Fagon J Y, Chastre J, Hance A J, Domart Y, Trouillet J L, Gibert C
Service de Réanimation Médicale, Hôpital Bichat, Paris, France.
Chest. 1993 Feb;103(2):547-53. doi: 10.1378/chest.103.2.547.
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.
为评估临床判断在机械通气患者医院获得性肺炎诊断和治疗中的准确性，我们研究了84例因出现新的肺部浸润影和脓性气管分泌物而疑似医院获得性肺炎的患者。我们前瞻性地评估了一组知晓所有临床、放射学和实验室数据（包括革兰染色支气管吸出物结果）的医生独立制定的诊断预测和治疗方案的准确性。根据严格的组织病理学和/或细菌学标准，所有患者均可确诊为确诊（n = 51）或疑似（n = 33）肺炎。仅27/84例患者被诊断为肺炎。通过使用防污染标本刷获取的样本定量培养或胸腔积液培养来鉴定引起肺炎的病原体。对84例研究患者共做出了408次预测。随后被诊断为肺炎的患者，其临床诊断在81/131例（62%）中是准确的。此外，针对这些患者提出的治疗方案中，只有43/131（33%）代表有效治疗。治疗不当的常见原因包括未能诊断出肺炎（50个方案）、未能有效治疗高度耐药菌（21个方案）以及在多重微生物肺炎病例中未能治疗所有病原体（14个方案）。为未患肺炎的患者制定的治疗方案中，45/277例（16%）存在不必要使用抗生素的情况。这些发现表明，仅使用临床标准无法准确诊断机械通气患者的医院获得性肺炎，并且通常会导致对这些患者进行不恰当或不充分的抗生素治疗。
