A prospective evaluation of a simple disease management plan for nosocomial pneumonia in the ventilated trauma patient

Introduction: Nosocomial pneumonia accounts for ∼20% of all infections in the intensive care unit. Additionally, nosocomial pneumonia is the most common cause of mortality accounting for up to 70% of deaths amongst all nosocomial infections. We have developed a disease management plan that utilizes a daily pneumonia score with the results of non-bronchoscopic bronchoalveolar lavage (nbBAL). It was the goal of this study to prospectively evaluate the value of this plan in monitoring the progress of patients with pneumonia and to determine appropriate duration of therapy. Methods: Adult patients admitted to the surgery ICU's at the University of Missouri Hospital & Clinics between 12/96 and 10/97 who were suspected of pneumonia by CDC clinical criteria, were eligible for participation in this study. All such patients with a positive quantitative culture obtained by PSB (defined as >10³ cfu/ml) were said to have nosocomial pneumonia. Concomitant infection was ruled out. A pneumonia score was developed from the evaluation of predictive variables of more than 100 cases of nosocomial pneumonia. This score was simplified through clinical use to include four variables (FiO2, Sputum character and quantity, WBC/band count, and Temp max) ("Show-me Pneumonia Score"). The pneumonia score was recorded daily. A non-bronchoscopic bronchoalveolar lavage was performed between 3 to 5 days after the institution of antibiotics and if necessary at 3 to 5 day increments until antibiotic treatment was stopped. Results: There were 35 patients with nosocomial pneumonia. A Show-me Pneumonia score of ≤4/11 always correlated with progressive resolution of pneumonia. Antibiotic therapy was successfully discontinued in 31/35 cases, when the score stayed at ≤4/11 for 72 hours. Antibiotic therapy was successfully discontinued in 34/35 cases when the score stayed at ≤4/11 for 72 hours and the repeat nbBAL and was negative (<10² cfu/ml). Conclusions: In adult trauma patients who met CDC criteria for nosocomial pneumonia, had a positive PSB and had no concurrent infection, the Show-me Pneumonia Score combined with information from the nbBAL served as a useful clinical aid in following patients with pneumonia and to determine appropriate duration of therapy. The Show-me pneumonia score was easy to use and data were attainable for scoring on every patient for every day. When the score dropped below 4 for ≥ 72 hours and the repeat nbBAL was negative, antibiotics were succesfully terminated in most patients.