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: 7.21). 06/2008; 34(5):865-72. DOI: 10.1007/s00134-008-1015-x
Source: PubMed


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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    • "The BAL fluid was regarded non-representative if the volume of recovery was <20 mL, the total cell count was <60.000/ mL, the presence of squamous epithelial cells was >1%, the presence of bronchial epithelial cells was >5% or in the presence of extensive amounts of debris and damaged cells. A clinically suspected VAP episode was considered microbiologically confirmed when the following criteria were met in BAL fluid: presence of !2% cells containing intracellular organisms (ICO) and/or quantitative culture results of !10 4 colony forming units (cfu) per millilitre of BAL fluid [11] [12]. Before BAL was conducted, exhaled breath samples were collected into a sterile Tedlar bag from the expiratory limb of the Draeger ® Evita XL ventilator for subsequent e-nose analysis. "
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    • "Bronchoscopy with subsequent lavage was performed as described previously [Linssen et al., 2008]. Bronchoalveolar lavage fluid samples were transported to the laboratory within 15 min after collection and processed immediately upon arrival at the microbiology laboratory. "
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    • "Furthermore, the percentage of ICOs is not influenced by antibiotic therapy in the 72 hours prior to the BAL. This makes it an important parameter for distinguishing VAP from non-VAP conditions [15]. However, BAL fluid workup and its microscopic analysis are time-consuming and must be done by experienced technicians. "
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