A qualitative assessment of the diagnosis and management of ventilator-associated pneumonia among critical care clinicians exploring opportunities for diagnostic stewardship

Abstract

Background: Prompt diagnosis and intervention for ventilator-associated pneumonia (VAP) is critical but can lead to overdiagnosis and overtreatment. Objectives: We investigated healthcare provider (HCP) perceptions and challenges associated with VAP diagnosis, and we sought to identify opportunities for diagnostic stewardship. Methods: We conducted a qualitative study of 30 HCPs at a tertiary-care hospital. Participants included attending physicians, residents and fellows (trainees), advanced practice providers (APPs), and pharmacists. Interviews were composed of open-ended questions in 4 sections: (1) clinical suspicion and thresholds for respiratory culture ordering, (2) preferences for respiratory sample collection, (3) culture report interpretation, and (4) VAP diagnosis and treatment. Interviews transcripts were analyzed using Nvivo 12 software, and responses were organized into themes. Results: Overall, 10 attending physicians (75%) and 16 trainees (75%) trainees and APPs believed they were overdiagnosing VAP; this response was frequent among HCPs in practice 5–10 years (91%, n = 12). Increased identification of bacteria as a result of frequent respiratory culturing, misinterpretation of culture data, and fear of missing diagnosis were recognized as drivers of overdiagnosis and overtreatment. Although most HCPs rely on clinical and radiographic changes to initiate work-up, the fear of missing a diagnosis leads to sending cultures even in the absence of those changes. Conclusions: HCPs believe that VAP overdiagnosis and overtreatment are common due to fear of missing diagnosis, overculturing, and difficulty distinguishing colonization from infection. Although we identified opportunities for diagnostic stewardship, interventions influencing the ordering of cultures and starting antimicrobials will need to account for strongly held beliefs and ICU practices.

Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment

“…12 Our findings suggest that respiratory-tract culturing may be driven by sepsis vigilance. 6,13 In a retrospective study by Kumar et al, 14 the linear relationship outlining worsening mortality with delay in administration of antibiotics since onset of hypotension was instrumental in defining the management of sepsis. The surviving sepsis guideline has placed a strong emphasis on monitoring hemodynamics and promptly initiating antimicrobial therapy to improve outcomes in the critically ill. 12 Although recognizing that early recognition of sepsis and antibiotics administration improves overall mortality, 12 successfully differentiating infectious from noninfectious causes as contributory to worsening clinical status in the ICU remains challenging.…”

“…4,22 Advocates of lower respiratory culturing also highlight the benefit of site-specific sample collection for diagnostic accuracy. 6 Furthermore, the resulting quantitative culture data could more reliably rule out infectious causes and could potentially contribute to early discontinuation of antibiotics. 23 Our findings also highlight the ongoing debate regarding the validity and utility of changes in oxygenation as an important marker toward VAP clinical diagnosis and surveillance reporting.…”

“…In our previous study that examined healthcare provider (HCP) perceptions of VAP diagnosis and treatment, most HCPs considered clinical changes or attributes, such as increase in oxygen requirement, temperature and sputum characteristics, and radiographic changes to initiate diagnostic work-up. 6 However, HCPs also described a low threshold for culturing due to a fear of missing a diagnosis. 6 Specifically, it is unclear whether respiratory-specific changes, such as radiographic changes, worsening oxygenation, and sputum characteristics, are considered equally by clinicians as nonspecific clinical characteristics, such as changes in temperature, WBC, and blood pressure.…”

“…6 However, HCPs also described a low threshold for culturing due to a fear of missing a diagnosis. 6 Specifically, it is unclear whether respiratory-specific changes, such as radiographic changes, worsening oxygenation, and sputum characteristics, are considered equally by clinicians as nonspecific clinical characteristics, such as changes in temperature, WBC, and blood pressure. The purpose of this study was to quantify the extent to which those clinical changes influence an HCP's decision to perform respiratory culturing in intensive care unit (ICU) patients.…”

“…Furthermore, in our prior study, HCP in our institution demonstrated a preference for invasive respiratory sampling using bronchoscopy with bronchoalveolar lavage (BAL) or mini-BAL over blind endotracheal sampling (ETA) for VAP diagnosis. 6 Therefore, as a secondary objective, we estimated the influence of these clinical changes on requests for invasive sampling (ie, BAL) versus noninvasive ETA.…”