['To assess outcomes with de-escalation therapy in ventilator-associated pneumonia (VAP).', 'Prospective observational study.', 'Multidisciplinary intensive care unit.', 'VAP was diagnosed by positive quantitative cultures of both tracheal aspirate and bronchoalveolar lavage (BAL) and treated appropriately for all significant isolates of tracheal aspirate and BAL in 143 patients who were assigned to de-escalation therapy by BAL or tracheal aspirate.', 'None.', 'Antibiotic therapy was de-escalated in 58 patients (40.5%), who had decreased mortality at day 15 (5.1% vs. 31.7%) and day 28 (12% vs. 43.5%) and shorter intensive care unit (17.2 +/- 1.2 vs. 22.7 +/- 6.3 days) and hospital (23.7 +/- 2.8 vs. 29.8 +/- 11.1 days) stay (p < 0.05). Of the 81 patients assigned to tracheal aspirate, the 17 (21%) who achieved de-escalation of therapy had reduced 15-day mortality (5.8% vs. 34.3%), reduced 28-day mortality (11.6% vs. 45.3%), and shorter intensive care unit (17.2 +/- 1.6 vs. 22.4 +/- 6.4 days) and hospital (23.1 +/- 4.4 vs. 29.9 +/- 11.1 days) stay (p < 0.05). Of the 62 patients assigned to BAL, the 41 (66.1%) who achieved de-escalation of therapy had decreased 15-day mortality (4.8% vs. 23.8%), decreased 28-day mortality (12.1% vs. 38%), and shorter intensive care unit (17.2 +/- 1.1 vs. 23.2 +/- 6 days) and hospital (23.8 +/- 2.4 vs. 29.8 +/- 11.4 days) stay (p < 0.05).'] Are de-escalation therapy rates significantly higher by bronchoalveolar lavage than by tracheal aspirate?