Da Concei?ao et al. performed BAL in hypoxemic and hypercapnic sellekchem chronic obstructive pulmonary disease patients using bilevel ventilatory support [19].The use of bronchoscopy allows us to select the sampling site with chest X-ray. The low volume used for mini-BAL (20 ml) probably has a better tolerance than the larger volume used for BAL (250 ml).Based on our results, we agree with Brito et al. when they suggest that HCAP is a heterogeneous disease and that all patients do not need the same broad-spectrum antibiotic therapy [20]. Our bacteriological results are in agreement with this idea. Moreover, a recent study suggested that the HCAP concept does not correlate well with the presence of infection due to a resistant pathogen [5].

From our point of view, this debate promotes the use of an efficient pathogen identification technique to avoid the use of broad-spectrum antibiotics and to de-escalate initial antibiotics as soon as possible [21]. Besides, some authors propose to redefine the concept of HCAP which may contribute to confusion more than provide a guide to pneumonia management, and potentially leads to overtreatment [22]. Achieving bacteriological identification in a larger population study should define new HCAP criteria and adapt empirical antibiotic therapy to these new categories.Our study has several limitations. It appears that the main limitation of our strategy is the availability of the fiberoptic bronchoscope and an experienced operator when the patient is admitted to the emergency department.

Indeed, the examination should be completed promptly after hospital admittance so that antibiotic therapy can be started as soon as possible. We describe our local bacteriological ecology. It has been shown that pathogens and their drug-sensitivity may be different in other areas [3]. An additional limitation is that our study is observational. We did not compare the effectiveness of our strategy regarding outcomes with an antibiotic strategy based on non-invasive pathogen identification. Large scale, multi-center studies are needed to confirm our strategy regarding outcome, as well as ecological and economic costs.ConclusionsOur study demonstrates that early FODP mini-BAL is safe and more efficient than blood cultures to identify pathogens and de-escalate antibiotic therapy in patients presenting with HCAP.

We demonstrated that HCAP classification is relevant in our hospital. However, other studies are needed to compare the efficiency of this strategy Anacetrapib including mini-BAL with a non-invasive strategy including sputum cultures, blood cultures, and an epidemiologic approach in terms of outcome and the economic impact of early antibiotic de-escalation.Key messages? Early FODP mini-BAL is safe and more efficient than blood cultures to identify pathogens and de-escalate antibiotic therapy in the treatment of HCAP (46.