Causes and predictors of nonresponse to treatment of intensive care unit-acquired pneumonia.
OBJECTIVE
To prospectively evaluate the predictive factors for the nonresponse to empirical antibiotic treatment and mortality in patients with intensive care unit-acquired pneumonia.


METHODS
A 1-yr prospective cohort of patients with suspicion of intensive care unit-acquired pneumonia.


METHODS
Five medical and surgical intensive care units of Hospital Clinic in Barcelona.


METHODS
A total of 71 patients with intensive care unit-acquired pneumonia were studied. The definition of nonresponse included at least one of the following: failure to improve the Pao2/Fio2 ratio or need of intubation because of pneumonia, persistence of fever or hypothermia and purulent respiratory secretions, worsening of pulmonary infiltrates, or occurrence of septic shock or multiple organ dysfunction not present at onset of pneumonia.


METHODS
Clinical assessment, including severity scores, blood and quantitative cultures of respiratory secretions, and cytokine measurements in serum and bronchoalveolar lavage at onset of pneumonia and 72 hrs after antimicrobial treatment.


RESULTS
A total of 44 patients (62%) fulfilled criteria of nonresponse, and at least one cause of nonresponse could be determined in 28 cases (64%): inappropriate treatment in ten (23%), superinfection in six (14%), concomitant foci of infection in 12 (27%), and noninfectious causes in seven cases (16%). The remaining 16 patients with no definite cause of nonresponse presented with septic shock, multiple organ dysfunction, or acute respiratory distress syndrome. Increased levels of interleukin-6 at onset of pneumonia (odds ratio, 9.7; p =.014) was an independent predictor of nonresponse to treatment. Likewise, increased level of interleukin-6 at follow-up (odds ratio, 27; p =.001) was the only independent predictor for hospital mortality.


CONCLUSIONS
Increased systemic inflammatory response was the main predictor of nonresponse to treatment and mortality.
Ioanas
Malina
M
Institut Clinic de Pneumologia i Cirurgia Toracica, Hospital Clinic, Barcelona, Spain.
Ferrer
Miquel
M
Cavalcanti
Manuela
M
Ferrer
Ricard
R
Ewig
Santiago
S
Filella
Xavier
X
de la Bellacasa
Jordi Puig
JP
Torres
Antoni
A
D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D015415:Biomarkers / Q000097:blood; D002423:Cause of Death; D015331:Cohort Studies; D003428:Cross Infection / Q000188:drug therapy* / Q000401:mortality / Q000635:transmission; D018450:Disease Progression; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D015850:Interleukin-6 / Q000097:blood; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000401:mortality; D010100:Oxygen / Q000097:blood; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000401:mortality / Q000635:transmission; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012121:Respiration, Artificial; D012772:Shock, Septic / Q000401:mortality; D016019:Survival Analysis; D017211:Treatment Failure; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; D015415:Biomarkers; D015850:Interleukin-6; D010100:Oxygen