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Perspectives on Critical Care Infectious Diseases: Ventilator-Associated Pneumonia FREE TO VIEW

Lee K. Brown
Chest. 2003;124(6):2410. doi:10.1378/chest.124.6.2410
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By Richard G. Wunderink, MD, and Jordi Rello, MD, eds. Boston, MA: Kluwer Academic Publishers, 2001; 200 pp; $170.00

Most of the edited, multiauthor texts available in the medical marketplace avoid repetitive coverage of specific topics by design, if not always in practice. For instance, a typical book on ventilator-associated pneumonia (VAP) would include one chapter on epidemiology, one on diagnosis, one on treatment, and so on. The series Perspectives on Critical Care Infectious Diseases, of which the present volume represents the fourth contribution, is quite different in that any given subject is discussed by more than one author or group of authors. As stated in the preface by the series editor, Jordi Rello, MD, this was a calculated plan meant to present “… the different management perspectives for these controversial and evolving topics.” Dr. Rello goes on to specify that two guest editors are chosen for each volume, one from Europe and one from North America, thus further guaranteeing a more international perspective. After reading Ventilator-Associated Pneumonia, it is clear that such an approach has many advantages for the sophisticated reader but presents a significant challenge to the novice.

The book begins with two discussions of diagnostic strategies for VAP, as presented by Jean-Yves Fagon and Jean Chastre (presumably, the European experience) and Michael S. Niederman (presumably, the North American counterpart). The editors clearly chose their authors wisely, since one could hardly imagine two more opposite viewpoints. The first advocates invasive, quantitative culture techniques, while the latter maintains that a “clinical and empiric approach” makes better sense. Both chapters marshal considerable supporting evidence from the literature, but neither can cite definitive randomized controlled trials providing unequivocal evidence of the superiority of either approach. The reader is still left with the essential controversy unresolved. While the empiric view may be easier and more convenient, a diagnosis that relies on “a new or progressive infiltrate with at least 2 of the following 3 criteria: fever, purulent sputum, or leukocytosis” can hardly be specific when other common intensive care syndromes can, and often do, duplicate these findings. On the other hand, quantitative culture techniques may lack sensitivity, particularly in the case of early infection, and may be prone to false-negative results, especially when performed after antibiotic treatment already has been started.

The remainder of the book seems far less controversial. The prevention of VAP is covered by two different authors, the pathogenesis of VAP (including the putative roles of the oropharynx and digestive tract) is covered in one chapter, and the treatment of VAP in Europe and North America is discussed by representatives from those respective medical communities. The text concludes with two views on the emergence and control of resistant organisms, and with a brief chapter further discussing some of the controversies existing in the VAP literature (as exemplified in the previous chapters). This last chapter provides a degree of summation and resolution for the opposing opinions presented earlier in the book, but it could have been more comprehensive in that regard. Also, this particular chapter contained numerous grammatical and typographic errors that interfered with readability. There is much repetition present throughout the text, mainly among the chapters on treatment and antibiotic resistance, but this is certainly unavoidable given the central premise of a book that seeks to present differing opinions on identical topics.

Ventilator-Associated Pneumonia serves the needs of a more restricted audience compared to other texts. Since it presents varying points of view on many topics, it is not particularly suitable for medical students, residents, or fellows who are new to critical care medicine and who will have difficulty coming away with a unified “game plan” for VAP management. Rather, this book is a useful tool for the experienced critical care, pulmonary, or infectious disease clinician or researcher, who can interpret the material presented in light of his/her own experience and knowledge, and perhaps alter an already mature practice style accordingly.




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