Abstract
Objective
Infection is the most frequent cause of acute respiratory distress syndrome (ARDS). However, little is known about the influence of infection sites on ARDS. This study aimed to assess the associations of infection sites with ARDS development and mortality in critically ill infected patients.
Design
Prospective observational study.
Setting
Adult intensive care units (ICUs) of an academic medical center.
Patients
Study population included 1,973 consecutive patients admitted to ICUs with bacteremia, pneumonia or sepsis. During follow-up, 549 patients developed ARDS and 212 of them died within 60 days.
Main results
The distribution of infection sites in ARDS patients was: lung (77.2%), abdomen (19.3%), skin/soft tissues (6.0%), urinary tract (4.7%), unknown (2.6%), and multiple sites (17.7%). On multivariate analysis, lung was the only infection site associated with increased ARDS risk [adjusted odds ratio (OR) 3.49]. Urinary tract (adjusted OR 0.43), skin/soft tissue (adjusted OR 0.64), and unknown-site infections (adjusted OR 0.38) were associated with decreased risk. No association was found between individual infection site and ARDS mortality. However, unknown-site [adjusted hazard ratio (HR) 3.08] and multiple-site infections (adjusted HR 1.63) were associated with increased ARDS mortality. When grouping patients into pulmonary, nonpulmonary, and combined infections, nonpulmonary infection was associated with decreased ARDS risk (adjusted OR 0.28) and combined infections was associated with increased ARDS mortality (adjusted HR 1.69), compared with pulmonary infection.
Conclusions
In critically ill infected patients, pulmonary infection is associated with higher risk of ARDS development than are infections at other sites. Pulmonary versus nonpulmonary infection significantly affects ARDS development but not mortality.
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References
Ware LB, Matthay MA (2000) The acute respiratory distress syndrome. N Engl J Med 342:1334–1349
Phua J, Badia JR, Adhikari NK, Friedrich JO, Fowler RA, Singh JM, Scales DC, Stather DR, Li A, Jones A, Gattas DJ, Hallett D, Tomlinson G, Stewart TE, Ferguson ND (2009) Has mortality from acute respiratory distress syndrome decreased over time? A systematic review. Am J Respir Crit Care Med 179:220–227
Rubenfeld GD, Herridge MS (2007) Epidemiology and outcomes of acute lung injury. Chest 131:554–562
Matthay MA, Zimmerman GA, Esmon C, Bhattacharya J, Coller B, Doerschuk CM, Floros J, Gimbrone MA Jr, Hoffman E, Hubmayr RD, Leppert M, Matalon S, Munford R, Parsons P, Slutsky AS, Tracey KJ, Ward P, Gail DB, Harabin AL (2003) Future research directions in acute lung injury: summary of a National Heart, Lung, and Blood Institute working group. Am J Respir Crit Care Med 167:1027–1035
Matute-Bello G, Frevert CW, Martin TR (2008) Animal models of acute lung injury. Am J Physiol Lung Cell Mol Physiol 295:L379–L399
Niederman MS, Fein AM (1990) Sepsis syndrome, the adult respiratory distress syndrome, and nosocomial pneumonia. A common clinical sequence. Clin Chest Med 11:633–656
Sevransky JE, Martin GS, Mendez-Tellez P, Shanholtz C, Brower R, Pronovost PJ, Needham DM (2008) Pulmonary vs. nonpulmonary sepsis and mortality in acute lung injury. Chest 134:534–538
Pelosi P, D’Onofrio D, Chiumello D, Paolo S, Chiara G, Capelozzi VL, Barbas CS, Chiaranda M, Gattinoni L (2003) Pulmonary and extrapulmonary acute respiratory distress syndrome are different. Eur Respir J Suppl 42:48s–56s
Gong MN, Thompson BT, Williams P, Pothier L, Boyce PD, Christiani DC (2005) Clinical predictors of and mortality in acute respiratory distress syndrome: potential role of red cell transfusion. Crit Care Med 33:1191–1198
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 149:818–824
Murray JF, Matthay MA, Luce JM, Flick MR (1988) An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 138:720–723 (published erratum appears in Am Rev Respir Dis 1989 139:1065)
Alberti C, Brun-Buisson C, Goodman SV, Guidici D, Granton J, Moreno R, Smithies M, Thomas O, Artigas A, Le Gall JR (2003) Influence of systemic inflammatory response syndrome and sepsis on outcome of critically ill infected patients. Am J Respir Crit Care Med 168:77–84
Iscimen R, Cartin-Ceba R, Yilmaz M, Khan H, Hubmayr RD, Afessa B, Gajic O (2008) Risk factors for the development of acute lung injury in patients with septic shock: an observational cohort study. Crit Care Med 36:1518–1522
Brun-Buisson C, Minelli C, Bertolini G, Brazzi L, Pimentel J, Lewandowski K, Bion J, Romand JA, Villar J, Thorsteinsson A, Damas P, Armaganidis A, Lemaire F (2004) Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study. Intensive Care Med 30:51–61
Erickson SE, Martin GS, Davis JL, Matthay MA, Eisner MD (2009) Recent trends in acute lung injury mortality: 1996–2005. Crit Care Med 37:1574–1579
Wind J, Versteegt J, Twisk J, van der Werf TS, Bindels AJ, Spijkstra JJ, Girbes AR, Groeneveld AB (2007) Epidemiology of acute lung injury and acute respiratory distress syndrome in The Netherlands: a survey. Respir Med 101:2091–2098
Irish Critical Care Trials Group (2008) Acute lung injury and the acute respiratory distress syndrome in Ireland: a prospective audit of epidemiology and management. Crit Care 12:R30
Squara P, Dhainaut JF, Artigas A, Carlet J (1998) Hemodynamic profile in severe ARDS: results of the European Collaborative ARDS Study. Intensive Care Med 24:1018–1028
Delclaux C, Azoulay E (2003) Inflammatory response to infectious pulmonary injury. Eur Respir J Suppl 42:10s–14s
Zhang P, Summer WR, Bagby GJ, Nelson S (2000) Innate immunity and pulmonary host defense. Immunol Rev 173:39–51
Adrie C, Francais A, Alvarez-Gonzalez A, Mounier R, Azoulay E, Zahar JR, Clec’h C, Goldgran-Toledano D, Hammer L, Descorps-Declere A, Jamali S, Timsit JF (2009) Model for predicting short-term mortality of severe sepsis. Crit Care 13:R72
Brun-Buisson C, Doyon F, Carlet J, Dellamonica P, Gouin F, Lepoutre A, Mercier JC, Offenstadt G, Regnier B (1995) Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. JAMA 274:968–974
Adrie C, Alberti C, Chaix-Couturier C, Azoulay E, De Lassence A, Cohen Y, Meshaka P, Cheval C, Thuong M, Troche G, Garrouste-Orgeas M, Timsit JF (2005) Epidemiology and economic evaluation of severe sepsis in France: age, severity, infection site, and place of acquisition (community, hospital, or intensive care unit) as determinants of workload and cost. J Crit Care 20:46–58
Bell RC, Coalson JJ, Smith JD, Johanson WG Jr (1983) Multiple organ system failure and infection in adult respiratory distress syndrome. Ann Intern Med 99:293–298
Leibovici L, Konisberger H, Pitlik SD, Samra Z, Drucker M (1992) Bacteremia and fungemia of unknown origin in adults. Clin Infect Dis 14:436–443
Valles J, Rello J, Ochagavia A, Garnacho J, Alcala MA (2003) Community-acquired bloodstream infection in critically ill adult patients: impact of shock and inappropriate antibiotic therapy on survival. Chest 123:1615–1624
Leibovici L, Shraga I, Drucker M, Konigsberger H, Samra Z, Pitlik SD (1998) The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. J Intern Med 244:379–386
Leibovici L, Drucker M, Konigsberger H, Samra Z, Harrari S, Ashkenazi S, Pitlik SD (1997) Septic shock in bacteremic patients: risk factors, features and prognosis. Scand J Infect Dis 29:71–75
Bauer TT, Ewig S, Rodloff AC, Muller EE (2006) Acute respiratory distress syndrome and pneumonia: a comprehensive review of clinical data. Clin Infect Dis 43:748–756
Acknowledgments
This study was supported by grants ES00002, HL60710, and HL087934 from National Institutes of Health, USA. The authors would like to thank Thomas McCabe, Julia Shin, Hanae Fujii-Rios, Ian Taggart, and Kezia Ellison for patient recruitment; Andrea Shafer and Starr Sumpter for research support; Janna Frelich, Marcia Chertok, and Julie DelPrato for data management; and the patients and staff of ICUs at Massachusetts General Hospital.
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The authors have not disclosed any potential conflicts of interest.
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Sheu, CC., Gong, M.N., Zhai, R. et al. The influence of infection sites on development and mortality of ARDS. Intensive Care Med 36, 963–970 (2010). https://doi.org/10.1007/s00134-010-1851-3
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DOI: https://doi.org/10.1007/s00134-010-1851-3