Intensive Care Medicine

, Volume 35, Issue 9, pp 1518–1525

Incidence and risk factors for ventilator-associated pneumonia after major heart surgery

  • Javier Hortal
  • Maddalena Giannella
  • Maria Jesús Pérez
  • José Maria Barrio
  • Manuel Desco
  • Emilio Bouza
  • Patricia Muñoz
Original

Abstract

Purpose

Major heart surgery (MHS) patients are a particularly high-risk population for nosocomial infections. Our objective was to identify risk factors for ventilator-associated pneumonia (VAP) in patients undergoing MHS.

Methods

Prospective study including 1,844 patients operated from 2003 to 2006.

Results

Overall 106 patients (140 episodes) developed one or more episodes of VAP (5.7%, 22.2 episodes per 1,000 days of mechanical ventilation). VAP incidence was 45.9% in those patients requiring more than 48 h of MV. Enterobacteriaceae (32.8), Pseudomonas aeruginosa (28.6%) and Staphylococcus aureus (27.1%, of which 65.8% were methicillin resistant) were the principal microorganisms causing VAP. The independent risk factors for VAP were: age >70, perioperative transfusions, days of mechanical ventilation, reintubation, previous cardiac surgery, emergent surgery and intraoperative inotropic support. Median length of stay in the ICU for patients who developed VAP or not was, respectively, 25.5 versus 3 days (P < 0.001), and mortality was, respectively, 45.7 versus 2.8% in both populations (P < 0.001). We developed a predictive preoperative score with a sensitivity of 93% and a specificity of 40%.

Conclusions

VAP is common in patients undergoing MHS that require more than 48 h of MV. In that “high-risk” population, innovative preventive measures should be developed and applied.

Keywords

Ventilator-associated pneumonia Heart surgery Nosocomial infection Nosocomial pneumonia Risk factors for ICU nosocomial infection 

References

  1. 1.
    Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH (2002) Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 122:2115–2121PubMedCrossRefGoogle Scholar
  2. 2.
    Bercault N, Boulain T (2001) Mortality rate attributable to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective case–control study. Crit Care Med 29:2303–2309PubMedCrossRefGoogle Scholar
  3. 3.
    Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C (1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med 159:1249–1256PubMedGoogle Scholar
  4. 4.
    Warren DK, Shukla SJ, Olsen MA, Kollef MH, Hollenbeak CS, Cox MJ, Cohen MM, Fraser VJ (2003) Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 31:1312–1317PubMedCrossRefGoogle Scholar
  5. 5.
    Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C (1993) Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94:281–288PubMedCrossRefGoogle Scholar
  6. 6.
    Cunnion KM, Weber DJ, Broadhead WE, Hanson LC, Pieper CF, Rutala WA (1996) Risk factors for nosocomial pneumonia: comparing adult critical-care populations. Am J Respir Crit Care Med 153:158–162PubMedGoogle Scholar
  7. 7.
    Kollef MH (1993) Ventilator-associated pneumonia. A multivariate analysis. Jama 270:1965–1970PubMedCrossRefGoogle Scholar
  8. 8.
    Kollef MH, Sharpless L, Vlasnik J, Pasque C, Murphy D, Fraser VJ (1997) The impact of nosocomial infections on patient outcomes following cardiac surgery. Chest 112:666–675PubMedCrossRefGoogle Scholar
  9. 9.
    Sodano L, Agodi A, Barchitta M, Musumeci F, Menichetti A, Bellocchi P, Cunsolo R, Coco G (2004) Nosocomial infections in heart surgery patients: active surveillance in two Italian hospitals. Ann Ig 16:735–743PubMedGoogle Scholar
  10. 10.
    Bouza E, Hortal J, Munoz P, Pascau J, Perez MJ, Hiesmayr M (2006) Postoperative infections after major heart surgery and prevention of ventilator-associated pneumonia: a one-day European prevalence study (ESGNI-008). J Hosp Infect 64:224–230PubMedCrossRefGoogle Scholar
  11. 11.
    Bouza E, Hortal J, Munoz P, Perez MJ, Riesgo MJ, Hiesmayr M (2006) Infections following major heart surgery in European intensive care units: there is room for improvement (ESGNI 007 Study). J Hosp Infect 63:399–405PubMedCrossRefGoogle Scholar
  12. 12.
    Bouza E, Perez A, Munoz P, Jesus Perez M, Rincon C, Sanchez C, Martin-Rabadan P, Riesgo M (2003) Ventilator-associated pneumonia after heart surgery: a prospective analysis and the value of surveillance. Crit Care Med 31:1964–1970PubMedCrossRefGoogle Scholar
  13. 13.
    Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M (2000) Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest 118:459–467PubMedCrossRefGoogle Scholar
  14. 14.
    Kress JP, Pohlman AS, O’Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477PubMedCrossRefGoogle Scholar
  15. 15.
    Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R (1999) European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 16:9–13PubMedCrossRefGoogle Scholar
  16. 16.
    Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM (1988) CDC definitions for nosocomial infections, 1988. Am J Infect Control 16:128–140PubMedCrossRefGoogle Scholar
  17. 17.
    Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM (1991) Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis 143:1121–1129PubMedGoogle Scholar
  18. 18.
    American Thoracic Society, Infectious Diseases Society of America (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
  19. 19.
    Institute CaLS (2005) Performance standards for antimicrobial susceptibility testing; 15th informational supplement. CLSI/NCCLS M100–S15. Clinical and Laboratory Standards Institute, WayneGoogle Scholar
  20. 20.
    Ang RP (1998) Use of the Jacknife statistic to evaluate result replicability. J Gen Psychol 125:218–228CrossRefGoogle Scholar
  21. 21.
    Fagon JY, Chastre J, Domart Y, Trouillet JL, Pierre J, Darne C, Gibert C (1989) Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis 139:877–884PubMedGoogle Scholar
  22. 22.
    Ibrahim EH, Mehringer L, Prentice D, Sherman G, Schaiff R, Fraser V, Kollef MH (2002) Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial. JPEN J Parenter Enteral Nutr 26:174–181PubMedCrossRefGoogle Scholar
  23. 23.
    Kollef MH, Vlasnik J, Sharpless L, Pasque C, Murphy D, Fraser V (1997) Scheduled change of antibiotic classes: a strategy to decrease the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 156:1040–1048PubMedGoogle Scholar
  24. 24.
    Sirvent JM, Torres A, El-Ebiary M, Castro P, de Batlle J, Bonet A (1997) Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma. Am J Respir Crit Care Med 155:1729–1734PubMedGoogle Scholar
  25. 25.
    Beck-Sague CM, Sinkowitz RL, Chinn RY, Vargo J, Kaler W, Jarvis WR (1996) Risk factors for ventilator-associated pneumonia in surgical intensive-care-unit patients. Infect Control Hosp Epidemiol 17:374–376PubMedCrossRefGoogle Scholar
  26. 26.
    Richards MJ, Edwards JR, Culver DH, Gaynes RP (1999) Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Crit Care Med 27:887–892PubMedCrossRefGoogle Scholar
  27. 27.
    Pujol M, Corbella X, Pena C, Pallares R, Dorca J, Verdaguer R, Diaz-Prieto A, Ariza J, Gudiol F (1998) Clinical and epidemiological findings in mechanically-ventilated patients with methicillin-resistant Staphylococcus aureus pneumonia. Eur J Clin Microbiol Infect Dis 17:622–628PubMedGoogle Scholar
  28. 28.
    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
  29. 29.
    Torres A, Gatell JM, Aznar E, el-Ebiary M, de la Puig Bellacasa J, Gonzalez J, Ferrer M, Rodriguez-Roisin R (1995) Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 152:137–141PubMedGoogle Scholar
  30. 30.
    Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, Simonneau G, Benito S, Gasparetto A, Lemaire F et al (1995) Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 333:817–822PubMedCrossRefGoogle Scholar
  31. 31.
    Antonelli M, Conti G, Rocco M, Bufi M, De Blasi RA, Vivino G, Gasparetto A, Meduri GU (1998) A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 339:429–435PubMedCrossRefGoogle Scholar
  32. 32.
    Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi-Benissan G, Dupon M, Reiffers J, Cardinaud JP (2001) Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 344:481–487PubMedCrossRefGoogle Scholar
  33. 33.
    Antonelli M, Conti G, Esquinas A, Montini L, Maggiore SM, Bello G, Rocco M, Maviglia R, Pennisi MA, Gonzalez-Diaz G, Meduri GU (2007) A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med 35:18–25PubMedCrossRefGoogle Scholar
  34. 34.
    Shorr AF, Duh MS, Kelly KM, Kollef MH (2004) Red blood cell transfusion and ventilator-associated pneumonia: a potential link? Crit Care Med 32:666–674PubMedCrossRefGoogle Scholar
  35. 35.
    Levy JH, Tanaka KA, Steiner ME (2005) Evaluation and management of bleeding during cardiac surgery. Curr Hematol Rep 4:368–372PubMedGoogle Scholar
  36. 36.
    Bouza E, Pérez MJ, Muñoz P, Rincón C, Barrio JM, Hortal J (2008) Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest 134:938–946PubMedCrossRefGoogle Scholar
  37. 37.
    Kollef MH (2000) Opinion: the clinical use of selective digestive decontamination. Crit Care 4:327–332PubMedCrossRefGoogle Scholar
  38. 38.
    Kollef MH (2003) Selective digestive decontamination should not be routinely employed. Chest 123:464S–468SPubMedCrossRefGoogle Scholar
  39. 39.
    Valles J, Pobo A, Garcia-Esquirol O, Mariscal D, Real J, Fernandez R (2007) Excess ICU mortality attributable to ventilator-associated pneumonia: the role of early vs late onset. Intensive Care Med 33:1363–1368PubMedCrossRefGoogle Scholar
  40. 40.
    Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Javier Hortal
    • 1
  • Maddalena Giannella
    • 2
  • Maria Jesús Pérez
    • 1
  • José Maria Barrio
    • 1
  • Manuel Desco
    • 3
  • Emilio Bouza
    • 2
    • 4
  • Patricia Muñoz
    • 2
    • 4
  1. 1.Department of AnesthesiaHospital General Universitario Gregorio MarañónMadridSpain
  2. 2.Department of Clinical Microbiology and Infectious DiseasesHospital General Universitario Gregorio MarañónMadridSpain
  3. 3.Department of Experimental MedicineHospital General Universitario Gregorio MarañónMadridSpain
  4. 4.CIBER de Enfermedades Respiratorias (CIBERES)BarcelonaSpain

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