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Bhat JI, Tramboo ZM, Shah TH, Charoo BA, Qazi IA. Enhancing respiratory disease diagnosis by bronchoalveolar lavage in Kashmir: an audit of findings. Arch Dis Child 2022; 107:1079-1082. [PMID: 35948407 DOI: 10.1136/archdischild-2022-323823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/30/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study bronchoalveolar lavage (BAL) findings in various respiratory diseases in children in Kashmir India. DESIGN Prospective observational study. SETTING Paediatric department of the tertiary care hospital. PATIENTS Children of both genders from 1 month to 17 years of age INTERVENTION: All studied patients underwent flexible bronchoscopy and BAL. OUTCOME MEASURE To observe the BAL findings in various respiratory diseases in the studied population. RESULTS A total of 283 patients underwent BAL procedure. The positive BAL report was received in 131 (46%) patients. Out of these, 55 (42%) patients had positive BAL culture/ microscopy for different bacterial (50) and fungal species (Candida spp (3), Mucormycosis (1) and Aspergillus (1)). MTB was isolated in 25 (19%) patients. Twenty-three (17.5%) patients had bronchoalveolar lavage fluid (BALF) positive for pulmonary hydatidosis. Foamy macrophages were seen in 13 patients, significant eosinophilia in nine patients and hemosiderin-laden macrophages were seen in three patients. CONCLUSION We found BALF a very useful sample for the evaluation of many infective and non-infective respiratory diseases in our region, which otherwise lacks high end diagnostics. 46% of our patients had some abnormalities in the BAL specimen. It provided us with valuable information regarding organism profile and drug sensitivity in case of lung infection. BALF analysis was also found useful in the diagnosis of some non-infective pulmonary disorders like acute eosinophilic pneumonia, aspiration syndromes and bronchial asthma.
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Affiliation(s)
- Javeed Iqbal Bhat
- Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Zubair M Tramboo
- Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Tajamul Hussain Shah
- Department of Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Iqbal Ahmad Qazi
- Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
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Pathak KV, McGilvrey MI, Hu CK, Garcia-Mansfield K, Lewandoski K, Eftekhari Z, Yuan YC, Zenhausern F, Menashi E, Pirrotte P. Molecular Profiling of Innate Immune Response Mechanisms in Ventilator-associated Pneumonia. Mol Cell Proteomics 2020; 19:1688-1705. [PMID: 32709677 PMCID: PMC8014993 DOI: 10.1074/mcp.ra120.002207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Indexed: 12/12/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection, leading to high morbidity and mortality. Currently, bronchoalveolar lavage (BAL) is used in hospitals for VAP diagnosis and guiding treatment options. Although BAL collection procedures are invasive, alternatives such as endotracheal aspirates (ETA) may be of diagnostic value, however, their use has not been thoroughly explored. Longitudinal ETA and BAL were collected from 16 intubated patients up to 15 days, of which 11 developed VAP. We conducted a comprehensive LC-MS/MS based proteome and metabolome characterization of longitudinal ETA and BAL to detect host and pathogen responses to VAP infection. We discovered a diverse ETA proteome of the upper airways reflective of a rich and dynamic host-microbe interface. Prior to VAP diagnosis by microbial cultures from BAL, patient ETA presented characteristic signatures of reactive oxygen species and neutrophil degranulation, indicative of neutrophil mediated pathogen processing as a key host response to the VAP infection. Along with an increase in amino acids, this is suggestive of extracellular membrane degradation resulting from proteolytic activity of neutrophil proteases. The metaproteome approach successfully allowed simultaneous detection of pathogen peptides in patients' ETA, which may have potential use in diagnosis. Our findings suggest that ETA may facilitate early mechanistic insights into host-pathogen interactions associated with VAP infection and therefore provide its diagnosis and treatment.
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Affiliation(s)
- Khyatiben V Pathak
- Collaborative Center for Translatinal Mass Spectrometry, Translational Genomics Research Institute, Phoenix, Arizona, USA
| | - Marissa I McGilvrey
- Collaborative Center for Translatinal Mass Spectrometry, Translational Genomics Research Institute, Phoenix, Arizona, USA
| | - Charles K Hu
- HonorHealth Clinical Research Institute, Scottsdale, Arizona, USA
| | - Krystine Garcia-Mansfield
- Collaborative Center for Translatinal Mass Spectrometry, Translational Genomics Research Institute, Phoenix, Arizona, USA
| | - Karen Lewandoski
- Translational Genomics Research Institute, Phoenix, Arizona, USA
| | - Zahra Eftekhari
- Applied AI and Data Science, City of Hope Medical Center, Duarte, California, USA
| | - Yate-Ching Yuan
- Center for Informatics, City of Hope Medical Center, Duarte, California, USA
| | - Frederic Zenhausern
- Translational Genomics Research Institute, Phoenix, Arizona, USA; HonorHealth Clinical Research Institute, Scottsdale, Arizona, USA; Center for Applied NanoBioscience and Medicine, University of Arizona, Phoenix, Arizona, USA
| | - Emmanuel Menashi
- HonorHealth Clinical Research Institute, Scottsdale, Arizona, USA
| | - Patrick Pirrotte
- Collaborative Center for Translatinal Mass Spectrometry, Translational Genomics Research Institute, Phoenix, Arizona, USA.
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Enomoto Y, Yokomura K, Hasegawa H, Ozawa Y, Matsui T, Suda T. Healthcare-associated pneumonia with positive respiratory methicillin-resistant Staphylococcus aureus culture: Predictors of the true pathogenicity. Geriatr Gerontol Int 2016; 17:456-462. [PMID: 26846905 DOI: 10.1111/ggi.12739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 12/14/2015] [Accepted: 12/22/2015] [Indexed: 11/28/2022]
Abstract
AIM Although methicillin-resistant Staphylococcus aureus (MRSA) is commonly isolated from respiratory specimens in healthcare-associated pneumonia (HCAP), it is difficult to determine the causative pathogen because of the possibilities of contamination/colonization. The present study aimed to identify clinical predictors of the true pathogenicity of MRSA in HCAP. METHODS Patients with HCAP with positive MRSA cultures in the sputum or endotracheal aspirates who were admitted to Seirei Mikatahara General Hospital, Hamamatsu, Japan, from 2009 to 2014 were enrolled. According to the administered drugs and the treatment outcomes, patients with true MRSA pneumonia (MP) and those with contamination/colonization of MRSA (false MP) were identified. Baseline characteristics were compared between groups, and clinical predictors of true MP were evaluated by logistic regression analyses. RESULTS A total of 93 patients (mean age 78.7 ± 12.6 years) were identified and classified into the true MP (n = 16) or false MP (n = 77) groups. Although baseline characteristics were broadly similar between groups, the true MP group had significantly more patients with PaO2 ≤ 60 Torr/pulse oximetry saturation ≤90% and those with MRSA single cultivation. Both variables were significant predictors of true MP in multivariate analysis (odds ratio of PaO2 ≤ 60 Torr/pulse oximetry saturation ≤90%: 5.64, 95% confidence interval 1.17-27.32; odds ratio of MRSA single cultivation: 4.76, 95% confidence interval 1.22-18.60). CONCLUSIONS Poor oxygenation and MRSA single cultivation imply the true pathogenicity of MRSA in HCAP with positive respiratory MRSA cultures. The present results might be helpful for the proper use of anti-MRSA drugs in this population. Geriatr Gerontol Int 2017; 17: 456-462.
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Affiliation(s)
- Yasunori Enomoto
- Department of Respiratory Medicine, Respiratory Disease Center, Seirei Mikatahara General Hosipital, Hamamatsu, Japan.,Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Koshi Yokomura
- Department of Respiratory Medicine, Respiratory Disease Center, Seirei Mikatahara General Hosipital, Hamamatsu, Japan
| | - Hirotsugu Hasegawa
- Department of Respiratory Medicine, Respiratory Disease Center, Seirei Mikatahara General Hosipital, Hamamatsu, Japan
| | - Yuichi Ozawa
- Department of Respiratory Medicine, Respiratory Disease Center, Seirei Mikatahara General Hosipital, Hamamatsu, Japan
| | - Takashi Matsui
- Department of Respiratory Medicine, Respiratory Disease Center, Seirei Mikatahara General Hosipital, Hamamatsu, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Sircar M, Ranjan P, Gupta R, Jha OK, Gupta A, Kaur R, Chavhan N, Singh M, Singh SK. Impact of bronchoalveolar lavage multiplex polymerase chain reaction on microbiological yield and therapeutic decisions in severe pneumonia in intensive care unit. J Crit Care 2015; 31:227-32. [PMID: 26611381 DOI: 10.1016/j.jcrc.2015.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 09/23/2015] [Accepted: 10/11/2015] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of the study is to evaluate the impact of adding bronchoalveolar lavage multiplex polymerase chain reaction (M-PCR) to conventional cultures (CC) on microbiological yield and therapeutic decisions in adult intensive care unit patients with pneumonia and severe sepsis or septic shock. MATERIAL AND METHODS In this retrospective case-control study, bronchoalveolar lavage cultures were taken for control (58 patients, 58 admissions) and study arms (57 patients, 58 admissions). Bronchoalveolar lavage M-PCR was sent simultaneously for the latter. RESULTS A total of 267 microorganisms were identified (M-PCR alone, 211; CC alone, 15; both, 41) in the study arm vs 64 in controls. Concordance between M-PCR and culture was complete in 32 (55.17%), partial in 4 (6.9%), and discordant in 22 (37.93%) including 17 with positive M-PCR but negative CC. Time to antibiotic therapy modification was significantly less (P < .001) in M-PCR group compared to controls (32.40 ± 14.41 vs 41.74 ± 45.61 hours). There was no significant difference in index episode resolution (48.3% vs 50%; P = 1), intensive care unit mortality (57.4% vs 51.2%; P = .67), and hospital mortality (59.6% vs 61.5%; P = 1) in study and control arms, respectively, despite more septic shock patients in the study arm (89.7% vs 75.9%; P = .05). CONCLUSION Bronchoalveolar lavage M-PCR with culture leads to higher microbiological yield and earlier modification of antibiotics compared to conventional culture.
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Affiliation(s)
- Mrinal Sircar
- Department of Pulmonology and Critical Care Medicine, Fortis Hospital, Noida, Uttar Pradesh, India.
| | - Prashant Ranjan
- Department of Pulmonology and Critical Care Medicine, Fortis Hospital, Noida, Uttar Pradesh, India.
| | - Rajesh Gupta
- Department of Pulmonology and Critical Care Medicine, Fortis Hospital, Noida, Uttar Pradesh, India.
| | - Onkar Kumar Jha
- Department of Pulmonology and Critical Care Medicine, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Amit Gupta
- Department of Pulmonology and Critical Care Medicine, Fortis Hospital, Noida, Uttar Pradesh, India.
| | | | - Neela Chavhan
- Department of Pulmonology and Critical Care Medicine, Fortis Hospital, Noida, Uttar Pradesh, India.
| | - Mukta Singh
- Department of Pulmonology and Critical Care Medicine, Fortis Hospital, Noida, Uttar Pradesh, India.
| | - Sujeet Kumar Singh
- Department of Pulmonology and Critical Care Medicine, Fortis Hospital, Noida, Uttar Pradesh, India.
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Hashimoto S, Shime N. Evaluation of semi-quantitative scoring of Gram staining or semi-quantitative culture for the diagnosis of ventilator-associated pneumonia: a retrospective comparison with quantitative culture. J Intensive Care 2013; 1:2. [PMID: 25705397 PMCID: PMC4336129 DOI: 10.1186/2052-0492-1-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 09/13/2013] [Indexed: 12/02/2022] Open
Abstract
Background Semi-quantitative Gram stain and culture methods are still commonly used for diagnosing ventilator-associated pneumonia (VAP), due to its convenience. Only a few studies, however, have assessed the reliability of these methods when compared with quantitative cultures, a current standard for the diagnosis of VAP. The objective of this study was to assess the utility of semi-quantitative scores obtained using Gram stains and cultures of endotracheal aspirates when compared with quantitative cultures in the diagnosis of VAP. Methods A retrospective chart review of mechanically ventilated patients with clinically suspected VAP in a single intensive care unit was performed. Semi-quantitative scores of Gram stains or culture results were compared with quantitative culture results of endotracheal aspirate for the diagnosis of VAP in 136 samples for 51 patients. Results The semi-quantitative scores of Gram stains and the semi-quantitative culture results significantly correlated with the log value of the quantitative culture results (rs = 0.64 and 0.75). When using a log count ≥6 of quantitative cultures as the reference standard for the diagnosis of VAP, the sensitivity and specificity was 95% and 61% for Gram stain score of ≥1+, and was 42% and 96% for Gram stain score ≥3+, respectively. The sensitivity and specificity was 96% and 40% for the semi-quantitative culture score of ≥2+, and was 59% and 86% for the semi-quantitative culture score of ≥3+, respectively. Conclusions Absence of bacteria in semi-quantitative Gram stain and poor growth (≤1+) in semi-quantitative culture method could be utilized to exclude the possibility of VAP, whereas detection of abundant (≥3+) bacteria in semi-quantitative Gram stain could be utilized to strongly suspect VAP.
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Affiliation(s)
- Soshi Hashimoto
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan ; Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan
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Quantitative cultures of bronchoscopically obtained specimens should be performed for optimal management of ventilator-associated pneumonia. J Clin Microbiol 2013; 51:740-4. [PMID: 23284021 DOI: 10.1128/jcm.03383-12] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is a leading cause of health care-associated infection. It has a high rate of attributed mortality, and this mortality is increased in patients who do not receive appropriate empirical antimicrobial therapy. As a result of the overuse of broad-spectrum antimicrobials such as the carbapenems, strains of Acinetobacter, Enterobacteriaceae, and Pseudomonas aeruginosa susceptible only to polymyxins and tigecycline have emerged as important causes of VAP. The need to accurately diagnose VAP so that appropriate discontinuation or de-escalation of antimicrobial therapy can be initiated to reduce this antimicrobial pressure is essential. Practice guidelines for the diagnosis of VAP advocate the use of bronchoalveolar lavage (BAL) fluid obtained either bronchoscopically or by the use of a catheter passed through the endotracheal tube. The CDC recommends that quantitative cultures be performed on these specimens, using ≥ 10(4) CFU/ml to designate a positive culture (http://www.cdc.gov/nhsn/TOC_PSCManual.html, accessed 30 October 2012). However, there is no consensus in the clinical microbiology community as to whether these specimens should be cultured quantitatively, using the aforementioned designated bacterial cell count to designate infection, or by a semiquantitative approach. We have asked Vickie Baselski, University of Tennessee Health Science Center, who was the lead author on one of the seminal papers on quantitative BAL fluid culture, to explain why she believes that quantitative BAL fluid cultures are the optimal strategy for VAP diagnosis. We have Stacey Klutts, University of Iowa, to advocate the semiquantitative approach.
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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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Abstract
PURPOSE OF REVIEW The increasing number of hospitals reporting ventilator-associated pneumonia (VAP) rates at or close to zero begs the question of whether zero should become the national benchmark for VAP. This article explores the significance of very low VAP rates, reviews differences in surveillance and clinical rates, proposes reasons for their discrepancies, and suggests possible objective alternatives for surveillance. RECENT FINDINGS Surveillance rates of VAP are decreasing, whereas clinical diagnoses and antibiotic prescribing remain prevalent. This growing discrepancy reflects the lack of objective and definitive signs to diagnose VAP. External reporting pressures may be encouraging stricter interpretation of subjective signs and other surveillance initiatives that can artifactually lower rates. It is impossible to disentangle the relative contribution of care improvements versus surveillance effects to currently observed low VAP rates. SUMMARY The increasing mismatch between surveillance rates and clinical diagnoses limits the utility of official VAP rates to estimate disease burden and guide quality improvement. Advocates are advised to consider objective alternatives such as average duration of mechanical ventilation, length of stay, mortality, and antibiotic prescribing. Emerging surveillance definitions that use more objective criteria may better reflect and inform future clinical practice.
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