title: Alternative diagnosis in the putative ventilator-associated pneumonia patient not meeting lavage-based diagnostic criteria.
abstract: BACKGROUND
  The clinical picture of ventilator-associated pneumonia (VAP) can be mimicked by other infectious and non-infectious diseases. The aim of this study was to determine the alternative diagnoses and to develop a diagnostic flow chart for patients suspected of having VAP not meeting the diagnostic broncho-alveolar lavage (BAL) criteria.
  
  
  METHODS
  Adult intensive care patients with a clinical suspicion of VAP and negative BAL results were included. The clinical suspicion of VAP was based on the combination of clinical, radiological, and microbiological criteria. BAL was considered positive if cell differentiation revealed ≥ 2% cells with intracellular organisms and/or quantitative culture results of ≥ 10(4) cfu/ml. The most likely alternative diagnosis of fever and pulmonary densities was retrospectively determined by two authors independently.
  
  
  RESULTS
  In all, 110 of 207 patients with suspected VAP did not meet the diagnostic BAL criteria and required further diagnostic evaluation. In 67 patients an alternative diagnosis for fever could be found. In 51 patients an alternative diagnosis of both fever and pulmonary densities could be established. In almost 40% of patients no alternative diagnosis could be provided. Non-bacterial pneumonia was diagnosed in 10 patients with Herpes simplex virus 1 (HSV-1) as the most common pathogen. In eight patients non-infectious pneumonitis was diagnosed.
  
  
  CONCLUSIONS
  Due to the wide range of alternative diagnoses and applied tests the diagnostic work-up proved to be necessarily individualized and guided by repeated clinical assessment. The most frequently found alternative diagnoses were viral pneumonia and non-infectious pneumonitis.
authors.affiliation: From the Department of Intensive Care, Maastricht University Medical Centre+ , Maastricht , The Netherlands.
authors.forename: Rik J
authors.initials: RJ
authors.lastname: Schoemakers
authors.forename: Ronny
authors.initials: R
authors.lastname: Schnabel
authors.forename: Guy J
authors.initials: GJ
authors.lastname: Oudhuis
authors.forename: Catharina F M
authors.initials: CF
authors.lastname: Linssen
authors.forename: Walther N K A
authors.initials: WN
authors.lastname: van Mook
authors.forename: Annelies
authors.initials: A
authors.lastname: Verbon
authors.forename: Dennis C J J
authors.initials: DC
authors.lastname: Bergmans
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology*; D003937:Diagnosis, Differential; D005260:Female; D005334:Fever; D018259:Herpesvirus 1, Human / Q000302:isolation & purification*; D006801:Humans; D007362:Intensive Care Units; D008168:Lung / Q000473:pathology; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000175:diagnosis* / Q000401:mortality; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis* / Q000382:microbiology / Q000401:mortality; D011024:Pneumonia, Viral / Q000175:diagnosis* / Q000401:mortality; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D062606:Tertiary Care Centers; D013997:Time Factors; D055815:Young Adult
keywords: Ventilator-associated pneumonia; broncho-alveolar lavage; critical care