De-escalation Therapy for Ventilator Associated Pneumonia - Correlation Between Bronchoalveolar Lavage and Clinical Pulmonary Infection Score

Abstract

SESSION TYPE: ICU Safety and Improvement StrategiesPRESENTED ON: Tuesday, October 23, 2012 at 02:45 PM - 04:15 PMPURPOSE: Antibiotic are commonly indicated in Intensive Care unit (ICU) for Ventilator-Associated pneumonia (VAP). A surrogate tool for VAP diagnosis is the Clinical Pulmonary Infection Score (CPIS). Goal of the study was to evaluated role of bronchoscopic bronchoalveolar lavage (BAL) in de-escalation of antibioticsMETHODS: Retrospectively review of ICU patients undergoing BAL for VAP from January 2010 to July 2011. Based in the risk for VAP three groups were identified: low (CPIS≤3), intermediate ( CPIS 4-6) and high-risk ( CPIS>6). Demographics, severity of illness and BAL data were compared between the intermediate and high risk groups. Primary outcome was antibiotic de-escalation; secondary outcomes were: identification of organism, quantitative BAL cultures≥ 104(+QC), ICU length of stay (ICULOS), hospital mortality.RESULTS: 147 BAL were performed for suspected VAP; 117(80%) patients had intermediate and 28(19%) had high risk for VAP. There was a difference for presence of severe sepsis/septic shock and low albumin levels in high-risk VAP patients (39.4%versus78.5%, p 0.001) and (2.6± 0.69 versus 2.9±0.78, p 0.05) respectively. No differences were found for age, gender, APACHE IV, incidence of nursing home and HIV infected patients; neither for PaO2, PaO2/FiO2, WBC and platelets count, creatinine levels. The high-risk group had more organisms identified (85.7%versus 53.7% p=0.002 and a trend for higher +QC (35.7% versus 27.7%, p 0.48) compared to the intermediate risk-group. Antibiotic de-escalation was done in 100% of intermediate versus 66% of the high risk-group (p 0.47). De-escalation occurred in 90% with identified organism and in all patients with +QC and identified organism. No difference in ICULOS or mortality was found.CONCLUSIONS: Reported de-escalation of antibiotics in VAP varies from 22-74%. In our study, bronchoscopic BAL resulted in de-escalation in 90% of patients when organism was identified.CLINICAL IMPLICATIONS: We suggest bronchoscopic BAL for suspected VAP with CPIS≥4 as 27.7% of the intermediate risk patients had +QC which is considered diagnostic of VAP. In high risk-group we recommend use of combined +QC and presence of organism before de-escalationDISCLOSURE: The following authors have nothing to disclose: Vimala Rapaka, Anmol Kharbanda, Parthiv Desai, Sindhaghatta Venkatram, Gilda Diaz-FuentesNo Product/Research Disclosure InformationBronx Lebanon Hospital Center, Bronx, NY