Published ahead of print on July 3, 2003, doi:10.1164/rccm.200302-199OC Am. J. Respir. Crit. Care Med., Volume 168, Number 9, November 2003, 1060-1067 A more recent version of this article appeared on November 1, 2003
Submitted on February 11, 2003 Decision Analysis of Antibiotic and Diagnostic Strategies In Ventilator Associated PneumoniaDavid E Ost1*,1 Pulmonary and Critical Care, North Shore-Long Island Jewish Health System, Manhasset, NY, USA; Medicine, New York University School of Medicine, New York, NY, USA, 2 Pulmonary and Critical Care, North Shore-Long Island Jewish Health System, Manhasset, NY, USA, 3 Laboratory Medicine, North Shore-Long Island Jewish Health System, Manhasset, NY, USA; Medicine, State University of New York, Stony Brook, NY, USA, 4 Laboratory Medicine, North Shore-Long Island Jewish Health System, Manhasset, NY, USA, 5 Pharmacy, North Shore-Long Island Jewish Health System, Manhasset, NY, USA, 6 Finance, North Shore-Long Island Jewish Health System, Manhasset, NY, USA, 7 Pulmonary and Critical Care, North Shore-Long Island Jewish Health System, Manhasset, NY, USA; Medicine, State University of New York, Stony Brook, NY, USA * To whom correspondence should be addressed. 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 non-bronchoscopic mini-bronchoalveolar lavage. Outcomes included dollar cost, antibiotic utilization, survival, cost-effectiveness, antibiotic utilization per survivor, and the outcome perspective of financial cost-antibiotic utilization per survivor. Initial coverage with 3 antibiotics was better than expectant management or 1 or 2 antibiotic approaches, leading to both improved survival (54% vs. 66%) and decreased cost ($55,447 vs. $41,483 per survivor). Testing with mini-bronchoalveolar lavage did not improve survival but did decrease costs ($41,483 vs. $39,967) and antibiotic utilization (63 vs. 39 antibiotic days per survivor). From the perspective of minimizing cost, minimizing antibiotic utilization, and maximizing survival, the best strategy was 3 antibiotics with mini-BAL. Key words: Pneumonia, Bacterial, Decision Support Techniques-Decision Trees, Evidence-Based Medicine, Ventilator Associated Pneumonia
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