Clinical Microbiology and Antimicrobial Chemotherapy. 2010; 12(2):106-116
To study prospectively clinical course of hospital-acquired pneumonia (HAP), mortality, and risk factors for poor outcome as well as etiology and antibiotic resistance of HAP in trauma patients; to assess antimicrobial therapy in patients with head trauma and orthopedic trauma in Smolensk Clinical Hospital of Emergency Medical Care.
A prospective observational study in 96 patients with head trauma or orthopedic trauma and concurrent HAP, confirmed by clinical examination, chest X-ray, and Clinical Pulmonary Infection Scale (CPIS) score of ≥5.
HAP in trauma patients was mainly caused by microbial associations including S. aureus, A. baumannii, K. pneumoniae, E. coli and P. aeruginosa with multi-drug resistance. The most active antimicrobials against Gramnegative bacteria were carbapenems and cefoperazone/ sulbactam; and against methicillin-resistant S. aureus (MRSA) – vancomycin, linezolid, and co-trimoxazole. Selection of resistance was facilitated by the use of antibiotics in most patients (74%) before development of HAP. Antimicrobial agents were not changed or not initiated in a timely manner after development of HAP in 43.8% of patients. Initial empiric antimicrobial therapy was considered as appropriate in 10.4% of patients only. Mortality rate was significantly higher in patients who received inappropriate initial antimicrobial therapy than that with adequate treatment (62.3% vs 10%, р=0.004). Mortality in patients treated with carbapenems was significantly lower (p=0.039) compared to patients who received other antimicrobial regimens.
The real practice of the management of trauma patients with HAP in our hospital appeared to be very different from the current treatment strategy for serious infections accepted worldwide. Based on the data on prevalent nosocomial pathogens causing HAP in trauma patients and their antibiotic resistance patterns, the following antimicrobial combinations “carbapenem ± linezolid or vancomycin” or “cefoperazone/sulbactam ± linezolid or vancomycin” may be recommended as an appropriate initial therapy with subsequent de-escalation based on culture results. Hospital guidelines for the management of patients with head or orthopedic trauma and concurrent HAP should be developed and implemented in order to improve clinical and healthcare outcomes.