Healthcare-associated pneumonia (HAP)

Risk of symptomatic infection and duration of disease

Healthcare-associated pneumonia (HAP) was defined in accordance with the ECDC case definition (ECDC, 2012). A systematic review of the literature was performed to estimate the sequelae and the probability of developing these sequelae following HAP. This review took into consideration the role of co-morbidities by estimating the attributable impact of HAP: attributable mortality, attributable risk of developing sequelae and its duration (effect on the length of hospital stay).

The extracted literature was limited to ventilator-associated pneumonia (VAP) because no specific literature was found for the more general search terms 'pneumonia' and 'lower respiratory tract infection'.

Attributable ICU mortality due to VAP varied from 0.1% to 9% based on the studies by Aybar Türkoglu et al. (2008) and Rello et al. (2002). The report on surveillance of healthcare-associated infections in intensive care units in Europe, 2008-2012, stemming from the HAI-Net ICU surveillance (ECDC, 2016), found an overall attributable case fatality proportion for pneumonia patients of 3.5% that was used as the median estimate in our model.

Attributable length of stay in an intensive care unit (ICU) due to VAP varied from 2.03 to 7 days whereas attributable length of hospital stay following VAP varied from 7 to 11.5 days. The latter range is included in the outcome tree (Aybar-Türkoglu, 2008; Rello, 2002).

Sepsis and acute respiratory distress syndrome (ARDS) are generally considered to be frequent consequences of VAP. However, only one study provided data on the transitional probability which amounted to 39% (proportion of patients suffering from severe sepsis and/or septic shock) for sepsis/ARDS as a health consequence of VAP (Damas, 2011). Duration of severe sepsis or septic shock was 9.9–13 days (Olaechea, 2013; Renaud, 2001). The long-term health outcomes following sepsis and ARDS were taken from the model developed for healthcare-associated primary bloodstream infection.

Model input summary

Table 1. Transition probabilities used in the outcome tree

Health outcome
 (Health state)

Distribution of health states in health outcome

Transition probability

Source/assumption

Fatal cases following symptomatic infection

 

3.5% (0.1-9%)

Aybar Türkoglu, 2008; Rello, 2002; ECDC, 2016

Severe sepsis or septic shock

 

39%

Damas, 2011

Post-traumatic stress disorder (PTSD) following severe sepsis or septic shock

 

13-21%

Kessler, 1995; Deja, 2006; Schelling, 1998; Stoll, 1999; Kapfhammer, 2004; Hopkins, 2005

Cognitive impairment following severe sepsis or septic shock

 

11-47%

Hopkins, 2005; Iwashyna, 2010

Physical impairment following severe sepsis or septic shock

 

100%

Hopkins, 2005; Herridge, 2003; Hofhuis, 2008

Renal failure and renal replacement therapy following severe sepsis or septic shock

 

0.9-1.3%

Gallagher, 2014; Wisplinghoff, 2004

Table 2. Disability weights and duration

Health outcome
(Health state)

Disability Weight (DW) (Haagsma, 2015)

Duration

DW

Label

In years

Source/assumption

Symptomatic infection

0.125 (0.104-0.152)

Infectious disease, acute episode, severe

0.019-0.031

Aybar Türkoglu, 2008; Rello, 2002

Severe sepsis or septic shock

0.655 (0.579-0.727)

Intensive care unit admission

0.027-0.036

Olaechea, 2013; Renaud, 2001

Post-traumatic stress disorder (PTSD) following severe sepsis or septic shock

0.088 (0.07-0.108)

Subacute sclerosing panencephalitis – phase 1

(chosen according to best fitting description)

Remaining life expectancy

 

Cognitive impairment following severe sepsis or septic shock

0.043 (0.026-0.064)

Intellectual disability, mild

Remaining life expectancy

 

Physical impairment following severe sepsis or septic shock

0.011-0.053

Range between motor impairment, mild and motor impairment, moderate

Remaining life expectancy

 

Renal failure and renal replacement therapy following severe sepsis or septic shock

0.030-0.487

Range between end-stage renal disease, on dialysis and end-stage renal disease, with kidney transplant

Remaining life expectancy

 

References

Aybar Türkoglu, m. & Topeli Iskit, A. 2008. Ventilator-associated pneumonia caused by high risk microorganisms: a matched case-control study. Tüberküloz ve toraks, 56, 139-49.

Bercault, N. & Boulain, T. 2001. Mortality rate attributable to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective case-control study. Critical care medicine, 29, 2303-9.

Damas, P., Layios, N., Seidel, l., Nys, M., Melin, P. & Ledoux, D. 2011. Severity of ICU-acquired pneumonia according to infectious microorganisms. Intensive care medicine, 37, 1128-35.

European Centre for Disease Prevention and Control. Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals – protocol version 4.3. Stockholm: ECDC; 2012. Available at: http://ecdc.europa.eu/en/publications/Publications/0512-TED-PPS-HAI-antimicrobial-use-protocol.pdf

Gallagher, M., Cass, A., bellomo, R., Finfer, S., Gattas, D., Lee, J., Lo, S., Mcguinness, S., Myburgh, j., Parke, R. & Rajbhandari, D. 2014. Long-Term Survival and Dialysis Dependency Following Acute Kidney Injury in Intensive Care: Extended Follow-up of a Randomized Controlled Trial. PLoS Med, 11, e1001601.

Haagsma JA, Maertens de Noordhout C, Polinder S, Vos T, Havelaar AH, Cassini A, Devleesschauwer B, Kretzschmar ME, Speybroeck N, Salomon JA. Assessing disability weights based on the responses of 30,660 people from four European countries. Population Health Metrics 2015; 13: 10

Herridge, M. S., Cheung, A. M., tansey, C. M., Matte-martyn, A., Diaz-granados, N., Al-saidi, F., Cooper, A. b., Guest, C. B., Mazer, C. D., Mehta, S., Stewart, T. E., Barr, A., Cook, D. & Slutsky, A. S. 2003. One-Year Outcomes in Survivors of the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 348, 683-693.

Hofhuis, J. G., Spronk, P. E., van Stel, H. F., Schrijvers, A. J., Rommes, J. H. & Bakker, J. 2008. The impact of severe sepsis on health-related quality of life: a long-term follow-up study. Anesth Analg, 107, 1957-64.

Hopkins, R. O., Weaver, L. K., collingridge, D., Parkinson, R. B., Chan, K. J. & Orme, J. F., Jr. 2005. Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med, 171, 340-7

Iwashyna, T. J., Ely, E. W., smith, D. M. & Langa, K. M. 2010. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA, 304, 1787-94.

Kessler, R. C., Sonnega, A., bromet, E., Hughes, M. & Nelson, C. B. 1995. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry, 52, 1048-60.

Olaechea, P. M., Palomar, M., alvarez-lerma, F., Otal, J. J., Insausti, J., Lopez-pueyo, M. J. & Group, e.-h. 2013. Morbidity and mortality associated with primary and catheter-related bloodstream infections in critically ill patients. Rev Esp Quimioter, 26, 21-9.

Melsen, W. G., Rovers, M. M., Groenwold, r. H., Bergmans, D. C., Camus, C., Bauer, T. T., Hanisch, E. W., Klarin, B., koeman, M., Krueger, W. A., Lacherade, J. C., Lorente, L., Memish, Z. A., morrow, L. E., Nardi, G., Van Nieuwenhoven, C. A., O'keefe, G. E., Nakos, G., scannapieco, F. A., Seguin, P., Staudinger, T., Topeli, A., Ferrer, M. & bonten, M. J. 2013. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. The Lancet infectious diseases, 13, 665-71.

Rello, J., Ollendorf, D. A., oster, G., Vera-llonch, M., Bellm, L., Redman, R., Kollef, M. H. & Group, v. A. P. O. S. A. 2002. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest, 122, 2115-21.

Renaud, B., Brun-buisson, C. & Group, I. C.-b. S. 2001. Outcomes of primary and catheter-related bacteremia. A cohort and case-control study in critically ill patients. Am J Respir Crit Care Med, 163, 1584-90.

European Centre for Disease Prevention and Control. Surveillance of healthcare-associated infections in intensive care units in Europe, 2008-2012. Stockholm: ECDC; 2016. In press