The Science Journal of the American Association for Respiratory Care

2000 OPEN FORUM Abstracts

THE EFFECT OF BLIND PROTECTED SPECIMEN BRUSH SAMPLING ON ANTIBIOTICS USAGE IN PATIENTS WITH SUSPECTED VENTILATOR ASSOCIATED PNEUMONIA

Paul E. Marik, MD, FCCM; Joseph Lynott, MS, RRT; Michelle Croxton, MT(ASCP)SM Edward Palmer, RRT; Larry Miller, RRT and Gary P. Zaloga, MD, FCCM Division of Critical Care Medicine, Respiratory Services and Microbiology, Washington Hospital Center, Washington, DC

Background: The diagnosis of pneumonia in ventilated patients is exceedingly difficult. Although culture of tracheal aspirates have poor diagnostic value they are frequently used to diagnose ventilator associated pneumonia (VAP). Recently, a number of studies have reported on the diagnostic value of "blind" protected specimen brush (B-PSB) sampling in the diagnosis of VAP. B-PSB can readily and safely be performed by Respiratory Care Practitioner's (RCP's). The aim of this study was to determine the cost-effectiveness of B-PSB sampling performed by RCP's in patients with suspected VAP.
Methods: During a three month run in period, patients in our MICU with suspected VAP were treated based on clinical criteria and tracheal-aspirate culture. Following this run in period the house-staff, nurses and RT's were prevented from sending tracheal aspirates for culture. All patients suspected of having ventilator associated pneumonia underwent B-PSB sampling with quantitative culture. The B-PSB sampling was performed by RCP's who had been trained to perform the technique. A PSB with a potential bacterial pathogen in a concentration >500 CFU/ml was regarded as positive.
Results: During the 3 month run in period 172 patients received mechanical ventilation with an average of 4.9 ± 3.1 ventilator days/patient. During this period 79 patients were treated for VAP. During the 3 month study period 160 patients received mechanical ventilation with an average of 5.1 ± 2.9 ventilator days per patient (NS). 58 B-PSB samplings were performed in 50 patients for suspected VAP. No complications related to the procedure were reported. No tracheal-aspirates were cultured during this time period. Eight patients had positive PSB cultures. Antibiotics were changed in 3 of these patients based on the PSB results. Thirty-eight courses of antibiotics (in 36 patients) were stopped based on negative PSB results. Twelve cases of VAP were suspected in 6 patients receiving antibiotics for other reasons. No change in antibiotics were made in these cases based on negative PSB results. The length of mechanical ventilation was 5.4 ± 3.2 days in the 38 culture negative patients in whom antibiotics were stopped compared to 8.2 ± 4.7 days in the eight patients with PSB positive VAP (NS; p=014s). The direct cost savings, as a result of discontinuing antibiotics was $9500. There were additional cost savings due to the reduced number of culture specimens sent to the lab (approximately $2,000), with a projected annual cost saving of $46,000.
Conclusion: B-PSB sampling is a simple and cost efficient diagnostic test that can safely be performed by RCP's. Furthermore, this study confirms that antibiotics may be safely discontinued in patients with negative quantitative culture results.

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