James R. Johnson, MD
Johnson JR. Management of Suspected Ventilator-Associated Pneumonia. Ann Intern Med. 2000;133:1008. doi: 10.7326/0003-4819-133-12-200012190-00019
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Published: Ann Intern Med. 2000;133(12):1008.
TO THE EDITOR:
Fagon and colleagues' findings (1) suggest patients with suspected ventilator-associated pneumonia have better clinical outcomes when antibiotic therapy is individualized and tailored to cover only bacteria present in the lower respiratory tract in high concentrations than when therapy is instituted empirically according to a generic protocol and then adjusted to cover all bacterial isolates from tracheal secretions, regardless of concentration.
This approach, which is consistent with traditional principles of infectious disease practice (2), increases the likelihood that true pathogens will be covered, while minimizing unnecessary antimicrobial therapy (1). However, how this information can best be translated into clinical practice remains to be determined. The authors' invasive protocol included diagnostic bronchoscopy, a labor-intensive and costly procedure that is not without risk (3). It is possible that respiratory secretions obtained by nurse-performed mini-bronchoalveolar lavage (3) might be equally informative (as even conventionally suctioned tracheal secretions might be, if cultures were performed and interpreted appropriately ). Quantitative cultures of respiratory secretions, as used by Fagon and colleagues in their invasive protocol, are also labor intensive and are not available at most centers. However, even conventional semi-quantitative smears and cultures might provide the discriminating power needed to differentiate high-concentration from low-concentration organisms in the respiratory tract, if interpreted appropriately (2). (The authors' noninvasive protocol included only qualitative cultures.) Selection of initial antimicrobial therapy based on patient-specific microbiological data has long been advocated (2) and can be done regardless of the methods used to collect and process specimens.
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