title: A comparative analysis of patients with early-onset vs late-onset nosocomial pneumonia in the ICU setting.
abstract: OBJECTIVE
  To compare the clinical outcomes of critically ill patients developing early-onset nosocomial pneumonia (NP; ie, within 96 h of ICU admission) and late-onset NP (ie, occurring after 96 h of ICU admission).
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  A medical ICU and a surgical ICU from a university-affiliated urban teaching hospital.
  
  
  METHODS
  Between July 1997 and November 1998, 3, 668 patients were prospectively evaluated.
  
  
  METHODS
  Prospective patient surveillance and data collection.
  
  
  RESULTS
  Four hundred twenty patients (11.5%) developed NP. Early-onset NP was observed in 235 patients (56.0%), whereas 185 patients (44.0%) developed late-onset NP. Among patients with early onset NP, 114 patients (48. 5%) spent at least 24 h in the hospital prior to ICU admission, compared to 57 patients (30.8%) with late-onset NP (p = 0.001). One hundred eighty-three patients (77.9%) with early-onset NP received antibiotics prior to the development of NP, as compared to 162 patients (87.6%) with late-onset NP (p = 0.010). The most common pathogens associated with early-onset NP were Pseudomonas aeruginosa (25.1%), oxacillin-sensitive Staphylococcus aureus (OSSA; 17.9%), oxacillin-resistant S aureus (ORSA; 17.9%), and Enterobacter species (10.2%). P aeruginosa (38.4%), ORSA (21.1%), Stenotrophomonas maltophilia (11.4%), OSSA (10.8%), and Enterobacter species (10.3%) were the most common pathogens associated with late-onset NP. The ICU length of stay was significantly longer for patients with early-onset NP (10.3 +/- 8.3 days; p < 0.001) and late-onset NP (21. 0 +/- 13.7 days; p < 0.001), as compared to patients without NP (3.5 +/- 3.2 days). Hospital mortality was significantly greater for patients with early-onset NP (37.9%; p = 0.001) and late-onset NP (41.1%; p = 0.001) compared to patients without NP (13.1%).
  
  
  CONCLUSIONS
  Both early-onset and late-onset NP are associated with increased hospital mortality rates and prolonged lengths of stay. The pathogens associated with NP were similar for both groups. This may be due, in part, to the prior hospitalization and use of antibiotics in many patients developing early-onset NP. These data suggest that P aeruginosa and ORSA can be important pathogens associated with early-onset NP in the ICU setting. Additionally, clinicians should be aware of the common microorganisms associated with both early-onset NP and late-onset NP in their hospitals in order to avoid the administration of inadequate antimicrobial treatment.
authors.affiliation: Pulmonary and Critical Care Medicine Division, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
authors.forename: E H
authors.initials: EH
authors.lastname: Ibrahim
authors.forename: S
authors.initials: S
authors.lastname: Ward
authors.forename: G
authors.initials: G
authors.lastname: Sherman
authors.forename: M H
authors.initials: MH
authors.lastname: Kollef
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D015897:Comorbidity; D003422:Critical Care; D003428:Cross Infection / Q000175:diagnosis* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000175:diagnosis* / Q000401:mortality; D011446:Prospective Studies; D012307:Risk Factors; D016019:Survival Analysis