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VAP Outcome Not Affected by Diagnostic Techniques

Outcomes were comparable whether ventilator-associated pneumonia was diagnosed with nonquantitative endotracheal cultures or with quantitative bronchoalveolar-lavage cultures.

Although ventilator-associated pneumonia (VAP) is one of the most severe nosocomial infections, it is perhaps the most difficult to diagnose accurately. Various invasive techniques have been proposed to improve diagnostic accuracy, but their effects on clinical outcome are unknown. Now, in a prospective, controlled trial conducted at 28 North American intensive care units (ICUs), investigators have compared clinical outcomes with two diagnostic techniques: endotracheal aspiration with nonquantitative culture of the aspirate, and radiographically directed bronchoalveolar lavage with quantitative culture of the bronchiolar-lavage fluid. The study was partially industry-supported.

From May 2000 through February 2005, 740 critically ill adults with suspected VAP were enrolled in the trial. The patients were randomized to undergo one of the diagnostic approaches and to receive empirical therapy with either meropenem plus ciprofloxacin or meropenem alone. The overall 28-day mortality rate was 18.7%. No significant differences were seen between the two diagnostic techniques in 28-day mortality, time to discontinuation of ventilation, time to ICU or hospital discharge, rate of targeted antibiotic therapy, or number of days alive without antibiotic therapy.

Comment: As an editorialist notes, patients were excluded from the trial if they were immunocompromised, had already received one of the study drugs, or were colonized with or had a respiratory tract infection with a pathogen not sensitive to the study drugs. Defining the precise etiology of VAP in such patients is extremely important, and more-invasive diagnostic testing might have proven beneficial for them. Thus, the present findings may not be generalizable to all patients on mechanical ventilation.

— Richard T. Ellison III, MD

Published in Journal Watch Infectious Diseases December 20, 2006

Citation(s):

The Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006 Dec 21; 355:2619-30.

• Original article (Subscription may be required)
• Medline abstract (Free)

Kollef MH. Diagnosis of ventilator-associated pneumonia. N Engl J Med 2006 Dec 21; 355:2691-3.

• Original article (Subscription may be required)
• Medline abstract (Free)