Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis

doi:10.5847/wjem.j.1920-8642.2018.03.007

Abstract

Abstract:

BACKGROUND: We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients.
METHODS: Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients’ demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP.
RESULTS: Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models.
CONCLUSION: In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Key words: Ventilator-associated pneumonia, Trauma, Mechanical ventilation, Intubation location, Intensive care unit

Suresh Kumar Arumugam, Insolvisagan Mudali, Gustav Strandvik, Ayman El-Menyar, Ammar Al-Hassani, Hassan Al-Thani. Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis[J]. World Journal of Emergency Medicine, 2018, 9(3): 203-210.

Figures/Tables 8

Table 1

Table 2

Table 3

Table 4

Table 5

Figure 1.

Table 6

Table 7

References 27

[1]	Kalanuria AA, Ziai W, Mirski M. Ventilator-associated pneumonia in the ICU. Crit Care. 2014; 18:208. doi: 10.1186/cc13775 pmid: 25029020
[2]	Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, Tablan OC, et al. Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004; 53(RR-3):1-36. pmid: 15048056
[3]	Dudeck MA, Weiner LM, Allen-Bridson K, Malpiedi PJ, Peterson KD, Pollock DA, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. Am J Infect Control. 2013; 41(12):1148-66. doi: 10.1016/j.ajic.2013.09.002 pmid: 24274911
[4]	Mangram AJ, Sohn J, Zhou N, Hollingworth AK, Ali-Osman FR, Sucher JF, et al. Trauma-associated pneumonia: time to redefine ventilator-associated pneumonia in trauma patients. Am J Surg. 2015; 210:1056-61; discussion 1061-2. doi: 10.1016/j.amjsurg.2015.06.029 pmid: 26477792
[5]	Magnotti LJ, Croce MA, Fabian TC. Is ventilator-associated pneumonia in trauma patients an epiphenomenon or a cause of death? Sur Infect (Larchmt). 2004; 5:237-42.
[6]	Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002; 122(6):2115-21. doi: 10.1378/chest.122.6.2115 pmid: 12475855
[7]	Wallace WC, Cinat M, Gornick WB, Lekawa ME, Wilson SE. Nosocomial infections in the surgical intensive care unit: a difference between trauma and surgical patients. Am Surg. 1999; 65:987-90. pmid: 10515549
[8]	Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med. 1998; 129(6):433-40. doi: 10.7326/0003-4819-129-6-199809150-00002 pmid: 9735080
[9]	Eckert MJ, Davis RL 2nd, Reed KA, Santaniello JM, Poulakidas S, Esposito TJ, et al. Urgent airways after trauma: who gets pneumonia? J Trauma. 2004; 57(4):750-5. doi: 10.1097/01.ta.0000147499.73570.12 pmid: 15514528
[10]	Eckert MJ, Davis KA, Reed RL 2nd, Esposito TJ, Santaniello JM, Poulakidas S, et al. Ventilator-associated pneumonia, like real estate: location really matters. J Trauma. 2006; 60(1):104-10; discussion 110. doi: 10.1097/01.ta.0000197376.98296.7c pmid: 16456443
[11]	Jovanovic B, Milan Z, Markovic-Denic L, Djuric O, Radinovic K, Doklestic K, et al. Risk factors for ventilator-associated pneumonia in patients with severe traumatic brain injury in a Serbian trauma centre. Int J Infect Dis. 2015; 38:46-51. doi: 10.1016/j.ijid.2015.07.005 pmid: 26166697
[12]	Zarzaur BL, Bell TM, Croce MA, Fabian TC. Geographic variation in susceptibility to ventilator-associated pneumonia after traumatic injury. J Trauma Acute Care Surg. 2013; 75(2):234-40. doi: 10.1097/TA.0b013e3182924c18 pmid: 23823609
[13]	Croce MA, Fabian TC, Tolley EA. A formula for prediction of post-traumatic pneumonia based on early anatomic and physiologic parameters. J Trauma. 2003; 54:724-30. doi: 10.1097/01.TA.0000054643.54218.C5 pmid: 12707535
[14]	Karch SB, Lewis T, Young S, Hales D, Ho CH. Field intubation of trauma patients: complications, indications and outcomes. Am J Emerg Med. 1996; 4(7):617-9.
[15]	Evans HL, Zonies DH, Warner KJ, Bulger EM, Sharar SR, Maier RV, et al. Timing of intubation and ventilator-associated pneumonia following injury. Arch Surg. 2010; 145(11):1041-6. doi: 10.1001/archsurg.2010.239 pmid: 21079091
[16]	Mohr NM, Harland KK, Skeete D, Pearson K, Choi K. Duration of prehospital intubation is not a risk factor for development of early ventilator-associated pneumonia. J Crit Care. 2014; 29(4):539-44. doi: 10.1016/j.jcrc.2014.03.030 pmid: 24793661
[17]	American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005; 171(4):388-416. pmid: 15699079
[18]	Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002; 165(7):867-903. doi: 10.1164/ajrccm.165.7.2105078 pmid: 11934711
[19]	Cook DJ, Kollef MH. Risk factors for ICU acquired pneumonia. JAMA. 1998; 279(20):1605-6. doi: 10.1001/jama.279.20.1605 pmid: 9613899
[20]	Evans HL, Warner K, Bulger EM, Sharar SR, Maier RV, Cuschieri J. Pre-hospital intubation factors and pneumonia in trauma patients. Surg Infect (Larchmt). 2011; 12(5):339-44.
[21]	Gianakis A, McNett M, Belle J, Moran C, Grimm D. Risk factors for ventilator-associated pneumonia: among trauma patients with and without brain injury. J Trauma Nurs. 2015; 22(3):125-31. doi: 10.1097/JTN.0000000000000121 pmid: 25961478
[22]	Chen LP, Chen JH, Chen Y, Wu C, Yang XH. Efficacy and safety of glucocorticoids in the treatment of community-acquired pneumonia: A meta-analysis of randomized controlled trials. World J Emerg Med. 2015; 6(3):172-8. doi: 10.5847/wjem.j.1920-8642.2015.03.002 pmid: 26401176
[23]	Michelet P, Couret D, Brégeon F, Perrin G, D'Journo XB, Pequignot V, et al. Early onset pneumonia in severe chest trauma: a risk factor analysis. J Trauma. 2010; 68(2):395-400. doi: 10.1097/TA.0b013e3181a601cb pmid: 20154552
[24]	Centers for Disease Control and Prevention. Ventillator-associated Pneumonia (VAP) Events 2017. Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/10-vae_final.pdf Accessed March 4, 2017.
[25]	Antonelli M, Moro ML, Capelli O, De Blasi RA, D'Errico RR, Conti G, et al. Risk factors for early onset pneumonia in trauma patients. Chest. 1994; 105(1):224-8. doi: 10.1378/chest.105.1.224 pmid: 8275735
[26]	Magret M, Amaya-Villar R, Garnacho J, Lisboa T, Díaz E, Dewaele J, et al. Ventilator-associated pneumonia in trauma patients is associated with lower mortality: results from EU-VAP study. J Trauma. 2010; 69(4):849-54. pmid: 20938271
[27]	Melsen WG, Rovers MM, Bonten MJ. Ventilator-associated pneumonia and mortality: a systematic review of observational studies. Crit Care Med. 2009; 37(10):2709-18. doi: 10.1097/ccm.0b013e3181ab8655 pmid: 19885994

Variables	All patients (n=332)	PHI (n=124)	TRI (n=208)	P value
Age (years)	30.7±14.8	31±12.7	30.5±16.0	0.80
Males, n (%)	307 (92.5)	114 (91.9)	193 (92.8)	0.77
Mechanism of injury, n (%)
Traffic-related	213 (64.4)	89 (71.8)	124 (59.9)	0.26 for all
Fall from height	76 (22.7)	22 (17.7)	53 (25.6)
Gunshot/Assault/Stab	18 (5.4)	4 (3.2)	14 (6.8)
Fall of heavy object	6 (1.8)	2 (1.6)	4 (1.9)
Self-inflicted	5 (1.5)	1 (0.8)	4 (1.9)
ATV/sports	7 (2.1)	2 (1.6)	5 (2.4)
Others	7 (2.1)	4 (3.2)	3 (1.4)
Vital signs at ED
Systolic blood pressure (mmHg)	123.8±28.9	121.8±29.9	125.0±28.4	0.34
Diastolic blood pressure (mmHg)	75.9±19.8	78.0±22.8	74.7±17.8	0.18
Respiratory rate (beats/minute)	17.3±7.8	10.6±7.5	21.3±4.6	0.001
Oxygen saturation (%)	96.9±6.3	97.4±6.8	96.6±6.0	0.25
Glasgow coma score	7.4±5.1	3.6±2.6	9.6±4.9	0.001
Injury severity score	21.0±9.4	22.3±9.3	20.2±9.3	0.05
Polytrauma (ISS≥16), n (%)	252 (76.1)	99 (79.8)	153 (73.9)	0.22
Head injury, n (%)	245 (74.0)	100 (81.3)	145 (69.7)	0.02
Chest injury, n (%)	172 (52.0)	73 (59.3)	99 (47.6)	0.04
Head AIS	3.6±0.9	3.7±0.9	3.6±0.9	0.25
Chest AIS	2.9±0.6	2.8±0.5	2.9±0.6	0.16
Alcohol positive, n (%)	39 (11.9)	13 (10.7)	26 (12.6)	0.59
Blood alcohol level	43.7±18	39.4±16.6	45.8±18.5	0.29
Ventilator-associated pneumonia, n(%)	57 (17.2)	23 (18.5)	34 (16.3)	0.60
Ventilatory days (days)	3 (1-163)	5 (1-163)	3 (1-56)	0.09
ICU length of stay (days)	7 (1-155)	9.5 (1-155)	6 (1-150)	0.004
Hospital length of stay (days)	19 (1-254)	23 (1-199)	18 (2-254)	0.09
Mortality, n (%)	25 (7-5)	12 (9.7)	13 (6.3)	0.25

Variables	All VAP cases (n=57)	VAP in PHI cases (n=23)	VAP in TRI cases (n=34)	P value
Age (years)	36.2±14.7	34.6±10.6	37.3±17.0	0.50
Males, n (%)	52 (91.2)	21 (91.3)	31 (91.2)	0.98
SBP (mmHg)	126.4±27.8	128.5±30.0	125.0±26.7	0.65
DBP (mmHg)	78.2±21.2	78.1±22.8	78.2±20.4	0.99
Respiratory rate (beats/minute)	15.6±8.5	7.6±6.6	20.8±4.8	0.001
Oxygen saturation (%)	95.3±7.2	96.2±8.6	94.6±6.0	0.43
GCS	3 (3-15)	3 (3-3)	6.5 (3-15)	0.001
ISS	25.1±9.5	23.9±8.6	25.8±10.1	0.45
Polytrauma (ISS≥16), n (%)	51 (89.5)	20 (87.0)	31 (91.2)	0.61
Head injury, n (%)	51 (91.1)	21 (95.5)	30 (88.2)	0.35
Chest injury, n (%)	36 (64.3)	13 (59.1)	23 (67.6)	0.51
Head AIS	3.9±0.9	3.9±0.8	4.0±0.9	0.85
Chest AIS	2.9±0.6	2.8±0.4	3.0±0.7	0.45
Alcohol positive, n (%)	8 (15.1)	2 (9.5)	6 (18.8)	0.35
Blood alcohol level	40.6±15.2	41.6±20.4	40.2±15.5	0.92
Days to development VAP (days)	4 (2-31)	4 (2-30)	5 (2-31)	0.08
Early-onset VAP (≤4 days), n (%)	31 (54.4)	15 (65.2)	16 (47.1)	0.71 for all
Late-onset VAP (>4 days), n (%)	26 (45.6)	8 (34.8)	18 (52.9)	0.71 for all
WBC (on the day of VAP)	11.1±4.6	12.7±6.3	9.9±2.8	0.03
Ventilatory days (days)	9.5 (1-163)	9 (1-163)	10 (2-56)	0.66
ICU length of stay (days)	16 (3-155)	16 (5-155)	15 (3-150)	0.95
Hospital length of stay (days)	33 (5-186)	38 (13-186)	29 (5-114)	0.07
Mortality, n (%)	2 (3.5)	0 (0.0)	2 (5.9)	0.23

Variables	No VAP (n=275)	VAP (n=57)	Pvalue
Age (mean±SD) (years)	29.5±14.5	35.6±14.7	0.002
Males, n (%)	255 (92.7)	52 (91.2)	0.69
SBP (mmHg)	123.3±29.2	126.4±27.9	0.46
DBP (mmHg)	75.5±19.6	78.2±21.2	0.37
Respiratory rate (beats/minute)	17.6±7.6	15.6±8.5	0.08
Oxygen saturation (%)	97.2±6.1	95.3±7.2	0.06
GCS	7.7±5.2	5.6±4.1	0.007
ISS	20±9	25.1±9.5	0.001
Polytrauma (ISS≥16), n (%)	201 (73.4)	51 (89.5)	0.009
Head injury, n (%)	194 (70.5)	51 (91.1)	0.001
Chest injury, n (%)	136 (49.5)	36 (64.3)	0.04
Head AIS	3.5±0.9	3.9±0.9	0.003
Chest AIS	2.8±0.6	2.9±0.6	0.57
Alcohol positive, n(%)	31 (11.3)	8 (15.1)	0.43
Blood alcohol level	44.5±18.8	40.6±15.2	0.58
Ventilatory days (days)	3 (1-36)	9.5 (1-163)	0.001
ICU length of stay (days)	6 (1-47)	16 (3-155)	0.001
Hospital length of stay (days)	17 (1-254)	33 (5-186)	0.001
Mortality, n (%)	23 (8.4)	2 (3.5)	0.20

Variables	All VAP cases (n=57)	VAP in PHI (n=23)	VAP in TRI (n=34)
Klebsiella pneumoniae	18 (36.1)	5 (21.7)	13 (38.2)
Hemophilus influenza	17 (29.8)	7 (30.4)	10 (29.4)
Staphylococcus aureus	16 (28.1)	8 (34.8)	8 (23.5)
Streptococcal pneumoniae	9 (15.8)	3 (13.0)	6 (17.6)
Enterobacter cloacae	7 (12.3)	2 (8.7)	5 (14.7)
Pseudomonas aureriginosa	7 (12.3)	2 (8.7)	5 (14.7)
Acenatobacter banumanii	4 (7.0)	1 (4.3)	3 (8.8)
Moraxella catterhallis	3 (5.3)	1 (4.3)	2 (5.9)
Klebsiella oxytoca	2 (3.5)	1 (4.3)	1 (2.9)
Klebsiella ozonae	3 (5.3)	3 (13.0)	0 (0.0)
Streptococcal group C	1 (1.8)	1 (4.3)	0 (0.0)
Proteus vulgaris	1 (1.8)	0 (0.0)	1 (2.9)
Serratia margascens	1 (1.8)	1 (4.3)	0 (0.0)
Escheritia coli	1 (1.8)	0 (0.0)	1 (2.9)
Burkholdia cepacia	1 (1.8)	1 (4.3)	0 (0.0)

Micro-organisms	Field intubation		ED intubation
Micro-organisms	Early VAP (≤ 4 days) (n=15)	Late VAP (> 4 days) (n=8)	Early VAP (≤ 4 days) (n=16)	Late VAP (> 4 days) (n=18)
Staphylococcus aureus	5 (33.3)	3 (37.5)	5 (31.3)	3 (16.7)
Streptococcal group C	0 (0.0)	1 (12.5)	0 (0.0)	0 (0.0)
Klebsiella pneumoniae	3 (20.0)	2 (25.0)	6 (37.5)	7 (38.9)
Streptococcal pneumoniae	3 (20.0)	0 (0.0)	4 (25.0)	2 (11.1)
Hemophilus influenza	7 (46.7)	0 (0.0)	7 (43.8)	3 (16.7)
Moraxella catterhallis	1 (6.7)	0 (0.0)	2 (12.5)	0 (0.0)
Pseudomonas aureriginosa	2 (13.3)	0 (0.0)	0 (0.0)	5 (27.8)
Klebsiella oxytoca	1 (6.3)	1 (12.5)	0 (0.0)	1 (5.6)
Proteus vulgaris	0 (0.0)	0 (0.0)	0 (0.0)	1 (5.6)
Serratia margascens	0 (0.0)	1 (12.5)	0 (0.0)	0 (0.0)
Klebsiella ozonae	2 (13.3)	1 (12.5)	0 (0.0)	0 (0.0)
Enterobacter cloacae	2 (13.3)	0 (0.0)	1 (6.3)	4 (22.2)
Acenatobacter banumanii	1 (6.7)	0 (0.0)	1 (6.3)	2 (11.1)
Escheritia coli	0 (0.0)	0 (0.0)	0 (0.0)	1 (5.6)
Burkholdia cepacia	1 (6.7)	0 (0.0)	0 (0.0)	0 (0.0)