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VOLUME 27 , ISSUE 6 ( June, 2023 ) > List of Articles

Original Article

Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile

Anitha Gunalan, Apurba Sankar Sastry, Venkateswaran Ramanathan, Sujatha Sistla

Keywords : Healthcare-associated infections, Intubation, Ventilator, Ventilator-associated pneumonia

Citation Information : Gunalan A, Sastry AS, Ramanathan V, Sistla S. Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile. Indian J Crit Care Med 2023; 27 (6):411-415.

DOI: 10.5005/jp-journals-10071-24465

License: CC BY-NC 4.0

Published Online: 31-05-2023

Copyright Statement:  Copyright © 2023; The Author(s).


Background: Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections, which develops in mechanically ventilated patients after 48 hours of mechanical ventilation. The purpose of this study was to determine the incidence rate, various risk factors, microbiological profile, and outcome of early- vs late-onset ventilator-associated pneumonia (VAP) in medical intensive care unit (MICU). Materials and methods: This prospective study was conducted on 273 patients admitted to the MICU in JIPMER, Puducherry, from October 2018 to September 2019. Results: The incidence of VAP was 39.59 per 1000 ventilation days of MICU patients (93/273). Of these, 53 (56.9%) patients had early-onset VAP and 40 (43.1%) had late-onset VAP. Multiple logistic regression analysis showed that steroid therapy, supine head position, coma or impaired unconsciousness, tracheostomy, and re-intubation were found to be independent predictors of early- and late-onset VAP, respectively. Most cases of VAP were caused by Gram-negative bacteria (90.6%), with nonfermenters contributing to 61.8%. The most frequent pathogens causing early-onset VAP were Acinetobacter baumannii (28.9%) and Pseudomonas aeruginosa (20.6%), while in late-onset VAP, A. baumannii (32.9%) and Klebsiella pneumoniae (21.9%) were the most common. Maximum death rate was seen in patients infected with Escherichia coli (50%) and Stenotrophomonas maltophilia (38.5%). There was no significant association between the presence of VAP and mortality among the studied population. Conclusion: The incidence of VAP in our study was high. There were no significant differences in the prevalence of pathogens associated with early-onset or late-onset VAP. Our study shows that early-onset and late-onset VAP have different risk factors, highlighting the need for developing different preventive and therapeutic strategies.

  1. Goel V, Gupta S, Goel T. Ventilator-associated pneumonia: A review of the clinically relevant challenges in diagnosis and prevention. Br J Med Practitioners 2016;9(2):a910. DOI:
  2. Hunter JD. Ventilator associated pneumonia. BMJ 2012;344:e3325. DOI: 10.1136/bmj.e3325.
  3. Charles MP, Kali A, Easow JM, Joseph NM, Ravishankar M, Srinivasan S, et al. Ventilator-associated pneumonia. Australas Med J 2014;7(8):334–344. DOI: 10.4066/AMJ.2014.2105.
  4. Blot S, Koulenti D, Dimopoulos G, Martin C, Komnos A, Krueger WA, et al. Prevalence, risk factors, and mortality for ventilator-associated pneumonia in middle-aged, old, and very old critically ill patients. Crit Care Med 2014;42(3):601–609. DOI: 10.1097/01.ccm.0000435665.07446.50.
  5. Rello J, Ollendorf D, Oster G, Vera-Llonch M, Bellm L, Redman R, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122(6):2115–2121. DOI: 10.1378/chest.122.6.2115.
  6. Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, et al. The prevalence of nosocomial infection in intensive care units in Europe. JAMA 1995;274(8):639–644. PMID: 7637145.
  7. Koenig SM, Truwit JD. Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clin Microbiol Rev 2006;19(4):637–657. DOI: 10.1128/CMR.00051-05.
  8. Kausar SH, Bansal VP, Bhalchandra M. Prevalence and susceptibility profiles of non-fermentative Gram-negative Bacilli infection in tertiary care hospital. Int J Curr Microbiol Appl Sci 2018;7:740–744. DOI:
  9. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the healthcare infection control practices advisory committee. MMWR Recomm Rep 2004;53 (RR–3):1–36. PMID: 15048056.
  10. Fagon JY, Chastre J, Wolff M, Gervais C, Parer-Aubas S, Stéphan F, et al. Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: A randomized trial. Ann Intern Med 2000;132(8):621–630. DOI: 10.7326/0003-4819-132-8-200004180-00004.
  11. Pugin J, Auchentaler R, Mili N, Jannsens JP, Lew PD, Suter M. Diagnosis of ventilator-associated pneumonia by bacterilogic analysis of bronchoscopic and nonbronchoscopic “blind” broncoalveolar lavage fluid. Am Rev Respir Dis 1991;143(5 Pt 1):1121–1129. DOI: 10.1164/ajrccm/143.5_Pt_1.1121.
  12. Başyiğit S. Clinical pulmonary infection score (CPIS) as a screening tool in ventilatory associated pneumonia (VAP). Med Bull Sisli Etfal Hosp 51(2):133–141. DOI: 10.5350/SEMB.20170208030528
  13. Mathai AS, Phillips A, Isaac R. Ventilator-associated pneumonia: A persistent healthcare problem in Indian Intensive Care Units! Lung India 2016;33(5):512–516. DOI: 10.4103/0970-2113.188971.
  14. Joseph NM, Sistla S, Dutta TK, Badhe AS, Parija SC. Ventilator-associated pneumonia in a tertiary care hospital in India: incidence and risk factors. J Infect Dev Ctries 2009;3(10):771–777. DOI: 10.3855/jidc.396.
  15. Kollef MH. What is ventilator-associated pneumonia and why is it important? Respir Care 2005;50(6):714–724. PMID: 15913464.
  16. Elkolaly RM, Bahr HM, El-Shafey BI, Basuoni AS, Elber EH. Incidence of ventilator-associated pneumonia: Egyptian study. Egypt J Bronchol 2019;13(2):258–266. DOI:
  17. Sharpe JP, Magnotti LJ, Weinberg JA, Brocker JA, Schroeppel TJ, Zarzaur BL, et al. Gender disparity in ventilator-associated pneumonia following trauma: Identifying risk factors for mortality. J Trauma Acute Care Surg 2014;77(1):161–165. DOI: 10.1097/TA.0000000000000251.
  18. Goel V, Hogade SA, Karadesai S. Ventilator associated pneumonia in a medical intensive care unit: microbial aetiology, susceptibility patterns of isolated microorganisms and outcome. Indian J Anaesth 2012;56(6):558–562. DOI: 10.4103/0019-5049.104575.
  19. Rit K, Chakraborty B, Saha R, Majumder U. Ventilator associated pneumonia in a tertiary care hospital in India: Incidence, etiology, risk factors, role of multidrug resistant pathogens. Int J Med Public Health 2014;4(1):51–56. DOI: 10.4103/2230-8598.127125.
  20. Hanson LC, Weber DJ, Rutala WA. Risk factors for nosocomial pneumonia in the elderly. Am J Med 1992;92(2):161–166. DOI: 10.1016/0002-9343(92)90107-m.
  21. Celis R, Torres A, Gatell JM, Almela M, Rodriguez-Roisin R, Agusti-Vidal A. Nosocomial pneumonia. A multivariate analysis of risk and prognosis. Chest 1988;93(2):318–324. DOI: 10.1378/chest.93.2.318.
  22. Hashemi SH, Hashemi N, Esna-Ashari F, Taher A, Dehghan A. Clinical features and antimicrobial resistance of bacterial agents of ventilator-associated tracheobronchitis in Hamedan, Iran. Oman Med J 2017;32(5):403–408. DOI: 10.5001/omj.2017.76.
  23. Rocha LD, Vilela CA, Cezário RC, Almeida AB, Gontijo Filho P. Ventilator-associated pneumonia in an adult clinical-surgical intensive care unit of a Brazilian university hospital: Incidence, risk factors, etiology, and antibiotic resistance. Braz J Infect Dis 2008;12(1):80–85. DOI: 10.1590/s1413-86702008000100017.
  24. Hejazi ME, Nazemiyeh M, Seifar F, Beheshti F. Polymicrobial ventilator associated pneumonia and antibiotic susceptibility of bacterial isolates in a university hospital, Tabriz, Iran. Afr J Bacteriol Res 2015;7(5):52–55. DOI: 10.5897/JBR2015.
  25. Kapaganty VC, Pilli R. Microbiological profile of ventilator-associated pneumonia in the intensive care unit of a tertiary hospital in Visakhapatnam, India. Indian J Microbiol Res 2018;5(2):252–257. DOI: 10.18231/2394-5478.2018.0053.
  26. Golia S, Sangeetha KT, Vasudha CL. Microbial profile of early and late onset ventilator associated pneumonia in the intensive care unit of a tertiary care hospital in Bangalore, India. J Clin Diagn Res 2013;7(11):2462–2466. DOI: 10.7860/JCDR/2013/6344.3580.
  27. Gastmeier P, Sohr D, Geffers C, Ruden H, Vonberg RP, Welte T. Early- and late-onset pneumonia: Is this still a useful classification? Antimicrob Agents Chemother 2009; 53(7):2714–2718. DOI: 10.1128/AAC.01070-08.
  28. Melsen WG, Rovers MM, Groenwald RHH, Bergmans DCJJ, Camus C, Bauer TT, et al. Attributable mortality of ventilator-associated pneumonia: A meta-analysis of individual patient date from randomised prevention studies. Lancet Infect Dis 2013;13(8):665–671. DOI: 10.1016/S1473-3099(13)70081-1. DOI: 10.1016/S1473-3099(13)70081-1.
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