Decision analysis of antibiotic and diagnostic strategies in ventilator-associated pneumonia.
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.
Ost
David E
DE
Center for Pulmonary and Critical Care Medicine, Department of Laboratory Medicine, North Shore University Hospital, Manhasset, NY 11030, USA. dost@nshs.edu
Hall
Charles S
CS
Joseph
Gnanaraj
G
Ginocchio
Christine
C
Condon
Susan
S
Kao
Emily
E
LaRusso
Michele
M
Itzla
Richard
R
Fein
Alan M
AM
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
D000900:Anti-Bacterial Agents