Ventilator-associated pneumonia in an academic intensive care unit in Johannesburg, South Africa.

Background: Ventilator-associated pneumonia (VAP) has an estimated incidence of 10 - 41.5 events per 1 000 ventilator days in developing countries, and carries high mortality. Little is known about the incidence and outcomes of VAP in Johannesburg, South Africa.

Objectives: To describe VAP in a tertiary public hospital in Johannesburg, assess the microbiological pathogens associated with VAP (both early and late), and outline the outcomes of these patients.

Methods: The study was a retrospective record review of patients admitted to the Helen Joseph Hospital intensive care unit (ICU) between March 2013 and January 2016.

Results: VAP developed in 24/842 ventilated patients (2.9%; 95% confidence interval (CI) 1.8 - 4.2), with an incidence of 23 events per 1 000 ventilator days, during the study period. Of these patients, one-third (29.2%) died and 70.8% were discharged from the ICU. Late-onset VAP (onset ≥5 days after intubation, incidence 45.8%) was associated with higher mortality (54.6%) than early-onset VAP (onset within 4 days after intubation, incidence 54.2% and mortality 7.7%). Commonly isolated organisms were Klebsiellai pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa. There was a trend towards an increased risk of multidrug-resistant organisms with late-onset VAP (adjusted relative risk 2.26; 95% CI 0.92 - 5.57; p=0.077) and airway access through a tracheostomy (relative risk 1.68; 95% CI 0.78 - 3.57).

Conclusion: The study showed a low to moderate incidence of VAP of 23 events per 1 000 ventilator days. A tracheostomy and late-onset VAP were associated with infection by drug-resistant organisms. The mortality rate was 29.2% in this setting, with a seven-fold increase in mortality with late-onset VAP.

Study synopsis: What the study adds. This study helps to improve understanding of the incidence of ventilator-associated pneumonia in South Africa, a low- to middle-income country, and the commonly encountered causative pathogens. It indicates the importance of a short intensive care unit (ICU) stay as a target outcome for prevention of nosocomial infections and other complications.Implications of the findings. The study: reinforces the importance of preventive mesures in the ICU and keeping up to date with the evidence in the fieldhighlights the importance of knowing local microbial resistance patterns in order to develop precise antibiogramsshows the need for research in ICU care for people of advanced age, and the impact that admission rationing has on our ICU populations.