Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East: Findings of the International Nosocomial Infection Control Consortium (INICC)
Authors: Rosenthal Victor Daniel , Jin Zhilin , Memish Ziad A. , Rodrigues Camilla , Myatra Sheila Nainan , Kharbanda Mohit , Valderrama-Beltran Sandra Liliana , Mehta Yatin , Daboor Mohammad Abdellatif , Todi Subhash Kumar , Aguirre-Avalos Guadalupe , Guclu Ertugrul , Gan Chin Seng , Jiménez Alvarez Luisa Fernanda , Chawla Rajesh , Hlinkova Sona , Arjun Rajalakshmi , Agha Hala Mounir , Zuniga Chavarria Maria Adelia , Davaadagva Narangarav , Mohd Basri Mat Nor , Gomez Katherine , Aguilar De Moros Daisy , Tai Chian-Wern , Sassoe Gonzalez Alejandro , Aguilar Moreno Lina Alejandra , Sandhu Kavita , Janc Jarosław , Aleman Bocanegra Mary Cruz , Yildizdas Dincer , Cano Medina Yuliana Andrea , Villegas Mota Maria Isabel , Omar Abeer Aly , Duszynska Wieslawa , BelKebir Souad , El-Kholy Amani Ali , Abdulaziz Alkhawaja Safaa , Horhat Florin George , Medeiros Eduardo Alexandrino , Tao Lili , Tumu Nellie , Elanbya May Gamar , Dongol Reshma , Mioljević Vesna , Raka Lul , Dueñas Lourdes , Carreazo Nilton Yhuri , Dendane Tarek , Ikram Aamer , Kanj Souha S. , Petrov Michael M. , Bouziri Asma , Hung Nguyen Viet , Belskiy Vladislav , Elahi Naheed , Bovera María Marcela , Yin Ruijie 
Published: January 2023

Abstract

Objective:
Rates of ventilator-associated pneumonia (VAP) in low- and middle-income countries (LMIC) are several times above those of high-income countries. The objective of this study was to identify risk factors (RFs) for VAP cases in ICUs of LMICs.

Design:
Prospective cohort study.

Setting:
This study was conducted across 743 ICUs of 282 hospitals in 144 cities in 42 Asian, African, European, Latin American, and Middle Eastern countries.

Participants:
The study included patients admitted to ICUs across 24 years.

Results:
In total, 289,643 patients were followed during 1,951,405 patient days and acquired 8,236 VAPs. We analyzed 10 independent variables. Multiple logistic regression identified the following independent VAP RFs: male sex (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.16–1.28; P < .0001); longer length of stay (LOS), which increased the risk 7% per day (aOR, 1.07; 95% CI, 1.07–1.08; P < .0001); mechanical ventilation (MV) utilization ratio (aOR, 1.27; 95% CI, 1.23–1.31; P < .0001); continuous positive airway pressure (CPAP), which was associated with the highest risk (aOR, 13.38; 95% CI, 11.57–15.48; P < .0001); tracheostomy connected to a MV, which was associated with the next-highest risk (aOR, 8.31; 95% CI, 7.21–9.58; P < .0001); endotracheal tube connected to a MV (aOR, 6.76; 95% CI, 6.34–7.21; P < .0001); surgical hospitalization (aOR, 1.23; 95% CI, 1.17–1.29; P < .0001); admission to a public hospital (aOR, 1.59; 95% CI, 1.35-1.86; P < .0001); middle-income country (aOR, 1.22; 95% CI, 15–1.29; P < .0001); admission to an adult-oncology ICU, which was associated with the highest risk (aOR, 4.05; 95% CI, 3.22–5.09; P < .0001), admission to a neurologic ICU, which was associated with the next-highest risk (aOR, 2.48; 95% CI, 1.78–3.45; P < .0001); and admission to a respiratory ICU (aOR, 2.35; 95% CI, 1.79–3.07; P < .0001). Admission to a coronary ICU showed the lowest risk (aOR, 0.63; 95% CI, 0.51–0.77; P < .0001).

Conclusions:
Some identified VAP RFs are unlikely to change: sex, hospitalization type, ICU type, facility ownership, and country income level. Based on our results, we recommend focusing on strategies to reduce LOS, to reduce the MV utilization ratio, to limit CPAP use and implementing a set of evidence-based VAP prevention recommendations.