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Decision Analysis of Antibiotic and Diagnostic Strategies in Ventilator-associated Pneumonia

Center for Pulmonary and Critical Care Medicine, Department of Laboratory Medicine, Pharmacy, and Finance, North Shore-Long Island Jewish Health System, Manhasset; New York University School of Medicine, New York; and SUNY at Stony Brook, Stony Brook, New York

Correspondence and requests for reprints should be addressed to David E. Ost, M.D., Center for Pulmonary and Critical Care Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. E-mail: dost{at}nshs.edu

The optimal strategy for ventilator-associated pneumonia remains controversial. To clarify the tradeoffs involved, we performed a decision analysis. Strategies evaluated included antibiotic therapy with and without diagnostic testing. Tests that were explored included endotracheal aspirates, bronchoscopy with protected brush or bronchoalveolar lavage, and nonbronchoscopic mini-bronchoalveolar lavage (mini-BAL). Outcomes included dollar cost, antibiotic use, survival, cost-effectiveness, antibiotic use per survivor, and the outcome perspective of financial cost–antibiotic use per survivor. Initial coverage with three antibiotics was better than expectant management or one or two antibiotic approaches, leading to both improved survival (54% vs. 66%) and decreased cost ($55,447 vs. $41,483 per survivor). Testing with mini-BAL did not improve survival but did decrease costs ($41,483 vs. $39,967) and antibiotic use (63 vs. 39 antibiotic days per survivor). From the perspective of minimizing cost, minimizing antibiotic use, and maximizing survival, the best strategy was three antibiotics with mini-BAL.

Key Words: ventilator-associated pneumonia • decision analysis • evidence-based medicine • bronchoscopy

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