Impact of BAL in the management of pneumonia with treatment failure -: Positivity of BAL culture under antibiotic therapy
Impact of BAL in the management of pneumonia with treatment failure -: Positivity of BAL culture under antibiotic therapy
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DOI：
10.1378/chest.118.6.1739
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发表时间：
2000-12-01
期刊：
影响因子：
9.6
通讯作者：
Velasco, IT
中科院分区：
文献类型：
--
作者：
Gomes, JCP;Pedreira, WL;Velasco, IT
背景：肺炎是ICU中50%的抗生素处方的原因。治疗失败，即在抗生素治疗下没有改善或临床恶化，给医生带来了困境。BAL是一种经验证可用于肺炎病原学诊断的侵入性方法。研究目的：评价BAL在ICU患者中对治疗失败的肺炎的病原学诊断、治疗和结局的影响。设计：前瞻性临床研究。设置：巴西一所大学医院的非外科、内科ICU。患者和参与者：在53例因不同临床急症住院的患者中，62例肺炎发作治疗至少72小时，但无临床改善。平均住院时间为14.2天。抗生素治疗的平均持续时间为11.4天。干预措施：每次发作均进行支气管镜检查和支气管肺泡灌洗。培养BAL液中的需氧菌和厌氧菌;认为阳性的临界值为10（4）cfu/mL;如果接受治疗，还分析了10（3）cfu/mL。卡氏肺孢子虫，真菌，军团菌属，和分枝杆菌spp也researched. Measures和结果：58 62支BAL抗生素下进行。结果显示，62例中有45例（72.6%）为阳性; 45例阳性发作中有42例（93.3%）> 10（4）cfu/ml。103 - 104 cfu/ml的3例病例被认为是阳性，并根据BAL培养进行治疗。主要病原体为鲍曼不动杆菌（37.1%）、铜绿假单胞菌（17.7%）和耐甲氧西林金黄色葡萄球菌（MRSA; 16.1%）; 46.7%的发作（21/45）为多种微生物。BAL结果指导34例（54.8%）患者改变治疗。总死亡率为43.5%。结论：（1）62例急性支气管肺泡灌洗液（BAL）检查阳性者45例（72.6%），其中58例使用抗生素治疗。这表明，BAL可能是临床诊断肺炎治疗失败的敏感诊断方法，即使在抗生素下进行;（2）我们研究的主要病原体是鲍曼不动杆菌、铜绿假单胞菌和MRSA，约45%的感染是多种微生物感染;（3）支气管肺泡灌洗液培养阳性者中75.6%的患者需改变治疗（45例中的34例）和所有治疗失败事件的54.8%（62例中的34例）;（4）在BAL培养指导下，阳性、阴性和改变治疗的患者之间的死亡率没有差异。
Background: Pneumonia is responsible for 50% of antibiotics prescribed in ICUs. Treatment failure, ie, absence of improvement or clinical deterioration under antibiotic therapy, presents a dilemma to physicians. BAL is an invasive method validated for etiologic diagnosis in pneumonia.Study objective: To evaluate in ICU patients the impact of BAL in the etiologic diagnosis, treatment, and outcome of pneumonia with treatment failure.Design: Prospective clinical study.Setting: Nonsurgical, medical ICU of a university hospital in Brazil.Patients and participants: Sixty-two episodes of pneumonia treated for at least 72 h without clinical improvement in 53 patients hospitalized for diverse clinical emergencies. Mean duration of hospitalization was 14.2 days. Mean duration of precious antibiotic therapy was 11.4 days.Interventions: Bronchoscopy and BAL were performed in each episode. BAL fluid was cultivated for aerobic and anaerobic bacteria; the cutoff considered positive was 10(4) cfu/mL; 10(3) cfu/ml was also analyzed if under treatment. Pneumocystis carinii, fungi, Legionella spp, and Mycobacterium spp were also researched.Measurements and results: Fifty-eight of 62 BAL were performed under antibiotics. The results showed positivity in 45 of 62 (72.6%); 42 of the 45 positive episodes (93.3%) had > 10(4) cfu/ml. The three cases with between 103 and 104 cfu/ml were considered positive and were treated according to BAL cultures. The main agents were Acinetobacter baumannii (37.1%), Pseudomonas aeruginosa (17.7%), and methicillin-resistant Staphylococcus aureus (MRSA; 16.1%); 46.7% of the episodes (21 of 45) were polymicrobial. BAL results directed a change of therapy in 34 episodes (54.8%). Overall mortality was 43.5%. There was no difference in mortality among positives, negatives, and patients who changed therapy guided by BAL culture.Conclusions: (1) BAL fluid examination was positive in 45 of 62 episodes (72.6%), with 58 of 62 BAL performed under antibiotics. This suggests that BAL may be a sensitive diagnostic method for treatment failures of clinically diagnosed pneumonias, even if performed under antibiotics; (2) the main pathogens in our study were A baumannii, P aeruginosa, and MRSA, and approximately 45% of infections were polymicrobial; (3) BAL culture results directed a change of therapy in 75.6% of positive episodes (34 of 45) and in 54.8% of all episodes of treatment failure (34 of 62); and (4) there was no difference in mortality among positives, negatives, and patients who changed therapy guided by BAL culture.