Intensive Care Unit, Department of Anesthesiology and Critical Care B (DAR B), Centre Hospitalier Universitaire (CHU) Montpellier, INSERM ERI 25, Montpellier, France.
Intensive Care Med. 2010 May;36(5):790-8. doi: 10.1007/s00134-010-1833-5. Epub 2010 Mar 9.
Early and adequate treatment of ventilator-associated pneumonia (VAP) is mandatory to improve the outcome. The aim of this study was to evaluate, in medical ICU patients, the respective and combined impact of the Clinical Pulmonary Infection Score (CPIS), broncho-alveolar lavage (BAL) gram staining, endotracheal aspirate and a biomarker (procalcitonin) for the early diagnosis of VAP.
Prospective, observational study
A medical intensive care unit in a teaching hospital.
Over an 8-month period, we prospectively included 57 patients suspected of having 86 episodes of VAP.
The day of suspicion, a BAL as well as alveolar and serum procalcitonin determinations and evaluation of CPIS were performed.
Of 86 BAL performed, 48 were considered positive (cutoff of 10(4) cfu ml(-1)). We found no differences in alveolar or serum procalcitonin between VAP and non-VAP patients. Including procalcitonin in the CPIS score did not increase its accuracy (55%) for the diagnosis of VAP. The best tests to predict VAP were modified CPIS (threshold at 6) combined with microbiological data. Indeed, both routinely twice weekly performed endotracheal aspiration at a threshold of 10(5) cfu ml(-1) and BAL gram staining improved pre-test diagnostic accuracy of VAP (77 and 66%, respectively).
This study showed that alveolar procalcitonin performed by BAL does not help the clinician to identify VAP. It confirmed that serum procalcitonin is not an accurate marker of VAP. In contrast, microbiological resources available at the time of VAP suspicion (BAL gram staining, last available endotracheal aspirate) combined or not with CPIS are helpful in distinguishing VAP diagnosed by BAL from patients with a negative BAL.
早期和充分的呼吸机相关性肺炎（VAP）治疗对于改善预后至关重要。本研究旨在评估在重症监护病房（ICU）患者中，临床肺部感染评分（CPIS）、支气管肺泡灌洗（BAL）革兰染色、气管内抽吸物和生物标志物（降钙素原）在 VAP 早期诊断中的各自和联合作用。
前瞻性观察性研究
教学医院的重症监护病房。
在 8 个月的时间内，我们前瞻性地纳入了 57 例疑似患有 86 例 VAP 的患者。
在怀疑的当天，进行 BAL 以及肺泡和血清降钙素原测定，并评估 CPIS。
在 86 次 BAL 中，48 次被认为是阳性（临界值为 10⁴cfu/ml）。我们发现 VAP 和非 VAP 患者的肺泡或血清降钙素原之间没有差异。将降钙素原纳入 CPIS 评分并未提高其对 VAP 诊断的准确性（55%）。预测 VAP 的最佳检测方法是改良 CPIS（阈值为 6）与微生物学数据相结合。实际上，常规每周两次进行的气管内抽吸在 10⁵cfu/ml 的阈值和 BAL 革兰染色均提高了 VAP 的预测试诊断准确性（分别为 77%和 66%）。
本研究表明，BAL 检测的肺泡降钙素原无助于临床医生识别 VAP。它证实血清降钙素原不是 VAP 的准确标志物。相反，在怀疑 VAP 时可获得的微生物资源（BAL 革兰染色、最近的气管内抽吸物）与 CPIS 相结合或不结合有助于区分通过 BAL 诊断的 VAP 与 BAL 阴性的患者。
