Abstract
: BackgroundIt is unknown whether neonatal ventilator-associated pneumonia (VAP) caused by multidrug-resistant (MDR) pathogens and inappropriate initial antibiotic treatment is associated with poor outcomes after adjusting for confounders. Methods: We prospectively observed all neonates with a definite diagnosis of VAP from a tertiary level neonatal intensive care unit (NICU) in Taiwan between October 2017 and March 2020. All clinical features, therapeutic interventions, and outcomes were compared between the MDR–VAP and non-MDR–VAP groups. Multivariate regression analyses were used to investigate independent risk factors for treatment failure. Results: Of 720 neonates who were intubated for more than 2 days, 184 had a total of 245 VAP episodes. The incidence rate of neonatal VAP was 10.1 episodes/per 1000 ventilator days. Ninety-six cases (39.2%) were caused by MDR pathogens. Neonates with MDR–VAP were more likely to receive inadequate initial antibiotic therapy (51.0% versus 4.7%; p < 0.001) and had delayed resolution of clinical symptoms (38.5% versus 25.5%; p = 0.034), although final treatment outcomes were comparable with the non-MDR–VAP group. Inappropriate initial antibiotic treatment was not significantly associated with worse outcomes. The VAP-attributable mortality rate and overall mortality rate of this cohort were 3.7% and 12.0%, respectively. Independent risk factors for treatment failure included presence of concurrent bacteremia (OR 4.83; 95% CI 2.03–11.51; p < 0.001), septic shock (OR 3.06; 95% CI 1.07–8.72; p = 0.037), neonates on high-frequency oscillatory ventilator (OR 4.10; 95% CI 1.70–9.88; p = 0.002), and underlying neurological sequelae (OR 3.35; 95% CI 1.47–7.67; p = 0.004). Conclusions: MDR–VAP accounted for 39.2% of all neonatal VAP in the neonatal intensive care unit (NICU), but neither inappropriate initial antibiotics nor MDR pathogens were associated with treatment failure. Neonatal VAP with concurrent bacteremia, septic shock, and underlying neurological sequelae were independently associated with final worse outcomes.
Highlights
While ventilator-associated pneumonia (VAP) is the second most common cause of healthcare-associated infections in neonatal intensive care units (NICUs), it remains challenging to accurately diagnose VAP in neonates [1,2]
We cannot conclude whether clinical deterioration or organ dysfunction would have happened if limited-spectrum antibiotics were used at the onset of VAP, we found inappropriate initial antibiotics did not significantly affect the outcomes
MDR–VAP accounted for nearly two-fifths of all VAP episodes and was more likely to be initially treated with inappropriate antibiotics
Summary
While ventilator-associated pneumonia (VAP) is the second most common cause of healthcare-associated infections in neonatal intensive care units (NICUs), it remains challenging to accurately diagnose VAP in neonates [1,2]. There have been various studies of antibiotic stewardship programs in the NICU in order to promote the appropriate use of antibiotics for neonates [12,13,14]. Both Infectious Diseases Society of America and American Academy of Pediatrics guidelines recommend restricting the use of broad-spectrum antibiotics to neonates with a high risk of meningitis or those present with respiratory failure and/or septic shock [15,16]. Justified broad-spectrum empirical antibiotics are often used by clinicians in neonates with high-risk of resistance, i.e., previous antibiotic exposure or endotracheal Pseudomonas genus colonization [7,17]. We aim to examine empiric antibiotic administration for neonatal VAP and the impacts of MDR pathogens on the outcomes
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