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Adherence to an established diagnostic threshold for ventilator-associated pneumonia contributes to low
Background:
The diagnosis of ventilator-associated pneumonia (VAP) in our institution has followed an established diagnostic threshold (DT) of equal to or greater than 10 colony-forming units (CFU) per milliliter on bronchoalveolar lavage (BAL) based on our previous study (PS). Because mortality from VAP is related to treatment delay, some have advocated a lower DT. The purpose of the current study (CS) was to evaluate the impact of adherence to this DT for VAP on false-negative (FN) rates and mortality in trauma patients.
Methods:
Consecutive patients over 9 years with VAP (defined as ≥10 CFU/mL in the BAL effluent) subsequent to the PS were identified. Data regarding each BAL performed and the colony counts of each organism identified were recorded. An FN BAL result was defined as any patient who had less than 10 CFU/mL and developed VAP with the same organism up to 7 days after the previous culture. The CS was then compared with the PS.
Results:
Over 9 years, 1,679 patients underwent 3,202 BALs. Of these, 79% were male, 88% experienced blunt injury, mean age and Injury Severity Score (ISS) were 44 years and 31, respectively. Overall, there were 73 FN BAL results (2.3%) in the CS compared with 3% in the PS (p = 0.092). In those patients with 10 organisms, the FN rate was reduced (7.5% vs. 11%, p = 0.045), and mortality was unchanged (5.4% vs. 8.3%, p = 0.361) in the CS compared with the PS. The use of the threshold equal to or greater than 10 resulted in a cumulative reduction in antibiotic charges of $1.57 million.
Conclusion:
Continued adherence to the diagnostic threshold of equal to or greater than 10 for quantitative BAL in trauma patients has maintained a low incidence of FN BALs and reduced patient charges without impacting mortality. The purported benefit of a lower threshold is not supported. In addition, the potential sequelae of increased resistant organisms, antibiotic-related complications, and costs associated with prolonged unnecessary antibiotic exposure are minimized.
Level Of Evidence:
Prognostic study, level III.
Insights
Maintaining a diagnostic threshold of 10 colony-forming units (CFU) per milliliter for ventilator-associated pneumonia (VAP) in trauma patients prevents false negatives and reduces costs without increasing mortality. A lower threshold is not supported.
Area of Science:
- Critical Care Medicine
- Infectious Diseases
- Trauma Surgery
Background:
- The diagnosis of ventilator-associated pneumonia (VAP) traditionally uses a diagnostic threshold (DT) of ≥10 colony-forming units (CFU)/mL in bronchoalveolar lavage (BAL).
- Concerns about delayed VAP treatment and associated mortality have led to proposals for a lower DT.
- This study evaluated the impact of adhering to the established ≥10 CFU/mL DT in trauma patients.
Purpose of the Study:
- To assess the effect of the current VAP diagnostic threshold (≥10 CFU/mL in BAL) on false-negative (FN) rates.
- To evaluate the impact of this DT on mortality in trauma patients.
- To compare the current study (CS) findings with previous study (PS) data.
Main Methods:
- A 9-year retrospective analysis of consecutive trauma patients diagnosed with VAP (≥10 CFU/mL in BAL).
- Data on BAL results, organism counts, and patient outcomes were recorded.
- False-negative BAL results were defined as <10 CFU/mL with subsequent VAP development from the same organism within 7 days.
Main Results:
- Over 9 years, 1,679 patients underwent 3,202 BALs; 73 FN BAL results (2.3%) were identified in the CS.
- The FN rate in the CS was comparable to the PS (2.3% vs. 3%, p=0.092).
- Adherence to the ≥10 CFU/mL DT reduced antibiotic charges by $1.57 million without impacting mortality.
Conclusions:
- Continued use of the ≥10 CFU/mL DT for quantitative BAL in trauma patients effectively minimizes FN BALs and reduces healthcare costs.
- The proposed benefit of a lower DT for VAP diagnosis is not supported by this study.
- Maintaining the current DT helps mitigate risks of increased antibiotic resistance, complications, and costs.
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