Intensive Care Medicine

, Volume 33, Issue 8, pp 1387–1395 | Cite as

Management of ventilator-associated pneumonia in a multidisciplinary intensive care unit: does trauma make a difference?

  • Kemal Agbaht
  • Thiago Lisboa
  • Angel Pobo
  • Alejandro Rodriguez
  • Alberto Sandiumenge
  • Emili Diaz
  • Jordi Rello



Antibiotic exposure and timing of pneumonia onset influence ventilator-associated pneumonia (VAP) isolates. The first goal of this investigation was to evaluate whether trauma also influences prevalence of microorganisms.


A retrospective, single-center, observational cohort study.


Multidisciplinary teaching ICU.


Adult patients requiring mechanical ventilation identified as having VAP.


Retrospective evaluation of a prospective manual database.

Measurements and main results

VAP isolates in a multidisciplinary ICU documented by quantitative respiratory cultures and recorded in a 42-month database were compared, based on the presence or absence of trauma. Causative microorganisms were classified in four groups, based on mechanical ventilation duration (> 5 days), and previous antibiotic exposure. One hundred eighty-three patients developed 196 episodes of VAP (98 trauma). Methicillin-sensitive Staphylococcus aureus (MSSA) was more frequent (34.5% vs. 11.5%, p < 0.01) in trauma, whereas methicillin-resistant Staphylococcus aureus (MRSA) was more frequent (2% vs. 11.5%, p < 0.01) in non-trauma. No significant differences were found between trauma and non-trauma patients regarding prevalence of other microorganisms. In trauma patients, MSSA episodes were equally distributed between early- and late-onset VAP (51% vs. 49%), but no MRSA episode occurred in the early-onset group.


Trauma influences the microbiology of pneumonia and it should be considered in the initial antibiotic regimen choice. Our data demonstrate that patients with trauma had a higher prevalence of MSSA, but the overall prevalence was sufficiently high to warrant S. aureus coverage for both groups. On the other hand, since no MRSA was isolated during the first 10 days of mechanical ventilation on trauma patients, MRSA coverage in these patients becomes necessary only 10 days after admission.


Ventilator-associated pneumonia Trauma Antibiotics Methicillin resistance Staphylococcus aureus 



We are indebted to Mr. Michael Maudsley for editing our English.


  1. 1.
    Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M (1995) The prevalence of nosocomial infection in intensive care units in europe. Results of the European prevalence of infection in intensive care (EPIC) study. Epic international advisory committee. JAMA 274:639–644PubMedCrossRefGoogle Scholar
  2. 2.
    Fagon JY, Chastre J, Vuagnat A, Trouillet JL, Novara A, Gibert C (1996) Nosocomial pneumonia and mortality among patients in intensive care units. JAMA 275:866–869PubMedCrossRefGoogle Scholar
  3. 3.
    Heininger A, Krueger WA, Doring G, Unertl K (2002) Ventilator-associated pneumonia. Curr Opin Anaesthesiol 15(2):153–159PubMedCrossRefGoogle Scholar
  4. 4.
    Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH (2002) Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest 122:262–268PubMedCrossRefGoogle Scholar
  5. 5.
    Dupont H, Mentec H, Sollet JP, Bleichner G (2001) Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator-associated pneumonia. Intensive Care Med 27:355–362PubMedCrossRefGoogle Scholar
  6. 6.
    Sandiumenge A, Diaz E, Bodi M, Rello J (2003) Therapy of ventilator-associated pneumonia. A patient-based approach based on the ten rules of “The Tarragona Strategy”. Intensive Care Med 29:876–883PubMedGoogle Scholar
  7. 7.
    American Thoracic Society (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171:388–416CrossRefGoogle Scholar
  8. 8.
    Rello J, Jubert P, Valles J, Artigas A, Rue M, Niederman MS (1996) Evaluation of outcome for intubated patients with pneumonia due to Pseudomonas aeruginosa. Clin Infect Dis 23:973–978PubMedGoogle Scholar
  9. 9.
    Rello J, Ausina V, Ricart M, Puzo C, Quintana E, Net A, Prats G (1994) Risk factors for infection by Pseudomonas aeruginosa in patients with ventilator-associated pneumonia. Intensive Care Med 20:193–198PubMedCrossRefGoogle Scholar
  10. 10.
    Antonelli M, Moro ML, Capelli O, De Blasi RA, D'Errico DA, Conti G (1994) Risk factors for early-onset pneumonia in trauma patients. Chest 105:224–228PubMedGoogle Scholar
  11. 11.
    Kollef MH, Morrow LE, Niederman MS, Leeper KV, Anzueto A, Benz-Scott L, Rodino FJ (2006) Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest 129:1210–1218PubMedCrossRefGoogle Scholar
  12. 12.
    Vidaur L, Gualis B, Rodriguez A, Ramirez R, Sandiumenge A, Sirgo G, Diaz E, Rello J (2005) Clinical resolution in patients with suspicion of ventilator-associated pneumonia: A cohort study comparing patients with and without acute respiratory distress syndrome. Crit Care Med 33:1248–1253PubMedCrossRefGoogle Scholar
  13. 13.
    Rello J, Vidaur L, Sandiumenge A, Rodriguez A, Gualis B, Boque C, Diaz E (2004) De-escalation therapy in ventilator-associated pneumonia. Crit Care Med 32:2183–2190PubMedGoogle Scholar
  14. 14.
    Meduri GU, Chastre J (1992) The standardization of bronchoscopic techniques for ventilator-associated pneumonia. Chest 102:557S–564SPubMedGoogle Scholar
  15. 15.
    Centers for Disease Control (1989) CDC definitions for nosocomial infections. Am Rev Respir Dis 139:1058–1059Google Scholar
  16. 16.
    Beardsley J, Williamson J, Johnson J, Ohl C, Karchmer T, Bowton D (2006) Using local microbiologic data to develop institution-specific guidelines for the treatment of hospital-acquired pneumonia. Chest 130:787–793PubMedCrossRefGoogle Scholar
  17. 17.
    Rello J, Sa-Borges M, Correa H, Leal SR, Baraibar J (1999) Variations in etiology of ventilator-associated pneumonia across four treatment sites: implications for antimicrobial prescribing practices. Am J Respir Crit Care Med 160:608–613PubMedGoogle Scholar
  18. 18.
    Rimel RW, Tyson GW (1979) The neurologic examination in patients with central nervous system trauma. J Neurosurg Nurs 11:148–155PubMedGoogle Scholar
  19. 19.
    Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R (1994) The American–European consensus conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824PubMedGoogle Scholar
  20. 20.
    Lujan M, Gallego M, Fontanals D, Mariscal D, Rello J (2004) Prospective observational study of bacteremic pneumococcal pneumonia: Effect of discordant therapy on mortality. Crit Care Med 32:625–631PubMedCrossRefGoogle Scholar
  21. 21.
    Rello J, Mariscal D, Gallego M, Valles J (2002) Effect of enriched thioglycolate on direct examination of respiratory specimens and guiding initial empirical therapy in intubated patients with pneumonia: a prospective, randomized study. Crit Care Med 30:311–314PubMedCrossRefGoogle Scholar
  22. 22.
    Rincon-Ferrari MD, Flores-Cordero JM, Leal-Noval SR, Murillo-Cabezas F, Cayuelas A, Munoz-Sanchez MA, Sanchez-Olmedo JI (2004) Impact of ventilator-associated pneumonia in patients with severe head injury. J Trauma 57:1234–1240PubMedGoogle Scholar
  23. 23.
    Bochicchio GV, Joshi M, Bochicchio K, Tracy K, Scalea TM (2004) A time-dependent analysis of intensive care unit pneumonia in trauma patients. J Trauma 56:296–301PubMedCrossRefGoogle Scholar
  24. 24.
    Espersen F, Gabrielsen J (1981) Pneumonia due to Staphylococcus aureus during mechanical ventilation. J Infect Dis 144:19–23PubMedGoogle Scholar
  25. 25.
    Rello J, Ausina V, Castella J, Net A, Prats G (1992) Nosocomial respiratory tract infections in multiple trauma patients. Influence of level of consciousness with implications for therapy. Chest 102:525–529PubMedGoogle Scholar
  26. 26.
    Rello J, Quintana E, Ausina V, Puzo C, Net A, Prats G (1990) Risk factors for Staphylococcus aureus nosocomial pneumonia in critically ill patients. Am Rev Respir Dis 142:1320–1324PubMedGoogle Scholar
  27. 27.
    Pickworth KK, Falcone RE, Hoogeboom JE, Santanello SA (1993) Occurrence of nosocomial pneumonia in mechanically ventilated trauma patients: a comparison of sucralfate and ranitidine. Crit Care Med 21:1856–1862PubMedCrossRefGoogle Scholar
  28. 28.
    Koulenti D, Myrianthefs P, Dimopoulos G, Baltopoulos G (2005) Hospital-acquired pneumonia caused by methicillin-resistant Staphylococcus aureus. Enferm Infecc Microbiol Clin S3:37–45CrossRefGoogle Scholar
  29. 29.
    Rello J, Torres A, Ricart M, Valles J, Gonzalez J, Artigas A, Rodriguez-Roisin R (1994) Ventilator-associated pneumonia by Staphylococcus aureus. Comparison of methicillin-resistant and methicillin-sensitive episodes. Am J Respir Crit Care Med 150:1545–1549PubMedGoogle Scholar
  30. 30.
    Kuehnert MJ, Hill HA, Kupronis BA, Tokars JI, Solomon SL, Jernigan DB (2005) Methicillin-resistant-Staphylococcus aureus hospitalizations, United States. Emerg Infect Dis 11:868–872PubMedGoogle Scholar
  31. 31.
    Campbel W, Hendrix E, Schwalbe R, Fattom A, Edelman R (1999) Head-injured patients who are nasal carriers of Staphylococcus aureus are at high risk for Staphylococcus aureus pneumonia. Crit Care Med 27:798–801CrossRefGoogle Scholar
  32. 32.
    Brochard R, Albaladejo P, Brezac A, Geffroy P, Seince F, Morris W, Branger C, Marty J (2004) Early-onset pneumonia: risk factors and consequences in head trauma patients. Anesthesiology 100:234–239CrossRefGoogle Scholar
  33. 33.
    Sirvent J, Torres A, Vidaur L, Armengol J, de Batle J, Bonet A (2000) Tracheal colonisation within 24h of intubation in patients with head trauma: risk factor for developing early-onset ventilator-associated pneumonia. Intensive Care Med 26:1369–1372PubMedCrossRefGoogle Scholar
  34. 34.
    Ewig S, Torres A, El-Ebiary M, Fabregas N, Hernandez C, Gonzales J, Nicolas JM, Soto L (1999) Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury. Incidence, risk factors, and association with ventilator-associated pneumonia. Am J Respir Crit Care Med 159:188–198PubMedGoogle Scholar
  35. 35.
    Navon-Venezia S, Ben-Ami R, Carmeli Y (2005) Update on Pseudomonas aeruginosa and Acinetobacter baumannii infections in the healthcare setting. Curr Opin Infect Dis 18:306–313PubMedCrossRefGoogle Scholar
  36. 36.
    Falagas ME, Kopterides P (2006) Risk factors for the isolation of multi-drug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa: a systematic review of the literature. J Hosp Infect 64:7–15PubMedCrossRefGoogle Scholar
  37. 37.
    Baraibar J, Correa H, Mariscal D, Gallego M, Valles J, Rello J (1997) Risk factors for infection by Acinetobacter baumanii in intubated patients with nosocomial pneumonia. Chest 112:1050–1054PubMedGoogle Scholar
  38. 38.
    Garnacho-Montero J, Ortys-Leiba C, Fernandez-Hinojosa E, Aldabo-Pallas T, Cayuela A, Marquez-Vacaro JA, Garcia-Curiel A, Jimenez-Jimenez FJ (2005) Acinetobacter baumanii ventilatior-associated pneumonia: epidemiological and clinical findings. Intensive Care Med 31:649–655PubMedCrossRefGoogle Scholar
  39. 39.
    Eveillard M, Lancien E, Barnaud G, Hidri N, Gaba S, Benlolo JA, Joly-Guillou ML (2005) Impact of screening for MRSA carriers at hospital admission on risk-adjusted indicators according to the imported MRSA colonization pressure. J Hosp Infect 59:254–258PubMedCrossRefGoogle Scholar
  40. 40.
    Muller AA, Mauny F, Bertin M, Cornette C, Lopez-Lozano JM, Viel JF, Talon DR, Bertrand X (2003) Relationship between spread of methicillin-resistant Staphylococcus aureus and antimicrobial use in a French university hospital. Clin Infect Dis 36:971–978PubMedCrossRefGoogle Scholar
  41. 41.
    Heyland D, Cook D, Dodek P, Muscedere J, Day A, The Canadian Critical Care Trials Group (2006) A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 355:2619–2630CrossRefGoogle Scholar
  42. 42.
    Shorr A, Sherner J, Jackson W, Kollef M (2005) Invasive approaches to the diagnosis of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 33:46–53PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Kemal Agbaht
    • 1
  • Thiago Lisboa
    • 1
  • Angel Pobo
    • 1
  • Alejandro Rodriguez
    • 1
  • Alberto Sandiumenge
    • 1
  • Emili Diaz
    • 1
  • Jordi Rello
    • 1
  1. 1.Critical Care Department, Joan XXIII University Hospital, Institut Pere VirgiliCIBER – Enfermedades Respiratorias, University of Rovira & VirgiliTarragonaSpain

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