De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate

Objective: To assess outcomes with de- escalation therapy in ventilator- associated pneumonia ( VAP). Design: Prospective observational study. Setting: Multidisciplinary intensive care unit. Patients and participants: VAP was diagnosed by positive quantitative cultures of both tracheal aspirate and bronchoalveolar lavage ( BAL) and treated appropriately for all significant isolates of tracheal aspirate and BAL in 143 patients who were assigned to de- escalation therapy by BAL or tracheal aspirate. Interventions: None. Measurements and results: Antibiotic therapy was de- escalated in 58 patients ( 40.5%), who had decreased mortality at day 15 ( 5.1% vs. 31.7%) and day 28 ( 12% vs. 43.5%) and shorter intensive care unit ( 17.2 +/- 1.2 vs. 22.7 +/- 6.3 days) and hospital ( 23.7 +/- 2.8 vs. 29.8 +/- 11.1 days) stay ( p < 0.05). Of the 81 patients assigned to tracheal aspirate, the 17 ( 21%) who achieved de- escalation of therapy had reduced 15- day mortality ( 5.8% vs. 34.3%), reduced 28- day mortality ( 11.6% vs. 45.3%), and shorter intensive care unit ( 17.2 +/- 1.6 vs. 22.4 +/- 6.4 days) and hospital ( 23.1 +/- 4.4 vs. 29.9 +/- 11.1 days) stay ( p < 0.05). Of the 62 patients assigned to BAL, the 41 ( 66.1%) who achieved de- escalation of therapy had decreased 15- day mortality ( 4.8% vs. 23.8%), decreased 28- day mortality ( 12.1% vs. 38%), and shorter intensive care unit ( 17.2 +/- 1.1 vs. 23.2 +/- 6 days) and hospital ( 23.8 +/- 2.4 vs. 29.8 +/- 11.4 days) stay ( p < 0.05). Conclusions: For patients with VAP who have had appropriate treatment and shown a favorable clinical response, mortality and duration of stay can be further improved by de- escalation therapy.