title: Decision analysis of antibiotic and diagnostic strategies in ventilator-associated pneumonia.
abstract: The optimal strategy for ventilator-associated pneumonia remains controversial. To clarify the tradeoffs involved, we performed a decision analysis. Strategies evaluated included antibiotic therapy with and without diagnostic testing. Tests that were explored included endotracheal aspirates, bronchoscopy with protected brush or bronchoalveolar lavage, and nonbronchoscopic mini-bronchoalveolar lavage (mini-BAL). Outcomes included dollar cost, antibiotic use, survival, cost-effectiveness, antibiotic use per survivor, and the outcome perspective of financial cost-antibiotic use per survivor. Initial coverage with three antibiotics was better than expectant management or one or two antibiotic approaches, leading to both improved survival (54% vs. 66%) and decreased cost (US dollars 55447 vs. US dollars 41483 per survivor). Testing with mini-BAL did not improve survival but did decrease costs (US dollars 41483 vs. US dollars 39967) and antibiotic use (63 vs. 39 antibiotic days per survivor). From the perspective of minimizing cost, minimizing antibiotic use, and maximizing survival, the best strategy was three antibiotics with mini-BAL.
authors.affiliation: Center for Pulmonary and Critical Care Medicine, Department of Laboratory Medicine, North Shore University Hospital, Manhasset, NY 11030, USA. dost@nshs.edu
authors.forename: David E
authors.initials: DE
authors.lastname: Ost
authors.forename: Charles S
authors.initials: CS
authors.lastname: Hall
authors.forename: Gnanaraj
authors.initials: G
authors.lastname: Joseph
authors.forename: Christine
authors.initials: C
authors.lastname: Ginocchio
authors.forename: Susan
authors.initials: S
authors.lastname: Condon
authors.forename: Emily
authors.initials: E
authors.lastname: Kao
authors.forename: Michele
authors.initials: M
authors.lastname: LaRusso
authors.forename: Richard
authors.initials: R
authors.lastname: Itzla
authors.forename: Alan M
authors.initials: AM
authors.lastname: Fein
mesh_terms: D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use*; D018893:Bronchoalveolar Lavage / Q000191:economics / Q000379:methods; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology; D001999:Bronchoscopy / Q000191:economics; D003365:Costs and Cost Analysis; D003661:Decision Support Techniques; D004359:Drug Therapy, Combination; D006801:Humans; D007442:Intubation, Intratracheal / Q000191:economics; D018410:Pneumonia, Bacterial / Q000175:diagnosis* / Q000191:economics / Q000209:etiology / Q000628:therapy*; D012121:Respiration, Artificial / Q000009:adverse effects*; D012984:Software; D016019:Survival Analysis
chemical_list: D000900:Anti-Bacterial Agents