title: The diagnosis of ventilator-associated pneumonia: a comparison of histologic, microbiologic, and clinical criteria.
abstract: OBJECTIVE
  To evaluate histologic, microbiological, and clinical criteria in the recognition of ventilator-associated pneumonia (VAP) in patients who died while mechanically ventilated.
  
  
  METHODS
  The study group consisted of 39 patients who died after a mean of 14 days of mechanical ventilation. Postmortem fiberoptic bronchoscopy (FOB) and open lung biopsy were performed with collection of specimens initiated <1 h after death. The microbiological specimens included suction catheter aspirate of tracheal secretions, FOB-guided protected specimen brush (PSB) of tracheal secretions, blindly placed PSB in a distal airway, FOB-guided PSB in a distal airway, and FOB-guided BAL fluid (BALF) in a distal airway. Qualitative bacteriologic study was performed on all specimens, and quantitative bacteriologic study was performed on all but the suction catheter aspirate of the trachea. A biopsy specimen of peripheral lung parenchyma from the same region sampled by FOB was sent for quantitative culture and histologic analysis. The BALF was analyzed for cell population and percent of neutrophils containing intracellular organisms. The clinical criteria selected for comparison with histologic and microbiological results included a temperature > or =38.5 degrees C during the 48 h prior to death, a WBC count > or =15,000/mm3 in the 48 h prior to death, presence of a bacterial or fungal pathogen on the last sputum culture, radiographic worsening in the week prior to death, and worsening gas exchange defined as a 15% decrease in the PaO2/fraction of inspired oxygen ratio in the 72 h prior to death.
  
  
  RESULTS
  None of the quantitative cultures had a reliable positive predictive value for histologic pneumonia. None of the five clinical criteria tested showed agreement with the presence or absence of histologic pneumonia. There was a significant correlation between qualitative and quantitative microbiological results from the distal airway/FOB-guided PSB, distal airway/BALF, and quantitative culture of the lung parenchyma. Also, suction catheter aspirate of the trachea had a sensitivity of 87% in recognizing the bacterial species simultaneously present in lung parenchyma. None of the patients with histologic pneumonia had <50% neutrophils in the BALF.
  
  
  CONCLUSIONS
  Neither the bacterial, density from the four airway quantitative cultures, nor the bacterial density from quantitative culture of lung parenchyma accurately separated the histologic pneumonia and nonpneumonia groups. No clinical criteria or combination of clinical criteria correlated with the presence or absence of histologic pneumonia. A BALF with <50% neutrophils had a 100% negative predictive value for histologic pneumonia. A BALF quantitative culture had a sensitivity of 63%, specificity of 96%, and positive predictive value of 91% in recognizing sterile lung parenchyma. Thus, BALF may have a role in excluding pneumonia/infection in the ventilated patient. Antibiotic choice for the empiric therapy of VAP can be accurately guided by the microbial population recognized through culture of a tracheal suction catheter aspirate.
authors.affiliation: Section of Pulmonary and Critical Care Medicine, Virginia Mason Medical Center, Seattle, WA 98111, USA.
authors.forename: S H
authors.initials: SH
authors.lastname: Kirtland
authors.forename: D E
authors.initials: DE
authors.lastname: Corley
authors.forename: R H
authors.initials: RH
authors.lastname: Winterbauer
authors.forename: S C
authors.initials: SC
authors.lastname: Springmeyer
authors.forename: K R
authors.initials: KR
authors.lastname: Casey
authors.forename: N B
authors.initials: NB
authors.lastname: Hampson
authors.forename: D F
authors.initials: DF
authors.lastname: Dreis
mesh_terms: D000368:Aged; D001992:Bronchoalveolar Lavage Fluid / Q000166:cytology / Q000382:microbiology; D001999:Bronchoscopy; D015169:Colony Count, Microbial; D003428:Cross Infection / Q000175:diagnosis* / Q000401:mortality; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008168:Lung / Q000382:microbiology / Q000473:pathology; D008297:Male; D009181:Mycoses / Q000175:diagnosis / Q000401:mortality; D011014:Pneumonia / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality; D018410:Pneumonia, Bacterial / Q000175:diagnosis* / Q000401:mortality; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000009:adverse effects*; D012680:Sensitivity and Specificity; D013048:Specimen Handling