title: Screening for Ventilator-Associated Pneumonia in the Surgical Intensive Care Unit: A Single-Institution Analysis of 1,013 Lower Respiratory Tract Cultures.
abstract: BACKGROUND
  Refinement of criteria for both screening and initiation of empiric therapy in ventilator-associated pneumonia (VAP) will minimize antibiotic overuse. We hypothesized that variables within the commonly used Clinical Pulmonary Infection Score (CPIS) have unfavorable test performance characteristics.
  
  
  METHODS
  Consecutive bronchoalveolar lavage (BAL) cultures obtained from surgical intensive care unit patients were abstracted (2009-2012). Ventilator-associated pneumonia was defined as ≥10(5) cfu/mL. The CPIS both without (CPISclinical) and with (CPISclinical+GS) the result of gram stain (GS) was calculated. Test performance characteristics for the sample, as well as several subgroups, were compared.
  
  
  RESULTS
  One thousand thirteen lower respiratory tract cultures from 492 patients were analyzed; 438 (43.2%) of cultures were classified as VAP, and 310 of 492 patients (62.4%) had ≥1 episode of VAP. Both CPISclinical and CPISclinical+GS had poor discrimination for VAP (Receiver-operating characteristic area under the curve=0.55 and 0.66, respectively). Sensitivity of CPISclinical using a threshold of >6 was 21%; the lowest threshold for CPISclinical for which the sensitivity was at least 85% was 3. The highest sensitivity among the individual CPIS components was new CXR infiltrate (91.1%). Among the subset of cultures sent during the early VAP window (days intubated 2-5), organisms on GS had a sensitivity of 93.3%. The CPISclinical, CPISclinical+GS, organisms, and neutrophils on GS parameters all became less accurate in both the late VAP window and when screening for recurrent VAP. Every case of VAP had at least one of the following: 1) fever; 2) new CXR infiltrate, or 3) organisms on GS.
  
  
  CONCLUSIONS
  In this series of BALs, traditional screening tools for VAP missed the majority of microbiological confirmed cases. Screening based on either new CXR infiltrate or fever yielded an acceptably high sensitivity. The only scenario identified in which empiric antibiotics could be withheld safely was the absence of organisms on GS in the early VAP window.
authors.affiliation: Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado.
authors.forename: Fredric M
authors.initials: FM
authors.lastname: Pieracci
authors.affiliation: Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado.
authors.forename: Maria
authors.initials: M
authors.lastname: Rodil
authors.affiliation: Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado.
authors.forename: James
authors.initials: J
authors.lastname: Haenel
authors.affiliation: Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado.
authors.forename: Robert T
authors.initials: RT
authors.lastname: Stovall
authors.affiliation: Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Johnson
authors.affiliation: Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado.
authors.forename: Clay C
authors.initials: CC
authors.lastname: Burlew
authors.affiliation: Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Jurkovich
authors.affiliation: Denver Health Medical Center/University of Colorado Health Sciences Center , Department of Surgery, Denver, Colorado.
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology; D011183:Postoperative Complications / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013183:Sputum / Q000382:microbiology; D014132:Trachea / Q000382:microbiology; D055815:Young Adult