Ventilator-Associated Pneumonia in Traumatic Brain Injury: Incidence, Risk Factors, and Outcomes

Introduction: Ventilator-associated pneumonia (VAP) occurs in an estimated 40–60% of patients with traumatic brain injury (TBI). Risk factors include male sex, TBI severity, thoracic trauma, elevated head-acute injury scores, and blood transfusion. However, diagnostic criteria are inconsistent, with many studies requiring microbiologic confirmation despite guidelines favoring a clinical diagnosis. We aimed to evaluate the incidence, risk factors, and outcomes of VAP in mechanically ventilated TBI patients.


Methods: This multicenter, retrospective review included adult TBI patients mechanically ventilated in surgical ICUs across 3 NYU academic medical centers over a 3-year period. Patients chronically intubated or who died within 48 hours were excluded. VAP was defined as a new pulmonary infiltrate on imaging plus at least 2 of the following: fever of 38°C or higher, purulent sputum, leukocytosis, or hypoxia. Demographics, comorbidities, injury severity, and outcomes were extracted from the electronic medical record. Multivariate analysis was used to identify independent risk factors for VAP or mortality.


Results: Among 100 patients included, VAP incidence was 64.0%. VAP patients had longer duration of mechanical ventilation (median 35.2 vs 6.6 days; p< 0.001), hospital stay (39.0 vs 17.1 days; p< 0.001), and higher rates of tracheostomy (82.8% vs 22.2%; p< 0.001) and percutaneous endoscopic gastrostomy (PEG) placement (76.6% vs 33.3%; p< 0.001). More VAP patients were discharged to long-term care (46.9% vs 11.1%; p< 0.001). Independent risk factors for VAP or death included age (OR 1.1; p=0.039), multiple intracranial injuries (OR 10.3; p=0.002), presence of midline shift (OR 6.4; p=0.019), PF ratio below 200 (OR 21.4; p=0.027), and injury mechanism other than fall (OR 5.8; p=0.047).


Conclusions: VAP occurred in nearly 2/3 of ventilated TBI patients and was associated with longer hospitalization and increased procedures. Although crude mortality was lower in VAP patients, this likely reflects survivorship bias, as early deaths precluded VAP development. Risk factors for VAP or mortality included older age, multiple intracranial injuries, presence of midline shift, PF ratio, and injury mechanism other than fall. Future direction for the project includes a VAP prophylaxis protocol in high risk TBI patients.