Chest
Volume 103, Issue 2, February 1993, Pages 547-553
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Evaluation of Clinical Judgment in the Identification and Treatment of Nosocomial Pneumonia in Ventilated Patients

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To evaluate the accuracy of clinical judgment in the diagnosis and treatment of nosocomial pneumonia in ventilated patients, we studied 84 patients suspected of having nosocomial pneumonia because of the presence of a new pulmonary infiltrate and purulent tracheal secretions. We prospectively evaluated the accuracy of diagnostic predictions and therapeutic plans independently formulated by a team of physicians aware of all clinical, radiologic and laboratory data, including the results of Gram-stained bronchial aspirates. Definite (n=51) or probable (n = 33) diagnoses could be established in all patients by strict histopathologic and/or bacteriologic criteria. Only 27/84 patients were diagnosed as having pneumonia. Organisms responsible for pneumonias were identified by quantitative cultures of samples obtained using a protected specimen brush or pleural fluid cultures. Four hundred eight predictions were made for the 84 studied patients. Clinical diagnoses for patients subsequently diagnosed as having pneumonia were accurate in 81/131 cases (62 percent). Furthermore, only 43/131 (33 percent) therapeutic plans proposed for these patients represented effective therapy. Common causes of inappropriate treatment included failure to diagnose pneumonia (50 plans), failure to effectively treat highly resistant organisms (21 plans), and failure to treat all organisms in cases of polymicrobial pneumonia (14 plans). Therapeutic plans formulated for patients without pneumonia included the unnecessary use of antibiotics in 45/277 cases (16 percent). These findings indicate that the use of clinical criteria alone does not permit the accurate diagnosis of nosocomial pneumonia in ventilated patients, and commonly results in inappropriate or inadequate antibiotic therapy for these patients.

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Study Population

Patients meeting the following criteria were eligible for the study: (1) the patient had been receiving mechanical ventilation for more than 72 h in the medical intensive care unit of Hopital Bichat, Paris, France; (2) had a new and persistent (>24 h) infiltrate on chest roentgenograms; (3) had macroscopically purulent tracheal aspirates; and (4) had a clinical status permitting the performance of flexible fiberoptic bronchoscopy. No patients were included in the study if changes in antibiotic

RESULTS

Clinical Outcome of Patients Suspected of Having Nosocomial Pneumonia

Among the 84 patients suspected of having nosocomial pneumonia, the diagnosis of bacterial pneumonia was ultimately made in only 27 patients (definite, n = 17; probable, n = 10) and excluded in 57 patients (definite no pneumonia, n = 34; probable no pneumonia, n= 23).

The clinical characteristics of patients who had pneumonia and of those who did not were very similar (Table 1). No significant differences in clinical

DISCUSSION

In this study, we have evaluated the reliability of clinical judgment in identifying nosocomial pneumonia in patients receiving mechanical ventilation and in selecting appropriate antimicrobial therapy. We observed that clinical assessment alone often resulted in substandard management of patients with pneumonia, either because pneumonia was not correctly diagnosed or because the antibiotics selected were inappropriate. Overall, only 33 percent of the predictions made in patients with pneumonia

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  • Cited by (0)

    Supported in part by a grant from the Faculté Xavier Bichat.

    Presented in part at the Annual Meeting, American Thoracic Society, Las Vegas, April 1988.

    Manuscript received March 6; revision accepted June 16.

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