ANALYSIS OF CHARGES ASSOCIATED WITH DIAGNOSIS OF NOSOCOMIAL PNEUMONIA- CAN ROUTINE BRONCHOSCOPY BE JUSTIFIED

Many ventilated trauma patients thought to have nosocomial pneumonia h ave pulmonary contusion or systemic inflammatory response syndrome wit h tracheobronchial colonization. Fiberoptic bronchoscopy with quantita tive culture techniques of protected specimen brush (PSB; threshold 10 (3) cfu/mL) or bronchoalveolar lavage (BAL; threshold 10(5) cfu/mL) ca n potentially eliminate the false positive cultures of the upper airwa y seen with routine sputum aspirates (RS). However, bronchoscopy is ex pensive, and routine use may not be cost effective. This prospective s tudy evaluated the patient charges associated with bronchoscopy and qu antitative cultures compared with RS for the diagnosis of nosocomial p neumonia. Specimens were obtained by RS, PSB, and BAL from the lower a irway in 107 trauma patients (136 sets of triplicate cultures). All pa tients had clinical evidence suggestive of pneumonia (fever, leukocyto sis, purulent sputum, abnormal roentgenographic findings). Typical ora l flora were considered contaminants; no gram-negative specimens were excluded. Mean age was 40 years and mean ISS was 29. Seventy-eight per cent had blunt injuries, 22% penetrating, and 42% had chest injuries. The incidence of nosocomial pneumonia according to each method was: RS -73%; PSB-34%; BAL-25%. Considering all charges involved (bronchoscopy , equipment, microbiologic analysis, and antibiotics), and based on a 14-day course of ceftazidime and vancomycin, the charges for PSB were 58% of RS, and charges for BAL were 43% of RS. We conclude that the ch arges associated with bronchoscopy are high, but can be offset by anti biotic savings. Side effects of unnecessary antibiotic therapy would b e avoided. Further study is needed to determine the efficacy of PSB or BAL in trauma patients.