Abstract
Patients undergoing major oncological surgery for head and neck cancer (SHNC) have a particularly high risk of nosocomial infections. We aimed to identify risk factors for ventilator-associated pneumonia (VAP) in patients undergoing SHNC. The study included 465 patients who underwent SHNC between June 2011 and June 2014. The rate of VAP, risk factors for VAP, and biological aspects of VAP were retrospectively evaluated. The incidence of VAP was 19.6% (n = 95) in patients who required more than 48 h of mechanical ventilation. Staphylococcus (37.7%), Enterobacteriaceae (32.1%), Pseudomonas (20.8%), and Haemophilus (16.9%) were the major bacterial species that caused VAP. The independent risk factors for VAP were advanced age, current smoking status, chronic obstructive pulmonary disease, and a higher simplified acute physiology score system II upon admission. Tracheostomy was an independent protective factor for VAP. The median length of stay in the ICU for patients who did or did not develop VAP was 8.0 and 6.5 days, respectively (P = 0.006). Mortality among patients who did or did not develop VAP was 16.8% and 8.4%, respectively (P < 0.001). The potential economic impact of VAP was high because of the significantly extended duration of ventilation. A predictive regression model was developed with a sensitivity of 95.3% and a specificity of 69.4%. VAP is common in patients who are undergoing SHNC and who require more than 48 h of mechanical ventilation. Therefore, innovative preventive measures should be developed and applied in this high-risk population.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Bigham MT, Amato R, Bondurrant P, Fridriksson J, Krawczeski CD, Raake J, Ryckman S, Schwartz S, Shaw J, Wells D, Brilli RJ. Ventilator-associated pneumonia in the pediatric intensive care unit: characterizing the problem and implementing a sustainable solution. J Pediatr 2009; 154(4): 582–587.e2
Shorr AF, Tabak YP, Gupta V, Johannes RS, Liu LZ, Kollef MH. Morbidity and cost burden of methicillin-resistant Staphylococcus aureus in early onset ventilator-associated pneumonia. Crit Care 2006; 10(3): R97
Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH; VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002; 122(6): 2115–2121
Vallés J, Pobo A, García-Esquirol O, Mariscal D, Real J, Fernández R. Excess ICU mortality attributable to ventilator-associated pneumonia: the role of early vs. late onset. Intensive Care Med 2007; 33(8): 1363–1368
Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 2005; 33(10): 2184–2193
Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. Am J Respir Crit Care Med 1999; 159(4): 1249–1256
Petrar S, Bartlett C, Hart RD, MacDougall P. Pulmonary complications after major head and neck surgery: a retrospective cohort study. Laryngoscope 2012; 122(5): 1057–1061
Ong SK, Morton RP, Kolbe J, Whitlock RM, McIvor NP. Pulmonary complications following major head and neck surgery with tracheostomy: a prospective, randomized, controlled trial of prophylactic antibiotics. Arch Otolaryngol Head Neck Surg 2004; 130(9): 1084–1087
McCulloch TM, Jensen NF, Girod DA, Tsue TT, Weymuller EA Jr. Risk factors for pulmonary complications in the postoperative head and neck surgery patient. Head Neck 1997; 19(5): 372–377
Kakavas S, Mongardon N, Cariou A, Gulati A, Xanthos T. Earlyonset pneumonia after out-of-hospital cardiac arrest. J Infect 2015; 70(6): 553–562
Li S, Zhang Y, Li S, Wang X, Zhang R, Lu Z, Yan J. Risk factors associated with prolonged mechanical ventilation after corrective surgery for tetralogy of Fallot. Congenit Heart Dis 2015; 10(3): 254–262
Inchai J, Pothirat C, Liwsrisakun C, Deesomchok A, Kositsakulchai W, Chalermpanchai N. Ventilator-associated pneumonia: epidemiology and prognostic indicators of 30-day mortality. Jpn J Infect Dis 2015; 68(3): 181–186
Gianakis A, McNett M, Belle J, Moran C, Grimm D. Risk factors for ventilator-associated pneumonia: among trauma patients with and without brain injury. J Trauma Nurs 2015; 22(3): 125–131
Berlet T, Etter R, Fehr T, Berger D, Sendi P, Merz TM. Sonographic patterns of lung consolidation in mechanically ventilated patients with and without ventilator-associated pneumonia: a prospective cohort study. J Crit Care 2015; 30(2): 327–333
Semenov YR, Starmer HM, Gourin CG. The effect of pneumonia on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 2012; 122(9): 1994–2004
Goutier JM, Holzmueller CG, Edwards KC, Klompas M, Speck K, Berenholtz SM. Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review. Infect Control Hosp Epidemiol 2014; 35(8): 998–1005
Maselli DJ, Restrepo MI. Strategies in the prevention of ventilatorassociated pneumonia. Ther Adv Respir Dis 2011; 5(2): 131–141
Klompas M, Kleinman K, Murphy MV, Program CPE. Descriptive epidemiology and attributable morbidity of ventilator-associated events. Infect Control Hosp Epidemiol 2014; 35(5): 502–510
Bercault N, Boulain T. Mortality rate attributable to ventilatorassociated nosocomial pneumonia in an adult intensive care unit: a prospective case-control study. Crit Care Med 2001; 29(12): 2303–2309
Warren DK, Shukla SJ, Olsen MA, Kollef MH, Hollenbeak CS, Cox MJ, Cohen MM, Fraser VJ. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 2003; 31(5): 1312–1317
Bird D, Zambuto A, O’Donnell C, Silva J, Korn C, Burke R, Burke P, Agarwal S. Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit. Arch Surg 2010; 145(5): 465–470
Bronchard R, Albaladejo P, Brezac G, Geffroy A, Seince PF, Morris W, Branger C, Marty J. Early onset pneumonia: risk factors and consequences in head trauma patients. Anesthesiology 2004; 100(2): 234–239
Lepelletier D, Roquilly A, Demeure dit latte D, Mahe PJ, Loutrel O, Champin P, Corvec S, Naux E, Pinaud M, Lejus C, Asehnoune K. Retrospective analysis of the risk factors and pathogens associated with early-onset ventilator-associated pneumonia in surgical-ICU head-trauma patients. J Neurosurg Anesthesiol 2010; 22(1): 32–37
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospitalacquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171(4): 388–416
Weksler ME, Hütteroth TH. Impaired lymphocyte function in aged humans. J Clin Invest 1974; 53(1): 99–104
Nakagawa M, Tanaka H, Tsukuma H, Kishi Y. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 2001; 120(3): 705–710
Barrera R, Shi W, Amar D, Thaler HT, Gabovich N, Bains MS, White DA. Smoking and timing of cessation: impact on pulmonary complications after thoracotomy. Chest 2005; 127(6): 1977–1983
Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth 2012; 59(3): 268–279
Kotani N, Kushikata T, Hashimoto H, Sessler DI, Muraoka M, Matsuki A. Recovery of intraoperative microbicidal and inflammatory functions of alveolar immune cells after a tobacco smoke-free period. Anesthesiology 2001; 94(6): 999–1006
Makris D, Desrousseaux B, Zakynthinos E, Durocher A, Nseir S. The impact of COPD on ICU mortality in patients with ventilatorassociated pneumonia. Respir Med 2011; 105(7): 1022–1029
Nseir S, Di Pompeo C, Soubrier S, Cavestri B, Jozefowicz E, Saulnier F, Durocher A. Impact of ventilator-associated pneumonia on outcome in patients with COPD. Chest 2005; 128(3): 1650–1656
Rinaudo M, Ferrer M, Terraneo S, De Rosa F, Peralta R, Fernández-Barat L, Li Bassi G, Torres A. Impact of COPD in the outcome of ICU-acquired pneumonia with and without previous intubation. Chest 2015; 147(6): 1530–1538
Di Pasquale M, Esperatti M, Crisafulli E, Ferrer M, Bassi GL, Rinaudo M, Escorsell A, Fernandez J, Mas A, Blasi F, Torres A. Impact of chronic liver disease in intensive care unit acquired pneumonia: a prospective study. Intensive Care Med 2013; 39(10): 1776–1784
Ranzani OT, Ferrer M, Esperatti M, Giunta V, Bassi GL, Carvalho CR, Torres A. Association between systemic corticosteroids and outcomes of intensive care unit-acquired pneumonia. Crit Care Med 2012; 40(9): 2552–2561
Vestbo J, Hurd SS, Agustí AG, Jones PW, Vogelmeier C, Anzueto A, Barnes PJ, Fabbri LM, Martinez FJ, Nishimura M, Stockley RA, Sin DD, Rodriguez-Roisin R. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013; 187(4): 347–365
Kanna B, Ayman HA, Soni A. Early tracheostomy in intensive care trauma patient improves resource utilization: a cohort study and literature review. Crit Care 2005; 9(4): 414–416
Schneider GT, Christensen N, Doerr TD. Early tracheotomy in elderly patients results in less ventilator-associated pneumonia. Otolaryngol Head Neck Surg 2009; 140(2): 250–255
Terragni PP, Antonelli M, Fumagalli R, Faggiano C, Berardino M, Pallavicini FB, Miletto A, Mangione S, Sinardi AU, Pastorelli M, Vivaldi N, Pasetto A, Della Rocca G, Urbino R, Filippini C, Pagano E, Evangelista A, Ciccone G, Mascia L, Ranieri VM. Early vs. late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA 2010; 303(15): 1483–1489
Arabi Y, Haddad S, Shirawi N, Al Shimemeri A. Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review. Crit Care 2004; 8 (5): R347–R352
Devarajan J, Vydyanathan A, Xu M, Murthy SM, McCurry KR, Sessler DI, Sabik J, Bashour CA. Early tracheostomy is associated with improved outcomes in patients who require prolonged mechanical ventilation after cardiac surgery. J Am Coll Surg 2012; 214(6): 1008–16.e4
Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004; 32(8): 1689–1694
Blot F, Similowski T, Trouillet JL, Chardon P, Korach JM, Costa MA, Journois D, Thiéry G, Fartoukh M, Pipien I, Bruder N, Orlikowski D, Tankere F, Durand-Zaleski I, Auboyer C, Nitenberg G, Holzapfel L, Tenaillon A, Chastre J, Laplanche A. Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients. Intensive Care Med 2008; 34(10): 1779–1787
Nieszkowska A, Combes A, Luyt CE, Ksibi H, Trouillet JL, Gibert C, Chastre J. Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Crit Care Med 2005; 33(11): 2527–2533
Kollef MH, Zilberberg MD, Shorr AF, Vo L, Schein J, Micek ST, Kim M. Epidemiology, microbiology and outcomes of healthcareassociated and community-acquired bacteremia: a multicenter cohort study. J Infect 2011; 62(2): 130–135
Moore CL, Hingwe A, Donabedian SM, Perri MB, Davis SL, Haque NZ, Reyes K, Vager D, Zervos MJ. Comparative evaluation of epidemiology and outcomes of methicillin-resistant Staphylococcus aureus (MRSA) USA300 infections causing community- and healthcare-associated infections. Int J Antimicrob Agents 2009; 34(2): 148–155
Fujita T, Sakurai K. Multivariate analysis of risk factors for postoperative pneumonia. Am J Surg 1995; 169(3): 304–307
Liu C, Du Z, Zhou Q, Hu B, Li Z, Yu L, Xu T, Fan X, Yang J, Li J. Microscopic examination of intracellular organisms in bronchoalveolar lavage fluid for the diagnosis of ventilator-associated pneumonia: a prospective multi-center study. Chin Med J (Engl) 2014; 127(10): 1808–1813
Author information
Authors and Affiliations
Corresponding author
Additional information
These authors contributed equally to this work.
Rights and permissions
About this article
Cite this article
Liu, Y., Di, Y. & Fu, S. Risk factors for ventilator-associated pneumonia among patients undergoing major oncological surgery for head and neck cancer. Front. Med. 11, 239–246 (2017). https://doi.org/10.1007/s11684-017-0509-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11684-017-0509-8