Early antibiotic treatment for BAL-confirmed ventilator-associated pneumonia: a role for routine endotracheal aspirate cultures.
OBJECTIVE
To test whether routine quantitative cultures of endotracheal aspirates obtained before the onset of ventilator-associated pneumonia (VAP) could help to predict the causative microorganisms and to select early appropriate antimicrobial therapy before obtaining BAL culture results.


METHODS
Prospective observational study.


METHODS
French medical ICU.


METHODS
A total of 299 patients received mechanical ventilation for at least 48 h.


METHODS
Endotracheal aspiration (EA) was performed twice weekly in all mechanically ventilated patients. A diagnosis of VAP was made by BAL culture. Only the EA performed just before the suspicion of VAP (EA-pre) were evaluated. This strategy (ie, the EA-pre-based strategy) was compared with an antibiotic therapy that would have been prescribed if the recommendations of both the American Thoracic Society (ATS) and Trouillet et al (Am J Respir Crit Care Med 1998; 157:531-539) had been applied.


RESULTS
VAP was diagnosed (by BAL culture) in 41 of the 75 patients in whom BAL was performed. Among the 41 BAL specimens that were positive for VAP, EA-pre had identified the same microorganisms (with the same antibiotic resistance patterns) in 34 cases (83%). In one case, EA-pre was not available at the time BAL was performed (a case of early-onset VAP), but the empiric antibiotic therapy was adequate. While EA-pre did not give the same results as the BAL culture, the antibiotic therapy based on the results of the EA-pre was adequate in four other cases. Finally, antibiotic therapy was delayed in only two cases. Antibiotic treatment was therefore adequate in 38 of the 40 assessable cases (95%). If the Trouillet-based strategy had been used, the antibiotic treatment would have been adequate in 34 of the 41 cases (83%; p = 0.15 [vs EA-pre strategy]). Based on the ATS classification, the antibiotic treatment would have been adequately prescribed in only 28 of the 41 cases (68%; p = 0.005 [vs EA-pre strategy]).


CONCLUSIONS
Routine EA performed twice a week makes it possible to prescribe adequate antibiotic therapy (while waiting for BAL culture results) in 95% of the patients in whom a VAP is ultimately diagnosed by BAL culture.
Michel
Fabrice
F
Réanimation Médicale, Hôpital Sainte-Marguerite, 13274 Marseille Cedex 9, France. laurent.papazian@ap-hm.fr
Franceschini
Bruno
B
Berger
Pierre
P
Arnal
Jean-Michel
JM
Gainnier
Marc
M
Sainty
Jean-Marie
JM
Papazian
Laurent
L
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D001431:Bacteriological Techniques; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology*; D002511:Cephalosporins / Q000008:administration & dosage; D003428:Cross Infection / Q000175:diagnosis / Q000188:drug therapy*; D042241:Early Diagnosis; D005260:Female; D005602:France; D006801:Humans; D015378:Imipenem / Q000008:administration & dosage; D007362:Intensive Care Units; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D010406:Penicillins / Q000008:administration & dosage; D018410:Pneumonia, Bacterial / Q000175:diagnosis / Q000188:drug therapy*; D011159:Population Surveillance; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D011552:Pseudomonas Infections / Q000175:diagnosis / Q000188:drug therapy; D016896:Treatment Outcome; D012122:Ventilators, Mechanical / Q000382:microbiology*
D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D010406:Penicillins; D015378:Imipenem