Antibiotic utilization and outcomes for patients with clinically suspected ventilator-associated pneumonia and negative quantitative BAL culture results
Antibiotic utilization and outcomes for patients with clinically suspected ventilator-associated pneumonia and negative quantitative BAL culture results
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DOI：
10.1378/chest.128.4.2706
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发表时间：
2005-10-01
期刊：
影响因子：
9.6
通讯作者：
Kollef, KE
中科院分区：
文献类型：
--
作者：
Kollef, MH;Kollef, KE
目的：评价临床疑似呼吸机相关性肺炎（VAP）和培养阴性BAL（CNBAL）患者的抗生素使用和临床结局。设计：前瞻性观察队列研究。设置：一所大学附属城市教学医院的医学ICU，采用先前描述的抗生素停药指南管理VAP。患者：在2002年7月至2004年12月期间，对101例临床怀疑VAP和CNBAL的患者进行了评估。干预措施：前瞻性患者随访和数据收集。抗生素停药由临床指南决定，而不是BAL culture.Results的结果：患者的平均年龄为60.4 +/- 17.9岁，平均APACHE II评分为23.2 +/- 8.7（+/- SD）。在临床疑似VAP之前，机械通气的平均持续时间为2.9 ± 1.9天。19例患者（18.8%）在BAL前接受抗生素治疗其他适应症。65例患者（64.4%）在BAL后开始经验性抗生素治疗VAP。BAL后经验性抗生素治疗的持续时间为2.1 ± 0.8天。这些患者均未接受超过3天的抗生素治疗（中位数，2天;范围，1至3天）。6例患者（5.9%）在CNBAL后至少72小时接受抗生素治疗VAP或医院获得性肺炎的继发性发作，并停止最初疑似VAP发作的经验性抗生素治疗。总体而言，35例患者（34.7%）在住院期间死亡。在CNBAL和经验性抗菌药物治疗中止后VAP继发发作的患者中发生了2例死亡。这两个死亡都不是归因于VAP.Conclusions：虽然决定停止抗生素治疗是基于临床标准，而不是BAL培养结果，这项研究表明，临床怀疑VAP和CNBAL的患者可以有经验性的抗菌治疗安全地停止在72小时内或在某些情况下完全扣留。需要进行前瞻性研究以确定采用CNBAL作为VAP经验性开始抗生素治疗终止的主要标准的安全性。
Objective: To evaluate antibiotic utilization and clinical outcomes among patients with clinically suspected ventilator-associated pneumonia (VAP) and culture-negative BAL (CNBAL).Design: Prospective observational cohort study.Setting: A medical ICU from a university-affiliated urban teaching hospital employing a previously described antibiotic discontinuation guideline for the management of VAP.Patients: One hundred one patients with a clinical suspicion of VAP and CNBAL were evaluated between July 2002 and December 2004.Interventions: Prospective patient follow-up and data collection. Antibiotic discontinuation was determined by the clinical guideline and not the results of BAL cultures.Results: The average age of the patients was 60.4 +/- 17.9 years and the mean APACHE II score was 23.2 +/- 8.7 (+/- SD). The mean duration of mechanical ventilation prior to clinically suspected VAP was 2.9 +/- 1.9 days. Nineteen patients (18.8%) received antibiotics for other indications prior to BAL. Empiric antibiotic therapy, for VAP was begun in 65 patients (64.4%) following BAL. The duration of empiric antibiotic treatment following BAL was 2.1 +/- 0.8 days. None of these patients received antibiotics for > 3 days (median, 2 days; range, 1 to 3 days). Six patients (5.9%) were treated with antibiotics for a secondary episode of VAP or hospital-acquired pneumonia developing at least 72 h after the CNBAL was performed and discontinuation of the empiric antibiotic therapy prescribed for the initially suspected episode of VAP. Overall, 35 patients (34.7%) died during hospitalization. Two deaths occurred in patients with a secondary episode of VAP following CNBAL and discontinuation of empiric antimicrobial therapy. Neither of these two deaths was attributed to VAP.Conclusions: Although the decision to discontinue antibiotic treatment was based on clinical criteria and not BAL culture results, this study suggests that patients with a clinical suspicion of VAP and CNBAL can have empiric antimicrobial therapy safely discontinued within 72 h or in some cases withheld altogether. Prospective studies are needed to determine the safety of employing CNBAL as the primary criterion for the discontinuation of empirically begun antibiotic treatment for VAP.