PROPHETIC: Prospective Identification of Pneumonia in Hospitalized Patients in the ICU

Stephen P Bergin, Adrian Coles, Sara B Calvert, John Farley, John H Powers, Marcus J Zervos, Matthew Sims, Marin H Kollef, Michael J Durkin, Badih A Kabchi, Helen K Donnelly, Ana Cecilia Bardossy, Claire Greenshields, Daniel Rubin, Jie-Lena Sun, Karen Chiswell, Jonas Santiago, Peidi Gu, Pamela Tenaerts, Vance G Fowler Jr, Thomas L Holland, Stephen P Bergin, Adrian Coles, Sara B Calvert, John Farley, John H Powers, Marcus J Zervos, Matthew Sims, Marin H Kollef, Michael J Durkin, Badih A Kabchi, Helen K Donnelly, Ana Cecilia Bardossy, Claire Greenshields, Daniel Rubin, Jie-Lena Sun, Karen Chiswell, Jonas Santiago, Peidi Gu, Pamela Tenaerts, Vance G Fowler Jr, Thomas L Holland

Abstract

Background: Pneumonia is the leading infection-related cause of death. The use of simple clinical criteria and contemporary epidemiology to identify patients at high risk of nosocomial pneumonia should enhance prevention efforts and facilitate development of new treatments in clinical trials.

Research question: What are the clinical criteria and contemporary epidemiology trends that are helpful in the identification of patients at high risk of nosocomial pneumonia?

Study design and methods: Within the ICUs of 28 US hospitals, we conducted a prospective cohort study among adults who had been hospitalized >48 hours and were considered high risk for pneumonia (defined as treatment with invasive or noninvasive ventilatory support or high levels of supplemental oxygen). We estimated the proportion of high-risk patients who experienced the development of nosocomial pneumonia. Using multivariable logistic regression, we identified patient characteristics and treatment exposures that are associated with increased risk of pneumonia development during the ICU admission.

Results: Between February 6, 2016, and October 7, 2016, 4,613 high-risk patients were enrolled. Among 1,464 high-risk patients (32%) who were treated for possible nosocomial pneumonia, 537 (37%) met the study pneumonia definition. Among high-risk patients, a multivariable logistic model was developed to identify key patient characteristics and treatment exposures that are associated with increased risk of nosocomial pneumonia development (c-statistic, 0.709; 95% CI, 0.686-0.731). Key factors associated with increased odds of nosocomial pneumonia included an admission diagnosis of trauma or cerebrovascular accident, receipt of enteral nutrition, documented aspiration risk, and receipt of systemic antibacterials within the preceding 90 days.

Interpretation: Treatment for nosocomial pneumonia is common among patients in the ICU who are receiving high levels of respiratory support, yet more than one-half of patients who are treated do not fulfill standard diagnostic criteria for pneumonia. Application of simple clinical criteria may improve the feasibility of clinical trials of pneumonia prevention and treatment by facilitating prospective identification of patients at highest risk.

Keywords: ICU; nosocomial; pneumonia.

Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1
Figure 1
Screening, eligibility, and enrollment of patients who are at risk for nosocomial pneumonia. HABP = hospital-acquired bacterial pneumonia; VABP = ventilator-associated bacterial pneumonia.
Figure 2
Figure 2
Study outcome for high-risk patients. Of 4,613 enrolled high-risk patients, 1,464 (32%) were treated for possible pneumonia during their ICU course; of these, 537 patients (37%) met the study HABP/VABP definition over a median follow-up time of 7 days. See Figure 1 legend for expansion of abbreviations.
Figure 3
Figure 3
Cumulative incidence of nosocomial pneumonia for high-risk patients. See Figure 1 legend for expansion of abbreviations.

References

    1. Magill S.S., O’Leary E., Janelle S.J. Changes in prevalence of health care-associated infections in U.S. hospitals. N Engl J Med. 2018;379(18):1732–1744.
    1. Vincent J.L., Bihari D.J., Suter P.M. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA. 1995;274(8):639–644.
    1. Kalil A.C., Metersky M.L., Klompas M. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61–e111.
    1. Melsen W.G., Rovers M.M., Groenwold R.H. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis. 2013;13(8):665–671.
    1. Klompas M. Does this patient have ventilator-associated pneumonia? JAMA. 2007;297(14):1583–1593.
    1. Kuti E.L., Patel A.A., Coleman C.I. Impact of inappropriate antibiotic therapy on mortality in patients with ventilator-associated pneumonia and blood stream infection: a meta-analysis. J Crit Care. 2008;23(1):91–100.
    1. Muscedere J.G., Shorr A.F., Jiang X., Day A., Heyland D.K., Canadian Critical Care Trials Group The adequacy of timely empiric antibiotic therapy for ventilator-associated pneumonia: an important determinant of outcome. J Crit Care. 2012;27(3):322.e7–322.e14.
    1. Jones R.N. Microbial etiologies of hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia. Clin Infect Dis. 2010;51(suppl 1):S81–S87.
    1. Kinch M.S., Patridge E., Plummer M., Hoyer D. An analysis of FDA-approved drugs for infectious disease: antibacterial agents. Drug Discov Today. 2014;19(9):1283–1287.
    1. Barriere S.L. Challenges in the design and conduct of clinical trials for hospital-acquired pneumonia and ventilator-associated pneumonia: an industry perspective. Clin Infect Dis. 2010;51(suppl 1):S4–S9.
    1. Bettiol E., Wetherington J.D., Schmitt N., Harbarth S., COMBACTE Consortium Challenges and solutions for clinical development of new antibacterial agents: results of a survey among pharmaceutical industry professionals. Antimicrob Agents Chemother. 2015;59(7):3695–3699.
    1. Stergiopoulos S., Calvert S.B., Brown C.A. Cost drivers of a hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia phase 3 clinical trial. Clin Infect Dis. 2018;66(1):72–80.
    1. Ego A., Preiser J.C., Vincent J.L. Impact of diagnostic criteria on the incidence of ventilator-associated pneumonia. Chest. 2015;147(2):347–355.
    1. Klompas M., Anderson D., Trick W. The preventability of ventilator-associated events: the CDC Prevention Epicenters Wake Up and Breathe Collaborative. Am J Respir Crit Care Med. 2015;191(3):292–301.
    1. Magill S.S., Li Q., Gross C., Dudeck M., Allen-Bridson K., Edwards J.R. Incidence and characteristics of ventilator-associated events reported to the National Healthcare Safety Network in 2014. Crit Care Med. 2016;44(12):2154–2162.
    1. Knirsch C., Alemayehu D., Botgros R. Improving conduct and feasibility of clinical trials to evaluate antibacterial drugs to treat hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia: recommendations of the Clinical Trials Transformation Initiative Antibacterial Drug Development Project Team. Clin Infect Dis. 2016;63(suppl 2):S29–S36.
    1. US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research Guidance for industry. Hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia: developing drugs for treatment (draft guidance, revision 2). Food and Drug Administration web site. Published May 2014. Accessed July 20, 2018.
    1. Dudeck M.A., Weiner L.M., Allen-Bridson K. National Healthcare Safety Network (NHSN) report, data summary for 2012, device-associated module. Am J Infect Control. 2013;41(12):1148–1166.
    1. Wang Y., Eldridge N., Metersky M.L. National trends in patient safety for four common conditions, 2005-2011. N Engl J Med. 2014;370(4):341–351.
    1. Skrupky L.P., McConnell K., Dallas J., Kollef M.H. A comparison of ventilator-associated pneumonia rates as identified according to the National Healthcare Safety Network and American College of Chest Physicians criteria. Crit Care Med. 2012;40(1):281–284.
    1. Kollef M.H., Burnham C.D. Ventilator-associated pneumonia: the role of emerging diagnostic technologies. Semin Respir Crit Care Med. 2017;38(3):253–263.
    1. Wunderink R.G., Woldenberg L.S., Zeiss J., Day C.M., Ciemins J., Lacher D.A. The radiologic diagnosis of autopsy-proven ventilator-associated pneumonia. Chest. 1992;101(2):458–463.
    1. Martin-Loeches I., Povoa P., Rodriguez A. Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study. Lancet Respir Med. 2015;3(11):859–868.
    1. Wunderink R.G. Ventilator-associated tracheobronchitis: public-reporting scam or important clinical infection? Chest. 2011;139(3):485–488.
    1. Tamma P.D., Avdic E., Li D.X., Dzintars K., Cosgrove S.E. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med. 2017;177(9):1308–1315.
    1. Chastre J., Trouillet J.L., Vuagnat A. Nosocomial pneumonia in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 1998;157(4):1165–1172.
    1. Kollef M.H. Ventilator-associated pneumonia: s multivariate analysis. JAMA. 1993;270(16):1965–1970.
    1. Collard H.R., Saint S., Matthay M.A. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med. 2003;138(6):494–501.
    1. Kollef M.H. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med. 2004;32(6):1396–1405.
    1. Shenoy E.S., Rosenthal E.S., Shao Y.P. Real-time, automated detection of ventilator-associated events: avoiding missed detections, misclassifications, and false detections due to human error. Infect Control Hosp Epidemiol. 2018;39(7):826–833.
    1. Corneli A., Perry B., Collyar D. Assessment of the perceived acceptability of an early enrollment strategy using advance consent in health care-associated pneumonia. JAMA Netw Open. 2018;1(8)
    1. Ericson JE, McGuire J, Michaels MG, et al. Hospital-acquired pneumonia and ventilator-associated pneumonia in children: a prospective natural history and case-control study. Ped Infect Dis J. 2018;39(8):658-664.
    1. Corrado R.E., Lee D., Lucero D.E., Varma J.K., Vora N.M. Burden of adult community-acquired, health-care-associated, hospital-acquired, and ventilator-associated pneumonia: New York City, 2010 to 2014. Chest. 2017;152(5):930–942.
    1. Giuliano K.K., Baker D., Quinn B. The epidemiology of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. 2018;46(3):322–327.
    1. Shorr A.F., Fisher K., Micek S.T., Kollef M.H. The burden of viruses in pneumonia associated with acute respiratory failure: an underappreciated issue. Chest. 2018;154(1):84–90.
    1. Shorr A.F., Zilberberg M.D., Micek S.T., Kollef M.H. Viruses are prevalent in non-ventilated hospital-acquired pneumonia. Respir Med. 2017;122:76–80.

Source: PubMed

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