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Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial.

Abstract：

BACKGROUND:Optimal management of patients who are clinically suspected of having ventilator-associated pneumonia remains open to debate. OBJECTIVE:To evaluate the effect on clinical outcome and antibiotic use of two strategies to diagnose ventilator-associated pneumonia and select initial treatment for this condition. DESIGN:Multicenter, randomized, uncontrolled trial. SETTING:31 intensive care units in France. PATIENTS:413 patients suspected of having ventilator-associated pneumonia. INTERVENTION:The invasive management strategy was based on direct examination of bronchoscopic protected specimen brush samples or bronchoalveolar lavage samples and their quantitative cultures. The noninvasive ("clinical") management strategy was based on clinical criteria, isolation of microorganisms by nonquantitative analysis of endotracheal aspirates, and clinical practice guidelines. MEASUREMENTS:Death from any cause, quantification of organ failure, and antibiotic use at 14 and 28 days. RESULTS:Compared with patients who received clinical management, patients who received invasive management had reduced mortality at day 14 (16.2% and 25.8%; difference, -9.6 percentage points [95% CI, -17.4 to -1.8 percentage points]; P = 0.022), decreased mean Sepsis-related Organ Failure Assessment scores at day 3 (6.1+/-4.0 and 7.0+/-4.3; P = 0.033) and day 7 (4.9+/-4.0 and 5.8+/-4.4; P = 0.043), and decreased antibiotic use (mean number of antibiotic-free days, 5.0+/-5.1 and 2.2+/-3.5; P < 0.001). At 28 days, the invasive management group had significantly more antibiotic-free days (11.5+/-9.0 compared with 7.5+/-7.6; P < 0.001), and only multivariate analysis showed a significant difference in mortality (hazard ratio, 1.54 [CI, 1.10 to 2.16]; P = 0.01). CONCLUSIONS:Compared with a noninvasive management strategy, an invasive management strategy was significantly associated with fewer deaths at 14 days, earlier attenuation of organ dysfunction, and less antibiotic use in patients suspected of having ventilator-associated pneumonia.

journal_name

Ann Intern Med

journal_title

Annals of internal medicine

authors

Fagon JY,Chastre J,Wolff M,Gervais C,Parer-Aubas S,Stéphan F,Similowski T,Mercat A,Diehl JL,Sollet JP,Tenaillon A

doi

10.7326/0003-4819-132-8-200004180-00004

subject

Has Abstract

pub_date

2000-04-18 00:00:00

pages

621-30

issue

eissn

0003-4819

issn

1539-3704

pii

200004180-00004

journal_volume

132

pub_type

临床试验,杂志文章,多中心研究,随机对照试验

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Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial.