Influence of antibiotic therapy on the cytological diagnosis of ventilator-associated pneumonia.

Department of Medical Microbiology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
Intensive Care Medicine (Impact Factor: 5.54). 06/2008; 34(5):865-72. DOI: 10.1007/s00134-008-1015-x
Source: PubMed

ABSTRACT To assess the influence of antibiotics on the value of various cytological parameters, and their combinations, in diagnosing ventilator-associated pneumonia (VAP).
Prospective study.
The general intensive care unit (17 beds) of the University Hospital Maastricht.
Three hundred and thirty-five episodes of clinically suspected VAP (defined by the clinical and radiological criteria previously described by Bonten et al.) in 282 patients were studied.
No additional interventions were conducted.
Bronchoalveolar lavage fluid cytology included a total cell count per millilitre, differential cell count and the percentage of infected cells (cells containing phagocytised organisms). Antibiotic therapy from 72 h prior to lavage was recorded. Areas under the curve (AUCs) of receiver operating characteristic curves were calculated for various cytological parameters and their combinations, in patients with and without antibiotic therapy. In 126 episodes (37.6%) in 106 patients, VAP was confirmed. There was no difference in AUCs between patients with and without antibiotic therapy for any parameter studied. The most prominent AUCs were (for patient groups with and without antibiotics combined): total cell count, 0.65; percentage polymorphonuclear neutrophils, 0.71; and percentage infected cells, 0.90. The combination of percentage infected cells with any other cytological parameter did not increase the AUC.
Antibiotic therapy did not influence the predictive value of the percentage infected cells in BALF in diagnosing VAP.

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    ABSTRACT: Ventilator-associated pneumonia (VAP) is the main nosocomial infection in patients receiving mechanical ventilation. Despite numerous advances in the understanding of this disorder, the incidence rate continues in an unacceptable range. In this review, we discuss some important findings of recently published studies on diagnosis, prevention and treatment. The microbiological sampling of the lower airways may be performed by invasive or noninvasive methods. The use of blind techniques to sample the lower respiratory tree has gained wide acceptance within the critical care setting. The use of cytological parameters such as the percentage of infected cells (cells containing phagocytised bacteria) may add objectivity to the unspecific clinical suspicion of VAP. A lot of information on the subject of prevention of VAP has been published recently that evaluates several preventive measures including new antiseptic-coated endotracheal tubes, new cuff shape and meta-analysis of known techniques. However, the clinicians must choose a bundle of measures and implement them in their intensive care units. The effectiveness of the bundles must be documented. New studies emphasize the key role of an appropriate empirical treatment. The de-escalation strategy increases the reduction of antimicrobials without worsening the outcome of VAP patients. The efficacy of monotherapy in the treatment of this infectious disease has been evaluated in new studies with controversial results. The diagnostic approach and therapy of the VAP patients are clarified with these studies. In the last year, numerous articles have been published on diagnosis, treatment and prevention of VAP. In this review, we have selected those articles that potentially could lead to changes in clinical practice: Use of noninvasive techniques for diagnosis, new methods and strategies for prevention, and, finally, the efficacy of monotherapy and de-escalation in the treatment of VAP.
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