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A qualitative assessment of the diagnosis and management of ventilator-associated pneumonia among critical care clinicians exploring opportunities for diagnostic stewardship

Published online by Cambridge University Press:  16 April 2021

Blaine Kenaa Open the ORCID record for Blaine Kenaa [Opens in a new window] ,
Lyndsay M. O’Hara ,
Mary Elizabeth Richert ,
Jessica P. Brown ,
Carl Shanholtz ,
Michael J. Armahizer  and
Surbhi Leekha
Blaine Kenaa*
Affiliation:
Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Lyndsay M. O’Hara
Affiliation:
Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Mary Elizabeth Richert
Affiliation:
Department of Critical Care Medicine, National Institute of Health, Bethesda, Maryland
Jessica P. Brown
Affiliation:
Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Carl Shanholtz
Affiliation:
Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Michael J. Armahizer
Affiliation:
Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
Surbhi Leekha
Affiliation:
Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
*
Author for correspondence: Blaine Kenaa, E-mail: Blaine.kenaa@som.umaryland.edu
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Abstract

Background:

Prompt diagnosis and intervention for ventilator-associated pneumonia (VAP) is critical but can lead to overdiagnosis and overtreatment.

Objectives:

We investigated healthcare provider (HCP) perceptions and challenges associated with VAP diagnosis, and we sought to identify opportunities for diagnostic stewardship.

Methods:

We conducted a qualitative study of 30 HCPs at a tertiary-care hospital. Participants included attending physicians, residents and fellows (trainees), advanced practice providers (APPs), and pharmacists. Interviews were composed of open-ended questions in 4 sections: (1) clinical suspicion and thresholds for respiratory culture ordering, (2) preferences for respiratory sample collection, (3) culture report interpretation, and (4) VAP diagnosis and treatment. Interviews transcripts were analyzed using Nvivo 12 software, and responses were organized into themes.

Results:

Overall, 10 attending physicians (75%) and 16 trainees (75%) trainees and APPs believed they were overdiagnosing VAP; this response was frequent among HCPs in practice 5–10 years (91%, n = 12). Increased identification of bacteria as a result of frequent respiratory culturing, misinterpretation of culture data, and fear of missing diagnosis were recognized as drivers of overdiagnosis and overtreatment. Although most HCPs rely on clinical and radiographic changes to initiate work-up, the fear of missing a diagnosis leads to sending cultures even in the absence of those changes.

Conclusions:

HCPs believe that VAP overdiagnosis and overtreatment are common due to fear of missing diagnosis, overculturing, and difficulty distinguishing colonization from infection. Although we identified opportunities for diagnostic stewardship, interventions influencing the ordering of cultures and starting antimicrobials will need to account for strongly held beliefs and ICU practices.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 43 , Issue 3 , March 2022 , pp. 284 - 290
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Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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References

Ruiz, R, Moragas, A, Trapero-Bertran, M, et al. Effectiveness and cost-effectiveness of Improving clinicians’ diagnostic and communication skills on antibiotic prescribing appropriateness in patients with acute cough in primary care in CATalonia (the ISAAC-CAT study): study protocol for a cluster rando. Trials 2019;20:740.Google Scholar
Nussenblatt, V, Avdic, E, Berenholtz, S, et al. Ventilator-associated pneumonia: overdiagnosis and treatment are common in medical and surgical intensive care units. Infect Control Hosp Epidemiol 2014;35:278–284.Google ScholarPubMed
Ferrer, M, Torres, A. Epidemiology of ICU-acquired pneumonia. Curr Opin Crit Care 2018;24:325–331.Google ScholarPubMed
Piriyapatsom, A, Lin, H, Pirrone, M, et al. Evaluation of the infection-related ventilator-associated events algorithm for ventilator-associated pneumonia surveillance in a trauma population. Respir Care 2016;61:269–276.Google Scholar
Nussenblatt, V, Avdic, E, Berenholtz, S, et al. Ventilator-associated pneumonia: overdiagnosis and treatment are common in medical and surgical intensive care units. Infect Control Hosp Epidemiol 2014;35:278–284.Google ScholarPubMed
Browne, E, Hellyer, TP, Baudouin, SV, et al. A national survey of the diagnosis and management of suspected ventilator-associated pneumonia. BMJ Open Respir Res 2014. doi: 10.1136/bmjresp-2014-000066.Google Scholar
Kalil, AC, Metersky, ML, Klompas, M, et al. Executive summary: management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016;63:575–582.Google Scholar
Morgan, DJ, Malani, P, Diekema, DJ. Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use. JAMA 2017;318:607–608.Google ScholarPubMed
Global framework for development and stewardship to combat antimicrobial resistance—draft roadmap. World Health Organization website. http://apps.who.int/medicinedocs/en/d/Js23198en/. Published 2017. Accessed March 29, 2021.Google Scholar
Cordoba, G, Llor, C. Overdiagnosis paradigm: not suitable for decreasing the overuse of antibiotics. BMJ Evidence-Based Med 2019;24:174–176.Google ScholarPubMed
Kenaa, B, Richert, ME, Claeys, KC, et al. Ventilator-associated pneumonia: diagnostic test stewardship and relevance of culturing practices. Curr Infect Dis Rep 2019;21:50.Google ScholarPubMed
Guest, G, Bunce, A, Johnson, L. How many interviews are enough? An experiment with data saturation and variability. Field Methods 2006;18:59–82.Google Scholar
Tasbakan, MS, Gurgun, A, Basoglu, OK, Ekren, PK, Pullukcu, H, Bacakoglu, F. Comparison of bronchoalveolar lavage and mini-bronchoalveolar lavage in the diagnosis of pneumonia in immunocompromised patients. Respiration 2011;81:229–235.Google Scholar
Quick, JA, Breite, MD, Barnes, SL. Inadequacy of algorithmic ventilator-associated pneumonia diagnosis in acute care surgery. Am Surg 2018;84:300–304.Google ScholarPubMed
Singh, N, Rogers, P, Atwood, CW, Wagener, MM, Yu, VL. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med 2000;162:505–511.Google ScholarPubMed
Patzke, CL, Armahizer, MJ, Badjatia, N, Motta, M. A retrospective analysis of prolonged empiric antibiotic therapy for pneumonia among adult neurocritical care patients. Neurohospitalist 2018;9:15–21.Google ScholarPubMed
Sick-Samuels, AC, Fackler, JC, Berenholtz, SM, Milstone, AM. Understanding reasons clinicians obtained endotracheal aspirate cultures and impact on patient management to inform diagnostic stewardship initiatives. Infect Control Hosp Epidemiol 2019;240–242.Google Scholar
Pneumonia (ventilator-associated [VAP] and non–ventilator-associated pneumonia [PNEU]) events. Centers for Disease Control and Prevention website. https//www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf. Published January 2021. Accessed January 27, 2021.Google Scholar
Chao, WC, Chang, WL, Wu, CL, Chan, MC. Using objective fluid balance data to identify pulmonary edema in subjects with ventilator-associated events. Respir Care 2018;63:1413–1420.Google ScholarPubMed
Musgrove, MA, Tibbetts, R, Peters, M, et al. Microbiology comment nudge improves pneumonia prescribing. Open Forum Infect Dis 2018;5(7):1–5.Google ScholarPubMed
Cunney, R. Interpretative reporting and selective antimicrobial susceptibility release in non-critical microbiology results. J Antimicrob Chemother 2002;45:705–708.Google Scholar
Berton, DC, Kalil, AC, Teixeira, PJ. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database Syst Rev 2014;10:CD006(10):CD006482.Google Scholar
Raman, K, Nailor, MD, Nicolau, DP, Aslanzadeh, J, Nadeau, M, Kuti, JL. Early antibiotic discontinuation in patients with clinically suspected ventilator-associated pneumonia and negative quantitative bronchoscopy cultures. Crit Care Med 2013;41:1656–1663.Google ScholarPubMed
Fagon, JY, Chastre, J, Wolff, M, et al. Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial. Ann Intern Med 2000;132:621–630.Google ScholarPubMed
Scholte, JBJ, Van Dessel, HA, Linssen, CFM, et al. Endotracheal aspirate and bronchoalveolar lavage fluid analysis: interchangeable diagnostic modalities in suspected ventilator-associated pneumonia? J Clin Microbiol 2014;52:3597–3604.Google ScholarPubMed
Broom, J, Broom, A. Guideline relevance, diagnostic uncertainty, fear and hierarchy: intersecting barriers to antibiotic optimization in respiratory infections. Respirology 2018;23:733–734.Google ScholarPubMed
Wunderink, RG, Srinivasan, A, Barie, PS, et al. Antibiotic stewardship in the intensive care unit. An official American Thoracic Society workshop report in collaboration with the AACN, CHEST, CDC, and SCCM. Ann Am Thorac Soc 2020;17:531–540.Google ScholarPubMed
Klompas, M, Li, L, Menchaca, JT, Gruber, S. Ultra-short-course antibiotics for patients with suspected ventilator-associated pneumonia but minimal and stable ventilator settings. Clin Infect Dis 2017;64:870–876.Google ScholarPubMed
Dallas, J, Skrupky, L, Abebe, N, Boyle WA 3d, Kollef MH. Ventilator-associated tracheobronchitis in a mixed surgical and medical ICU population. Chest 2011;139:513–518.Google Scholar
Agrafiotis, M, Siempos, II, Falagas, ME. Frequency, prevention, outcome and treatment of ventilator-associated tracheobronchitis: systematic review and meta-analysis. Respir Med 2010;104:325–36.Google ScholarPubMed
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