Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models
Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models
复制标题
DOI：
10.1007/s00134-010-1824-6
复制
发表时间：
2010-05-01
影响因子：
38.9
通讯作者：
Timsit, Jean-Francois
中科院分区：
文献类型：
--
作者：
Nguile-Makao, Moliere;Zahar, Jean-Ralph;Timsit, Jean-Francois
估计呼吸机相关性肺炎 (VAP) 导致的超额死亡率的方法应将 VAP 作为时间依赖性协变量处理，因为发生 VAP 的可能性随着机械通气时间的延长而增加。 VAP 归因死亡率 (VAP-AM) 因定义、病例组合、致病微生物和治疗充分性而异。我们的目标是比较使用传统队列分析、多状态渐进性残疾模型和匹配队列分析获得的 VAP-AM 估计值；并根据 VAP 特征比较 VAP-AM 估计值。我们使用了 Outcomerea(A(R)) 数据库中 2,873 名机械通气患者的数据。在来自 12 个重症监护病房的这些患者中，有 434 名（15.1%）患有 VAP；其余患者中，1,969 人（68.5%）存活出院，470 人（16.4%）死亡。在多状态模型中，120 天的完整观察中，VAP-AM 为 8.1%（95% 置信区间 [95%CI]，3.1-13.1%），而使用匹配队列方法（2,769 名患者），匹配机械通气持续时间，然后进行条件逻辑回归，则为 10.4%（5.6-24.5%）。手术患者和入住 ICU 时简化急性生理评分 II 值中等（但不高）的患者的 VAP-AM 较高。 VAP-AM 受 VAP 时间的显着影响，但不受致病微生物耐药性的影响。 VAP 发病时逻辑器官功能障碍评分较高，VAP-AM 显着增加（评分高于 7 的患者为 31.9%）。将 VAP 适当处理为时间依赖性事件的多状态模型产生的 VAP-AM 值低于条件逻辑回归。 VAP-AM 随病例组合的不同而变化很大。 VAP 发病时的疾病严重程度显着影响 VAP-AM；这可能会导致先前估计的可变性。
Methods for estimating the excess mortality attributable to ventilator-associated pneumonia (VAP) should handle VAP as a time-dependent covariate, since the probability of experiencing VAP increases with the time on mechanical ventilation. VAP-attributable mortality (VAP-AM) varies with definitions, case-mix, causative microorganisms, and treatment adequacy. Our objectives here were to compare VAP-AM estimates obtained using a traditional cohort analysis, a multistate progressive disability model, and a matched-cohort analysis; and to compare VAP-AM estimates according to VAP characteristics.We used data from 2,873 mechanically ventilated patients in the Outcomerea(A (R)) database. Among these patients from 12 intensive care units, 434 (15.1%) experienced VAP; of the remaining patients, 1,969 (68.5%) were discharged alive and 470 (16.4%) died. With the multistate model, VAP-AM was 8.1% (95% confidence interval [95%CI], 3.1-13.1%) for 120 days' complete observation, compared to 10.4% (5.6-24.5%) using a matched-cohort approach (2,769 patients) with matching on mechanical ventilation duration followed by conditional logistic regression. VAP-AM was higher in surgical patients and patients with intermediate (but not high) Simplified Acute Physiologic Score II values at ICU admission. VAP-AM was significantly influenced by time to VAP but not by resistance of causative microorganisms. Higher Logistic Organ Dysfunction score at VAP onset dramatically increased VAP-AM (to 31.9% in patients with scores above 7).A multistate model that appropriately handled VAP as a time-dependent event produced lower VAP-AM values than conditional logistic regression. VAP-AM varied widely with case-mix. Disease severity at VAP onset markedly influenced VAP-AM; this may contribute to the variability of previous estimates.