title: Repeat bronchoalveolar lavage to guide antibiotic duration for ventilator-associated pneumonia.
abstract: BACKGROUND
  Using an arbitrary day cutoff or clinical signs to decide the duration of antibiotic therapy for ventilator-associated pneumonia (VAP) may be suboptimal for some patients. We sought to determine whether antibiotic duration for VAP can be safely abbreviated in trauma patients using repeat bronchoalveolar lavage (BAL).
  
  
  METHODS
  This was an observational case-controlled pilot study. Fifty-two patients were treated for VAP using a repeat BAL clinical pathway. Definitive antibiotic therapy for VAP was discontinued if pathogen growth was <10,000 colony forming units/mL on repeat BAL performed on day 4 of antibiotic therapy (responder), otherwise therapy was continued per managing team. A matched control group of 52 VAP patients treated before (immediately consecutive) the pathway was used for comparison.
  
  
  RESULTS
  Antibiotic duration in pathway patients was shorter than control patients (9.8 days +/- 3.8 days vs. 16.7 days +/- 7.4 days; p < 0.001), including nonfermenting gram-negative bacilli VAP (10.7 days +/- 4.1 days vs. 14.4 days +/- 4.2 days; p < 0.001). There were no differences in pneumonia relapse, mechanical ventilator-free intensive care unit (ICU) days, ICU-free hospital days, or mortality. Of study group isolates, 86 (82.7%) responded on repeat BAL and were treated for 8.8 days +/- 3.3 days. Of these without concomitant infections (n = 65), antibiotic duration was 7.3 days +/- 1.2 days compared with 14.4 days +/- 2.6 days for nonresponding isolates (n = 18) (p < 0.001).
  
  
  CONCLUSIONS
  Repeat BAL decreased the duration of antibiotic therapy for VAP in trauma patients. More adequately powered investigations are needed to appropriately determine the effects of this strategy on patient outcome.
authors.affiliation: Department of Pharmacy Services, The University Hospital, Cincinnati, Ohio, USA. MuelleEW@healthall.com
authors.forename: Eric W
authors.initials: EW
authors.lastname: Mueller
authors.forename: Martin A
authors.initials: MA
authors.lastname: Croce
authors.forename: Bradley A
authors.initials: BA
authors.lastname: Boucher
authors.forename: Scott D
authors.initials: SD
authors.lastname: Hanes
authors.forename: G Christopher
authors.initials: GC
authors.lastname: Wood
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Swanson
authors.forename: Shanna K
authors.initials: SK
authors.lastname: Chennault
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Fabian
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D018893:Bronchoalveolar Lavage / Q000379:methods*; D016022:Case-Control Studies; D004334:Drug Administration Schedule; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy* / Q000382:microbiology
chemical_list: D000900:Anti-Bacterial Agents