Reintubation increases Ventilator-Associated Pneumonia in Pediatric Intensive Care Unit Patients

Objective: To determine the incidence, risk factors, mortality, and causative organisms of Nosocomial Pneumonia (NP) in patients with endotracheal (ET) tube, with or without mechanical ventilation. Materials and Methods: Patients admitted to the Pediatric Intensive Care Unit (PICU), over a period of 1 year who had ET intubations, were enrolled consecutively into the study. Diagnosis of NP was based on CDC criteria (1988). Semiquantiative assay of endotracheal aspirate (ETA) with a colony count of >105 cfu/mL was taken as evidence of infection. Colonization was defined as isolation of organism with <105 cfu/mL. Age, nutritional status, number and duration of intubations, duration of mechanical ventilation, sedation, nasogastric feeding were the risk factors studied for development of NP. Intubation attempts of more than one were defined as reintubation. Risk factors found significant on univariate analysis, were subjected to multiple regression analysis to determine the most important predictors of NP. Results: The study group comprised of 72 children with a median age of 3.7 years and boys: girls' ratio of 1.9:1.Twenty two of 72 (30.5%) developed NP; the predominant isolates from ETA were Pseudomonas aeruginosa (12), Acinetobacter anitratus (5), Klebsiella sp (3) and Staphylococcus aureus and E.coli (1) each. Additionally, 18(39%) had evidence of ET colonization, with Pseudomonas aeruginosa being the commonest 9(50%). Re-intubation, prolonged duration of intubation and mechanical ventilation were the significant risk factors on univariate analysis for development of NP. On multiple regression analysis, reintubation was the only independent risk factor for NP (OR 0.72, 95% CI 0.55-0.94). Overall mortality was 21% (15/72);7(47%)of these deaths were secondary to NP. Conclusions: NP developed in nearly one third of the intubated patients; Gram negative organisms were the predominant etiological agents and associated with high mortality. Re-intubation, prolonged duration of intubation and mechanical ventilation were the significant risk factors on univariate analysis for development of NP. On multiple regression analysis, reintubation was the only independent risk factor for NP. (Rawal Med J 2008;33:145-149).