Quantitative culture of endotracheal aspirate and BAL fluid samples in
               the management of patients with ventilator-associated pneumonia: a randomized
               clinical trial

Corrêa, Ricardo de Amorim; Luna, Carlos Michel; Anjos, José Carlos Fernandez Versiani dos; Barbosa, Eurípedes Alvarenga; Rezende, Cláudia Juliana de; Rezende, Adriano Pereira; Pereira, Fernando Henrique; Rocha, Manoel Otávio da Costa

doi:10.1590/S1806-37132014000600008

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Original Articles • J. bras. pneumol. 40 (6) • Nov-Dec 2014 • https://doi.org/10.1590/S1806-37132014000600008 copy

Quantitative culture of endotracheal aspirate and BAL fluid samples in the management of patients with ventilator-associated pneumonia: a randomized clinical trial^* * Study carried out under the auspices of the Postgraduate Program in Health Sciences, Infectology and Tropical Medicine, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil ^ A versão completa em português deste artigo está disponível em www.jornaldepneumologia.com.br

SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVE:

To compare 28-day mortality rates and clinical outcomes in ICU patients with ventilator-associated pneumonia according to the diagnostic strategy used.

METHODS:

This was a prospective randomized clinical trial. Of the 73 patients included in the study, 36 and 37 were randomized to undergo BAL or endotracheal aspiration (EA), respectively. Antibiotic therapy was based on guidelines and was adjusted according to the results of quantitative cultures.

RESULTS:

The 28-day mortality rate was similar in the BAL and EA groups (25.0% and 37.8%, respectively; p = 0.353). There were no differences between the groups regarding the duration of mechanical ventilation, antibiotic therapy, secondary complications, VAP recurrence, or length of ICU and hospital stay. Initial antibiotic therapy was deemed appropriate in 28 (77.8%) and 30 (83.3%) of the patients in the BAL and EA groups, respectively (p = 0.551). The 28-day mortality rate was not associated with the appropriateness of initial therapy in the BAL and EA groups (appropriate therapy: 35.7% vs. 43.3%; p = 0.553; and inappropriate therapy: 62.5% vs. 50.0%; p = 1.000). Previous use of antibiotics did not affect the culture yield in the EA or BAL group (p = 0.130 and p = 0.484, respectively).

CONCLUSIONS:

In the context of this study, the management of VAP patients, based on the results of quantitative endotracheal aspirate cultures, led to similar clinical outcomes to those obtained with the results of quantitative BAL fluid cultures.

Bronchoalveolar lavage fluid/diagnosis; Respiratory aspiration; Pneumonia, ventilator-associated

Variable	BAL	EA	p
Variable	(n = 36)	(n = 37)	p
Male/female, n/n	15/21	11/26	0.287*
Age, years	67.1 ± 13.9	64.5 ± 14.8	0.438***
Duration of MV before VAP, h^b	155.5 (111.0-270.0)	192.0 (108.0-384.0)	0.429**
Comorbidities, n	7	6	0.719*
Previous use of antibiotics^c	16 (44.0)	18 (48.6)	0.719*
Duration of previous antibiotic therapy, days^b,d	6.0 (1.0-10.0)	6.0 (1.7-12.3)	0.721**
Body temperature, °C^b	38.5 (38.0-38.7)	38.4 (38.0-38.5)	0.481**
Mean arterial pressure^b	80.0 (67.5-90.7)	79.0 (71.0-96.5)	0.440**
Leukocyte count, cells/mm^3b	13,250 (9,525-16,200)	12,700 (9,950-16,300)	0.851**
PaO₂/FiO₂^b	197.5 (134.3-267.5)	205.0 (154.0-274.0)	0.651**
APACHE II	17.5 ± 5.7	15.3 ± 6.9	0.146***
APACHE II predicted mortality^b	19.5 (10.1-29.1)	13.4 (7.7-32.2)	0.477**
Blood culture			0.758*
Not performed^c	2 (5.6)	1 (2.7)
Negative^c	22 (61.1)	25 (67.6)
Positive^c	12 (33.3)	11 (29.7)
Negative/positive, n/n	22/12	25/11	0.867*

Mortality	BAL	EA	p*
Mortality	(n = 36)	(n = 37)	p*
At 14 days	8 (22.2)	11 (29.7)	0.643
At 28 days	9 (25.0)	14 (37.8)	0.353
Overall^b	19 (52.8)	23 (62.2)	0.417

Variable	BAL	EA	p
Variable	(n = 36)	(n = 37)	p
Antibiotic therapy, days	14.0 (13.3-17.0)	14.0 (10.5-20.0)	0.708**
Length of ICU stay, days^b
≤ 14	8 (22.2)	8 (21.6)	0.797*
15-27	12 (33.3)	15 (40.5)
≥ 28	16 (44.5)	14 (37.9)
Length of mechanical ventilation, days	16.0 (9.7-32.5)	19.5 (12.0-33.2)	0.597**
Appropriate antibiotic therapy^b	28 (77.8)	30 (83.3)	0.551*
Mortality^b,d
Appropriate therapy	10 (35.7)	13 (43.3)	0.553*
Inappropriate therapy	5 (62.5)	3 (50.0)	1.000***
Antibiotic therapy changes after culture^b,d
Appropriate therapy	16 (57.1)	16 (53.3)	0.771*
Inappropriate therapy	7 (87.5)	6 (100.0)	1.000***
Reasons for antibiotic change (appropriate group)^c,e
BALF/endotracheal aspirate results	15	13	0.498***
Another site of infection	1	2
Clinical deterioration	0	2
Reasons for antibiotic change (inappropriate group)^c,f
BALF/endotracheal aspirate results	6	4	0.706***
Another site of infection	1	1
Clinical deterioration	0	1

Variable	Group
	BAL			EA
	AAT	IAT	p	AAT	IAT	p
Duration of antibiotic therapy, days	14 (14.0-17.0)	14 (3.5-16.3)	0.348*	15 (11.7-20.0)	12 (7.0-21.0)	0.622*
Length of ICU stay, days^b
≤ 14	7 (25.0)	1 (12.5)	0.775**	6 (20.0)	1 (16.7)	0.851**
15-27	9 (32.1)	3 (37.5)		13 (43.3)	2 (33.3)
≥ 28	12 (42.9)	4 (50.0)		11 (36.7)	3 (50.0)
Antibiotic therapy changes after culture^b	16 (57.1)	7 (53.3)	0.213**	16 (53.3)	6 (100.0)	0.062**

Variable	BAL	EA	p
Responders to the modified antibiotic therapy^b	23 (92.0)	19 (79.2)	0.247**
Secondary complications
SIRS^c	3 (75.0)	2 (66.7)	1.000**
Sepsis^d	20 (95.2)	20 (95.2)	1.000**
Severe sepsis^e	5 (20.0)	2 (10.5)	0.680**
Septic shock^f	10 (28.6)	15 (45.5)	0.149*
Secondary VAP^g	0 (0.0)	2 (5.6)	0.151*
Organ failure^g	5 (13.9)	9 (25.0)	0.234*
Non-infectious complications^g	4 (11.1)	4 (11.1)	0.645**
Second EA^h	0 (0.0)	4 (36.4)	0.085**
Second BAL^h	0 (0.0)	0 (0.0)	-
Blood culture^h	2 (25.0)	2 (18.2)	1.000**

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E-mail: jbp@sbpt.org.br

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[1] Correspondence to: Ricardo de Amorim Corrêa. Department of Pulmonology and Thoracic Surgery, Federal University of Minas Gerais School of Medicine, Avenida Alfredo Balena, 190, Sala 216, Ala Leste, CEP 30130-100, Belo Horizonte, MG, Brasil Tel/Fax: 55 31 3409-9255. E-mail: racorrea9@gmail.com