title: Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial.
abstract: BACKGROUND
  Optimal management of patients who are clinically suspected of having ventilator-associated pneumonia remains open to debate.
  
  
  OBJECTIVE
  To evaluate the effect on clinical outcome and antibiotic use of two strategies to diagnose ventilator-associated pneumonia and select initial treatment for this condition.
  
  
  METHODS
  Multicenter, randomized, uncontrolled trial.
  
  
  METHODS
  31 intensive care units in France.
  
  
  METHODS
  413 patients suspected of having ventilator-associated pneumonia.
  
  
  METHODS
  The invasive management strategy was based on direct examination of bronchoscopic protected specimen brush samples or bronchoalveolar lavage samples and their quantitative cultures. The noninvasive ("clinical") management strategy was based on clinical criteria, isolation of microorganisms by nonquantitative analysis of endotracheal aspirates, and clinical practice guidelines.
  
  
  METHODS
  Death from any cause, quantification of organ failure, and antibiotic use at 14 and 28 days.
  
  
  RESULTS
  Compared with patients who received clinical management, patients who received invasive management had reduced mortality at day 14 (16.2% and 25.8%; difference, -9.6 percentage points [95% CI, -17.4 to -1.8 percentage points]; P = 0.022), decreased mean Sepsis-related Organ Failure Assessment scores at day 3 (6.1+/-4.0 and 7.0+/-4.3; P = 0.033) and day 7 (4.9+/-4.0 and 5.8+/-4.4; P = 0.043), and decreased antibiotic use (mean number of antibiotic-free days, 5.0+/-5.1 and 2.2+/-3.5; P < 0.001). At 28 days, the invasive management group had significantly more antibiotic-free days (11.5+/-9.0 compared with 7.5+/-7.6; P < 0.001), and only multivariate analysis showed a significant difference in mortality (hazard ratio, 1.54 [CI, 1.10 to 2.16]; P = 0.01).
  
  
  CONCLUSIONS
  Compared with a noninvasive management strategy, an invasive management strategy was significantly associated with fewer deaths at 14 days, earlier attenuation of organ dysfunction, and less antibiotic use in patients suspected of having ventilator-associated pneumonia.
authors.affiliation: Hôpital Broussais, Paris, France.
authors.forename: J Y
authors.initials: JY
authors.lastname: Fagon
authors.forename: J
authors.initials: J
authors.lastname: Chastre
authors.forename: M
authors.initials: M
authors.lastname: Wolff
authors.forename: C
authors.initials: C
authors.lastname: Gervais
authors.forename: S
authors.initials: S
authors.lastname: Parer-Aubas
authors.forename: F
authors.initials: F
authors.lastname: Stéphan
authors.forename: T
authors.initials: T
authors.lastname: Similowski
authors.forename: A
authors.initials: A
authors.lastname: Mercat
authors.forename: J L
authors.initials: JL
authors.lastname: Diehl
authors.forename: J P
authors.initials: JP
authors.lastname: Sollet
authors.forename: A
authors.initials: A
authors.lastname: Tenaillon
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D018893:Bronchoalveolar Lavage; D001999:Bronchoscopy; D003428:Cross Infection / Q000175:diagnosis* / Q000188:drug therapy* / Q000209:etiology; D003627:Data Interpretation, Statistical; D006801:Humans; D009026:Mortality; D009102:Multiple Organ Failure / Q000209:etiology; D018410:Pneumonia, Bacterial / Q000175:diagnosis* / Q000188:drug therapy* / Q000209:etiology; D012121:Respiration, Artificial / Q000009:adverse effects*; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents