Invasive oder nicht-invasive Diagnostik der Ventilator-assoziierten Pneumonie: Ergebnisse der Canadian Critical Care Trials Group
ABSTRACT Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection on intensive care units (ICU). VAP has consequences on mortality, duration of stay on the ICU and in the hospital and increases costs of treatment. Clinical studies indicated that an early and calculated treatment with broad-spectrum antibiotics is highly important for the success of treatment on the ICU. To minimize formation of resistance, early deescalation or termination of this chosen therapy is necessary and may be based on clinical criteria and especially microbiological examination. The latter case needs extraction of secretions in the upper respiratory tract. Invasive techniques (bronchoalveolar lavage, BAL) and non-invasive techniques (endotracheal aspiration, ETA) can be used. There is no agreement between studies about which method leads most frequently to correct results and results in improving outcome of patients. The study performed by the Canadian critical care trials group (December 21, 2006, NEJM) examined 740 patients on intensive care units. Patients were randomized both depending on the diagnostic method (ETA vs BAL) and the antibiotic treatment (mono- vs combined antibiotic therapy). The 28-day mortality was chosen as the primary outcome parameter, while duration of mechanical ventilation and duration of stay on the ICU were chosen among other things as secondary parameters. The results indicated no significant differences between the groups for these parameters. Patients undergoing BAL were treated significantly later by study antibiotics. This difference had no effect on patients' outcome. The special selection of the study population, which excluded pre-colonized and chronically ill patients, reduces the possibility to rate these results. Furthermore, based on the results of this study, recommendation for one of the used techniques in diagnosing VAP can not be given.
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ABSTRACT: To facilitate the decision-making process for therapy and prevention of ventilator-associated pneumonia (VAP) in patients undergoing recent antibiotic exposure, this study investigated whether the development of VAP episodes caused by Pseudomonas aeruginosa or other pathogens are related to different risk factors, thereby distinguishing two risk population for this serious complication. A 5-year retrospective case-control observational study was conducted. Cases of VAP caused by P. aeruginosa were compared with those caused by other pathogens. Univariate and multivariate analysis was performed using SPSS 11.0 software (SPSS Inc., Chicago, IL). Two groups were identified: P. aeruginosa (group P) was isolated in 58 (63.7%) episodes, and 33 episodes served as controls (group C), after a median of 12 days (interquartile range, 4-28 days) and 9 days (interquartile range, 3-12.5 days) of mechanical ventilation, respectively. P. aeruginosa was identified in 34.7% of episodes with early-onset pneumonia and in 73.5% with late-onset pneumonia. In a logistic regression analysis, P. aeruginosa was independently associated with duration of stay of 5 days or longer (relative risk = 3.59; 95% confidence interval, 1.04-12.35) and absence of coma (relative risk = 8.36; 95% confidence interval, 2.68-26.09). Risk for pathogens different from P. aeruginosa (group C) in early-onset pneumonia associated with coma was estimated to be 87.5%. Risk factors in episodes under recent antibiotic treatment caused by P. aeruginosa or other microorganism are not the same, a fact that could have implications for preventive and therapeutic approaches for this infection.Anesthesiology 11/2006; 105(4):709-14. · 6.17 Impact Factor
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ABSTRACT: Ventilator-associated pneumonia (VAP) has been implicitly accused of increasing mortality. However, it is not certain that pneumonia is responsible for death or whether fatal outcome is caused by other risk factors for death that exist before the onset of pneumonia. The aim of this study was to evaluate the attributable mortality caused by VAP by performing a matched-paired, case-control study between patients who died and patients who were discharged from the intensive care unit after more than 48 h of mechanical ventilation. During the study period, 135 consecutive deaths were included in the case group. Case-control matching criteria were as follows: (1) diagnosis on admission that corresponded to 1 of 11 predefined diagnostic groups; (2) age difference within 10 yr; (3) sex; (4) admission within 1 yr; (5) APACHE II score within 7 points; (6) ventilation of control patients for at least as long as the cases. Precise clinical, radiologic, and microbiologic definitions were used to identify VAP. Analysis was performed on 108 pairs that were matched with 91% of success. There were 39 patients (36.1%) who developed VAP in each group. Multivariate analysis showed that renal failure, bone marrow failure, and treatment with corticosteroids but not VAP were independent risk factors for death. There was no difference observed between cases and controls concerning the clinical and microbiologic diagnostic criteria for pneumonia. Ventilator-associated pneumonia does not appear to be an independent risk factor for death.Anesthesiology 05/2001; 94(4):554-60. · 6.17 Impact Factor
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ABSTRACT: The optimal duration of antimicrobial treatment for ventilator-associated pneumonia (VAP) is unknown. Shortening the length of treatment may help to contain the emergence of multiresistant bacteria in the intensive care unit (ICU). To determine whether 8 days is as effective as 15 days of antibiotic treatment of patients with microbiologically proven VAP. Prospective, randomized, double-blind (until day 8) clinical trial conducted in 51 French ICUs. A total of 401 patients diagnosed as having developed VAP by quantitative culture results of bronchoscopic specimens and who had received initial appropriate empirical antimicrobial therapy were enrolled between May 1999 and June 2002. A total of 197 patients were randomly assigned to receive 8 days and 204 to receive 15 days of therapy with an antibiotic regimen selected by the treating physician. Primary outcome measures-death from any cause, microbiologically documented pulmonary infection recurrence, and antibiotic-free days-were assessed 28 days after VAP onset and analyzed on an intent-to-treat basis. Compared with patients treated for 15 days, those treated for 8 days had neither excess mortality (18.8% vs 17.2%; difference, 1.6%; 90% confidence interval [CI], -3.7% to 6.9%) nor more recurrent infections (28.9% vs 26.0%; difference, 2.9%; 90% CI, -3.2% to 9.1%), but they had more mean (SD) antibiotic-free days (13.1 [7.4] vs 8.7 [5.2] days, P<.001). The number of mechanical ventilation-free days, the number of organ failure-free days, the length of ICU stay, and mortality rates on day 60 for the 2 groups did not differ. Although patients with VAP caused by nonfermenting gram-negative bacilli, including Pseudomonas aeruginosa, did not have more unfavorable outcomes when antimicrobial therapy lasted only 8 days, they did have a higher pulmonary infection-recurrence rate compared with those receiving 15 days of treatment (40.6% vs 25.4%; difference, 15.2%, 90% CI, 3.9%-26.6%). Among patients who developed recurrent infections, multiresistant pathogens emerged less frequently in those who had received 8 days of antibiotics (42.1% vs 62.0% of pulmonary recurrences, P =.04). Among patients who had received appropriate initial empirical therapy, with the possible exception of those developing nonfermenting gram-negative bacillus infections, comparable clinical effectiveness against VAP was obtained with the 8- and 15-day treatment regimens. The 8-day group had less antibiotic use.JAMA The Journal of the American Medical Association 12/2003; 290(19):2588-98. · 29.98 Impact Factor