PURPOSE: The clinical approach to VAP is likely to lead to more antibiotic utilization with no clinical benefit compared to BAL. Both the CPIS and BAL have been shown to decrease the unnecessary utilization of antibiotics compared to the traditional methods. The objective of this study was to compare the potential impact of CPIS versus BAL on the utilization of antibiotics in patients with suspected VAP.
METHODS: We identified 50 patients who had cultures of both endotracheal aspirate and BAL for suspected VAP. Patients without research authorization and those who died within 3 days of BAL were excluded. CPIS on the first and third days of the suspected VAP were calculated. CPIS > 6 and quantitative culture by BAL of 10,000 CFU/mL or higher were used for the diagnosis of VAP.
RESULTS: Patients’ mean (SD) age was 58.8 (18.0) years. The most common reason for mechanical ventilation was previous episode of pneumonia (19). At the onset of the suspected VAP, patients were receiving mechanical ventilation for a median of 7.0 and had been in the ICU for 8 days. The mean (SD) CPIS on the first day was 5.6 (1.8) and on the third day 5.4 (1.9). Seven patients (14%) had VAP by the BAL criteria, of whom only three fulfilled the CPIS criteria of VAP on the first or third day. Twenty-two patients (44%) had VAP by the CPIS criteria, of whom only 3 (14%) had VAP by the BAL criteria.
CONCLUSION: There is significant discrepancy between bronchoalveolar lavage and clinical pulmonary infection score in the diagnosis of VAP. A randomized clinical trial comparing CPIS versus bronchoscopy is needed to determine the differences in patient outcome, overall antibiotic utilization and emergence of resistant pathogens.
CLINICAL IMPLICATIONS: Compared to BAL, CPIS guided approach in patients with suspected VAP may lead to both under- and over-utilization of antibiotics resulting in the emergence of resistant pathogens.
DISCLOSURE: Dereje Ayo, None.