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Attributable mortality of ventilator associated pneumonia: a reappraisal using causal analysis

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Abstract
Rationale: Measuring the attributable mortality of ventilator-associated pneumonia (VAP) is challenging and prone to different forms of bias. Studies addressing this issue have produced variable and controversial results. Objectives: We estimate the attributable mortality of VAP in a large multicenter cohort using statistical methods from the field of causal inference. Methods: Patients (n = 4,479) from the longitudinal prospective (1997-2008) French multicenter Outcomerea database were included if they stayed in the intensive care unit (ICU) for at least 2 days and received mechanical ventilation (MV) within 48 hours after ICU admission. A competing risk survival analysis, treating ICU discharge as a competing risk for ICU mortality, was conducted using a marginal structural modeling approach to adjust for time-varying confounding by disease severity. Measurements and Main Results: Six hundred eighty-five (15.3%) patients acquired at least one episode of VAP. We estimated that 4.4% (95% confidence interval, 1.6-7.0%) of the deaths in the ICU on Day 30 and 5.9% (95% confidence interval, 2.5-9.1%) on Day 60 are attributable to VAP. With an observed ICU mortality of 23.3% on Day 30 and 25.6% on Day 60, this corresponds to an ICU mortality attributable to VAP of about 1% on Day 30 and 1.5% on Day 60. Conclusions: Our study on the attributable mortality of VAP is the first that simultaneously accounts for the time of acquiring VAP, informative loss to follow-up after ICU discharge, and the existence of complex feedback relations between VAP and the evolution of disease severity. In contrast to the majority of previous reports, we detected a relatively limited attributable ICU mortality of VAP.
Keywords
Severity of illness, Ventilator associated pneumonia, Causal inference, Attributable mortality, INTENSIVE-CARE UNITS, MARGINAL STRUCTURAL MODELS, NOSOCOMIAL PNEUMONIA, COMPETING RISKS, SURVIVAL, EPIDEMIOLOGY, INFECTIONS, THERAPY, SEPSIS, SCORE

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Chicago
Bekaert, Maarten, Jean-Francois Timsit, Stijn Vansteelandt, Pieter Depuydt, Aurélien Vésin, Maité Garrouste-Orgeas, Johan Decruyenaere, Christoph Clec’h, Elie Azoulay, and Dominique Benoit. 2011. “Attributable Mortality of Ventilator Associated Pneumonia: a Reappraisal Using Causal Analysis.” American Journal of Respiratory and Critical Care Medicine 184 (10): 1133–1139.
APA
Bekaert, Maarten, Timsit, J.-F., Vansteelandt, S., Depuydt, P., Vésin, A., Garrouste-Orgeas, M., Decruyenaere, J., et al. (2011). Attributable mortality of ventilator associated pneumonia: a reappraisal using causal analysis. AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, 184(10), 1133–1139.
Vancouver
1.
Bekaert M, Timsit J-F, Vansteelandt S, Depuydt P, Vésin A, Garrouste-Orgeas M, et al. Attributable mortality of ventilator associated pneumonia: a reappraisal using causal analysis. AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE. 2011;184(10):1133–9.
MLA
Bekaert, Maarten, Jean-Francois Timsit, Stijn Vansteelandt, et al. “Attributable Mortality of Ventilator Associated Pneumonia: a Reappraisal Using Causal Analysis.” AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE 184.10 (2011): 1133–1139. Print.
@article{1891089,
  abstract     = {Rationale: Measuring the attributable mortality of ventilator-associated pneumonia (VAP) is challenging and prone to different forms of bias. Studies addressing this issue have produced variable and controversial results. 
Objectives: We estimate the attributable mortality of VAP in a large multicenter cohort using statistical methods from the field of causal inference. 
Methods: Patients (n = 4,479) from the longitudinal prospective (1997-2008) French multicenter Outcomerea database were included if they stayed in the intensive care unit (ICU) for at least 2 days and received mechanical ventilation (MV) within 48 hours after ICU admission. A competing risk survival analysis, treating ICU discharge as a competing risk for ICU mortality, was conducted using a marginal structural modeling approach to adjust for time-varying confounding by disease severity. 
Measurements and Main Results: Six hundred eighty-five (15.3\%) patients acquired at least one episode of VAP. We estimated that 4.4\% (95\% confidence interval, 1.6-7.0\%) of the deaths in the ICU on Day 30 and 5.9\% (95\% confidence interval, 2.5-9.1\%) on Day 60 are attributable to VAP. With an observed ICU mortality of 23.3\% on Day 30 and 25.6\% on Day 60, this corresponds to an ICU mortality attributable to VAP of about 1\% on Day 30 and 1.5\% on Day 60. 
Conclusions: Our study on the attributable mortality of VAP is the first that simultaneously accounts for the time of acquiring VAP, informative loss to follow-up after ICU discharge, and the existence of complex feedback relations between VAP and the evolution of disease severity. In contrast to the majority of previous reports, we detected a relatively limited attributable ICU mortality of VAP.},
  author       = {Bekaert, Maarten and Timsit, Jean-Francois and Vansteelandt, Stijn and Depuydt, Pieter and V{\'e}sin, Aur{\'e}lien and Garrouste-Orgeas, Mait{\'e} and Decruyenaere, Johan and Clec'h, Christoph and Azoulay, Elie and Benoit, Dominique},
  issn         = {1073-449X},
  journal      = {AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE},
  keyword      = {Severity of illness,Ventilator associated pneumonia,Causal inference,Attributable mortality,INTENSIVE-CARE UNITS,MARGINAL STRUCTURAL MODELS,NOSOCOMIAL PNEUMONIA,COMPETING RISKS,SURVIVAL,EPIDEMIOLOGY,INFECTIONS,THERAPY,SEPSIS,SCORE},
  language     = {eng},
  number       = {10},
  pages        = {1133--1139},
  title        = {Attributable mortality of ventilator associated pneumonia: a reappraisal using causal analysis},
  url          = {http://dx.doi.org/10.1164/rccm.201105-0867OC},
  volume       = {184},
  year         = {2011},
}

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