|
|||||||||
Ventilator-associated PneumoniaDiagnosis
Fagon J, Chastre J, Wolff M, et al. Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. Ann Intern Med 2000;132:621-30. Randomized study found use of BAL or PSB to dictate antibiotic treatment in suspected VAP resulted in lower mortality at 14 days and less antibiotic use compared to standard approach of clinical impression coupled with endotracheal aspirates. Initiation of antibiotic treatment for VAP was withheld until after obtaining specimens and antibiotics were stopped if cultures were negative. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10766680 Chastre J, Fagon J, Bornet-Lesco M, et al. Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 1995; 152:231-240. Study compared immediate post-mortem BAL and PSB to lung biopsy histology and culture and found bronchoscopic specimens had a sensitivity of 82-91% and specificity of 78-89% compared to the gold standard of lung biopsy cultures, provided patients had no recent antibiotic changes prior to death and had not developed pneumonia prior to the terminal phase of their disease. Pertinent in that the above study by Fagon et al is predicated on the belief that BAL and PSB accurately diagnose VAP. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7599829 Kirtland SH, Corley DE, Winterbauer RH, et al. The diagnosis of VAP: a comparison of histologic, microbiologic, and clinical criteria. Chest 1997;112:445-57. Study with a similar design to the Chastre study but without restrictions on use of antibiotics or recent pneumonia. Authors found poor correlation between histologic findings and quantitative cultures from bronch specimens. Tracheal aspirates were 87% sensitive but 31% specific compared to biopsy culture. A sterile BAL had a PPV of 91% for sterile lung parenchyma. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9266883
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia:Official statement of ATS and IDSA 2004. Am J Respir Crit Care Med 2005; 171:388-416. This in-depth evidence-based guideline on the management of nosocomial pneumonia emphasizes early collection of lower respiratory tract samples, early institution of antibiotics, a shorter duration of antibiotics for uncomplicated pneumonia, and use of linezolid, colistin, inhaled antibiotics, and combination therapy. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15699079 Drakulovic MB, Torres A, Bauer TT, et al. Semirecumbancy to prevent VAP.Lancet 1999;354:1851-8. Study found supine position is an independent risk factor for VAP and positioning at 45 reduces the risk, especially if patient receiving tube feeds. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10584721 De Smet AM, Kluytmans JA, Cooper BS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009; 360:20-31. Previous smaller, single-center studies found selective digestive tract decontamination (SDD) improves ICU survival, but concern for antibiotic resistance and the generalizability of previous studies have kept this approach from gaining widespread acceptance. This large (5,939 patients) multicenter Dutch study found SDD and selective oropharyngeal decontamination (SOD) reduced mortality by about 3% after logistic regression. There was no emergence of resistant organisms, but the duration of monitoring was limited to the 6 months of the study. http://www.ncbi.nlm.nih.gov/pubmed/19118302?ordinalpos=26&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
| |||||||||
61 Broadway · New York, NY 10006-2755 · Voice: 212-315-8600 · Fax: 212-315-6498 |
|||||||||