Factors associated with ventilator-associated pneumonia and outcomes in mechanically ventilated patients with nontraumatic intracerebral hemorrhage: a real-world data analysisABSTRACT
Objective: To investigate the association between ventilator-associated pneumonia and outcomes in mechanically ventilated nontraumatic intracerebral hemorrhage patients.
Methods: Retrospective data analysis from the National Inpatient Sample database, including patients from 2008 to 2022, for adult hospitalized intracerebral hemorrhage patients on mechanical ventilation. Variables included age, sex, race, hospital location, comorbidities, indicators of intracerebral hemorrhage severity, and neurosurgical procedures. The cohort was divided into ventilator-associated pneumonia and non-ventilator-associated pneumonia groups. Propensity-score matching was applied to balance comorbidities and severity between the two groups. Binary logistic regression was used to analyze the predetermined outcomes. P value was set at 0.05.
Results: Of 70,870 mechanically ventilated intracerebral hemorrhage patients, 3,183 (4.5%) developed ventilator-associated pneumonia. Intracerebral hemorrhage patients with ventilator-associated pneumonia were younger (59 [49 - 69] versus 65 [54 - 76]), more frequently male (62.3% versus 54.3%), and more frequently black (27.4% versus 21.2%), p < 0.001 for all. Ventilator-associated pneumonia patients had a higher rate of cerebral edema (50.7% versus 37%), brain compression (32.5% versus 27.3%), obstructive hydrocephalus (36.1% versus 24.7%), and neurosurgical procedures, both external ventricular drain (38.2% versus 20.2%) and hematoma evacuation (13.8% versus 8.6%), p < 0.001 for all. Time from presentation to intubation was longer in ventilator-associated pneumonia (days; 0 [0 - 3] versus 0 [0 - 1], p < 0.001). After 1:1 propensity-score matching, binary logistic regression revealed that ventilator-associated pneumonia remained independently associated with prolonged length of hospital stay (OR = 1.56, 95%CI 1.3 - 1.82; p < 0.01), higher hospitalization cost (OR = 1.47, 95%CI 1.26 - 1.7; p < 0.01) and higher odds of unfavorable discharge disposition (OR = 1.26, 95%CI 1.06 - 1.49; p = 0.01).
Conclusion: Ventilator-associated pneumonia significantly complicates the care of mechanically ventilated intracerebral hemorrhage patients, increasing the healthcare resource utilization, prolonging length of stay, and being associated with worse short-term functional outcomes.
Keywords:
Cerebral hemorrhage; Ischemic stroke; Ventilator-associated pneumonia; Length of stay; Cost of hospitalization
INTRODUCTION
Nontraumatic intracerebral hemorrhage (ICH) represents one of the most devastating forms of stroke, accounting for 10 - 15% of all stroke cases, yet contributing disproportionately to high morbidity and mortality.(1,2) Despite advances in neurocritical care and supportive strategies, outcomes remain poor, with in-hospital mortality rates exceeding 20% and significant long-term disability among survivors.(3,4) A substantial proportion of ICH patients require intensive care unit (ICU) admission and invasive supportive measures, including mechanical ventilation, due to decreased level of consciousness, airway compromise, or associated medical complications.(5,6)
Among critically ill patients with ICH, ventilator-associated pneumonia (VAP) is a relevant complication. Ventilator-associated pneumonia is defined as pneumonia occurring more than 48 hours after endotracheal intubation; it is a well-characterized condition in general critical care, and it is associated with increased risk of systemic complications, prolonged intensive care unit (ICU) stay, and worse discharge outcomes.(7–9) In the broader critical care literature, VAP has been extensively studied, with several preventive strategies and care management implemented to prevent and mitigate its effects.(10) However, in patients with ICH, who often have a significantly depressed level of consciousness, limited spontaneous mobility, and impaired protective airway reflexes, the risk of VAP may be uniquely high, and its implications particularly unfavorable. The interplay between VAP and the pathophysiology of acute brain injury is complex: systemic infections can exacerbate neuroinflammation, disrupt cerebral autoregulation, and trigger secondary injury mechanisms that worsen neurological outcomes.(11,12)
This study aims to investigate the association between VAP and outcomes in mechanically ventilated nontraumatic ICH patients. Primary outcome included in-hospital metrics (length of stay, cost, discharge disposition). Secondary outcome included procedural interventions (gastrostomy and tracheostomy).
METHODS
Study design and data source
We conducted a retrospective cohort study using data from the National Inpatient Sample (NIS) database, covering January 2008 to December 2022. The NIS is the largest publicly available all-payer inpatient database in the United States and includes a 20% stratified sample of all hospital discharges, weighted to estimate national hospitalizations. Adult patients (age ≥ 18) admitted with a diagnosis of nontraumatic ICH (International Classification of Diseases [ICD]-9 codes: 431, 432; ICD-10 codes: I61x, I629) and who underwent mechanical ventilation were identified. Patients were further categorized based on the presence or absence of VAP (ICD-9 code: 99731; ICD-10 code: J95851). Patients with missing outcome data were excluded. This study was performed according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines for observational cohort studies and followed the Good Clinical Practice Guidelines (GCP) and the principles of the Declaration of Helsinki. Institutional Review Board approval and informed consent were not required for this study because the dataset was deidentified.
Data selection
Demographic variables included age, sex, and race. Clinical variables included comorbidities (hypertension, diabetes, chronic kidney disease, obesity, chronic obstructive pulmonary disease [COPD]), anticoagulant use, smoking, and time from presentation to intubation. Markers of ICH severity were coma, cerebral edema, brain compression, and obstructive hydrocephalus. Neurosurgical interventions included external ventricular drain (EVD) or ventriculoperitoneal shunt placement and hematoma evacuation/decompression. Neurological complications included acute ischemic stroke, seizures; medical complications included deep vein thrombosis, pulmonary embolism, acute kidney injury, sepsis, and acute respiratory distress syndrome (ARDS). Outcomes included hospital procedures (gastrostomy, tracheostomy) and in-hospital outcomes (length of stay, hospitalization cost, discharge disposition). Variables were identified by ICD-9 and ICD-10 codes (Table 1S - Supplementary Material).
Definitions
Ventilator-associated pneumonia was defined as pneumonia developing 48 hours or more after endotracheal intubation and mechanical ventilation, where the infection was not present before intubation (ICD-10 code from October 2015 to December 2022) and as pneumonia that arises in a patient receiving mechanical ventilation (ICD-9 code from January 2008 to September 2015). Non-VAP was defined as patients who received mechanical ventilation but did not have ICD-9 or ICD-10 codes for VAP. Prolonged length of stay (PLOS) was defined as length of stay exceeding the 75th percentile of the entire cohort, and within each subgroup analyzed. The threshold for a higher hospitalization cost was set at the 75th percentile of the entire cohort, and within each subgroup, it was analyzed. The cost of hospitalization was adjusted for inflation to 2022 based on publicly available Consumer Price Index (CPI) data. An unfavorable discharge disposition was defined as in-hospital mortality or discharge to a setting other than home or acute inpatient rehabilitation.
Statistical analysis
Continuous variables were presented as medians with interquartile ranges (IQR), and categorical variables as frequencies and percentages. Between-group differences were assessed using Mann-Whitney U tests and Chi-squared tests. Propensity score matching (PSM) was applied to balance baseline demographics (age, sex, race), comorbidities (hypertension, diabetes mellitus, chronic kidney disease, COPD, obesity), use of anticoagulants, tobacco use, hospital location, ICH severity (coma, cerebral edema, brain compression, and obstructive hydrocephalus) and neurosurgical procedures (EVD and hematoma evacuation) between patients with and without VAP. A 1:1 nearest-neighbor greedy matching without replacement was performed, using a caliper of 0.1 standard deviations of the logit of the propensity score to derive matched pairs. Balance was verified by standardized mean differences (< 0.1 threshold), Love plots, and overlap plots. Logistic regression was used to assess the independent association of VAP with each predetermined outcome in the matched cohort. Effect modification by age and sex was assessed by including interaction terms between VAP and the stratifying variable (sex, age ≥ 65, or age ≥ 80) in the logistic regression models. Interaction p-values were derived from the interaction term's coefficient to test for statistically significant heterogeneity of effects across subgroups. To evaluate the robustness of significant associations to potential unmeasured confounding, E-values were calculated for each outcome using the point estimate and the lower bound of the 95% confidence interval. Significance was set at p < 0.05. All statistical analyses were computed using Statistical Package for Social Sciences (SPSS) Version 29.0.2.0 (IBM Corp., Armonk, NY).
RESULTS
Baseline characteristics
The study flowchart is depicted in figure 1. Of 70,870 mechanically ventilated ICH patients identified, 3,183 (4.5%) developed VAP. Ventilator-associated pneumonia patients were younger (59 [49 - 69] versus 65 [54 - 76], p < 0.001), more likely to be male (62.3% versus 54.3%) and black (27.4% versus 21.2%). They were more frequently treated in teaching hospitals (91.7% versus 78.5%). Ventilator-associated pneumonia patients had higher rates of cerebral edema (50.7% versus 37%), brain compression (32.5% versus 27.3%), and obstructive hydrocephalus (36.1% versus 24.7%). Neurosurgical procedures were more common among VAP patients, including EVD placement (38.2% versus 20.2%) and hematoma evacuation (13.8% versus 8.6%), p < 0.001. Time from presentation to intubation was longer in VAP, days (0 [0 - 3] versus 0 [0 - 1], p < 0.001). Ventilator-associated pneumonia patients had significantly higher rates of complications, including acute ischemic stroke (25.5% versus 19%), acute kidney injury (42.1% versus 27.9%), pulmonary embolism (6.4% versus 2.9%), sepsis (38.2% versus 17.5%), and septic shock (16.6% versus 8.1%). They also underwent gastrostomy (50.7% versus 19.6%) and tracheostomy (53.6% versus 13.7%) more frequently (p < 0.01 for both). Median length of stay was longer (26 [17 - 40] versus 8 [2 - 19] days), and hospitalization costs were significantly higher (452,178 [258,318 - 785,440] versus 158,227 [61,006 - 341,490] $) (Table 1).
Adjusted outcomes in the propensity-matched cohort
After applying 1:1 propensity score matching to control for confounding factors (Table 1, Figures 1 - 3 [Supplementary Material]), logistic regression analysis revealed that VAP remained independently associated with a significantly increased likelihood of undergoing gastrostomy (OR 1.32, 95%CI 1.15 - 1.53) and tracheostomy (OR 3.26, 95%CI 2.81 - 3.78). Additionally, VAP was associated with higher odds of prolonged length of stay (odds ratio [OR] 1.56, 95% confidence interval [95%CI] 1.33 - 1.82), higher hospitalization costs (OR 1.47, 95%CI 1.26 - 1.7), and greater odds of an unfavorable discharge disposition (OR 1.26, 95%CI 1.06 - 1.49) (Table 2).
Binary logistic regression analysis of predetermined in-hospital procedures and outcomes in ventilator-associated pneumonia
Stratified analyses by age and sex
Age- and sex-stratified analyses demonstrated heterogeneity in outcomes (Table 3). Among patients ≥ 80, VAP was significantly associated with prolonged LOS (OR: 2.85, 95%CI 1.60 - 5.07; interaction p value: 0.01), but not with unfavorable discharge. Both male and female patients had increased odds of sepsis and tracheostomy, with women showing a stronger association with prolonged LOS (OR 1.87, 95%CI 1.44 - 2.44; interaction p value 0.02) without increased odds of unfavorable outcomes (Table 2S - Supplementary Material).
Binary logistic regression stratified analyses of predetermined in-hospital procedures and outcomes in ventilator-associated pneumonia with relative interaction p value
DISCUSSION
In this nationally representative cohort of mechanically ventilated patients with nontraumatic ICH, VAP emerged as an independent factor associated with worse clinical outcomes, greater procedural intervention, and higher healthcare resource utilization.
These findings reinforce the concept that VAP represents a marker of more complex and prolonged critical illness in patients with ICH.(13,14) While patients who develop VAP may be inherently more critically ill, the persistence of adverse associations after score matching and adjustment suggests a substantial and independent contribution of VAP to the development of morbidity in this patient population.(15)
The first observation pertains to the incidence of VAP in our cohort (4.5%), which is lower than the 10 - 40%.(14,16–18) range reported in the literature. It is important to note that our study is based on real-world data, outside a controlled observational environment. It includes non-teaching hospitals, which introduce variability in mechanical ventilation use among ICH patients. Additionally, the population examined excludes a broader group of traumatic brain injury (traumatic ICH), in which critical care is more complex and systemic complications are more frequent compared to nontraumatic ICH. A selection bias may also have occurred, including patients who were electively intubated for neurosurgical procedures (placement of an EVD), patients who died before developing VAP, or patients managed at centers with strong adherence to ventilator bundles in the United States.(19–21) These factors may have contributed to the lower observed VAP rate in our cohort compared to prior reports.
While the methodology used for case ascertainment is likely highly specific, it may lack sensitivity, potentially underestimating the true incidence of VAP. This limitation is consistent with several validation studies that report low sensitivity but high specificity when using ICD-9 and ICD-10 codes to identify VAP.(22,23) Administrative coding systems often fail to capture all true cases due to documentation and coding inconsistencies.(24) Consequently, while prognostic outcomes linked to VAP may remain valid due to the high specificity of the case definition, the actual burden of disease is likely underestimated.
The relationship between VAP and ischemic stroke may reflect systemic inflammatory processes and cerebral hypoperfusion triggered by sepsis, which can exacerbate ischemic injury in a brain already vulnerable from hemorrhage and elevated intracranial pressure. Similarly, the association with acute kidney injury and pulmonary embolism may reflect the systemic consequences of infection and immobility in these critically ill patients.(25)
Time from presentation to intubation was significantly longer in patients who developed VAP. This finding may reflect several possible pathophysiological and clinical dynamics. Delayed intubation in the context of ICH could result from a more conservative initial management approach or clinical uncertainty about the trajectory of neurological deterioration. In some cases, neurointensivists may attempt to avoid invasive ventilation to better track the patients’ neurological status, particularly in patients with borderline mental status or fluctuating airway protection. However, prolonged periods of reduced consciousness without definitive airway control may increase the risk of aspiration, a well-established precursor to VAP.(7,10) Notably, the time delay from presentation to intubation may also serve as a proxy for the overall efficiency and readiness of critical care delivery, with longer intervals reflecting potential systemic delays or differences in provider thresholds for escalating care. In contrast, earlier intubation may lead to more rapid implementation of ventilator bundles and earlier ICU admission, potentially mitigating infection risk. This observation supports the hypothesis that timing of intubation may not simply be a marker of illness severity, but also an actionable factor influencing VAP risk.
The striking increase in the likelihood of tracheostomy and gastrostomy among patients with VAP underscores the broader implications of nosocomial infections in neurocritical care. Prolonged ventilatory support often requires tracheostomy for airway protection and secretion management in mechanically ventilated ICH patients. At the same time, gastrostomy may be needed for safe and sustained enteral nutrition in patients with impaired consciousness or dysphagia. These procedures carry their own risks and are associated with long-term morbidity, caregiver burden, and increased resource demands.(26)
Our stratified analyses reveal interesting differences both by age and sex. Younger patients exhibited the highest odds of developing pulmonary embolism and sepsis and were also more likely to undergo tracheostomy and experience poor functional outcomes. This suggests that younger patients with ICH who develop VAP may follow a particularly severe clinical trajectory, possibly due to the selection of more aggressive treatment strategies and prolonged attempts at recovery. Conversely, among patients ≥ 80, VAP was significantly associated with medical complications and resource use, though not with discharge outcomes, possibly reflecting decisions to limit aggressive interventions.
Nuanced sex differences also emerged in our analysis. Women with VAP were more likely than men to require prolonged hospitalization and gastrostomy, whereas men exhibited higher odds of tracheostomy. According to prior research, VAP is an independent predictor of mortality in women, particularly when developed within seven days of admission.(27) These differences may reflect sex-related variation in recovery trajectories or provider decision-making. Such disparities warrant further investigation to ensure equitable care delivery across demographic groups.(15)
Our findings contribute to a growing body of literature emphasizing the importance of infection prevention in neurocritical care settings. While protocols to reduce VAP, such as elevation of the head of the bed, oral hygiene, subglottic suctioning, and early mobilization, are standard in many ICUs, their implementation may be inconsistent in the context of acute brain injury.(20,21) Sedation protocols, neuromonitoring, and concerns over elevated intracranial pressure may limit opportunities for early weaning or spontaneous breathing trials, prolonging intubation and predisposing patients to pulmonary infections. These challenges emphasize the need for multidisciplinary approaches that balance neuroprotection with infection control.
Finally, from a systems perspective, the significantly higher costs associated with VAP in ICH patients, nearly threefold in our study, highlight the broader implications for hospital resource planning, bundled payments, and quality benchmarks. Reducing the incidence of VAP may not only improve patient outcomes but also increase hospital efficiency and reduce financial burden.
Future research should aim to validate these findings in prospective cohorts and to examine the impact of targeted preventive interventions for VAP in the mechanically ventilated ICH population. Studies accounting for clinical details such as hematoma volume, imaging findings, and longitudinal follow-up are needed to better characterize the trajectory of recovery and long-term outcomes in ICH patients with VAP.(7,28,29)
Limitations
This study is limited by its retrospective design and reliance on administrative coding, which may introduce misclassification bias. The timing of VAP onset relative to outcomes cannot be established, limiting causal inference. Despite propensity score matching to balance baseline demographics, comorbidities, ICH severity markers, and neurosurgical procedures, residual confounding is likely to persist in this analysis. The NIS lacks several important clinical variables, such as ventilator duration, treatment intensity for intracranial hypertension, neurological examination scores, and imaging findings, that may influence both the risk of VAP and clinical outcomes. Moreover, many of the observed associations are confounded by time-varying factors, as the occurrence of VAP is closely related to the duration of mechanical ventilation and critical care management strategies. As such, the findings of this study should be interpreted as associations rather than causal relationships.
Furthermore, the database lacks data on VAP timing; therefore, it is not possible to distinguish between early and late VAP or to sub-analyze them. The database lacks information on institutional ventilator management practices, such as ventilator bundles, daily sedation interruption, and standardized weaning protocols, which have been shown in clinical trials to influence ventilator duration and VAP rates. Functional outcomes beyond discharge were not available.
CONCLUSION
Ventilator-associated pneumonia significantly complicates the hospital course of patients with mechanically ventilated intracerebral hemorrhage, being associated with a higher rate of procedural interventions, prolonged length of stay, higher costs, and worse short-term functional outcomes. These findings highlight the importance of infection prevention, early detection of ventilator-associated pneumonia, and tailored intensive care unit care management in this high-risk neurocritical care population.
-
Publisher's note
-
ETHICAL GUIDELINES
Ethical approval and informed consent were not required for this study because the dataset was deidentified.
-
FUNDING
This work was supported by the Mid America Regional Coordinating Center (MARCC) of StrokeNet. The authors are solely responsible for the content of this publication, which does not necessarily represent the views of the MARCC.
AVAILABILITY OF DATA AND MATERIALS
The data of this study are available from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). These data were used under license for the current study and are not publicly available. Data are available from HCUP upon completion of the required Data Use Agreement.
REFERENCES
- 1 An SJ, Kim TJ, Yoon BW. Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: an update. J Stroke. 2017;19(1):3-10.
- 2 Cordonnier C, Demchuk A, Ziai W, Anderson CS. Intracerebral haemorrhage: current approaches to acute management. Lancet. 2018;392(10154):1257-68.
- 3 Wolsink A, Cliteur MP, van Asch CJ, Boogaarts HD, Dammers R, Hannink G, et al. Incidence, case fatality, and functional outcome of intracerebral haemorrhage, according to age, sex, and country income level: a systematic review and meta-analysis. Lancet Reg Health Eur. 2024;49:101180
- 4 Loggini A, Saleh Velez FG, Towner JE, Hornik J, Wallery Md SS, Battaglini D, et al. Two decades of trends in nontraumatic intracerebral hemorrhage care: A nationwide analysis. J Clin Neurosci. 2025;137:111300.
- 5 Reyes R, Viswanathan M, Aiyagari V. An update on neurocritical care for intracerebral hemorrhage. Expert Rev Neurother. 2019;19(6):557-78.
- 6 Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, et al.; American Heart Association/American Stroke Association. 2022 Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage: A Guideline from the American Heart Association/American Stroke Association. Stroke. 2022;53(7):e282-361.
- 7 Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med. 2020;46(5):888-906.
- 8 Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med. 2005;33(10):2184-93.
- 9 Howroyd F, Chacko C, MacDuff A, Gautam N, Pouchet B, Tunnicliffe B, et al. Ventilator-associated pneumonia: pathobiological heterogeneity and diagnostic challenges. Nat Commun. 2024;15(1):6447.
- 10 Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022;43(6):687-713.
- 11 Albaiceta GM, Brochard L, Dos Santos CC, Fernández R, Georgopoulos D, Girard T, et al. The central nervous system during lung injury and mechanical ventilation: a narrative review. Br J Anaesth. 2021;127(4):648-59.
- 12 Blanch L, Quintel M. Lung-brain cross talk in the critically ill. Intensive Care Med. 2017;43(4):557-9.
- 13 Xue LY, Gaowa S, Wang W, Zhao F, Zhu HC, Yu XY, et al. Ventilator-associated pneumonia in patients with cerebral hemorrhage: impact on mortality and microbiological characterization. Med Clin (Barc). 2020;154(10):400-5.
- 14 Robba C, Rebora P, Banzato E, Wiegers EJ, Stocchetti N, Menon DK, et al.; Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Participants and Investigators. Incidence, risk factors, and effects on outcome of ventilator-associated pneumonia in patients with traumatic brain injury: analysis of a large, multicenter, prospective, observational longitudinal study. Chest. 2020;158(6):2292-303.
- 15 Battaglini D, Parodi L, Cinotti R, Asehnoune K, Taccone FS, Orengo G, et al. Ventilator-associated pneumonia in neurocritically ill patients: insights from the ENIO international prospective observational study. Respir Res. 2023;24(1):146.
- 16 Kalanuria AA, Fellerman D, Nyquist P, Geocadin R, Kowalski RG, Nussenblatt V, et al. Variability in diagnosis and treatment of ventilator-associated pneumonia in neurocritical care patients. Neurocrit Care. 2015;23(1):44-53.
- 17 Abulhasan YB, Rachel SP, Châtillon-Angle MO, Alabdulraheem N, Schiller I, Dendukuri N, et al. Healthcare-associated infections in the neurological intensive care unit: results of a 6-year surveillance study at a major tertiary care center. Am J Infect Control. 2018;46(6):656-62.
- 18 van der Kooi TI, Boshuizen H, Wille JC, de Greeff SC, van Dissel JT, Schoffelen AF, et al. Using flexible methods to determine risk factors for ventilator-associated pneumonia in the Netherlands. PLoS One. 2019;14(6):e0218372.
- 19 Josephson SA, Moheet AM, Gropper MA, Nichols AD, Smith WS. Ventilator-associated pneumonia in a neurologic intensive care unit does not lead to increased mortality. Neurocrit Care. 2010;12(2):155-8.
- 20 Lord AS, Nicholson J, Lewis A. Infection prevention in the neurointensive care unit: a systematic review. Neurocrit Care. 2019;31(1):196-210.
- 21 Torres A, Niederman MS, Chastre J, Ewig S, Fernandez-Vandellos P, Hanberger H, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J. 2017;50(3):1700582.
- 22 Smithee RB, Markus TM, Soda E, Grijalva CG, Xing W, Shang N, et al. Pneumonia Hospitalization Coding Changes Associated with Transition From the 9th to 10th Revision of International Classification of Diseases. Health Serv Res Manag Epidemiol. 2020;7:2333392820939801.
- 23 Hanquet G, Theilacker C, Vietri J, Sepúlveda-Pachón I, Menon S, Gessner B, et al. Best practices for identifying hospitalized lower respiratory tract infections using administrative data: a systematic literature review of validation studies. Infect Dis Ther. 2024;13(4):921-40.
- 24 Corrales-Medina VF, van Walraven C. Accuracy of administrative database algorithms for hospitalized pneumonia in adults: a systematic review. J Gen Intern Med. 2021;36(3):683-90.
- 25 Loggini A, Del Brutto VJ, Qureshi AI, Hornik J, Wallery SS, Schwertman A, et al. Medical complications associated with prolonged length of stay in patients with nontraumatic intracerebral hemorrhage: a nationwide cohort study. Clin Neurol Neurosurg. 2025;254:108934.
- 26 Pelosi P, Ferguson ND, Frutos-Vivar F, Anzueto A, Putensen C, Raymondos K, et al.; Ventila Study Group. Management and outcome of mechanically ventilated neurologic patients. Crit Care Med. 2011;39(6):1482-92.
- 27 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):161-5.
- 28 Halperin JJ, Moran S, Prasek D, Richards A, Ruggiero C, Maund C. Reducing hospital-acquired infections among the neurologically critically ill. Neurocrit Care. 2016;25(2):170-7.
- 29 Crespo-Rivas JC, Guisado-Gil AB, Peñalva G, Rodríguez-Villodres Á, Martín-Gandul C, Pachón-Ibáñez ME, et al. Are antimicrobial stewardship interventions effective and safe in long-term care facilities? A systematic review and meta-analysis. Clin Microbiol Infect. 2021;27(10):1431-8.
Edited by
-
Responsible editor:
Antonio Paulo Nassar Junior
