Online Letters to the Editor

Review Award) and has received grants from Aspect Medical Systems, Eli Lilly, and honoraria from Hospira and Masimo. Paula L. Watson, MD, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, and Division of Sleep Disorders, Vanderbilt University Medical Center, Nashville, TN; Beth A. Malow, MD, MS, Division of Sleep Disorders, Vanderbilt University Medical Center, Nashville, TN, and Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; E. Wesley Ely, MD, MPH, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, and VA Tennessee Health Care System, Geriatric Research Education and Clinical Center

REFERENCES

1. Bridoux A, Thille AW, Quentin S, et  al: Sleep in ICU: Atypical Sleep or Atypical Electroencephalography. Crit Care Med 2014; 42:e312–e313 2. Watson PL, Pandharipande P, Gehlbach BK, et al: Atypical sleep in ventilated patients: Empirical electroencephalography findings and the path toward revised ICU sleep scoring criteria. Crit Care Med 2013; 41:1958–1967 DOI: 10.1097/CCM.0000000000000207

Something Behind “Age” To the Editor:

I

n a recent issue of Critical Care Medicine, we read with interest the article by Blot et al (1) who investigated the risk factors and mortality for ventilator-associated pneumonia (VAP) among adult and elderly patients. They found that age itself was independently significant with VAP-associated mortality. The author had adjusted several possible risk factors for VAP-associated mortality into logistic regression analysis; however, one other important factor—early appropriate use of antibiotic—was not taken into analysis. In fact, previous study had demonstrated that delayed initiation of appropriate therapy would cause inadequate antibiotic treatment and increase the mortality of patients with VAP (2). However, in the present study, the authors noted that new temperature rise was less common in the elderly patients with VAP. We wonder whether this atypical presentation of VAP among elderly patients would delay the diagnosis and further delay the use of appropriate antibiotics or not. Most important of all, this possible delay may pose negative impact on the mortality of elderly patients with VAP. In summary, it suggests that the impact of delay to initiate appropriate antibiotic treatment among patients with VAP should be taken into the outcome analysis, especially for the elderly patients with less typical features of VAP—new temperature rise. The author has disclosed that she does not have any potential conflicts of interest. Hsin-Lan Lin, RN, Department of Nursing, Chi Mei Medical Center, Liouying, Tainan, Taiwan e314

www.ccmjournal.org

REFERENCES

1. Blot S, Koulenti D, Dimopoulos G, et  al; and the EU-VAP Study Investigators: Prevalence, Risk Factors, and Mortality for ­Ventilator-Associated Pneumonia in Middle-Aged, Old, and Very Old Critically Ill Patients. Crit Care Med 2013 Oct 23. [Epub ahead of print] 2. Luna CM, Aruj P, Niederman MS, et al; Grupo Argentino de Estudio de la Neumonía Asociada al Respirador group: Appropriateness and delay to initiate therapy in ventilator-associated pneumonia. Eur Respir J 2006; 27:158–164 DOI: 10.1097/CCM.0000000000000159

The authors reply:

W

e appreciate the reflections raised by Lin (1) regarding our study on elderly and ventilator-associated pneumonia (VAP) (2). We are well aware of the necessity of early initiated and appropriate empiric antibiotic therapy to improve the likelihood of clinical success (3, 4). The primary objective of this study, however, was to identify the impact of older age on survival within a cohort of patients with VAP. No difference existed in rates of appropriate therapy between the age groups that were compared, nor was it significantly associated with worse outcome in this particular cohort. As such, it was unlikely that inappropriate therapy confounded the results of the regression model. More important, however, is that appropriate empiric antibiotic therapy is closely related with the causative pathogen being multidrug resistant. As such, appropriate therapy is instrumental within the biological pathway leading from exposure (infection) to outcome and is therefore preferably not included in the regression model (5). The observation that elderly less frequently experience fever at onset of infection fits within the concept of the blunted inflammatory response, which is repeatedly documented in older critically ill patients and elderly in general (6, 7). We concur with Lin (1) that a more atypical presentation of infection may result in a tardy diagnosis, delayed processes of care, including initiation of antibiotic therapy, and unfavorable outcomes (8). Yet, and as already mentioned, no difference in rates of appropriate therapy was noted between the age categories. We believe that the difference in new temperature rise associated with VAP—although statistically significant (59% vs 75%; p = 0.035)—did not substantially impact on therapeutic ­decision making. The authors have disclosed that they do not have any potential conflicts of interest. Stijn Blot, PhD, Department of Internal Medicine, Ghent University, Ghent, Belgium; Despoina Koulenti, PhD, The Burns, Trauma, and Critical Care Research Center, The University of Queensland, Brisbane, Australia; Jordi Rello, PhD, Department of Intensive Care, Vall d’ Hebron University Hospital, CIBERES, Universitat Autonoma de Barcelona, Barcelona, Spain

REFERENCES

1. Lin H-L: Something Behind “Age.” Crit Care Med 2014; 42:e314 2. Blot S, Koulenti D, Dimopoulos G, et al; EU-VAP Study Investigators: Prevalence, Risk Factors, and Mortality for Ventilator-Associated April 2014 • Volume 42 • Number 4

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