This retrospective cohort study evaluated differences in all-cause mortality associated with quantitative versus qualitative cultures in critically ill patients with suspected hospital-acquired pneumonia (HAP). Patients were included if lower respiratory tract (LRT) cultures were obtained and were stratified by culture strategy: invasive (bronchial alveolar lavage [BAL] or nonbronchoscopic BAL) or noninvasive (endotracheal tube aspirate or sputum culture). Mortality data and secondary endpoints were compared between groups. A total of 113 patients met inclusion criteria (invasive = 72, noninvasive = 41). No significant difference in all-cause mortality was detected between the groups (37.5% and 31.7%, respectively; P = 0.54). Secondary endpoints were similar; however, patients in the invasive group had greater mean total antibiotic days of therapy compared to the noninvasive group (21.2 ± 13.5 days vs 15.5 ± 8.3 days, P = 0.01). The present study suggests that using invasive methods to obtain LRT cultures in critically ill patients with suspected HAP did not offer a detectable benefit in mortality or clinical outcomes when compared to noninvasive diagnostic methods.
American Thoracic Society, Infectious Diseases Society.Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med.2005; 171(4): 388–416.
2.
RelloJ.Bench-to-bedside review: therapeutic options and issues in the management of ventilator-associated bacterial pneumonia. Crit Care.2005; 9(3): 259–265.
3.
TablanO.C., AndersonL.J., BesserR., BridgesC., HajjehR.; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep.2004; 53(RR-3): 1–36.
4.
RichardsM.J., EdwardsJ.R., CulverD.H., GaynesR.P.Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Crit Care Med.1999; 27(5): 887–892.
5.
ChastreJ., FagonJ.Y.Ventilator-associated pneumonia. Am J Respir Crit Care Med.2002; 165(7): 867–903.
6.
RelloJ., OllendorfD.A., OsterG.; VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest.2002; 122(6): 2115–2121.
7.
VincentJ.L., BihariD.J., SuterP.M.; EPIC International Advisory Committee. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. JAMA.1995; 274(8): 639–644.
8.
Alvarez-LermaF.; ICU-Acquired Pneumonia Study Group. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. Intensive Care Med.1996; 22(5): 387–394.
9.
IreguiM., WardS., ShermanG., FraserV.J., KollefM.H.Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest.2002; 122(1): 262–268.
10.
KollefM.H.Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients. Clin Infect Dis.2000; 31(Suppl 4): S131–S138.
11.
KollefM.H., ShermanG., WardS., FraserV.J.Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest.1999; 115(2): 462–474.
12.
LunaC.M., VujacichP., NiedermanM.S.Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest.1997; 111(3): 676–685.
13.
RelloJ., GallegoM., MariscalD., SonoraR., VallesJ.The value of routine microbial investigation in ventilator-associated pneumonia. Am J Respir Crit Care Med.1997; 156(1): 196–200.
14.
TorresA., EwigS., LodeH., CarletJ; European HAP Working Group. Defining, treating and preventing hospital acquired pneumonia: European perspective. Intensive Care Med.2009; 35(1): 9–29.
15.
FagonJ.Y., ChastreJ., WolffM.Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial. Ann Intern Med.2000; 132(8): 621–630.
16.
PuginJ., AuckenthalerR., MiliN., JanssensJ.P., LewP.D., SuterP.M.Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis.1991; 143(5, pt 1): 1121–1129.
17.
SinghN., RogersP., AtwoodC.W., WagenerM.M., YuV.L.Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med.2000; 162(2, pt 1): 505–511.
18.
CroceM.A., SwansonJ.M., MagnottiL.J.The futility of the clinical pulmonary infection score in trauma patients. J Trauma.2006; 60(3): 523–528.
19.
FartoukhM., MaitreB., HonoreS., CerfC., ZaharJ.R., Brun-BuissonC.Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med.2003; 168(2): 173–179.
20.
LuytC.E., ChastreJ., FagonJ.Y.Value of the clinical pulmonary infection score for the identification and management of ventilator-associated pneumonia. Intensive Care Med.2004; 30(5): 844–852.
21.
ZimmermanJ.E., KramerA.A., McNairD.S., MalilaF.M.Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients. Crit Care Med.2006; 34(5): 1297–1310.
22.
PolkR.E., FoxC., MahoneyA., LetcavageJ., MacDougallC.Measurement of adult antibacterial drug use in 130 US hospitals: comparison of defined daily dose and days of therapy. Clin Infect Dis.2007; 44(5): 664–670.
23.
US Department of Health and Human Services, US Food and Drug Administration, Center for Drug Evaluation and Research. Guidance for industry: nosocomial pneumonia - developing antimicrobial drugs for treatment. US Food and Drug Administration Web site. http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm071170.pdf. Published July 21, 1998. Accessed May 30, 2008.
24.
FagonJ.Y., ChastreJ., RoubyJ.J.Is bronchoalveolar lavage with quantitative cultures a useful tool for diagnosing ventilator-associated pneumonia?Crit Care.2007; 11(2): 123.
25.
GiantsouE., LiratzopoulosN., EfraimidouE.De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate. Intensive Care Med.2007; 33(9): 1533–1540.
26.
RexJ.H., PfallerM.A.Has antifungal susceptibility testing come of age?Clin Infect Dis.2002; 35(8): 982–989.
27.
PetrosA.J., MarshallJ.C., van SaeneH.K.Should morbidity replace mortality as an endpoint for clinical trials in intensive care?Lancet.1995; 345(8946): 369–371.
28.
Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med.2006; 355(25): 2619–2630.
