Neumonía en la uci asociada o no a la ventilación mecánicacaracterísticas y factores de mortalidad hospitalaria

Resumen

La neumonía es una infección del parénquima pulmonar responsable de importantes tasas de morbilidad y mortalidad. En general, los procesos neumónicos que ocurren en pacientes hospitalizados suelen ser graves. Es la denominada neumonía intrahospitalaria o nosocomial. Dentro de la neumonía intrahospitalaria existe una variante asociada a la estancia en la Unidad de Cuidados Intensivos, y dentro de la misma se pueden distinguir la Neumonía Asociada a la Ventilación Mecánica (VAP) y la Neumonía Adquirida en la Unidad de Cuidados Intensivos No Asociada al Ventilador (NV-ICUAP). La mayor parte de estudios de neumonía se centran en la VAP y los resultados se extrapolan a los pacientes con NV-ICUAP. Este trabajo de Tesis compara en el contexto de una amplia base de datos los pacientes VAP versus los pacientes NV-ICUAP en relación a las características de los pacientes, la etiología, la respuesta inflamatoria, el tratamiento empírico, y el fracaso de tratamiento. Así mismo, se realizó un análisis de mortalidad y se detectaron predictores específicos de VAP y de NV-ICUAP. Para ello se llevó a cabo un estudio prospectivo observacional durante 9 años en 6 unidades de cuidados intensivos médicas y quirúrgicas de un prestigioso hospital de Barcelona. Los resultados concluyen que los pacientes con VAP se encontraban más graves en el momento de la admisión y que la estancia en UCI antes y después del inicio de los síntomas es más larga. Sin embargo, la estancia hospitalaria y la tasa de mortalidad son similares en ambos grupos. Cuando tomamos en cuenta sólo pacientes con confirmación microbiológica de neumonía, no existen diferencias en los patógenos aislados entre los grupos, salvo por un proporción más alta de bacilos entéricos gram-negativos en el grupo de VAP. Los niveles de procalcitonina resultaron más elevados en el grupo de NV-ICUAP. La respuesta clínica inicial al tratamiento empírico y la adherencia al tratamiento definido por las guías de la ATS/IDSA son similares en ambos grupos. El 60% de fracaso de tratamiento corresponde a los casos de VAP. NV-ICUAP y VAP no están relacionados con la mortalidad hospitalaria. Incluso cuando se ajustan todas las variables asociadas con la mortalidad hospitalaria continúan sin mantener relación. American Thoracic Society. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med 2005 Feb 15;171:388-416. Langer M, Cigada M, Mandelli M, Mosconi P, Tognoni G. Early-onset pneumonia: a multicenter study in intensive care units. Intensive Care Med 1987;13:342-6. Ministerio de Sanidad y Consumo. REAL DECRETO 1277/2003, de 10 de octubre, por el que se establecen las bases generales sobre autorización de centros, servicios y establecimientos sanitarios. BOE núm. 254, 37893-37902. 10-10-2003. Ref Type: Statute Chastre J, Luyt CE, Combes A, Trouillet JL. Use of quantitative cultures and reduced duration of antibiotic regimens for patients with ventilator-associated pneumonia to decrease resistance in the intensive care unit. Clin Infect Dis 2006 Sep 1;43 Suppl 2:S75-S81. Murray AE, Chambers JJ, van Saene HKF. Infections in patients requiring ventilation in intensive care: application of a new classification. Clin Microbiol Infect 1998;4(2):94-102. Van Leeuween P, Boermeester M, Houdijk A, Ferwerda C, Cuesta M. Clinical significance of translocation. Gut 1994 Jan;35(1 Suppl):S 35-S 38. Esperatti M, Ferrer M, Theessen A, Liapikou A, Valencia M, Saucedo L, et al. Nosocomial Pneumonia in the Intensive Care Unit Acquired by Mechanically Ventilated versus Nonventilated Patients. Am J Respir Crit Care Med 2010 Dec 15;182(12):1533-9. Aguaviva J. Soporte vital avanzado politraumático. 1ª ed. Prensas Universitarias de Zaragoza; 2003. Arias J, Aller M, Aldamendi I. Enfermería Médico-Quirúrgica. Ed. Tébar; 2000. López M, Cárdenas M, Urbano A. Manual de laboratorio de microbiología para el diagnóstico de infecciones respiratorias. 1ª ed. OmniaScience; 2012. Grenvik A, Ayres S, Holbrook P, Shoemaker W. Tratado de medicina crítica y terapia intensiva. 4ª ed. Ed. Médica Panamericana; 2002. Álvarez J, Artigas A, Belda F, Bonet B, Caparrós T, Espino M, et al. Tratado de cuidados críticos y emergencias. Ediciones Arán S.L.; 2002. Safdar N, Crnich C, Maki D. The Pathogenesis of Ventilator-Associated Pneumonia: Its Relevance to Developing Effective Strategies for Prevention. Respiratory Care 2005 Jun;50(6):725-41. Arenal S. Síndrome de disfunción multiorgánica: Análisis de morbilidad o mortalidad: Evaluación funcional a largo plazo 2012. Mälstam J, Lind L. Therapeutic intervention scoring system (TISS)--a method for measuring workload and calculating costs in the ICU. Acta Anaesthesiol Scand 1992 Nov;36(8):758-63. Miranda D, de Rijk A, Schaufeli W. Simplified Therapeutic Intervention Scoring System: the TISS-28 items--results from a multicenter study. Crit Care Med 1996 Jan;24(1):64-73. Castillo-Lorente E, Rivera-Fernández R, Rodríguez-Elvira M, Vázquez-Mata G. Tiss 76 and Tiss 28: correlation of two therapeutic activity indices on a Spanish multicenter ICU database. Intensive Care Med 2000 Jan;26(1):57-61. Knaus W, Draper E, Wagner D, Zimmerman J. APACHE II: a severity of disease classification system. Crit Care Med 1985 Oct;13(10):818-29. Serrano Hernández N, García de Lorenzo A, Mora Quintero M, Fedriani Gorria J. Validación de los Mortality Probability Models II al ingreso (MPM II-0), a las 24 horas (MPM II-24), y a las 48 horas (MPM II-48) comparados con las predicciones de mortalidad hospitalaria de APACHE II y SAPS II realizadas en los días 1 y 2 de estancia en UCI. Medicina Intensiva 2000 Feb;24(2):49-60. Vincent J, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related organ failure assessmente) score to describe organ dysfunction/failure. Intensive Care Med 1996;22(7):707-10. Le Gall J, Lemeshow S, Saulnier F. A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA 1993 Dec 22;270(24):2957-63. García de Lorenzo A. Scores pronósticos y criterios diagnósticos en el paciente crítico. 2ª ed. Ediciones Ergón; 2006. Zilberberg M, Shor A. Ventilator-associated pneumonia: The clinical pulmonary infection score as a currogate for diagnostics and outcome. Clin Infect Dis 2010;51(S31):S131-S135. Fàbregas N, Ewig S, Torres A, El-Ebiary M, Ramirez J, de la Bellacasa JP, et al. Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies. Thorax 1999 Oct;54(10):867-73. Colimon K-M. Fundamentos de epidemiología. Ediciones Díaz de Santos, S.A.; 1990. Torres A, Rello J. Update in community-acquired and nosocomial pneumonia 2009. Am J Respir Crit Care Med 2010 Apr 15;181(8):782-7. Alcon A, Fabregas N, Torres A. Pathophysiology of pneumonia. Clin Chest Med 2005 Mar;26(1):39-46. Sopena N, Sabria M. Multicenter study of hospital-acquired pneumonia in non-ICU patients. Chest 2005 Jan;127:213-9. Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 1998 Sep 15;129:433-40. (32) ventilator-associated pneumonia. Clinical Infectious Diseases 2010;51(Suppl 1):S 48-S 53. ALp E, Güven M, Yildiz O, Aygen B, Voss A, Doganay M. Incidence, risk factors and mortality of nosocomial pneumonia in Intensive Care Units: A prospective study. Ann Clin Microbiol Antimicrob 2004 Sep 15;3(17). Valles J, Pobo A, Garcia-Esquirol O, Mariscal D, Real J, Fernandez R. Excess ICU mortality attributable to ventilator-associated pneumonia: the role of early vs late onset. Intensive Care Med 2007 Aug;33(8):1363-8. Hernández Ávila M. Epidemiología: diseño y análisis de estudios. Ed. Panamericana; 2007. Bonten MJ, Kollef MH, Hall JB. Risk factors for ventilator-associated pneumonia: from epidemiology to patient management. Clin Infect Dis 2004 Apr 15;38:1141-9. Luna CM, Aruj P, Niederman MS, Garzon J, Violi D, Prignoni A, et al. Appropriateness and delay to initiate therapy in ventilator-associated pneumonia. Eur Respir J 2006 Jan;27(1):158-64. Craven DE, De Rosa FG, Thornton D. Nosocomial pneumonia: emerging concepts in diagnosis, management, and prophylaxis. Curr Opin Crit Care 2002 Oct;8(5):421-9. Hyllienmark P. Hospital-Acquired Pneumonia in Intensive Care Patients Karolinska Institutet; 2013. Sackner MA, Hirsch J, Epstein S. Effect of cuffed endotracheal tubes on tracheal mucous velocity. Chest 1975 Dec;68(6):774-7. Konrad F, Schreiber T, Brecht-Kraus D, Georgieff M. Mucociliary transport in ICU patients. Chest 1994 Jan;105(1):237-41. Wunderink RG. Nosocomial pneumonia, including ventilator-associated pneumonia. Proc Am Thorac Soc 2005;2(5):440-4. Fumeaux T, Pugin J. Role of interleukin-10 in the intracellular sequestration of human leukocyte antigen-DR in monocytes during septic shock. Am J Respir Crit Care Med 2002 Dec 1;166(11):1475-82. Hynninen M, Pettila V, Takkunen O, Orko R, Jansson SE, Kuusela P, et al. Predictive value of monocyte histocompatibility leukocyte antigen-DR expression and plasma interleukin-4 and -10 levels in critically ill patients with sepsis. Shock 2003 Jul;20(1):1-4. Lekkou A, Karakantza M, Mouzaki A, Kalfarentzos F, Gogos CA. Cytokine production and monocyte HLA-DR expression as predictors of outcome for patients with community-acquired severe infections. Clin Diagn Lab Immunol 2004 Jan;11(1):161-7. Muehlstedt SG, Lyte M, Rodriguez JL. Increased IL-10 production and HLA-DR suppression in the lungs of injured patients precede the development of nosocomial pneumonia. Shock 2002 Jun;17:443-50. Lanken P. Manual de cuidados intensivos. Ed. Médica Panamericana; 2003. Dullenkopf A, Gerber A, Weiss M. Fluid leakage past tracheal tube cuffs: evaluation of the new Microcuff endotracheal tube. Intensive Care Med 2003 Oct;29:1849-53. Inglis TJ, Millar MR, Jones JG, Robinson DA. Tracheal tube biofilm as a source of bacterial colonization of the lung. J Clin Microbiol 1989;27:2014-8. Inglis TJ, Lim TM, Ng ML, Tang EK, Hui KP. Structural features of tracheal tube biofilm formed during prolonged mechanical ventilation. Chest 1995;108(4):1049-52. Li BAssi G, Ferrer M, Torres A. Nosocomial Pneumonia. In: Vincent J, Abraham E, Kochanek P, Moore F, Fink M, editors. Textbook of Critical Care. 6ª ed. Elsevier; 2011. p. 464-80. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science 1999;21:1318-22. Lasa I. Biofilms bacterianos. Boletín Informativo de la Sociedad Española de Microbiología 2004 Jul;37:14-8. Berra L, De ML, Yu ZX, Laquerriere P, Baccarelli A, Kolobow T. Endotracheal tubes coated with antiseptics decrease bacterial colonization of the ventilator circuits, lungs, and endotracheal tube. Anesthesiology 2004 Jun;100(6):1446-56. Berra L, Kolobow T, Laquerriere P, Pitts B, Bramati S, Pohlmann J, et al. Internally coated endotracheal tubes with silver sulfadiazine in polyurethane to prevent bacterial colonization: a clinical trial. Intensive Care Med 2008 Jun;34:1030-7. Nazar C. Biofilms bacterianos. Rev Otrorrinolaringol Cir Cabeza Cuello 2007;67(1). Ng KS, Kumarasinghe G, Inglis TJ. Dissemination of respiratory secretions during tracheal tube suctioning in an intensive care unit. Ann Acad Med Singapore 1999;28(2):178-82. Adair CG, Gorman SP, Feron BM, Byers LM, Jones DS, Goldsmith CE, et al. Implications of endotracheal tube biofilm for ventilator-associated pneumonia. Intensive Care Med 1999;25:1072-6. Bou R, Aguilar A, Perpinan J, Ramos P, Peris M, Lorente L, et al. Nosocomial outbreak of Pseudomonas aeruginosa infections related to a flexible bronchoscope. J Hosp Infect 2006 Oct;64(2):129-35. Srinivasan A, Wolfenden LL, Song X, Mackie K, Hartsell TL, Jones HD, et al. An outbreak of Pseudomonas aeruginosa infections associated with flexible bronchoscopes. N Engl J Med 2003 Jan 16;348(3):221-7. Crane LR, Tagle LC, Palutke WA. Outbreak of pseudomonas paucimobilis in an intensive care facility. JAMA 1981 Aug 28;246(9):985-7. Eckmanns T, Oppert M, Martin M, Amorosa R, Zuschneid I, Frei U, et al. An outbreak of hospital-acquired Pseudomonas aeruginosa infection caused by contaminated bottled water in intensive care units. Clin Microbiol Infect 2008 May;14(5):454-8. Lee JK. Two outbreaks of Burkholderia cepacia nosocomial infection in a neonatal intensive care unit. J Paediatr Child Health 2008 Jan;44(1-2):62-6. Kikuchi T, Nagashima G, Taguchi K, Kuraishi H, Nemoto H, Yamanaka M, et al. Contaminated oral intubation equipment associated with an outbreak of carbapenem-resistant Pseudomonas in an intensive care unit. J Hosp Infect 2007 Jan;65(1):54-7. Bou R, Ramos P. Outbreak of nosocomial Legionnaires' disease caused by a contaminated oxygen humidifier. J Hosp Infect 2009 Apr;71(4):381-3. Berthelot P, Grattard F, Mahul P, Jospe R, Pozzetto B, Ros A, et al. Ventilator temperature sensors: an unusual source of Pseudomonas cepacia in nosocomial infection. J Hosp Infect 1993 Sep;25(1):33-43. Rogues AM, Maugein J, Allery A, Fleureau C, Boulestreau H, Surcin S, et al. Electronic ventilator temperature sensors as a potential source of respiratory tract colonization with Stenotrophomonas maltophilia. J Hosp Infect 2001 Dec;49(4):289-92. Pegues CF, Pegues DA, Ford DS, Hibberd PL, Carson LA, Raine CM, et al. Burkholderia cepacia respiratory tract acquisition: epidemiology and molecular characterization of a large nosocomial outbreak. Epidemiol Infect 1996 Jun;116(3):309-17. Cobben NA, Drent M, Jonkers M, Wouters EF, Vaneechoutte M, Stobberingh EE. Outbreak of severe Pseudomonas aeruginosa respiratory infections due to contaminated nebulizers. J Hosp Infect 1996 May;33(1):63-70. Enoch DA, Summers C, Brown NM, Moore L, Gillham MI, Burnstein RM, et al. Investigation and management of an outbreak of multidrug-carbapenem-resistant Acinetobacter baumannii in Cambridge, UK. J Hosp Infect 2008 Oct;70(2):109-18. The American Institure of Architects. Guidelines for design and construction of hospital and health care facilities. 1996. Johanson WG, Pierce AK, Sanford JP. Changing pharyngeal bacterial flora of hospitalized patients: Emergence of Gram-negative bacilli. N Engl J Med 1969;281:1137-40. Johanson WG, Pierce AK, Sanford JP, Thomas GD. Nosocomial respiratory infection with Gram-negative bacilli: the significance of colonization of the respiratory tract. Ann Intern Med 1972;77:701-6. Feldman C, Kassel M, Cantrell J, Kaka S, Morar R, Goolam Mahomed A, et al. The presence and sequence of endotracheal tube colonization in patients undergoing mechanical ventilation. Eur Respir J 1999;13:546-51. Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med 1992 Jun;20(6):740-5. Fourrier F, Duvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: a source of nosocomial infections in intensive care unit patients. Crit Care Med 1998 Feb;26(2):301-8. Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol 2006 Sep;77(9):1465-82. Heo SM, Haase EM, Lesse AJ, Gill SR, Scannapieco FA. Genetic relationships between respiratory pathogens isolated from dental plaque and bronchoalveolar lavage fluid from patients in the intensive care unit undergoing mechanical ventilation. Clin Infect Dis 2008 Dec 15;47(12):1562-70. Bach A, Boehrer H, Schmidt H, Geiss HK. Nosocomial sinusitis in ventilated patients. Nasotracheal versus orotracheal intubation. Anaesthesia 1992 Apr;47(4):335-9. Michelson A, Kamp HD, Schuster B. [Sinusitis in long-term intubated, intensive care patients: nasal versus oral intubation]. Anaesthesist 1991 Feb;40(2):100-4. Salord F, Gaussorgues P, Marti-Flich J, Sirodot M, Allimant C, Lyonnet D, et al. Nosocomial maxillary sinusitis during mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal route for intubation. Intensive Care Med 1990;16(6):390-3. Rouby JJ, Laurent P, Gosnach M, Cambau E, Lamas G, Zouaoui A, et al. Risk factors and clinical relevance of nosocomial maxillary sinisitis in the critically ill. Am J Respir Crit Care Med 1994;150:776-83. Holzapfel L, Chevret S, Madinier G, Ohen F, Demingeon G, Coupry A, et al. Influence of long-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective, randomized, clinical trial. Crit Care Med 1993 Aug;21(8):1132-8. Torres A, El Ebiary M, Soler N, Monton C, Fabregas N, Hernandez C. Stomach as a source of colonization of the respiratory tract during mechanical ventilation: association with ventilator-associated pneumonia. Eur Respir J 1996 Aug;9(8):1729-35. Donowitz LG, Page MC, Mileur BL, Guenthner SH. Alteration of normal gastric flora in critical care patients receiving antacid and cimetidine therapy. Infect Control 1986 Jan;7(1):23-6. Hillman KM. Colonisation of the gastric contents in critically ill patients. Acta Anaesthesiol Belg 1983 Sep;34(3):191-2. Apte NM, Karnad DR, Medhekar TP, Tilve GH, Morye S, Bhave GG. Gastric colonization and pneumonia in intubated critically ill patients receiving stress ulcer prophylaxis: a randomized, controlled trial. Crit Care Med 1992;80:590-3. Driks MR, Craven DE, Celli BR, Manning M, Burke RA, Garvin GM, et al. Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. The role of gastric colonization. N Engl J Med 1987 Nov 26;317:1376-82. Prod hom G, Leuenberger P, Koerfer J, Blum A, Chiolero R, Schaller MD, et al. Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. Ann Intern Med 1994;120:653-62. Bonten MJ, Gaillard CA, van der Geest S, van Thiel FH, Beysens AJ, Smeets HG, et al. The role of intragastric acidity and stress ulcer prophylaxis on colonization and infection in mechanically ventilated ICU patients. A stratified, randomized, double-blind study of sucralfate versus antacids. Am J Respir Crit Care Med 1995;152:1825-34. Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. N Engl J Med 1998;338:791-7. Thomason MH, Payseur ES, Hakenewerth AM, Norton HJ, Mehta B, Reeves TR, et al. Nosocomial pneumonia in ventilated trauma patients during stress ulcer prophylaxis with sucralfate, antacid, and ranitidine. J Trauma 1996 Sep;41(3):503-8. Kantorova I, Svoboda P, Scheer P, Doubek J, Rehorkova D, Bosakova H, et al. Stress ulcer prophylaxis in critically ill patients: a randomized controlled trial. Hepatogastroenterology 2004 May;51(57):757-61. Cardeñosa Cendrero JA, Sole-Violan J, Bordes Benitez A, Noguera Catalan J, Arroyo Fernandez J, Saavedra Santana P, et al. Role of different routes of tracheal colonization in the development of pneumonia in patients receiving mechanical ventilation. Chest 1999;116:462-70. de Latorre FJ, Pont T, Ferrer A, Rosselló J, Palomar M, Planas M. Pattern of tracheal colonization during mechanical ventilation. Am J Respir Crit Care Med 1995;152:1028-33. Garrouste-Orgeas M, Chevret S, Arlet G, Marie O, Rouveau M, Popoff N, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med 1997;156:1647-55. Palmer LB, Donelan SV, Fox G, Bellemore E, Greene WH. Gastric flora in chronically mechanically ventilated patients. Relationship to upper and lower airway colonization. Am J Respir Crit Care Med 1995 Apr;151(4):1063-7. Valles J, Mariscal D, Cortes P, Coll P, Villagra A, Diaz E, et al. Patterns of colonization by Pseudomonas aeruginosa in intubated patients: a 3-year prospective study of 1,607 isolates using pulsed-field gel electrophoresis with implications for prevention of ventilator-associated pneumonia. Intensive Care Med 2004 Sep;30(9):1768-75.