Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study


We report on intensive care nosocomial pneumonia (NP) in Europe through a review of EU-VAP/CAP manuscripts: a prospective observational study, enrolling patients from 27 ICUs in nine European countries. From 2,436 eligible ICU patients, 827 cases presented NP, with 18.3 episodes of VAP per 1000 ventilator-days. Most common findings were worsening oxygenation, purulent respiratory secretions and temperature increase. At least three criteria from Clinical Pulmonary Infection score (CPIS) were present in 77.9 % of episodes, but only 0.2 % met six CPIS criteria. Diagnosis was confirmed mainly noninvasively (74.8 %), with half qualitative and quantitative cultures. The dominant isolate was S. aureus in Spain, France, Belgium and Ireland, P. aeruginosa in Italy and Portugal, Acinetobacter in Greece and Turkey, but Escherichia coli in Germany. NP resulted in 6 % higher mortality, longer ICU stay and duration of mechanical ventilation (12 and 10 days). COPD and age ≥45 years were not associated with higher VAP incidence but did correlate with increased mortality. Trauma had higher VAP incidence but lower mortality. Bacteremia (led by MRSA and Acinetobacter baumannii) was documented in 14.6 %, being associated with extra ICU stay and mortality. Vasopressors and ICUs with above 25 % prevalence of Potential Resistant Organisms (PRM) were independently associated with PRM, being documented in 50.7 % of patients with early-onset VAP without known risk factors. Most patients initially received combination therapy. Delay in appropriate antimicrobial choice significantly increased mortality, and LOS in survivors was six days longer (p < 0.05). In conclusion, NP management in Europe presents local differences and major shifts when compared to reports from North America, outcomes of randomized trials and general guidelines.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.

Fig. 1


  1. 1.

    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 171:388–416

  2. 2.

    Woodhead M, Welch CA, Harrison DA et al (2006) Community-acquired pneumonia on the intensive care unit: secondary analysis of 17,869 cases in the ICNARC Case Mix Programme Database. Crit Care 10:S1

  3. 3.

    Walden AP, Clarke GM, McKechnie S et al (2014) Patients with community acquired pneumonia admitted to European intensive care units: an epidemiological survey of the GenOSept cohort. Crit Care 18:R58

  4. 4.

    Koulenti D, Rello J (2006) Hospital-acquired pneumonia in the 21st century: a review of current treatment options and their impact on patient care. Expert Opin Pharmacother 7:1555–1569

  5. 5.

    Kalanuria AA, Zai W, Marek M (2014) Ventilator-associated pneumonia in the ICU. Crit Care 18:208

  6. 6.

    Rello J, Lisboa T, Koulenti D (2014) Respiratory infections in patients undergoing mechanical ventilation. Lancet Respir Med 2:764–744

  7. 7.

    Sopena N, Sabria M, Neunos 2000 Study Group (2000) Study group (2005) Multicentre study of hospital-acquired pneumonia in non-ICU patients. Chest 127:213–219

  8. 8.

    Ohi H, Yanagihara K, Miyazaki Y et al (2004) Hospital-acquired pneumonia in general wards of a Japanese tertiary hospital. Respirology 9:120–124

  9. 9.

    Cakir Edis E, Hatipoglu O, Yilmam I et al (2009) Hospital-acquired pneumonia developed in nonintensive care units. Respiration 78:416–422

  10. 10.

    Klompas M (2012) What can we learn from international-ventilator associated pneumonia rates? Crit Care Med 40:3303–3304

  11. 11.

    Koulenti D, Lisboa T, Brun-Buisson C et al (2009) Spectrum of practice in the diagnosis of nosocomial pneumonia in patients requiring mechanical ventilation in European intensive care units. Crit Care Med 37:2360–2368

  12. 12.

    Magret M, Amaya-Villar R, Garnacho J et al (2010) Ventilator-associated pneumonia in trauma patients is associated with lower mortality: results from EU-VAP study. J Trauma 69:849–854

  13. 13.

    Koulenti D, Blot S, Dulhunty JM et al (2015) COPD patients with ventilator-associated pneumonia: implications for management. Eur J Clin Microbiol Infect Dis 34:2403–2411

  14. 14.

    Blot S, Koulenti D, Dimopoulos G et al (2014) Prevalence, risk factors, and mortality for ventilator-associated pneumonia in middle-aged, old, and very old critically ill patients. Crit Care Med 42:601–609

  15. 15.

    Magret M, Lisboa T, Martin-Loeches I et al (2011) Bacteremia is an independent risk factor for mortality in nosocomial pneumonia: a prospective and observational multicenter study. Crit Care 15:R62

  16. 16.

    Martin-Loeches I, Deja M, Koulenti D et al (2013) Potentially resistant microorganisms in intubated patients with hospital-acquired pneumonia: the interaction of ecology, shock and risk factors. Intensive Care Med 39:672–681

  17. 17.

    Rello J, Ulldemolins M, Lisboa T et al (2011) Determinants of prescription and choice of empirical therapy for hospital-acquired and ventilator-associated pneumonia. Eur Respir J 37:1332–1339

  18. 18.

    Blot S, Serra ML, Koulenti D et al (2011) Patient to nurse ratio and risk of ventilator associated pneumonia in critically ill patients. Am J Crit Care 20:e1–e9

  19. 19.

    Rello J, Diaz E, Roque M, Vallés J (1999) Risk factors for developing pneumonia within 48 hours of intubation. Am J Respir Crit Care Med 159:1742–1746

  20. 20.

    American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874

  21. 21.

    Vincent JL, Moreno R, Takala J et al (1996) The SOFA (Sepsis related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710

  22. 22.

    Cavalcanti M, Ferrer M, Ferrer R et al (2006) Risk and prognostic factors of ventilator-associated pneumonia in trauma patients. Crit Care Med 34:1067–1072

  23. 23.

    Magnotti LJ, Croce MA, Fabian TC (2004) Is ventilator-associated pneumonia in trauma patients an epiphenomenon or a cause of death? Surg Infect 5:237–242

  24. 24.

    Agbaht K, Lisboa T, Pobo A et al (2007) Management of ventilator-associated pneumonia in a multidisciplinary intensive care unit: does trauma make a difference? Intensive Care Med 33:1387–1395

  25. 25.

    Rodríguez A, Lisboa T, Solé-Violán J et al (2011) Impact of nonexacerbated COPD on mortality in critically ill patients. Chest 139:1354–1360

  26. 26.

    Makris D, Desrousseaux B, Zakynthinos E et al (2011) The impact of COPD on ICU mortality in patients with ventilator-associated pneumonia. Respir Med 105(7):1022–1029

  27. 27.

    Blot S, Cankurtaran M, Petrovic M et al (2009) Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middle-aged, old, and very old patients. Crit Care Med 37:1634–1641

  28. 28.

    Bagshaw SM, Webb SA, Delaney A et al (2009) Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis. Crit Care 13:R45

  29. 29.

    Boots RJ, Lipman J, Bellomo R et al (2005) The spectrum of practice in the diagnosis and management of pneumonia in patients requiring mechanical ventilation. Australian and New Zealand Practice in Intensive Care (ANZPIC II). Anaesth Intensive Care 33:87–100

  30. 30.

    Kollef MH, Morrow LE, Niederman MS et al (2006) Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest 129(5):1210–1218

  31. 31.

    Tabah A, Koulenti D, Laupland K et al (2012) Characteristics and determinants of outcome of hospital-acquired bloodstream infections in intensive care units: the EUROBACT International Cohort Study. Intensive Care Med 38(12):1930–1945

  32. 32.

    Timsit JF, Tabah A, Koulenti D et al (2014) Update of hospital-acquired bacteremia respiratory infection: experience from the EURO-BACT study. Clin Pulm Med 21:9–15

  33. 33.

    Martin GMD, Mannino DM, Moss M (2006) The effect of age on the development and outcome of adult sepsis. Crit Care Med 34:15–21

  34. 34.

    Kumar A, Roberts D, Wood KE et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 34:1589–1596

  35. 35.

    Cho SH, Hwang JH, Kim J (2008) Nurse staffing and patient mortality in intensive care units. Nurs Res 57(5):322–330

  36. 36.

    Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL (2004) Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. J Nurs Adm 34(7–8):326–337

  37. 37.

    Schwab F, Meyer E, Geffers C, Gastmeier P (2012) Understaffing, overcrowding, inappropriate nurse:ventilated patient ratio and nosocomial infections: which parameter is the best reflection of deficits? J Hosp Infect 80:133–139

Download references


EU-VAP/CAP Study was endorsed by the European Critical Care Research Network (ECCRN).

Conflict of interest

JR served in the speakers’ bureau or as consultant for Pfizer, Paratek, Astra-Zeneca, KENTA, Nabriva. DK and ET report no conflict of interest.

EU-VAP/CAP Study Investigators

Djilali Annane (Raymond Poincaré Univ. Hospital, Garches, France), Rosario Amaya-Villar (Virgen de Rocio Univ. Hospital, Seville, Spain), Apostolos Armaganidis (Attikon Univ. Hospital, Athens, Greece; National Coordinator [NC]), Stijn Blot (1,2Ghent Univ. Hospital, Ghent, Belgium, 1RBWH University of Queenland,), Christian Brun-Buisson (Henri-Mondor Univ. Hospital, Paris, France; NC), Silvano Cardellino (Cardinal Massaia Hospital, Asti, Italy), Antonio Carneiro (2Santo Antonio Hospital, Porto, Portugal; NC), Maria Deja (Charite Univ. Hospital, Berlin, Germany), Jan DeWaele (Ghent Univ. Hospital, Ghent, Belgium; NC), Emili Diaz (Joan XIII Univ. Hospital, CIBERES, Tarragona, Spain), George Dimopoulos (1,2Attikon Univ. Hospital, 2Sotiria Hospital, Athens, Greece), Jose Garnacho-Montero (Virgen de Rocio Univ. Hospital, Seville, Spain), Muhammet Guven (Erciyes Univ. Hospital, Kayseri, Turkey), Apostolos Komnos (Larisa Hospital, Larisa, Greece), Despoina Koulenti (Study Coordinator, 1,2Attikon Univ. Hospital, Athens, Greece, 1RBWH University of Queenland), Wolfgang Krueger (1Constance Hospital, Constance, Germany,2Tuebingen Univ. Hospital, Tuebingen, Germany; NC), Thiago Lisboa (2Joan XIII Univ. Hospital, Tarragona, Spain and CIBERES), Antonio Macor (Amedeo di Savoia Hospital, Torino, Italy; NC), Emilpaolo Manno (Maria Vittoria Hospital, Torino, Italy), Rafael Mañez (Bellvitge Univ. Hospital, Barcelona, Spain), Brian Marsh (Mater Misericordiae Univ. Hospital, Dublin, Ireland), Claude Martin (Nord Univ. Hospital, Marseille, France), Pavlos Myrianthefs (Aghioi Anargyroi Hospital1, KAT Hospital2, Athens, Greece), Marc Nauwynck (St Jan Hospital, Brugges, Belgium), Laurent Papazian (Hôpitaux de Marseille Aix-Marseille Université, 2Sainte-Marguerite Univ. Hospital, Marseille, France), Christian Putensen (Bonn Univ. Hospital, Bonn, Germany), Bernard Regnier (Claude Bernard Univ. Hospital, Paris, France), Jordi Rello (Principal Investigator, 1CIBERES, Universitat Autonoma de Barcelona, Spain, 2Joan XIII Univ. Hospital, Tarragona, Spain; NC), Jordi Sole-Violan (Dr Negrin Univ. Hospital, Gran Canarias, Spain), Giuseppe Spina (Mauriziano Umberto I Hospital, Torino, Italy), Arzu Topeli (Hacettepe Univ. Hospital, Ankara, Turkey; NC), Hermann Wrigge (Bonn Univ. Hospital, Bonn, Germany). [1Current affiliation, 2affiliation during the period of the study].


CIBERES (PCI Pneumonia) Instituto Salud Carlos III, Madrid.

Author information

Correspondence to J. Rello.

Additional information

The EU-VAP/CAP study of the WG on Pneumonia of the Infection Section of ESICM was a project endorsed by ESICM.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Koulenti, D., Tsigou, E. & Rello, J. Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study. Eur J Clin Microbiol Infect Dis 36, 1999–2006 (2017).

Download citation


  • Chronic Obstructive Pulmonary Disease
  • Chronic Obstructive Pulmonary Disease Patient
  • Colistin
  • Nosocomial Pneumonia
  • Acinetobacter Baumannii