Impact of quantitative invasive diagnostic techniques in the management and outcome of mechanically ventilated patients with suspected pneumonia

Violan, J. Sole; Fernandez, J.; Benítez, Ana Bordes; Cendrero, José A. Cardeñosa; Castro, Felipè Rodríguez de

doi:10.1097/00003246-200008000-00009

Cited by 187 publications

(93 citation statements)

References 17 publications

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“…In the three, randomized, controlled Spanish studies, no differences in mortality and morbidity were found when either invasive (PSB and/or BAL) or QEA techniques were used to diagnose VAP (175,176,186). However, these studies contained relatively few patients (51, 76, and 88 patients) and therefore were not powered sufficiently to demonstrate a difference in mortality.…”

Section: Microbiologic Diagnosismentioning

confidence: 97%

Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention

2006

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SUMMARY While critically ill patients experience a life-threatening illness, they commonly contract ventilator-associated pneumonia. This nosocomial infection increases morbidity and likely mortality as well as the cost of health care. This article reviews the literature with regard to diagnosis, treatment, and prevention. It provides conclusions that can be implemented in practice as well as an algorithm for the bedside clinician and also focuses on the controversies with regard to diagnostic tools and approaches, treatment plans, and prevention strategies.

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Section: Microbiologic Diagnosismentioning

confidence: 97%

Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention

2006

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“…Basically, the following conclusions appear evident: 1) the diagnostic value of the quantitative culture from endotracheal aspirate is similar to that provided by invasive methods (protected specimen brush, bronchoalveolar lavage) [23,87]; 2) the invasive techniques lead to more changes of the antibiotic treatment but without any improvement of mortality and morbidity rate [22,23,85]; and 3) the endotracheal aspirate is less expensive compared to the invasive investigation [23,88]. However, further studies are required to establish which is the best approach for the diagnosis of ventilator-associated pneumonia, since the experts9 opinions are still divided.…”

Section: Invasive Versus Noninvasive Techniques For Diagnosing Ventilmentioning

confidence: 89%

“…There are only three studies complying with these criteria [22,23,85]. SANCHEZ-NIETO et al [22] reported that bronchoscopy led to more frequent antibiotic changes and a greater cost of antibiotic therapy, with no change in morbidity and mortality rate.…”

Section: Invasive Versus Noninvasive Techniques For Diagnosing Ventilmentioning

confidence: 99%

“…The study of RUIZ et al [23] reported a similar diagnostic yield of invasive and noninvasive techniques, similar mortality rate in the two groups of patients but, in contrast, a signi®cantly higher cost of the microbial investigation when using invasive techniques. Finally, SOLE-VIOLAN et al [85] concluded also that, when empirical antibiotic treatment is appropriately standardized, quantitative culture of samples obtained by invasive techniques does not improve the outcome of VAP in comparison with qualitative culture of samples obtained by noninvasive techniques. The conclusion of these three studies is practically the same: using invasive techniques for diagnosing VAP leads to more antibiotic changes but with no improvement in mortality or morbidity rate and with additional costs.…”

Section: Invasive Versus Noninvasive Techniques For Diagnosing Ventilmentioning

confidence: 99%

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Microbial investigation in ventilator-associated pneumonia

Ioanăş¹,

Ferrer²,

Angrill³

et al. 2001

Eur Respir J

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Ventilator-associated pneumonia (VAP) is a serious infectious condition in intensive care unit (ICU) patients, currently related to a high mortality rate. Therefore, this complication of mechanical ventilation requires a prompt diagnosis and adequate antibiotic treatment. The detection of the causative organism is imperative for guiding an appropriate therapy as there is strong evidence of the adverse effect of inadequate empirical treatment on outcome. The major difficulty of the microbial investigation is to obtain the sample from the lower respiratory tract, mainly because of the potential contamination with upper airways flora, which may result in a misinterpretation of the cultures.Microbial investigation in VAP is based on the culture of samples obtained from lower respiratory tract by noninvasive or invasive methods. The most common techniques of sampling are the endotracheal aspirate (ETA), which is considered a noninvasive method, the protected specimen brush (PSB) and the bronchoalveolar lavage (BAL), both being invasive methods of investigation. The latter were designed as an attempt to avoid the colonizing flora of the upper airways. The best of these diagnostic approaches is still controversial. In terms of outcome, there is strong evidence that the impact of both invasive and noninvasive methods seems to be similar. In terms of cost, however, the endotracheal aspirate is less expensive compared to BAL or PSB. On the other hand, invasive methods could be particularly beneficial in patients who are not responding to the initial empirical antibiotic treatment.The rationale for the quantitative culture of the respiratory samples is to differentiate between infection and colonization of lower airways, because the bacterial colonization is a frequent event in mechanically ventilated patients. The thresholds currently employed for the diagnosis of the pneumonia are the following: ETA samples, ≥105–106colony forming units (cfu)·mL−1; PSB samples, ≥103cfu·mL−1; and BAL samples, ≥104 cfu·mL−1.Intending to provide a practical approach to the issue, the present manuscript reviews the available noninvasive (blood culture, endotracheal aspirate) and invasive (protected specimen brush, bronchoalveolar lavage, blinded methods and lung biopsy) techniques used for the diagnosis of ventilator-associated pneumonia.

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“…This has paved the way for less invasive tests such as endotracheal aspirates (ETA) and quantitative ETA cultures with a threshold of 10 5 to 10 6 bacteria per milliliter of exudates that is considered as optimal for the microbiological conÞ rmation of VAP. [3] More importantly, recent small trials have repeatedly shown that there is no advantage of bronchoscopic cultures over quantitative ETA cultures when mortality was considered as the end-point, [4][5][6] further strengthening the case for quantitative ETA as a diagnostic tool.…”

Section: Introductionmentioning

confidence: 99%