Early diagnosis of ventilator-associated pneumonia (VAP) is necessary to reduce morbidity and improve survival of critically ill patients in the ICU. The purpose of the present study is to examine the performance of macroscopic bronchoscopic findings and cytological analysis of bronchoalveolar lavage fluid (BALF) as an early diagnostic tool for VAP, either alone or in combination with clinically oriented scores (modified Clinical Pulmonary Infection Score [CPIS] or Johanson criteria).
METHODS:
BAL was performed in 54 consecutive mechanically ventilated subjects. The predictive value of isolated or combined clinical characteristics, BALF, and/or other laboratory measurements in diagnosing VAP was analyzed by logistic regression analysis. A separate diagnostic score was derived from a linear combination of independent variables included in the multivariate model and compared with CPIS, Johanson criteria, and their combinations with BALF cytology (receiver operating characteristic curve analysis).
RESULTS:
Integrating relative neutrophil cell count in CPIS or Johanson criteria optimized their specificity (>80%) but decreased sensitivity (<70%). Radiographic progression and the presence of distal purulent secretions on bronchoscopy were independently associated with VAP diagnosis. A new score that incorporates clinical, radiographic, and early bronchoscopic findings presented excellent diagnostic accuracy (area under curve = 0.96, sensitivity 94.3%, specificity 84.2%).
CONCLUSIONS:
The diagnostic performance of classical clinical scores for VAP did not improve after combination with BALF cytology. A new composite score proved to be more accurate than previous scores in early VAP diagnosis.
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med, 2005; 171(4):388–416.
2.
Rea-NetoA, YoussefNCM, TucheF, BrunkhorstF, RanieriVM, ReinhartK, SakrY. Diagnosis of ventilator-associated pneumonia: a systematic review of the literature. Crit Care, 2008; 12(2):R56.
3.
KollefMH, ShermanG, WardS, FraserVJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest, 1999; 115(2):462–474.
4.
LunaCM, ArujP, NiedermanMS, GarzónJ, VioliD, PrignoniA, et al. Appropriateness and delay to initiate therapy in ventilator-associated pneumonia. Eur Respir J, 2006; 27(1):158–164.
5.
JacobsJA, De BrauwerEI, RamsayG, CobbenNA, WagenaarSS, van der VenAJ, et al. Detection of non-infectious conditions mimicking pneumonia in the intensive care setting: usefulness of bronchoalveolar fluid cytology. Respir Med, 1999; 93(8):571–578.
6.
CorleyDE, KirtlandSH, WinterbauerRH, HammarSP, DailDH, BauermeisterDE, BolenJW. Reproducibility of the histologic diagnosis of pneumonia among a panel of four pathologists: analysis of a gold standard. Chest, 1997; 112(2):458–465.
7.
JohansonWGJr, PierceAK, SanfordJP, ThomasGD. Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med, 1972; 77(5):701–706.
8.
FàbregasN, EwigS, TorresA, El-EbiaryM, RamirezJ, de La BellacasaJP, et al. Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies. Thorax, 1999; 54(10):867–873.
9.
PuginJ, AuckenthalerR, MiliN, JanssensJP, LewPD, SuterPM. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis, 1991; 143(5 Pt 1):1121–1129.
10.
ZilberbergMD, ShorrAF. Ventilator-associated pneumonia: the clinical pulmonary infection score as a surrogate for diagnostics and outcome. Clin Infect Dis, 2010; 51(Suppl 1):S131–S135.
11.
MagillSS, RhodesB, KlompasM. Improving ventilator-associated event surveillance in the National Healthcare Safety Network and addressing knowledge gaps: update and review. Curr Opin Infect Dis, 2014; 27(4):394–400.
FartoukhM, MaitreB, HonoréS, CerfC, ZaharJR, Brun-BuissonC. Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med, 2003; 168(2):173–179.
14.
PhamTN, NeffMJ, SimmonsJM, GibranNS, HeimbachDM, KleinMB. The clinical pulmonary infection score poorly predicts pneumonia in patients with burns. J Burn Care Res, 2007; 28(1):76–79.
15.
LuytCE, ChastreJ, FagonJY. Value of the clinical pulmonary infection score for the identification and management of ventilator-associated pneumonia. Intensive Care Med, 2004; 30(5):844–852.
16.
JungB, EmbriacoN, RouxF, ForelJM, DemoryD, Allardet-ServentJ, et al. Microbiogical data, but not procalcitonin improve the accuracy of the clinical pulmonary infection score. Intensive Care Med, 2010; 36(5):790–798.
17.
RamirezP, GarciaMA, FerrerM, AznarJ, ValenciaM, SahuquilloJM, et al. Sequential measurements of procalcitonin levels in diagnosing ventilator-associated pneumonia. Eur Respir J, 2008; 31(2):356–362.
18.
CroceMA, SwansonJM, MagnottiLJ, ClaridgeJA, WeinbergJA, WoodGC, et al. The futility of the clinical pulmonary infection score in trauma patients. J Trauma, 2006; 60(3):523–527; discussion 527-528.
19.
ShanJ, ChenHL, ZhuJH. Diagnostic accuracy of clinical pulmonary infection score for ventilator-associated pneumonia: a meta-analysis. Respir Care, 2011; 56(8):1087–1094.
20.
ChoiSH, HongSB, HongHL, KimSH, HuhJW, SungH, et al. Usefulness of cellular analysis of bronchoalveolar lavage fluid for predicting the etiology of pneumonia in critically ill patients. PLoS One, 2014; 9(5):e97346.
21.
StolzD, StulzA, MüllerB, GratwohlA, TammM. BAL neutrophils, serum procalcitonin, and C-reactive protein to predict bacterial infection in the immunocompromised host. Chest, 2007; 132(2):504–514.
22.
SternbergRI, BaughmanRP, DohnMN, FirstMR. Utility of bronchoalveolar lavage in assessing pneumonia in immunosuppressed renal transplant recipients. Am J Med, 1993; 95(4):358–364.
23.
HuhJW, LimCM, KohY, OhYM, ShimTS, LeeSD, et al. Diagnostic utility of the soluble triggering receptor expressed on myeloid cells-1 in bronchoalveolar lavage fluid from patients with bilateral lung infiltrates. Crit Care, 2008; 12(1):R6.
24.
TsangarisI, LekkaME, KitsiouliE, ConstantopoulosS, NakosG. Bronchoalveolar lavage alterations during prolonged ventilation of patients without acute lung injury. Eur Respir J, 2003; 21(3):495–501.
25.
NakosG, KitsiouliEI, TsangarisI, LekkaME. Bronchoalveolar lavage fluid characteristics of early intermediate and late phases of ARDS: alterations in leukocytes, proteins, PAF and surfactant components. Intensive Care Med, 1998; 24(4):296–303.
26.
NakosG, TsangarisH, LiokatisS, KitsiouliE, LekkaME. Ventilator-associated pneumonia and atelectasis: evaluation through bronchoalveolar lavage fluid analysis. Intensive Care Med, 2003; 29(4):555–563.
27.
NseirS, Di PompeoC, PronnierP, BeagueS, OnimusT, SaulnierF, et al. Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome. Eur Respir J, 2002; 20(6):1483–1489.
CravenDE, HjalmarsonKI. Ventilator-associated tracheobronchitis and pneumonia: thinking outside the box. Clin Infect Dis, 2010; 51(Suppl 1):S59–S66.
30.
TimsitJF, MissetB, AzoulayE, RenaudB, Garrouste-OrgeasM, CarletJ. Usefulness of airway visualization in the diagnosis of nosocomial pneumonia in ventilated patients. Chest, 1996; 110(1):172–179.
31.
KnausWA, DraperEA, WagnerDP, ZimmermanJE. APACHE II: a severity of disease classification system. Crit Care Med, 1985; 13(10):818–829.
32.
OhTE, HutchinsonR, ShortS, BuckleyT, LinE, LeungD. Verification of the Acute Physiology and Chronic Health Evaluation scoring system in a Hong Kong intensive care unit. Crit Care Med, 1993; 21(5):698–705.
33.
EscarceJJ, KelleyMA. Admission source to the medical intensive care unit predicts hospital death independent of APACHE II score. JAMA, 1990:264(18):2389–2394.
34.
MarquetteCH, CopinMC, WalletF, NeviereR, SaulnierF, MathieuD, et al. Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard. Am J Respir Crit Care Med, 1995; 151(6):1878–1888.
35.
RoubyJJ, Martin De LassaleE, PoeteP, NicolasMH, BodinL, JarlierV, et al. Nosocomial bronchopneumonia in the critically ill: histologic and bacteriologic aspects. Am Rev Respir Dis, 1992; 146(4):1059–1066.
