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Editorials |

Is a Silver Coating a Silver Lining?

Robert A. Balk, MD, FCCP
Author and Funding Information

Affiliations: Chicago, IL
 ,  Dr. Balk is Professor of Medicine, Rush Medical College and Director of Pulmonary and Critical Care Medicine, Rush-Presbyterian-St. Luke’s Medical Center, and Cook County Hospital.

Correspondence to: Robert A. Balk, MD, FCCP, Section of Pulmonary and Critical Care Medicine, 1753 West Congress Pkwy, Chicago, IL; e-mail: rbalk@rush.edu



Chest. 2002;121(3):682-683. doi:10.1378/chest.121.3.682
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Infection and its major consequence, sepsis, are ever-increasing problems in the ICU environment. A recent study1 by Angus and coworkers suggest that there are > 750,000 episodes of severe sepsis each year in the United States. Their projections suggest that the incidence will continue to increase at a rate of 1.5%/yr.1 One of the most common ICU infections and the nosocomial infection associated with the highest mortality rate is hospital-acquired pneumonia.26 Ventilator-associated pneumonia (VAP) is the term for hospital-acquired pneumonia that develops in an intubated patient receiving mechanical ventilatory support.35 VAP presents multiple diagnostic and therapeutic challenges for the clinician.35 One of the most controversial areas concerns the benefits of an aggressive diagnostic approach vs empiric treatment for VAP.711 The aggressive diagnostic approach utilizes fiberoptic bronchoscopy along with a protected specimen brush or BAL coupled with quantitative cultures to ensure that sufficient thresholds of microorganisms are present.78 Advocates of this approach point out the poor specificity of the clinical diagnosis of VAP and our need to use antibiotics judiciously in this time of increasing antibiotic resistance.89,1112 However, the supporters of empiric treatment contend that the aggressive invasive approach is more costly, and only defines treatment failure, and emphasize the need for additional randomized, prospective, multicentered controlled clinical trials to determine if either strategy is associated with a survival benefit.7,10 Another controversial area surrounds the determination of the attributable mortality of VAP that typically develops in patients with comorbid conditions that are associated with significant mortality.3,5

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