Ventilator-Associated Pneumonia Linked to Worse Outcomes in Critically Ill Children
Posted by Darryl Virgiawan on April 9, 2009
Laurie Barclay, MD
April 8, 2009 — Mechanically ventilated, critically ill children with ventilator-associated pneumonia (VAP) have a prolonged need for mechanical ventilation, longer intensive care unit (ICU) stay, and higher mortality, according to the results of a prospective, observational study reported in the April issue of Pediatrics.
"The epidemiology, associated risk factors, and outcomes of VAP are not as well documented in pediatric patients as they are in adult patients," write Ramya Srinivasan, MD, from University of California, San Francisco, and colleagues. "In adults, independent risk factors for development of VAP include duration of mechanical ventilation, severity of illness, patient age, supine head position, previous antibiotic treatment, reintubation, transport out of the ICU, and use of histamine-2 blockers. In addition, VAP in adults has been associated with prolonged duration of mechanical ventilation as well as increased length of ICU stay, hospital stay, hospital cost, and absolute mortality."
The study goal was to assess risk factors for the development of and outcomes from VAP in a tertiary care pediatric center. Inclusion criteria were all neonatal ICU and pediatric ICU patients from November 2004 to June 2005 who were mechanically ventilated for more than 24 hours and for whom parents gave informed consent. The main study endpoint was the development of VAP, as defined by clinician diagnosis and National Nosocomial Infections Surveillance criteria from the Centers for Disease Control and Prevention. Secondary endpoints were duration of mechanical ventilation, length of stay in hospital and ICU, cost of hospitalization, and mortality.
The study sample consisted of 58 patients, of whom 57% were boys; median age was 6 months. Organisms most commonly associated with VAP were gram-negative bacteria (42%), Staphylococcus aureus (22%), and Haemophilus influenzae (11%).
Factors associated with VAP, based on multivariate analysis, were female sex, postsurgical admission, presence of enteral feeds, and use of narcotic medications. Compared with children without VAP, those with VAP had increased need for mechanical ventilation (12 vs 22 median ventilator-free days), longer length of ICU stay (6 vs 13 median ICU-free days), higher total median hospital costs (US $308,534 vs $252,652), and increased absolute hospital mortality (10.5% vs 2.4%).
"In mechanically ventilated, critically ill children, those with ventilator associated pneumonia had a prolonged need for mechanical ventilation, a longer ICU stay, and a higher mortality rate," the study authors write. "Female gender, postsurgical diagnosis, the use of narcotics, and the use of enteral feeds were associated with an increased risk of developing ventilator-associated pneumonia in these patients."
Limitations of this study include small sample size, subpopulation size inadequate to determine pertinent differences in risk factors and outcomes for VAP in neonatal ICU vs pediatric ICU patients, lack of enrollment of extremely high-risk patients who had high ventilatory and cardiovascular support, and lack of gold standard for the definition of VAP.
"Our study is one of the few prospective studies in pediatrics that elucidates risk factors for VAP within a 72-hour period before diagnosis and the only pediatric study to state the cost of VAP in pediatric patients," the study authors conclude.
"These findings need to be confirmed in larger, multicenter studies to clarify risk factors and the impact of prevention strategies, such as spontaneous breathing trials and daily sedation weaning protocols, on the development of VAP."
SCCOR grants and the CHRCO Neonatal Pediatric Research Group supported this study. The authors have disclosed no relevant financial relationships.
Laurie Barclay, MD is a freelance reviewer and writer for Medscape LLC.
Medscape Medical News 2009. © 2009 Medscape
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