1264. Nonbronchoscopic-BAL for Suspected Ventilator-Associated Pneumonia: Factors that Drive Unnecessary Antimicrobial Prescribing
Session: Poster Abstract Session: Clinical Infectious Diseases: Respiratory Infections
Friday, October 28, 2016
Room: Poster Hall
  • IDSA poster 2016.pdf (441.5 kB)
  • Background: For diagnosis and directed therapy of ventilator-associated pneumonia (VAP), lower respiratory tract specimens can be obtained by non-bronchoscopic, bronchoalveolar lavage (NB-BAL). NB-BALs are relatively easy to perform, thus they may be ordered for patients with a low likelihood of VAP. Also, poor NB-BAL collection technique may yield specimens with significant oropharyngeal contamination. We hypothesized that these factors lead to unnecessary antimicrobial prescribing.

    Methods: This retrospective study evaluated NB-BAL ordering practices, specimen quality, and antimicrobial use in response to positive NB-BAL cultures. Adult patients were included if they received mechanical ventilation for >48 hrs, did not receive antimicrobials prior to specimen collection, and had bacterial growth on NB-BAL cultures from January 2013 to December 2015. Patient demographics, microbiologic and pharmacologic data were obtained from the electronic medical record. National Healthcare Safety Network (NHSN) PNU-2 criteria and Clinical Pulmonary Infection Score (CPIS) ≥5 were used to determine likelihood of VAP.

    Results: Of 79 patients included, 37 (47%) had CPIS <5 and 68 (86%) did not meet the criteria for NHSN PNU-2. Thirty-two (41%) of the cultures grew >1 species of bacteria at >104 CFU/ml, 57 (32%) grew mixed flora at <104 CFU/ml, and 24 (30%) had <5 WBC/hpf. Quality assessments (e.g.; # of squamous epithelial cells) were not reported for 85% of the specimens. Antimicrobial therapy was prescribed to 76% and 74% of patients with CPIS <5 and without NHSN PNU-2, respectively. The median days of antimicrobial therapy was 11 (range: 4-21) for patients with CPIS <5 and 10 (range: 4-46) for those not meeting NHSN PNU-2 criteria.

    Conclusion: Our data suggest that suboptimal NB-BAL ordering and culturing practices drive antimicrobial overuse. We highlight this so that institutions can evaluate their practices. Current guidelines do not routinely recommend quality assessments for NB-BAL specimens; we suggest that institutions consider performing such assessments.

    Kaitlyn Moorehead, PharmD1, Elizabeth Zhu, PharmD, BCPS1, Monica Donnelley, PharmD, BCPS1, Machelle D. Wilson, PhD2 and Jennifer Brown, MD3, (1)Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA, (2)Department of Public Health Sciences, University of California, Davis, Sacramento, CA, (3)Division of Infectious Diseases,, University of California, Davis Medical Center, Sacramento, CA


    K. Moorehead, None

    E. Zhu, None

    M. Donnelley, None

    M. D. Wilson, None

    J. Brown, None

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