USING BRONCHOALVEOLAR LAVAGE TO DISTINGUISH NOSOCOMIAL PNEUMONIA FROMSYSTEMIC INFLAMMATORY RESPONSE SYNDROME - A PROSPECTIVE ANALYSIS

Objective: Ventilator-associated pneumonia (PN) is difficult to distin guish from trauma-induced systemic inflammatory response syndrome (SIP S), especially in patients with multiple injuries. Previous work using bronchoscopy and quantitative cultures demonstrated significant bacte rial growth in about one-third of patients with clinical evidence of P N, In this prospective study, antibiotic therapy for PN was based sole ly on quantitative bronchoalveolar lavage (BAL) cultures. Methods: Mec hanically ventilated trauma patients underwent bronchoscopy with BAL w hen they developed clinical evidence of PN: fever (temperature > 100.5 degrees F), white blood cells > 10,000 or >10% immature forms, purule nt sputum, and new or changing infiltrate on chest roentgenogram, Pati ents with other infections or those receiving antibiotics for any othe r reason were excluded, Empiric antibiotic therapy for PN was started at the time of BAL, If the quantitative cultures revealed greater than or equal to 10(5) colony-forming units (CFU)/mL, that patient was def ined as having PN and was treated, If the cultures revealed <10(5) CFU /mL, that patient was defined as having SIPS, and empiric therapy was stopped. Results: Forty-three patients (88% blunt, 12% penetrating) un derwent bronchoscopy with BAI, 55 times, Mean age was 40 and Injury Se verity Score was 25, Twenty patients had greater than or equal to 10(5 ) CFU/mL (47%) and 23 had <10(5) CFU/mL (53%). There were no differenc es in age, Injury Severity Score, temperature, white blood cell count, or ventilator days before BAL, between groups, Sixty-five percent of those with SIPS improved after empiric therapy was stopped (average 3. 3 days), and 35% underwent repeat BAL, Three patients with the initial diagnosis of SIRS developed PN (13% of SIPS, Mortality for PN was 15% , compared with 17% for SIPS; no deaths were related to antibiotic the rapy. Conclusions: SIPS, which can mimic PN, is common in trauma patie nts, These entities can he distinguished by bronchoscopy with BAL, Bas ing antibiotic therapy solely on quantitative BAL cultures is efficaci ous in trauma patients.