Prediction of clinical severity and outcome of ventilator-associated pneumonia. Comparison of simplified acute physiology score with systemic inflammatory mediators.

Systemic kinetics of three inflammatory mediators (bactericidal/permeability-increasing protein [BPI], soluble intercellular adhesion molecule [sICAM], and soluble E-selectin [sE-selectin]) were studied during the development of ventilator-associated pneumonia (VAP) (n = 42), diagnosed on quantitative cultures of bronchoscopic samples. From a pool of collected samples, nested samples were used to measure mediators on Days -4, -2, 0, and +2, relative to diagnosis. Correlations between systemic levels of mediators and clinical severity of infection (VAP with or without severe sepsis or septic shock) and patient outcome (mortality at Day 10 after diagnosis) were studied. Predictive values of inflammatory mediators were compared with daily Simplified Acute Physiology Score II (SAPS II) values and the logarithmic number of bacteria in bronchoscopic samples. During the development of VAP, increasing SAPS II scores and rising systemic mediator levels were only found in patients in whom VAP was accompanied with severe sepsis or septic shock. Values of SAPS II and plasma levels of BPI and sE-selectin, but not sICAM, increased from the day of diagnosis on in patients who died within 10 d of diagnosis. Systemic levels of inflammatory mediators did not better predict clinical severity or patient outcome than daily SAPS II scores. The logarithmic number of bacteria in bronchoscopic samples poorly correlated with circulating levels of inflammatory mediators, severity of infection, and patient outcome. Our findings show that a clinical scoring system (SAPS II score) is at least as good as a predictor for the clinical severity of infection and patient outcome, and provide new information on the kinetics of inflammatory mediators during the development of VAP.