Ventilator-associated Pneumonia in Wounded Military Personnel During Combat Operations

For a long time, ventilator-associated pneumonia (VAP) remains a common hospital-acquired infection, but its diagnosis and treatment require constant updating. The objective: to determine the features of the clinical course, diagnostics and treatment of VAP in wounded military personnel. Materials and methods. 47 wounded persons with VAP who were undergoing inpatient treatment at the National Military Medical Clinical Center “The Main Military Clinical Hospital” from April 2022 to September 2024 were examined. The inclusion criteria for patients in the study were: 1) the presence of an injury; 2) the presence of an X-ray confirmed diagnosis of VAP; 3) being on mechanical ventilation (MV). The exclusion criteria: clinical and X-ray signs that require differential diagnosis with diseases of specific etiology (tuberculosis). Patients were divided into two randomized groups: 1st group – 22 servicemen with “early” VAP, and 2nd group – 25 servicemen with “late” VAP. The following indicators were analyzed: type of injury and its severity, time of onset – early or late, duration of the patient’s stay on MV, evaluation of the results of general clinical research methods, bacteriological examination of sputum, data from chest X-rays, results of laboratory and instrumental examination methods, effectiveness of antibiotic therapy. Results. The study of the distribution of patients by the nature of the injurious factor showed that the main type of injury in both groups was mine-explosive trauma – 78.3% (18 people) and 84.0% (21 patients), respectively, and gunshot and shrapnel injuries were observed in a significantly smaller number of patients. In both groups, bilateral lung damage prevailed: 77.3% – in 1st group and 80.0% – in 2nd group. In the case of unilateral localization of VAP, polysegmental infiltration was detected, which was complicated by abscessation in 20.0% of cases, and exudative pleurisy – in 13.7%. The majority of patients in both groups had thoraco-abdominal trauma combined with open craniocerebral trauma and thoraco-skeletal trauma combined with non-penetrating traumatic brain injury. All wounded persons with VAP had a high level of C-reactive protein without significant differences between groups – 96.5 ± 0.5 mg/L – in 1st group and 102.1 ± 0.4 mg/L – in 2nd group, respectively (p > 0.05). Serum concentration of procalcitonin was significantly higher in 2nd group and was 4.07 ± 0.05 ng/mL (p < 0.05), which can be as an additional marker to the CPIS scale in establishing the diagnosis of VAP. Analysis of the factors of VAP development showed a high percentage of detection of a combination of highly pathogenic pathogens with a significant difference between the groups (p < 0.05, χ2 = 11.8): 64.0% – in 2nd group and 27.3% – in 1st group. In 2nd group, a significant percentage of strains of Pseudomonas aeruginosa, Acinetobacter, Proteus mirabilis, Klebsiella pneumoniae were detected. Conclusions. A comprehensive clinical and functional examination of wounded servicemen with VAP showed that the development of hospital infection occurs against the background of massive multiple and combined wounds involving many body systems. The etiological factors of VAP are highly virulent and multidrug-resistant microorganisms – primarily Acinetobacter, Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella pneumoniae and various types of mixed infections. The isolated pathogens are characterized by multidrug resistance to antibacterial drugs, retaining sensitivity only to colistimethate sodium, cefoperazone/sulbactam, and amikacin. Taking into account the severity of the course, late onset, and high virulence of the pathogens, the initial empirical antibiotic therapy included two broad-spectrum drugs that have anti-cyanopneusin activity and affect Gram-negative microorganisms.