Aged; Bacteria/isolation & purification; Bronchi/microbiology; Bronchoalveolar Lavage Fluid/microbiology; Bronchoscopy; Colony Count, Microbial; Cross Infection/diagnosis; Evaluation Studies as Topic; Humans; Middle Aged; Pneumonia, Bacterial/diagnosis; Predictive Value of Tests; ROC Curve; Respiration, Artificial/adverse effects; Sensitivity and Specificity; Specimen Handling/methods; Intensive Care Units; bronchoalveolar lavage; diagnostic procedures; nosocomial pneumonia; plugged telescoping catheter; protected specimen brush; ROC curves; Pulmonary and Respiratory Medicine; Critical Care and Intensive Care Medicine; Cardiology and Cardiovascular Medicine
Abstract :
[en] BACKGROUND: The thresholds of the diagnostic procedures performed to diagnose ICU-acquired pneumonia (IAP) are either speculated or incompletely tested.
PURPOSE: To evaluate the best threshold of protected specimen brush (PSB), plugged telescoping catheter (PTC), BAL culture (BAL C), and direct examination of cytocentrifugated lavage fluid (BAL D) to diagnose IAP. Each mechanically ventilated patient with suspected IAP underwent bronchoscopy successively with PSB, PTC, and BAL in the lung segment identified radiographically.
POPULATION: One hundred twenty-two episodes of suspected IAP (occurring in 26% of all mechanically ventilated patients) were studied. Forty-five patients had definite IAP, and 58 had no IAP. Diagnosis was uncertain in 19 cases.
RESULTS: Using the classic thresholds, sensitivity was 67% for PSB, 54% for PTC, 59% for BAL D, and 77% for BAL C. Specificity was 88% for PSB, 77% for PTC, 98% for BAL D, and 77% for BAL C. We used receiver operating characteristics methods to reappraise thresholds. Decreasing the thresholds to 500 cfu/mL for PSB, 10(2) cfu/mL for PTC, 2% cells containing bacteria for BAL D, 4 x 10(3) cfu/mL for BAL C increased the sensitivities (plus 14%, 23%, 25%, 10%, respectively) and moderately decreased the specificities (minus 4%, 9%, 2%, 4%, respectively) of the four examinations. The association of PSB with a 500 cfu/mL threshold and BAL D with a 2% threshold recovered all but one episode of pneumonia (SE 96 +/- 4%) with a 84 +/- 10% specificity. For a similar ICU population, these "best" thresholds increased negative predictive value with a minimal decrease of positive predictive value. They need to be confirmed in multiple ICU settings in prospective fashion.
Disciplines :
Anesthesia & intensive care
Author, co-author :
Timsit, Jean-François; Intensive Care Unit, Hôpital Saint Joseph, Paris, France
Misset, Benoît ; Centre Hospitalier Universitaire de Liège - CHU > > Service des soins intensifs ; Intensive Care Unit, Department of Microbiology, Hopital Saint Joseph, Paris, France
Goldstein, Fred W.; Intensive Care Unit, Department of Microbiology, Hopital Saint Joseph, Paris, France
Vaury, Philippe; Intensive Care Unit, Department of Microbiology, Hopital Saint Joseph, Paris, France
Carlet, Jean; Intensive Care Unit, Department of Microbiology, Hopital Saint Joseph, Paris, France
Language :
English
Title :
Reappraisal of distal diagnostic testing in the diagnosis of ICU-acquired pneumonia.
Publication date :
December 1995
Journal title :
CHEST
ISSN :
0012-3692
eISSN :
1931-3543
Publisher :
American College of Chest Physicians, United States
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