title: Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study.
abstract: Ventilator-associated tracheobronchitis has been suggested as an intermediate process between tracheobronchial colonisation and ventilator-associated pneumonia in patients receiving mechanical ventilation. We aimed to establish the incidence and effect of ventilator-associated tracheobronchitis in a large, international patient cohort.
  
  
  
  We did a multicentre, prospective, observational study in 114 intensive care units (ICU) in Spain, France, Portugal, Brazil, Argentina, Ecuador, Bolivia, and Colombia over a preplanned time of 10 months. All patients older than 18 years admitted to an ICU who received invasive mechanical ventilation for more than 48 h were eligible. We prospectively obtained data for incidence of ventilator-associated lower respiratory tract infections, defined as ventilator-associated tracheobronchitis or ventilator-associated pneumonia. We grouped patients according to the presence or absence of such infections, and obtained data for the effect of appropriate antibiotics on progression of tracheobronchitis to pneumonia. Patients were followed up until death or discharge from hospital. To account for centre effects with a binary outcome, we fitted a generalised estimating equation model with a logit link, exchangeable correlation structure, and non-robust standard errors. This trial is registered with ClinicalTrials.gov, number NCT01791530.
  
  
  
  Between Sept 1, 2013, and July 31, 2014, we obtained data for 2960 eligible patients, of whom 689 (23%) developed ventilator-associated lower respiratory tract infections. The incidence of ventilator-associated tracheobronchitis and that of ventilator-associated pneumonia at baseline were similar (320 [11%; 10·2 of 1000 mechanically ventilated days] vs 369 [12%; 8·8 of 1000 mechanically ventilated days], p=0·48). Of the 320 patients with tracheobronchitis, 250 received appropriate antibiotic treatment and 70 received inappropriate antibiotics. 39 patients with tracheobronchitis progressed to pneumonia; however, the use of appropriate antibiotic therapy for tracheobronchitis was associated with significantly lower progression to pneumonia than was inappropriate treatment (19 [8%] of 250 vs 20 [29%] of 70, p<0·0001; crude odds ratio 0·21 [95% CI 0·11-0·41]). Significantly more patients with ventilator-associated pneumonia died (146 [40%] of 369) than those with tracheobronchitis (93 [29%] of 320) or absence of ventilator-associated lower respiratory tract infections (673 [30%] of 2271, p<0·0001). Median time to discharge from the ICU for survivors was significantly longer in the tracheobronchitis (21 days [IQR 15-34]) and pneumonia (22 [13-36]) groups than in the group with no ventilator-associated lower respiratory tract infections (12 [8-20]; hazard ratio 1·65 [95% CI 1·38-1·97], p<0·0001).
  
  
  
  This large database study emphasises that ventilator-associated tracheobronchitis is a major health problem worldwide, associated with high resources consumption in all countries. Our findings also show improved outcomes with use of appropriate antibiotic treatment for both ventilator-associated tracheobronchitis and ventilator-associated pneumonia, underlining the importance of treating both infections, since inappropriate treatment of tracheobronchitis was associated with a higher risk of progression to pneumonia.
  
  
  
  None.
authors.affiliation: Department of Clinical Medicine, St James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland. Electronic address: drmartinloeches@gmail.com.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Martin-Loeches
authors.affiliation: Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
authors.forename: Pedro
authors.initials: P
authors.lastname: Povoa
authors.affiliation: Hospital Joan XXIII, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Bunyola, Mallorca, Spain.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Rodríguez
authors.affiliation: Hospital Municipal de Chivilcoy, Chivilcoy Nueva, Buenos Aires, Argentina.
authors.forename: Daniel
authors.initials: D
authors.lastname: Curcio
authors.affiliation: Epidemiology and Assessment Unit, Fundació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain.
authors.forename: David
authors.initials: D
authors.lastname: Suarez
authors.affiliation: Cochin University Hospital, APHP, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Medical Faculty, Paris, France.
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Mira
authors.affiliation: Complejo Hospitalario A Coruna, Galicia, Spain.
authors.forename: Maria Lourdes
authors.initials: ML
authors.lastname: Cordero
authors.affiliation: Centre Hospitalier d'Argenteuil, Argenteuil, France.
authors.forename: Raphaël
authors.initials: R
authors.lastname: Lepecq
authors.affiliation: Hospital Center University Rouen, Rouen, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Girault
authors.affiliation: Hospital Sante Maria, Lisbon, Portugal.
authors.forename: Carlos
authors.initials: C
authors.lastname: Candeias
authors.affiliation: Hospital Center University De Rennes, Rennes, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Seguin
authors.affiliation: Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
authors.forename: Carolina
authors.initials: C
authors.lastname: Paulino
authors.affiliation: Hospital Louis Mourier, Colombes, France.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Messika
authors.affiliation: Hospital Universitario Marques de Valdecilla, Santander, Cantabria, Spain.
authors.forename: Alejandro G
authors.initials: AG
authors.lastname: Castro
authors.affiliation: Corporacion Sanitaria Parc Tauli CIBER Enfermedades respiratorias, Parc Tauli, University Institute, Sabadell, Spain.
authors.forename: Jordi
authors.initials: J
authors.lastname: Valles
authors.affiliation: Hospital Pulido Valente, Lisbon, Portugal.
authors.forename: Luis
authors.initials: L
authors.lastname: Coelho
authors.affiliation: Intensive Care Unit, Instituto Nacional de Câncer, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
authors.forename: Ligia
authors.initials: L
authors.lastname: Rabello
authors.affiliation: Critical Care Department and Infection Control Committee, Hospital de Clinicas de Porto Alegre, Rede Institucional de Pesquisa e Inovação em Medicina Intensiva, Complexo Hospitalar Santa Casa, Porto Alegre, Brazil.
authors.forename: Thiago
authors.initials: T
authors.lastname: Lisboa
authors.affiliation: Department of Clinical Medicine, St James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland.
authors.forename: Daniel
authors.initials: D
authors.lastname: Collins
authors.affiliation: Hospital Clinic, Barcelona, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Torres
authors.affiliation: Intensive Care Unit, Instituto Nacional de Câncer, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
authors.forename: Jorge
authors.initials: J
authors.lastname: Salluh
authors.affiliation: Centre Hospitalier Régional Universitaire de Lille, Lille, France.
authors.forename: Saad
authors.initials: S
authors.lastname: Nseir
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001991:Bronchitis / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D003428:Cross Infection / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy / Q000453:epidemiology*; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000009:adverse effects*; D013020:South America / Q000453:epidemiology; D014136:Tracheitis / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents