Evaluation of the effect of diagnostic methodology on the reported incidence of ventilator-associated pneumonia.
BACKGROUND
The optimal method for diagnosing ventilator-associated pneumonia (VAP) is controversial and its effect on reported incidence uncertain. This study aimed to model the impact of using either endotracheal aspirate or bronchoalveolar lavage on the reported incidence of pneumonia and then to test effects suggested from theoretical modelling in clinical practice.


METHODS
A three-part single-centre study was undertaken. First, diagnostic performance of aspirate and lavage were compared using paired samples from 53 patients with suspected VAP. Secondly, infection surveillance data were used to model the potential effect on pneumonia incidence and antibiotic use of using exclusively aspirate or lavage to investigate suspected pneumonia (643 patients; 110 clinically suspected pneumonia episodes). Thirdly, a practice change initiative was undertaken to increase lavage use; pneumonia incidence and antibiotic use were compared for the 12 months before and after the change.


RESULTS
Aspirate overdiagnosed VAP compared with lavage (89% vs 21% of clinically suspected cases, p<0.0001). Modelling suggested that changing from exclusive aspirate to lavage diagnosis would decrease reported pneumonia incidence by 76% (95% CI 67% to 87%) and antibiotic use by 30% (95% CI 20% to 42%). After the practice change initiative, lavage use increased from 37% to 58%. Although clinically suspected pneumonia incidence was unchanged, microbiologically confirmed VAP decreased from 18 to 9 cases per 1000 ventilator days (p = 0.001; relative risk reduction 0.61 (95% CI 0.46 to 0.82)), and mean antibiotic use fell from 9.1 to 7.2 antibiotic days (21% decrease, p = 0.08).


CONCLUSIONS
Diagnostic technique impacts significantly on reported VAP incidence and potentially on antibiotic use.
Morris
A Conway
AC
MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Little France Crescent, Edinburgh, UK.
Kefala
K
K
Simpson
A J
AJ
Wilkinson
T S
TS
Everingham
K
K
Kerslake
D
D
Raby
S
S
Laurenson
I F
IF
Swann
D G
DG
Walsh
T S
TS
D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology; D003422:Critical Care / Q000379:methods; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008828:Microbiological Techniques / Q000379:methods; D008875:Middle Aged; D008954:Models, Biological; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology; D011446:Prospective Studies; D012606:Scotland / Q000453:epidemiology; D014132:Trachea / Q000382:microbiology
D000900:Anti-Bacterial Agents