Abstract
BackgroundDiagnosis of lower respiratory tract infections (LRTI) depends on the presence of clinical, radiological and microbiological findings. Endotracheal suction aspirate (ETSA) is the commonest respiratory sample sent for culture from intubated patients. Very few studies have compared quantitative and semi-quantitative processing of ETSA cultures for LRTI diagnosis. We determined the diagnostic accuracy of quantitative and semi-quantitative ETSA culture for LRTI diagnosis, agreement between the quantitative and semi quantitative culture techniques and the yield of respiratory pathogens with both methods.MethodsThis was a cross-sectional study conducted at the Aga Khan University clinical laboratory, Karachi, Pakistan. One hundred and seventy-eight ETSA samples sent for routine bacteriological cultures were processed quantitatively as part of regular specimen processing method and semi-quantitatively. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy was calculated for both methods using clinical diagnosis of pneumonia as reference standard. Agreement between the quantitative and semi quantitative methods was assessed via the kappa statistic test. Pathogen yield between the two methods was compared using Pearson’s chi-square test.ResultsThe quantitative and semi-quantitative methods yielded pathogens in 81 (45.5%) and 85 (47.8%) cases respectively. There was complete concordance of both techniques in 155 (87.1%) ETSA samples. No growth was observed in 45 (25.3%) ETSA specimens with quantitative culture and 37 (20.8%) cases by semi-quantitative culture. The diagnostic accuracy of both techniques were comparable; 64.6% for quantitative and 64.0% for semi-quantitative culture. The kappa agreement was found to be 0.84 (95% CI, 0.77–0.91) representing almost perfect agreement between the two methods. Although semi-quantitative cultures yielded more pathogens (47.8%) as compared to quantitative ETSA cultures (45.5%), the difference was only 2.3%. However, this difference achieved statistical (chi-square p-value < 0.001) favoring semi-quantitative culture methods over quantitative culture techniques for processing ETSA.ConclusionIn conclusion, there is a strong agreement between the performances of both methods of processing ETSA cultures in terms of accuracy of LRTI diagnosis. Semi-quantitative cultures of ETSA yielded more pathogens as compared to quantitative cultures. Although both techniques were comparable, we recommend processing of ETSA using semi-quantitative technique due to its ease and reduced processing time.
Highlights
Diagnosis of lower respiratory tract infections (LRTI) depends on the presence of clinical, radiological and microbiological findings
In conclusion, there is a strong agreement between the performances of both methods of processing Endotracheal suction aspirate (ETSA) cultures in terms of accuracy of LRTI diagnosis
ETSA were digested using an equal amount of sputasol and mixed on a vortex mixer (1:2 dilution). 100 μl (0.1 ml) of the digested specimen was diluted into 9.9 ml of Ringers' solution (1:200 of the original sample). 10 μl (0.01 ml) of the diluted sample was inoculated on Blood Colistin Nalidixic Acid Agar (BCNA), Chocolate Agar (CHOC) and MacConkey Agar (MAC) and streaked in quadrants
Summary
Diagnosis of lower respiratory tract infections (LRTI) depends on the presence of clinical, radiological and microbiological findings. The commonest respiratory sample from intubated patients with suspected pneumonia or lower respiratory tract infection (LRTI) sent for microbiological analysis is ETSA [3]. The international European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the Latin American Thoracic Association (ALAT) guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia recommend obtaining distal quantitative samples (prior to any antibiotic treatment) in order to reduce antibiotic exposure in stable patients with suspected ventilator associated pneumonia (VAP) and to improve the accuracy of the results; and a lower respiratory tract sample (distal quantitative including BAL and PSB or proximal quantitative or qualitative culture including ETSA) to focus and narrow the initial empiric antibiotic therapy [10]. We hypothesized that the performance of ETSA culture using quantitative or semi-quantitative technique for LRTI diagnosis is similar
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