Use of the clinical pulmonary infection score to guide therapy for ventilator-associated pneumonia risks antibiotic overexposure in patients with trauma

Nancy A. Parks, Louis J. Magnotti, Jordan A. Weinberg, Ben L. Zarzaur, Thomas J. Schroeppel, Joseph Swanson, Timothy Fabian, Martin Croce

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

BACKGROUND: The clinical pulmonary infection score (CPIS) has been advocated to guide both the diagnosis and duration of therapy in ventilator-associated pneumonia (VAP). However, the clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury and inflammation, unnecessarily prolonging VAP therapy. This study evaluates the use of CPIS in determining the appropriate duration of antimicrobial therapy for VAP in patients with critical illness and trauma. METHODS: Patients with VAP (≫10 CFU/mL in bronchoalveolar lavage [BAL] effluent) over 6 years were evaluated. Duration of antimicrobial therapy was determined by microbiologic resolution (≤10 CFU/mL) on repeated BAL. Recurrence was defined as >10 CFU/mL on BAL performed within 2 weeks of appropriate therapy. A CPIS of less than 6 was used as a threshold for VAP resolution. RESULTS: Of the patients with VAP, 1,028 were identified: 523 had community-acquired pathogens (mean CPIS, 6.9), and 505 had hospital-acquired (HA) pathogens (mean CPIS, 6.3). Using a CPIS of less than 6 yielded a sensitivity and specificity of 69% and 51% for community-acquired pathogens and 72% and 53% for HA pathogens, respectively. Antimicrobial therapy would have continued inappropriately in 59% of patients. Overall recurrence was 1%, occurring only with HA pathogens (mean CPIS, 5.9). CONCLUSION: CPIS should not be used to determine VAP resolution in patients with critical injury and trauma. It cannot reliably differentiate VAP from the systemic inflammatory response syndrome in the face of confounding clinical factors. Using CPIS to determine appropriate duration of antimicrobial therapy for patients with trauma is costly and could be harmful by unnecessarily prolonging exposure to antibiotics. LEVEL OF EVIDENCE: Therapeutic study, level III.

Original languageEnglish (US)
Pages (from-to)52-59
Number of pages8
JournalJournal of Trauma and Acute Care Surgery
Volume73
Issue number1
DOIs
StatePublished - Jul 1 2012

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Ventilator-Associated Pneumonia
Anti-Bacterial Agents
Lung
Wounds and Injuries
Infection
Bronchoalveolar Lavage
Therapeutics
Recurrence
Systemic Inflammatory Response Syndrome
Critical Illness
Inflammation

All Science Journal Classification (ASJC) codes

  • Surgery
  • Critical Care and Intensive Care Medicine

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Use of the clinical pulmonary infection score to guide therapy for ventilator-associated pneumonia risks antibiotic overexposure in patients with trauma. / Parks, Nancy A.; Magnotti, Louis J.; Weinberg, Jordan A.; Zarzaur, Ben L.; Schroeppel, Thomas J.; Swanson, Joseph; Fabian, Timothy; Croce, Martin.

In: Journal of Trauma and Acute Care Surgery, Vol. 73, No. 1, 01.07.2012, p. 52-59.

Research output: Contribution to journalArticle

Parks, Nancy A. ; Magnotti, Louis J. ; Weinberg, Jordan A. ; Zarzaur, Ben L. ; Schroeppel, Thomas J. ; Swanson, Joseph ; Fabian, Timothy ; Croce, Martin. / Use of the clinical pulmonary infection score to guide therapy for ventilator-associated pneumonia risks antibiotic overexposure in patients with trauma. In: Journal of Trauma and Acute Care Surgery. 2012 ; Vol. 73, No. 1. pp. 52-59.
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abstract = "BACKGROUND: The clinical pulmonary infection score (CPIS) has been advocated to guide both the diagnosis and duration of therapy in ventilator-associated pneumonia (VAP). However, the clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury and inflammation, unnecessarily prolonging VAP therapy. This study evaluates the use of CPIS in determining the appropriate duration of antimicrobial therapy for VAP in patients with critical illness and trauma. METHODS: Patients with VAP (≫10 CFU/mL in bronchoalveolar lavage [BAL] effluent) over 6 years were evaluated. Duration of antimicrobial therapy was determined by microbiologic resolution (≤10 CFU/mL) on repeated BAL. Recurrence was defined as >10 CFU/mL on BAL performed within 2 weeks of appropriate therapy. A CPIS of less than 6 was used as a threshold for VAP resolution. RESULTS: Of the patients with VAP, 1,028 were identified: 523 had community-acquired pathogens (mean CPIS, 6.9), and 505 had hospital-acquired (HA) pathogens (mean CPIS, 6.3). Using a CPIS of less than 6 yielded a sensitivity and specificity of 69{\%} and 51{\%} for community-acquired pathogens and 72{\%} and 53{\%} for HA pathogens, respectively. Antimicrobial therapy would have continued inappropriately in 59{\%} of patients. Overall recurrence was 1{\%}, occurring only with HA pathogens (mean CPIS, 5.9). CONCLUSION: CPIS should not be used to determine VAP resolution in patients with critical injury and trauma. It cannot reliably differentiate VAP from the systemic inflammatory response syndrome in the face of confounding clinical factors. Using CPIS to determine appropriate duration of antimicrobial therapy for patients with trauma is costly and could be harmful by unnecessarily prolonging exposure to antibiotics. LEVEL OF EVIDENCE: Therapeutic study, level III.",
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AU - Parks, Nancy A.

AU - Magnotti, Louis J.

AU - Weinberg, Jordan A.

AU - Zarzaur, Ben L.

AU - Schroeppel, Thomas J.

AU - Swanson, Joseph

AU - Fabian, Timothy

AU - Croce, Martin

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N2 - BACKGROUND: The clinical pulmonary infection score (CPIS) has been advocated to guide both the diagnosis and duration of therapy in ventilator-associated pneumonia (VAP). However, the clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury and inflammation, unnecessarily prolonging VAP therapy. This study evaluates the use of CPIS in determining the appropriate duration of antimicrobial therapy for VAP in patients with critical illness and trauma. METHODS: Patients with VAP (≫10 CFU/mL in bronchoalveolar lavage [BAL] effluent) over 6 years were evaluated. Duration of antimicrobial therapy was determined by microbiologic resolution (≤10 CFU/mL) on repeated BAL. Recurrence was defined as >10 CFU/mL on BAL performed within 2 weeks of appropriate therapy. A CPIS of less than 6 was used as a threshold for VAP resolution. RESULTS: Of the patients with VAP, 1,028 were identified: 523 had community-acquired pathogens (mean CPIS, 6.9), and 505 had hospital-acquired (HA) pathogens (mean CPIS, 6.3). Using a CPIS of less than 6 yielded a sensitivity and specificity of 69% and 51% for community-acquired pathogens and 72% and 53% for HA pathogens, respectively. Antimicrobial therapy would have continued inappropriately in 59% of patients. Overall recurrence was 1%, occurring only with HA pathogens (mean CPIS, 5.9). CONCLUSION: CPIS should not be used to determine VAP resolution in patients with critical injury and trauma. It cannot reliably differentiate VAP from the systemic inflammatory response syndrome in the face of confounding clinical factors. Using CPIS to determine appropriate duration of antimicrobial therapy for patients with trauma is costly and could be harmful by unnecessarily prolonging exposure to antibiotics. LEVEL OF EVIDENCE: Therapeutic study, level III.

AB - BACKGROUND: The clinical pulmonary infection score (CPIS) has been advocated to guide both the diagnosis and duration of therapy in ventilator-associated pneumonia (VAP). However, the clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury and inflammation, unnecessarily prolonging VAP therapy. This study evaluates the use of CPIS in determining the appropriate duration of antimicrobial therapy for VAP in patients with critical illness and trauma. METHODS: Patients with VAP (≫10 CFU/mL in bronchoalveolar lavage [BAL] effluent) over 6 years were evaluated. Duration of antimicrobial therapy was determined by microbiologic resolution (≤10 CFU/mL) on repeated BAL. Recurrence was defined as >10 CFU/mL on BAL performed within 2 weeks of appropriate therapy. A CPIS of less than 6 was used as a threshold for VAP resolution. RESULTS: Of the patients with VAP, 1,028 were identified: 523 had community-acquired pathogens (mean CPIS, 6.9), and 505 had hospital-acquired (HA) pathogens (mean CPIS, 6.3). Using a CPIS of less than 6 yielded a sensitivity and specificity of 69% and 51% for community-acquired pathogens and 72% and 53% for HA pathogens, respectively. Antimicrobial therapy would have continued inappropriately in 59% of patients. Overall recurrence was 1%, occurring only with HA pathogens (mean CPIS, 5.9). CONCLUSION: CPIS should not be used to determine VAP resolution in patients with critical injury and trauma. It cannot reliably differentiate VAP from the systemic inflammatory response syndrome in the face of confounding clinical factors. Using CPIS to determine appropriate duration of antimicrobial therapy for patients with trauma is costly and could be harmful by unnecessarily prolonging exposure to antibiotics. LEVEL OF EVIDENCE: Therapeutic study, level III.

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