Ventilator-associated pneumonia in adult ICU patients with epidermal necrolysis: A retrospective cohort study from the French National Reference Centre.

BACKGROUND: Epidermal necrolysis (EN) is a rare yet severe drug-induced disease that results in the detachment of the epidermis leading to infection and acute respiratory failure requiring mechanical ventilation. This study aims to describe the prevalence of ventilator-associated pneumonia (VAP) and its microbiological characteristics in patients with EN, as well as identifying the associated risk factors and outcomes.

METHODS: This is an observational, retrospective, single-centre cohort study of adult patients with EN who were admitted to the intensive care unit (ICU) and required mechanical ventilation between 2000 and 2022. A Cox proportional hazards model was used to identify risk factors associated with the first episode of VAP. EN patients were matched with non-EN patients according to age, sex, SAPS II score, acute respiratory distress syndrome status, period of admission, and duration of mechanical ventilation.

RESULTS: A total of 77 patients were included in the study. Of these, 40 (51%) experienced at least one VAP episode. Patients who developed VAP exhibited more frequent bronchial lesions (n = 26/40 [65%] vs n = 15/37 [41%]; p = 0.046), larger detached-detachable body surface area (BSA) involvement (40% [25-60] vs 25% [10-41]; p = 0.011), and had been treated more frequently with cyclosporine (n = 19/40 [48%] vs n = 9/37 [24%]; p = 0.041), as compared to those who did not develop VAP. In-hospital and ICU mortality was 36% (n = 28/77), with no significant difference between groups. By multivariable Cox regression analysis, deep (digestive and/or bronchial) mucosal involvement (adjusted standardized hazard ratio [aSHR] 2.22 IC95% [1.01;4.88]; p = 015), maximal BSA in ICU (aSHR 1.01 IC95 [1.00;1.02] for each percent; p = 0.011), and the use of cyclosporine (aSHR 2.46 [1.22;4.96]; p = 0.012) were identified as risk factors for VAP development. After matching EN and non-EN patients, it was found that EN patients were more likely to experience VAP during their stay in the ICU than non-EN patients (standardized mean difference 0.29).

CONCLUSIONS: One out of two mechanically ventilated patients with EN will develop VAP, especially if they present with deep mucosal involvement, an extensive BSA in ICU, and have previously been treated by cyclosporine.