A consensus of European experts on the definition of ventilator-associated pneumonia recurrences obtained by the Delphi method: the RECUVAP study

Intensive Care Medicine: Published 31 March 2025

Background

There are recognized diagnostic criteria for a first ventilator-associated pneumonia (VAP) episode, but not for recurrences. Many randomized clinical trials (RCTs) have used the recurrence of VAP as a criterion for efficacy evaluation. Still, the different definitions used in RCTs make it difficult to compare studies. We aimed to develop a consensual definition of VAP recurrences and of the various types of VAP recurrences.

Methods

Thirty-six European experts constituting a multidisciplinary group of physicians (critical care, infectious diseases, microbiology) with special interest in the management of VAP were polled using the Delphi methodology.

Results

After the completion of four iterations of the DELPHI method, 94% of experts agreed that the diagnostic criteria for a first VAP episode could also be used for recurrences, except for the radiological criterion, which not all the experts considered to be mandatory. Consensus was also reached regarding the definition of four distinct entities: relapse, persistent VAP, superinfection, and new-pathogen VAP. For relapse and persistent VAP, bacteriological findings were identical for different VAP episodes, whereas they differed for superinfection and new-pathogen VAP. The distinction between relapse and persistent VAP, and between superinfection and new-pathogen VAP depended on the timing of antibiotic treatment (before or after 48–72 h after the end of antibiotic therapy) and the clinical course. Microbiological criteria were proposed to facilitate the diagnosis of persistent VAP.

Conclusion

This consensus by European experts proposes four different VAP recurrence entities which should facilitate the harmonization of recurrence criteria for clinical practice and future studies.

Risk of Recurrence After Surviving Severe Sepsis: A Matched Cohort Study

Risk of Recurrence After Surviving Severe Sepsis: A Matched Cohort Study
Shen H et al
Critical Care Medicine October 2016 - Volume 44 - Issue 10 - p 1833–1841

Objectives: To examine the risk of recurrence in adults who survived first-episode severe sepsis for at least 3 months. 
Design: A matched cohort study. Setting: Inpatient claims data from Taiwan’s National Health Insurance Research Database. Subjects: We analyzed 10,818 adults who survived first-episode severe sepsis without recurrence for at least 3 months in 2000 (SS group; mean age, 62.7 yr; men, 54.7%) and a group of age/sex-matched (1:1) population controls who had no prior history of severe sepsis. All subjects were followed from the study entry to the occurrence of end-point, death, or until December 31, 2008, whichever date came first. Interventions: None. Measurements and Main 
Results: Primary end-point was severe sepsis that occurred after January 1, 2001 (the study entry). Relative risk of the end-point was assessed using competing risk regression model. During the follow-up period, severe sepsis and death occurred in 35.0% and 26.5% of SS group and in 4.3% and 18.6% of controls, respectively, representing a covariate-adjusted sub–hazard ratio of 8.89 (95% CI, 8.04–9.83) for the risk of recurrence. In stratified analysis by patient characteristics, the sub–hazard ratios ranged from 7.74 in rural area residents to 23.17 in young adults. In subgroup analysis by first-episode infection sites in SS group, the sub–hazard ratios ranged from 4.82 in intra-abdominal infection to 9.99 in urinary tract infection. 
Conclusions: Risk of recurrence after surviving severe sepsis is substantial regardless of patient characteristics or infection sites. Further research is necessary to find underlying mechanisms for the high risk of recurrence in these patients.