IS EARLY INITIATION OF ANTIBIOTIC THERAPY IN CRITICALLY ILL TRAUMA PATIENTS WITH VENTILATOR ASSOCIATED PNEUMONIA AN APPROPRIATE QUALITY METRIC?

Authors:
Andrew Kerwin, Neeraj Namburu, Saskya Byerly, Swanson Joseph, Dina Filiberto, G. Christopher Wood

Body of Abstract:
Background: Current Surviving Sepsis guidelines recommend initiating antibiotics within 1-3 hours of presentation for patients with suspicion of sepsis. This early administration of antibiotics is associated with improved outcomes. However, for hospital-acquired infections such as ventilator-associated pneumonia (VAP), it is unclear whether the timing of antibiotic initiation is associated with better outcomes in patients with suspicion of sepsis. We hypothesized that in critically ill trauma patients admitted to the intensive care unit (ICU), a longer time from the onset of VAP symptoms to the start of appropriate antibiotic therapy (AAT) with in vitro activity against the causative organisms will be associated with worse outcomes.

Methods: This was a retrospective study of critically ill trauma patients who developed one episode of VAP between March 2019 and December 2022. Routine demographics, hospital length of stay (HLOS), ICU length of stay (ICU LOS), ventilator days, and mortality were recorded. VAP was diagnosed using fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) for quantitative culture. Empiric antibiotic therapy (EAT), in accordance with our long-standing clinical pathway, was then started and changed to AAT if needed based on the culture and sensitivity report. Patients were stratified according to whether they received antibiotics within 3 hours of the onset of signs and symptoms of VAP.

Results: We identified 364 patients who developed VAP after admission to the ICU . Mean age was 44 ±19 years. Median ISS was 26 (IQR 17-34). Mean time from the onset of VAP symptoms to BAL was 10.1 ± 6 hours, and mean time from BAL to administering EAT was 1.8 ± 5 hrs. Patients with inappropriate EAT required an extra 50 ± 24 hours to be changed to AAT. Outcomes in patients who received AAT within 3 hours of developing signs and symptoms of VAP compared to patients who received AAT after 3 hours were as follows: mortality 14% vs. 19% (p=0.6), mean ventilator days 23.2 ± 15.6 vs. 19 ± 12.4 (p=0.14), mean ICU LOS 22.2 ±10.6 vs. 20.9 ± 13.7 (p=0.65), and HLOS 37.1 ± 19.5 vs. 31.6 ± 26.8 (p=0.34). Median time to AAT was statistically similar between patients who lived compared to patients who died (12.9 hours (IQR 8-26) vs. 14.7 (9-31), p=0.5).

Conclusions: Outcomes were not significantly improved among VAP patients who received AAT within 3 hours of developing signs and symptoms of VAP compared to those who received AAT more than 3 hours after developing signs and symptoms of VAP. These results suggest that time to AAT may be less important in trauma ICU patients than in septic emergency department patients and provide a framework for quality metrics on the timing of events to inform potential process improvements in VAP management.