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A 7-year study of severe hospital-acquired pneumonia requiring ICU admission



To examine the characteristics, prognostic factors, and outcome of patients with severe hospital-acquired pneumonia admitted to the ICU.

Design and setting

Prospective observational clinical study in two medical-surgical ICUs with 16 and 20 beds

Patients and participants

During a 7-year period all hospitalized patients requiring admission to either ICU for hospital-acquired pneumonia were followed up.

Measurements and results

We diagnosed 96 episodes of severe hospital-acquired pneumonia, and in 67 cases a causal diagnosis was made. Most episodes were late-onset pneumonia. Gram-negative micro-organisms were isolated in 51% of episodes diagnosed, and Pseudomonas aeruginosa was the most frequent pathogen isolated (24%). Clearly significant variations happened between hospitals, particularly affecting the incidence of Aspergillus spp. and Legionella pneumophila. Forty-nine patients developed septic shock (51%). Fifty-one patients died (53%). Aspergillosis and pneumonia due to P. aeruginosa were associated with the highest mortality. Septic shock (OR: 14.27) and chronic obstructive pulmonary disease (OR: 6.11) were independently associated with a poor prognosis.


Patients with severe hospital-acquired pneumonia admitted to the ICU present high mortality. The presence of septic shock and chronic obstructive pulmonary disease in conjunction with specific microorganisms are associated with a poor prognosis. Local epidemiological data combined with a patient-based approach may allow a more accurate therapy decision making.

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  1. 1.

    Craven DE, Steger KA, Barber TW (1991) Preventing nosocomial pneumonia: state of the art and perspectives for the 1990's. Am J Med 91:44S–53S

  2. 2.

    Gross PA, Van Antwerpen C (1983) Nosocomial infections and hospital deaths: a case-control study. Am J Med 75:658–662

  3. 3.

    Gross PA, New HC, Aswapokee P, Van Antwerpen C, Aswapokee N (1980) Deaths from nosocomial infections: experience in a university hospital and a community hospital. Am J Med 68:219–223

  4. 4.

    McEachern R, Campbell GD Jr (1998) Hospital-acquired pneumonia: epidemiology, etiology, and treatment. Infect Dis Clin North Am 12:761–779

  5. 5.

    Mayhall CG (1997) Nosocomial pneumonia: diagnosis and prevention. Infect Dis Clin North Am 11:427–457

  6. 6.

    American Thoracic Society (1996) Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies. Am J Respir Crit Care Med 153:1711–1725

  7. 7.

    Craven DE, Driks MR (1987) Pneumonia in the intubated patient. Semin Respir Infect 2:20–33

  8. 8.

    Celis R, Torres A, Gatell JM, Almela M, Rodriguez-Roisin R, Agusti-Vidal A (1988) Nosocomial pneumonia: a multivariate analysis of risk and prognosis. Chest 93:318–324

  9. 9.

    Fagon GY, Chastre J, Hance A, Montravers P, Novara A, Gibert C (1993) Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94:281–288

  10. 10.

    Fagon GY, Chastre J, Domart Y, Trouillet JL, Pierre J, Carne C, Gibert C (1989) Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 139:877–884

  11. 11.

    Rello J, Jubert P, Vallés J, Artigas A, Rue M, Niederman MS (1996) Evaluation of outcome for intubated patients with pneumonia due to Pseudomonas aeruginosa. Clin Infect Dis 23:973–978

  12. 12.

    Timsit JF, Chevret S, Valcke J, Misset B, Renaud B, Goldstein FW, Vaury P, Carlet J (1996) Mortality of nosocomial pneumonia in ventilated patients: influence of diagnostic tools. Am J Respir Crit Care Med 154:116–123

  13. 13.

    Heyland D, Cook D, Griffith L, Keenan SP, Brun-Buisson C (1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. Am J Respir Crit Care Med 159:1249–1256

  14. 14.

    Haley RW, Hooton TM, Culver DH, Stanley RC, Emori TG (1981) Nosocomial infections in U.S. hospitals, 1975–1976. Am J Med 70:947–959

  15. 15.

    Hughees JM, Culver DH, White JW, Jarvis WR, Munn VP, Mosser JL, Emori TG (1983) Nosocomial infection surveillance, 1980–1982. MMWR 32 (4SS):1SS-15SS

  16. 16.

    Leu H, Kaiser DL, Mori M, Woolson RF, Wenzel RP (1989) Hospital-acquired pneumonia. Attributable mortality and morbidity. Am J Epidemiol 129:1258–1267

  17. 17.

    Richards M, Edwards J, Culver D, Gaynes RP (1999) Nosocomial infections in medical intensive care units in the United States. Crit Care Med 27:887–892

  18. 18.

    NNIS System (1999) National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1990-May 1999, issued June 1999. Am J Infect Control 27:520–532

  19. 19.

    Tablan O, Anderson L, Arden NH, Breiman RF, Butler JC, McNeil MM (1994) Guidelines for prevention of nosocomial pneumonia. Am J Infect Control 22:247–292

  20. 20.

    Friedman L, Niederman MS, Chalfin DB, Flaster E, Fein AM (1994) Use of a prognostic scoring index to accurately predict survival from severe pneumonia. Am J Respir Crit Care Med 149:A806

  21. 21.

    Cassiere HA, Fein MA (1996) Severe community-acquired pneumonia. Curr Opin Pulm Med 2:186–191

  22. 22.

    Leeper KV (1996) Severe community-acquired pneumonia. Semin Respir Infect 11:96–108

  23. 23.

    Leroy O, Santre C, Beuscart C, Georges H, Guery B, Jacquier JM, Beaucaire G (1995) A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit. Intensive Care Med 21:24–31

  24. 24.

    Ewig S, Ruiz M, Mensa J, Marcos MA, Martinez JA, Arancibia F, Niederman MS, Torres A (1998) Severe community-acquired pneumonia. Assessment of severity criteria. Am J Respir Crit Care Med 158:1102–1108

  25. 25.

    Hirani NA, Macfarlane JT (1997) Impact of management guidelines on the outcome of severe community-acquired pneumonia. Thorax 52:17–21

  26. 26.

    Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN (1997) A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 336:243–250

  27. 27.

    American Thoracic Society (1993) Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 148:1418–1426

  28. 28.

    Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829

  29. 29.

    Vallés J, Leon C, Alvarez F, and Spanish Collaborative Group for Infections in ICUs (1997) Nosocomial bacteremia in critically ill patients: a multicenter study evaluating epidemiology and prognosis. Clin Infect Dis 24:387–395

  30. 30.

    Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 101:1644–1655

  31. 31.

    Pauwels RA, Buist AS, Calverley PMA, Jenkins CR, Hurd SJ (2001) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO global initiative for chronic obstructive lung disease (GOLD) workshop summary. Am J Respir Crit Care Med 163:1256–1276

  32. 32.

    Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, LeGall JR, Morris A, Spragg R (1994) Report of the American-European consensus coonference on ARDS: definitions, mechanisms, relevant outcomes and clinical trial coordination. Intensive Care Med 20:225–232

  33. 33.

    Denning DW, Lee JY, Hostetler JS, Pappas P, Kauffman CA, Dewsnup DH, Galgiani JN, Graybill JR, Sugar AM, Catanzaro A (1994) NIAID Mycoses Study Group Multicenter Trial of Oral Itraconazole Therapy for Invasive Aspergillosis. Am J Med 97:135–144

  34. 34.

    Meduri GU, Chastre J (1992) The standardization of bronchoscopic techniques for ventilator-associated pneumonia. Chest 102:557S-564S

  35. 35.

    Murray PR, Washington JA II (1975) Microscopic and bacteriologic analysis of expectorated sputum. Mayo Clin Proc 50:339–344

  36. 36.

    Fisher LlD, Van Belle G (1993) Biostatistics: a methodology for the health sciences. In: Fisher LlD, Van Belle (ed) Wiley, New York, pp 496–595

  37. 37.

    Hosmer DW Jr, Lemeshow S (1989) Applied logistic regression. In: Hosmer DW, Lemeshow S (ed) Wiley, New York, pp 82–134

  38. 38.

    Rello J, Esandi ME, Mariscal D, Gallego M, Domingo C, Vallés J (1998) Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease: report of eight cases and review. Clin Infect Dis 26:1473–1475

  39. 39.

    Carratalá J, Gudiol F, Pallarés R, Dorca J, Verdaguer R, Ariza J, Manresa F (1994) Risk factors for nosocomial Legionella pneumophila pneumonia. Am J Respir Crit Care Med 149:625–629

  40. 40.

    Rodrigues J, Niederman MS, Fein AM, Pai PB (1992) Nonresolving pneumonia in steroid-treated patients with obstructive lung disease. Am J Med 93:29–34

  41. 41.

    Crean JM, Niederman MS, Fein AM, Feinsilver SH (1992) Rapidily progressive respiratory failure due to Aspergillus pneumonia: a complication of short-term corticosteroid therapy. Crit Care Med 20:148–150

  42. 42.

    Stout JE, Yu VL, Vickers RM, Zuravleff J, Best M, Brown A, Yee RB, Wadowsky R (1982) Ubiquitousness of Legionella pneumophila in the water suply of a hospital with endemic Legionnaires' disease. N Engl J Med 306:466–468

  43. 43.

    Kirby BD, Snyder KM, Meyer RD, Finegold SM (1978) Legionnaires' disease: clinical features of 24 cases. Ann Intern Med 89:297–309

  44. 44.

    Tobin JO (1980) Legionnaires' disease in a transplant unit: isolation of the causative agent from shower baths. Lancet II:118–121

  45. 45.

    Rello J, Quintana E, Ausina V, Puzo C, Net A, Prats G (1990) Risk factors for Staphylococcus aureus nosocomial pneumonia in critically ill patients. Am Rev Respir Dis 142:1320–1324

  46. 46.

    Rello J, Torres A, Ricart M, Vallés J, González J, Artigas A, Rodríguez-Roisín R (1994) Ventilator-associated pneumonia by Staphylococcus aureus. Comparison of methicillin-resistant and methicillin-sensitive episodes. Am J Respir Crit Care Med 150:1545–1549

  47. 47.

    Pujol M, Corbella X, Peña C, Pallarés, R, Dorca J, Verdaguer R, Díaz-Prieto A, Ariza J, Gudiol F (1998) Clinical and epidemiological findings in mechanically ventilated patients with methicillin-resistant Staphylococcus aureus pneumonia. Eur J Clin Microbiol Infect Dis 17:622–628

  48. 48.

    Pachón J, Prados MD, Capote F, Cuello JA, Garnacho J, Verano A (1990) Severe community-acquired pneumonia. Etiology, prognosis, and treatment. Am Rev Respir Dis 142:369–373

  49. 49.

    Rello J, Quintana E, Ausina V, Net A, Prats G (1993) A three-year study of severe community-acquired pneumonia with emphasis on outcome. Chest 103:232–235

  50. 50.

    Annane D, Sebille V, Charpentier C, Bollaert PE, François B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellisant E (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871

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This research was supported in part by grants from Comissio Interdepartamental de Recerca i Tecnologia (CIRIT): SGR2000/128, SGR2001/414, and RED RESPIRA (RTIC C03/11).

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Correspondence to Jordi Vallés.

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Vallés, J., Mesalles, E., Mariscal, D. et al. A 7-year study of severe hospital-acquired pneumonia requiring ICU admission. Intensive Care Med 29, 1981–1988 (2003).

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  • Pneumonia
  • Intensive care unit
  • Hospital-acquired infection