Risk factors for relapse of ventilator-associated pneumonia in trauma patients.

BACKGROUND: Our goal was to define risk factors for ventilator-associated pneumonia (VAP) relapse and examine the implications, if any, for initial therapy in trauma patients.

METHODS: Trauma patients cared for in the surgical intensive care unit during a 48-month period with confirmed VAP recurrence were evaluated. Recurrent VAP was defined as a positive quantitative culture (> or = 10(4) colony-forming units/mL in a bronchoalveolar lavage or protected catheter lavage specimen) > or = 4 days after initiation of antibiotics for the primary episode. Recurrence with at least one of the initial causative pathogens was defined as a relapse. Initial causal pathogen, Acute Physiology and Chronic Health Evaluation II score, injury severity score, Glasgow Coma Score (GCS), age, white blood cell count (WBC), and duration of hospital stay before diagnosis were analyzed in univariate and multivariate regression models.

RESULTS: A total of 55 patients met the criteria of recurrent VAP. Of these 55 recurrences, 19 (35%) were relapses. Acute Physiology and Chronic Health Evaluation II score, injury severity score, and GCS were not associated with VAP relapse by univariate analyses. Patients who relapsed had primary VAP involving nonfermenting gram-negative bacilli (NFGNB) (Acinetobacter, Pseudomonas, and Stenotrophomonas species) more frequently than other organisms (68% vs. 32%, p = 0.001). Primary VAP with NFGNB was found to be a significant predictor of VAP relapse by univariate and multivariate logistic regression analysis (OR = 5.1, p = 0.003; OR = 4.63, p = 0.005, respectively).

CONCLUSIONS: There is a high rate of VAP relapse associated with primary infection by NFGNB, suggesting initial treatment failure. Trauma patients with primary VAP involving these organisms may benefit from increased surveillance for relapse.