Am. J. Respir. Crit. Care Med., Volume 162, Number 1, July 2000, 119-125

Noninvasive Versus Invasive Microbial Investigation in Ventilator-associated Pneumonia
Evaluation of Outcome

MAURICIO RUIZ, ANTONI TORRES, SANTIAGO EWIG, MARIA ANGELES MARCOS, AMALIA ALCÓN, RAFAEL LLEDÓ, MIGUEL ANGEL ASENJO, and ABEL MALDONALDO

Hospital Clinic i Provincial, Servei de Pneumologia i Al.lergia Respiratoria, Servei de Microbiologia, Servei de Anesthesiologia, Direcció Tècmica, Barcelona, Spain

Noninvasive and invasive diagnostic techniques have been shown to achieve comparable performances in the evaluation of suspected ventilator-associated pneumonia (VAP). We studied the impact of both approaches on outcome in a prospective, open, and randomized study in three intensive care units (ICUs) of a 1,000-bed tertiary care university hospital. Patients with suspected VAP were randomly assigned to noninvasive (Group 1) versus invasive (Group 2) investigation (tracheobronchial aspirates [TBAS] versus bronchoscopically retrieved protected specimen brush [PSB] and bronchoalveolar lavage [BAL]. Samples were cultured quantitatively, and BAL fluid (BALF) was examined for intracellular organisms (ICO) additionally. Initial empiric antimicrobial treatment was administered following the guidelines of the American Thoracic Society (ATS) and adjusted according to culture results (and ICO counts in Group 2). Outcome variables included length of ICU stay and mechanical ventilation as well as mortality. Overall, 76 patients (39 noninvasive, 37 invasive) were investigated. VAP was microbiologically confirmed in 23 of 39 (59%) and 23 of 37 (62%) (p = 0.78). There were no differences with regard to the frequencies of community-acquired and potentially drug-resistant microorganisms (PDRM). Antimicrobial treatment was changed in seven patients (18%) of Group 1 and 10 patients (27%) of Group 2 because of etiologic findings (including five of 17 with ICO = 2% (p = not significant [NS]). Length of ICU stay and mechanical ventilation were also not significantly different in both groups. Crude 30-d mortality was 31 of 76 (41%), and 18 of 39 (46%) in Group 1 and 14 of 37 (38%) in Group 2 (p = 0.46). Adjusted mortality was 16% versus 11% (p = 0.53), and mortality of microbiologically confirmed pneumonia 10 of 23 (44%) in both groups (p = 1.0). We conclude that the outcome of VAP was not influenced by the techniques used for microbial investigation.

This article has been cited by other articles:

				R. G. Masterton, A. Galloway, G. French, M. Street, J. Armstrong, E. Brown, J. Cleverley, P. Dilworth, C. Fry, A. D. Gascoigne, et al. Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy J. Antimicrob. Chemother., July 1, 2008; 62(1): 5 - 34. [Abstract] [Full Text] [PDF]

				M. Moss Clinical Year in Review II: Interstitial Lung Disease, Sepsis, Pulmonary Infections, and Sleep Medicine Proceedings of the ATS, September 15, 2007; 4(6): 482 - 488. [Full Text] [PDF]

				J. Brozek, E. McDonald, F. Clarke, C. Gosse, R. Jaeschke, and D. Cook Pneumonia Observational Incidence and Treatment: A Multidisciplinary Process Improvement Study Am. J. Crit. Care., May 1, 2007; 16(3): 214 - 219. [Abstract] [Full Text] [PDF]

				The Canadian Critical Care Trials Group A Randomized Trial of Diagnostic Techniques for Ventilator-Associated Pneumonia N. Engl. J. Med., December 21, 2006; 355(25): 2619 - 2630. [Abstract] [Full Text] [PDF]

				S. M. Koenig and J. D. Truwit Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention Clin. Microbiol. Rev., October 1, 2006; 19(4): 637 - 657. [Abstract] [Full Text] [PDF]

				C. Clec'h, F. Jaureguy, L. Hamza, P. Karoubi, J.-P. Fosse, A. Hamdi, F. Vincent, F. Gonzalez, and Y. Cohen Agreement Between Quantitative Cultures of Postintubation Tracheal Aspiration and Plugged Telescoping Catheter, Protected Specimen Brush, or BAL for the Diagnosis of Nosocomial Pneumonia. Chest, October 1, 2006; 130(4): 956 - 961. [Abstract] [Full Text] [PDF]

				I. Porzecanski and D. L. Bowton Diagnosis and treatment of ventilator-associated pneumonia. Chest, August 1, 2006; 130(2): 597 - 604. [Abstract] [Full Text] [PDF]

				J D Hunter Ventilator associated pneumonia. Postgrad. Med. J., March 1, 2006; 82(965): 172 - 178. [Abstract] [Full Text] [PDF]

				D. S. Burgess and C. R. Frei Comparison of {beta}-lactam regimens for the treatment of Gram-negative pulmonary infections in the intensive care unit based on pharmacokinetics/pharmacodynamics J. Antimicrob. Chemother., November 1, 2005; 56(5): 893 - 898. [Abstract] [Full Text] [PDF]

				A. Wattanathum, S. Manocha, H. Groshaus, J. A. Russell, and K. R. Walley Interleukin-10 Haplotype Associated With Increased Mortality in Critically Ill Patients With Sepsis From Pneumonia But Not in Patients With Extrapulmonary Sepsis Chest, September 1, 2005; 128(3): 1690 - 1698. [Abstract] [Full Text] [PDF]

				Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia Am. J. Respir. Crit. Care Med., February 15, 2005; 171(4): 388 - 416. [Full Text] [PDF]

				F. Michel, B. Franceschini, P. Berger, J.-M. Arnal, M. Gainnier, J.-M. Sainty, and L. Papazian Early Antibiotic Treatment for BAL-Confirmed Ventilator-Associated Pneumonia: A Role for Routine Endotracheal Aspirate Cultures Chest, February 1, 2005; 127(2): 589 - 597. [Abstract] [Full Text] [PDF]

				M. Ioanas, M. Cavalcanti, M. Ferrer, M. Valencia, C. Agusti, J. Puig de la Bellacasa, and A. Torres Hospital-acquired pneumonia: coverage and treatment adequacy of current guidelines Eur. Respir. J., December 1, 2003; 22(6): 876 - 882. [Abstract] [Full Text] [PDF]

				D. E. Ost, C. S. Hall, G. Joseph, C. Ginocchio, S. Condon, E. Kao, M. LaRusso, R. Itzla, and A. M. Fein Decision Analysis of Antibiotic and Diagnostic Strategies in Ventilator-associated Pneumonia Am. J. Respir. Crit. Care Med., November 1, 2003; 168(9): 1060 - 1067. [Abstract] [Full Text] [PDF]

				J-Y. Fagon and J. Chastre Diagnosis and treatment of nosocomial pneumonia in ALI/ARDS patients Eur. Respir. J., August 1, 2003; 22(42_suppl): 77s - 83s. [Abstract] [Full Text] [PDF]

				C. Brun-Buisson Antibiotic Therapy of Ventilator-Associated Pneumonia: In Search of the Magic Bullet Chest, March 1, 2003; 123(3): 670 - 673. [Full Text] [PDF]

				G. W. Waterer The Diagnostic Dilemma in Suspected Ventilator-Associated Pneumonia: One Size Will Never Fit All Chest, February 1, 2003; 123(2): 335 - 337. [Full Text] [PDF]

				G. Hoffken and M. S. Niederman Nosocomial Pneumonia: The Importance of a De-escalating Strategy for Antibiotic Treatment of Pneumonia in the ICU Chest, December 1, 2002; 122(6): 2183 - 2196. [Abstract] [Full Text] [PDF]

				S. Michaud, S. Suzuki, and S. Harbarth Effect of Design-related Bias in Studies of Diagnostic Tests for Ventilator-associated Pneumonia Am. J. Respir. Crit. Care Med., November 15, 2002; 166(10): 1320 - 1325. [Full Text] [PDF]

				D. L. Bowton Cultures and Ventilator-Associated Pneumonia : Not How, But How Many Chest, August 1, 2002; 122(2): 401 - 402. [Full Text] [PDF]

				C. L. Wu, D. I. Yang, N. Y. Wang, H. T. Kuo, and P. Z. Chen Quantitative Culture of Endotracheal Aspirates in the Diagnosis of Ventilator-Associated Pneumonia in Patients With Treatment Failure* Chest, August 1, 2002; 122(2): 662 - 668. [Abstract] [Full Text] [PDF]

				J. Chastre and J.-Y. Fagon Ventilator-associated Pneumonia Am. J. Respir. Crit. Care Med., April 1, 2002; 165(7): 867 - 903. [Abstract] [Full Text] [PDF]

				S Ewig, T Bauer, and A Torres The pulmonary physician in critical care * 4: Nosocomial pneumonia Thorax, April 1, 2002; 57(4): 366 - 371. [Abstract] [Full Text] [PDF]

				R. A. Balk Is a Silver Coating a Silver Lining? Chest, March 1, 2002; 121(3): 682 - 683. [Full Text] [PDF]

				J Dakin and M Griffiths The pulmonary physician in critical care 1: Pulmonary investigations for acute respiratory failure Thorax, January 1, 2002; 57(1): 79 - 85. [Abstract] [Full Text] [PDF]

				M. J. TOBIN Critical Care Medicine in AJRCCM 2000 Am. J. Respir. Crit. Care Med., October 15, 2001; 164(8): 1347 - 1361. [Full Text] [PDF]

				J. Rello, J. A. Paiva, J. Baraibar, F. Barcenilla, M. Bodi, D. Castander, H. Correa, E. Diaz, J. Garnacho, M. Llorio, et al. International Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-Associated Pneumonia Chest, September 1, 2001; 120(3): 955 - 970. [Abstract] [Full Text] [PDF]

				E. H. Ibrahim, L. Tracy, C. Hill, V. J. Fraser, and M. H. Kollef The Occurrence of Ventilator-Associated Pneumonia in a Community Hospital : Risk Factors and Clinical Outcomes Chest, August 1, 2001; 120(2): 555 - 561. [Abstract] [Full Text] [PDF]

				Members of the Task Force:, E. Bouza, C. Brun-Buisson, J. Chastre, S. Ewig, J-Y. Fagon, C.H. Marquette, P. Munoz, M.S. Niederman, L. Papazian, et al. Ventilator-associated pneumonia: European Task Force on ventilator-associated pneumonia Chairmen of the Task Force: A. Torres and J. Carlet Eur. Respir. J., May 1, 2001; 17(5): 1034 - 1045. [Full Text] [PDF]

				M. Ioanas, R. Ferrer, J. Angrill, M. Ferrer, and A. Torres Microbial investigation in ventilator-associated pneumonia Eur. Respir. J., April 1, 2001; 17(4): 791 - 801. [Abstract] [Full Text] [PDF]