Invasive procedures available for diagnosing ventilator-associated pneumonia

Servei de Pneumologia, Hospital Clinic, Barcelona, Spain.
Intensive care world 07/1993; 10(2):91-5.
Source: PubMed
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    ABSTRACT: To assess the usefulness of quantification of infected cells (ICs) in BAL fluid for the diagnosis of ventilator-associated pneumonia (VAP). A prospective study. A medico-surgical ICU in a tertiary health-care institution. One hundred thirty-two patients (mean age, 52 +/- 19 years). The suspicion of nosocomial pneumonia was strong in these patients: all had fever (> or = 38.5 degrees C), purulent tracheal aspirates, leukocytosis (> or = 10,000 cells per cubic millimeter), and new or persistent radiographic lung infiltrates. One hundred sixty-three samples (BAL and protected specimen brushes [PSB]) were obtained. VAP was present in 56 cases. The diagnosis was excluded in the remaining 107 cases. The IC count was performed on 100 cells in BAL fluid. The percentage of IC was significantly higher (12.6 +/- 12.4 vs 1.14 +/- 3.39; p < 0.0001) in patients with pneumonia: the area under the receiver operating characteristic (ROC) curve was 0.888 and a threshold of 2% of IC corresponded to a sensitivity of 84%, a specificity of 80%, a positive predictive value of 69%, and a negative predictive value of 90%. It is possible to define a threshold of IC in BAL fluid with a good reliability by using an ROC curve. This technique is useful for the early diagnosis (< 2 h) of nosocomial bacterial pneumonia in mechanically ventilated patients and allows a rapid and appropriate treatment of most of the patients with suspected VAP.
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    ABSTRACT: To determine the frequency, etiology, and risk factors of ventilator-associated pneumonia (VAP) and purulent tracheobronchitis (TBX) in patients who have undergone heart surgery. To study the predictive role of systematic surveillance cultures. Prospective study. Heart surgery intensive care unit. Intubated heart surgical patients. Systematic tracheal aspirate and protected brush catheter cultures of all intubated patients. Studied were the frequency of lower respiratory tract infection in ventilated patients and the role of surveillance cultures. The frequency of VAP was 7.87% (34.5 per 1,000 days of mechanical ventilation), and the criteria for purulent tracheobronchitis was fulfilled by 8.15% of patients (31.13 per 1,000 days of mechanical ventilation). After multivariate analysis, the variables independently associated with the development of respiratory tract infection were central nervous system disorder (relative risk [RR] = 4.7), ulcer disease (RR = 3.6), New York Heart Association score >/=3 (RR = 4), need for mechanical circulatory support (RR = 6.8), duration of mechanical ventilation >96 hrs (RR = 12.3), and reintubation (RR = 63.7). Mortality in our study was as follows: VAP patients, 57.1%; purulent tracheobronchitis patients, 20.7%; colonized patients, 11.5%; and noncolonized patients, 1.6%. Regular surveillance cultures were taken from all ventilated patients to assess the anticipative value of the cultures in predicting respiratory tract infection. A total of 1,626 respiratory surveillance samples were obtained. Surveillance cultures effectively predicted only one episode of VAP and one of tracheobronchitis. Patients undergoing heart surgery have a high frequency of VAP. VAP is associated with a poor prognosis. In this study, surveillance cultures failed as an anticipative diagnostic method.
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    ABSTRACT: 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. 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). 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. 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.
    Respirology 01/2008; 13(1):87-96. DOI:10.1111/j.1440-1843.2007.01211.x · 3.35 Impact Factor
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