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Fanning J, Panigada M, Li Bassi G. Nosocomial Pneumonia in the Mechanically Ventilated Patient. Semin Respir Crit Care Med 2022; 43:426-439. [PMID: 35714627 DOI: 10.1055/s-0042-1749448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a common complication occurring in critically ill patients who are mechanically ventilated and is the leading cause of nosocomial infection-related death. Etiologic agents for VAP widely differ based on the population of intensive care unit patients, duration of hospital stay, and prior antimicrobial therapy. VAP due to multidrug-resistant pathogens is associated with the highest morbidity and mortality, likely due to delays in appropriate antimicrobial treatment. International guidelines are currently available to guide diagnostic and therapeutic strategies. VAP can be prevented through various pharmacological and non-pharmacological interventions, which are more effective when grouped as bundles. When VAP is clinically suspected, diagnostic strategies should include early collection of respiratory samples to guide antimicrobial therapy. Empirical treatment should be based on the most likely etiologic microorganisms and antibiotics likely to be active against these microorganisms. Response to therapy should be reassessed after 3 to 5 days and antimicrobials adjusted or de-escalated to reduce the burden of the disease. Finally, considering that drug resistance is increasing worldwide, several novel antibiotics are being tested to efficiently treat VAP in the coming decades.
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Affiliation(s)
- Jonathon Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, Royal Brisbane and Women's Hospital, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Nuffield Department of Population Health, Oxford University, United Kingdom
| | - Mauro Panigada
- Department of Anaesthesiology, Intensive Care and EmergencyFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Queensland University of Technology, Brisbane, Australia.,Intensive Care Unit, The Wesley Hospital, Auchenflower, Queensland, Australia.,Wesley Medical Research, The Wesley Hospital, Auchenflower, Australia
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2
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Enne VI, Aydin A, Baldan R, Owen DR, Richardson H, Ricciardi F, Russell C, Nomamiukor-Ikeji BO, Swart AM, High J, Colles A, Barber J, Gant V, Livermore DM, O'Grady J. Multicentre evaluation of two multiplex PCR platforms for the rapid microbiological investigation of nosocomial pneumonia in UK ICUs: the INHALE WP1 study. Thorax 2022; 77:1220-1228. [PMID: 35027473 DOI: 10.1136/thoraxjnl-2021-216990] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 11/29/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Culture-based microbiological investigation of hospital-acquired or ventilator-associated pneumonia (HAP or VAP) is insensitive, with aetiological agents often unidentified. This can lead to excess antimicrobial treatment of patients with susceptible pathogens, while those with resistant bacteria are treated inadequately for prolonged periods. Using PCR to seek pathogens and their resistance genes directly from clinical samples may improve therapy and stewardship. METHODS Surplus routine lower respiratory tract samples were collected from intensive care unit patients about to receive new or changed antibiotics for hospital-onset lower respiratory tract infections at 15 UK hospitals. Testing was performed using the BioFire FilmArray Pneumonia Panel (bioMérieux) and Unyvero Pneumonia Panel (Curetis). Concordance analysis compared machine and routine microbiology results, while Bayesian latent class (BLC) analysis estimated the sensitivity and specificity of each test, incorporating information from both PCR panels and routine microbiology. FINDINGS In 652 eligible samples; PCR identified pathogens in considerably more samples compared with routine microbiology: 60.4% and 74.2% for Unyvero and FilmArray respectively vs 44.2% by routine microbiology. PCR tests also detected more pathogens per sample than routine microbiology. For common HAP/VAP pathogens, FilmArray had sensitivity of 91.7%-100.0% and specificity of 87.5%-99.5%; Unyvero had sensitivity of 50.0%-100.0%%, and specificity of 89.4%-99.0%. BLC analysis indicated that, compared with PCR, routine microbiology had low sensitivity, ranging from 27.0% to 69.4%. INTERPRETATION Conventional and BLC analysis demonstrated that both platforms performed similarly and were considerably more sensitive than routine microbiology, detecting potential pathogens in patient samples reported as culture negative. The increased sensitivity of detection realised by PCR offers potential for improved antimicrobial prescribing.
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Affiliation(s)
- Virve I Enne
- Division of Infection and Immunity, University College London, London, UK
| | - Alp Aydin
- Division of Infection and Immunity, University College London, London, UK
| | - Rossella Baldan
- Centre for Clinical Infection and Diagnostic Research, King's College London, London, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - Dewi R Owen
- Division of Infection and Immunity, University College London, London, UK
| | | | - Federico Ricciardi
- Department of Statistical Science, University College London, London, UK
| | | | | | - Ann-Marie Swart
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
| | - Juliet High
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
| | - Antony Colles
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
| | - Julie Barber
- Department of Statistical Science, University College London, London, UK
| | - Vanya Gant
- Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK.,NIHR Biomedical research Centre, University College London Hospitals, London, UK
| | | | - Justin O'Grady
- Norwich Medical School, University of East Anglia, Norwich, UK.,Quadram Institute Bioscience, Norwich, UK
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3
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Development and characterization of a new swine model of invasive pneumococcal pneumonia. Lab Anim (NY) 2021; 50:327-335. [PMID: 34675433 DOI: 10.1038/s41684-021-00876-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/16/2021] [Indexed: 11/08/2022]
Abstract
Streptococcus pneumoniae is the most common microbial cause of community-acquired pneumonia. Currently, there are no available models of severe pneumococcal pneumonia in mechanically ventilated animals to mimic clinical conditions of critically ill patients. We studied endogenous pulmonary flora in 4 healthy pigs and in an additional 10 pigs in which we intra-bronchially instilled S. pneumoniae serotype 19 A, characterized by its resistance to penicillin, macrolides and tetracyclines. The pigs underwent ventilation for 72 h. All pigs that were not challenged with S. pneumoniae completed the 72-h study, whereas 30% of infected pigs did not. At 24 h, we clinically confirmed pneumonia in the infected pigs; upon necropsy, we sampled lung tissue for microbiological/histological confirmation of pneumococcal pneumonia. In control pigs, Streptococcus suis and Staphylococcus aureus were the most commonly encountered pathogens, and their lung tissue mean ± s.e.m. concentration was 7.94 ± 20 c.f.u./g. In infected pigs, S. pneumoniae was found in the lungs of all pigs (mean ± s.e.m. pulmonary concentration of 1.26 × 105 ± 2 × 102 c.f.u./g). Bacteremia was found in 50% of infected pigs. Pneumococcal pneumonia was confirmed in all infected pigs at 24 h. Pneumonia was associated with thrombocytopenia, an increase in prothrombin time, cardiac output and vasopressor dependency index and a decrease in systemic vascular resistance. Upon necropsy, microbiological/histological pneumococcal pneumonia was confirmed in 8 of 10 pigs. We have therefore developed a novel model of penicillin- and macrolide-resistant pneumococcal pneumonia in mechanically ventilated pigs with bacteremia and severe hemodynamic compromise. The model could prove valuable for appraising the pathogenesis of pneumococcal pneumonia, the effects associated with macrolide resistance and the outcomes related to the use of new diagnostic strategies and antibiotic or complementary therapies.
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Bardet C, Barraud O, Clavel M, Fortin T, Charrier JP, Rodrigue M, François B, Yugueros-Marcos J, Lemoine J, Ploy MC. Early and specific targeted mass spectrometry-based identification of bacteria in endotracheal aspirates of patients suspected with ventilator-associated pneumonia. Eur J Clin Microbiol Infect Dis 2021; 40:1291-1301. [PMID: 33486654 PMCID: PMC7826153 DOI: 10.1007/s10096-020-04132-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/14/2020] [Indexed: 11/26/2022]
Abstract
Rapid and reliable pathogen identification is compulsory to confirm ventilator-associated pneumonia (VAP) in order to initiate appropriate antibiotic treatment. In the present proof of concept, the effectiveness of rapid microorganism identification with a targeted bottom-up proteomics approach was investigated in endotracheal aspirate (ETA) samples of VAP patients. To do so, a prototype selected-reaction monitoring (SRM)-based assay was developed on a triple quadrupole mass spectrometer tracking proteotypic peptide surrogates of bacterial proteomes. Through the concurrent monitoring of 97 species-specific peptides, this preliminary assay was dimensioned to characterize the occurrence of six most frequent bacterial species responsible for over more than 65% of VAP. Assay performance was subsequently evaluated by analyzing early and regular 37 ETA samples collected from 15 patients. Twenty-five samples were above the significant threshold of 105 CFU/mL and five samples showed mixed infections (both pathogens ≥ 105 CFU/mL). The targeted proteomics assay showed 100% specificity for Acinetobacter baumannii, Escherichia coli, Haemophilus influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus pneumoniae. No false bacterial identification was reported and no interference was detected arising from the commensal flora. The overall species identification sensitivity was 19/25 (76%) and was higher at the patient level (84.6%). This successful proof of concept provides a rational to broaden the panel of bacteria for further clinical evaluation.
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Affiliation(s)
- Chloé Bardet
- Université Limoges, INSERM, CHU Limoges, RESINFIT, U1092, F-87000, Limoges, France
- bioMerieux, MD3 & Microbiology Research Departments, Marcy l'Etoile, France
- Anaquant, 5 rue de La Doua, Villeurbanne, France
| | - Olivier Barraud
- Université Limoges, INSERM, CHU Limoges, RESINFIT, U1092, F-87000, Limoges, France
| | - Marc Clavel
- CHU Limoges, Service de Réanimation polyvalente, Limoges, France
- CHU Limoges, INSERM, CIC1435, Limoges, France
- Etablissement de médecine et SSR, Sainte-Feyre, France
| | - Tanguy Fortin
- bioMerieux, MD3 & Microbiology Research Departments, Marcy l'Etoile, France
- Anaquant, 5 rue de La Doua, Villeurbanne, France
| | | | - Marc Rodrigue
- bioMerieux, MD3 & Microbiology Research Departments, Marcy l'Etoile, France
- bioMérieux, Global Medical Affairs Department, Marcy l'Etoile, France
| | - Bruno François
- Université Limoges, INSERM, CHU Limoges, RESINFIT, U1092, F-87000, Limoges, France
- CHU Limoges, Service de Réanimation polyvalente, Limoges, France
- CHU Limoges, INSERM, CIC1435, Limoges, France
| | | | - Jerome Lemoine
- Université de Lyon, CNRS, Université Claude Bernard Lyon 1, Institut des Sciences Analytiques, UMR 5280, 5 rue de La Doua, 69100, Villeurbanne, France.
| | - Marie-Cécile Ploy
- Université Limoges, INSERM, CHU Limoges, RESINFIT, U1092, F-87000, Limoges, France.
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5
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Diagnosis of ventilator-associated pneumonia in critically ill adult patients-a systematic review and meta-analysis. Intensive Care Med 2020; 46:1170-1179. [PMID: 32306086 PMCID: PMC7223448 DOI: 10.1007/s00134-020-06036-z] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/02/2020] [Indexed: 02/01/2023]
Abstract
The accuracy of the signs and tests that clinicians use to diagnose ventilator-associated pneumonia (VAP) and initiate antibiotic treatment has not been well characterized. We sought to characterize and compare the accuracy of physical examination, chest radiography, endotracheal aspirate (ETA), bronchoscopic sampling cultures (protected specimen brush [PSB] and bronchoalveolar lavage [BAL]), and CPIS > 6 to diagnose VAP. We searched six databases from inception through September 2019 and selected English-language studies investigating accuracy of any of the above tests for VAP diagnosis. Reference standard was histopathological analysis. Two reviewers independently extracted data and assessed study quality. We included 25 studies (1639 patients). The pooled sensitivity and specificity of physical examination findings for VAP were poor: fever (66.4% [95% confidence interval [CI]: 40.7-85.0], 53.9% [95% CI 34.5-72.2]) and purulent secretions (77.0% [95% CI 64.7-85.9], 39.0% [95% CI 25.8-54.0]). Any infiltrate on chest radiography had a sensitivity of 88.9% (95% CI 73.9-95.8) and specificity of 26.1% (95% CI 15.1-41.4). ETA had a sensitivity of 75.7% (95% CI 51.5-90.1) and specificity of 67.9% (95% CI 40.5-86.8). Among bronchoscopic sampling methods, PSB had a sensitivity of 61.4% [95% CI 43.7-76.5] and specificity of 76.5% [95% CI 64.2-85.6]; while BAL had a sensitivity of 71.1% [95% CI 49.9-85.9] and specificity of 79.6% [95% CI 66.2-85.9]. CPIS > 6 had a sensitivity of 73.8% (95% CI 50.6-88.5) and specificity of 66.4% (95% CI 43.9-83.3). Classic clinical indicators had poor accuracy for diagnosis of VAP. Reliance upon these indicators in isolation may result in misdiagnosis and potentially unnecessary antimicrobial use.
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6
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Chen CY, Lin WC, Yang HY. Diagnosis of ventilator-associated pneumonia using electronic nose sensor array signals: solutions to improve the application of machine learning in respiratory research. Respir Res 2020; 21:45. [PMID: 32033607 PMCID: PMC7006122 DOI: 10.1186/s12931-020-1285-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/07/2020] [Indexed: 01/07/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is a significant cause of mortality in the intensive care unit. Early diagnosis of VAP is important to provide appropriate treatment and reduce mortality. Developing a noninvasive and highly accurate diagnostic method is important. The invention of electronic sensors has been applied to analyze the volatile organic compounds in breath to detect VAP using a machine learning technique. However, the process of building an algorithm is usually unclear and prevents physicians from applying the artificial intelligence technique in clinical practice. Clear processes of model building and assessing accuracy are warranted. The objective of this study was to develop a breath test for VAP with a standardized protocol for a machine learning technique. Methods We conducted a case-control study. This study enrolled subjects in an intensive care unit of a hospital in southern Taiwan from February 2017 to June 2019. We recruited patients with VAP as the case group and ventilated patients without pneumonia as the control group. We collected exhaled breath and analyzed the electric resistance changes of 32 sensor arrays of an electronic nose. We split the data into a set for training algorithms and a set for testing. We applied eight machine learning algorithms to build prediction models, improving model performance and providing an estimated diagnostic accuracy. Results A total of 33 cases and 26 controls were used in the final analysis. Using eight machine learning algorithms, the mean accuracy in the testing set was 0.81 ± 0.04, the sensitivity was 0.79 ± 0.08, the specificity was 0.83 ± 0.00, the positive predictive value was 0.85 ± 0.02, the negative predictive value was 0.77 ± 0.06, and the area under the receiver operator characteristic curves was 0.85 ± 0.04. The mean kappa value in the testing set was 0.62 ± 0.08, which suggested good agreement. Conclusions There was good accuracy in detecting VAP by sensor array and machine learning techniques. Artificial intelligence has the potential to assist the physician in making a clinical diagnosis. Clear protocols for data processing and the modeling procedure needed to increase generalizability.
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Affiliation(s)
- Chung-Yu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Douliu, Taiwan
| | - Wei-Chi Lin
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Hsiao-Yu Yang
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan. .,Institute of Environmental and Occupational Health Sciences, National Taiwan University College of Public Health, Taipei, Taiwan. .,Department of Public Health, National Taiwan University College of Public Health, Taipei, Taiwan. .,Department of Environmental and Occupational Medicine, National Taiwan University Hospital, Taipei, Taiwan. .,Innovation and Policy Center for Population Health and Sustainable Environment, College of Public Health, National Taiwan University, Taipei, Taiwan.
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Abstract
Acute respiratory distress syndrome (ARDS) was first described in 1967 by Ashbaugh and colleagues. Acute respiratory distress syndrome is a clinical syndrome, not a disease, and has no ideal definition or gold standard diagnostic test. There are multiple causes and different pathways of pathogenesis as well as various histological findings. Given these variations, there are many clinical entities that can get confused with ARDS. These entities are discussed in this article as "Mimics of ARDS." It imperative to correctly identify ARDS and distinguish it from other diseases to implement correct management strategy.
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8
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Dsouza R, Spillman DR, Barkalifa R, Monroy GL, Chaney EJ, White KC, Boppart SA. In vivo detection of endotracheal tube biofilms in intubated critical care patients using catheter-based optical coherence tomography. JOURNAL OF BIOPHOTONICS 2019; 12:e201800307. [PMID: 30604487 PMCID: PMC6470036 DOI: 10.1002/jbio.201800307] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/21/2018] [Accepted: 01/02/2019] [Indexed: 06/09/2023]
Abstract
The formation of biofilms in the endotracheal tubes (ETTs) of intubated patients on mechanical ventilation is associated with a greater risk of ventilator-associated pneumonia and death. New technologies are needed to detect and monitor ETTs in vivo for the presence of these biofilms. Longitudinal OCT imaging was performed in mechanically ventilated subjects at 24-hour intervals until extubation to detect the formation and temporal changes of in vivo ETT biofilms. OCT-derived attenuation coefficient images were used to differentiate between mucus and biofilm. Extubated ETTs were examined with optical and electron microscopy, and all imaging results were correlated with standard-of-care clinical test reports. OCT and attenuation coefficient images from four subjects were positive for ETT biofilms and were negative for two subjects. The processed and stained extubated ETTs and clinical reports confirmed the presence/absence of biofilms in all subjects. Our findings confirm that OCT can detect and differentiate between biofilm-positive and biofilm-negative groups (P < 10-5 ). OCT image-based features may serve as biomarkers for direct in vivo detection of ETT biofilms and help drive investigation of new management strategies to reduce the incidence of VAP.
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Affiliation(s)
- Roshan Dsouza
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, 405 N Mathews Ave, Urbana, Illinois 61801, USA
| | - Darold R. Spillman
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, 405 N Mathews Ave, Urbana, Illinois 61801, USA
| | - Ronit Barkalifa
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, 405 N Mathews Ave, Urbana, Illinois 61801, USA
| | - Guillermo L. Monroy
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, 405 N Mathews Ave, Urbana, Illinois 61801, USA
- Department of Bioengineering, University of Illinois at Urbana-Champaign, 1270 Digital Computer Laboratory, MC-278, Urbana, Illinois 61801, USA
| | - Eric J. Chaney
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, 405 N Mathews Ave, Urbana, Illinois 61801, USA
| | - Karen C. White
- Critical Care Medicine, Carle Foundation Hospital, 611 W. Park Street, Urbana, Illinois 61801, USA
| | - Stephen A. Boppart
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, 405 N Mathews Ave, Urbana, Illinois 61801, USA
- Department of Bioengineering, University of Illinois at Urbana-Champaign, 1270 Digital Computer Laboratory, MC-278, Urbana, Illinois 61801, USA
- Carle-Illinois College of Medicine, University of Illinois at Urbana-Champaign, 807 S. Wright St., Urbana, Illinois 61801, USA
- Department of Electrical and Computer Engineering, University of Illinois at Urbana-Champaign, 306 N. Wright St., Urbana, Illinois 61801, USA
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Ranzani OT, Forte DN, Forte AC, Mimica I, Forte WCN. The value of antibody-coated bacteria in tracheal aspirates for the diagnosis of ventilator-associated pneumonia: a case-control study. J Bras Pneumol 2016; 42:203-10. [PMID: 27383934 PMCID: PMC5569617 DOI: 10.1590/s1806-37562015000000244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 04/19/2016] [Indexed: 11/22/2022] Open
Abstract
Objective: Ventilator-associated pneumonia (VAP) is the leading type of hospital-acquired infection in ICU patients. The diagnosis of VAP is challenging, mostly due to limitations of the diagnostic methods available. The aim of this study was to determine whether antibody-coated bacteria (ACB) evaluation can improve the specificity of endotracheal aspirate (EA) culture in VAP diagnosis. Methods: We conducted a diagnostic case-control study, enrolling 45 patients undergoing mechanical ventilation. Samples of EA were obtained from patients with and without VAP (cases and controls, respectively), and we assessed the number of bacteria coated with FITC-conjugated monoclonal antibodies (IgA, IgM, or IgG) or an FITC-conjugated polyvalent antibody. Using immunofluorescence microscopy, we determined the proportion of ACB among a fixed number of 80 bacteria. Results: The median proportions of ACB were significantly higher among the cases (n = 22) than among the controls (n = 23)-IgA (60.6% vs. 22.5%), IgM (42.5% vs. 12.5%), IgG (50.6% vs. 17.5%), and polyvalent (75.6% vs. 33.8%)-p < 0.001 for all. The accuracy of the best cut-off points for VAP diagnosis regarding monoclonal and polyvalent ACBs was greater than 95.0% and 93.3%, respectively. Conclusions: The numbers of ACB in EA samples were higher among cases than among controls. Our findings indicate that evaluating ACB in EA is a promising tool to improve the specificity of VAP diagnosis. The technique could be cost-effective and therefore useful in low-resource settings, with the advantages of minimizing false-positive results and avoiding overtreatment.
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11
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Surveillance versus clinical adjudication: differences persist with new ventilator-associated event definition. Am J Infect Control 2015; 43:589-91. [PMID: 25845723 DOI: 10.1016/j.ajic.2015.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/06/2015] [Accepted: 03/09/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The National Healthcare Safety Network (NHSN) has recently supported efforts to shift surveillance away from ventilator-associated pneumonia to ventilator-associated events (VAEs) to decrease subjectivity in surveillance and minimize concerns over clinical correlation. The goals of this study were to compare the results of an automated surveillance strategy using the new VAE definition with a prospectively performed clinical application of the definition. METHODS All patients ventilated for ≥2 days in a medical and surgical intensive care unit were evaluated by 2 methods: retrospective surveillance using an automated algorithm combined with manual chart review after the NHSN's VAE methodology and prospective surveillance by pulmonary physicians in collaboration with the clinical team administering care to the patient at the bedside. RESULTS Overall, a similar number of events were called by each method (69 vs 67). Of the 1,209 patients, 56 were determined to have VAEs by both methods (κ = .81, P = .04). There were 24 patients considered to be a VAE by only 1 of the methods. Most discrepancies were the result of clinical disagreement with the NHSN's VAE methodology. CONCLUSIONS There was good agreement between the study teams. Awareness of the limitations of the surveillance definition for VAE can help infection prevention personnel in discussions with critical care partners about optimal use of these data.
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Boyer AF, Schoenberg N, Babcock H, McMullen KM, Micek ST, Kollef MH. A prospective evaluation of ventilator-associated conditions and infection-related ventilator-associated conditions. Chest 2015; 147:68-81. [PMID: 24854003 DOI: 10.1378/chest.14-0544] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The Centers for Disease Control and Prevention has shifted policy away from using ventilator-associated pneumonia (VAP) and toward using ventilator-associated conditions (VACs) as a marker of ICU quality. To date, limited prospective data regarding the incidence of VAC among medical and surgical ICU patients, the ability of VAC criteria to capture patients with VAP, and the potential clinical preventability of VACs are available. METHODS This study was a prospective 12-month cohort study (January 2013 to December 2013). RESULTS We prospectively surveyed 1,209 patients ventilated for ≥ 2 calendar days. Sixty-seven VACs were identified (5.5%), of which 34 (50.7%) were classified as an infection-related VAC (IVAC) with corresponding rates of 7.0 and 3.6 per 1,000 ventilator days, respectively. The mortality rate of patients having a VAC was significantly greater than that of patients without a VAC (65.7% vs 14.4%, P < .001). The most common causes of VACs included IVACs (50.7%), ARDS (16.4%), pulmonary edema (14.9%), and atelectasis (9.0%). Among IVACs, 44.1% were probable VAP and 17.6% were possible VAP. Twenty-five VACs (37.3%) were adjudicated to represent potentially preventable events. Eighty-six episodes of VAP occurred in 84 patients (10.0 of 1,000 ventilator days) during the study period. The sensitivity of the VAC criteria for the detection of VAP was 25.9% (95% CI, 16.7%-34.5%). CONCLUSIONS Although relatively uncommon, VACs are associated with greater mortality and morbidity when they occur. Most VACs represent nonpreventable events, and the VAC criteria capture a minority of VAP episodes.
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Affiliation(s)
- Anthony F Boyer
- Division of Pulmonary and Critical Care Medicine, Division of Infectious Diseases, Washington University School of Medicine
| | - Noah Schoenberg
- Division of Pulmonary and Critical Care Medicine, Division of Infectious Diseases, Washington University School of Medicine
| | - Hilary Babcock
- Division of Pulmonary and Critical Care Medicine, Division of Infectious Diseases, Washington University School of Medicine
| | - Kathleen M McMullen
- Hospital Epidemiology and Infection Prevention Department, Barnes-Jewish Hospital
| | | | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Division of Infectious Diseases, Washington University School of Medicine.
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Filipiak W, Beer R, Sponring A, Filipiak A, Ager C, Schiefecker A, Lanthaler S, Helbok R, Nagl M, Troppmair J, Amann A. Breath analysis for
in vivo
detection of pathogens related to ventilator-associated pneumonia in intensive care patients: a prospective pilot study. J Breath Res 2015; 9:016004. [DOI: 10.1088/1752-7155/9/1/016004] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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14
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da Silva PSL, de Aguiar VE, de Carvalho WB, Machado Fonseca MC. Value of clinical pulmonary infection score in critically ill children as a surrogate for diagnosis of ventilator-associated pneumonia. J Crit Care 2014; 29:545-50. [PMID: 24581947 DOI: 10.1016/j.jcrc.2014.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 01/15/2014] [Accepted: 01/19/2014] [Indexed: 11/17/2022]
Abstract
RATIONALE Although the modified clinical pulmonary infection score (mCPIS) has been endorsed by national organizations, only a very few pediatric studies have assessed it for the diagnosis of ventilator-associated pneumonia (VAP). METHODS Seventy children were prospectively included if they fulfilled the diagnosis criteria for VAP referenced by the Centers for Disease Control and Prevention. The primary outcome was performance of mCPIS calculated on day 1 to accurately identify VAP as defined by microbiological data. RESULTS The data showed that an mCPIS of 6 or higher had a sensitivity of 94%, specificity of 50%, positive predictive value of 64%, negative predictive value of 90%, a positive likelihood ratio of 1.88, and a negative likelihood ratio of 0.11. The area under the receiver operating characteristic curve was 0.70. A positive posttest result increased the disease probability by 15.4%, whereas a negative test result reduced the probability by 38.6%. Patients with an mCPIS of 6 or higher had longer length of mechanical ventilation and pediatric intensive care unit stay compared with patients with an mCPIS lower than 6. CONCLUSION The mCPIS had a clinically acceptable performance, and it can be a helpful screening tool for VAP diagnosis. An mCPIS lower than 6 was highly able in distinguishing patients without VAP. Despite its high sensitivity and negative predictive value of this score, further studies are required to assess the use of mCPIS in guiding therapeutic decisions.
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Affiliation(s)
- Paulo Sérgio Lucas da Silva
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital do Servidor Público Municipal, São Paulo, Brazil.
| | - Vânia Euzébio de Aguiar
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital do Servidor Público Municipal, São Paulo, Brazil
| | - Werther Brunow de Carvalho
- Pediatric Intensive Care Unit and Department of Neonatology, Universidade de São Paulo, São Paulo, Brazil; Children's Institute, Faculty of Medicine Clinics Hospital, University of São Paulo, São Paulo, Brazil
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Klompas M. Set a Short Course But Follow the Patient's Course for Ventilator-Associated Pneumonia. Chest 2013; 144:1745-1747. [DOI: 10.1378/chest.13-1744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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16
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Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, Fridkin S, Greene L, Guh A, Gutterman D, Hammer B, Henderson D, Hess D, Hill NS, Horan T, Kollef M, Levy M, Septimus E, VanAntwerpen C, Wright D, Lipsett P. Developing a new, national approach to surveillance for ventilator-associated events*. Crit Care Med 2013; 41:2467-75. [PMID: 24162674 PMCID: PMC10847970 DOI: 10.1097/ccm.0b013e3182a262db] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop and implement an objective, reliable approach to surveillance for ventilator-associated events in adult patients. DESIGN The Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group in September 2011. Working Group members included representatives of stakeholder societies and organizations and federal partners. MAIN RESULTS The Working Group finalized a three-tier, adult surveillance definition algorithm for ventilator-associated events. The algorithm uses objective, readily available data elements and can identify a broad range of conditions and complications occurring in mechanically ventilated adult patients, including but not limited to VAP. The first tier definition, ventilator-associated condition (VAC), identifies patients with a period of sustained respiratory deterioration following a sustained period of stability or improvement on the ventilator, defined by changes in the daily minimum fraction of inspired oxygen or positive end-expiratory pressure. The second tier definition, infection-related ventilator-associated complication (IVAC), requires that patients with VAC also have an abnormal temperature or white blood cell count, and be started on a new antimicrobial agent. The third tier definitions, possible and probable VAP, require that patients with IVAC also have laboratory and/or microbiological evidence of respiratory infection. CONCLUSIONS Ventilator-associated events surveillance was implemented in January 2013 in the CDC's National Healthcare Safety Network. Modifications to improve surveillance may be made as additional data become available and users gain experience with the new definitions.
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Affiliation(s)
- Shelley S Magill
- 1Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA. 2Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA. 3Infection Control Department, Brigham and Women's Hospital, Boston, MA. 4Society for Healthcare Epidemiology of America, Arlington, VA. 5Division of Pulmonary and Critical Care Medicine, Rush University School of Medicine, Chicago, IL. 6Critical Care Societies Collaborative-American Association of Critical-Care Nurses, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine. 7School of Nursing, Critical and Acute Care, University of Virginia, Charlottesville, VA. 8Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 9Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA. 10Healthcare Infection Control Practices Advisory Committee Surveillance Working Group, Atlanta, GA. 11Infection Prevention and Control Department, Rochester General Health System, Rochester, NY. 12Association for Professionals in Infection Control and Epidemiology, Washington, DC. 13Department of Medicine, Medical College of Wisconsin, Milwaukee, WI. 14Department of Cardiology, Zablocki VA Medical Center, Milwaukee, WI. 15Hospital Epidemiology and Quality Improvement, The Clinical Center, National Institutes of Health, Bethesda, MD. 16Department of Respiratory Care, Massachusetts General Hospital, Boston, MA. 17Department of Anesthesia, Harvard Medical School, Boston, MA. 18American Association for Respiratory Care, Irving, TX. 19Division of Pulmonary and Critical Care Medicine, Tufts Medical Center, Boston, MA. 20Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, MO. 21Division of Pulmonary, Critical Care, and Sleep, Warren Alpert Medical School at Brown University, Rhode Island Hospital, Providenc
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Bercault N. Pneumonie acquise sous ventilation mécanique et mortalité : réelle implication ou simple association ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0672-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Khalil MM, Abdel Dayem AM, Farghaly AAAH, Shehata HM. Pattern of community and hospital acquired pneumonia in Egyptian military hospitals. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013. [DOI: 10.1016/j.ejcdt.2013.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Lin Q, Fu F, Shen L, Zhu B. Pentraxin 3 in the assessment of ventilator-associated pneumonia: an early marker of severity. Heart Lung 2012; 42:139-45. [PMID: 23273657 DOI: 10.1016/j.hrtlng.2012.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 11/19/2012] [Accepted: 11/21/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The aim was to assess the diagnostic and prognostic value of measuring pentraxin 3 (PTX3) together with C-reactive protein (CRP) in patients with ventilator-associated pneumonia (VAP). BACKGROUND The PTX3 values increase rapidly during multiple inflammatory conditions, but little is known about its characteristics in VAP. METHODS Measurement of PTX3 and CRP levels in plasma from 136 consecutive patients receiving mechanical ventilation > 48 h in a prospective single center study. RESULTS A PTX3 threshold of >16.43 ng/ml provided a specificity of 74.0% and a sensitivity of 68.6% for the diagnosis of VAP. PTX3 correlated with severity of sepsis and peaked earlier than CRP in patients with confirmed VAP. Multivariate Cox regression analysis showed PTX3 was the independent predictor for mortality of VAP. CONCLUSIONS PTX3 was not superior to CRP as a biomarker to diagnose VAP, but it was an early indicator of inflammation and had better prognostic value to predict mortality than CRP.
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Affiliation(s)
- Qionghua Lin
- Department of Anaesthesia, Critical Care and Pain Medicine, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, PR China
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Kollef MH. Ventilator-associated complications, including infection-related complications: the way forward. Crit Care Clin 2012. [PMID: 23182526 DOI: 10.1016/j.ccc.2012.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute respiratory failure represents the most common condition requiring admission to an adult intensive care unit. Ventilator-associated pneumonia (VAP) has been used as a marker of quality for patients with respiratory failure. Hospital-based process-improvement initiatives to prevent VAP have been successfully used. The use of ventilator-associated complications (VACs) has been proposed as an objective marker to assess the quality of care for this patient population. The use of evidence-based bundles targeting the reduction of VACs, as well as the conduct of prospective studies showing that VACs are preventable complications, are reasonable first-steps in addressing this important clinical problem.
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Affiliation(s)
- Marin H Kollef
- Washington University School of Medicine, St Louis, MO 63110, USA.
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Tenover FC. Developing molecular amplification methods for rapid diagnosis of respiratory tract infections caused by bacterial pathogens. Clin Infect Dis 2011; 52 Suppl 4:S338-45. [PMID: 21460293 DOI: 10.1093/cid/cir049] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Current diagnostic methods for bacterial respiratory tract infections are slow and often of marginal value for patient management if the adequacy of the specimen is not confirmed before culture. Molecular amplification tests, which are highly sensitive, can provide results in hours rather than days but may not distinguish colonization from infection unless a quantification step is included. Defining the reference method to be used for evaluating a novel molecular assay, with input from the US Food and Drug Administration (FDA), is critical before initiating development of a potential product. Although expectorated sputum may be the clinician's specimen of choice for testing because of ease of collection, the poor quality of such specimens may pose problems for clinical trials of novel amplification tests. There are still many gaps in our understanding of the interplay between colonization and infection and of the role that amplification tests may play in guiding anti-infective therapy. Thus, the performance parameters of a new diagnostic method should be closely matched to a precisely defined intended use statement.
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Abstract
OBJECTIVE A review of the existing literature on ventilator-associated pneumonia in children with emphasis on problems in diagnosis. DATA SOURCES A systematic literature review from 1947 to 2010 using Ovid MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and ISI Web of Science using key words "ventilator associated pneumonia" and "children." Where pediatric data were lacking, appropriate adult studies were reviewed and similarly referenced. STUDY SELECTION Two hundred sixty-two pediatric articles were reviewed and data from 48 studies selected. Data from 61 adult articles were also included in this review. DATA EXTRACTION AND SYNTHESIS Ventilator-associated pneumonia is the second most common nosocomial infection and the most common reason for antibiotic use in the pediatric intensive care unit. Attributable mortality is uncertain but ventilator-associated pneumonia is associated with significant morbidity and cost. Diagnosis is problematic in that clinical, radiologic, and microbiologic criteria lack sensitivity and specificity relative to autopsy histopathology and culture. Qualitative tracheal aspirate cultures are commonly used in diagnosis but lack specificity. Quantitative tracheal aspirate cultures have sensitivity (31-69%) and specificity (55-100%) comparable to bronchoalveolar lavage (11-90% and 43-100%, respectively) but concordance for the same bacterial species when compared with autopsy lung culture was better for bronchoalveolar lavage (52-90% vs. 50-76% for quantitative tracheal aspirate). Staphylococcus aureus and Pseudomonas species are the most common organisms, but microbiologic flora change over time and with antibiotic use. Initial antibiotics should offer broad-spectrum coverage but should be narrowed as clinical response and cultures dictate. CONCLUSIONS Ventilator-associated pneumonia is an important nosocomial infection in the pediatric intensive care unit. Conclusions regarding epidemiology, treatment, and outcomes are greatly hampered by the inadequacies of current diagnostic methods. We recommend a more rigorous approach to diagnosis by using the Centers for Disease Control and Prevention algorithm. Given that ventilator-associated pneumonia is the most common reason for antibiotic use in the pediatric intensive care unit, more systematic studies are sorely needed.
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Affiliation(s)
- Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Recognition and prevention of nosocomial pneumonia in the intensive care unit and infection control in mechanical ventilation. Crit Care Med 2010; 38:S352-62. [PMID: 20647793 DOI: 10.1097/ccm.0b013e3181e6cc98] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Nosocomial pneumonia (NP) is a difficult diagnosis to establish in the critically ill patient due to the presence of underlying cardiopulmonary disorders (e.g., pulmonary contusion, acute respiratory distress syndrome, atelectasis) and the nonspecific radiographic and clinical signs associated with this infection. Additionally, the classification of NP in the intensive care unit setting has become increasingly complex, as the types of patients who develop NP become more diverse. The occurrence of NP is especially problematic as it is associated with a greater risk of hospital mortality, longer lengths of stay on mechanical ventilation and in the intensive care unit, a greater need for tracheostomy, and significantly increased medical care costs. The adverse effects of NP on healthcare outcomes has increased pressure on clinicians and healthcare systems to prevent this infection, as well as other nosocomial infections that complicate the hospital course of patients with respiratory failure. This manuscript will provide a brief overview of the current approaches for the diagnosis of NP and focus on strategies for prevention. Finally, we will provide some guidance on how standardized or protocolized care of mechanically ventilated patients can reduce the occurrence of and morbidity associated with complications like NP.
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Microbiogical data, but not procalcitonin improve the accuracy of the clinical pulmonary infection score. Intensive Care Med 2010; 36:790-8. [PMID: 20217042 DOI: 10.1007/s00134-010-1833-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 11/06/2009] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Early and adequate treatment of ventilator-associated pneumonia (VAP) is mandatory to improve the outcome. The aim of this study was to evaluate, in medical ICU patients, the respective and combined impact of the Clinical Pulmonary Infection Score (CPIS), broncho-alveolar lavage (BAL) gram staining, endotracheal aspirate and a biomarker (procalcitonin) for the early diagnosis of VAP. DESIGN Prospective, observational study SETTING A medical intensive care unit in a teaching hospital. PATIENTS Over an 8-month period, we prospectively included 57 patients suspected of having 86 episodes of VAP. INTERVENTION The day of suspicion, a BAL as well as alveolar and serum procalcitonin determinations and evaluation of CPIS were performed. MEASUREMENTS AND MAIN RESULTS Of 86 BAL performed, 48 were considered positive (cutoff of 10(4) cfu ml(-1)). We found no differences in alveolar or serum procalcitonin between VAP and non-VAP patients. Including procalcitonin in the CPIS score did not increase its accuracy (55%) for the diagnosis of VAP. The best tests to predict VAP were modified CPIS (threshold at 6) combined with microbiological data. Indeed, both routinely twice weekly performed endotracheal aspiration at a threshold of 10(5) cfu ml(-1) and BAL gram staining improved pre-test diagnostic accuracy of VAP (77 and 66%, respectively). CONCLUSION This study showed that alveolar procalcitonin performed by BAL does not help the clinician to identify VAP. It confirmed that serum procalcitonin is not an accurate marker of VAP. In contrast, microbiological resources available at the time of VAP suspicion (BAL gram staining, last available endotracheal aspirate) combined or not with CPIS are helpful in distinguishing VAP diagnosed by BAL from patients with a negative BAL.
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Fartoukh M, Ricard JD. Pneumonies nosocomiales : aspects pratiques de la prise en charge. Rev Mal Respir 2009; 26:463-7. [DOI: 10.1016/s0761-8425(09)74056-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Current Issues in Ventilator-Associated Pneumonia. EMERGING ISSUES AND CONTROVERSIES IN INFECTIOUS DISEASE 2009. [PMCID: PMC7121435 DOI: 10.1007/978-0-387-84841-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and treatment. J Crit Care 2008; 23:138-47. [PMID: 18359431 DOI: 10.1016/j.jcrc.2007.12.008] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 12/21/2007] [Accepted: 12/28/2007] [Indexed: 12/31/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients. Despite a large amount of research evidence, the optimal diagnostic and treatment strategies for VAP remain controversial. PURPOSE The aim of this study was to develop evidence-based clinical practice guidelines for the diagnosis and treatment of VAP. Data sources include Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials. STUDY SELECTION The authors systematically searched for all relevant randomized controlled trials and systematic reviews on the diagnosis and treatment of VAP in mechanically ventilated adults that were published from 1980 to October 1, 2006. DATA EXTRACTION Independently and in duplicate, the panel critically appraised each published trial. The effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. The full guideline development panel arrived at a consensus for scores on safety, feasibility, and economic issues. LEVELS OF EVIDENCE Based on the scores for each topic, the following statements of recommendation were used: recommend, consider, do not recommend, and no recommendation because of insufficient or conflicting evidence. DATA SYNTHESIS For the diagnosis of VAP in immunocompetent patients, we recommend that endotracheal aspirates with nonquantitative cultures be used as the initial diagnostic strategy. When there is a suspicion of VAP, we recommend empiric antimicrobial therapy (in contrast to delayed or culture directed therapy) and appropriate single agent antimicrobial therapy for each potential pathogen as empiric therapy for VAP. Choice of antibiotics should be based on patient factors and local resistance patterns. We recommend that an antibiotic discontinuation strategy be used in patients who are treated of suspected VAP. For patients who receive adequate initial antibiotic therapy, we recommend 8 days of antibiotic therapy. We do not recommend nebulized endotracheal tobramycin or intratracheal instillation of tobramycin for the treatment of VAP. CONCLUSION We present evidence-based recommendations for the diagnosis and treatment of VAP. Implementation of these recommendations into clinical practice may lessen the morbidity and mortality of patients who develop VAP.
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Affiliation(s)
- John Muscedere
- Department of Medicine, Queen's University, Kingston, Canada K7L 2V7
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Boots RJ, Phillips GE, George N, Faoagali JL. Surveillance culture utility and safety using low-volume blind bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia. Respirology 2008; 13:87-96. [PMID: 18197916 DOI: 10.1111/j.1440-1843.2007.01211.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Surveillance cultures may improve the prediction of ventilator-associated pneumonia (VAP) and empirical antibiotic selection. This study examined the utility and patient safety of blind, non-protected, low-volume mini-bronchial lavage (BM-BAL) surveillance cultures in predicting VAP. METHODOLOGY A prospective, cohort study was performed in a large general intensive care unit. BM-BALs were collected within 12 h of admission then thrice weekly. Each BM-BAL was screened by Gram staining for intracellular organisms and then quantitatively cultured. VAP was diagnosed using the Clinical Pulmonary Infection Score. The concordance for isolates from the BM-BAL was assessed against concurrently collected endotracheal aspirates (EA). RESULTS Four hundred and twelve patients requiring a minimum of 48 h of mechanical ventilation were enrolled. Fifty patients developed 58 episodes of VAP. Concordant pathogens were found in 85% of BM-BAL specimens collected 2 days prior to VAP onset. Their antibiograms were stable over the preceding 4 days. The isolation of pathogens with colony counts >or=10(4) cfu/mL from BM-BAL performed 2 days prior to the clinical onset of VAP had a sensitivity of 84%, specificity of 50%, positive predictive value of 31% and a negative predictive value of 93% for predicting the development of VAP. BM-BAL WCC, quantification of bacterial growth and the percentage of intracellular organisms were not helpful in predicting VAP diagnosis. CONCLUSIONS BM-BAL surveillance cultures are well tolerated and useful in predicting the pathogens and their antibiograms causing VAP. Diagnostic specimen collection at the time of VAP onset is still required as surveillance cultures may be negative even one day prior to VAP onset.
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Affiliation(s)
- Robert J Boots
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia.
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Rea-Neto A, Youssef NCM, Tuche F, Brunkhorst F, Ranieri VM, Reinhart K, Sakr Y. Diagnosis of ventilator-associated pneumonia: a systematic review of the literature. Crit Care 2008; 12:R56. [PMID: 18426596 PMCID: PMC2447611 DOI: 10.1186/cc6877] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2008] [Revised: 04/01/2008] [Accepted: 04/21/2008] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Early, accurate diagnosis is fundamental in the management of patients with ventilator-associated pneumonia (VAP). The aim of this qualitative review was to compare various criteria of diagnosing VAP in the intensive care unit (ICU) with a special emphasis on the value of clinical diagnosis, microbiological culture techniques, and biomarkers of host response. METHODS A MEDLINE search was performed using the keyword 'ventilator associated pneumonia' AND 'diagnosis'. Our search was limited to human studies published between January 1966 and June 2007. Only studies of at least 25 adult patients were included. Predefined variables were collected, including year of publication, study design (prospective/retrospective), number of patients included, and disease group. RESULTS Of 572 articles fulfilling the initial search criteria, 159 articles were chosen for detailed review of the full text. A total of 64 articles fulfilled the inclusion criteria and were included in our review. Clinical criteria, used in combination, may be helpful in diagnosing VAP, however, the considerable inter-observer variability and the moderate performance should be taken in account. Bacteriologic data do not increase the accuracy of diagnosis as compared to clinical diagnosis. Quantitative cultures obtained by different methods seem to be rather equivalent in diagnosing VAP. Blood cultures are relatively insensitive to diagnose pneumonia. The rapid availability of cytological data, including inflammatory cells and Gram stains, may be useful in initial therapeutic decisions in patients with suspected VAP. C-reactive protein, procalcitonin, and soluble triggering receptor expressed on myeloid cells are promising biomarkers in diagnosing VAP. CONCLUSION An integrated approach should be followed in diagnosing and treating patients with VAP, including early antibiotic therapy and subsequent rectification according to clinical response and results of bacteriologic cultures.
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Affiliation(s)
- Alvaro Rea-Neto
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Hospital, 07743 Jena, Germany
| | - Nazah Cherif M Youssef
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Hospital, 07743 Jena, Germany
| | - Fabio Tuche
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Hospital, 07743 Jena, Germany
| | - Frank Brunkhorst
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Hospital, 07743 Jena, Germany
| | - V Marco Ranieri
- Department of Anesthesiology and Intensive Care, S. Giovanni Battista Hospital, University of Turin, Turin, 10126, Italy
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Hospital, 07743 Jena, Germany
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Hospital, 07743 Jena, Germany
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Abstract
In Osier’s time, bacterial pneumonia was a dreaded event, so important that he borrowed John Bunyan’s characterization of tuberculosis and anointed the pneumococcus, as the prime pathogen, “Captain of the men of death.”1 One hundred years later much has changed, but much remains the same. Pneumonia is now the sixth most common cause of death and the most common lethal infection in the United States. Hospital-acquired pneumonia is now the second most common nosocomial infection.2 It was documented as a complication in 0.6% of patients in a national surveillance study,3 and has been reported in as many as 20% of patients in critical care units.4 Furthermore, it is the leading cause of death among nosocomial infections.5 Leu and colleagues6 were able to associate one third of the mortality in patients with nosocomial pneumonia to the infection itself. The increase in hospital stay, which averaged 7 days, was statistically significant. It has been estimated that nosocomial pneumonia produces costs in excess of $500 million each year in the United States, largely related to the increased length of hospital stay.
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Timsit JF. Bronchoalveolar lavage for VAP diagnosis: patients must be sampled before any change of antimicrobial therapy. Intensive Care Med 2007; 33:1690-3. [PMID: 17673973 DOI: 10.1007/s00134-007-0812-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 06/05/2007] [Indexed: 11/28/2022]
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Brandão da Silva N, Martins L, Martins F, Anflor J, Tonietto T, Koefender C, Cardoso PG, Moreira J. Direct examination and cultures of bronchoalveolar lavage in pneumonia diagnosis: a comparative experimental study. Intensive Care Med 2007; 33:1840-7. [PMID: 17673974 DOI: 10.1007/s00134-007-0811-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 07/10/2007] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To assess the accuracy of direct examination and quantitative cultures of BAL to diagnose pneumonia with or without antibiotic treatment. DESIGN Experimental rat models. INTERVENTIONS Pneumonia was induced by intratracheal inoculation of S. pneumoniae (10(9) cfu/ml) or P. aeruginosa (10(8)cfu/ml). Controls (n = 10) received sterile inoculum. Study animals received penicillin (n = 19) or saline (n = 18) (pneumococcal model); amikacin (n = 13), ceftazidime (n = 11), or saline (n = 13) (Pseudomonas model). BAL was assessed 48 h after infection. The animals were killed for histopathological analysis. RESULTS All study animals developed pneumonia, which was more extensive in the pneumococcal than in the Pseudomonas model. In pneumococcal pneumonia the sensitivity of BAL cultures (10(3) cfu/ml or higher) was 77.8% with saline and 21.0% with penicillin. In the Pseudomonas ceftazidime group all specimens were negative, precluding diagnosis. The sensitivity of cultures with amikacin was 23.1% vs. 30.8% with saline. In the pneumococcal model intracellular organism (ICO) count of 2% or higher had a sensitivity of 100% for detecting pneumonia with saline and 57.9% with penicillin. In the Pseudomonas model the sensitivity of ICO was 69.2% with both amikacin and saline and 36.3% with ceftazidime. The sensitivity of neutrophil count above 50% in pneumococcal pneumonia was 77.8% and 64.7% with saline and penicillin, respectively, and 69.2%, 61.5%, and 81.8% with saline, amikacin, and ceftazidime, respectively, in Pseudomonas pneumonia. CONCLUSIONS BAL-positive intracellular organisms were more accurate than cultures for the diagnosis of recent pneumonia, and were less affected by antibiotic treatment.
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Weber MD, Thammasitboon S. A critical appraisal of "Blind and bronchoscopic sampling methods in suspected ventilator-associated pneumonia: a multicentre prospective study" by Mentec et al. (Intensive Care Med 2004; 30:1319-1326). Pediatr Crit Care Med 2007; 8:272-5. [PMID: 17417116 DOI: 10.1097/01.pcc.0000262901.82640.4b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mark D Weber
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV, USA.
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Bauer TT, Ewig S, Rodloff AC, Müller EE. Acute respiratory distress syndrome and pneumonia: a comprehensive review of clinical data. Clin Infect Dis 2006; 43:748-56. [PMID: 16912951 PMCID: PMC7107989 DOI: 10.1086/506430] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2005] [Accepted: 04/24/2006] [Indexed: 01/11/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) and pneumonia are closely correlated in the critically ill patient. Whereas ARDS is often complicated by nosocomial pneumonia, pulmonary infection is also the most frequent single cause of ARDS. The prevalence of pneumonia during the course of ARDS seems to be particularly high, but whether persons with ARDS are more susceptible to pneumonia or simply have more risk factors remains unknown because of methodological limitations. Recent research suggests that host factors have a major bearing on the development of ARDS. To date, sepsis seems to be the principal link between pneumonia and ARDS. However, prospective observational data on this supposed sequence are not available. The individual role of specific pathogens for the development of ARDS is difficult to assess, because prospective studies are missing. Respiratory viruses have received particular attention, but this review suggests that infections with coronavirus and avian influenza virus (H5N1) are associated with a high incidence of ARDS.
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Affiliation(s)
- Torsten T Bauer
- Helios Clinic Emil von Behring, Respiratory Diseases Clinic Heckeshorn, Berlin, Germany.
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Schultz MJ, Visser C, Duim B. Quantitative Real-Time Polymerase Chain Reaction for Detection of Bacteria: Wanted, Dead or Alive? Crit Care Med 2005; 33:2720; author reply 2720-1. [PMID: 16276226 DOI: 10.1097/01.ccm.0000187090.91547.4d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Brun-Buisson C, Fartoukh M, Lechapt E, Honoré S, Zahar JR, Cerf C, Maitre B. Contribution of Blinded, Protected Quantitative Specimens to the Diagnostic and Therapeutic Management of Ventilator-Associated Pneumonia. Chest 2005; 128:533-44. [PMID: 16100135 DOI: 10.1378/chest.128.2.533] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Sampling techniques for microbiological diagnosis of ventilator-associated pneumonia (VAP) remain debated, and it is unclear to what extent invasive diagnostic techniques impact the management of patients. DESIGN A prospective observational study of 68 first episodes of suspected pneumonia in which specimens were obtained blindly (endotracheal aspirate [EA] and blinded protected telescoping catheter [PTC]) and via bronchoscopy (directed PTC bronchoscopy and BAL), and in sequence, and the results were provided to the attending physicians in the same order. Therapeutic plans resulting at each step were examined, and their adequacy was assessed using quantitative BAL fluid culture as the diagnostic standard. PARTICIPANTS Sixty-eight patients with clinically suspected VAP hospitalized in two ICUs in a tertiary care university hospital. RESULTS There were 35 patients (51%) with VAP confirmed by BAL fluid culture (13 early onset and 22 late onset). EA specimens grew organisms (light growth or more) in all BAL-confirmed VAP cases and 59% of nonconfirmed cases, whereas the sensitivity and specificity of blinded PTC quantitative cultures were 77% and 97%, and did not differ from those of directed PTC cultures (77% and 94%, respectively). Antibiotic therapy based on the clinical severity and likelihood of VAP, Gram stain results, and early blinded PTC culture results was adequate in 54% (19 of 35 VAP patients) within 2 h of sampling and 80% (28 of 35 patients) within 24 h; therapy was revised in only 3 more patients following BAL culture results. New antibiotics were introduced within the first 24 h in 14 of 33 nonconfirmed episodes (42%), and antibiotics were withheld or withdrawn within 48 h in 23 episodes (70%); three of these patients-with both blinded PTC and BAL growing organisms below the threshold-had early subsequently confirmed pneumonia with the same organism. CONCLUSIONS A therapeutic approach guided by quantitative cultures of blinded specimens helps achieve early adequate management of approximately 90% of patients suspected of having VAP.
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Affiliation(s)
- Christian Brun-Buisson
- Service de Réanimation Médicale, Hôpital Henri Mondor, Assistance Publique--Hôpitaux de Paris, 51, Avenue du Mal de Lattre de Tassigny, 94010 Créteil Cedex, France.
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Wahl WL, Ahrns KS, Brandt MM, Rowe SA, Hemmila MR, Arbabi S. Bronchoalveolar lavage in diagnosis of ventilator-associated pneumonia in patients with burns. ACTA ACUST UNITED AC 2005; 26:57-61. [PMID: 15640736 DOI: 10.1097/01.bcr.0000150305.25484.1a] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ventilator-associated pneumonia (VAP) remains a major cause of morbidity and mortality for patients with burns. In nonburn populations, bronchoalveolar lavage (BAL) excludes other pathology such as systemic inflammatory response syndrome. We hypothesized that BAL would decrease our false-positive VAP rate. All ventilated patients with burn injury who were admitted to our institution from July 2000 through June 2003 were included. After June 2001, BAL was used to make the diagnosis of VAP, with > or =10(4) organisms considered a positive result. Fifty patients met criteria for VAP, 21 in the pre-BAL period and 29 in the BAL period. Six patients (21%) in the BAL group had quantitative cultures <10(4) and were not treated. The outcomes for these patients were not different than those treated for VAP. There were no differences in age, TBSA size, antibiotic use, or ventilator days for the pre-BAL or BAL groups, although the pneumonia rate was lower for the BAL time period. The use of BAL eliminated the unnecessary antibiotic treatment of 21% of patients in the BAL time period and was associated with a lower rate of VAP.
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Affiliation(s)
- Wendy L Wahl
- University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0033, USA
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Guidelines for the Diagnosis and Treatment of Community-Acquired Pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). ACTA ACUST UNITED AC 2005. [PMCID: PMC7128950 DOI: 10.1016/s1579-2129(06)60222-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cohen J, Brun-Buisson C, Torres A, Jorgensen J. Diagnosis of infection in sepsis: An evidence-based review. Crit Care Med 2004; 32:S466-94. [PMID: 15542957 DOI: 10.1097/01.ccm.0000145917.89975.f5] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for the diagnosis of infection in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSIONS Obtaining a precise bacteriological diagnosis before starting antibiotic therapy is, when possible, of paramount importance for the success of therapeutic strategy during sepsis. Two to three blood cultures should be performed, preferably from a peripheral vein, without interval between samples to avoid delaying therapy. A quantitative approach is preferred in most cases when possible, in particular for catheter-related infections and ventilator-associated pneumonia. Diagnosing community-acquired pneumonia is complex, and a diagnostic algorithm is proposed. Appropriate samples are indicated during soft tissue and intraabdominal infections, but cultures obtained through the drains are discouraged.
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Affiliation(s)
- Jonathan Cohen
- Department of Medicine, Brighton & Sussex Medical School, Brighton, UK
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Camargo LFA, De Marco FV, Barbas CSV, Hoelz C, Bueno MAS, Rodrigues Jr M, Amado VM, Caserta R, Martino MDV, Pasternak J, Knobel E. Ventilator associated pneumonia: comparison between quantitative and qualitative cultures of tracheal aspirates. Crit Care 2004; 8:R422-30. [PMID: 15566587 PMCID: PMC1065063 DOI: 10.1186/cc2965] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2004] [Revised: 08/19/2004] [Accepted: 09/02/2004] [Indexed: 11/17/2022] Open
Abstract
Introduction Deferred or inappropriate antibiotic treatment in ventilator-associated pneumonia (VAP) is associated with increased mortality, and clinical and radiological criteria are frequently employed to establish an early diagnosis. Culture results are used to confirm the clinical diagnosis and to adjust or sometimes withdraw antibiotic treatment. Tracheal aspirates have been shown to be useful for these purposes. Nonetheless, little is known about the usefulness of quantitative findings in tracheal secretions for diagnosing VAP. Methods To determine the value of quantification of bacterial colonies in tracheal aspirates for diagnosing VAP, we conducted a prospective follow-up study of 106 intensive care unit patients who were under ventilatory support. In total, the findings from 219 sequential weekly evaluations for VAP were examined. Clinical and radiological parameters were recorded and evaluated by three independent experts; a diagnosis of VAP required the agreement of at least two of the three experts. At the same time, cultures of tracheal aspirates were analyzed qualitatively and quantitatively (105 colony-forming units [cfu]/ml and 106 cfu/ml) Results Quantitative cultures of tracheal aspirates (105 cfu/ml and 106 cfu/ml) exhibited increased specificity (48% and 78%, respectively) over qualitative cultures (23%), but decreased sensitivity (26% and 65%, respectively) as compared with the qualitative findings (81%). Quantification did not improve the ability to predict a diagnosis of VAP. Conclusion Quantitative cultures of tracheal aspirates in selected critically ill patients have decreased sensitivity when compared with qualitative results, and they should not replace the latter to confirm a clinical diagnosis of VAP or to adjust antimicrobial therapy.
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Affiliation(s)
| | | | | | - Cristiane Hoelz
- Assistant Physican, Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brasil
| | | | - Milton Rodrigues Jr
- Assistant Physican, Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brasil
| | - Verônica Moreira Amado
- Assistant Physican, Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brasil
| | - Raquel Caserta
- Respiratory Therapist, Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brasil
| | | | - Jacyr Pasternak
- Microbiology Laboratory, Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brasil
| | - Elias Knobel
- Head, Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brasil
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Huvent-Grelle D, Puisieux F, Tettart-Hevin K, Tettart V, Bulckaen H, Simovic B, Leroy O, Dewailly P. Pneumopathies du sujet âgé. Presse Med 2004; 33:522-9. [PMID: 15235503 DOI: 10.1016/s0755-4982(04)98653-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We developed a prescribing guideline containing recommendations for the initial empirical antibiotic therapy in community or nosocomial pneumonia. The aim of the present study was to examine the impact of this measure. METHOD The prescribing guideline was implemented in May 1999. We retrospectively reviewed the charts of all patients>65 years with community-, or nursing home- or hospital-acquired pneumonia hospitalised in our department of acute geriatric care between May 1999 and November 2000. The criteria assessed were: consistence with the guideline, clinical effectiveness within 72 hours, adequation with the isolated germs and intra-hospital mortality. RESULTS Data were collected on 112 patients (63 women et 49 men; mean age=80 +/- 8 Years). The pneumonia was community-acquired in 52 cases (46%), nursing home acquired in 25 cases (22%) and hospital-acquired in 35 cases (31%). Antibiotic prescription was consistent with the guideline in 64 cases (57%). When the antibiotic therapy was consistent, the patients were more likely to improve within 72 hours (45/64 versus 23/48; p=0.01). Despite a tendency, the number of antimicrobial treatments adapted to the isolated microorganisms was not significantly higher in the consistent group (22/36 adapted treatments versus 10/20). The intra-hospital mortality (25%) was similar in the two groups consistent and not consistent with the guideline. SARM was the most frequent multiresistant bacteria that was isolated. CONCLUSION The use of a prescribing guideline might improve the efficiency of empirical probabilistic antibiotic therapies. The impact of the guideline use on overall antibiotic costs and microbiological flora remains to be determined.
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Affiliation(s)
- Dominique Huvent-Grelle
- Service de médecine interne et gériatrie, Hôpital gériatrique, Les Bateliers, CHRU de Lille.
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Abstract
Postmortem human and animal studies provided important insights into the relationship between histology and bacteriology in VAP. According to the results of these studies, VAP is a multifocal and polymicrobial infectious process. The lesions are predominately located in dependent segments of lower lobes. There is no straightforward relationship between the intensity of lung damage and the local microbial burden. Histobacteriologic discrepancy may explain why even such techniques as PSB and BAL can be unreliable for the diagnosis of VAP. The histopathologic examination of the lung tissue has been traditionally regarded as the gold standard for diagnosis of VAP. Even with histology, however, pneumonia is frequently difficult to define. For daily practice, antimicrobial decisions and the guidance of antimicrobial regimens should not rely exclusively on the results of quantitative cultures in the individual patient. Instead, finding a balance between clinical judgment and microbiologic results is crucial to manage patients with VAP appropriately.
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Affiliation(s)
- Saad Nseir
- Service de Réanimation Médicale, Hôpital A. Calmette, CHRU, Lille, France
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Brasel KJ, Allen B, Edmiston C, Weigelt JA. Correlation of intracellular organisms with quantitative endotracheal aspirate. THE JOURNAL OF TRAUMA 2003; 54:141-4; discussion 144-6. [PMID: 12544909 DOI: 10.1097/00005373-200301000-00017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The presence of intracellular organisms (ICOs) in polymorphonuclear cells obtained from respiratory secretions is a possible method for rapid diagnosis of ventilator-associated pneumonia. We correlated ICOs with quantitative endotracheal aspirate (QA) in intubated patients. METHODS Consecutive intubated patients in the surgical intensive care unit had respiratory samples obtained every 2 days until extubation. Two thresholds for ICOs and quantitative culture were examined. Sensitivity, specificity, and positive and negative predictive values were calculated using QA as reference. RESULTS One hundred one samples were obtained from 35 patients. Colony counts >or= 100,000 were found in 34 samples; 60 samples had colony counts >or= 10,000. Antibiotic use did not affect the sensitivity or specificity of ICOs. Sensitivity of ICOs was 39% to 85%, and specificity was 82% to 97%. Positive predictive value was 70% to 96%, and negative predictive value was 50% to 91%. CONCLUSION ICOs provide a quick method for establishing the presence of a significant bacterial load in the respiratory tract. Accuracy of ICOs in predicting a positive QA is not affected by concurrent antibiotics.
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Affiliation(s)
- Karen J Brasel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Michaud S, Suzuki S, Harbarth S. Effect of design-related bias in studies of diagnostic tests for ventilator-associated pneumonia. Am J Respir Crit Care Med 2002; 166:1320-5. [PMID: 12421741 DOI: 10.1164/rccm.200202-130cp] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sophie Michaud
- Medical Faculty of the University of Sherbrooke, Sherbrooke, Quebec, Canada.
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Rappold JF, Coimbra R, Hoyt DB, Potenza BM, Fortlage D, Holbrook T, Minard G. Female gender does not protect blunt trauma patients from complications and mortality. THE JOURNAL OF TRAUMA 2002; 53:436-41; discussion 441. [PMID: 12352477 DOI: 10.1097/00005373-200209000-00007] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The protective effect of gender on posttraumatic mortality or acute complications (acute respiratory distress syndrome [ARDS], pneumonia, and sepsis) is unclear. To assess potential effects, we performed a retrospective case-controlled study, matching patients for injury factors including overall severity (Injury Severity Sscore), the presence of shock (systolic blood pressure [SBP] < 90 mm Hg) at admission, and the presence of closed head injury (CHI). METHODS All female patients admitted over a 61/2-year period were reviewed and divided into four groups: group 1, SBP > 90, no CHI; group 2, SBP < 90, no CHI; group 3, SBP > 90, with CHI; and group 4, SBP < 90, with CHI. Each cohort was matched one to one with an equivalent male counterpart. Cohorts were compared for mortality or the development of ARDS, pneumonia, and systemic sepsis using standard definitions. RESULTS Overall, 1,229 female patients were identified for study. The average Injury Severity Score was 16.3 and overall mortality was 2.7%. Analysis of the groups described previously demonstrated no statistically significant difference in the development of ARDS, pneumonia, systemic sepsis, or overall mortality between male and female patients including patients presenting with shock, CHI, or both. CONCLUSION We conclude that female gender offers no protection from the development of ARDS, pneumonia, sepsis, or decreased mortality after blunt trauma.
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Affiliation(s)
- Joseph F Rappold
- Department of Surgery, Division of Trauma, Critical Care, and Burns, University of California San Diego, 92103, USA
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Hasan R, Babar SI. Nosocomial and ventilator-associated pneumonias: developing country perspective. Curr Opin Pulm Med 2002; 8:188-94. [PMID: 11981307 DOI: 10.1097/00063198-200205000-00007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nosocomial pneumonias are recognized as an important cause of morbidity and mortality in industrialized nations. Emerging data show that they play a similar role in the developing world. A host of extrinsic and intrinsic factors predispose individuals to the development of pneumonias, and a modification of some of these factors provides a low cost solution to prevention of pneumonias. The ideal modality for microbiologic diagnosis of pneumonia remains to be determined. Recent data suggest that there is no difference in outcome when noninvasive techniques are compared with invasive techniques. Antimicrobial resistance is a rapidly increasing problem globally, and combating this with appropriate antibiotic policies, close surveillance, and physician education is essential.
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Affiliation(s)
- Rumina Hasan
- Department of Microbiology and Pathology, Aga Khan University, Karachi, Pakistan.
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Abstract
Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. When fiberoptic bronchoscopy is not available to physicians treating patients clinically suspected of having VAP, we recommend using either a simplified nonbronchoscopic diagnostic procedure or following a strategy in which decisions regarding antibiotic therapy are based on a clinical score constructed from seven variables. Selection of the initial antimicrobial therapy should be based on predominant flora responsible for VAP at each institution, clinical setting, information provided by direct examination of pulmonary secretions, and intrinsic antibacterial activities of antimicrobial agents and their pharmacokinetic characteristics. Further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.
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Affiliation(s)
- Jean Chastre
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, France.
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