Early nonbronchoscopic bronchoalveolar lavage: predictor of ventilator-associated pneumonia?
BACKGROUND
Ventilator-associated pneumonia is a problem in trauma and emergency general surgery patients. Our hospital-acquired infection prevention committee approved the use of early nonbronchoscopic bronchoalveolar lavage (screening-BAL) in the surgical intensive care unit (SICU) to identify ventilated patients with bronchiolar bacteria before 48 hours. We reviewed the results of this quality improvement initiative.


METHODS
All ventilated patients in the SICU (March 2011 to June 2012) underwent a screening-BAL 36 hours to 48 hours after intubation; quantitative culture results (>5 × 10(4) colony-forming unit per milliliter) were used to identify positive specimens. Clinical pneumonia was defined as clinical pulmonary infection score greater than 6 with a subsequent positive diagnostic-BAL result. Sequential organ failure assessment scores were averaged for the first 48 hours in the SICU. Continuous and dichotomous data were compared, and a multivariate regression analysis was performed on the screening-BAL and pneumonia results.


RESULTS
Screening-BALs were performed in 150 patients (99 trauma and 51 emergency general surgery patients), 72 of these specimens had positive findings. Fifty-three clinical pneumonias were diagnosed, and 45 (positive predictive value, 0.85) identified the same organism as the screening-BAL. Clinical pneumonia developed in eight patients with a negative screening-BAL (negative predictive value, 0.85). Antibiotic therapy at the time of the screening-BAL was associated with a negative screen (odds ratio, 0.44; p = 0.026). Pneumonia developed on median postintubation Day 4 (2-15 days) in patients with a positive screening-BAL results as compared with day 7.5 in the patients with a negative screening-BAL results (3.5-15 days; p = 0.007). Field intubation is an independent risk factor (odds ratio, 3.5; p = 0.004).


CONCLUSIONS
Positive screening-BAL results in trauma and emergency general surgery patients are associated with the development of ventilator-associated pneumonia by the same organism and may play a role in identifying patients at risk for pneumonia. Further studies must be conducted to evaluate the role of screening-BAL in this patient population.


METHODS
Diagnostic/prognostic study, level III.
Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas Southwestern, Dallas, Texas 75390, USA. Christian.minshall@utsouthwestern.edu
Christian Todd
CT
Minshall
Evert A
EA
Eriksson
Kenneth S
KS
Hawkins
Steven
S
Wolf
Joseph P
JP
Minei
D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D018893:Bronchoalveolar Lavage / Q000379:methods*; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis* / Q000188:drug therapy; D012189:Retrospective Studies; D012307:Risk Factors
D000900:Anti-Bacterial Agents