Diagnostic Value of Quantitative Cultures of Endotracheal Aspirate in Ventilator-Associated Pneumonia: A Multicenter Study

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Resultados de un ensayo clínico multicéntrico" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "JR Jardim, G Rico, C de la Roza, E Obispo, J Urueta, M Wolff, M Miravitlles" "autores" => array:7 [ 0 => array:2 [ "Iniciales" => "JR" "apellidos" => "Jardim" ] 1 => array:2 [ "Iniciales" => "G" "apellidos" => "Rico" ] 2 => array:2 [ "Iniciales" => "C" "apellidos" => "de la Roza" ] 3 => array:2 [ "Iniciales" => "E" "apellidos" => "Obispo" ] 4 => array:2 [ "Iniciales" => "J" "apellidos" => "Urueta" ] 5 => array:2 [ "Iniciales" => "M" "apellidos" => "Wolff" ] 6 => array:2 [ "Iniciales" => "M" "apellidos" => "Miravitlles" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13051509?idApp=UINPBA00003Z" "url" => "/15792129/0000003900000009/v0_201307090907/13051509/v0_201307090907/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Diagnostic Value of Quantitative Cultures of Endotracheal Aspirate in Ventilator-Associated Pneumonia: A Multicenter Study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "394" "paginaFinal" => "399" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "M Valencia Arango, A Torres Martí, J Insausti Ordeñana, F Álvarez Lerma, N Carrasco Joaquinet, M Herranz Casado, JP Tirapu León" "autores" => array:7 [ 0 => array:3 [ "Iniciales" => "M" "apellidos" => "Valencia Arango" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "A" "apellidos" => "Torres Martí" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 2 => array:3 [ "Iniciales" => "J" "apellidos" => "Insausti Ordeñana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 3 => array:3 [ "Iniciales" => "F" "apellidos" => "Álvarez Lerma" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] 4 => array:3 [ "Iniciales" => "N" "apellidos" => "Carrasco Joaquinet" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "affe" ] ] ] 5 => array:3 [ "Iniciales" => "M" "apellidos" => "Herranz Casado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "afff" ] ] ] 6 => array:3 [ "Iniciales" => "JP" "apellidos" => "Tirapu León" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Universidad Pontificia Bolivariana, Colombia. Hospital Clínic, Barcelona, Spain." "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Hospital Clínic, Barcelona, Spain." "etiqueta" => "b" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Hospital de Navarra, Pamplona-Iruña, Navarra, Spain." "etiqueta" => "c" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Hospital del Mar, Barcelona, Spain." "etiqueta" => "d" "identificador" => "affd" ] 4 => array:3 [ "entidad" => "Hospital de la Princesa, Madrid, Spain." "etiqueta" => "e" "identificador" => "affe" ] 5 => array:3 [ "entidad" => "Hospital Río Hortega, Valladolid, Spain." "etiqueta" => "f" "identificador" => "afff" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valor diagnóstico del cultivo cuantitativo del aspirado endotraqueal en la neumonía adquirida durante la ventilación mecánica. Estudio multicéntrico" ] ] "textoCompleto" => "Introduction Ventilator-associated pneumonia (VAP) is a common complication in patients requiring mechanical ventilation. Its incidence varies widely (9%-70%) depending on the type of population studied1,2 and the diagnostic methods used. In recent years, the most appropriate method for diagnosing VAP has been the subject of growing controversy. For some time now, invasive techniques, such as the plugged telescoping catheter (PTC) and bronchoalveolar lavage via fiberoptic bronchoscopy have been mentioned in the literature as the most valid techniques for the diagnosis of this condition.3 These methods are, however, invasive, expensive, and not exempt from complications. Moreover, they require the use of an invasive procedure not always available in intensive care units. Some authors have indicated that quantitative cultures of tracheal aspirate (TA) are of equal diagnostic value to the invasive techniques.4,5 The current situation is, therefore, that the scientific community has not yet agreed upon the best routine technique for the diagnosis of VAP.6-11 The objective of this study, proposed by the Infectious Diseases Work Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (GTEI-SEMICYUC), was to investigate the validity of quantitative cultures of TA and compare that method with another conventional method generally considered valid, such as PTC, in patients with suspected VAP.Materials and MethodsPatient SelectionThis prospective, multicenter study enrolled patients undergoing mechanical ventilation for more than 72 hours who were admitted over the period of one year to the intensive care units of the 10 participating hospitals: Hospital Clínic and Hospital del Mar in Barcelona, Hospital de Navarra, Hospital de la Princesa in Madrid, Hospital Río Hortega in Valladolid, Hospital Valme and Hospital Duque del Infantado in Seville, Hospital Son Dureta in Palma de Mallorca, Hospital Parc Taulí in Sabadell, and Hospital Conxo in Santiago de Compostela. The following variables were recorded for each patient: number of days on mechanical ventilation at the time of the study, underlying disease, white blood cell count, positive end-expiratory pressure, simplified acute physiology score (SAPS),12 clinical pulmonary infection score (CPIS)13 for VAP, presence of acute respiratory distress syndrome, antibiotics taken during the week prior to the study (number and type), and total duration of antibiotic therapy. Quantitative TA and PTC were performed in patients suspected of having VAP on the basis of the clinical criteria listed below. The diagnostic procedures to be carried out (TA and PTC) were explained to all patients or to their close family members, and informed consent was requested. The procedures were performed in the same way in all the hospitals: TA first, and then PTC.Study ProtocolTA specimens were obtained by sterile means using an aspiration catheter and were placed in sterile containers. Then, without interrupting mechanical ventilation, the fiberoptic bronchoscope was passed through the endotracheal tube via a special adaptor using the standard technique described in the literature,3,14 and without aspirating through the internal channel prior to collection of respiratory secretions. Local anesthetics were not used. Then the PTC sample was collected from the area of maximum local inflammation and purulence using the procedure described by Wimberley et al.15 In the case of diffuse infiltrate, the specimen was taken from the right lower lobe. Specimens were dispatched immediately to the laboratory for bacteriological processing. Two blood samples for culture were extracted prior to the above procedure.Diagnostic CriteriaSuspicion of VAP was based on the presence of a new and persistent pulmonary infiltrate, together with clinical signs indicative of lower respiratory tract infection (fever ≥38°C or hypothermia of ≤35°C, increase in the volume and/or purulence of respiratory secretions), and laboratory findings (leukocytosis ≥12 000/µL or leukopenia ≤4000/µL). The following criteria were used to confirm the diagnosis of pneumonia: clinical response to appropriate antibiotic treatment, absence of an alternative diagnosis during follow up, cavitation of an infiltrate, or autopsy data demonstrating the existence of pneumonia. Pneumonia was considered not to be present in patients for whom an alternative diagnosis emerged during follow up and who did not require subsequent antibiotic treatment, and in patients whose antibiotic treatment was withdrawn when the absence of pneumonia was confirmed. These patients were included in the control group. Patients not suspected of having pneumonia and in whom no radiologic evidence of infiltrate was observed were also included as controls.Microbiological ProcessingAll the samples obtained were cultured quantitatively using serial dilutions. The TA samples were mechanically homogenized using glass beads and vortexed for one minute. Serial dilutions of the TA were prepared with normal sterile saline solution in the proportion 1:1. The dilutions were then inoculated in various agar culture media and were incubated at 37ºC in aerobic conditions. The personnel in the microbiology laboratory were not aware of the diagnosis of the patients who produced the specimens, but they were aware of the type of sample delivered in each case.All microorganisms isolated were identified by standard laboratory methods. Bacterial pathogens in concentrations of ≥103 cfu per mL in cultures of PTC specimens, and ≥106 cfu/mL in cultures of TA were considered to be causative agents of VAP. The growth of microorganisms that are ordinarily not pathogenic, such as Streptococcus viridans and Staphylococcus epidermidis, were in general considered to be colonization.The identification of Legionella spp, mycobacteria or Aspergillus spp was considered diagnostic irrespective of the colony count obtained. Isolations of Candida spp were only considered significant when associated with positive blood cultures, or when histological evidence of pneumonia caused by Candida was present.Statistical AnalysisThe data were analyzed with the statistical software package SPSS for Microsoft Windows, version 6 (Chicago, Illinois, USA).Quantitative variables are expressed as means (SD), and qualitative variables as the frequency of distribution of each one of the categories. Means were compared the Student t test or Mann-Whitney U-test depending on whether or not the distribution of the variable was normal.Causative variables were compared using the χ² test. When any of the expected values in a 2x2 table were below 5, the Fisher exact test was used.Sensitivity and specificity were calculated for a specified 95% CI.The sensitivity and specificity of the different methods were compared (separately for patients with and without pneumonia) using the McNemar test.The level of statistical significance accepted was 95% (P<.05).ResultsA total of 120 cases were studied, of which 84 were diagnosed with pneumonia and 36 were not (control group). Of the 36 cases without pneumonia, 25 had some kind of radiologic infiltrate. No significant differences were found between the baseline variables of the patients with and without pneumonia except for CPIS and SAPS II scores and the duration of antibiotic treatment, which were all significantly higher in the group with pneumonia (Table 1).<img src="260v39n09-13051510tab01.gif"></img>The organism most often isolated both by TA and PTC was Staphylococcus aureus, followed by Pseudomonas aeruginosa and Acinetobacter baumannii by TA, and Haemophilus influenzae and P aeruginosa by PTC. Table 2 shows the different organisms isolated using the 2 diagnostic methods in patients with pneumonia, and their frequency.<img src="260v39n09-13051510tab02.gif"></img>On 3 occasions primary pathogens were detected in the TA specimens that were not isolated in those obtained by PTC: Aspergillus spp, Mycobacterium tuberculosis and Legionella pneumophila.Table 3 shows the number of positive cultures and the total number of microorganisms isolated with each technique in the 2 groups studied. In most cultures, growth of microorganisms was obtained independently of the quantification value and technique used.<img src="260v39n09-13051510tab03.gif"></img>Table 4 shows the diagnostic yield for TA at 2 different cutoff points for bacterial counts (≥105 and ≥106), and for PTC. The sensitivity of TA with a cutoff of ≥105 and that of PTC were significantly higher than that of TA with a cutoff of ≥106 (P=.0001 and .01, respectively), and the difference between TA≥105 and PTC≥103 was not significant (P=.40). The kappa (κ) statistic for the agreement between PTC≥103 and TA≥106 was 0.41, and the same statistic between PTC≥103 and TA≥105 was 0.63.<img src="260v39n09-13051510tab04.gif"></img>Comparison of the specificities of the tests gave the following results: the specificity of TA≥106 and PTC≥103 was significantly higher than that of TA≥105 (P=.014), but no significant difference was found between TA≥106 and PTC≥103 (P=1.00). The κ statistic for the agreement between TA≥106 and PTC≥103 was 0.70, and κ between TA≥105 and PTC≥103 was 0.63.Positive predictive values were 80% (69%-88%), 83% (71%-92%) and 86% (76%-94%) for TA≥105, TA≥106 and PTC≥103 respectively.Figures 1 and 2 show the ROC curves for TA and PTC with the corresponding areas under the curve and CI. The sensitivity/specificity relationship is very similar in both techniques.<img src="260v39n09-13051510tab05.gif"></img>Fig. 1. ROC curve of tracheal aspirate specimens. Area under the curve: 0.716 (95% confidence interval, 0.625-0.746).<img src="260v39n09-13051510tab06.gif"></img>Fig. 2. ROC curve of plugged telescoping catheter specimens. Area under the curve: 0.790 (95% confidence interval, 0.705-0.860).Of a total of 84 cases of pneumonia, concordant isolations (both tests positive for the same microorganism or both tests negative) were produced with both TA and PTC in 71 cases (83.8%), and the results did not agree in 13 cases (16.2%) (Table 5). The analysis of the association between the quantitative cultures of microorganisms that were detected with both TA≥105 and PTC produced a correlation coefficient (r) of 0.139 (P=.329).<img src="260v39n09-13051510tab07.gif"></img>DiscussionThe most noteworthy finding in this study was that, when a cutoff point of 106 cfu/mL or higher was used for TA in the diagnosis of VAP, reasonable specificity was obtained (>70%), similar to that obtained with PTC, although the sensitivity of TA at ≥106 was lower than that of both PTC and TA with a cutoff of ≥105 cfu/mL. When the cutoff of TA was changed to ≥105, the sensitivity did not differ significantly from that of PTC. These results show an acceptable yield for the clinical use of quantitative cultures of TA in the diagnosis of VAP, making it an alternative to bronchoscopic methods. Our findings are consistent with those of previous studies, which mention a cutoff point of ≥106 cfu/mL used to differentiate between colonization and infection with TA.5 In 2 earlier studies, sensitivity and specificity values of ≥70% (70% and 72%, respectively) were obtained using a cutoff of 105 cfu/mL, and the results of the present study confirm those findings.4,16It is known that both PTC and bronchoalveolar lavage are valid methods for the diagnosis of VAP.1,17 On the other hand, the currently most widely held opinion is that the use of qualitative cultures of TA is not a very specific diagnostic method owing to the airway colonization found in this type of patient. Although some groups still continue to use qualitative cultures of TA in the diagnosis of patients with suspected VAP, few doubts remain about the low specificity of the technique. Two earlier studies, carried out by Torres et al3 and Chastre et al,14 which evaluated the methods used to diagnose lower respiratory tract infection in patients on mechanical ventilation, found specificities as low as 14% and 29%, respectively.In recent years, various investigators have tried to improve bronchoscopic procedures for the diagnosis of VAP. In a relatively surprising manner some of them have achieved acceptable results using methods that do not involve obtaining samples from the area close to the inflamed site of the infection. Blind sampling using bronchoalveolar lavage (protected and unprotected) or using PTC has been shown to produce a high diagnostic yield given the multifocal and dynamic nature of VAP.18-22On the other hand, quantitative analysis of TA has been recommended as a simple and useful procedure in the diagnosis of VAP,4,7,23 and has the added advantages of being a noninvasive and more inexpensive technique. This study showed low sensitivity and acceptable specificity and a positive predictive value for TA with a cutoff of ≥106 in the diagnosis of VAP. Sensitivity improved with a cutoff of ≥105. PTC, on the other hand, showed better results in sensitivity and in positive predictive value. The specificity of PTC was the same as that of TA at a cutoff of ≥106.Reasonable agreement was found in this study between the results from TA and PTC samples. The same microorganism was obtained in 51 positive cultures from 84 patients with pneumonia (60%), and 20 negative concordant results were obtained (23.8%). Overall agreement was 83%. In only 2 cases (2.3%) were both tests positive but with different microorganisms (Table 5).Papazian et al24 compared PTC and TA in 35 mechanically-ventilated patients with bronchopneumonia, and reported a 93% agreement between the microorganisms cultured with the two techniques. However, the quantitative correlation between cultures obtained using the different techniques was not high.One of the aspects of VAP diagnosis that has given rise to most debate is the role played by invasive and noninvasive methods in the prognosis of these patients and the antibiotic therapy administered. The debate still continues, but some aspects have become clearer. When only randomized clinical trials are analyzed, we find that Sánchez-Nieto et al25 in a pilot study of 51 patients observed that bronchoscopic methods gave rise to more changes in initial antibiotic treatment (42% as opposed to 16%; P<.05), although no significant differences in mortality, either global or attributable, or in morbidity were observed. A limitation of that study was its small sample size and the absence of a standard treatment protocol in the invasive group. A study carried out by Solé Violan et al26 demonstrated that while antibiotic therapy was modified more often based on information from invasive techniques, the changes had no clear effect on mortality, length of stay in the intensive care unit, or duration of mechanical ventilation. Ruiz et al27 compared 76 patients with suspected VAP (39 noninvasive and 37 invasive) and concluded that the diagnostic yield for VAP was similar with both techniques, as was mortality at 30 days, number of days on mechanical ventilation, and length of stay in the intensive care unit. The cost of the invasive investigation was obviously higher.A study published by Fagon et al28 has reported positive results with respect to the reduction of mortality on day 14, lower sequential organ failure assessment scores on days 3 and 7, a reduction in the use of antibiotics, and more days free of antibiotics with the invasive technique. The limitation of this study was that qualitative cultures of TA were used, thereby limiting comparison with the other studies.The results obtained using quantitative cultures of TA and a threshold of ≥106 cfu/mL as the differentiator between colonization and infection can be considered relatively acceptable as part of the clinical approach to patients with suspected VAP when the possibility of using bronchoscopic techniques is not available, even though overall they are not as satisfactory as the results obtained with PTC.*Other members of the Work Group on Ventilator-Associated Pneumonia: M. El-Ebiary (Hospital Clínic, Barcelona); C. León, M. Guerrero and F. Ortega (Hospital Valme, Seville); F. Castillo (Hospital Duque del Infantado, Seville); R. Jordá (Hospital Son Dureta, Palma de Mallorca); J. Barado (Hospital de Navarra); J. Vallés and J. Rello (Hospital Parc Taulí, Sabadell, Barcelona); A. Santos Bouza (Hospital Conxo, Santiago de Compostela, A Coruña).<hr></hr>Correspondence: Dr. A. Torres Martí. Unidad de Vigilancia Intensiva Respiratoria (UVIR). Instituto Clínico de Neumología y Cirugía Torácica. Hospital Clínic. Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS). Universidad de Barcelona. Villarroel, 170. 08036 Barcelona. Spain. E-mail: <a href="mailto:atorres@medicina.ub.es" class="elsevierStyleCrossRefs"> atorres@medicina.ub.es</a>Manuscript received October 31, 2002. Accepted for publication February 18, 2003." "pdfFichero" => "260v39n09a13051510pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec191409" "palabras" => array:3 [ 0 => "Pneumonia" 1 => "Mechanical ventilation" 2 => "Tracheal aspirate" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec191410" "palabras" => array:3 [ 0 => "Neumonía" 1 => "Ventilación mecánica" 2 => "Aspirado traqueal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Objective: To study the validity of quantitative cultures of tracheal aspirate (TA) in comparison with the plugged telescoping catheter (PTC) for the diagnosis of mechanical ventilator-associated pneumonia. Method: Prospective multicenter study enrolling patients undergoing mechanical ventilation for longer than 72 hours. TA samples were collected from patients with suspected ventilator-associated pneumonia, followed by PTC sampling. Quantitative cultures were performed on all samples. Patients were classified according to the presence or not of pneumonia, based on clinical and radiologic criteria, clinical course and autopsy findings. The cutoff points were ≥103 colony-forming units (cfu) per mL for PTC cultures; the TA cutoffs analyzed were ≥105 and ≥106 cfu/mL. Results: Of the 120 patients studied, 84 had diagnoses of pneumonia and 36 did not (controls). The sensitivity values for TA≥106, TA≥105, and PTC, respectively, were 54% (95% confidence interval [CI], 42%-64%), 71% (95% CI, 60%-81%), and 68% (95% CI, 57%-78%). The specificity values were 75% (95% CI, 58%-88%), 58% (95% CI, 41%-74%), and 75% (95% CI, 58%-88%), respectively. Staphylococcus aureus was the microorganism most frequently isolated in both TA and PTC samples, followed in frequency by Pseudomomonas aeruginosa in TA samples and Haemophilus influenzae in PTC samples. No significant differences were found between the sensitivity of TA≥105 and that of PTC, nor between the specificities of TA≥106 and PTC. Conclusions: No differences in the specificities of PTC and TA were found when a TA cutoff of ≥106 cfu/ml was used. Moreover, at a cutoff of ≥105 the sensitivity of TA was not statistically different from that of PTC. Quantitative cultures of TA can be considered acceptable for the diagnosis of ventilator-associated pneumonia." ] "es" => array:1 [ "resumen" => "Objetivo: Estudiar la validez del aspirado traqueal (AT) con cultivos cuantitativos y compararla con el catéter telescopado (CTP) en el diagnóstico de la neumonía relacionada con la ventilación mecánica (NVM). Método: Estudio prospectivo y multicéntrico en el que se incluyó a pacientes sometidos a ventilación mecánica durante más de 72 h. A los pacientes con sospecha clínica de NVM se les realizaron AT y posteriormente CTP. A todas estas muestras se les practicó un cultivo cuantitativo. De acuerdo con criterios clínicos, radiológicos, de seguimiento y autópsicos se dividieron los pacientes en casos con neumonía y sin neumonía (controles). Se escogió como punto de corte para el CTP ≥ 103 unidades formadoras de colonias (ufc)/ml y para el AT se evaluó con ≥ 105 y > 106 ufc/ml, respectivamente. Resultados: Se estudió a 120 pacientes; se consideró que 84 presentaban neumonía y 36 no la presentaban (controles). La sensibilidad fue del 54% (intervalo de confianza [IC] del 95%, 42-64%), el 71% (IC del 95%, 60-81%) y el 68% (IC del 95%, 57-78%) para AT ≥ 106, AT ≥ 105 y CTP, respectivamente. Las especificidades encontradas fueron del 75% (IC del 95%, 58 - 88%), el 58% (IC del 95%, 41-74%) y el 75% (IC del 95%, 58 -88%), respectivamente. El organismo aislado más frecuentemente fue Staphylococcus aureus tanto por AT como por CTP, seguido por Pseudomomonas aeruginosa en AT y por Haemophilus influenzae en CTP. No se encontraron diferencias significativas entre la sensibilidad del AT ≥ 105 y del CTP, y tampoco con las especificidades del AT ≥ 106 y el CTP. Conclusiones: Cuando se utiliza un punto de corte de 106 ufc/ml o mayor para el AT en el diagnostico de la NVM se obtienen porcentajes de especificidad similares a los obtenidos con el CTP, y con el punto de corte 105 o mayor, porcentajes de sensibilidad aceptables. Los cultivos cuantitativos del AT pueden considerarse aceptables en el diagnóstico de la NVM." ] ] "multimedia" => array:14 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "TABLE 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n09-13051510tab01.gif" "imagenAlto" => 443 "imagenAncho" => 391 "imagenTamanyo" => 17754 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic and Clinical Characteristics of the Patients*" ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "TABLE 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n09-13051510tab02.gif" "imagenAlto" => 288 "imagenAncho" => 383 "imagenTamanyo" => 13485 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Isolation of Pathogens in Tracheal Aspirate and Plugged Telescoping Catheter Specimens in Patients With Pneumonia*" ] ] 2 => array:8 [ "identificador" => "tbl3" "etiqueta" => "TABLE 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n09-13051510tab03.gif" "imagenAlto" => 196 "imagenAncho" => 389 "imagenTamanyo" => 8539 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Qualitative Microbiological Evaluation*" ] ] 3 => array:8 [ "identificador" => "tbl4" "etiqueta" => "TABLE 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n09-13051510tab04.gif" "imagenAlto" => 194 "imagenAncho" => 387 "imagenTamanyo" => 9454 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Diagnostic Yield of Tests*" ] ] 4 => array:8 [ "identificador" => "tbl5" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n09-13051510tab05.gif" "imagenAlto" => 371 "imagenAncho" => 380 "imagenTamanyo" => 7026 ] ] ] ] ] "descripcion" => array:1 [ "en" => "ROC curve of tracheal aspirate specimens. 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Valor diagnóstico del cultivo cuantitativo del aspirado endotraqueal en la neumonía adquirida durante la ventilación mecánica. Estudio multicéntrico

M. Valencia Arangoa, A. Torres Martíb, J. Insausti Ordeñanac, F. Álvarez Lermad, N. Carrasco Joaquinete, M. Herranz Casadof, JP. Tirapu Leónc

a Unidad de Cuidados Intensivos, Universidad Pontificia Bolivariana, Colombia. Hospital Clínic, Barcelona, Spain.

b Hospital Clínic, Barcelona, Spain.

c Hospital de Navarra, Pamplona-Iruña, Navarra, Spain.

d Hospital del Mar, Barcelona, Spain.

e Hospital de la Princesa, Madrid, Spain.

f Hospital Río Hortega, Valladolid, Spain.

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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Ventilator-associated pneumonia &#40;VAP&#41; is a common complication in patients requiring mechanical ventilation&#46; Its incidence varies widely &#40;9&#37;-70&#37;&#41; depending on the type of population studied<span class="elsevierStyleSup">1&#44;2</span> and the diagnostic methods used&#46; In recent years&#44; the most appropriate method for diagnosing VAP has been the subject of growing controversy&#46; For some time now&#44; invasive techniques&#44; such as the plugged telescoping catheter &#40;PTC&#41; and bronchoalveolar lavage via fiberoptic bronchoscopy have been mentioned in the literature as the most valid techniques for the diagnosis of this condition&#46;<span class="elsevierStyleSup">3</span> These methods are&#44; however&#44; invasive&#44; expensive&#44; and not exempt from complications&#46; Moreover&#44; they require the use of an invasive procedure not always available in intensive care units&#46; Some authors have indicated that quantitative cultures of tracheal aspirate &#40;TA&#41; are of equal diagnostic value to the invasive techniques&#46;<span class="elsevierStyleSup">4&#44;5</span> The current situation is&#44; therefore&#44; that the scientific community has not yet agreed upon the best routine technique for the diagnosis of VAP&#46;<span class="elsevierStyleSup">6&#173;-11</span> The objective of this study&#44; proposed by the Infectious Diseases Work Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#40;GTEI-SEMICYUC&#41;&#44; was to investigate the validity of quantitative cultures of TA and compare that method with another conventional method generally considered valid&#44; such as PTC&#44; in patients with suspected VAP&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Materials and Methods</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Patient Selection</span></p><p class="elsevierStylePara">This prospective&#44; multicenter study enrolled patients undergoing mechanical ventilation for more than 72 hours who were admitted over the period of one year to the intensive care units of the 10 participating hospitals&#58; Hospital Cl&#237;nic and Hospital del Mar in Barcelona&#44; Hospital de Navarra&#44; Hospital de la Princesa in Madrid&#44; Hospital R&#237;o Hortega in Valladolid&#44; Hospital Valme and Hospital Duque del Infantado in Seville&#44; Hospital Son Dureta in Palma de Mallorca&#44; Hospital Parc Taul&#237; in Sabadell&#44; and Hospital Conxo in Santiago de Compostela&#46; The following variables were recorded for each patient&#58; number of days on mechanical ventilation at the time of the study&#44; underlying disease&#44; white blood cell count&#44; positive end-expiratory pressure&#44; simplified acute physiology score &#40;SAPS&#41;&#44;<span class="elsevierStyleSup">12</span> clinical pulmonary infection score &#40;CPIS&#41;<span class="elsevierStyleSup">13</span> for VAP&#44; presence of acute respiratory distress syndrome&#44; antibiotics taken during the week prior to the study &#40;number and type&#41;&#44; and total duration of antibiotic therapy&#46; Quantitative TA and PTC were performed in patients suspected of having VAP on the basis of the clinical criteria listed below&#46; The diagnostic procedures to be carried out &#40;TA and PTC&#41; were explained to all patients or to their close family members&#44; and informed consent was requested&#46; The procedures were performed in the same way in all the hospitals&#58; TA first&#44; and then PTC&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Study Protocol</span></p><p class="elsevierStylePara">TA specimens were obtained by sterile means using an aspiration catheter and were placed in sterile containers&#46; Then&#44; without interrupting mechanical ventilation&#44; the fiberoptic bronchoscope was passed through the endotracheal tube via a special adaptor using the standard technique described in the literature&#44;<span class="elsevierStyleSup">3&#44;14</span> and without aspirating through the internal channel prior to collection of respiratory secretions&#46; Local anesthetics were not used&#46; Then the PTC sample was collected from the area of maximum local inflammation and purulence using the procedure described by Wimberley et al&#46;<span class="elsevierStyleSup">15</span> In the case of diffuse infiltrate&#44; the specimen was taken from the right lower lobe&#46; Specimens were dispatched immediately to the laboratory for bacteriological processing&#46; Two blood samples for culture were extracted prior to the above procedure&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Diagnostic Criteria</span></p><p class="elsevierStylePara">Suspicion of VAP was based on the presence of a new and persistent pulmonary infiltrate&#44; together with clinical signs indicative of lower respiratory tract infection &#40;fever &#8805;38&#176;C or hypothermia of &#8804;35&#176;C&#44; increase in the volume and&#47;or purulence of respiratory secretions&#41;&#44; and laboratory findings &#40;leukocytosis &#8805;12 000&#47;&#181;L or leukopenia &#8804;4000&#47;&#181;L&#41;&#46; The following criteria were used to confirm the diagnosis of pneumonia&#58; clinical response to appropriate antibiotic treatment&#44; absence of an alternative diagnosis during follow up&#44; cavitation of an infiltrate&#44; or autopsy data demonstrating the existence of pneumonia&#46; Pneumonia was considered not to be present in patients for whom an alternative diagnosis emerged during follow up and who did not require subsequent antibiotic treatment&#44; and in patients whose antibiotic treatment was withdrawn when the absence of pneumonia was confirmed&#46; These patients were included in the control group&#46; Patients not suspected of having pneumonia and in whom no radiologic evidence of infiltrate was observed were also included as controls&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Microbiological Processing</span></p><p class="elsevierStylePara">All the samples obtained were cultured quantitatively using serial dilutions&#46; The TA samples were mechanically homogenized using glass beads and vortexed for one minute&#46; Serial dilutions of the TA were prepared with normal sterile saline solution in the proportion 1&#58;1&#46; The dilutions were then inoculated in various agar culture media and were incubated at 37&#186;C in aerobic conditions&#46; The personnel in the microbiology laboratory were not aware of the diagnosis of the patients who produced the specimens&#44; but they were aware of the type of sample delivered in each case&#46;</p><p class="elsevierStylePara">All microorganisms isolated were identified by standard laboratory methods&#46; Bacterial pathogens in concentrations of &#8805;10<span class="elsevierStyleSup">3</span> cfu per mL in cultures of PTC specimens&#44; and &#8805;10<span class="elsevierStyleSup">6</span> cfu&#47;mL in cultures of TA were considered to be causative agents of VAP&#46; The growth of microorganisms that are ordinarily not pathogenic&#44; such as <span class="elsevierStyleItalic">Streptococcus viridans</span> and <span class="elsevierStyleItalic">Staphylococcus epidermidis</span>&#44; were in general considered to be colonization&#46;</p><p class="elsevierStylePara">The identification of <span class="elsevierStyleItalic">Legionella</span> spp&#44; mycobacteria or <span class="elsevierStyleItalic"> Aspergillus</span> spp was considered diagnostic irrespective of the colony count obtained&#46; Isolations of <span class="elsevierStyleItalic">Candida</span> spp were only considered significant when associated with positive blood cultures&#44; or when histological evidence of pneumonia caused by <span class="elsevierStyleItalic"> Candida</span> was present&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Statistical Analysis</span></p><p class="elsevierStylePara">The data were analyzed with the statistical software package SPSS for Microsoft Windows&#44; version 6 &#40;Chicago&#44; Illinois&#44; USA&#41;&#46;</p><p class="elsevierStylePara">Quantitative variables are expressed as means &#40;SD&#41;&#44; and qualitative variables as the frequency of distribution of each one of the categories&#46; Means were compared the Student <span class="elsevierStyleItalic">t</span> test or Mann-Whitney U-test depending on whether or not the distribution of the variable was normal&#46;</p><p class="elsevierStylePara">Causative variables were compared using the &#967;&#178; test&#46; When any of the expected values in a 2x2 table were below 5&#44; the Fisher exact test was used&#46;</p><p class="elsevierStylePara">Sensitivity and specificity were calculated for a specified 95&#37; CI&#46;</p><p class="elsevierStylePara">The sensitivity and specificity of the different methods were compared &#40;separately for patients with and without pneumonia&#41; using the McNemar test&#46;</p><p class="elsevierStylePara">The level of statistical significance accepted was 95&#37; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;05&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara">A total of 120 cases were studied&#44; of which 84 were diagnosed with pneumonia and 36 were not &#40;control group&#41;&#46; Of the 36 cases without pneumonia&#44; 25 had some kind of radiologic infiltrate&#46; No significant differences were found between the baseline variables of the patients with and without pneumonia except for CPIS and SAPS II scores and the duration of antibiotic treatment&#44; which were all significantly higher in the group with pneumonia &#40;Table 1&#41;&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051510tab01.gif"></img></p><p class="elsevierStylePara">The organism most often isolated both by TA and PTC was <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; followed by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> and <span class="elsevierStyleItalic"> Acinetobacter baumannii</span> by TA&#44; and <span class="elsevierStyleItalic">Haemophilus influenzae</span> and <span class="elsevierStyleItalic">P aeruginosa</span> by PTC&#46; Table 2 shows the different organisms isolated using the 2 diagnostic methods in patients with pneumonia&#44; and their frequency&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051510tab02.gif"></img></p><p class="elsevierStylePara">On 3 occasions primary pathogens were detected in the TA specimens that were not isolated in those obtained by PTC&#58; <span class="elsevierStyleItalic">Aspergillus</span> spp&#44; <span class="elsevierStyleItalic"> Mycobacterium tuberculosis</span> and <span class="elsevierStyleItalic">Legionella pneumophila&#46;</span></p><p class="elsevierStylePara">Table 3 shows the number of positive cultures and the total number of microorganisms isolated with each technique in the 2 groups studied&#46; In most cultures&#44; growth of microorganisms was obtained independently of the quantification value and technique used&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051510tab03.gif"></img></p><p class="elsevierStylePara">Table 4 shows the diagnostic yield for TA at 2 different cutoff points for bacterial counts &#40;&#8805;10<span class="elsevierStyleSup">5</span> and &#8805;10<span class="elsevierStyleSup">6</span>&#41;&#44; and for PTC&#46; The sensitivity of TA with a cutoff of &#8805;10<span class="elsevierStyleSup">5</span> and that of PTC were significantly higher than that of TA with a cutoff of &#8805;10<span class="elsevierStyleSup">6</span> &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;0001 and &#46;01&#44; respectively&#41;&#44; and the difference between TA&#8805;10<span class="elsevierStyleSup">5</span> and PTC&#8805;10<span class="elsevierStyleSup">3</span> was not significant &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;40&#41;&#46; The kappa &#40;&#954;&#41; statistic for the agreement between PTC&#8805;10<span class="elsevierStyleSup">3</span> and TA&#8805;10<span class="elsevierStyleSup">6</span> was 0&#46;41&#44; and the same statistic between PTC&#8805;10<span class="elsevierStyleSup">3</span> and TA&#8805;10<span class="elsevierStyleSup">5</span> was 0&#46;63&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051510tab04.gif"></img></p><p class="elsevierStylePara">Comparison of the specificities of the tests gave the following results&#58; the specificity of TA&#8805;10<span class="elsevierStyleSup">6</span> and PTC&#8805;10<span class="elsevierStyleSup">3</span> was significantly higher than that of TA&#8805;10<span class="elsevierStyleSup">5</span> &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;014&#41;&#44; but no significant difference was found between TA&#8805;10<span class="elsevierStyleSup">6</span> and PTC&#8805;10<span class="elsevierStyleSup">3</span> &#40;<span class="elsevierStyleItalic">P</span>&#61;1&#46;00&#41;&#46; The &#954; statistic for the agreement between TA&#8805;10<span class="elsevierStyleSup">6</span> and PTC&#8805;10<span class="elsevierStyleSup">3</span> was 0&#46;70&#44; and &#954;  between TA&#8805;10<span class="elsevierStyleSup">5</span> and PTC&#8805;10<span class="elsevierStyleSup">3</span> was 0&#46;63&#46;</p><p class="elsevierStylePara">Positive predictive values were 80&#37; &#40;69&#37;-88&#37;&#41;&#44; 83&#37; &#40;71&#37;-92&#37;&#41; and 86&#37; &#40;76&#37;-94&#37;&#41; for TA&#8805;10<span class="elsevierStyleSup">5</span>&#44; TA&#8805;10<span class="elsevierStyleSup">6</span> and PTC&#8805;10<span class="elsevierStyleSup">3</span> respectively&#46;</p><p class="elsevierStylePara">Figures 1 and 2 show the ROC curves for TA and PTC with the corresponding areas under the curve and CI&#46; The sensitivity&#47;specificity relationship is very similar in both techniques&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051510tab05.gif"></img></p><p class="elsevierStylePara">Fig&#46; 1&#46; ROC curve of tracheal aspirate specimens&#46; Area under the curve&#58; 0&#46;716 &#40;95&#37; confidence interval&#44; 0&#46;625-0&#46;746&#41;&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051510tab06.gif"></img></p><p class="elsevierStylePara">Fig&#46; 2&#46; ROC curve of plugged telescoping catheter specimens&#46; Area under the curve&#58; 0&#46;790 &#40;95&#37; confidence interval&#44; 0&#46;705-0&#46;860&#41;&#46;</p><p class="elsevierStylePara">Of a total of 84 cases of pneumonia&#44; concordant isolations &#40;both tests positive for the same microorganism or both tests negative&#41; were produced with both TA and PTC in 71 cases &#40;83&#46;8&#37;&#41;&#44; and the results did not agree in 13 cases &#40;16&#46;2&#37;&#41; &#40;Table 5&#41;&#46; The analysis of the association between the quantitative cultures of microorganisms that were detected with both TA&#8805;10<span class="elsevierStyleSup">5</span> and PTC produced a correlation coefficient &#40;r&#41; of 0&#46;139 &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;329&#41;&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051510tab07.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">The most noteworthy finding in this study was that&#44; when a cutoff point of 10<span class="elsevierStyleSup">6</span> cfu&#47;mL or higher was used for TA in the diagnosis of VAP&#44; reasonable specificity was obtained &#40;&#62;70&#37;&#41;&#44; similar to that obtained with PTC&#44; although the sensitivity of TA at &#8805;10<span class="elsevierStyleSup">6</span> was lower than that of both PTC and TA with a cutoff of &#8805;10<span class="elsevierStyleSup">5</span> cfu&#47;mL&#46; When the cutoff of TA was changed to &#8805;10<span class="elsevierStyleSup">5</span>&#44; the sensitivity did not differ significantly from that of PTC&#46; These results show an acceptable yield for the clinical use of quantitative cultures of TA in the diagnosis of VAP&#44; making it an alternative to bronchoscopic methods&#46; Our findings are consistent with those of previous studies&#44; which mention a cutoff point of &#8805;10<span class="elsevierStyleSup">6</span> cfu&#47;mL used to differentiate between colonization and infection with TA&#46;<span class="elsevierStyleSup">5</span> In 2 earlier studies&#44; sensitivity and specificity values of &#8805;70&#37; &#40;70&#37; and 72&#37;&#44; respectively&#41; were obtained using a cutoff of 10<span class="elsevierStyleSup">5</span> cfu&#47;mL&#44; and the results of the present study confirm those findings&#46;<span class="elsevierStyleSup">4&#44;16</span></p><p class="elsevierStylePara">It is known that both PTC and bronchoalveolar lavage are valid methods for the diagnosis of VAP&#46;<span class="elsevierStyleSup">1&#44;17</span> On the other hand&#44; the currently most widely held opinion is that the use of qualitative cultures of TA is not a very specific diagnostic method owing to the airway colonization found in this type of patient&#46; Although some groups still continue to use qualitative cultures of TA in the diagnosis of patients with suspected VAP&#44; few doubts remain about the low specificity of the technique&#46; Two earlier studies&#44; carried out by Torres et al<span class="elsevierStyleSup">3</span> and Chastre et al&#44;<span class="elsevierStyleSup">14</span> which evaluated the methods used to diagnose lower respiratory tract infection in patients on mechanical ventilation&#44; found specificities as low as 14&#37; and 29&#37;&#44; respectively&#46;</p><p class="elsevierStylePara">In recent years&#44; various investigators have tried to improve bronchoscopic procedures for the diagnosis of VAP&#46; In a relatively surprising manner some of them have achieved acceptable results using methods that do not involve obtaining samples from the area close to the inflamed site of the infection&#46; Blind sampling using bronchoalveolar lavage &#40;protected and unprotected&#41; or using PTC has been shown to produce a high diagnostic yield given the multifocal and dynamic nature of VAP&#46;<span class="elsevierStyleSup">18-22</span></p><p class="elsevierStylePara">On the other hand&#44; quantitative analysis of TA has been recommended as a simple and useful procedure in the diagnosis of VAP&#44;<span class="elsevierStyleSup">4&#44;7&#44;23</span> and has the added advantages of being a noninvasive and more inexpensive technique&#46; This study showed low sensitivity and acceptable specificity and a positive predictive value for TA with a cutoff of &#8805;10<span class="elsevierStyleSup">6</span> in the diagnosis of VAP&#46; Sensitivity improved with a cutoff of &#8805;10<span class="elsevierStyleSup">5</span>&#46; PTC&#44; on the other hand&#44; showed better results in sensitivity and in positive predictive value&#46; The specificity of PTC was the same as that of TA at a cutoff of &#8805;10<span class="elsevierStyleSup">6</span>&#46;</p><p class="elsevierStylePara">Reasonable agreement was found in this study between the results from TA and PTC samples&#46; The same microorganism was obtained in 51 positive cultures from 84 patients with pneumonia &#40;60&#37;&#41;&#44; and 20 negative concordant results were obtained &#40;23&#46;8&#37;&#41;&#46; Overall agreement was 83&#37;&#46; In only 2 cases &#40;2&#46;3&#37;&#41; were both tests positive but with different microorganisms &#40;Table 5&#41;&#46;</p><p class="elsevierStylePara">Papazian et al<span class="elsevierStyleSup">24</span> compared PTC and TA in 35 mechanically-ventilated patients with bronchopneumonia&#44; and reported a 93&#37; agreement between the microorganisms cultured with the two techniques&#46; However&#44; the quantitative correlation between cultures obtained using the different techniques was not high&#46;</p><p class="elsevierStylePara">One of the aspects of VAP diagnosis that has given rise to most debate is the role played by invasive and noninvasive methods in the prognosis of these patients and the antibiotic therapy administered&#46; The debate still continues&#44; but some aspects have become clearer&#46; When only randomized clinical trials are analyzed&#44; we find that S&#225;nchez-Nieto et al<span class="elsevierStyleSup">25</span> in a pilot study of 51 patients observed that bronchoscopic methods gave rise to more changes in initial antibiotic treatment &#40;42&#37; as opposed to 16&#37;&#59; <span class="elsevierStyleItalic"> P</span>&#60;&#46;05&#41;&#44; although no significant differences in mortality&#44; either global or attributable&#44; or in morbidity were observed&#46; A limitation of that study was its small sample size and the absence of a standard treatment protocol in the invasive group&#46; A study carried out by Sol&#233; Violan et al<span class="elsevierStyleSup">26</span> demonstrated that while antibiotic therapy was modified more often based on information from invasive techniques&#44; the changes had no clear effect on mortality&#44; length of stay in the intensive care unit&#44; or duration of mechanical ventilation&#46; Ruiz et al<span class="elsevierStyleSup">27</span> compared 76 patients with suspected VAP &#40;39 noninvasive and 37 invasive&#41; and concluded that the diagnostic yield for VAP was similar with both techniques&#44; as was mortality at 30 days&#44; number of days on mechanical ventilation&#44; and length of stay in the intensive care unit&#46; The cost of the invasive investigation was obviously higher&#46;</p><p class="elsevierStylePara">A study published by Fagon et al<span class="elsevierStyleSup">28</span> has reported positive results with respect to the reduction of mortality on day 14&#44; lower sequential organ failure assessment scores on days 3 and 7&#44; a reduction in the use of antibiotics&#44; and more days free of antibiotics with the invasive technique&#46; The limitation of this study was that qualitative cultures of TA were used&#44; thereby limiting comparison with the other studies&#46;</p><p class="elsevierStylePara">The results obtained using quantitative cultures of TA and a threshold of &#8805;10<span class="elsevierStyleSup">6</span> cfu&#47;mL as the differentiator between colonization and infection can be considered relatively acceptable as part of the clinical approach to patients with suspected VAP when the possibility of using bronchoscopic techniques is not available&#44; even though overall they are not as satisfactory as the results obtained with PTC&#46;</p><p class="elsevierStylePara">&#42;Other members of the Work Group on Ventilator-Associated Pneumonia&#58; M&#46; El-Ebiary &#40;Hospital Cl&#237;nic&#44; Barcelona&#41;&#59; C&#46; Le&#243;n&#44; M&#46; Guerrero and F&#46; Ortega &#40;Hospital Valme&#44; Seville&#41;&#59; F&#46; Castillo &#40;Hospital Duque del Infantado&#44; Seville&#41;&#59; R&#46; Jord&#225; &#40;Hospital Son Dureta&#44; Palma de Mallorca&#41;&#59; J&#46; Barado &#40;Hospital de Navarra&#41;&#59; J&#46; Vall&#233;s and J&#46; Rello &#40;Hospital Parc Taul&#237;&#44; Sabadell&#44; Barcelona&#41;&#59; A&#46; Santos Bouza &#40;Hospital Conxo&#44; Santiago de Compostela&#44; A Coru&#241;a&#41;&#46;</p><hr></hr><p class="elsevierStylePara">Correspondence&#58; Dr&#46; A&#46; Torres Mart&#237;&#46;<br></br> Unidad de Vigilancia Intensiva Respiratoria &#40;UVIR&#41;&#46; Instituto Cl&#237;nico de<br></br> Neumolog&#237;a y Cirug&#237;a Tor&#225;cica&#46; Hospital Cl&#237;nic&#46; Instituto de Investigaciones<br></br> Biom&#233;dicas August Pi i Sunyer &#40;IDIBAPS&#41;&#46; Universidad de Barcelona&#46;<br></br> Villarroel&#44; 170&#46; 08036 Barcelona&#46; Spain&#46;<br></br> E-mail&#58; <a href="mailto&#58;atorres&#64;medicina&#46;ub&#46;es" class="elsevierStyleCrossRefs"> atorres&#64;medicina&#46;ub&#46;es</a></p><p class="elsevierStylePara">Manuscript received October 31&#44; 2002&#46;<br></br> Accepted for publication February 18&#44; 2003&#46;</p>"
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          "palabras" => array:3 [
            0 => "Pneumonia"
            1 => "Mechanical ventilation"
            2 => "Tracheal aspirate"
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          "palabras" => array:3 [
            0 => "Neumon&#237;a"
            1 => "Ventilaci&#243;n mec&#225;nica"
            2 => "Aspirado traqueal"
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        "resumen" => "Objective&#58; To study the validity of quantitative cultures of tracheal aspirate &#40;TA&#41; in comparison with the plugged telescoping catheter &#40;PTC&#41; for the diagnosis of mechanical ventilator-associated pneumonia&#46; Method&#58; Prospective multicenter study enrolling patients undergoing mechanical ventilation for longer than 72 hours&#46; TA samples were collected from patients with suspected ventilator-associated pneumonia&#44; followed by PTC sampling&#46; Quantitative cultures were performed on all samples&#46; Patients were classified according to the presence or not of pneumonia&#44; based on clinical and radiologic criteria&#44; clinical course and autopsy findings&#46; The cutoff points were &#8805;103 colony-forming units &#40;cfu&#41; per mL for PTC cultures&#59; the TA cutoffs analyzed were &#8805;105 and &#8805;106 cfu&#47;mL&#46; Results&#58; Of the 120 patients studied&#44; 84 had diagnoses of pneumonia and 36 did not &#40;controls&#41;&#46; The sensitivity values for TA&#8805;106&#44; TA&#8805;105&#44; and PTC&#44; respectively&#44; were 54&#37; &#40;95&#37; confidence interval &#91;CI&#93;&#44; 42&#37;-64&#37;&#41;&#44; 71&#37; &#40;95&#37; CI&#44; 60&#37;-81&#37;&#41;&#44; and 68&#37; &#40;95&#37; CI&#44; 57&#37;-78&#37;&#41;&#46; The specificity values were 75&#37; &#40;95&#37; CI&#44; 58&#37;-88&#37;&#41;&#44; 58&#37; &#40;95&#37; CI&#44; 41&#37;-74&#37;&#41;&#44; and 75&#37; &#40;95&#37; CI&#44; 58&#37;-88&#37;&#41;&#44; respectively&#46; Staphylococcus aureus was the microorganism most frequently isolated in both TA and PTC samples&#44; followed in frequency by Pseudomomonas aeruginosa in TA samples and Haemophilus influenzae in PTC samples&#46; No significant differences were found between the sensitivity of TA&#8805;105 and that of PTC&#44; nor between the specificities of TA&#8805;106 and PTC&#46; Conclusions&#58; No differences in the specificities of PTC and TA were found when a TA cutoff of &#8805;106 cfu&#47;ml was used&#46; Moreover&#44; at a cutoff of &#8805;105 the sensitivity of TA was not statistically different from that of PTC&#46; Quantitative cultures of TA can be considered acceptable for the diagnosis of ventilator-associated pneumonia&#46;"
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Article information

ISSN: 15792129
Original language: English

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2024 July	70	34	104
2024 June	94	31	125
2024 May	79	38	117
2024 April	43	26	69
2024 March	71	31	102
2024 February	37	43	80
2023 March	20	6	26
2023 February	82	23	105
2023 January	84	45	129
2022 December	85	26	111
2022 November	121	21	142
2022 October	84	48	132
2022 September	73	27	100
2022 August	69	36	105
2022 July	62	60	122
2022 June	85	44	129
2022 May	111	66	177
2022 April	78	48	126
2022 March	100	64	164
2022 February	70	44	114
2022 January	94	47	141
2021 December	64	42	106
2021 November	84	62	146
2021 October	78	45	123
2021 September	76	62	138
2021 August	80	56	136
2021 July	83	63	146
2021 June	114	72	186
2021 May	92	53	145
2021 April	235	131	366
2021 March	131	44	175
2021 February	90	22	112
2021 January	86	36	122
2020 December	64	25	89
2020 November	74	24	98
2020 October	96	25	121
2020 September	76	25	101
2020 August	75	17	92
2020 July	75	25	100
2020 June	71	12	83
2020 May	107	31	138
2020 April	98	21	119
2020 March	87	18	105
2020 February	88	37	125
2020 January	60	20	80
2019 December	81	26	107
2019 November	80	22	102
2019 October	52	26	78
2019 September	48	16	64
2019 August	59	15	74
2019 July	53	25	78
2019 June	46	32	78
2019 May	70	18	88
2019 April	72	39	111
2019 March	94	36	130
2019 February	51	15	66
2019 January	68	16	84
2018 December	60	17	77
2018 November	66	20	86
2018 October	79	23	102
2018 September	70	13	83
2018 May	27	0	27
2018 April	47	5	52
2018 March	44	7	51
2018 February	43	8	51
2018 January	53	6	59
2017 December	54	4	58
2017 November	58	7	65
2017 October	33	10	43
2017 September	54	9	63
2017 August	70	7	77
2017 July	93	6	99
2017 June	84	13	97
2017 May	112	10	122
2017 April	71	12	83
2017 March	99	30	129
2017 February	99	3	102
2017 January	59	8	67
2016 December	74	10	84
2016 November	131	6	137
2016 October	169	27	196
2016 September	223	18	241
2016 August	178	12	190
2016 July	92	10	102
2016 March	3	0	3
2016 February	1	0	1
2015 December	2	0	2
2015 October	123	3	126
2015 September	132	19	151
2015 August	90	15	105
2015 July	123	8	131
2015 June	66	12	78
2015 May	94	30	124
2015 April	85	10	95
2015 March	83	12	95
2015 February	150	11	161
2015 January	92	5	97
2014 December	93	6	99
2014 November	118	5	123
2014 October	175	12	187
2014 September	143	12	155
2014 August	108	8	116
2014 July	124	6	130
2014 June	139	8	147
2014 May	121	14	135
2014 April	106	12	118
2014 March	98	10	108
2014 February	103	11	114
2014 January	75	10	85
2013 December	69	10	79
2013 November	47	8	55
2013 October	65	7	72
2013 September	64	9	73
2013 August	58	11	69
2013 July	72	13	85
2013 June	57	11	68
2013 May	48	10	58
2013 April	43	10	53
2013 March	7	3	10

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