title: Non-Ventilator ICU-Acquired Pneumonia After Cardiothoracic Surgery: Accuracy of Diagnostic Tools and Outcomes.
abstract: BACKGROUND
  Non-ventilator ICU-acquired pneumonia after cardiothoracic surgery is challenging to diagnose, and little is known about its impact on patient outcomes. Here, our primary objective was to compare the sensitivity and specificity of cultures of 2 types of fiberoptic bronchoscopy (FOB) specimens: endotracheal aspirates (FOB-EA) and bronchoalveolar lavage fluid (FOB-BAL). The secondary objectives were to evaluate the sensitivity and specificity of spontaneous sputum cultures and of the modified Clinical Pulmonary Infection Score (CPIS) and to describe patient outcomes.
  
  
  METHODS
  We conducted a prospective observational study of consecutive cardiothoracic surgery subjects with suspected non-ventilator ICU-acquired pneumonia. Using FOB-BAL cultures ≥10(4) cfu/mL as the reference standard, we evaluated the accuracy of FOB-EA ≥10(5) cfu/mL and spontaneous sputum ≥10(7) cfu/mL. On the day of FOB, we determined the modified CPIS. Mortality and antibiotic treatments were recorded.
  
  
  RESULTS
  Of 105 subjects, 57 (54.3%) received a diagnosis of non-ventilator ICU-acquired pneumonia. FOB-EA cultures had 82% (95% CI 69-91%) sensitivity and 100% (95% CI 89-100%) specificity and were significantly less sensitive than FOB-BAL cultures (P < .004). Spontaneous sputum was obtained from one-third of subjects. Spontaneous sputum cultures had 82% (95% CI 56-95%) sensitivity and 94% (95% CI 68-100%) specificity and were non-significantly less sensitive than FOB-BAL (P = .061). A modified CPIS >6 had 42% (95% CI 29-56%) sensitivity and 87% (95% CI 74-95%) specificity for non-ventilator ICU-acquired pneumonia. Antibiotic therapy was stopped in all subjects without non-ventilator ICU-acquired pneumonia, after 1.6 ± 1.2 d, without deleterious effects.
  
  
  CONCLUSIONS
  The modified CPIS has low diagnostic accuracy for non-ventilator ICU-acquired pneumonia. FOB-EA cultures perform less well than do FOB-BAL cultures for diagnosing non-ventilator ICU-acquired pneumonia. Spontaneous sputum is valuable when FOB cannot be performed but could be obtained in only a minority of subjects. When cultures are negative, antibiotic discontinuation is safe.
authors.affiliation: Cardiothoracic Intensive Care Unit f.stephan@ccml.fr.
authors.forename: François
authors.initials: F
authors.lastname: Stéphan
authors.affiliation: Cardiothoracic Intensive Care Unit.
authors.forename: Youssef
authors.initials: Y
authors.lastname: Zarrouki
authors.affiliation: Bacteriology Laboratory, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
authors.forename: Christine
authors.initials: C
authors.lastname: Mougeot
authors.affiliation: Cardiothoracic Intensive Care Unit.
authors.forename: Audrey
authors.initials: A
authors.lastname: Imbert
authors.affiliation: Cardiothoracic Intensive Care Unit.
authors.forename: Talna
authors.initials: T
authors.lastname: Kortchinsky
authors.affiliation: Cardiothoracic Intensive Care Unit.
authors.forename: Catherine
authors.initials: C
authors.lastname: Pilorge
authors.affiliation: Cardiothoracic Intensive Care Unit.
authors.forename: Saida
authors.initials: S
authors.lastname: Rézaiguia-Delclaux
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001992:Bronchoalveolar Lavage Fluid / Q000382:microbiology; D001999:Bronchoscopy / Q000379:methods; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D003428:Cross Infection / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D011183:Postoperative Complications / Q000382:microbiology*; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013183:Sputum / Q000382:microbiology; D014132:Trachea / Q000382:microbiology
chemical_list: D000900:Anti-Bacterial Agents
keywords: antibiotics; bronchoalveolar lavage; cardiothoracic surgery; endotracheal aspirates; fiberoptic bronchoscopy; mortality; postoperative pneumonia; sensitivity; specificity; spontaneous sputum