title: The diagnosis of ventilator-associated pneumonia using non-bronchoscopic, non-directed lung lavages.
abstract: OBJECTIVE
  (1)To assess the diagnostic utility of quantitative cultures of non-bronchoscopic lung lavage (NBL) in ventilator-associated pneumonia and evaluate the role of the Bacterial Index; (2) To assess the predictive value of NBL surveillance quantitative cultures in ventilated patients; (3) To evaluate the Clinical Pulmonary Infection Score (CPIS) system in ventilated patients.
  
  
  METHODS
  A prospective comparison of NBL with bronchoscopic bronchoalveolar lavage and protected specimen brush.
  
  
  METHODS
  Three intensive care units in academic tertiary care centres.
  
  
  METHODS
  145 adults ventilated for 72 h, with and without clinical signs of pneumonia.
  
  
  METHODS
  Sampling of lower airway secretions by NBL, bronchoalveolar lavage and protected specimen brush.
  
  
  METHODS
  Diagnostic reliability of quantitative cultures, Bacterial Index and CPIS.
  
  
  RESULTS
  34 episodes of clinical ventilator-associated pneumonia were documented in 32 patients. 9 episodes were confirmed by concordant blood/pleural culture or post-mortem lung examination. Qualitative concordance of the predominant pathogen between sequential NBL: bronchoalveolar lavage and protected specimen brush was 83 %. Sensitivity and specificity of non-directed bronchial lavage at a threshold of 10(4) CFU/ml were 68 % and 70 % respectively (p = 0. 003) and were comparable with the bronchoscopic methods. However, the low positive predictive value of NBL indicates that quantitation in the absence of clinical signs is unlikely to be useful. Bacterial Index did not improve discriminatory power of quantitation compared with bacterial load of predominant organism. Mean CPIS for confirmed pneumonia cases was 8.4 +/- 1.01, significantly higher than for non-pneumonia observations (p = < 0.0001).
  
  
  CONCLUSIONS
  NBL is a simple, safe, cheap, readily-available method of diagnosing ventilator-associated pneumonia with comparable diagnostic accuracy to bronchoscopic techniques. Quantitation of respiratory tract cultures can exclude pneumonia in patients with equivocal clinical signs. The diagnostic threshold should vary depending on the length of ventilation, likelihood of pneumonia and antibiotic administration. The Bacterial Index is a flawed mathematical device that has no contributory role in pneumonia diagnosis. The CPIS has some diagnostic role in selected cohorts of ventilated patients.
authors.affiliation: Department of Medical Microbiology, University of Wales College of Medicine, Cardiff, Wales, CF4 4XN, UK. flanaganpg@cf.ac.uk
authors.forename: P G
authors.initials: PG
authors.lastname: Flanagan
authors.forename: G P
authors.initials: GP
authors.lastname: Findlay
authors.forename: J T
authors.initials: JT
authors.lastname: Magee
authors.forename: A
authors.initials: A
authors.lastname: Ionescu
authors.forename: R A
authors.initials: RA
authors.lastname: Barnes
authors.forename: M
authors.initials: M
authors.lastname: Smithies
mesh_terms: D018806:APACHE; D000328:Adult; D001419:Bacteria / Q000302:isolation & purification*; D001992:Bronchoalveolar Lavage Fluid; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000145:classification / Q000175:diagnosis* / Q000209:etiology* / Q000382:microbiology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000009:adverse effects*; D014852:Wales