Ventilator-associated pneumonia due to Pseudomonas aeruginosa.
OBJECTIVE
Ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa has been associated with higher case fatality rates than VAP caused by other bacterial etiologies. The causes of this excess mortality are unclear.


METHODS
Retrospective review of 38 consecutive ventilated patients with Pseudomonas pneumonia, documented by highly reliable methods. Charts of five additional patients were unavailable for review.


METHODS
Medical ICUs of a university-affiliated Veterans Affairs Medical Center and a university-affiliated municipal hospital.


METHODS
Prospectively collected hospital admission acute physiologic and chronic health examination (APACHE) II scores and cause of ICU admission. Retrospectively calculated organ failure and APACHE scores, VAP score. Clinical and microbiologic variables. Antibiotic treatment and outcome. Direct cause of death by standard definitions.


RESULTS
Overall mortality was 69% (26/38), significantly higher than the APACHE II predicted mortality of 42.6% (p=0.037). At least 38% (10/26) of deaths were directly attributable to Pseudomonas VAP. Multivariate analysis of factors associated with death found infectious cause for ICU admission (odds ratio [OR]=8.67; 95% confidence interval [CI], 0.86 to 85.94) and number of organ dysfunctions on the day of diagnosis (OR=1.73, 95% CI, 1.02 to 2.92) were significant. Septic shock from Pseudomonas VAP, septic shock from subsequent infection, and multiple organ dysfunction syndrome were the most common immediate causes of death. Mortality increased linearly with increasing APACHE III score on the day of diagnosis. Of initial antibiotic regimens, 67% (26/36) were considered failures. Persistent pneumonia occurred in 35% of patients while recurrent pneumonia was unusual (1/38).


CONCLUSIONS
Development of Pseudomonas pneumonia results in a mortality rate in excess of that due to the presenting illness. The attributable mortality determined by several means appears to approach 40%. The excess mortality appears to be related to the host defense response to the pneumonia rather than any characteristic of the pneumonia. Even standard antibiotic regimens fail frequently and do not prevent the excess mortality. Since at least 38% of deaths can be directly attributable to the Pseudomonas pneumonia, improvement in therapy is needed.
Crouch Brewer
S
S
Department of Medicine, University of Tennessee, Memphis, USA.
Wunderink
R G
RG
Jones
C B
CB
Leeper
K V
KV
D018806:APACHE; D000046:Academic Medical Centers; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002423:Cause of Death; D016001:Confidence Intervals; D003422:Critical Care; D005260:Female; D005544:Forecasting; D006773:Hospitals, Municipal; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000401:mortality; D015999:Multivariate Analysis; D016017:Odds Ratio; D010343:Patient Admission; D018410:Pneumonia, Bacterial / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality*; D011446:Prospective Studies; D011552:Pseudomonas Infections / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality*; D011550:Pseudomonas aeruginosa; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012772:Shock, Septic / Q000401:mortality; D015996:Survival Rate; D013714:Tennessee / Q000453:epidemiology; D016896:Treatment Outcome; D012122:Ventilators, Mechanical / Q000009:adverse effects*
D000900:Anti-Bacterial Agents