De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate
To assess outcomes with de-escalation therapy in ventilator-associated pneumonia (VAP).
Prospective observational study.
Multidisciplinary intensive care unit.
Patients and participants
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.
Measurements and 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).
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.
KeywordsDe-escalation therapy Ventilator-associated pneumonia
- 12.American Thoracic Society Documents (2005) Guidelines for the management of adults with hospital–acquired, ventilator-associated and healthcare-associated pneumonia. Am J Respir Crit Care Med 172:388–416Google Scholar
- 13.Trouillet JL, Chastre J, Vuagnat A, Joly-Guillou ML, Combaux D, Dombret D, Dombret MC, Gibert C (1998) Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med 1157:531–539Google Scholar
- 16.Kollef MH, Niedermann MS, Leeper KV (2004) Escalation/de-escalation of initial empiric ventilator-associated pneumonia therapy: interim results from the assessment of local antibiotic resistance measures study. Chest 126:718Google Scholar
- 18.Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the working group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710PubMedGoogle Scholar
- 19.Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C, Tasker R (2006) Year in review in Intensive Care Medicine, 2005. II. Infection and sepsis, ventilator-associated pneumonia, ethics, haematology and haemostasis, ICU organization and scoring, brain injury. Intensive Care Med 32:380–390 DOI 10.1007/s00134-005-0060-y PubMedCrossRefGoogle Scholar
- 22.Denesen PJ, van de Ven AJ, Kessels AG, Ramsay G, Bonten MJ (2001) Resolution of infectious parameters after antimicrobial therapy in patients with ventilator-associated pneumonia. Am J Respir Crit Care Med 163(6):1371–1375Google Scholar
- 24.Niedermann MS (2004) Therapy of ventilator-associated pneumonia: what more can we do to use less antibiotics? Crit Care Med 32:2344–2345Google Scholar
- 25.Giantsou E, Liratzopoulos N, Efraimidou E, Panopoulou M, Alepopoulou E, Kartali-Ktenidou S, Minopoulos G, Zakynthinos S, Manolas KI (2005) Both early-onset and late-onset ventilator-associated pneumonia are mainly caused by potentially multiresistant bacteria. Intensive Care Med 31:1388–1394 DOI 10.1007/s00134-005-2697-y CrossRefGoogle Scholar
- 27.Valles J, Marischal D, Cortes P, Coll P, Villagra A, Diaz E, Artigas A, Rello J (2004) Patterns of colonization by Pseudomonas aeruginosa in intubated patients: a 3-year prospective study of 1,607 isolates using pulsed-field gel electrophoresis with implications for prevention of ventilator-associated pneumonia. Intensive Care Med 30:1768–1775PubMedCrossRefGoogle Scholar