Ventilator-Associated Pneumonia in Traumatic Brain Injury: Incidence and Mortality

Ventilator-associated pneumonia (VAP) occurs less often than previously described in intubated patients following traumatic brain injury (TBI), and while it may have a detrimental effect on intensive care unit (ICU) length of stay (LOS), it does not appear to have the same effect on neurologic outcomes and mortality.

Researchers conducted an analysis of data from the large, multicenter, prospective, observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study (ClinicalTrials.gov Identifier: NCT02210221) and the results were published in CHEST.

Investigators sought to assess the incidence, timing, and risk factors for VAP following TBI and its effect on patient outcomes. They performed an analysis of the CENTER-TBI dataset, which includes patients with TBI admitted to ICUs in Europe who received mechanical ventilation for ≥48 hours and had an ICU LOS of ≥72 hours. They compared features of patients with VAP with those of individuals without VAP; patients’ outcomes were evaluated at 6 months following their injury via use of the extended Glasgow Outcome Scale.

A total of 962 patients were included in the study, with 20.4% (n=196) of them developing VAP at a median of 5 days (interquartile range, 3-7 days) from intubation. Those patients who developed VAP, compared with those who did not, had a significantly younger median age (39.5 vs 51.0 years, respectively; P <.0001), had a significantly higher incidence of alcohol abuse (36.6% vs 27.6%, respectively; P =.026) and drug abuse (10.1% vs 4.2%, respectively; P =.009), experienced thoracic trauma significantly more often (53.1% vs 43.0%, respectively; P =.014), and experienced significantly higher rates of respiratory failure during their ICU stay (69.9% vs 28.1%, respectively; P <.001).

Age (hazard ratio [HR], 0.99; 95% CI, 0.98-0.99; P =.001), chest trauma (HR, 1.40; 95% CI, 1.03-1.90; P =.033), H₂-receptor antagonist intake (HR, 2.16; 95% CI, 1.37-3.39; P =.001), and use of prophylactic antibiotics (HR, 0.69; 95% CI, 0.50-0.96; P =.026) were all significantly associated with the risk for VAP. Further, patients with VAP had a significantly longer duration of mechanical ventilation, compared with those without VAP (median, 15 vs 8 days, respectively; P <.001) and a significantly longer ICU LOS (median, 20 vs 13 days, respectively; P <.001).

The development of VAP, however, was not associated with increased morality rates or worse neurologic outcomes. Overall patient mortality at 6 months was 22.0%. A major limitation of the current study was its observational design.

The investigators concluded that additional randomized controlled trials are warranted to confirm and expand the understanding of risk factors for the development of VAP, promptly identify those patients at risk for VAP, and evaluate the effect of early antimicrobial therapy on the prevention of VAP.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Robba C, Rebora P, Banzato E, et al; for the CENTER-TBI Participants and Investigators. Incidence, risk factors, and effects on outcome of ventilator-associated pneumonia in patients with traumatic brain injury. Analysis of a large, multicenter, prospective, observational longitudinal study [published online July 4, 2020]. CHEST. doi:10.1016/j.chest.2020.06.064