📇 Rhumatologue · BLOIS · (41) · Libéral
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CABINET DU DR PIERRE DOMART
2 AVENUE DE VERDUN, 41000 BLOIS
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The American review of respiratory disease · 1989
Abstract Epidemiologic studies of nosocomial bacterial pneumonia in patients requiring mechanical ventilation have been limited because of the poor reliability of diagnosis procedures in this setting. To determine prognostic and descriptive factors of ventilator-associated (V-A) pneumonia, we prospectively studied 567 patients who had been receiving mechanical ventilation for more than 3 days in our unit. Fiberoptic bronchoscopy using a protected specimen brush (PSB) was performed on each patient suspected of having pneumonia because of the presence of a new pulmonary infiltrate and purulent tracheal secretions. The diagnosis of V-A pneumonia was retained only if PSB specimens yielded > 103 cfu/ml of at least one microorganism, unless this result was established to be a false positive result on follow-up. V-A pneumonia developed in 49 patients for a total of 52 episodes (9%). The actuarial risk of V-A pneumonia was 6.5% at 10 days, 19% at 20 days, and 28% at 30 days of ventilation. Patients with pneumonia were significantly older (65 versus 57 yr of age, p < 0.01) and more frequently had severe underlying illnesses (24 versus 10%, p < 0.01) than did patients without pneumonia. A total of 84 microorganisms (51 gram-negative and 33 gram-positive) were isolated in significant concentrations from PSB specimens. Pseudomonas aeruginosa and Staphylococcus aureus were involved in 31 and 33% of these pneumonias, respectively. Forty percent of all specimens yielded a polymicrobial flora with more than one potential pathogen. Prior antimicrobial therapy increased the rate of pneumonia caused by P. aeruginosa or Acinetobacter spp. (65 versus 19%, p < 0.01) and the frequency of methicillin resistance in staphylococcal infections (100 versus 33%, p < 0.05). Overall mortality in patients with V-A pneumonia was 71% compared with 29% in patients without pneumonia (p < 0.01). Only 13% of patients with pneumonia caused by P. aeruginosa or Acinetobacter spp. survived, whereas 31% of patients with pneumonia caused by other bacteria survived (p < 0.01).
The American review of respiratory disease · 1988
Abstract To determine the usefulness of samples obtained by bronchoscopy using a protected specimen brush and evaluated by quantitative culture techniques in establishing the diagnosis of nosocomial pneumonia in patients requiring mechanical ventilation, we prospectively studied 147 ventilated patients suspected of having nosocomial pneumonia because of the presence of a new pulmonary infiltrate and purulent tracheal secretions. Positive cultures of protected brush specimens (> 103 cfu/ml) were found in only 45 patients (31%). Subsequent follow-up confirmed the diagnosis of pneumonia in 34 of 45 patients, and in only 4 of 45 patients was a positive culture firmly established to be a false positive result. No patient with < 103 cfu/ml was subsequently shown to have had pneumonia, and the diagnosis was definitely excluded in 72 of 102 patients by the absence of pneumonia at autopsy or recovery without antibiotic therapy. In contrast, when 16 clinical variables were evaluated by stepwise logistic regression analysis, no combination could be identified that was useful in distinguishing patients with bacterial pneumonia. Furthermore, when the actual costs of evaluation and therapy of our patients were compared with the projected costs entailed in treating all patients suspected of having pneumonia with antibiotics, evaluation using the protected specimen brush and quantitative cultures was less expensive after only 6 days of treatment. These results suggest that the appearance of pulmonary infiltrates and purulent tracheal secretions does not result from bacterial pneumonia in a majority of patients. Patients requiring antimicrobial therapy can be accurately identified using samples obtained with a protected specimen brush and evaluated with quantitative culture techniques, but cannot be distinguished on clinical grounds alone. Evaluation of patients suspected of having nosocomial pneumonia by this procedure avoids the unnecessary use of antibiotics in such patients, thereby reducing toxicity associated with antibiotic use and the overall cost of patient management.
Lancet (London, England) · 1985
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The American review of respiratory disease · 1989 · Journal Article
Fagon JY, Chastre J, Domart Y, Trouillet JL, et al.
The American review of respiratory disease · 1988 · Journal Article
Fagon JY, Chastre J, Hance AJ, Guiguet M, et al.
Antimicrobial agents and chemotherapy · 1987 · Journal Article
Domart Y, Pierre C, Clair B, Garaud JJ, et al.
Lancet (London, England) · 1985 · Journal Article
Trouillet JL, Chastre J, Fagon JY, Pierre J, et al.