TY - JOUR
T1 - Machine learning links unresolving secondary pneumonia to mortality in patients with severe pneumonia, including COVID-19
AU - The NU SCRIPT Study Investigators
AU - Gao, Catherine A.
AU - Markov, Nikolay S.
AU - Stoeger, Thomas
AU - Pawlowski, Anna
AU - Kang, Mengjia
AU - Nannapaneni, Prasanth
AU - Grant, Rogan A.
AU - Pickens, Chiagozie
AU - Walter, James M.
AU - Kruser, Jacqueline M.
AU - Rasmussen, Luke
AU - Schneider, Daniel
AU - Starren, Justin
AU - Donnelly, Helen K.
AU - Donayre, Alvaro
AU - Luo, Yuan
AU - Scott Budinger, G. R.
AU - Wunderink, Richard G.
AU - Misharin, Alexander V.
AU - Singer, Benjamin D.
N1 - Publisher Copyright:
© 2023, Gao et al.
PY - 2023/6/15
Y1 - 2023/6/15
N2 - BACKGROUND. Despite guidelines promoting the prevention and aggressive treatment of ventilator-associated pneumonia (VAP), the importance of VAP as a driver of outcomes in mechanically ventilated patients, including patients with severe COVID-19, remains unclear. We aimed to determine the contribution of unsuccessful treatment of VAP to mortality for patients with severe pneumonia. METHODS. We performed a single-center, prospective cohort study of 585 mechanically ventilated patients with severe pneumonia and respiratory failure, 190 of whom had COVID-19, who underwent at least 1 bronchoalveolar lavage. A panel of intensive care unit (ICU) physicians adjudicated the pneumonia episodes and endpoints on the basis of clinical and microbiological data. Given the relatively long ICU length of stay (LOS) among patients with COVID-19, we developed a machine-learning approach called CarpeDiem, which grouped similar ICU patient-days into clinical states based on electronic health record data. RESULTS. CarpeDiem revealed that the long ICU LOS among patients with COVID-19 was attributable to long stays in clinical states characterized primarily by respiratory failure. While VAP was not associated with mortality overall, the mortality rate was higher for patients with 1 episode of unsuccessfully treated VAP compared with those with successfully treated VAP (76.4% versus 17.6%, P < 0.001). For all patients, including those with COVID-19, CarpeDiem demonstrated that unresolving VAP was associated with a transitions to clinical states associated with higher mortality. CONCLUSIONS. Unsuccessful treatment of VAP is associated with higher mortality. The relatively long LOS for patients with COVID-19 was primarily due to prolonged respiratory failure, placing them at higher risk of VAP.
AB - BACKGROUND. Despite guidelines promoting the prevention and aggressive treatment of ventilator-associated pneumonia (VAP), the importance of VAP as a driver of outcomes in mechanically ventilated patients, including patients with severe COVID-19, remains unclear. We aimed to determine the contribution of unsuccessful treatment of VAP to mortality for patients with severe pneumonia. METHODS. We performed a single-center, prospective cohort study of 585 mechanically ventilated patients with severe pneumonia and respiratory failure, 190 of whom had COVID-19, who underwent at least 1 bronchoalveolar lavage. A panel of intensive care unit (ICU) physicians adjudicated the pneumonia episodes and endpoints on the basis of clinical and microbiological data. Given the relatively long ICU length of stay (LOS) among patients with COVID-19, we developed a machine-learning approach called CarpeDiem, which grouped similar ICU patient-days into clinical states based on electronic health record data. RESULTS. CarpeDiem revealed that the long ICU LOS among patients with COVID-19 was attributable to long stays in clinical states characterized primarily by respiratory failure. While VAP was not associated with mortality overall, the mortality rate was higher for patients with 1 episode of unsuccessfully treated VAP compared with those with successfully treated VAP (76.4% versus 17.6%, P < 0.001). For all patients, including those with COVID-19, CarpeDiem demonstrated that unresolving VAP was associated with a transitions to clinical states associated with higher mortality. CONCLUSIONS. Unsuccessful treatment of VAP is associated with higher mortality. The relatively long LOS for patients with COVID-19 was primarily due to prolonged respiratory failure, placing them at higher risk of VAP.
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U2 - 10.1172/JCI170682
DO - 10.1172/JCI170682
M3 - Article
C2 - 37104035
AN - SCOPUS:85163904573
SN - 0021-9738
VL - 133
JO - Journal of Clinical Investigation
JF - Journal of Clinical Investigation
IS - 12
M1 - e170682
ER -