- Paper Report
- Open Access
Diagnosis of ventilator associated pneumonia, to invade or not?
- Naresh Ramakrishnan1
© Current Science Ltd 2000
- Published: 30 May 2000
- bronchoalveolar lavage
- protected specimen brush sample
- ventilator-associated pneumonia
Optimal management of patients who are suspected of having VAP is controversial and open to debate. This trial addressed this problem by evaluating both outcomes and antibiotic use in two groups who received antibiotics based on direct examination of organisms recovered either by bronchoscopic means, or by simple endotracheal aspiration.
. Multicentre (31 ICUs), prospective, randomized, unblinded and controlled trial
. Age > 18 years, mechanical ventilation > 48 h
. Involving 413 patients suspected of having VAP
. VAP defined as a persistent and new radiographic infiltrate associated with at least one of the following:
Purulent tracheal secretions
Fever > 38.3oC
. Excluded if commenced on an antibiotic therapy in 3 days prior to enrollment
. The initial use of empiric antibiotics was guided by Gram stain and the American Thoracic Society guidelines on hospital acquired pneumonia. The antibiotics were continued for 14 days (see below)
. Patients were randomized to either clinical management group (specimen collected using a mucus collector without instilling saline) or in the invasive group (samples taken via bronchoscopy with either bronchoalveolar lavage, PSBS, or both).
. Gram stains were positive in 180/209 in the clinical group, as opposed to 87/204 in the invasive strategy group
. If the Gram stain was negative no antibiotics were used. Antibiotics were also modified on the basis of quantitative cultures (PSBS yielding > 103 colony forming units (CFUs)/mL, BAL yielding > 104 CFU/mL) or qualitative cultures (endotracheal samples).
The 14-day mortality was statistically different in the two groups: 16.2% in the invasive group compared to 25.8% in the clinical management group (-9.6 percentage points, 95% CI, -17.4 to -1.8 percentage points, P = 0.022). The mean SOFA (sequential organ failure assessment) scores were significantly lowered at 7 and 14 days but not at 28 days in the invasive group. This group also received significantly fewer antibiotics and had more antibiotic-free days. In addition, infection or colonization by Candida species was more common in the clinical management group (22.6% vs 11.3%, P = 0.0025).
- Fagon J-Y, Chastre J, Wolff M, Geravis C, Parer-Aubas S, Stephan F, Similowski T, Mercat A, Diehl J-L, Sollet J-P, Tenaillon A, Tenaillon A , VAP trial group: Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia, a randomized controlled trial. Ann Intern Med. 2000, 132: 621-630.PubMedView ArticleGoogle Scholar