PURPOSE: Despite recent data suggesting no benefit from an invasive VAP diagnostic strategy, controversy remains regarding its role in patients at high risk for drug-resistant pathogens.
METHODS: We retrospectively evaluated our use of mini-BAL (Kimberly-Cook, Draper, UT) samples obtained in ICU patients with suspected VAP. The charts of these patients were reviewed for quality assurance to determine the clinical impact of this invasive strategy. A positive semi-quantitative culture was defined as > 10
3 CFU, and all management decisions were independently made by the primary ICU team.
RESULTS: Thirty-nine mini-BALs were performed on 23 patients between September 2005 and March 2006. Mean baseline clinical pulmonary infection score (CPIS) was 5.5+/-2.2. Seventy-eight percent of patients were receiving antibiotics at the time of sampling, and twenty (87%) patients had prior antibiotic exposure during the past 90 days. Fourteen (35%) cultures were positive, with resistant organisms in 13 (33%) samples (MRSA and Pseudomonas spp most common). Resistant pathogens were sensitive to the initial empiric antibiotic regimen in only 8 (62%) cases. Mini-BAL cultures resulted in management changes in 16 (40%) cases, including discontinuation of antibiotics in 4 (10%) and de-escalation in 7 (18%) cases. Antibiotics were appropriately employed for VAP or another clinical indication in 23 cases (58%). In 5 cases (12.5%), antibiotics were continued despite lack of clinical or microbiological evidence of infection. There were 7 deaths.
CONCLUSION: In this cohort, the use of mini-BAL combined with clinical practice guidelines reduced antibiotic use and identified a high number of resistant pathogens, many of which received inappropriate therapy.
CLINICAL IMPLICATIONS: This data suggests continued education on current practice guidelines and use of mini-BAL may lead to a more effective VAP management strategy in high risk patients. This study is ongoing.
DISCLOSURE: Alice Uy, None.