Original Research: Critical Care |

Is a Strategy Based on Routine Endotracheal Cultures the Best Way to Prescribe Antibiotics in Ventilator-Associated Pneumonia?Surveillance Tracheal Aspirate Cultures in VAP

Carlos M. Luna, MD, PhD, FCCP; Sergio Sarquis, MD; Michael S. Niederman, MD; Fernando A. Sosa, MD; Maria Otaola, MD; Nicolas Bailleau, MD; Carlos A. Vay, PhD; Angela Famiglietti, PhD; Célica Irrazabal, MD; Abelardo A. Capdevila, MD
Author and Funding Information

From the Pulmonary and Critical Medicine Divisions (Drs Luna, Sarquis, Sosa, Otaola, Bailleau, Irrazabal, and Capdevila), Department of Medicine, and Microbiology Section (Drs Vay and Famiglietti), Department of Clinical Biochemistry, Facultad de Farmacia y Bioquímica, Hospital de Clínicas, Universidad de Buenos Aires, Argentina; and the Department of Medicine (Dr Niederman), Winthrop University Hospital, Mineola, NY.

Correspondence to: Carlos M. Luna, MD, PhD, FCCP, Arenales 2557, Piso 1, Dto A, Buenos Aires, 1425, Capital Federal, Argentina; e- mail: dr.cm.luna@gmail.com

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

Funding/Support: Funding for this study was received from Asociacion Cooperadora del Hospital de Clinicas.

Chest. 2013;144(1):63-71. doi:10.1378/chest.12-1477
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Objectives:  The objectives of this study were to evaluate if a strategy based on routine endotracheal aspirate (ETA) cultures is better than using the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines to prescribe antimicrobials in ventilator-associated pneumonia (VAP).

Methods:  This was a prospective, observational, cohort study conducted in a 15-bed ICU and comprising 283 patients who were mechanically ventilated for ≥ 48 h. Interventions included twice-weekly ETA; BAL culture was done if VAP was suspected. BAL (collected at the time of VAP) plus ETA cultures (collected ≤ 7 days before VAP) (n = 146 different pairs) were defined. We compared two models of 10 days of empirical antimicrobials (ETA-based vs ATS/IDSA guidelines-based strategies), analyzing their impact on appropriateness of therapy and total antimicrobial-days, using the BAL result as the standard for comparison.

Results:  Complete ETA and BAL culture concordance (identical pathogens or negative result) occurred in 52 pairs; discordance (false positive or false negative) in 67, and partial concordance in two. ETA predicted the etiology in 62.4% of all pairs, in 74.0% of pairs if ETA was performed ≤ 2 days before BAL, and in 46.2% of pairs if ETA was performed 3 to 7 days before BAL (P = .016). Strategies based on the ATS/IDSA guidelines and on ETA results led to appropriate therapy in 97.9% and 77.4% of pairs, respectively (P < .001). The numbers of antimicrobial-days were 1,942 and 1,557 for therapies based on ATS/IDSA guidelines and ETA results, respectively (P < .001).

Conclusions:  The ATS/IDSA guidelines-based approach was more accurate than the ETA-based strategy for prescribing appropriate, initial, empirical antibiotics in VAP, unless a sample was available ≤ 2 days of the onset of VAP. The ETA-based strategy led to fewer days on prescribed antimicrobials.

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