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Invasive and Noninvasive Strategies for Management of Suspected Ventilator-Associated Pneumonia: A Randomized Trial

Jean-Yves Fagon, MD; Jean Chastre, MD; Michel Wolff, MD; Claude Gervais, MD; Sylvie Parer-Aubas, MD; François Stéphan, MD; Thomas Similowski, MD; Alain Mercat, MD; Jean-Luc Diehl, MD; Jean-Pierre Sollet, MD; Alain Tenaillon, MD, VAP Trial Group*
[+] Article and Author Information

From Hôpital Broussais, Hôpital Bichat-Claude Bernard, Hôpital Tenon, Hôpital Pitié-Salpêtrière, and Hôpital Boucicaut, Paris; Centre Hospitalier Universitaire Nîmes, Nîmes; Centre Hospitalier Universitaire Montpellier, Montpellier; Hôpital Bicêtre, Le Kremlin-Bicêtre; Centre Hospitalier Victor Dupouy, Argenteuil; and Centre Hospitalier Louise Michel, Evry, France.


Grant Support: In part by the Société de Réanimation de Langue Française and the Délégation à la Recherche Clinique, Assistance Publique-Hôpitaux de Paris.

Requests for Single Reprints: Jean-Yves Fagon, MD, Service de Réanimation Médicale, Hôpital Broussais, 96 rue Didot, 75674 Paris Cedex 14, France.

Requests To Purchase Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints@mail.acponline.org.

Current Author Addresses: Dr. Fagon: Service de Réanimation Médicale, Hopital Europeen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France.

Dr. Chastre: Service de Réanimation Médicale, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018 Paris, France.

Dr. Wolff: Clinique de Réanimation des Maladies Infectieuses, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018 Paris, France.

Dr. Gervais: Réanimation Médicale, CHU Nîmes, 5 rue Hoche, 30029 Nîmes Cedex, France.

Dr. Parer-Aubas: DAR A-Réanimation, CHU Montpellier, Hôpital Lapeyronie, 371 avenue du Doyen Gaston Girard, 34295 Montpellier Cedex 5, France.

Dr. Stéphan: Service d'Anesthesie-Réanimation, Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil Cedex, France.

Dr. Similowski: Service de Réanimation Pneumologique, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France.

Dr. Mercat: Service de Réanimation Médicale, Hôpital Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre Cedex, France.

Dr. Diehl: Service de Réanimation Médicale, Hopital Europeen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France.

Dr. Sollet: Service de Réanimation Médicale, Hôpital d'Argenteuil, 69 rue du Lieutenant Colonel Prudhon, 95100 Argenteuil, France.

Dr. Tenaillon: Service de Réanimation Médicale, Centre Hospitalier Louise Michel, Quartier du Canal, 91014 Evry Courcouronnes Cedex, France.

Author Contributions: Conception and design: J.-Y. Fagon, J. Chastre, C. Gervais.

Analysis and interpretation of the data: J.-Y. Fagon, J. Chastre.

Drafting of the article: J.-Y. Fagon, J. Chastre.

Critical revision of the article for important intellectual content: J.-Y. Fagon, J. Chastre, M. Wolff, C. Gervais, S. Parer-Aubas, F. Stéphan, T. Similowski, A. Mercat, J.-L. Diehl, J.-P. Sollet, A. Tenaillon.

Final approval of the article: J.-Y. Fagon, J. Chastre, M. Wolff, C. Gervais, S. Parer-Aubas, F. Stéphan, T. Similowski, A. Mercat, J.-L. Diehl, J.-P. Sollet, A. Tenaillon.

Provision of study materials or patients: J.-Y. Fagon, J. Chastre, M. Wolff, C. Gervais, S. Parer-Aubas, F. Stéphan, T. Similowski, A. Mercat, J.-L. Diehl, J.-P. Sollet, A. Tenaillon.

Statistical expertise: J.-Y. Fagon, J. Chastre.

Obtaining of funding: J.-Y. Fagon, J. Chastre.

Administrative, technical, or logistic support: J.-Y. Fagon, J. Chastre.

Collection and assembly of data: J.-Y. Fagon, J. Chastre.


Ann Intern Med. 2000;132(8):621-630. doi:10.7326/0003-4819-132-8-200004180-00004
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The diagnosis and treatment of ventilator-associated pneumonia, a nosocomial infection that develops in mechanically ventilated patients and causes considerable morbidity and mortality, remain a challenge (13). A presumptive clinical diagnosis of pneumonia is often made when a patient develops a new radiographic infiltrate associated with fever, leukocytosis, and purulent tracheal secretions and when microorganisms are isolated by nonquantitative analysis of endotracheal aspirates (4). This “clinical” approach leads to overestimation of the incidence of ventilator-associated pneumonia because cases of tracheobronchial colonization and noninfectious processes mimicking it are included (57). The nonspecificity of a strategy based on clinical evaluation has potentially deleterious consequences: Many patients may receive unneeded antibiotics; this exposes them to unnecessary toxicity, increases hospital costs, and favors the emergence of resistant microorganisms. In addition, antibiotic overuse in such patients delays diagnosis of the true cause of fever and pulmonary infiltrate.

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Figures

Grahic Jump Location
Figure 1.
Diagnostic and therapeutic strategy applied to patients managed with the clinical strategy (A) or invasive strategy (B).

ATS = American Thoracic Society; BAL = bronchoalveolar lavage; PSB = protected specimen brush.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Actuarial 28-day survival among 413 patients assigned to the invasive (solid line) or clinical (dashed line) management strategy.P

= 0.07 for difference between groups (log-rank test).

Grahic Jump Location
Grahic Jump Location
Figure 3.
Comparison of clinical (black circles) and invasive (white circles) management strategies for the number of days of survival without use of 1 of the 14 most commonly prescribed antibiotics.

For every antibiotic except imipenem, patients in the invasive management group had significantly more antibiotic-free days. Error bars represent 95% CIs.

Grahic Jump Location

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Summary for Patients

Managing Suspected Ventilator-Associated Pneumonia

The summary below is from the full report titled “ Invasive and Noninvasive Strategies for Management of Suspected Ventilator-Associated Pneumonia. A Randomized Trial”. It is in the 18 April 2000 issue of Annals of Internal Medicine (volume 132, pages 621-630). The authors are.-Y. Fagon, J. Chastre, M. Wolff, C. Gervais, S. Parer-Aubas, F. Stéphan, T. Similowski, A. Mercat, J.-L. Diehl, J.-P. Sollet, and A. Tenaillon, for the VAP Trial Group.

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