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      The Impact of Antimicrobial Resistance and Aging in VAP Outcomes: Experience from a Large Tertiary Care Center

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          Abstract

          Background

          Ventilator associated pneumonia (VAP) is a serious infection among patients in the intensive care unit (ICU).

          Methods

          We reviewed the medical charts of all patients admitted to the adult intensive care units of the Massachusetts General Hospital that went on to develop VAP during a five year period.

          Results

          200 patients were included in the study of which 50 (25%) were infected with a multidrug resistant pathogen. Increased age, dialysis and late onset (≥5 days from admission) VAP were associated with increased incidence of resistance. Multidrug resistant bacteria (MDRB) isolation was associated with a significant increase in median length of ICU stay (19 vs. 16 days, p = 0.02) and prolonged duration of mechanical ventilation (18 vs. 14 days, p = 0.03), but did not impact overall mortality (HR 1.12, 95% CI 0.51–2.46, p = 0.77). However, age (HR 1.04 95% CI 1.01–1.07, p = 0.003) was an independent risk factor for mortality and age ≥65 years was associated with increased incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections (OR 2.83, 95% CI 1.27–6.32, p = 0.01).

          Conclusions

          MDRB-related VAP is associated with prolonged ICU stay and mechanical ventilation. Interestingly, age ≥ 65 years is associated with MRSA VAP.

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          Most cited references30

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          The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs.

          Sara E Cosgrove (2006)
          There is an association between the development of antimicrobial resistance in Staphylococcus aureus, enterococci, and gram-negative bacilli and increases in mortality, morbidity, length of hospitalization, and cost of health care. For many patients, inadequate or delayed therapy and severe underlying disease are primarily responsible for the adverse outcomes of infections caused by antimicrobial-resistant organisms. Patients with infections due to antimicrobial-resistant organisms have higher costs (approximately 6,000-30,000 dollars) than do patients with infections due to antimicrobial-susceptible organisms; the difference in cost is even greater when patients infected with antimicrobial-resistant organisms are compared with patients without infection. Strategies to prevent nosocomial emergence and spread of antimicrobial-resistant organisms are essential.
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            Ventilator-associated pneumonia caused by potentially drug-resistant bacteria.

            M C Dombret, C Gibert, D Combaux … (1998)
            To determine risk factors for ventilator-associated pneumonia (VAP) caused by potentially drug-resistant bacteria such as methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, and/or Stenotrophomonas maltophilia, 135 consecutive episodes of VAP observed in a single ICU over a 25-mo period were prospectively studied. For all patients, VAP was diagnosed based on results of bronchoscopic protected specimen brush (> or = 10(3) cfu/ml) and bronchoalveolar lavage (> or = 10(4) cfu/ml) specimens. Seventy-seven episodes were caused by "potentially resistant" bacteria and 58 episodes were caused by "other" organisms. According to logistic regression analysis, three variables among potential factors remained significant: duration of mechanical ventilation (MV) > or = 7 d (odds ratio [OR] = 6.0), prior antibiotic use (OR = 13.5), and prior use of broad-spectrum drugs (third-generation cephalosporin, fluoroquinolone, and/or imipenem) (OR = 4.1). Distribution of the 245 causative bacteria was analyzed according to four groups defined by prior duration of MV ( or = 7 d) and prior use or lack of use (within 15 d) of antibiotics. Although 22 episodes of early-onset VAP in patients receiving no prior antibiotics were caused by antibiotic-susceptible bacteria, 84 episodes of late-onset VAP in patients receiving prior antibiotics were mainly caused by potentially resistant bacteria. Differences in the potential efficacies (ranging from 100% to 11%) against microorganisms of 15 antimicrobial regimens were studied according to classification into these four groups. These findings may provide a more rational basis for selecting the initial therapy of patients suspected of having VAP.
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              Hospital-acquired pneumonia and ventilator-associated pneumonia: recent advances in epidemiology and management.

              Antoine Andremont, Michel Wolff, François Barbier … (2013)
              The recent evidence is reviewed on clinical epidemiology, trends in bacterial resistance, diagnostic tools and therapeutic options in hospital-acquired pneumonia (HAP), with a special focus on ventilator-associated pneumonia (VAP). The current incidence of VAP ranges from two to 16 episodes for 1000 ventilator-days, with an attributable mortality of 3-17%. Staphylococcus aureus (with 50-80% of methicillin-resistant strains), Pseudomonas aeruginosa and Enterobacteriaceae represent the most frequent pathogens in HAP/VAP. The prevalence of carbapenemase-producing Gram-negative bacilli (GNB) and the emergence of colistin resistance are alarming. Procalcitonin seems to have a good value to monitor the response to treatment. Rapid molecular tests for the optimization of empirical therapy will be available soon. Recent studies support the use of a high-dosing regimen of colistin in HAP/VAP caused by extensively drug-resistant GNB. Linezolid may probably be preferred to vancomycin for a subset of methicillin-resistant S. aureus HAP/VAP. Given the scarcity of novel antimicrobial drugs, different approaches such as bacteriophage therapy or immunotherapy warrant further clinical evaluations. HAP/VAP is a major cause of deaths, morbidity and resources utilization, notably in patients with severe underlying conditions. The development of new diagnostic tools and therapeutic weapons is urgently needed to face the epidemic of multidrug-resistant pathogens.
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                Author and article information

                Contributors
                Lyle L. Moldawer: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2014
                Publication date (Electronic): 27 February 2014
                Volume: 9
                Issue: 2
                Electronic Location Identifier: e89984
                Affiliations
                [1 ]Department of Medicine, Infectious Diseases Division, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
                [2 ]Department of Medicine, Infectious Disease Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
                University of Florida College of Medicine, United States of America
                Author notes

                Competing Interests: There is one commercial funder to declare: Astellas Inc. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials. The authors have no other competing interests to declare.

                Conceived and designed the experiments: EM MA TA. Performed the experiments: TA TKK AD. Analyzed the data: MA PDZ EM. Contributed reagents/materials/analysis tools: PDZ EM. Wrote the paper: MA EM TA.

                Article
                Publisher ID: PONE-D-13-47988
                DOI: 10.1371/journal.pone.0089984
                PMC ID: 3937398
                PubMed ID: 24587166
                SO-VID: 75d2b04e-b470-4e65-a54e-39dfc7a13d19
                Copyright statement: Copyright @ 2014
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 16 November 2013
                Date accepted : 23 January 2014
                Page count
                Pages: 7
                Funding
                Part of this work was supported through a grant from Astellas, Inc. No additional funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Research Article
                Subject: Biology
                Subject: Microbiology
                Subject: Bacterial pathogens
                Subject: Staphylococci
                Subject: Medicine
                Subject: Critical care and emergency medicine
                Subject: Ventilatory support
                Subject: Epidemiology
                Subject: Geriatrics
                Subject: Infectious diseases
                Subject: Bacterial diseases
                Subject: Methicillin-resistant Staphylococcus aureus
                Subject: Staph infections
                Subject: Staphylococcal infection
                Subject: Staphylococcus aureus
                Subject: Fungal diseases

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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