L Ayzac1, R Girard2, L Baboi3, P Beuret4, M Rabilloud5,6,7,8, J C Richard3,6,7,9, C Guérin10,11,12,13. 1. Centre de Coordination et de Lutte Contre les Infections Nosocomiales Sud-Est, Saint Genis Laval, France. 2. Hospices Civils de Lyon, Service d'Hygiène, Groupement Hospitalier Sud, Pierre Bénite, France. 3. Hospices Civils de Lyon, Service de Réanimation Médicale, Groupement Hospitalier Nord, Grande Rue de la Croix-rousse, 69004, Lyon, France. 4. Service de Réanimation Polyvalente, Centre Hospitalier Général, Roanne, France. 5. Hospices Civils de Lyon, Service de Biostatistique, 69003, Lyon, France. 6. Université de Lyon, 69000, Lyon, France. 7. Université Lyon 1, 69100, Villeurbanne, France. 8. CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, 69100, Villeurbanne, France. 9. Créatis INSERM 1044, Lyon, France. 10. Hospices Civils de Lyon, Service de Réanimation Médicale, Groupement Hospitalier Nord, Grande Rue de la Croix-rousse, 69004, Lyon, France. claude.guerin@chu-lyon.fr. 11. Université de Lyon, 69000, Lyon, France. claude.guerin@chu-lyon.fr. 12. Université Lyon 1, 69100, Villeurbanne, France. claude.guerin@chu-lyon.fr. 13. Institut Mondor de Recherche Biomédicale INSERM 955 Eq 13, Créteil, France. claude.guerin@chu-lyon.fr.
Abstract
BACKGROUND: The goal of this study was to assess the impact of prone positioning on the incidence of ventilator-associated pneumonia (VAP) and the role of VAP in mortality in a recent multicenter trial performed on patients with severe ARDS. METHODS: An ancillary study of a prospective multicenter randomized controlled trial on early prone positioning in patients with severe ARDS. In suspected cases of VAP the diagnosis was based on positive quantitative cultures of bronchoalveolar lavage fluid or tracheal aspirate at the 10(4) and 10(7) CFU/ml thresholds, respectively. The VAP cases were then subject to central, independent adjudication. The cumulative probabilities of VAP were estimated in each position group using the Aalen-Johansen estimator and compared using Gray's test. A univariate and a multivariate Cox model was performed to assess the impact of VAP, used as a time-dependent covariate for mortality hazard during the ICU stay. RESULTS: In the supine and prone position groups, the incidence rate for VAP was 1.18 (0.86-1.60) and 1.54 (1.15-2.02) per 100 days of invasive mechanical ventilation (p = 0.10), respectively. The cumulative probability of VAP at 90 days was estimated at 46.5 % (27-66) in the prone group and at 33.5 % (23-44) in the supine group. The difference between the two cumulative probability curves was not statistically significant (p = 0.11). In the univariate Cox model, VAP was associated with an increase in the mortality rate during the ICU stay [HR 1.65 (1.05-2.61), p = 0.03]. HR increased to 2.2 (1.39-3.52) (p < 0.001) after adjustment for position group, age, SOFA score, McCabe score, and immunodeficiency. CONCLUSIONS: In severe ARDS patients prone positioning did not reduce the incidence of VAP and VAP was associated with higher mortality.
RCT Entities:
BACKGROUND: The goal of this study was to assess the impact of prone positioning on the incidence of ventilator-associated pneumonia (VAP) and the role of VAP in mortality in a recent multicenter trial performed on patients with severe ARDS. METHODS: An ancillary study of a prospective multicenter randomized controlled trial on early prone positioning in patients with severe ARDS. In suspected cases of VAP the diagnosis was based on positive quantitative cultures of bronchoalveolar lavage fluid or tracheal aspirate at the 10(4) and 10(7) CFU/ml thresholds, respectively. The VAP cases were then subject to central, independent adjudication. The cumulative probabilities of VAP were estimated in each position group using the Aalen-Johansen estimator and compared using Gray's test. A univariate and a multivariate Cox model was performed to assess the impact of VAP, used as a time-dependent covariate for mortality hazard during the ICU stay. RESULTS: In the supine and prone position groups, the incidence rate for VAP was 1.18 (0.86-1.60) and 1.54 (1.15-2.02) per 100 days of invasive mechanical ventilation (p = 0.10), respectively. The cumulative probability of VAP at 90 days was estimated at 46.5 % (27-66) in the prone group and at 33.5 % (23-44) in the supine group. The difference between the two cumulative probability curves was not statistically significant (p = 0.11). In the univariate Cox model, VAP was associated with an increase in the mortality rate during the ICU stay [HR 1.65 (1.05-2.61), p = 0.03]. HR increased to 2.2 (1.39-3.52) (p < 0.001) after adjustment for position group, age, SOFA score, McCabe score, and immunodeficiency. CONCLUSIONS: In severe ARDSpatients prone positioning did not reduce the incidence of VAP and VAP was associated with higher mortality.
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