Diagnosis of ventilator-associated pneumonia: a systematic review of the literature

IntroductionEarly, accurate diagnosis is fundamental in the management of patients with ventilator-associated pneumonia (VAP). The aim of this qualitative review was to compare various criteria of diagnosing VAP in the intensive care unit (ICU) with a special emphasis on the value of clinical diagnosis, microbiological culture techniques, and biomarkers of host response.MethodsA MEDLINE search was performed using the keyword 'ventilator associated pneumonia' AND 'diagnosis'. Our search was limited to human studies published between January 1966 and June 2007. Only studies of at least 25 adult patients were included. Predefined variables were collected, including year of publication, study design (prospective/retrospective), number of patients included, and disease group.ResultsOf 572 articles fulfilling the initial search criteria, 159 articles were chosen for detailed review of the full text. A total of 64 articles fulfilled the inclusion criteria and were included in our review. Clinical criteria, used in combination, may be helpful in diagnosing VAP, however, the considerable inter-observer variability and the moderate performance should be taken in account. Bacteriologic data do not increase the accuracy of diagnosis as compared to clinical diagnosis. Quantitative cultures obtained by different methods seem to be rather equivalent in diagnosing VAP. Blood cultures are relatively insensitive to diagnose pneumonia. The rapid availability of cytological data, including inflammatory cells and Gram stains, may be useful in initial therapeutic decisions in patients with suspected VAP. C-reactive protein, procalcitonin, and soluble triggering receptor expressed on myeloid cells are promising biomarkers in diagnosing VAP.ConclusionAn integrated approach should be followed in diagnosing and treating patients with VAP, including early antibiotic therapy and subsequent rectification according to clinical response and results of bacteriologic cultures.

[1]  M. Levy,et al.  Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 , 2007, Intensive Care Medicine.

[2]  B. Allaouchiche,et al.  An evaluation of the Gram stain in protected bronchoalveolar lavage fluid for the early diagnosis of ventilator-associated pneumonia. , 2001, Anesthesia and analgesia.

[3]  N B Hampson,et al.  The diagnosis of ventilator-associated pneumonia: a comparison of histologic, microbiologic, and clinical criteria. , 1997, Chest.

[4]  R. Rodríguez-Roisín,et al.  Use of elastin fibre detection in the diagnosis of ventilator associated pneumonia. , 1995, Thorax.

[5]  Margaret M Parker,et al.  Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock , 2004, Critical care medicine.

[6]  A. Boussuges,et al.  Diagnosis of nosocomial pneumonia in mechanically ventilated patients: repeatability of the bronchoalveolar lavage. , 1998, American journal of respiratory and critical care medicine.

[7]  P. V. Bottini,et al.  Diagnostic investigation of ventilator-associated pneumonia using bronchoalveolar lavage: comparative study with a postmortem lung biopsy. , 2001, Brazilian journal of medical and biological research = Revista brasileira de pesquisas medicas e biologicas.

[8]  B. Souweine,et al.  Diagnostic accuracy of protected specimen brush and bronchoalveolar lavage in nosocomial pneumonia: impact of previous antimicrobial treatments. , 1998, Critical care medicine.

[9]  古谷 良輔,et al.  Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. , 2008, American journal of respiratory and critical care medicine.

[10]  D. Cook,et al.  The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. , 1999, American journal of respiratory and critical care medicine.

[11]  M. Rumbak,et al.  Tracheal aspirate correlates with protected specimen brush in long-term ventilated patients who have clinical pneumonia. , 1994, Chest.

[12]  G. D. Thomas,et al.  Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. , 1972, Annals of internal medicine.

[13]  M. Dauge,et al.  Prospective evaluation of the protected specimen brush for the diagnosis of pulmonary infections in ventilated patients. , 1984, The American review of respiratory disease.

[14]  C. Tancrède,et al.  Diagnosis of nosocomial pneumonia in cancer patients undergoing mechanical ventilation: a prospective comparison of the plugged telescoping catheter with the protected specimen brush. , 1999, Chest.

[15]  J. Korevaar,et al.  Serial changes in soluble triggering receptor expressed on myeloid cells in the lung during development of ventilator-associated pneumonia , 2005, Intensive Care Medicine.

[16]  H. Lode,et al.  Ventilator-associated pneumonia in a surgical intensive care unit: epidemiology, etiology and comparison of three bronchoscopic methods for microbiological specimen sampling , 2001, Critical Care.

[17]  Marin H Kollef,et al.  Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. , 2002, Chest.

[18]  B. Allaouchiche,et al.  Alveolar and Serum Procalcitonin: Diagnostic and Prognostic Value in Ventilator-associated Pneumonia , 2002, Anesthesiology.

[19]  B. Allaouchiche,et al.  Gram stain of bronchoalveolar lavage fluid in the early diagnosis of ventilator-associated pneumonia. , 1999, British journal of anaesthesia.

[20]  P. Kilgo,et al.  Prospective comparison of bronchoalveolar lavage and quantitative deep tracheal aspirate in the diagnosis of ventilator associated pneumonia. , 2005, The Journal of trauma.

[21]  M. Klompas.  Does this patient have ventilator-associated pneumonia? , 2007, JAMA.

[22]  J. de Batlle,et al.  Microscopic examination of intracellular organisms in protected bronchoalveolar mini-lavage fluid for the diagnosis of ventilator-associated pneumonia. , 2003, Chest.

[23]  M. Lederman,et al.  Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients. , 1987, The American review of respiratory disease.

[24]  M. Niederman,et al.  Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. , 1997, Chest.

[25]  Chien-Liang Wu,et al.  Quantitative culture of endotracheal aspirates in the diagnosis of ventilator-associated pneumonia in patients with treatment failure. , 2002, Chest.

[26]  R. Auckenthaler,et al.  Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic "blind" bronchoalveolar lavage fluid. , 1991, The American review of respiratory disease.

[27]  D. Mozingo.  A randomized trial of diagnostic techniques for ventilator-associated pneumonia. , 2006, The New England journal of medicine.

[28]  G. Bleichner,et al.  Blind and bronchoscopic sampling methods in suspected ventilator-associated pneumonia , 2004, Intensive Care Medicine.

[29]  I. Catalá,et al.  Protected bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia. , 1996, The European respiratory journal.

[30]  M. Kollef,et al.  The Safety and Diagnostic Accuracy of Minibronchoalveolar Lavage in Patients with Suspected Ventilator-Associated Pneumonia , 1995, Annals of Internal Medicine.

[31]  M. Bonten,et al.  Clinical pulmonary infection score for ventilator-associated pneumonia: accuracy and inter-observer variability , 2004, Intensive Care Medicine.

[32]  F. Rodríguez de Castro,et al.  Usefulness of microscopic examination of intracellular organisms in lavage fluid in ventilator-associated pneumonia. , 1994, Chest.

[33]  C. Bryan,et al.  Bacteremic nosocomial pneumonia. Analysis of 172 episodes from a single metropolitan area. , 2015, The American review of respiratory disease.

[34]  T. Fabian,et al.  The futility of the clinical pulmonary infection score in trauma patients. , 2006, The Journal of trauma.

[35]  J. Rello,et al.  Role of bronchoalveolar lavage in mechanically ventilated patients with suspected pneumonia , 1994, European Journal of Clinical Microbiology and Infectious Diseases.

[36]  R. Rodríguez-Roisín,et al.  Diagnostic value of quantitative cultures of bronchoalveolar lavage and telescoping plugged catheters in mechanically ventilated patients with bacterial pneumonia. , 1989, The American review of respiratory disease.

[37]  C. Brun-Buisson,et al.  Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. , 2003, American journal of respiratory and critical care medicine.

[38]  J. Chastre,et al.  Role of quantitative cultures of endotracheal aspirates in the diagnosis of nosocomial pneumonia. , 1995, American journal of respiratory and critical care medicine.

[39]  R. Oster,et al.  Is bilateral protected specimen brush sampling necessary for the accurate diagnosis of ventilator-associated pneumonia? , 2004, The Journal of trauma.

[40]  L. Garbe,et al.  Diagnosis of Ventilator‐associated Pneumonia: An Evaluation of Direct Examination and Presence of Intracellular Organisms , 1997, Anesthesiology.

[41]  R. Rodríguez-Roisín,et al.  Value of intracellular bacteria detection in the diagnosis of ventilator associated pneumonia. , 1996, Thorax.

[42]  J. Wain,et al.  Elastin fibers and the diagnosis of bacterial pneumonia in the adult respiratory distress syndrome. , 1995, Critical care medicine.

[43]  F. Saulnier,et al.  Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard. , 1995, American journal of respiratory and critical care medicine.

[44]  M. Niederman,et al.  Blood cultures have limited value in predicting severity of illness and as a diagnostic tool in ventilator-associated pneumonia. , 1999, Chest.

[45]  Jordi Rello,et al.  Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. , 2002, Chest.

[46]  Jonathan J Deeks,et al.  Systematic reviews in health care: Systematic reviews of evaluations of diagnostic and screening tests. , 2001, BMJ.

[47]  Alexander J. Davit,et al.  A prospective assessment of diagnostic efficacy of blind protective bronchial brushings compared to bronchoscope-assisted lavage, bronchoscope-directed brushings, and blind endotracheal aspirates in ventilator-associated pneumonia. , 2003, The Journal of trauma.

[48]  C. Edmiston,et al.  Correlation of intracellular organisms with quantitative endotracheal aspirate. , 2003, The Journal of trauma.

[49]  S. Bello,et al.  "Blind" protected specimen brushing versus bronchoscopic techniques in the aetiolological diagnosis of ventilator-associated pneumonia. , 1996, The European respiratory journal.

[50]  P. Póvoa,et al.  C-reactive protein as a marker of infection in critically ill patients. , 2005, Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases.

[51]  R. Rodríguez-Roisín,et al.  Validation of different techniques for the diagnosis of ventilator-associated pneumonia. Comparison with immediate postmortem pulmonary biopsy. , 1994, American journal of respiratory and critical care medicine.

[52]  A. Anzueto,et al.  Incidence, risk factors, and outcome of ventilator-associated pneumonia. , 2006, Journal of critical care.

[53]  The Crash trial management group,et al.  Value of the clinical pulmonary infection score for the identification and management of ventilator-associated pneumonia , 2004, Intensive Care Medicine.

[54]  C. A'Court,et al.  The diagnosis of pneumonia in the critically ill. , 1995, Chest.

[55]  R. Reed,et al.  Ventilator-associated pneumonia in injured patients: do you trust your Gram's stain? , 2005, The Journal of trauma.

[56]  C. Dumontet,et al.  Early diagnosis of ventilator-associated pneumonia. Is it possible to define a cutoff value of infected cells in BAL fluid? , 1996, Chest.

[57]  R. Auckenthaler,et al.  Rapid diagnosis of gram negative pneumonia by assay of endotoxin in bronchoalveolar lavage fluid. , 1992, Thorax.

[58]  F Gouin,et al.  Bronchoscopic or Blind Sampling Techniques for Diagnosis of Ventilator‐Associated Pneumonia , 1996, American journal of respiratory and critical care medicine.

[59]  C. Brun-Buisson,et al.  Contribution of blinded, protected quantitative specimens to the diagnostic and therapeutic management of ventilator-associated pneumonia. , 2005, Chest.

[60]  T. Karchmer,et al.  National nosocomial infection surveillance system: from benchmark to bedside in trauma patients. , 2006, The Journal of trauma.

[61]  F. Abroug,et al.  Diagnosis of ventilator-associated pneumonia: agreement between quantitative cultures of endotracheal aspiration and plugged telescoping catheter , 2004, Intensive Care Medicine.

[62]  D. Heimbach,et al.  The Clinical Pulmonary Infection Score Poorly Predicts Pneumonia in Patients With Burns , 2007, Journal of burn care & research : official publication of the American Burn Association.

[63]  M. Kollef,et al.  Invasive approaches to the diagnosis of ventilator-associated pneumonia: A meta-analysis , 2005, Critical care medicine.

[64]  J. Rouby,et al.  A prospective study of protected bronchoalveolar lavage in the diagnosis of nosocomial pneumonia. , 1989, Anesthesiology.

[65]  C. Roussos,et al.  The diagnostic value of gram stain of bronchoalveolar lavage samples in patients with suspected ventilator-associated pneumonia. , 1998, Scandinavian journal of infectious diseases.

[66]  J. Carlet,et al.  Usefulness of a strategy based on bronchoscopy with direct examination of bronchoalveolar lavage fluid in the initial antibiotic therapy of suspected ventilator-associated pneumonia , 2001, Intensive Care Medicine.

[67]  J. Barker.  A Randomized Trial of Diagnostic Techniques for Ventilator-Associated Pneumonia , 2008 .

[68]  E. Knobel,et al.  Ventilator associated pneumonia: comparison between quantitative and qualitative cultures of tracheal aspirates , 2004, Critical care.

[69]  R. Wunderink,et al.  The radiologic diagnosis of autopsy-proven ventilator-associated pneumonia. , 1992, Chest.

[70]  P. Nordmann,et al.  Gram staining of protected pulmonary specimens in the early diagnosis of ventilator-associated pneumonia. , 2000, British journal of anaesthesia.

[71]  J. Bartlett,et al.  Soluble triggering receptor expressed on myeloid cells and the diagnosis of pneumonia , 2004 .

[72]  R. Wunderink,et al.  clinical investigations in critical care Management of Bacterial Pneumonia in Ventilated Patients * Protected Bronchoalveolar Lavage as a Diagnostic Tool , 2006 .

[73]  J. Rouby,et al.  Nosocomial bronchopneumonia in the critically ill. Histologic and bacteriologic aspects. , 1992, The American review of respiratory disease.

[74]  F. Rodríguez de Castro,et al.  Reliability of the bronchoscopic protected catheter brush in the diagnosis of pneumonia in mechanically ventilated patients. , 1991, Critical care medicine.

[75]  R. Rodríguez-Roisín,et al.  Quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia. , 1993, The American review of respiratory disease.

[76]  K. Eckardt,et al.  Elevations in procalcitonin but not C-reactive protein are associated with pneumonia after cardiopulmonary resuscitation. , 2002, Resuscitation.

[77]  J. Meredith,et al.  Optimal threshold for diagnosis of ventilator-associated pneumonia using bronchoalveolar lavage. , 2003, The Journal of trauma.

[78]  S. Jackson,et al.  Diagnosis of Gram negative, ventilator associated pneumonia by assaying endotoxin in bronchial lavage fluid , 2001, Journal of clinical pathology.

[79]  S. Ewig,et al.  Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies , 1999, Thorax.

[80]  P. Marik,et al.  A comparison of bronchoscopic vs blind protected specimen brush sampling in patients with suspected ventilator-associated pneumonia. , 1995, Chest.

[81]  R. A. Barnes,et al.  The diagnosis of ventilator-associated pneumonia using non-bronchoscopic, non-directed lung lavages , 2000, Intensive Care Medicine.

[82]  A. Torres,et al.  Sampling methods for ventilator-associated pneumonia: Validation using different histologic and microbiological references , 2000, Critical care medicine.

[83]  J. Timsit,et al.  Is protected specimen brush a reproducible method to diagnose ICU-acquired pneumonia? , 1993, Chest.

[84]  D. Spain,et al.  The appropriate diagnostic threshold for ventilator-associated pneumonia using quantitative cultures. , 2004, The Journal of trauma.