The New England Journal of Medicine. 355(25):2619–2630, DECEMBER 21ST, 2006

DOI: 10.1056/NEJMoa052904

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PMID: 17182987

Issn Print: 0028-4793

Publication Date: December 21st, 2006


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A Randomized Trial of Diagnostic Techniques for Ventilator-Associated Pneumonia

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Abstract

BackgroundCritically 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.MethodsIn 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.ResultsWe 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.ConclusionsTwo 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.)N Engl J Med 2006;3552619-30.

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