N Engl J Med. 2006 Dec 21;355(25):2619-30.
Canadian Critical Care Trials Group.
BACKGROUND: Critically ill patients who require mechanical ventilation are at
risk for ventilator-associated pneumonia. Current data are conflicting as to the
optimal diagnostic approach in patients who have suspected ventilator-associated
pneumonia. METHODS: In a multicenter trial, we randomly assigned immunocompetent
adults who were receiving mechanical ventilation and who had suspected
ventilator-associated pneumonia after 4 days in the intensive care unit (ICU) to
undergo either bronchoalveolar lavage with quantitative culture of the
bronchoalveolar-lavage fluid or endotracheal aspiration with nonquantitative
culture of the aspirate. Patients known to be colonized or infected with
pseudomonas species or methicillin-resistant Staphylococcus aureus were excluded.
Empirical antibiotic therapy was initiated in all patients until culture results
were available, at which point a protocol of targeted therapy was used for
discontinuing or reducing the dose or number of antibiotics, or for resuming
antibiotic therapy to treat a preenrollment condition if the culture was
negative. RESULTS: We enrolled 740 patients in 28 ICUs in Canada and the United
States. There was no significant difference in the primary outcome (28-day
mortality rate) between the bronchoalveolar-lavage group and the
endotracheal-aspiration group (18.9% and 18.4%, respectively; P=0.94). The
bronchoalveolar-lavage group and the endotracheal-aspiration group also had
similar rates of targeted therapy (74.2% and 74.6%, respectively; P=0.90), days
alive without antibiotics (10.4+/-7.5 and 10.6+/-7.9, P=0.86), and maximum
organ-dysfunction scores (mean [+/-SD], 8.3+/-3.6 and 8.6+/-4.0; P=0.26). The two
groups did not differ significantly in the length of stay in the ICU or hospital.
CONCLUSIONS: Two diagnostic strategies for ventilator-associated
pneumonia–bronchoalveolar lavage with quantitative culture of the
bronchoalveolar-lavage fluid and endotracheal aspiration with nonquantitative
culture of the aspirate–are associated with similar clinical outcomes and
similar overall use of antibiotics. (Current Controlled Trials number,
ISRCTN51767272 [controlled-trials.com].). Copyright 2006 Massachusetts Medical
Society.