Abstract Details

Title Variability in Diagnosis and Management of Ventilator-Associated Pneumonia Is Common in Comatose Patients in Neurocritical Care Units

Topic Critical Care/Emergency Neurology/Trauma

Presentation(s) P05 - (-)

Poster/Presentation
Number 205

Objective

Background BACKGROUND: VAP is a common complication in comatose patients. Clinical approach in this population varies widely despite training and validated criteria leading to variability in VAP diagnosis and potential inappropriate antimicrobial use.

Design/Methods DESIGN/METHODS: We investigated clinical features associated with misdiagnosis of VAP and excess antibiotic days (EAD). Ventilated comatose patients (Glasgow coma scale motor score < 6) suspected of having VAP were prospectively identified in a Neurocritical Care Unit in 2011. Appropriateness of VAP diagnosis and therapy was performed using clinical, microbiologic and radiographic data.

Results RESULTS: Of 173 comatose patients, 34 cases were treated as possible VAP by the NCCU team. Of these, 13 patients had VAP by CDC criteria. VAP and non-VAP groups did not differ in age, admission GCS, total ventilator days or mean total antibiotic days (11.4 ± 1.4 (VAP) vs. 12.8 ± 1.4 (non-VAP); p=0.52). Clinical features significantly associated with VAP (vs. non-VAP) were change in sputum character, tachypnea, oxygen desaturation, persistent infiltrate on chest xray and positive sputum microbiology. Two-thirds (66.7%) of non-VAP patients received pneumonia targeted antibiotics for >8 days vs. 30.1% of VAP patients (p=0.04), contributing 88 EADs, including 66 vancomycin days, 22 piperacillin-tazobactam days and 44 cephalosporin days. Median days from intubation to starting antibiotics was 1 (non-VAP) vs. 4 (VAP) days (p = 0.13). No pre-specified factors were associated with inappropriate continued VAP treatment.

Conclusions CONCLUSIONS: Inappropriate diagnosis and treatment of VAP resulted in a cumulative 141 EADs in one year in the NCCU. Clinician behaviors contributed to antibiotic prescribing beyond 8 days. Strategies to improve adherence to CDC based diagnosis and antibiotic use for VAP in NCCU patients is needed.

Authors/Disclosures
Atul Kalanuria, MD (The Hospital of The University of Pennsylvania) PRESENTER	Dr. Kalanuria has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for American Medical Experts. Dr. Kalanuria has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Expertiq.
	No disclosure on file
Robert G. Kowalski, MBChB, MS (Harbor Hospital)	The institution of Dr. Kowalski has received research support from Henry Ford Hospital. The institution of Dr. Kowalski has received research support from MaxQ. Dr. Kowalski has a non-compensated relationship as a Editor-in-Chief, newsletter with PRe-hospital Stroke Treatment Organization (PRESTO) that is relevant to AAN interests or activities.
Romergryko G. Geocadin, MD, FAAN (Johns Hopkins University School of Medicine)	Dr. Geocadin has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Medicolegal Consulting.
Wendy C. Ziai, MD (Johns Hopkins Univ, Neuro Critical Care)	Dr. Ziai has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Springer. Dr. Ziai has received research support from NIH. Dr. Ziai has received publishing royalties from a publication relating to health care. Dr. Ziai has received personal compensation in the range of $500-$4,999 for serving as a Consultant with DOJ.
Giancarlo Comi, MD (University Vita-Salute)	Dr. Comi has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Janssen. Dr. Comi has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Bristol Myers Squibb. Dr. Comi has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novartis. Dr. Comi has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Janssen. Dr. Comi has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Bristol Myers Squibb. Dr. Comi has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Novartis. Dr. Comi has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Aspen Healthcare. Dr. Comi has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Sanofi. Dr. Comi has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Sanofi. Dr. Comi has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Rewind.

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