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Archived Comments for: Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe

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  1. Ventilator-associated tracheobronchitis after major heart surgery: a plea for a randomized trial

    Saad Nseir, Réanimation Médicale, CHRU de Lille, Lille France

    13 July 2009

    I read with interest the article by Dr. Hortal and colleagues [1]. The authors are to be congratulated for conducting such a large multicentre study on the incidence of and risk factors for ventilator-associated pneumonia (VAP) after major heart surgery. Using modified CDC criteria to define ventilator-associated tracheobronchitis (VAT), the incidence rate of VAT was 3.7 per 1000 days of mechanical ventilation. If we consider only the patients with more than 72 hours of mechanical ventilation, 10.6% (7 of 66) developed VAT. Of these seven patients, two developed a VAP later on. The mean CPIS of the patients with VAT was 5.0 (1.7) points and the median number of days on mechanical ventilation at the time of VAT was five days (IQR = 3-6). Patients with VAT required mechanical ventilation during a median of 11 days (IQR = 8-25). These data merit further comment.
    VAT is an intermediate processes between tracheobronchial colonization and VAP [2]. The most frequently used definition for VAT is fever (>38° C) with no other recognizable cause, purulent sputum production, positive culture of respiratory specimen at significant threshold, and no radiographic signs of new pneumonia [3]. This definition has been validated by previous studies [4-6], and was accepted by a recent European expert statement [7]. The incidence of VAT found by the authors is in line with previous studies [4]. Interestingly, the study by Hortal and colleagues is the first prospective multicentre study to validate this definition of VAT in patients undergoing major heart surgery.
    Some clarifications would be helpful to determine the impact of VAT on outcome in this population. Authors stated that 28% of VAT patients developed subsequent VAP. However, was VAT a risk factor for subsequent VAP? Further, could the authors compare mortality, duration of mechanical ventilation, and ICU stay between VAT patients, VAP patients, and patients without ventilator-associated lower respiratory tract infection?
    Authors stated that in their opinion the use of anticipative or pre-emptive antimicrobial therapy should be explored as one of the few potential interventions to avoid VAP in the high-risk population. However, antimicrobial treatment is a well known risk factor for multidrug-resistant bacteria emergence [8]. Therefore, a targeted antibiotic therapy for VAT may be a new paradigm for VAP prevention and better patient outcomes [9]. Did all patients with VAT receive antimicrobial treatment? Was there any difference in subsequent VAP rate between patients who received antibiotics and those who did not? Two recent randomized studies, performed in patients with VAT [3,10], demonstrated that aerosolized and systemic antibiotics reduced subsequent VAP rate, and increased mechanical ventilation-free days, weaning and ICU-survival. Whether a short course of antibiotics in VAT patients could reduce VAP rate and improve outcome after major heart surgery should be determined by future randomized studies.


    1. Hortal J, Munoz P, Cuerpo G, Litvan H, Rosseel PM, Bouza E: Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe. Crit Care 2009, 13:R80.
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    4. Nseir S, Di Pompeo C, Pronnier P, Beague S, Onimus T, Saulnier F, Grandbastien B, Mathieu D, Delvallez-Roussel M, Durocher A: Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome. Eur Respir J 2002, 20:1483-1489.
    5. Nseir S, Favory R, Jozefowicz E, Decamps F, Dewavrin F, Brunin G, Di Pompeo C, Mathieu D, Durocher A: Antimicrobial treatment for ventilator-associated tracheobronchitis: a randomized, controlled, multicenter study. Crit Care 2008, 12:R62
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    8. Nseir S, Di Pompeo C, Diarra M, Brisson H, Tissier S, Boulo M, Durocher A: Relationship between immunosuppression and intensive care unit-acquired multidrug-resistant bacteria: a case-control study. Crit Care Med 2007, 35:1318-1323.
    9. Craven DE: Ventilator-associated tracheobronchitis (VAT): questions, answers, and a new paradigm? Crit Care 2008, 12:157.
    10. Palmer LB, Smaldone GC, Chen JJ, Baram D, Duan T, Monteforte M, Varela M, Tempone AK, O'Riordan T, Daroowalla F, Richman P: Aerosolized antibiotics and ventilator-associated tracheobronchitis in the intensive care unit. Crit Care Med 2008, 36:2008-2013.

    Competing interests