title: Hospital-acquired pneumonia is an independent predictor of poor global outcome in severe traumatic brain injury up to 5 years after discharge.
abstract: BACKGROUND
  Long-term outcomes following traumatic brain injury (TBI) correlate with initial head injury severity and other acute factors. Hospital-acquired pneumonia (HAP) is a common complication in TBI. Limited information exists regarding the significance of infectious complications on long-term outcomes after TBI. We sought to characterize risks associated with HAP on outcomes 5 years after TBI.
  
  
  METHODS
  This study involved data from the merger of an institutional trauma registry and the Traumatic Brain Injury Model Systems outcome data. Individuals with severe head injuries (Abbreviated Injury Scale [AIS] score ≥ 4) who survived to rehabilitation were analyzed. Primary outcome was Glasgow Outcome Scale-Extended (GOSE) at 1, 2, and 5 years. GOSE was dichotomized into low (GOSE score < 6) and high (GOSE score ≥ 6). Logistic regression was used to determine adjusted odds of low GOSE score associated with HAP after controlling for age, sex, head and overall injury severity, cranial surgery, Glasgow Coma Scale (GCS) score, ventilation days, and other important confounders. A general estimating equation model was used to analyze all outcome observations simultaneously while controlling for within-patient correlation.
  
  
  RESULTS
  A total of 141 individuals met inclusion criteria, with a 30% incidence of HAP. Individuals with and without HAP had similar demographic profiles, presenting vitals, head injury severity, and prevalence of cranial surgery. Individuals with HAP had lower presenting GCS score. Logistic regression demonstrated that HAP was independently associated with low GOSE scores at follow-up (1 year: odds ratio [OR], 6.39; 95% confidence interval [CI], 1.76-23.14; p = 0.005) (2 years: OR, 7.30; 95% CI, 1.87-27.89; p = 0.004) (5-years: OR, 6.89; 95% CI, 1.42-33.39; p = 0.017). Stratifying by GCS score of 8 or lower and early intubation, HAP remained a significant independent predictor of low GOSE score in all strata. In the general estimating equation model, HAP continued to be an independent predictor of low GOSE score (OR, 4.59; 95% CI, 1.82-11.60; p = 0.001).
  
  
  CONCLUSIONS
  HAP is independently associated with poor outcomes in severe TBI extending 5 years after injury. This suggests that precautions should be taken to reduce the risk of HAP in individuals with severe TBI.
  
  
  METHODS
  Prognostic study, level III.
authors.affiliation: From the Division of Trauma and General Surgery (J.C.P., A.P.P., T.R.B., J.L.S.), Department of Surgery, and Department of Physical Medicine and Rehabilitation (R.G.K., A.K.W.), School of Medicine (M.R.K.), University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Matthew Ryan
authors.initials: MR
authors.lastname: Kesinger
authors.forename: Raj G
authors.initials: RG
authors.lastname: Kumar
authors.forename: Amy K
authors.initials: AK
authors.lastname: Wagner
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Puyana
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Peitzman
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Billiar
authors.forename: Jason L
authors.initials: JL
authors.lastname: Sperry
mesh_terms: D015998:Abbreviated Injury Scale; D000328:Adult; D001930:Brain Injuries / Q000150:complications*; D003428:Cross Infection / Q000453:epidemiology*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000453:epidemiology*; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D015996:Survival Rate; D013997:Time Factors; D014193:Trauma Centers; D016896:Treatment Outcome