Update of the Treatment of Nosocomial Pneumonia in the ICU

Rafael Zaragoza; Pablo Vidal-Cortés; Gerardo Aguilar; Marcio Borges; Emili Diaz; Ricard Ferrer; Emilio Maseda; Mercedes Nieto; Francisco Xavier Nuvials; Paula Ramirez; Alejandro Rodriguez; Cruz Soriano; Javier Veganzones; Ignacio Martín-Loeches

Disclosures

Crit Care. 2020;24(383) 

In This Article

Impact on Outcome

According to a case-control study, HAP patients presented a worse clinical course: higher mortality (19% vs 3.9%), more ICU admissions (56.3% vs 22.8%) and longer hospital stay (15.9 days vs 4.4 days). Overall, patients with HAP presented an odds ratio of dying 8.4 times higher than non-HAP patients.[38] It has traditionally been considered that VAP-associated mortality is higher than HAP.[39] When ICU-HAP was compared to VAP,[25] the crude mortality was similar, which suggests that it is related more to patient-related factors than prior intubation. Therefore, when analysing data from 10 recent clinical trials in ICU patients, mortality was greater for HAP requiring MV, somewhat lower in VAP and less for non-ventilated HAP.[40] The need for intubation in this population is probably a marker of poor clinical progression of pneumonia. Adjusted mortality rates were similar for VAP and ventilated HAP. In a recent multicentre study that includes more than 14,000 patients and investigates the impact of VAP and HAP in the ICU, both were associated with a higher risk of death at 30 days [HR 1.38 (1.24–1.52) for VAP and 1.82 (1.35–2.45) for HAP].[37]

Overall, the mortality from HAP of 13% with an increase in hospital stay of 4 to 16 days and increased cost of 40,000 dollars per episode has been reported.[27] VAP has also been associated with an increased stay in the ICU and hospital, in addition to the increased time under mechanical ventilation.[41] The crude mortality rates of patients with VAP vary between 24 and 72%, with greater mortality in VAP caused by Pseudomonas aeruginosa.[42] The more recent data estimate attributable mortality of 13%, higher in patients with intermediate severity and in surgical patients.[43] As for VAT, this has been related in different studies to a longer stay in ICU and more days of MV. However, to date, there are no randomized controlled trials showing a beneficial effect for the treatment in VAT. Moreover, higher mortality in patients presenting this complication has not been observed.[21,36,44]

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