To the Editor:—

The September 2000 issue of Anesthesiology contains an article by Akça et al.  1that is of great potential importance to critical care anesthesiologists caring for patients with the clinical manifestations of ventilator-associated pneumonia (VAP). 2The authors 1report lower respiratory tract infections (VAP) with multidrug resistant organisms in certain patients “early” in their intensive care course. However, these findings are not entirely straightforward for the reasons noted herein.

The use of clinical criteria, even when supplemented by quantitative culture, to diagnose VAP is overly sensitive and of limited value 3in differentiating lower respiratory tract infection involving only the airways (colonization and purulent bronchitis for which antibiotic therapy is generally not indicated and, when used, can increase the number of multidrug resistant organisms as well as delay diagnosis of the true cause 2) from what also involves the lung parenchyma—VAP. VAP caused by multiresistant bacteria is associated with an increased attributable mortality, and timely, accurate antibiotic therapy has been shown to improve outcome.

As noted, it is the authors’1finding of “early” multidrug resistant organisms in the lower respiratory tract that is of great interest. This information may allow accurate initial therapy in patients who have VAP. However, most patients to whom antibiotics are administered and in whom pulmonary infiltrates develop in the intensive care unit do not have VAP. 2,4Therefore, until improved diagnostic and clinical strategies are shown to better differentiate lower respiratory tract colonization from VAP and allow better use of antibiotics, we must be cognizant of the ongoing potential to increase inadvertently the burden of multiply resistant organisms from excessive, inappropriate antibiotic treatment when using current standard diagnostic methods similar to those used by Akça et al.  1 

Akça O, Koltka K, Uzel S, Çakar N, Pembeci K, Sayan MA, Tütüncü AS, Karakas SE, Çalangu S, Özkan T, Esen F, Telci L, Sessler DI, Akpir K: Risk factors for early-onset, ventilator-associated pneumonia in critical care patients: Selected multiresistant versus  nonresistant bacteria. A nesthesiology 2000; 93: 638–45
Meduri GU, Mauldin GL, Wunderink RG, Leeper KV, Jones CB, Tolley E, Mayhall G: Causes of fever and pulmonary infiltrates in patients with clinical manifestations of ventilator-associated pneumonia. Chest 1994; 1–6:221–35
Torres A, Fabregas N, Ewig S, de la Bellacasa JP, Bauer TT, Ramirez J: Sampling methods for ventilator-associated pneumonia: Validation using different histologic and microbiological references. Crit Care Med 2000; 28: 2799–804
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. Am J Respir Crit Care Med 2000; 162: 505–11