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Clinical Investigations in Critical Care |

Antibiotic Utilization and Outcomes for Patients With Clinically Suspected Ventilator-Associated Pneumonia and Negative Quantitative BAL Culture Results*

Marin H. Kollef, MD, FCCP; Katherine E. Kollef
Author and Funding Information

*From the Pulmonary and Critical Care Medicine Division, Washington University School of Medicine, St. Louis, MO.

Correspondence to: Marin H. Kollef, MD, FCCP, Pulmonary and Critical Care Medicine, Washington University School of Medicine, Campus Box 8052, 660 South Euclid, St. Louis, MO 63110; e-mail: mkollef@im.wustl.edu



Chest. 2005;128(4):2706-2713. doi:10.1378/chest.128.4.2706
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Objective: To evaluate antibiotic utilization and clinical outcomes among patients with clinically suspected ventilator-associated pneumonia (VAP) and culture-negative BAL (CNBAL).

Design: Prospective observational cohort study.

Setting: A medical ICU from a university-affiliated urban teaching hospital employing a previously described antibiotic discontinuation guideline for the management of VAP.

Patients: One hundred one patients with a clinical suspicion of VAP and CNBAL were evaluated between July 2002 and December 2004.

Interventions: Prospective patient follow-up and data collection. Antibiotic discontinuation was determined by the clinical guideline and not the results of BAL cultures.

Results: The average age of the patients was 60.4 ± 17.9 years and the mean APACHE II score was 23.2 ± 8.7 (± SD). The mean duration of mechanical ventilation prior to clinically suspected VAP was 2.9 ± 1.9 days. Nineteen patients (18.8%) received antibiotics for other indications prior to BAL. Empiric antibiotic therapy for VAP was begun in 65 patients (64.4%) following BAL. The duration of empiric antibiotic treatment following BAL was 2.1 ± 0.8 days. None of these patients received antibiotics for > 3 days (median, 2 days; range, 1 to 3 days). Six patients (5.9%) were treated with antibiotics for a secondary episode of VAP or hospital-acquired pneumonia developing at least 72 h after the CNBAL was performed and discontinuation of the empiric antibiotic therapy prescribed for the initially suspected episode of VAP. Overall, 35 patients (34.7%) died during hospitalization. Two deaths occurred in patients with a secondary episode of VAP following CNBAL and discontinuation of empiric antimicrobial therapy. Neither of these two deaths was attributed to VAP.

Conclusions: Although the decision to discontinue antibiotic treatment was based on clinical criteria and not BAL culture results, this study suggests that patients with a clinical suspicion of VAP and CNBAL can have empiric antimicrobial therapy safely discontinued within 72 h or in some cases withheld altogether. Prospective studies are needed to determine the safety of employing CNBAL as the primary criterion for the discontinuation of empirically begun antibiotic treatment for VAP.

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