IMPACT OF BAL DATA ON THE THERAPY AND OUTCOME OF VENTILATOR-ASSOCIATED PNEUMONIA

Study objective: To define the impact of BAT, data on the selection of antibiotics and the outcomes of patients with ventilator-associated p neumonia (VAP). Design: Prospective observation and bronchoscopy with BAL, pet-formed within 24 h of establishing a clinical diagnosis of a new episode of hospital-acquired VAP or progression of a prior episode of nosocomial pneumonia (NP). Setting: A 15-bed medical and surgical ICU. Patients: One hundred thirty-two patients hospitalized for more t han 72 h, who were mechanically ventilated and had a new or progressiv e lung infiltrate plus at least two of the following three clinical cr iteria for VAP: abnormal temperature (>38 degrees C or <35 degrees C), abnormal leukocyte count (>10,000/mm(3) or <3,000/mm(3)), purulent br onchial secretions. Interventions: Bronchoscopy with BAL within 24 h o f establishing a clinical diagnosis of VAP or progression of an infilt rate due to prior VAP or NP. All patients received antibiotics, 107 pr ior to bronchoscopy and 25 immediately after bronchoscopy. Results: Si xty-five of the 132 patients were BAL positive (BAL[+]), satisfying a microbiologic definition of VAP (> 10(4) cfu/mL), while 67 were BAL ne gative (BAL[-]). The BAL(+) patients had no differences in mortality, prior antibiotic use, and demographic features when compared with the BAL(-) patients. More of the BAL(+) patients (38/65) satisfied all thr ee clinical criteria of VAP than did BAL(-) patients (24/67) (p < 0.05 ). A total of 50 BAL(+) patients received antibiotic therapy prior to bronchoscopy, and when this prior therapy was adequate (n = 16), as de fined by the results of BAL, then mortality was 38%, while if prior th erapy was inadequate (n = 34), mortality was 91% (p < 0.001), and if n o therapy was given (n = 15), mortality was 60%. When therapy changes were made after bronchoscopy, more patients (n = 42) received adequate therapy, but mortality in this group was comparable to mortality amon g those who continued to receive inadequate therapy (n = 23). A total of 46 of the 65 BAL(+) patients died, with 23 of these deaths occurrin g during the 48 h after the bronchoscopy, before BAL results were know n. When BAL data became available, 37 of the 42 surviving patients rec eived adequate therapy, but their mortality was comparable to the pati ents who continued to receive inadequate therapy. Conclusions: Patient s with a strong clinical suspicion of VAP have a high mortality rate, regardless of whether BAL cultures confirm the clinical diagnosis of V AP. When adequate antibiotic therapy is initiated very early (ie, befo re performing bronchoscopy), mortality rate is reduced if this empiric therapy is adequate, compared to when this therapy is inadequate or n o therapy is given. If adequate therapy is delayed until bronchoscopy is performed or until BAL results are known, mortality is higher than if it had been given at the time of first establishing a clinical diag nosis of VAP. When patients were changed from inadequate antibiotic th erapy to adequate therapy, based on the results of BAL, mortality was comparable to those who continued to receive inadequate therapy. Thus, even if bronchoscopy can accurately define the microbial etiology of VAP, this information becomes available too late to influence survival .