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J Y Fagon

Publications and source records attributed to J Y Fagon.

At least 19 recordsLinked to original sources
PubMed2003

Diagnosis and treatment of nosocomial pneumonia in ALI/ARDS patients.

Ventilator-associated pneumonia (VAP) is a common complication of the acute respiratory distress syndrome (ARDS) or acute lung injury (ALI), often leading to the development of sepsis, multiple organ failure, and death. However, the diagnosis of pulmonary infection in patients with ARDS/ALI is often difficult: the systemic signs of infection, such as fever, tachycardia, leukocytosis are nonspecific findings in such patients; a variety of causes other than pneumonia can explain asymmetric consolidation in patients with ARDS and marked asymmetry of radiographic abnormalities has also been reported in patients with uncomplicated ARDS. In 2003, physicians in charge of these patients have to identify patients with true bacterial lung infection, to select appropriate initial antibiotic therapy, to adjust therapy as soon as possible, and to withhold antibiotics in patients without VAP. To do that, a bacteriological strategy based on the use of quantitative cultures of specimen obtained with fibreoptic bronchoscopy performed before initiation or modification of antibiotic treatment seems better than a strategy based on clinical evaluation alone, lowering antibiotic consumption and improving outcome. When bronchoscopy is not available or contraindicated, a nonbronchoscopic strategy or a clinical strategy with reevaluation 3 days after initiation of treatment may be used. Antimicrobial treatment of VAP is a complex issue. Some general principles can be helpful for the selection of initial treatment: knowledge of most frequently identified responsible pathogens and their susceptibility patterns in the unit; prior duration of hospitalisation; previously prescribed antibiotics; information obtained by direct examination of pulmonary secretions; antibacterial activity and pharmacodynamic characteristics of antibiotics that could be used to treat this infection. Appropriateness of initial antimicrobial therapy is probably a major prognostic factor for patients with ventilator-associated pneumonia. Thus, before new antiboitics are administered, reliable pulmonary specimens must be obtained for direct examination and cultures.

Anti-Bacterial Agents↗
PubMed2001

[Epidemiology and antibiotic therapy in nosocomial pneumonia].

Nosocomial pneumonia occurs in 0.5 to 1.5% of all hospitalized patients and in 10 to 30% of those under artificial ventilation. The main causal agents are Staphylococcus aureus and resistant Gram-negative bacilli, particularly Pseudomonas aeruginosa. In case of early onset (before the fifth day), Haemophilus influenzae, Streptococcus pneumoniae and susceptible enterobacteria predominate. These infections are associated with overmortality, particularly in patients with P. aeruginosa pneumonia, severe respiratory failure, shock syndrome or given a poorly adapted antibiotic regimen. Management of patients with nosocomial pneumonia depends on the clinical presentation and prior bacteriology data often leading to empiric antibiotic prescription. Published guidelines, for example those recommended by the American Thoracic Society, can also be used to adapt the antibiotic therapy as a function of the severity of the clinical situation, the patient's comorbidities, and the date of onset. This type of strategy remains to be evaluated. It would be advisable to base therapeutic management on reliable microbiological data allowing selection of patients requiring antibiotics and treatment based on culture results. Currently a two-drug regimen is recommended for nosocomial pneumonia due to P. aeruginosa or particularly resistant strains.

Anti-Bacterial Agents↗
PubMed2000

[Duration of treatment of nosocomial pneumonia. What judgement criteria to use?].

AN UNRESOLVED ISSUE: Inappropriate duration of antibiotic treatment is one of the factors explaining the high mortality of nosocomial pneumonia. There are however few data on the ideal duration of treatment. An improvement in the radiological image is not a good criterion. The right duration would be one that is necessary and sufficient to achieve cure and avoid recurrence and relapse and also one that avoids the drawbacks of prolonged treatment. LIMITATIONS OF CLINICAL CRITERIA: High-grade fever, an alveolar image on the chest x-ray, and a high white cell count are synonymous with bacterial pneumonia in only 40 to 60% of the cases. PRIMARY AND SECONDARY INFECTION: Using reliable microbiological methodology is has been possible to demonstrate that the causal germs of primary infections disappear by day 3 of an adapted treatment but that early secondary infection occurs in 14% of the cases. PROSPECTS FOR PROGRESS: An open multicentric randomized study is being conducted in France to compare 7 day versus 14 day treatment against identified germs (irrespective of the strain isolated) using reliable microbial sampling techniques.

Cross Infection↗
PubMed2000

Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial.

BACKGROUND: Optimal management of patients who are clinically suspected of having ventilator-associated pneumonia remains open to debate. OBJECTIVE: To evaluate the effect on clinical outcome and antibiotic use of two strategies to diagnose ventilator-associated pneumonia and select initial treatment for this condition. DESIGN: Multicenter, randomized, uncontrolled trial. SETTING: 31 intensive care units in France. PATIENTS: 413 patients suspected of having ventilator-associated pneumonia. INTERVENTION: The invasive management strategy was based on direct examination of bronchoscopic protected specimen brush samples or bronchoalveolar lavage samples and their quantitative cultures. The noninvasive ("clinical") management strategy was based on clinical criteria, isolation of microorganisms by nonquantitative analysis of endotracheal aspirates, and clinical practice guidelines. MEASUREMENTS: Death from any cause, quantification of organ failure, and antibiotic use at 14 and 28 days. RESULTS: Compared with patients who received clinical management, patients who received invasive management had reduced mortality at day 14 (16.2% and 25.8%; difference, -9.6 percentage points [95% CI, -17.4 to -1.8 percentage points]; P = 0.022), decreased mean Sepsis-related Organ Failure Assessment scores at day 3 (6.1+/-4.0 and 7.0+/-4.3; P = 0.033) and day 7 (4.9+/-4.0 and 5.8+/-4.4; P = 0.043), and decreased antibiotic use (mean number of antibiotic-free days, 5.0+/-5.1 and 2.2+/-3.5; P < 0.001). At 28 days, the invasive management group had significantly more antibiotic-free days (11.5+/-9.0 compared with 7.5+/-7.6; P < 0.001), and only multivariate analysis showed a significant difference in mortality (hazard ratio, 1.54 [CI, 1.10 to 2.16]; P = 0.01). CONCLUSIONS: Compared with a noninvasive management strategy, an invasive management strategy was significantly associated with fewer deaths at 14 days, earlier attenuation of organ dysfunction, and less antibiotic use in patients suspected of having ventilator-associated pneumonia.

Anti-Bacterial Agents↗
PubMed1999

Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients. SRLF Collaborative Group on Mechanical Ventilation. Société de Réanimation de Langue Française.

OBJECTIVE: To evaluate the prevalence and outcome of the acute respiratory distress syndrome (ARDS) among patients requiring mechanical ventilation. DESIGN: A prospective, multi-institutional, initial cohort study including 28-day follow-up. SETTINGS: Thirty-six French intensive care units (ICUs) from a working group of the French Intensive Care Society (SRLF). PATIENTS: All the patients entering the ICUs during a 14-day period were screened prospectively. Hypoxemic patients, defined as having a PaO(2)/FIO(2) ratio (P/F) of 300 mmHg or less and receiving mechanical ventilation, were classified into three groups, according to the Consensus Conference on ARDS: group 1 refers to ARDS (P/F: 200 mmHg or less and bilateral infiltrates on the chest X-ray); group 2 to acute lung injury (ALI) without having criteria for ARDS (200 < P/F </= 300 mmHg and bilateral infiltrates) and group 3 to patients with P/F of 300 mmHg or less but having exclusion criteria from the previous groups. RESULTS: Nine hundred seventy-six patients entered the ICUs during the study period, 43 % of them being mechanically ventilated and 213 (22 %) meeting the criteria for one of the three groups. Among all the ICU admissions, ARDS, ALI and group 3 patients amounted, respectively, to 6.9 % (67), 1.8 % (17) and 13.3 % (129) of the patients, and represented 31.5 %, 8.1 % and 60.2 % of the hypoxemic, ventilated patients. The overall mortality rate was 41 % and was significantly higher in ARDS patients than in the others (60 % vs 31 % p < 0.01). In group 3, 42 patients had P/F less than 200 mmHg associated with unilateral lung injury; mortality was significantly lower (40.5 %) than in the ARDS group. In the whole group of hypoxemic, ventilated patients, septic shock and severity indices but not oxygenation indices were significantly associated with mortality, while the association with immunosuppression revealed only a trend (p = 0.06). CONCLUSIONS: In this survey we found that very few patients fulfilled the ALI non-ARDS criteria and that the mortality of the group with ARDS was high.

Adult↗
PubMed1998

Hospital-acquired pneumonia: methicillin resistance and intensive care unit admission.

Although epidemiologic investigations of hospital-acquired pneumonia have certain intrinsic limitations because of the heterogeneity of the study populations, the difficulties in making a clinical diagnosis of nosocomial pneumonia, and the need for better microbiologic assays, recent studies have provided new and important data concerning the role of Staphylococcus aureus in this disease. This pathogen has now been identified as the most frequent cause of nosocomial pneumonia in hospitals in both Europe and the United States among patients in general hospital units as well as in the intensive care unit (ICU). Patients who have been treated with mechanical ventilation are at especially high risk for S. aureus pneumonia. The incidence of nosocomial pneumonia related to methicillin-resistant S. aureus (MRSA) has increased in recent years in many countries, especially among patients in the ICU. Because hospitalized patients with suspected nosocomial pneumonia often have many risk factors for MRSA infection, it seems advisable to include coverage of MRSA in the initial therapeutic regimen for these patients until MRSA infection is excluded.

Cross Infection↗
PubMed1998

Colonization by Acinetobacter baumanii in intensive-care-unit patients.

We prospectively studied the value of systematic rectal swabs performed for the detection of colonization and the prediction of infections by Acinetobacter baumanii in 751 consecutive patients admitted to five intensive-care units (ICUs) over an 8-month period. Gastrointestinal tract colonization was found in 8.7% of ICU admissions. The positive and negative predictive values of rectal swabs for the detection of subsequent infection were 17% and 99%, respectively. Sensitivity and specificity were 55% and 93%, respectively. We also determined the comparative values of rectal or nasal swabs and skin cultures for the detection of A baumanii colonization in 25 patients already colonized or infected with A baumanii. The combination of rectal and nasal swabs was positive in 20 (80%) of 25. The results of the present study suggest that detection of gastrointestinal tract A baumanii colonization is not an accurate predictor of subsequent A baumanii infection and that combined rectal and nasal swabs might be used for the detection of A baumanii colonization in ICU patients.

Acinetobacter↗
PubMed1998

Determination of total effective vascular compliance in patients with sepsis syndrome.

Changes in capacitance vessels have important consequences on cardiac filling pressure and fluid volume distribution in patients with sepsis syndrome. Vascular compliance may be evaluated from the slope of the relationship between changes in total blood volume (deltaTBV) and changes in central venous pressure (deltaCVP) during acute volume expansion (450 ml of gelatin fluid over 6 min), i.e., from the deltaTBV/deltaCVP ratio. The mean ratio (ml x mm Hg-1 x kg-1) was 2.03 +/- 0.21 in control subjects, 1.43 +/- 0.25 in mechanically ventilated patients without sepsis syndrome, and 0.94 +/- 0.24 in mechanically ventilated patients with sepsis syndrome (p < 0.0001 versus the other two groups). Based on echocardiographic determinations, cardiac performance was constantly found within the normal range (cardiac output ranged from 5.6 +/- 1.2 to 6.7 +/- 2.0 L/min in nonseptic patients from 6.8 +/- 1.9 to 7.8 +/- 2.2 in septic patients). Effective compliance of the total vascular bed is therefore reduced in patients with sepsis syndrome, independently of the hemodynamic modifications due to mechanical ventilation.

Adolescent↗
PubMed1998

Risk factors and outcome of nosocomial infections: results of a matched case-control study of ICU patients.

Intensive-care-unit (ICU) patients are at risk for both acquiring nosocomial infection and dying, and require a high level of therapy whether infection occurs or not. The objective of the present study was to precisely define the interrelationships between underlying disease, severity of illness, therapeutic activity, and nosocomial infections in ICU patients, and their respective influences on these patients' outcome. In a 10-bed medical ICU, we conducted a case-control study with matching for initial severity of illness, with daily monitoring of severity of illness and therapeutic activity scores, and with analysis of the contribution of nosocomial infections to patients' outcomes. Forty-one cases of patients who developed nosocomial infections during a 1-yr period were paired with 41 controls without nosocomial infection according to three criteria: age (+/- 5 yr), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (+/- 5 points), and duration of exposure to risk. Successful matching was achieved for 118 of 123 (96%) variables. Neurologic failure on the third day after ICU admission was the sole independent risk factor for nosocomial infection (adjusted odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.09 to 1.64; p = 0.007). Unlike control patients, case patients showed no clinical improvement and required a high level of therapeutic activity between ICU admission and the day of infection. Mortality attributable to nosocomial infection was 44%. Excess length of stay and duration of antibiotic treatment attributable to nosocomial infection were 14 d and 10 d, respectively. Attributable therapeutic activity as measured with the Therapeutic Intervention Scoring System (TISS) and Omega score was 368 and 233 points, respectively. Such consequences were observed in patients who developed multiple infections. These findings suggest that a persistent high level of therapeutic activity and persistent impaired consciousness are risk factors for nosocomial infections in ICU patients. These infections are responsible for excess mortality, prolongation of stay, and excess therapeutic activity resulting in important cost overruns for health-care systems.

APACHE↗
PubMed1997

Improvement of internal jugular vein cannulation using an ultrasound-guided technique.

OBJECTIVE: To determine whether ultrasound guidance can help operators to improve the results of jugular vein access in the ICU. DESIGN: Prospective, randomized study. SETTING: General Intensive Care Unit of a University Hospital. PATIENTS: Seven-nine patients were assigned to internal jugular vein cannulation using anatomical landmarks alone (control group, n = 42) or with ultrasound guidance (ultrasound group, n = 37). INTERVENTION: All cannulations were performed by junior house staff under the direct supervision of a senior physician. In the ultrasound group, an ultrasonography (7.5 MHz) was used and the transducer was covered by a sterile sheath. The placement and direction of the cannulating needle were determined on the ultrasound image. MEASUREMENTS AND RESULTS: Internal jugular vein cannulation was successful in 37/37 (100%) patients in the ultrasound group and in 32/42 patients (76%) in the control group (p < 0.01). Average access time was longer in the control group (235 +/- 408 s vs 95 +/- 174 s, p = 0.06) and carotid artery puncture occurred in five patients in each group (p = 0.83). Jugular cannulation was successful at the first attempt in 26% in the control group and 43% in the ultrasound group (p = 0.11). Thirty-two patients (86%) in the ultrasound group and 23 patients (55%) in the control group (p < 0.05) were cannulated within 3 min. The cannula could therefore not be inserted within 3 min in 19 patients (45%) in the control group. Failure was explained by thrombosis (n = 1), small caliber of the internal jugular vein (< 5 mm, n = 3), abnormal vascular relations (n = 3). Among the ten primary failures of cannulation, an internal jugular vein catheter was able to be inserted in four cases by an experienced physician on the side initially selected and with ultrasound guidance in two cases. The catheter was inserted into the contralateral internal jugular vein under ultrasound guidance in the remaining four cases. CONCLUSION: Ultrasound guidance improved the success rate of jugular vein cannulation in ICU patients. Our results suggest that ultrasound guidance should be used when the internal jugular vein has not been successfully cannulated within 3 min by the external landmark-guided technique.

Aged↗
PubMed1997

[Prevention of acquired pneumonia during artificial ventilation (excluding the use of anti-infectious agents)].

Nosocomial pneumonia remains a serious complication which occurs in patients who are artificially ventilated; as neither frequency nor important sequelae have altered recently inspite of the progress which has been achieved both with diagnosis and treatment. Preventative measures ought to be developed and realistically assessed before their introduction. Today it is indispensable to measure the impact of these measures, whether they have been previously or recently proposed by therapeutic trials. The current techniques proposed to prevent the appearance of nosocomial pneumonia are integrated in the usual conventional group of measures in the struggle against nosocomial infection which rests predominantly on standard approaches to hospital hygiene. These may be more specifically directed at good practical measures for the care of the ventilated patient. Regular toilet to the digestive and respiratory pathway, care of the ventilator material, absence of the changing of ventilation tubing during the stay. A certain number of measures are specifically suggested to prevent pneumonias: they have been imperfectly evaluated in clinical practice and remain controversial. Thus selective decontamination of the digestive system has not been dealt with her but also the sitting position, the utilisation of turning or oscillating beds, the continuous aspiration of oropharyngeal secretions or the use of Sucralfate as a means of prevention stress ulcers. Today, and until a complete evaluation of different techniques, the prevention of acquired pneumopathy during artificial ventilation rests above all on extremely simple measures; these cost little and are essentially meticulous care of the upper respiratory and digestive apparatus, to tracheal aspiration and physiotherapy which assure effective drainage and secretions, the use of the semi-sitting position, a well positioned gastric tube, in other words, basic care of the ventilated patient of a very good quality.

Beds↗
PubMed1996

[Nosocomial pneumonia in intensive care units].

Nosocomial pneumonia is associated with substantial morbidity and mortality. Patients treated with mechanical ventilation have the highest risk for developing this intensive care unit acquired infection. Gram-negative bacilli are the predominant organisms responsible for pneumonia in this setting. However, Staphylococcus aureus has recently emerged as a significant isolate. Nosocomial pneumonia is difficult to diagnose clinically in ventilated patients because fever, lung infiltrate on chest X-ray, leukocytosis are frequent in severely ill patients under mechanical ventilation whatever lung infection is present or not and because lower respiratory tract of such patients is colonized by potentially pathogenic bacteria independently of the presence of true lung infection; thus, different diagnostic strategies are proposed. Our personal bias is that using bronchoscopic techniques to obtain bronchoalveolar lavage and protected-brush specimens permits us to devise a therapeutic strategy that is superior to one based only on clinical evaluation. Measures for prevention of nosocomial infection are essential to decrease the incidence of nosocomial pneumonia and the emergence of multiresistant pathogens.

Cross Infection↗
PubMed1996

Nosocomial pneumonia and mortality among patients in intensive care units.

OBJECTIVE: To evaluate the role that nosocomial pneumonia plays in the outcome of intensive care unit (ICU) patients. DESIGN: Cohort study. SETTING: Medical ICU, Hôpital Bichat, Paris, France, an academic tertiary care center. PATIENTS: A total of 1978 consecutive patients admitted to the ICU for at least 48 hours. MAIN OUTCOME MEASURES: Various parameters known to be strongly associated with death of ICU patients were recorded: age, location before admission to the ICU, diagnostic categories, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiologic Score, McCabe score, number and type of dysfunctional organs, and the development of nosocomial bacteremia and nosocomial urinary tract infection. These variables and the presence or absence of nosocomial pneumonia were compared between survivors and nonsurvivors and entered into a stepwise logistic regression model to evaluate their independent prognostic roles. RESULTS: Nosocomial pneumonia developed in 328 patients (16.6%) whose mortality was 52.4% compared with 22.4% for patients without ICU-acquired pneumonia (P < .001), APACHE II score (odds ratio [OR] = 1.08; 95% confidence interval [CI], 1.06 to 1.10; P < .001), number of dysfunctional organs (OR = 1.54; 95% CI, 1.36 to 1.74; P < .001), nosocomial pneumonia (OR = 2.08; 95% CI, 1.55 to 2.80; P < .001), nosocomial bacteremia (OR = 2.51; 95% CI, 1.78 to 3.55; P < .001), ultimately or rapidly fatal underlying disease (OR = 1.76; 95% CI, 1.38 to 2.25; P < .001), and admission from another ICU (OR = 1.30; 95% CI, 1.01 to 1.68; P =.04) were significantly associated with mortality. CONCLUSION: These data suggest that, in addition to the severity of underlying medical conditions and nosocomial bacteremia, nosocomial pneumonia independently contributes to ICU patient mortality.

APACHE↗
PubMed1996

Diagnostic and therapeutic implications of transesophageal echocardiography in medical ICU patients with unexplained shock, hypoxemia, or suspected endocarditis.

OBJECTIVE: To evaluate the diagnostic and therapeutic implications of transesophageal echocardiography (TEE) in intensive care patients. DESIGN: Comparative study. SETTING: A 10-bed general intensive care unit. PATIENTS: Between 1 January 1992 and 31 May 1993, 61 patients prospectively identified with shock (n = 14), severe, unexplained hypoxemia (Partial pressure of oxygen in arterial blood/fractional inspired oxygen < 200) (n = 31), or suspected endocarditis (n = 16) underwent a TEE examination to supplement transthoracic echocardiography (TTE) examination. INTERVENTIONS: The results of each TEE examination were compared with the clinical findings and TTE data. TEE examinations were classified as follows: 0, TEE results were similar to TTE results; 00, TEE examination resulted in exclusion of suspected abnormalities; 1, TEE revealed a new but minor diagnosis compared to the TTE diagnosis; 2, TEE revealed a new major diagnosis not requiring a change of treatment; 3, TEE results revealed a new major diagnosis requiring an immediate change of treatment. RESULTS: Intraobserver reliability of the TEE classification was confirmed by a 100% concordance and interobserver reliability was evaluated as an 84% concordance. Results of the TEE classification were: class 0, n = 21 (34%); class 00, n = 13 (21%); class 1, n = 7 (12%); class 2, n = 8 (13%); class 3, n = 12 (20%). Therapeutic implications of TEE in class 3 patients were cardiac surgery in 5 patients (2 cases of acute mitral regurgitation, 2 valvular abscesses, and 1 hematoma compressing the left atrium), discontinuation of positive end-expiratory pressure in 1 ventilated patient with an atrial septal defect, weaning off mechanical ventilation in 1 patient with an atrial septal defect, prescription of antimicrobial therapy in 3 patients with endocarditis, and prescription of anticoagulant therapy in 2 patients with left atrial thrombus. No difficulty inserting the transducer was observed in any of the 61 patients studied. The only noteworthy complication was a case of spontaneously resolving atrial fibrillation. CONCLUSION: TEE is safe and well tolerated and is useful in the management of patients in the intensive care unit with shock, unexplained and severe hypoxemia, or suspected endocarditis when TTE is inconclusive.

Aged↗
PubMed1996

Long-term outcome and quality of life of patients requiring multidisciplinary intensive care unit admission after cardiac operations.

Patients with organ failure or severe infection after cardiac operations may require prolonged stays in the intensive care unit. This study examined long-term mortality and determined quality of life for surviving patients in this group. This observational cohort study was conducted at Bichat Hospital, Paris, an academic tertiary care center. The study group consisted of 116 consecutive patients who underwent cardiac operations and were transferred to the multidisciplinary intensive care unit between January 1986 and December 1987. Patients referred for mediastinitis were automatically excluded. Respiratory failure (88.8%) and hemodynamic instability (81.9%) were the main causes of transfer; an infection was present in 23.3% of patients at entry into the intensive care unit. Twenty-seven patients (23.3%) died in the intensive care unit. Presurgical New York Heart Association functional class, postoperative bacteremia before admission to the intensive care unit, and severity of illness on admission to the intensive care unit were independent predictors of death in the intensive care unit. After an average follow-up of 81 months (range 70 to 93 months), 69% of the patients alive at transfer from the intensive care unit were still alive. Preoperative New York Heart Association functional class was the only long-term independent prognostic factor. Quality of life, as evaluated by the Nottingham Health Profile, was good for more than 70% of the survivors and was not influenced by any recorded variables, with the exception of age.

Aged↗
PubMed1996

Mortality due to ventilator-associated pneumonia or colonization with Pseudomonas or Acinetobacter species: assessment by quantitative culture of samples obtained by a protected specimen brush.

Ventilator-associated pneumonia (VAP) due to multiresistant pathogens is associated with a high death rate. We analyzed the relationship between VAP due to Pseudomonas or Acinetobacter species and death by comparing the outcomes for patients colonized with these pathogens (bacterial counts of < 10(3) cfu/mL) with those for patients with pneumonia due to these pathogens (bacterial counts of > or = 10(3) cfu/mL). Samples were obtained systematically with a protected specimen brush when pneumonia was suspected. Clinical characteristics at admission to our intensive care unit and clinical features at the time of suspicion of VAP were not significantly different between colonized patients and those with VAP. Mortality rates were 29% among colonized patients and 73% among patients with VAP (P < .001). These results demonstrate a relationship between a high mortality rate and the development of pneumonia due to multiresistant, nonfermenting, gram-negative bacilli ( > or = 10(3) cfu/mL) in the lower airways of patients receiving ventilatory support.

Acinetobacter↗
PubMed1996

Diagnosis of pulmonary infections in mechanically ventilated patients.

The optimal management strategy for ventilator-dependent patients who develop symptoms suggestive of lung infection remains controversial. Proponents of the empirical approach prefer to treat most patients with fever and pulmonary infiltrates with one or more new antibiotics, even if it may be difficult (1) to determine whether pneumonia has developed in such patients, (2) in case of infection, to precisely identify the responsible microorganisms and thereby select the optimal antimicrobial treatment, and (3) to avoid resorting to broad-spectrum drug coverage in patients without true infection. Our personal bias is that using bronchoscopic techniques to obtain protected specimen brush and bronchoalveolar lavage specimens from the affected area in the lung permits to devise a therapeutic strategy superior to the one based only on clinical evaluation. These bronchoscopic techniques, when they are performed before new antibiotics are administered, enable physicians to identify most patients who need immediate treatment and select optimal therapy, in a manner that is safe and well tolerated by patients. Furthermore, they frequently permit the clinician to withhold antimicrobial treatment in patients without infection, minimizing the risk of the emergence of resistant microorganisms in the intensive care unit. In patients with clinical evidence of severe sepsis, the initiation of antibiotic therapy should not, however, be delayed while awaiting bronchoscopy, and patients should be given immediate treatment with antibiotics. In that case, "simplified" non-bronchoscopic diagnostic procedures might allow obtaining reliable distal pulmonary secretions for quantitative cultures on a 24-hour basis just before the initiation of a new antimicrobial therapy.

Bacterial Infections↗