Fagon and colleagues180 used fiberoptic bronchoscopy
to obtain protected specimen brush samples or bronchoalveolar
lavage samples for quantitative culture. Patients were
considered to have VAP if at least 103 colony-forming units
(CFU)/mL of bacteria grew from the protected specimen
brush sample or at least 104 CFU/mL of bacteria grew from
the bronchoalveolar lavage fluid. The patients in the invasive
management group had reduced mortality at day 14 (16.2%
versus 25.8%, P = .022) and an increased number of antibiotic-
free days (5.0 ± 5.1 versus 2.2 ± 3.5 days, P < 0.001). This
study makes a compelling argument for a more definitive
diagnosis of VAP before initiating antibiotic therapy. Along
the same idea but with a less invasive approach, Bregeon
and associates181 showed that nonbronchoscopically guided
placement of protected brush catheters is just as sensitive as
directed bronchoscopy in detecting bacteria in the lungs.