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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; and
- for the VAP Trial Group*
- 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.
Abstract
Background: Optimal management of patients who are clinically suspected of having ventilator-associated pneumonia remains open to debate.
Objective: To evaluate the effect on clinical outcome and antibiotic use of two strategies to diagnose ventilator-associated pneumonia and select initial treatment for this condition.
Design: Multicenter, randomized, uncontrolled trial.
Setting: 31 intensive care units in France.
Patients: 413 patients suspected of having ventilator-associated pneumonia.
Intervention: The invasive management strategy was based on direct examination of bronchoscopic protected specimen brush samples or bronchoalveolar lavage samples and their quantitative cultures. The noninvasive (“clinical”) management strategy was based on clinical criteria, isolation of microorganisms by nonquantitative analysis of endotracheal aspirates, and clinical practice guidelines.
Measurements: Death from any cause, quantification of organ failure, and antibiotic use at 14 and 28 days.
Results: Compared with patients who received clinical management, patients who received invasive management had reduced mortality at day 14 (16.2% and 25.8%; difference, −9.6 percentage points [95% CI, −17.4 to −1.8 percentage points]; P = 0.022), decreased mean Sepsis-related Organ Failure Assessment scores at day 3 (6.1 ± 4.0 and 7.0 ± 4.3; P = 0.033) and day 7 (4.9 ± 4.0 and 5.8 ± 4.4; P = 0.043), and decreased antibiotic use (mean number of antibiotic-free days, 5.0 ± 5.1 and 2.2 ± 3.5; P < 0.001). At 28 days, the invasive management group had significantly more antibiotic-free days (11.5 ± 9.0 compared with 7.5 ± 7.6; P < 0.001), and only multivariate analysis showed a significant difference in mortality (hazard ratio, 1.54 [CI, 1.10 to 2.16]; P = 0.01).
Conclusions: 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.
*For members of the VAP Trial Group, see the Appendix.
Article and Author Information
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Grant Support: In part by the Société de Réanimation de Langue Française and the Délégation à la Recherche Clinique, Assistance Publique-Hôpitaux de Paris.
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Requests for Single Reprints: Jean-Yves Fagon, MD, Service de Réanimation Médicale, Hôpital Broussais, 96 rue Didot, 75674 Paris Cedex 14, France.
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Requests To Purchase Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints{at}mail.acponline.org.
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Current Author Addresses: Dr. Fagon: Service de Réanimation Médicale, Hopital Europeen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France.
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Dr. Chastre: Service de Réanimation Médicale, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018 Paris, France.
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Dr. Wolff: Clinique de Réanimation des Maladies Infectieuses, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018 Paris, France.
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Dr. Gervais: Réanimation Médicale, CHU Nîmes, 5 rue Hoche, 30029 Nîmes Cedex, France.
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Dr. Parer-Aubas: DAR A-Réanimation, CHU Montpellier, Hôpital Lapeyronie, 371 avenue du Doyen Gaston Girard, 34295 Montpellier Cedex 5, France.
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Dr. Stéphan: Service d'Anesthesie-Réanimation, Hôpital Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil Cedex, France.
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Dr. Similowski: Service de Réanimation Pneumologique, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France.
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Dr. Mercat: Service de Réanimation Médicale, Hôpital Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre Cedex, France.
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Dr. Diehl: Service de Réanimation Médicale, Hopital Europeen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France.
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Dr. Sollet: Service de Réanimation Médicale, Hôpital d'Argenteuil, 69 rue du Lieutenant Colonel Prudhon, 95100 Argenteuil, France.
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Dr. Tenaillon: Service de Réanimation Médicale, Centre Hospitalier Louise Michel, Quartier du Canal, 91014 Evry Courcouronnes Cedex, France.
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Author Contributions: Conception and design: J.-Y. Fagon, J. Chastre, C. Gervais.
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Analysis and interpretation of the data: J.-Y. Fagon, J. Chastre.
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Drafting of the article: J.-Y. Fagon, J. Chastre.
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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.
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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.
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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.
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Statistical expertise: J.-Y. Fagon, J. Chastre.
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Obtaining of funding: J.-Y. Fagon, J. Chastre.
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Administrative, technical, or logistic support: J.-Y. Fagon, J. Chastre.
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Collection and assembly of data: J.-Y. Fagon, J. Chastre.
- Copyright ©2004 by the American College of Physicians
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