Abstract
BackgroundPneumonia and septic pneumonic shock are the most common indications for long-term mechanical ventilation and prolonged weaning, independent of any comorbidities. Multidrug resistant (MDR) bacteria are emerging as a cause of pneumonia or occur as a consequence of antimicrobial therapy. The influence of MDR bacteria on outcomes in patients with prolonged weaning is unknown.MethodsPatients treated in a specialized weaning unit of a university hospital between April 2013 and April 2016 were analyzed. Demographic data, clinical characteristics, length of stay (LOS) in the intensive care unit (ICU) and weaning unit, ventilator-free days and mortality rates were determined in prolonged weaning patients with versus without MDR bacteria (methicillin-resistant Staphylococcus aureus bacteria, [MRSA]; extended spectrum beta lactamase [ESBL]- and Gyrase-producing gram negative bacteria resistant to three of four antibiotic groups [3 MRGN]; panresistant Pseudomonas aeruginosa and other carbapenemase-producing gram-negative bacteria resistant to all four antibiotic groups [4 MRGN]). Weaning failure was defined as death or discharge with invasive ventilation.ResultsOf 666 patients treated in the weaning unit, 430 fulfilled the inclusion criteria and were included in the analysis. A total of 107 patients had isolates of MDR bacteria suspected as causative pathogens identified during the treatment process. Patients with MDR bacteria had higher SAPS II values at ICU admission and a significantly longer ICU LOS. Four MRGN P. aeruginosa and Acinetobacter baumanii were the most common MDR bacteria identified. Patients with versus without MDR bacteria had significantly higher arterial carbon dioxide levels at the time of weaning admission and a significantly lower rate of successful weaning (23% vs 31%, p < 0.05). Mortality rate on the weaning unit was 12.4% with no difference between the two patient groups. There were no significant differences between patient groups in secondary infections and ventilator-free days.ConclusionsIn patients with pneumonia or septic pneumonic shock undergoing prolonged weaning, infection with MDR bacteria may influence the weaning success rate but does not appear to impact on patient survival.
Highlights
Pneumonia and septic pneumonic shock are the most common indications for long-term mechanical ventilation and prolonged weaning, independent of any comorbidities
Prolonged weaning from mechanical ventilation (MV) with ≥3 spontaneous breathing trials (SBTs) or ≥ 7 days of ventilation defines a group of patients who require complex and protracted treatment to achieve discontinuation of ventilation [1]
A total of 666 patients were treated in the weaning unit over the study period; 430 tracheotomized patients with prolonged weaning from invasive MV met the inclusion criteria and were analyzed (Table 1)
Summary
Pneumonia and septic pneumonic shock are the most common indications for long-term mechanical ventilation and prolonged weaning, independent of any comorbidities. The development of increasing antibiotic resistance, especially among gram-negative (GN) pathogens in VAP, presents a significant challenge in ICU patients. This makes it even more difficult to break. It has previously been shown that the presence of GN, multidrug resistant (MDR) bacteria predicts mortality, pneumonia per se and the complexity of treatment, and that the severity of a critical illness may be associated with worse outcome [5]. Data from a meta-analysis of 21 studies in patients with MDR versus non-MDR infections showed that the presence of MDR and inadequate treatment of MDR were predictors of mortality [5] These findings illustrate the clinical relevance of MDR bacteria. It is difficult to determine whether it is inappropriate treatment measures that resulted in MDR bacteria or that the MDR bacteria themselves that are the most important factors in contributing to worse outcomes
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