Introduction
Materials and methods
Results
Accuracy of the clinical diagnosis of VAP
Johanson criteria | • Presence of a new or progressive radiographic infiltrate | ||
• Plus at least two of three clinical features: | |||
- fever > 38°C | |||
- leukocyto sis or leukopeni | |||
- purulent secretions | |||
• Temperature | • Oxygenation (PaO2/FiO2) | • Tracheal secretions (score) | |
- 0 point: 36.5–38.4 C | - 0 point: PaO2/FiO2 > 240 or ARDS | -0 point: < 14 | |
- 1 point: 38.5–38.9 | - 2 points: PaO2/FiO2 < 240 and no evidence of ARDS | -1 point: > 14 | |
- 2 points: < 36 or > 39 | -2 points: purulent sputum | ||
Clinical Pulmonary Infection Score (CPIS) | • Blood leukocytes (cells/μL) | • Culture of tracheal aspirate | |
- 0 point: 4000–11000 | -0 point: minimal or no growth | ||
- 1 point: < 4000 or > 11000 | -1 point: moderate or more growth | ||
- 2 points: > 500 band forms | -2 points: moderate or greater growth | ||
• Pulmonary radiography | |||
-0 point: no infiltrate | |||
- 1 point: diffuse or patchy infiltrates | |||
- 2 points: localized infiltrate | |||
Total score of > 6 points suggests ventilator-associated pneumonia | |||
ARDS = acute respiratory distress syndrome | |||
Centers for Disease Control and Prevention (CDC) | • Radiology signs | • Clinical signs | |
Two or more serial chest radiographs with at least 1 of the following: | At least 1 of the following: | ||
- new or progressi ve and persistent infiltrate | - fever (temperat ure > 38 C) | ||
- consolidation | - leukopeni a (< 4000 WBC) or leukocyto sis (> 12000 WBC) | ||
- cavitation | - altered mental status, for adults 70 years or older, with no other recognized cause | ||
• Microbiological criteria | |||
At least one of the following: | Plus at least 2 of the following:- | ||
- positive growth in blood culture not related to another source of infection | - new onset of purulent sputum, or change in character of sputum | ||
- positive growth in culture or pleural field | - increased respiratory secretions, or increased suctioning requirements | ||
- positive quantitati ve culture from bronchoal veolar lavage (> 104) or protected specimen brushing (> 103) | - new-onset or worsening cough, or dyspnea, or tachypnea | ||
- five percent or more of cells with intracellul ar bacteria on direct microsco pic examinati on of Gram-stained bronchoal veolar lavage fluid | - rales or bronchial sounds | ||
- histopathological evidence of pneumonia | - worsening gas exchange | ||
- increased oxygen requirements |
First author | Sample | Dx Tests | Gold standard | Results |
---|---|---|---|---|
Fabregas, 1999, ** [11] | Medical ICU, 25 pts | Johanson criteria, CPIS, TBA(105), PSB (103), pBAL(104), BAL(104) | Pathology + Culture | • Johanson criteria (2 items): sens = 69%, spec = 75%. • Any Johanson criteria: Chest Rx: sens = 92%, spec = 33%; leukocytosis: sens = 77%, spec = 58%; fever: sens = 46%, spec = 42%; purulent secretions: sens = 69%, spec = 42% • CPIS: sens = 77%, spec = 42%. • TBA sens = 69%, spec = 92%. • pBAL sens = 39%, spec = 100%. • BAL sens = 77%, spec = 58%. • PSB sens = 62%, spec = 75%. • QtC added little to clinical diagnostic accuracy |
Papazian, 1995, ** [17] | Mixed ICU, 38 pts, consecutive | BBS (104) & mini-BAL (103) & PSB (103) & BAL (104) & CPIS | Pathology + Culture | • CPIS: sens = 72%; spec = 85% • BBS (104): sens = 83%, spec = 80% • mini-BAL (103): sens = 67%, spec = 80% • BAL: sens (104) = 58%, spec = 95% • PSB: sens (103) = 42%, spec = 95% • BBS was more accurate than PSB |
Croce, 2006 *, # [18] | Trauma ICU, 158 pts | CPIS (>6) | BAL (105) | • Frequency of VAP: BAL ≥ 105 = 42%, SIRS = 58% • Average CPIS: VAP = 6.9, SIRS = 6.8 • CPIS > 6: sens = 61%, spec = 43% |
Luyt, 2004 *, ** [19] | Mixed ICU, 201 pts | CPIS (>6) | PSB (103) BAL (104) | • CPIS: sens = 89%, spec = 44%, k = 0.33, PPV = 57%, NPV = 84% |
Schurink, 2004, ** [20] | Mixed ICU, 99 pts | CPIS | BAL (104) | • Frequency of VAP = 69% • ROC curve for CIPS > 6, 7 and 8 = 0.54, 0.64, 0.64; r = 0.115 • CPIS > 5: sens = 83%, spec = 17% • CIPS >6 or ≤ 6: k 0.16 |
Fartoukh, 2003, ** [21] | Mixed ICU, 68 pts | CE & PIS (>6) | BAL (104) or PTC (103) | • CE: sens = 50%, spec = 59% • CPIS > 6: sens = 60%, spec = 59% • Adding positive Gram stain to CIPS improves diagnostic accuracy |
Miller, 2006, ** [15] | Trauma ICU, 292 pts | NNIS | BAL (105) | • k = 0.73. • Sens = 84%, spec = 69%, PPV = 83%, NPV = 70% |
Pham, 2007*, ** [23] | Mixed ICU, 28 burn pts | CPIS | BAL | • CPIS: sens = 30%, spec = 80%, PPV = 70%, NPV = 50% |
Pugin, 1991, **, [16] | Surgical ICU, 28 pts, | CPIS & mini-BAL (BI ≥ 5) | BAL (BI ≥ 5) | • CPIS: sens = 93%, spec = 100%, r = 84% (CIPS and mini-BAL), r = 76% (CPIS and BAL) • Mini-BAL: sens = 73%, spec = 96% |
The role of bacteriological data in improving the accuracy of a clinical diagnosis of VAP
First author | Sample | Dx Tests | Gold standard | Results |
---|---|---|---|---|
Balthazar, 2001, ** [13] | Mixed ICU, 37 pts | BAL (104) & Gram & cells from BAL | Pathology + Culture | • BAL: sens = 19%, spec = 94%; fever: sens = 50%, spec = 76%; leucocytosis (>10000): sens = 60%, spec = 76%; Gram stain: sens = 85%, spec = 94%; total cell (>400000): sens = 90%, spec = 94%. |
Torres, 2000, ** [26] | Medical ICU, 25 pts | TBA (105) & PSB (103) & BAL (104) & pBAL (104) | Pathology + Culture | • TBA: sens = 50%, spec = 67%. • PSB: sens = 67%, spec = 75%. • pBAL: sens = 63%, spec = 83%. • BAL: sens = 83%, spec = 68%. |
Fabregas, 1999, ** [11] | MIxed ICU, 25 pts | Johanson & CPIS & TBA (105), PSB (103), pBAL (104) and BAL (104) | Pathology + Culture | • Johanson criteria (2): sens = 69%, spec = 75%. • Any Johanson criteria: Chest Rx: sens = 92%, spec = 33%; leukocytosis: sens = 77%, spec = 58%; fever: sens = 46%, spec = 42%; purulent secretions: sens = 69%, spec = 42%. • CPIS: sens = 77%, spec = 42%. • TBA: sens = 69%, spec = 92%. • pBAL: sens = 39%, spec = 100%. • BAL: sens = 77%, spec = 58%. • PSB: sens = 62%, spec = 75%. • QtC increased little to clinical diagnosis accuracy. |
Papazian, 1997, # [29] | Mixed ICU, 28 pts | Gram & ICO | Pathology + Culture | • BBS Gram stain: sens = 56%, spec = 73%. • mini-BAL Gram Stain: sens = 44%, spec = 87%. • BAL Gram stain: sens = 56%, spec = 100%. • BBS ICO (>10%): sens = 56%, spec = 40%. • Mini-BAL ICO (>5%): sens = 67%, spec = 53%. • BAL ICO (>4%): sens = 56%, spec = 40%. |
Kirtland, 1997, ** [27] | Mixed ICU, 39 pts | TA &PSB & pPSB & BAL & BAL cells | Pathology + Culture | • TA: sens = 87%, spec = 31%. • pPSB: sens = 30%, spec = 81%. • PSB: sens = 44%, spec = 81%. • BAL: sens = 65%, spec = 63%. • >50% neutrophils in BAL: sens = 100%. |
Marquette, 1995, ** [28] | Mixed ICU, 28 pts | TA (105 & 106) & PSB (103) & BAL (104) | Pathology | • TA (105): sens = 63%, spec = 75%. • TA (106): sens = 50%, spec = 85%. • PSB (103): sens = 57%, spec = 88%. • BAL (104): sens = 47%, spec = 100%. • ICO (any%): sens = 36%, spec = 100%. |
Torres, 1996 *, ** [25] | Mixed ICU, 25 pts | ICO (≥ 5%), mini-BAL (104) & BAL (104) | Pathology | • ICO (≥ 5%) compared to mini-BAL: PPV = 75%, NPV = 83%. • ICO (≥ 5%) compared to BAL: PPV = 57%, NPV = 8 3%. • Mini-BAL: sens = 22%, spec = 100%. • BAL: sens = 45%, spec = 55%. |
Papazian, 1995, ** [17] | MIxed ICU, 38 pts | BBS (104) & mini-BAL (103) & PSB (103) & BAL (104) & CPIS | Pathology + Culture | • CPIS: sens = 72%, spec = 85%. • BBS (104): sens = 83%, spec = 80%. • mini-BAL (103): sens = 67%, spec = 80%. • BAL (104): sens = 58%, spec = 95%. • PSB (103): sens = 42%, spec = 95%. |
Torres, 1994, ** [24] | Mixed ICU, 30 pts | TBA (105) & PSB (103) & BAL (104) & Clinical data | Pathology | • Clinical data: fever: sens = 55%, spec = 58%; purulent secretions: sens = 83%, spec = 33%; Rx infiltrate: sens = 78%, spec = 42%. • Pulmonary biopsy culture (≥103): sens = 40%, spec = 45%. • Quantitative cultures: TBA: sens = 44%, spec = 48%; PSB: sens = 36%, spec = 50%; BAL: sens = 50%, spec = 45%. |
Rouby, 1989, ** [30] | Surgical ICU, 59 pts | pBAL | Pathology + culture | • pBAL: sens = 80%, spec = 66% to identify VAP; sens = 73% to identify the microorganism. |
Chastre, 1984, ** [10] | Mixed ICU, 26 pts | PSB (103) | Lung culture | • PSB correlated well to lung cultures, especially in the subgroup of patients who received no antibiotics during the week preceding their death. |
First author | Sample | Dx tests | Gold standard | Results |
---|---|---|---|---|
Mondi, 2005, # [31] | Trauma ICU, 39 pts | TA (104) & (105) | BAL (105) | • TA (104): sens = 95%, spec = 58%, k = 0.5339 (p < 0.0001). • TA (105): sens = 90%, spec = 68%, k = 0.6384 (p < 0.0001). |
Brun-Buisson, 2005, ** [32] | Mixed ICU, 68 pts | TA (score ≥4+) & bPTC (103) & PTC (103) | BAL (104 or ICO > 2%) | • TA: sens = 77%, spec = 81%. • bPTC: sens = 77%, spec = 97%. • PTC: sens = 77%, spec = 94%. |
Davis, 2005, # [42] | Trauma ICU, 155 pts | Gram (BAL) | CDC + BAL (105) | • Gram (BAL): sens = 88% (any organism). • Gram (BAL): sens = 73%, spec = 49%; PPV = 78%, NPV = 42%, accuracy = 65% (Gram-negative). • Gram (BAL): sens = 87%, spec = 59%; PPV = 68%, NPV = 83%, accuracy = 74% (Gram-positive). |
Croce, 2004, ** [43] | Trauma ICU, 526 pts | BAL (104 & 105) | BAL (105) and ClEvol | • BAL (105): sens = 95%, spec = 10%. • BAL (104): sens = 99%, spec = 70%. |
Miller, 2003, ** [44] | Trauma ICU, 168 pts | BAL (102 to 104) | BAL (105) | • BAL (104 and 103): increased sensitivity = 14%. • BAL (102): increased sensitivity = 16%. |
Sirvent, 2003, ** [45] | Mixed ICU, 82 pts | ICO | Mini-BAL (103) | • ICO ≥ 2%: sens = 80%, spec = 82%. • ICO ≥ 2% better than 1, 5, 7 and 10%. |
Wu, 2002, ** [35] | Medical ICU, 48 pts | TA (105) | PSB (103) or BAL (104) | • TA and PSB: sens = 91%, spec = 72%; PPV = 75%, NPV = 90%. • TA and BAL: sens = 91%, spec = 75%; PPV = 78%, NPV = 90%. |
Duflo, 2001, ** [46] | Mixed ICU, 104 pts | Gram stain (mini-BAL) | Mini-BAL (103) | • Gram stain: sens = 76%, spec = 100%, k = 0.73, concordance = 86%. |
Prekates, 1998,*, ** [47] | BAL | • Gram stain: sens = 77%, spec = 87%, PPV = 71%, NPV = 90%. | ||
Bello, 1996, *, ** [48] | ICU, 74 pts, consecutive | Mini-PSB | PSB and BAL | • BAL and PSB: concordance = 92%. • mini-PSB and BAL: concordance = 84%. • mini-PSB and PSB: concordance = 85%. |
Pugin, 1991, ** [16] | Surgical ICU, 28 pts, | CPIS & mini-BAL (BI ≥ 5) | BAL (BI ≥ 5) | • CPIS: sens = 93%, spec = 100%, r = 84% (CIPS and mini-BAL), r = 76% (CPIS and BAL). • Mini-BAL: sens = 73%, spec = 96%. |
Jourdain, 1995, ** [36] | Mixed ICU, 39 pts | TA (103 to 107) | PSB (103) and ICO (≥ 5%) | • TA (103): sens = 90%, spec = 26%, accuracy = 47%. • TA (104): sens = 84%, spec = 40, accuracy = 54%. • TA (105): sens = 79%, spec = 66%, accuracy = 70%. • TA (106): sens = 68%, spec = 84%, accuracy = 79%, correlation = 40% (TA and PSB). • TA (107): sens = 21%, spec = 92%, accuracy = 68%. |
Marik, 1995, ** [37] | Medical ICU, 53 pts | Mini-PSB (103) | PSB (103) | • Mini-PSB and PSB: quantitative agreement = 85%. |
Kollef, 1995, # [38] | Medical ICU, 42 pts | Mini-BAL (103) & PSB (103) | Johanson (ATS) | • Mini-BAL: sens = 100%, spec = 95%. • PSB: sens = 71%, spec = 100%. Good agreement between mini-BAL and PSB cultures: k = 0,63, concordance = 83%. |
Rumbak, 1994, # [39] | Mixed ICU, 38 pts | TA | PSB (103) | • TA: sens = 97%, spec = 50%, PPV = 91%, NPV = 80%. |
Valles, 1994, ** [49] | Mixed ICU, 42 pts | ICO & BAL | Clinical criteria + PSB (103) | • BAL (103): sens = 89%, spec = 79%, PPV = 76%, NPV = 90%. • BAL (104): sens = 89%, spec = 100%, PPV = 100%, NPV = 92%. • ICO (≥ 2%): = 78%, spec = 88%, PPV = 82%, NPV = 84%. • ICO (≥ 5%): = 67%, spec = 96%, PPV = 92%, NPV = 79%. • ICO (≥ 7%): = 67%, spec = 100%, PPV = 100, NPV = 80%. • ICO for Pseudomonas: lower sens. • Previous antibiotic treatment decreased sens. |
El-Ebiary, 1993, ** [40] | Medical ICU, 102 pts | TA, PSB and BAL | Clinical ad hoc | • TA (105): sens = 70%, spec = 72%, accuracy = 71%. • PSB (103): sens = 60%, spec = 93, accuracy = 64%. • BAL (104): sens = 57%, spec = 87%, accuracy = 67%. |
Elatrous, 2004, ** [33] | Medical ICU, 100 pts, | TA (102 to 106) | PTC (106) | • TA (102): sens = 96%, spec = 66%. • TA (103): sens = 94%, spec = 66%. • TA (104): sens = 92%, spec = 85%, k = 0,78. • TA (105): sens = 84%, spec = 90%. • TA (106): sens = 44%, spec = 94%. |
Mimoz, 2000, ** [50] | Mixed ICU, 134 pts, | Gram stain (10 and 50 fields) | PSB (103) or bPTC (103) | • Gram (10 fields) vs PSB: sens = 74%, spec = 94%. • Gram (10 fields) vs PTC: sens = 81%, spec = 100%. • PSB: correlation between morphology and culture: sens = 54%, spec = 86%. • bPTC: correlation between morphology and culture: sens = 69% and spec = 89%. |
Flanagan, 2000, ** [22] | Mixed ICU, 145 pts, | Mini-BAL (104) & BAL (104) & PSB (103) & CPIS & BI (≥5) | Clinical (modified CDC) | • Mini-BAL: sens = 74%, spec = 70%, PPV = 17%, NPV = 96%. • BAL: sens = 76%, spec = 71%, PPV = 35%, NPV = 93%. • PSB: sens = 68%, spec = 86%, PPV = 54%, NPV = 95%. • CPIS > 7: sens = 85%, spec = 91%, PPV = 61%, NPV = 96%. • BI: sens = 62%, spec = 53%. |
Allaouchiche, 1999, ** [51] | Mixed ICU, 118 pts, | ICO (≥ 2%) & Gram stain (BAL) | PSB (103) | • ICO: sens = 86%, spec = 78%, PPV = 68%, NPV = 91%, k = 0.616, concordance = 81.5%. • Gram stain: sens = 90%, spec = 73%, PPV = 64%, NPV = 91%, k = 0.58, concordance = 79.4%. • Correlation between morphology and culture: complete = 51%, partial = 39.2%, no correlation = 9.8%. |
Casetta, 1999, ** [53] | Mixed ICU (Cancer), 42 pts | PTC (103) | PSB (103) | • PTC: sens = 67%, spec = 93%; PPV = 71%, NPV = 91%, agreement = 87%. |
Souweine, 1998, ** [54] | Mixed ICU, 52 pts | Antibiotic use & ICO (≥ 5%), PSB (103) & BAL (105) | Clin ad hoc | • ICO: sens = 71% (no antibiotics), 50% (current antibiotics), 67% (recent antibiotics). • PSB: sens = 88% (no antibiotics), 77% (current antibiotics), 40% (recent antibiotics). • BAL: sens = 71% (no antibiotics), 83% (current antibiotics), 38% (recent antibiotics). |
Allaouchiche, 1996, ** [52] | Mixed ICU, 132 pts | ICO | PSB (103) + clinical evolution | • ICO (≥ 2%): sens = 84%, spec = 80%, PPV = 69%, NPV = 90%, ROC = 0.888. |
Barreiro, 1996, ** [55] | Mixed ICU, 93 pts | pBAL (104) & Gram stain & ICO (≥ 2%) | PSB (103) + Follow-up | • pBAL: sens = 87%, spec = 91%, PPV = 87%, NPV = 91%. • ICO: sens = 75%, spec = 98%, PPV = 96%, NPV = 86%. |
Torres, 1989, ** [41] | Mixed ICU, 34 pts | BAL & BI | PTC & BI | • BAL: spec = 71%, r = 0,72 (between BAL and BI) • PTC: spec = 86%, r = 0.78 (between PTC and BI) |
Timsit, 1993, ** [56] | Mixed ICU, 26 pts | PSB 1 | PSB 2 (2 minutes interval) | • PSB 1: sens = 67%, spec = 94%. • PSB 2: sens = 54%, spec = 94%. |
Gerbeaux, 1998, ** [57] | Mixed ICU, 44 pts | BAL 1 | BAL 2 (30 minutes interval) | • BAL 1-BAL2 repeatability = 75% with no bias, agreement = 47%. |
Butler, 2004, ** [58] | Surgical ICU, 34 pts | Blind PSB | Directed PSB | • Blind PSB and Directed PSB: concordance = 53%. |
Wood, 2003, ** [34] | Trauma ICU, 90 pts | TA & BDPB & BPB & BAL | BDPB & BAL | • TA & BAL: k = 0.535. • BPB & BDPB: k = 0.467. • BPB & BAL: k = 0.547. |
First author | Sample | Dx tests | Gold standard | Results |
---|---|---|---|---|
Camargo, 2004, ** [59] | Mixed ICU, 106 pts | TA (105 and 106) & TA (qualit) | Clinical (ad hoc) | • TA (106): sens = 26%, spec = 78%, PPV = 20%, NPV = 83% • TA (105): sens = 65%, spec = 48%, PPV = 21%, NPV = 87% • TA (qualit): sens = 81%, spec = 23%, PPV = 18%, NPV = 86% |
Mentec, 2004, ** [60] | Mixed ICU, 63 pts | TA (105), bPTC (103), PTC (103), BAL (104) | Clinical + Rx (ad hoc) | • For quantitative cultures: TA: sens = 82%, spec = 67%, ROC = 0,78; bPTC: sens = 62%, spec = 94%, ROC = 0,83; PTC: sens = 71%, spec = 94%, ROC = 0,85; BAL: sens = 94%, spec = 100%, ROC = 0.98 • For Gram stain: TA: sens = 94%, spec = 50%; bPTC: sens = 56%, spec = 94%; PTC sens = 65%, spec = 83%; BAL sens = 100%, spec = 94% |
Woske, 2001, ** [61] | Surgical ICU, 103 pts, consecutive | BAL (104) & PSB (103) & TA (105 and 106) | CPIS ≥6 | • BAL: sens = 90%. • PSB: sens = 83%. • TA (105): sens = 90%. • TA (106): sens = 50%. |
Meduri, 1992, ** [84] | Mixed ICU, 25 pts | pBAL (104) & PSB | Clinical | • pBAL: Spec = 100%, NPV = 100% |
Salata, 1987, ** [85] | Mixed ICU, 51 pts | TA | Clinical | • TA: higher Gram stain grading for neutrophils: p < 0.05 • TA: higher bacterial colony count: p < 0.05 |
Castro, 1991, ** [86] | Mixed ICU, 103 pts | PSB (103) | Clinical | • PSB: sens = 84%, spec = 67% |
First author | Sample | Dx tests | Gold standard | Results |
---|---|---|---|---|
Davis, 2005, # [42] | Trauma ICU, 155 pts | Gram (BAL) | CDC + BAL (105) | • Gram (BAL): sens = 88% (any organism). • Gram (BAL): sens = 73%, spec = 49%, PPV = 78%, NPV = 42%, accuracy = 65% (Gram-negative). • Gram (BAL): sens = 87%, spec = 59%, PPV = 68%, NPV = 83%, accuracy = 74% (Gram-positive). |
Sirvent, 2003, ** [45] | Mixed ICU, 82 pts | ICO | Mini-BAL (103) | • ICO ≥ 2%: sens = 80%, spec = 82%. • ICO ≥ 2% better than 1, 5, 7 and 10%. |
Duflo, 2001, ** [46] | Mixed ICU, 104 pts | Gram stain (mini-BAL) | Mini-BAL (103) | • Gram stain: sens = 76%, spec = 100%, k = 0.73, concordance = 86%. |
Mimoz, 2000, ** [50] | Mixed ICU, 134 pts | Gram stain (10 and 50 fields) | PSB (103) or bPTC (103) | • Gram stain (10 fields) vs PSB: sens = 74%, spec = 94%. • Gram stain (10 fields) vs PTC: sens = 81%, spec = 100%. • Gram (50 fields): slight increase in spec, decrease in sens • Morphology and PSB culture: sens = 54%, spec = 86%. • Morpholgy and bPTC culture: sens = 69%, spec = 89%. |
Allaouchiche, 1999, ** [51] | Mixed ICU, 118 pts | ICO (≥ 2%) & Gram stain (BAL) | PSB (103) | • ICO: sens = 86%, spec = 78%, PPV = 68%, NPV = 91%, k = 0.616, concordance 81.5%. • Gram stain: sens = 90%, spec = 73%, PPV = 64%, NPV = 91%; k = 0.58, concordance 79.4%. • Correlation between morphology and culture: complete: 51%, partial: 39.%, no correlation: 9.8%. |
Allaouchiche, 1996, ** [52] | Mixed ICU, 132 pts | ICO | PSB (103) + clinical evolution | • ICO (≥ 2%): sens = 84%, spec = 80%, PPV = 69%, NPV = 90%, ROC = 0.888. |
Torres, 1996, *, ** [25] | Mixed ICU, 25 pts | ICO (≥ 5%), mini-BAL (104) & BAL (104) | Pathology | • ICO (≥ 5%) compared to mini-BAL: PPV = 75%, NPV = 83%. • ICO (≥ 5%) compared to BAL: PPV = 57%, NPV = 83%. • Mini-BAL: sens = 22%, spec = 100%. • BAL: sens = 45%, spec = 55%. |
Sole-Violan, 1994, ** [68] | Mixed ICU, 33 pts | ICO (BAL) & BAL (104) & PSB (103) | Clinical ad hoc | • BAL: sens = 87%, spec = 100%. • PSB: sens = 75%, spec = 100%. • ICO (>4%): sens = 62%, spec = 100%. |
Brasel, 2003, ** [66] | Surgical ICU, 35 pts | ICO 5% & ICO 7% | TA (104) & TA (105) | • ICO 5% and TA (104): sens = 61%, spec = 89%, PPV = 90%, NPV = 59%, ROC = 0.84. • ICO 5% and TA (105): sens = 85%, spec = 82%, PPV = 70%, NPV = 91%, ROC = 0.89. • ICO 7% and TA (104): sens = 39%, spec = 97%, PPV = 96%, NPV = 50%, ROC = 0.86. • ICO 7% and TA (105): sens = 61%, spec = 91%, PPV = 77%, NPV = 82%, ROC = 0.84. |
Timsit, 2001, ** [65] | Mixed ICU, 110 pts | BAL-D (1% of infected cells) | BAL (104) & PSB (103) | • BAL-D: sens = 93%, spec = 91%, AUC = 0.953, PPV = 90%, NPV = 98%. |
Prekates, 1998, ** [47] | Surgical and Trauma ICU, 75 pts, | Gram stain (BAL) | BAL | • Gram stain: sens = 77%, spec = 87%, PPV = 71%, NPV = 90%. |
Biomarkers and VAP diagnosis
First author | Sample | Dx Tests | Gold standard | Results |
---|---|---|---|---|
Povoa, 2005, # [73] | Mixed ICU, 112 pts | CRP | Johanson | CRP (>9.6 mg/dl): sens = 87%, spec = 88%, AUC = 0.92. |
Gibot, 2004, ** [75] | Mixed ICU, 148 pts | sTREM-1 in mini-BAL | Mini-BAL (103) Clinical (ad hoc) | Sens = 98%, spec = 90%. |
Duflo, 2002, ** [71] | Mixed ICU, 96 pts | PCT serum & alveolar | Mini-BAL (103) | Serum PCT (≥3.9 ng/ml): sens = 41%, spec = 100%, AUC = 0787. Alveolar PCT: not useful. |
Oppert, 2002, ** [72] | Mixed ICU, 28 pts | PCT and PCR | Clinical (ad hoc) | Serum PCT (>1 ng/ml): sens = 100%, spec = 75%. |
El-Ebiary, 1995, *, ** [69] | Mixed ICU, 78 pts | Elastin fibre | Clinical (ad hoc) | EF: sens = 32%, spec = 72%. |
Determann, 2005, ** [76] | Mixed ICU, 28 pts | sTREM-1 | Clinical & NBLF | Sens = 75%, spec = 84%. |
Pugin, 1992, ** [78] | Trauma ICU, 40 pts | BAL Endotoxin | Clinical & BAL | BAL endotoxin > 6 EU/ml suggests pneumonia due to Gram-negative bacteria. |
Flanagan, 2001, ** [77] | Mixed ICU, 64 pts | BAL Endotoxin | Clinical & BAL | Sens = 81%, spec = 87%, PPV = 67%, NPV = 95%. |
Discussion
Conclusion
Key messages
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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.
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Bacteriologic data do not increase the accuracy of diagnosis as compared to clinical diagnosis. Quantitative cultures obtained by different methods, including BAL, pBAL, PSB or TBA seem to be rather equivalent in diagnosing VAP.
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The rapid availability of cytological data, including inflammatory cells and Gram stains, may be useful in initial therapeutic decisions in patients with suspected VAP.
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CRP, PCT, and sTREM are promising biomarkers in diagnosing VAP.
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An 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.