Impact of BAL in the Management of Pneumonia With Treatment Failure
| Autor: | Elnara Marcia Negri, Francisco Garcia Soriano, Irineu Tadeu Velasco, João Carlos Gomes, Leila Antonângelo, Evangelina M.P.A. Arauójo, Wilson L. Pedreira |
|---|---|
| Rok vydání: | 2000 |
| Předmět: |
Pulmonary and Respiratory Medicine
medicine.medical_specialty medicine.diagnostic_test biology medicine.drug_class business.industry Respiratory disease Antibiotics Drug resistance Critical Care and Intensive Care Medicine medicine.disease biology.organism_classification Surgery Acinetobacter baumannii Pneumonia Bronchoalveolar lavage Community-acquired pneumonia Internal medicine medicine Anaerobic bacteria Cardiology and Cardiovascular Medicine business |
| Zdroj: | Chest. 118:1739-1746 |
| ISSN: | 0012-3692 |
| Popis: | Background: Pneumonia is responsible for 50% ofantibiotics prescribed in ICUs. Treatment failure, ie ,absence of improvement or clinical deterioration under antibiotictherapy, presents a dilemma to physicians. BAL is an invasive methodvalidated for etiologic diagnosis in pneumonia. Studyobjective: To evaluate in ICU patients the impact of BAL in theetiologic diagnosis, treatment, and outcome of pneumonia with treatmentfailure. Design: Prospective clinical study. Setting: Nonsurgical, medical ICU of a university hospitalin Brazil. Patients and participants: Sixty-twoepisodes of pneumonia treated for at least 72 h without clinicalimprovement in 53 patients hospitalized for diverse clinicalemergencies. Mean duration of hospitalization was 14.2 days. Meanduration of previous antibiotic therapy was 11.4 days. Interventions: Bronchoscopy and BAL were performed in eachepisode. BAL fluid was cultivated for aerobic and anaerobic bacteria; the cutoff considered positive was 10 4 cfu/mL;10 3 cfu/mL was also analyzed if under treatment. Pneumocystis carinii, fungi, Legionella spp, and, Mycobacterium spp were also researched. Measurements andresults: Fifty-eight of 62 BAL were performed under antibiotics. The results showed positivity in 45 of 62 (72.6%); 42 of the 45positive episodes (93.3%) had > 10 4 cfu/mL. The threecases with between 10 3 and 10 4 cfu/mL wereconsidered positive and were treated according to BAL cultures. Themain agents were Acinetobacter baumannii (37.1%), Pseudomonas aeruginosa (17.7%), andmethicillin-resistant Staphylococcus aureus (MRSA;16.1%); 46.7% of the episodes (21 of 45) were polymicrobial. BALresults directed a change of therapy in 34 episodes (54.8%). Overallmortality was 43.5%. There was no difference in mortality amongpositives, negatives, and patients who changed therapy guided by BALculture. Conclusions: (1) BAL fluid examination waspositive in 45 of 62 episodes (72.6%), with 58 of 62 BAL performedunder antibiotics. This suggests that BAL may be a sensitive diagnosticmethod for treatment failures of clinically diagnosed pneumonias, evenif performed under antibiotics; (2) the main pathogens in our studywere A baumannii , P aeruginosa, and MRSA,and approximately 45% of infections were polymicrobial; (3) BALculture results directed a change of therapy in 75.6% of positiveepisodes (34 of 45) and in 54.8% of all episodes of treatment failure(34 of 62); and (4) there was no difference in mortality amongpositives, negatives, and patients who changed therapy guided by BALculture. |
| Databáze: | OpenAIRE |
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