Ventilator-associated pneumonia: do patients that initiate mechanical ventilation outside the intensive care unit do worst?

Objective

To assess whether the incidence of ventilator-associated pneumonia (VAP) is greater in the patients with initiated mechanical ventilation (MV) in the Emergency Room (ER) compared with those that receive it in the intensive care unit (ICU)

Study design

A prospective cohort study.

Inclusion criteria

Patients that initiated MV from more than 12 hours in the ER or in the ICU.

Data collected

Age, sex, APACHE II score, MV initiation place, time in the ER, coming in different from the ER, VAP defined according to the ATS criteria, bacterial diagnostic procedures, germs, duration of the MV, length of stay at the hospital and at the ICU, and final destination (as death or discharge).

Statistical analysis

The chi-squared test and two-tailed Student t test. P < 0.05 was considered significant.

Results

From 1 August 2000 to 30 September 2001, 137 patients originated from the ER and 77 patients originated from other surgical or medical wards (OW) were admitted to the ICU. Both groups had no differences in sex (ER 74 males, OW 48 males, P = 0.92), age (ER 50 ± 20 years, OW 55 ± 16 years, P = 0.06), APACHE II score (ER 23.5 ± 16.7, OW 21.4 ± 18.3), hospital length of stay (ER 46, OW 52, P = 0.62), ICU length of stay (ER12 ± 13, OW 17 ± 23, P = 0.06), days of MV(ER 8 ± 10, OW11 ± 16, P = 0.12) and mortality (ER 50%, OW 55%). VAP incidence was 26% (36/137) in the ER group and 21% (16/77) in the OW group (P = 0.36). VAP incidence according to 1000 days of MV was 29 × 10³ for the complete set, 30 × 10³ in the ER group and 19 × 10³ in the OW group (P = 0.07). VAP diagnosis was done by means offiberoptic bronchioalveolar lavage (BAL) in 50%, nonfiberoptic BAL in 19% and tracheal aspiration in 31%. The early VAP incidence was 27% in the ER group and 25% in the OW group (P = 0.83). There were significant differences in the isolated germs in these groups (100% multiresistant germs in the OW group, P = 0.02). In the late VAP there were also differences due to Candida spp. isolation in 22% of the cultures (P = 0.03).

Conclusion

The initiation of MV in a setting different than the ICU is not related with a higher incidence of VAP. Patients coming from medical or surgical wards have a higher prevalence of multiresistant germs in early VAP and of Candida in late VAP.