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Al-Omari B, McMeekin P, Allen AJ, Akram AR, Graziadio S, Suklan J, Jones WS, Lendrem BC, Winter A, Cullinan M, Gray J, Dhaliwal K, Walsh TS, Craven TH. Systematic review of studies investigating ventilator associated pneumonia diagnostics in intensive care. BMC Pulm Med 2021; 21:196. [PMID: 34107929 PMCID: PMC8189711 DOI: 10.1186/s12890-021-01560-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is an important diagnosis in critical care. VAP research is complicated by the lack of agreed diagnostic criteria and reference standard test criteria. Our aim was to review which reference standard tests are used to evaluate novel index tests for suspected VAP. Methods We conducted a comprehensive search using electronic databases and hand reference checks. The Cochrane Library, MEDLINE, CINHAL, EMBASE, and web of science were searched from 2008 until November 2018. All terms related to VAP diagnostics in the intensive treatment unit were used to conduct the search. We adopted a checklist from the critical appraisal skills programme checklist for diagnostic studies to assess the quality of the included studies. Results We identified 2441 records, of which 178 were selected for full-text review. Following methodological examination and quality assessment, 44 studies were included in narrative data synthesis. Thirty-two (72.7%) studies utilised a sole microbiological reference standard; the remaining 12 studies utilised a composite reference standard, nine of which included a mandatory microbiological criterion. Histopathological criteria were optional in four studies but mandatory in none. Conclusions Nearly all reference standards for VAP used in diagnostic test research required some microbiological confirmation of infection, with BAL culture being the most common reference standard used. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01560-0.
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Affiliation(s)
- Basem Al-Omari
- College of Medicine and Health Sciences, Khalifa University, PO Box 127788, Abu Dhabi, UAE. .,Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.
| | - Peter McMeekin
- School of Health and Life Science, University of Northumbria, Newcastle upon Tyne, UK
| | - A Joy Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ahsan R Akram
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,York Health Economics Consortium, Enterprise House, Innovation Way, University of York, York, UK
| | - Jana Suklan
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - William S Jones
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - B Clare Lendrem
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Amanda Winter
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Milo Cullinan
- Laboratory Medicine, Newcastle-Upon-Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Joanne Gray
- School of Health and Life Science, University of Northumbria, Newcastle upon Tyne, UK
| | - Kevin Dhaliwal
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Thomas H Craven
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
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Sellares J, Ferrer M, Anton A, Loureiro H, Bencosme C, Alonso R, Martinez-Olondris P, Sayas J, Peñacoba P, Torres A. Discontinuing noninvasive ventilation in severe chronic obstructive pulmonary disease exacerbations: a randomised controlled trial. Eur Respir J 2017; 50:50/1/1601448. [PMID: 28679605 DOI: 10.1183/13993003.01448-2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 03/30/2017] [Indexed: 11/05/2022]
Abstract
We assessed whether prolongation of nocturnal noninvasive ventilation (NIV) after recovery from acute hypercapnic respiratory failure (AHRF) in chronic obstructive pulmonary disease (COPD) patients with NIV could prevent subsequent relapse of AHRF.A randomised controlled trial was performed in 120 COPD patients without previous domiciliary ventilation, admitted for AHRF and treated with NIV. When the episode was resolved and patients tolerated unassisted breathing for 4 h, they were randomly allocated to receive three additional nights of NIV (n=61) or direct NIV discontinuation (n=59). The primary outcome was relapse of AHRF within 8 days after NIV discontinuation.Except for a shorter median (interquartile range) intermediate respiratory care unit (IRCU) stay in the direct discontinuation group (4 (2-6) versus 5 (4-7) days, p=0.036), no differences were observed in relapse of AHRF after NIV discontinuation (10 (17%) versus 8 (13%) for the direct discontinuation and nocturnal NIV groups, respectively, p=0.56), long-term ventilator dependence, hospital stay, and 6-month hospital readmission or survival.Prolongation of nocturnal NIV after recovery from an AHRF episode does not prevent subsequent relapse of AHRF in COPD patients without previous domiciliary ventilation, and results in longer IRCU stay. Consequently, NIV can be directly discontinued when the episode is resolved and patients tolerate unassisted breathing.
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Affiliation(s)
- Jacobo Sellares
- Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, (CibeRes, CB06/06/0028) Instituto de Salud Carlos III, Madrid, Spain
| | - Miquel Ferrer
- Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain .,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, (CibeRes, CB06/06/0028) Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Anton
- Dept of Pneumology, Hospital de Sant Pau, Barcelona, Spain
| | - Hugo Loureiro
- Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, (CibeRes, CB06/06/0028) Instituto de Salud Carlos III, Madrid, Spain
| | - Carolina Bencosme
- Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Hospital General de la Plaza de la Salud, Santo Domingo, Dominican Republic
| | - Rodrigo Alonso
- Servicio de Neumologia, Hospital 12 de Octubre, Madrid, Spain
| | - Pilar Martinez-Olondris
- Servicio de Neumologia, Hospital del Mar, Barcelona, Spain.,Hospital Plato, Barcelona, Spain
| | - Javier Sayas
- Servicio de Neumologia, Hospital 12 de Octubre, Madrid, Spain
| | | | - Antoni Torres
- Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, (CibeRes, CB06/06/0028) Instituto de Salud Carlos III, Madrid, Spain
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3
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Heredia-Rodríguez M, Peláez MT, Fierro I, Gómez-Sánchez E, Gómez-Pesquera E, Lorenzo M, Álvarez-González FJ, Bustamante-Munguira J, Eiros JM, Bermejo-Martin JF, Gómez-Herreras JI, Tamayo E. Impact of ventilator-associated pneumonia on mortality and epidemiological features of patients with secondary peritonitis. Ann Intensive Care 2016; 6:34. [PMID: 27090531 PMCID: PMC4835417 DOI: 10.1186/s13613-016-0137-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 03/28/2016] [Indexed: 12/15/2022] Open
Abstract
Background Despite the significant impact of nosocomial infections on the morbidity and mortality of patients staying in the intensive care unit (ICU), no study over the past 20 years has focused specifically on VAP following secondary peritonitis. The objective of the present study was to determine in-hospital mortality and epidemiological features attributed to ventilator-associated pneumonia (VAP) following secondary peritonitis. Methods Prospective observational study involved 418 consecutive patients admitted in the ICU. Univariate and multivariate analyses were performed to identify risk factors associated with mortality and development of VAP. Results The incidence of VAP following secondary peritonitis was 9.6 %. Risk factors associated with the development of VAP were hospital-acquired peritonitis, requiring >48 h of mechanical ventilation, and SOFA score. The onset of VAP was late in majority of patients. VAP was developed about 16.8 days after the initiation of the peritonitis. Etiological microorganisms responsible for the peritonitis were different than for VAP. The 90-day in-hospital mortality rate was 47.5 % of VAP patients. Independent factors associated with 30- to 90-day in-hospital mortality were VAP and SOFA. Conclusions In light of the impact on morbidity and mortality in the ICU, more attention should be given to the concurrent features among VAP and secondary peritonitis.
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Affiliation(s)
- María Heredia-Rodríguez
- Anaesthesiology and Surgical Critical Care Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal, 3, 47005, Valladolid, Spain. .,Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
| | - María Teresa Peláez
- Anaesthesiology and Surgical Critical Care Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal, 3, 47005, Valladolid, Spain.
| | - Inmaculada Fierro
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Valladolid, Valladolid, Spain
| | - Esther Gómez-Sánchez
- Anaesthesiology and Surgical Critical Care Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal, 3, 47005, Valladolid, Spain.,Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Estefanía Gómez-Pesquera
- Anaesthesiology and Surgical Critical Care Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal, 3, 47005, Valladolid, Spain.,Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Mario Lorenzo
- Anaesthesiology and Surgical Critical Care Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal, 3, 47005, Valladolid, Spain.,Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - F Javier Álvarez-González
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Valladolid, Valladolid, Spain
| | | | - José María Eiros
- Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain.,Department of Microbiology, Faculty of Medicine, University of Valladolid, Valladolid, Spain
| | - Jesús F Bermejo-Martin
- Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain.,Investigación Médica en Infección e Inmunidad (IMI), Hospital Clínico Universitario de Valladolid-IECSCYL, Valladolid, Spain
| | - José I Gómez-Herreras
- Anaesthesiology and Surgical Critical Care Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal, 3, 47005, Valladolid, Spain.,Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Eduardo Tamayo
- Anaesthesiology and Surgical Critical Care Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal, 3, 47005, Valladolid, Spain.,Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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4
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Empirical antibiotic therapy for pneumonia in intensive care units: a multicentre, retrospective analysis of potentially pathogenic microorganisms identified by endotracheal aspirates cultures. Eur J Clin Microbiol Infect Dis 2015; 34:2295-305. [PMID: 26385348 PMCID: PMC4607706 DOI: 10.1007/s10096-015-2482-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 08/26/2015] [Indexed: 01/11/2023]
Abstract
The purpose of this investigation was to explore the presumed relationship between the days of hospitalisation and microorganisms identified by endotracheal aspirate cultures in relation to adequate empirical treatment strategies of pneumonia in the intensive care unit (ICU). All potentially pathogenic microorganisms identified by (surveillance) cultures of endotracheal aspirates obtained in the ICUs of two Dutch teaching hospitals in 2007 and 2012 were retrospectively collected and analysed. Antibiotic susceptibilities to 11 antibiotics were calculated for several time points (days or weeks) after hospital admission and expressed per patient-day. In total, 4184 potentially pathogenic microorganisms identified in 782 patients were analysed. Prevalence of the classic early-onset pneumonia-causing microorganisms decreased from 55 % on the first four days to 34 % on days 4–6 after hospital admission (p < 0.0001). Susceptibility to amoxicillin/clavulanic acid was below 70 % on all days. Except for days 0 and 12, susceptibility to ceftriaxone was below 80 %. The overall susceptibility to piperacillin/tazobactam was 1518/1973 (77 %) in 2007 vs. 727/1008 (67 %) in 2012 (p < 0.0001). After day 8 of hospital admission, susceptibility to piperacillin/tazobactam therapy was below 80 % in 2012. After one week of hospital admission, susceptibilities to antibiotics were lower in the hospital that included that antibiotic in the local empirical treatment protocols as compared to the hospitals in which that antibiotic was not or infrequently included: 90/434 (21 %) vs. 117/398 (29 %); p = 0.004 for amoxicillin/clavulanic acid and 203/433 (47 %) vs. 253/398 (64 %); p < 0.001 for ceftriaxone. No cut-off in the number of days after hospital admission could be identified to distinguish early-onset from late-onset pneumonia. Consequently, the choice of empirical antibiotics should probably not be based on the time of onset.
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Scholte JBJ, van der Velde JIM, Linssen CFM, van Dessel HA, Bergmans DCJJ, Savelkoul PHM, Roekaerts PMHJ, van Mook WNKA. Ventilator-associated Pneumonia caused by commensal oropharyngeal Flora; [corrected] a retrospective Analysis of a prospectively collected Database. BMC Pulm Med 2015; 15:86. [PMID: 26264828 PMCID: PMC4531521 DOI: 10.1186/s12890-015-0087-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 07/30/2015] [Indexed: 12/13/2022] Open
Abstract
Background The significance of commensal oropharyngeal flora (COF) as a potential cause of ventilator-associated pneumonia (VAP) is scarcely investigated and consequently unknown. Therefore, the aim of this study was to explore whether COF may cause VAP. Methods Retrospective clinical, microbiological and radiographic analysis of all prospectively collected suspected VAP cases in which bronchoalveolar lavage fluid exclusively yielded ≥ 104 cfu/ml COF during a 9.5-year period. Characteristics of 899 recent intensive care unit (ICU) admissions were used as a reference population. Results Out of the prospectively collected database containing 159 VAP cases, 23 patients were included. In these patients, VAP developed after a median of 8 days of mechanical ventilation. The patients faced a prolonged total ICU length of stay (35 days [P < .001]), hospital length of stay (45 days [P = .001]), and a trend to higher mortality (39 % vs. 26 %, [P = .158]; standardized mortality ratio 1.26 vs. 0.77, [P = .137]) compared to the reference population. After clinical, microbiological and radiographic analysis, COF was the most likely cause of respiratory deterioration in 15 patients (9.4 % of all VAP cases) and a possible cause in 2 patients. Conclusion Commensal oropharyngeal flora appears to be a potential cause of VAP in limited numbers of ICU patients as is probably associated with an increased length of stay in both ICU and hospital. As COF-VAP develops late in the course of ICU admission, it is possibly associated with the immunocompromised status of ICU patients.
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Affiliation(s)
- Johannes B J Scholte
- Department of Intensive Care Medicine, Luzerner Kantonspital, 6000, Luzern 16, Switzerland.
| | - Johan I M van der Velde
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Catharina F M Linssen
- Department of Medical Microbiology, Atrium Medical Centre, P.O. box 4446, 6401 CX, Heerlen, The Netherlands.
| | - Helke A van Dessel
- Department of Medical Microbiology, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Paul H M Savelkoul
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Paul M H J Roekaerts
- Department of Medical Microbiology, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Walther N K A van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
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Sharp C, Millar AB, Medford ARL. Advances in understanding of the pathogenesis of acute respiratory distress syndrome. Respiration 2015; 89:420-34. [PMID: 25925331 DOI: 10.1159/000381102] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 02/12/2015] [Indexed: 02/05/2023] Open
Abstract
The clinical syndrome of acute lung injury (ALI) occurs as a result of an initial acute systemic inflammatory response. This can be consequent to a plethora of insults, either direct to the lung or indirect. The insult results in increased epithelial permeability, leading to alveolar flooding with a protein-rich oedema fluid. The resulting loss of gas exchange leads to acute respiratory failure and typically catastrophic illness, termed acute respiratory distress syndrome (ARDS), requiring ventilatory and critical care support. There remains a significant disease burden, with some estimates showing 200,000 cases each year in the USA with a mortality approaching 50%. In addition, there is a significant burden of morbidity in survivors. There are currently no disease-modifying therapies available, and the most effective advances in caring for these patients have been in changes to ventilator strategy as a result of the ARDS network studies nearly 15 years ago. Here, we will give an overview of more recent advances in the understanding of the cellular biology of ALI and highlight areas that may prove fertile for future disease-modifying therapies.
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Affiliation(s)
- Charles Sharp
- Academic Respiratory Unit, University of Bristol, Southmead Hospital, Westbury-on-Trym, UK
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7
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Endotracheal aspirate and bronchoalveolar lavage fluid analysis: interchangeable diagnostic modalities in suspected ventilator-associated pneumonia? J Clin Microbiol 2014; 52:3597-604. [PMID: 25078907 DOI: 10.1128/jcm.01494-14] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Authoritative guidelines state that the diagnosis of ventilator-associated pneumonia (VAP) can be established using either endotracheal aspirate (ETA) or bronchoalveolar lavage fluid (BALF) analysis, thereby suggesting that their results are considered to be in accordance. Therefore, the results of ETA Gram staining and semiquantitative cultures were compared to the results from a paired ETA-BALF analysis. Different thresholds for the positivity of ETAs were assessed. This was a prospective study of all patients who underwent bronchoalveolar lavage for suspected VAP in a 27-bed university intensive care unit during an 8-year period. VAP was diagnosed when ≥ 2% of the BALF cells contained intracellular organisms and/or when BALF quantitative culture revealed ≥ 10(4) CFU/ml of potentially pathogenic microorganisms. ETA Gram staining and semiquantitative cultures were compared to the results from paired BALF analysis by Cohen's kappa coefficients. VAP was suspected in 311 patients and diagnosed in 122 (39%) patients. In 288 (93%) patients, the results from the ETA analysis were available for comparison. Depending on the threshold used and the diagnostic modality, VAP incidences varied from 15% to 68%. For the diagnosis of VAP, the most accurate threshold for positivity of ETA semiquantitative cultures was moderate or heavy growth, whereas the optimal threshold for BALF Gram staining was ≥ 1 microorganisms per high power field. The Cohen's kappa coefficients were 0.22, 0.31, and 0.60 for ETA and paired BALF Gram stains, cultures, and BALF Gram stains, respectively. Since the ETA and BALF Gram stains and cultures agreed only fairly, they are probably not interchangeable for diagnosing VAP.
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8
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Khilnani GC, Arafath TKL, Hadda V, Kapil A, Sood S, Sharma SK. Comparison of bronchoscopic and non-bronchoscopic techniques for diagnosis of ventilator associated pneumonia. Indian J Crit Care Med 2011; 15:16-23. [PMID: 21633541 PMCID: PMC3097537 DOI: 10.4103/0972-5229.78218] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The diagnosis of ventilator associated pneumonia (VAP) remains a challenge because the clinical signs and symptoms lack both sensitivity and specificity and the selection of microbiologic diagnostic procedure is still a matter of debate. Aims and Objective: To study the role of various bronchoscopic and non-bronchoscopic diagnostic techniques for diagnosis of VAP. Settings and Design: This prospective comparative study was conducted in a medical ICU of a tertiary care center. Materials and Methods: Twenty-five patients, clinically diagnosed with VAP, were evaluated by bronchoscopic and non-bronchoscopic procedures for diagnosis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of various bronchoscopic and non-bronchoscopic techniques were calculated, taking clinical pulmonary infection score (CPIS) of ≥6 as reference standard. Results: Our study has shown that for the diagnosis of VAP, bronchoscopic brush had a sensitivity, specificity, PPV and NPV of 94.9% [confidence interval (CI): 70.6–99.7], 57.1% (CI: 13.4–86.1), 85% (CI: 61.1–96) and 80% (CI: 21.9–98.7), respectively. Bronchoscopic bronchoalveolar lavage (BAL) had a sensitivity, specificity, PPV and NPV of 77.8% (CI: 51.9–92.6), 71.8% (CI: 24.1–94), 87.3% (CI: 60.4–97.8) and 55.5% (CI: 17.4–82.6), respectively. Sensitivity, specificity, PPV and NPV for non–bronchoscopic BAL (NBAL) were 83.3% (CI: 57.7–95.6), 71.43% (CI: 24.1–94), 88.2% (CI: 62.3–97.4) and 62.5% (CI: 20.2–88.2), respectively. Endotracheal aspirate (ETA) yield was only 52% and showed poor concordance with BAL (κ-0.351; P-0.064) and NBAL (k-0.272; P-0.161). There was a good microbiologic concordance among different bronchoscopic and non-bronchoscopic distal airway sampling techniques. Conclusion: NBAL is an inexpensive, easy, and useful technique for microbiologic diagnosis of VAP. Our findings, if verified, might simplify the approach for the diagnosis of VAP.
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Affiliation(s)
- G C Khilnani
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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9
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Vaz AP, Amorim A, Espinar MJ, Oliveira T, Pereira JM, Paiva JA. [Positive bronchoalveolar lavage and quantitative cultures results in suspected late-onset ventilator associated penumonia evaluation--retrospective study]. REVISTA PORTUGUESA DE PNEUMOLOGIA 2011; 17:117-23. [PMID: 21549670 DOI: 10.1016/j.rppneu.2011.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Accepted: 11/16/2010] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Bronchoalveolar lavage (BAL) with quantitative cultures has been used in order to increase ventilator associated pneumonia (VAP) diagnosis specificity, although the accurate technique for this entity diagnosis remains controversial. OBJECTIVES To evaluate the influence of using positive BAL and quantitative cultures results in microbiologic diagnosis and treatment of patients with suspected late VAP and prior antibiotherapy. MATERIAL AND METHODS Retrospective analysis of intensive care unit (UCI) patients, during a one year period, with clinical suspicion of late VAP and prior use of antibiotics that presented a growth in BAL cultures. RESULTS Of 243 BAL performed, there were 71 (29.2%) positive cultures (60 patients, 76.7% male, 54 ± 19 years). BAL was done after 13 days (median) of invasive mechanical ventilation, 11 days of ICU antibiotherapy and in the day in which a new antibiotic for VAP suspicion was started. Colony forming units (CFU)/ml count was performed in 71.8% and endotracheal aspirate (ETA) simultaneously collected for qualitative analysis in 85.9%. Therapeutic approach was changed in 38.0%: correction (16.9%), de-escalation (12.7%) and directed antibiotherapy start (8.4%). Therapeutic changes were made in the presence of CFU > 10(4) in 84.2% and in agreement with ETA in 70.8%. In cases in which antibiotherapy was maintained (62.0%), quantitative cultures would have allowed de-escalation in 9.1%. Changes in prescription were more frequent when CFU was > 10(4) (48.5%), comparing with situations in which counts were lower and BAL analysis was qualitative (28.9%), p = 0.091. There were no significant differences between patients submitted to different therapeutic approaches concerning to ICU mortality or length of stay. CONCLUSION In late onset VAP, positive BAL and quantitative cultures allowed therapeutic changes, leading to antibiotic adequacy and consumption reduction, which can however be maximised.
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Affiliation(s)
- A P Vaz
- Serviço de Pneumologia, Hospital de São João - EPE, Porto, Portugal.
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10
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Patel CB, Gillespie TL, Goslar PW, Sindhwani M, Petersen SR. Trauma-associated pneumonia in adult ventilated patients. Am J Surg 2011; 202:66-70. [PMID: 21497790 DOI: 10.1016/j.amjsurg.2010.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 10/31/2010] [Accepted: 10/31/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The clinical pulmonary infection score (CPIS) and bronchoalveolar lavage (BAL) are 2 tools that have been validated to diagnose pneumonia in critically ill patients. However, the role of the CPIS in diagnosing trauma-associated pneumonia (TAP) remains in question. METHODS This prospective observational study included all trauma patients who were ventilated for longer than 48 hours from September 2008 to September 2009. The CPIS and quantitative culture results from the BAL were collected and used to define pneumonia. RESULTS A total of 162 patients were identified. In all, 58 (35.8%) and 104 (64.2%) had a CPIS greater than 5 and a CPIS of 5 or less, respectively. There were 95 (58.6%) patients who had a BAL completed regardless of CPIS. There were 65 patients who met the bacteriologic definition of pneumonia (≥10(4) colonies/mL), for an overall TAP incidence of 40.1%. CONCLUSIONS The CPIS is unreliable as a clinical tool to predict a positive BAL at 10(4) or 10(5) or higher threshold. Therefore, BAL should be used for the diagnosis of TAP based on clinical rationale and not the CPIS.
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Affiliation(s)
- Chirag B Patel
- Department of Trauma, Department of General Surgery, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA.
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11
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