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


Crit Care. 2020;24(383) 

In This Article

Prognostic Factors

Pneumonia acquired in the ICU leads to a negative impact in terms of morbidity, prolonged stay and duration of MV in case of VAP and a consequent increase in healthcare cost.[24] More controversial is the direct relationship between the development of nosocomial pneumonia and increase in mortality.[50,51]

Various factors have been associated with a worse prognosis of pneumonia including the existence of comorbidities, the patient's performance status, the infection severity at the time of its development and the patient's response to infection. However, the study of these factors is routinely eclipsed when the same analysis is performed whether or not a suitable empirical antibiotic is used.[52]

The choice of an inappropriate antibiotic treatment, which is directly related to the existence of MDROs, is probably the most relevant and, even more important, potentially modifiable prognostic factor. In fact, the likelihood of death in case of inappropriate treatment substantially increases mortality in patients with severe infections.[53,54]

Therefore, to correctly evaluate the remaining prognostic factors, it is necessary to focus the analysis on those patients who receive a suitable empirical treatment. As a second step, we must choose between two possible clinical scenarios; to consider which factors, patient and disease-related are associated with a worse final outcome or to perform a more dynamic analysis and to try to elucidate which clinical course is associated with a poor response to the treatment and, consequently, a worse final outcome. Following the first option, older age, existence of a malignant haematology disease or clinical onset in the form of septic shock or severe acute respiratory failure will be associated with higher mortality, but there is not much clinical application of this association.[55] In the same way, it occurs with analytical aspects such as initial lymphopaenia.[56]

There is more interest in the evaluation of the response to early treatment strategies. Against this backdrop, Esperatti et al. validated a few years ago the association between a series of clinical variables 72 to 96 h from the onset of treatment with the prognosis of 335 patients with nosocomial pneumonia.[57] The absence of improved oxygenation, the need for mechanical ventilation in case of HAP, the persistence of fever or hypothermia together with purulent respiratory secretions, radiological worsening in more than 50% of the lung area or the development of septic shock or multi-organ failure after the onset of antibiotic treatment were more common in patients with a worse clinical course (in terms of ICU and hospital length of stay, duration of mechanical ventilation and mortality). Amongst all of these aforementioned factors, the absence of improved oxygenation was significantly associated with greater mortality (OR 2.18 [1.24–3.84] p = 0.007). In regard to both the original figure and course at 72–96 h of scales such as the CPIS or biomarkers such as C-reactive protein or procalcitonin, most studies agree over its prognostic use and follow-up of infection.[58]