Monitoring of hospital acquired pneumonia in patients with severe brain injury on first access to intensive neurological rehabilitation: First year of observation

Abstract

Nosocomial or hospital acquired pneumonia (HAP) is an illness contracted during a hospital stay, generally with onset 48 hours or more after admission to hospital, or within 14 days of discharge from hospital. HAP is divided into subgroups: Ventilator-associated pneumonia (VAP), accounting for 86% of hospital acquired pneumonia, and stroke-associated pneumonia (SAP). The incidence of SAP in neurological intensive care units (NICUs) is 4.1-56.6%, in medical intensive care units (MICUs) it is 17-50%, in stroke units it is 3.9-44% and in rehabilitation it is 3.2-11%, whereas in intensive rehabilitation following severe cranial trauma, the reported incidence of HAP is between 3.9 and 12% of cases. The aim of this study is to evaluate the cases of HAP occurring in a continuous series of patients with severe acquired brain injury (sABI) admitted to intensive rehabilitation units. The data collected can help evaluate the growing complexity of early rehabilitation of these patients, starting from how lung infections interfere with hospital stays and rehabilitation outcomes. This prospective observational cohort study evaluates, from 01/01/2015 to 31/12/2015, for patients with sABI on first admission to intensive neurological rehabilitation, the frequency of HAP and its impact on patient outcomes and complexity of care. A total of 61 patients were enrolled: 39 males and 22 females, average age 59.5 years (17-88 yrs, SD 3.53), coming from critical care (n=52), medical units (n=5), neurosurgery (n=3) and surgical units (n=1). The aetiology of hospital admission was haemorrhagic in 36% of cases, traumatic in 36%, anoxic in 13.1%, infectious in 6.5%, ischaemic in 4.9%, and other causes in 3.2%. Among the patients, 93.44% had received antibiotic therapy in their unit of provenance, and in 61.27% of cases a multidrug resistant (MDR) bacterium was isolated. On enrolment, 26 patients presented respiratory insufficiency, 29 subjects were in oxygen therapy, and 4 under invasive mechanical ventilation. There were 54 tracheostomized patients, 33 patients with percutaneous endoscopic gastrostomy (PEG) tubes, and 23 with nasogastric (NG) tubes. In 2015, among these subjects admitted to neurological rehabilitation, the incidence of HAP was 13.1%. For these 8 pneumonia cases, it was possible to isolate the bacterium in 62.5% of cases, and the detected microorganisms were K. pneumoniae (n=2), P. aeruginosa (n=1), P. mirabilis (n=1), S. maltophilia (n=1), E. cloacae + MRSCoN (n=1). Compared to the literature data, the results of the first year of monitoring show a slight increase in HAP cases (13.1%) in severe brain injury patients on first admission to neurological rehabilitation. These preliminary results need to be further confirmed and monitored over time. The findings moreover confirm the criticality and complexity of care for these patients admitted to neurological rehabilitation units.