Invasive and Noninvasive Strategies for Management of Suspected Ventilator-Associated Pneumonia

Fagon, Jean-Yves; Chastre, Jean; Wolff, Michel; Gervais, C; Parer-Aubas, Sylvie; Stéphan, François; Similowski, Thomas; Mercat, Alain; Diehl, Jean‐Luc; Sollet, Jean-Pierre; Tenaillon, Alain

doi:10.7326/0003-4819-132-8-200004180-00004

Cited by 807 publications

(529 citation statements)

References 37 publications

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“…Our criteria for clinical suspicion of E-HAP are widely accepted. 12,13,16,18,24 Moreover, the retrospective calculation of the mCPIS allowed a positive confirmation of the diagnosis of pneumonia. 24 In unselected populations of mixed ICU patients, an incidence of early-onset pneumonia between 5% and 25% has usually been reported.…”

Section: Discussionmentioning

confidence: 99%

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Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Weiss¹,

Dahmani²,

Bert³

et al. 2010

Liver Transpl

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Early-onset hospital-acquired pneumonia (E-HAP) is one of the leading causes of sepsis and mortality after liver transplantation (LT). The appropriate antimicrobial therapy is crucially important for surviving sepsis in this context. The aim of this study was to analyze microbiological findings, associated factors, and optimal antibiotic regimens for E-HAP after LT. Patients demonstrating E-HAP in a single-center cohort of 148 LT recipients were prospectively detected. The diagnosis of pneumonia relied on a combination of supportive clinical findings and a positive culture of a lower respiratory tract sample. E-HAP was considered present if pneumonia occurred within 6 days of intensive care unit (ICU) admission after LT. Twenty-three patients (15.5%) developed E-HAP, which were caused by 36 pathogens (61.1% were gram-negative bacilli, and 33.3% were classified as hospital-acquired). For patients who developed E-HAP, the duration of mechanical ventilation and the ICU stay were significantly longer. Despite a trend toward higher mortality at any time in the E-HAP group, there was no significant difference in mortality between patients with E-HAP and patients without E-HAP. Lactatemia, vasopressor requirements, Simplified Acute Physiology Score II (SAPS II) score on ICU admission, and mechanical ventilation lasting more than 48 hours after LT were associated with E-HAP. Combinations of broad-spectrum b-lactams and aminoglycosides were active against more than 91% of the encountered pathogens. However, antibiotic de-escalation was possible in more than one-third of cases after identification of the pathogens. In conclusion, E-HAP after LT is a severe condition that appears to be influenced by physiological derangements induced by the surgery, such as lactatemia, vasopressor requirements, and mechanical ventilation requirements, as well as the postoperative SAPS II score. At the time of treatment initiation, an antimicrobial regimen usually proposed for late-onset pneumonia should be followed. Orthotopic liver transplantation (LT) is a widely accepted treatment for patients with end-stage liver disease. Despite global improvements in survival over the last few decades, sepsis remains the leading cause of early postoperative mortality. 1,2 Lower respiratory tract infections are a major concern in this context.

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Section: Discussionmentioning

confidence: 99%

“…12,[16][17][18] All chest radiographs were analyzed prospectively by 2 of the investigators (S.J. and C.P.-B.).…”

Section: Perioperative Managementmentioning

confidence: 99%

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Weiss¹,

Dahmani²,

Bert³

et al. 2010

Liver Transpl

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“…55 58 61 A much larger study involving 413 patients suspected of having VAP suggested that an invasive diagnostic strategy was desirable. 59 Compared with patients who received clinical management, patients who received invasive management had reduced mortality rate at day 14 (16.2% and 25.8%, p = 0.02) and decreased antibiotic use (mean (SD) number of antibiotic free days, 5.0 (5.1) and 2.2 (3.5), p,0.001). Most recently a meta-analysis of randomised, controlled trials of invasive diagnostic strategies in suspected VAP reported that an invasive approach did not change mortality (odds ratio 0.89, 95% confidence interval 0.56 to 1.41), but did change antibiotic use (odds ratio for change in antibiotic management after invasive sampling, 2.85, 95% confidence interval 1.45 to 5.59).…”

Section: Microbiological Diagnosismentioning

confidence: 99%

Ventilator‐associated pneumonia

Hunter¹,

Corry²

2002

BJA CEPD Reviews

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“…In a large, multicenter, randomized, unblinded French study of 413 critically ill patients with a clinical suspicion of pneumonia, bronchoscopy with quantitative cultures of PSB or BAL was compared to nonquantitative endotracheal aspirates (64). Patients with recent changes in antibiotic therapy were excluded, limiting the ability to generalize the results.…”

Section: Microbiologic Diagnosismentioning

confidence: 99%

Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention

2006

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SUMMARY While critically ill patients experience a life-threatening illness, they commonly contract ventilator-associated pneumonia. This nosocomial infection increases morbidity and likely mortality as well as the cost of health care. This article reviews the literature with regard to diagnosis, treatment, and prevention. It provides conclusions that can be implemented in practice as well as an algorithm for the bedside clinician and also focuses on the controversies with regard to diagnostic tools and approaches, treatment plans, and prevention strategies.

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Invasive and Noninvasive Strategies for Management of Suspected Ventilator-Associated Pneumonia

Abstract: Compared with a noninvasive management strategy, an invasive management strategy was significantly associated with fewer deaths at 14 days, earlier attenuation of organ dysfunction, and less antibiotic use in patients suspected of having ventilator-associated pneumonia.

Cited by 807 publications

References 37 publications

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Ventilator‐associated pneumonia

Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention

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