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Clinical aspiration-related practice patterns in the intensive care unit: A physician survey

Rebuck, Jill A. PharmD; Rasmussen, Jon R. PharmD; Olsen, Keith M. PharmD, FCCP

FEATURE ARTICLES
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Objective  To characterize physician practice patterns regarding the clinical, microbiological, and antimicrobial-related events of suspected or documented aspiration and aspiration pneumonia within the intensive care unit.

Design  National mail survey.

Setting  University medical center.

Study Population  Critical care physician members of the Society of Critical Care Medicine.

Interventions  Survey questionnaire.

Measurements and Main Results  The response rate was 645 (32%) of 2,000 mailed surveys; analysis of data represents completed questionnaires from 605 respondents. Intensivists (42.3%), pulmonologists (22.6%), and surgeons (21.6%) represent the majority of respondents. Altered level of consciousness (67.9%) in the intensive care unit was identified as the predominant predisposing factor for aspiration pneumonia. Sixty-four percent of physicians used sputum specimens, rather than protected specimen brushes or bronchoalveolar lavage, as the diagnostic source of bacterial cultures in cases of suspected aspiration pneumonia. Microbiological assessment of aspiration pneumonia revealed the absence of any predominant pathogen, although Staphylococcus aureus and Pseudomonas aeruginosa were cited in 40.1% of combined responses, whereas anaerobes represented the fifth most prevalent cultured bacteria. In cases of suspected and confirmed aspiration, 51.9% and 77.7% of respondents, respectively, would prescribe an antimicrobial agent in the absence of a definitive infectious process, with administration of dual antimicrobial therapy increasing from 28.9% to 46.0% in suspected vs. confirmed cases of aspiration. In the treatment of aspiration pneumonia, 27.6% of physicians preferred pathogen-specific therapy, whereas the remainder (72.4%) selected an empirical antibiotic regimen based on prior clinical experience. Overall, a β-lactam/β-lactamase inhibitor, followed by a cephalosporin, aminoglycoside in combination, or clindamycin, was most often selected for empirical therapy of all defined aspiration-related clinical diagnoses.

Conclusions  Our study revealed a divergent approach to antimicrobial treatment of cases of aspiration in the intensive care unit. Further investigation is warranted to determine why empirical antimicrobials are initiated frequently for noninfectious stages of aspiration.

From the Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, NE.

Supported, in part, by Roche Pharmaceuticals, Nutley, NJ.

Address requests for reprints to: Keith M. Olsen, PharmD, University of Nebraska Medical Center, 986045 Nebraska Medical Center, Omaha, NE 68198-6045. E-mail: kolsen@unmc.edu

Our study revealed a divergent approach to antimicrobial treatment of cases of aspiration in the intensive care unit.

© 2001 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins