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

Maarten Bekaert, Jean-Francois Timsit, Stijn Vansteelandt UGent, Pieter Depuydt UGent, Aurélien Vésin, Maité Garrouste-Orgeas, Johan Decruyenaere UGent, Christoph Clec'h, Elie Azoulay and Dominique Benoit UGent (2011) AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE. 184(10). p.1133-1139
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.
Please use this url to cite or link to this publication:
author
organization
year
type
journalArticle (original)
publication status
published
subject
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
journal title
AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
Am. J. Respir. Crit. Care Med
volume
184
issue
10
pages
1133 - 1139
Web of Science type
Article
Web of Science id
000297015600013
JCR category
RESPIRATORY SYSTEM
JCR impact factor
11.08 (2011)
JCR rank
1/48 (2011)
JCR quartile
1 (2011)
ISSN
1073-449X
DOI
10.1164/rccm.201105-0867OC
language
English
UGent publication?
yes
classification
A1
copyright statement
I have transferred the copyright for this publication to the publisher
id
1891089
handle
http://hdl.handle.net/1854/LU-1891089
date created
2011-08-19 16:20:30
date last changed
2016-12-19 15:46:39
@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},
}

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.