title: De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate.
abstract: OBJECTIVE
  To assess outcomes with de-escalation therapy in ventilator-associated pneumonia (VAP).
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  Multidisciplinary intensive care unit.
  
  
  METHODS
  VAP was diagnosed by positive quantitative cultures of both tracheal aspirate and bronchoalveolar lavage (BAL) and treated appropriately for all significant isolates of tracheal aspirate and BAL in 143 patients who were assigned to de-escalation therapy by BAL or tracheal aspirate.
  
  
  METHODS
  None.
  
  
  RESULTS
  Antibiotic therapy was de-escalated in 58 patients (40.5%), who had decreased mortality at day 15 (5.1% vs. 31.7%) and day 28 (12% vs. 43.5%) and shorter intensive care unit (17.2 +/- 1.2 vs. 22.7 +/- 6.3 days) and hospital (23.7 +/- 2.8 vs. 29.8 +/- 11.1 days) stay (p < 0.05). Of the 81 patients assigned to tracheal aspirate, the 17 (21%) who achieved de-escalation of therapy had reduced 15-day mortality (5.8% vs. 34.3%), reduced 28-day mortality (11.6% vs. 45.3%), and shorter intensive care unit (17.2 +/- 1.6 vs. 22.4 +/- 6.4 days) and hospital (23.1 +/- 4.4 vs. 29.9 +/- 11.1 days) stay (p < 0.05). Of the 62 patients assigned to BAL, the 41 (66.1%) who achieved de-escalation of therapy had decreased 15-day mortality (4.8% vs. 23.8%), decreased 28-day mortality (12.1% vs. 38%), and shorter intensive care unit (17.2 +/- 1.1 vs. 23.2 +/- 6 days) and hospital (23.8 +/- 2.4 vs. 29.8 +/- 11.4 days) stay (p < 0.05).
  
  
  CONCLUSIONS
  For patients with VAP who have had appropriate treatment and shown a favorable clinical response, mortality and duration of stay can be further improved by de-escalation therapy.
authors.affiliation: Demokritus University of Thrace, Intensive Care Unit, Department of Surgery, Medical School, University Campus, 68100 Alexandropolis, Greece. elpisgiantsou@yahoo.com
authors.forename: Elpis
authors.initials: E
authors.lastname: Giantsou
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Liratzopoulos
authors.forename: Eleni
authors.initials: E
authors.lastname: Efraimidou
authors.forename: Maria
authors.initials: M
authors.lastname: Panopoulou
authors.forename: Eleonora
authors.initials: E
authors.lastname: Alepopoulou
authors.forename: Sofia
authors.initials: S
authors.lastname: Kartali-Ktenidou
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Manolas
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology*; D003422:Critical Care / Q000379:methods*; D005260:Female; D006115:Greece / Q000453:epidemiology; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy* / Q000401:mortality; D011446:Prospective Studies; D014132:Trachea / Q000382:microbiology*
chemical_list: D000900:Anti-Bacterial Agents