was observed in 87 patients (27.7%). Thirty-four (39.1%) patients with late-onset VAP died during hospitalization compared with 85 patients (37.4%) without late-onset VAP (relative risk, 1.04; 95% confidence interval [CI], 0.76 to 1.43). Twenty patients (6.4%) developed late-onset VAP due to a "high-risk" pathogen (ie, Pseudomonas aeruginosa, Acinetobacter sp, Xanthomonas maltophilia) with an associated mortality rate of 65%. Stepwise logistic regression analysis identified five variables as independent risk factors for hospital mortality (p < 0.05): an organ system failure index of 3 or greater (adjusted odds ratio [AOR], 3.4; 95% CI, 2.0 to 5.8; p < 0.001), having a nonsurgical diagnosis (AOR, 2.1; 95% CI, 1.3 to 3.6; p = 0.002), a premorbid lifestyle score of 2 or greater (AOR, 1.8; 95% CI, 1.1 to 2.9; p = 0.015), acquiring late-onset VAP due to a "high-risk" pathogen (AOR, 3.4; 95% CI, 1.2 to 10.0; p = 0.025), and having received antacids or histamine type-2 receptor antagonists (AOR, 1.7; 95% CI, 1.0 to 2.9; p = 0.034). Additionally, we found the occurrence of late-onset VAP due to high-risk pathogens to be the most important predictor of hospital mortality among patients developing VAP (AOR, 5.4; 95% CI, 2.8 to 10.3; p = 0.009).
Nosocomial pneumonia due to certain high-risk microorganisms is an independent risk factor for hospital mortality among patients requiring prolonged mechanical ventilation. We suggest that future investigations of late-onset VAP stratify patient outcomes according to the distribution of high-risk pathogens when reporting their results.
确定迟发性呼吸机相关性肺炎（VAP）的发生是否与医院死亡率增加相关。
前瞻性队列研究。
两家大学附属医院的重症监护病房。
314名入住重症监护病房且需要机械通气超过5天的患者。
前瞻性患者监测和数据收集。
主要结局指标为迟发性VAP（即插管后>96小时发生）和医院死亡率。
87名患者（27.7%）发生迟发性VAP。34名（39.1%）迟发性VAP患者在住院期间死亡，而无迟发性VAP的患者有85名（37.4%）（相对风险，1.04；95%置信区间[CI]，0.76至1.43）。20名患者（6.4%）因“高危”病原体（即铜绿假单胞菌、不动杆菌属、嗜麦芽窄食单胞菌）发生迟发性VAP，相关死亡率为65%。逐步逻辑回归分析确定了五个变量为医院死亡率的独立危险因素（p<0.05）：器官系统衰竭指数为3或更高（调整优势比[AOR]，3.4；95%CI，2.0至5.8；p<0.001），非手术诊断（AOR，2.1；95%CI，1.3至3.6；p = 0.002），病前生活方式评分为2或更高（AOR，1.8；95%CI，1.1至2.9；p = 0.015），因“高危”病原体发生迟发性VAP（AOR，3.4；95%CI，1.2至10.0；p = 0.025），以及接受过抗酸剂或组胺2型受体拮抗剂治疗（AOR，1.7；95%CI，1.0至2.9；p = 0.034）。此外，我们发现因高危病原体导致的迟发性VAP的发生是发生VAP患者中医院死亡率的最重要预测因素（AOR，5.4；95%CI，2.8至10.3；p = 0.009）。
某些高危微生物引起的医院获得性肺炎是需要长期机械通气患者医院死亡率的独立危险因素。我们建议，未来关于迟发性VAP的研究在报告结果时应根据高危病原体的分布对患者结局进行分层。
