Deep Tracheal Aspirate Research Articles

Risk Factors and Clinical Follow-Up Features of Meconium Aspiration Syndrome

Abstract Aim: Meconium aspiration syndrome is usually seen in full-term and post-term infants and may cause complications including respiratory failure, pulmonary air leaks, and persistent pulmonary hypertension. The aim of this study was to determine risk factors of meconium aspiration syndrome and assess the clinical course of the disease. Material and Methods: Fourteen of 508 infants diagnosed with meconium aspiration syndrome between January 2013 and April 2014 were retrospectively analyzed. The risk factors including the first and fifth minute Apgar scores, the mode of delivery, need for advanced intervention and deep tracheal aspiration in the delivery room, and the presence of perinatal asphyxia were recorded and patients were classified according to the severity of disease. The clinical features and complications of the disease were also recorded. Results: Fourteen infants with a mean gestational age of 38.7±2.1 weeks and mean birth weight of 2828±810 grams enrolled in the study. Two patients had perinatal asphyxia, three pulmonary hypertension, and one of our patients developed pneumothorax. During the follow-up, nine patients needed mechanical ventilation support while five patients received surfactant therapy. In our study, one infant had mild, ten infants had moderate, and three infants had severe meconium aspiration syndrome. All patients responded well to the treatment. Conclusion: Meconium aspiration syndrome is an important problem with high morbidity and mortality rates. The determination of risk factors and close follow-up during perinatal and neonatal period may prevent the disease and decrease morbidity and mortality rates. Key Words: Meconium Aspiration Syndrome; Risk Factor; Complications.

Analysis of Hypoxemia in Early Ventilator-Associated Pneumonia Secondary to Haemophilus in Trauma Patients.

Haemophilus species bacteria (HSB) are known pathogens responsible for early pneumonia in intubated trauma patients. The primary goal of this study was to examine the incidence and extent of hypoxemia in intubated trauma patients who develop early ventilator-associated pneumonia (VAP) secondary to HSB. On the basis of our clinical experiences, we hypothesized that patients with Haemophilus species bacteria pneumonia (HSBP) would have a high rate of hypoxemia but that the effect would be transient. Retrospective review of intubated trauma patients from an urban level I trauma center with HSBP diagnosed by deep tracheal aspirate or bronchoalveolar lavage from April 2007 to November 2012. Collected variables included day of HSBP diagnosis; PaO2 to FIO2 ratio (P:F) at HSBP diagnosis as well as HSBP day three and HSBP day seven; injury severity score (ISS) and its component parts; admission Glasgow Coma Scale (GCS) score; and mortality. Hypoxemia was defined as P:F <200. χ(2) Tests were utilized to assess factors that differed between hypoxemic and non-hypoxemic patients; data are presented as median (interquartile range, IQR). Sixty-nine patients were identified (80% male; age, 35 y [range, 24-49]; ISS 27 [9-59]). Diagnosis of HSBP occurred early (hospital day 4 [range, 3-5]). Forty-three percent of patients had acute respiratory distress syndrome (ARDS) on HSBP day 1; this decreased to 26% on day three and to 30% on day seven. Forty patients (77%) had a tracheostomy performed. Patients with hypoxemia were significantly less likely to have a severe head injury (GCS<9), p<0.05. Patients with hypoxemia had similar hospital length of stay and mortality to patients who did not develop hypoxemia. Haemophilus species bacteria pneumonia in trauma patients is associated with high rates of transient hypoxemia and a high tracheostomy rate, although subsequent outcomes are not affected. Patients with head injuries had a lower incidence of hypoxemia from pneumonia.

The accuracy of Gram stain of respiratory specimens in excluding Staphylococcus aureus in ventilator-associated pneumonia

ObjectiveTo evaluate the Gram stain of deep tracheal aspirate as a tool to direct empiric antibiotic therapy, and more specifically as a tool to exclude the need for empiric antibiotic coverage against Staphylococcus aureus in ventilator-associated pneumonia (VAP). DesignA prospective, single-center, observational, cohort study. SettingAll wards at a community hospital. PatientsAdult patients requiring mechanical ventilation, identified as having VAP in a 54-month prospective surveillance database. InterventionsSampling of lower airway secretions by deep endotracheal aspiration was taken from each patient who developed VAP. Samples were sent immediately for Gram stain and qualitative bacterial cultures. Demographic and relevant clinical data were collected; Gram stain, culture, and antibiotic susceptibility results were documented; and outcome was followed prospectively. Measurements and Main ResultsThe analysis included 114 consecutive patients with 115 episodes of VAP from June 2007 to January 2012. Sensitivity of Gram stain compared with culture was 90.47% for gram-positive cocci, 69.6% for gram-negative rods, and 50% for sterile cultures. Specificity was 82.5%, 77.8%, and 79%, respectively. Negative predictive value was high for gram-positive cocci (97%) and sterile cultures (96%) but low for gram-negative rods (20%). Acinetobacter baumanii (45%) and Pseudomonas aeruginosa (38 %) were the prevailing isolates. S aureus was found in 18.3% of the patients. Most isolates were multiresistant. ConclusionsAbsence of gram-positive bacteria on Gram stain had a high negative predictive value. These data can be used to narrow the initial empiric antibiotic regimen and to avoid unnecessary exposure of patients to vancomycin and other antistaphyloccocal agents.

Bacterial and viral etiology in hospitalized community acquired pneumonia with molecular methods and clinical evaluation.

Polymerase chain reaction (PCR) method has improved the diagnosis rates for patients with community-acquired pneumonia (CAP). We aimed to evaluate the bacterial and viral etiology of hospitalized CAP cases and compare clinical and laboratory findings of patients with pure bacterial and bacterial and viral (mixed) infections. A total of 55 patients hospitalized with CAP were enrolled into the prospective study between February 2010 and December 2010. Clinical and laboratory follow-up were performed on days 0, 7 and 14. Deep tracheal aspiration samples were examined for bacterial and viral pathogens by multiplex PCR, and standard bacteriological culture method. The etiological identification rate in 50 patients for bacteria, viruses and mixed virus-bacteria combination by PCR were 62%, 4%, 32%, respectively and 60% in 55 patients by bacterial culture method. Streptococcus pneumoniae concomitant with Haemophilus influenzae (36%) and rhinovirus (16%) was very common, whereas atypical pathogens (only Mycoplasma pneumoniae) were rare (6%). Rhinovirus was the most common viral agent (20%). Recently identified viruses, human coronavirus HKU1 and human bocavirus were not detected except for human metapneumovirus (one case). There was no significant difference in terms of mean age, immune status, leukocyte count, C-reactive protein (CRP) values, hospitalization duration and CURB-65 score between bacterial and mixed viral-bacterial detections. Advanced age (p < 0.01) and higher CURB-65 score (p = 0.01) were found to be associated with increased mortality. Concomitance of bacterial and viral agents is frequent and resemble with bacterial infections alone. Further studies are needed for the clinical significance of mixed detections.

Evaluation of infections in geriatric patients at intensive care unit

Background: Infection is a major problem among hospitalized geriatric patients due to reduced immune functions and comorbidities. The course of infections seen in this group are more serious than young people. Duration of hospitalization, morbidity and mortality rates are high. The aim of this study is to evaluate geriatric infections and infection agents in geriatric patients. Methods & Materials: The study was performed in January 2012–December 2012 for one year at Izmir Tepecik Education and Research Hospital. Infections and causative agents among hospitalized patients over 65 years old at Anaesthesiology and Reanimation Intensive Care Unit were evaluated, retrospectively. Data of the patients was achieved from the infection control comitee records. Results: A total of 294 patients were followed-up at intensive care unit during study period. One hundred and seventy six patients (60.8%) who were over 65 years old, enrolled into the study. Infection was detected in 77 (43.7%) of the geriatric patients. The most common infection was ventilatory associated pneumonia (68.8%), following urinary tract infection (32.4%), primary bacteremia (31.3%), catheter related bacteremia (11.6%), pneumonia (6.4%) and skin and soft tissue infections (5.1%). In deep tracheal aspirate cultures, 104 microorganism were isolated. The most common isolated microorganisms were A. baumannii (39.4%) and P. aeruginosa (28.8%). In 35 positive urine cultures, E.coli and P. aeruginosa were both the most prevalent bacterias (20%). The most common primary bacteremia agents were coagulase negative staphylococci (26.9%), A. baumannii (19.2%), E. faecium (15.3%). A. baumannii (30%) was the major cause of catheter related bacteremia. Sputum culture yielded P. aeruginosa (54.5%) and A. baumannii (27.2%) mostly in patient with pneumonia. Tissue biopsy cultures revealed seven (42.8%) isolates of K. pneumoniae. Conclusion: Hospital-acquired infections are major health problem in geriatric patients especially in intensive care units. Cause of infections are predominantly polymicrobial resistant agents such as A. baumannii and P. aeruginosa. Judicious use of antibiotics, limitation of invasive instruments, applying infection control measures can reduce the morbidity and mortality due to infections

Determining of The Prevalence of Nosocomial Infections and Causative Gram Negative Bacilli in The Intensive Care Unit

Purpose: Nosocomial infections develop after 48-72 hours of hospitalization. Gram negativebacilli are generally the causative agent. 25% of all nosocomial infections develop in theintensive care units. Therefore, patients in the intensive care units are at high risk. This studyaimed to determine the prevalence of nosocomial infections and causative gram negative bacilliin the Intensive Care Unit (ICU).Materials and Methods: 269 patients who were hospitalized in internal medicine intensivecare unit (IMICU) of Dicle University Faculty of Medicine between june 2010- December 2010were included in this study. Culture samples were taken from all of the patients who developsfever ( ≥38.5 C) after the hospitalization to the IMICU. Culture of blood, urine, sputum, centralvenous catheters, open wounds and deep tracheal aspirate were taken. Source and the prevalenceof infection and distribution of the isolated causative pathogens were determined in the patientswith gram negative bacilli reproduction.Results: 158 of the patients were male ( 58.7%) and 111 of the patients were female ( 41.3%).The mean ages of men and female were 58.81±16.91 and 56.44±19.16 years, respectively (p=0.286). culture samples were taken from blood (16%), urine ( 8.6%), central venous cathetertips ( 6.3%), deep tracheal aspirates (10%), sputum (2.2%) and wound stabs (2.2%). Nosocomialinfections were detected in 109 patients ( 40.5%). Pneumonia, urinary tract infections andgastrointestinal system infections were the most frequent infections respectively.Microorganisms were isolated from one sample in 97 patients, while 12 patients had more thanfocus. The most commonly isolated organisms were E.Coli (13.8%) and PseudomonasAeruginosa (7.4%), followed by Acinetobacter Baumannii (6.3%) and StenotrophomonasMaltophilia (3.3%). Conclusion: Nosocomial infections in intensive care units have proved to be a serious problem.Surveillance studies should be performed for the isolated causative pathogens and measuresshould be taken to prevent the development of the ICU infections

Evaluation of antimicrobial susceptibility patterns of Pseudomonas aeruginosa and Acinetobacter baumannii strains that were isolated from deep tracheal aspirate specimens in Çorum Hitit University Training and Research Hospital

Evaluation of antimicrobial susceptibility patterns of Pseudomonas aeruginosa and Acinetobacter baumannii strains that were isolated from deep tracheal aspirate specimens in Çorum Hitit University Training and Research Hospital

233 Presence of Bile Acids and Pepsin in Saliva and Broncho-Alveolar Lavage of Patients With Idiopathic Pulmonary Fibrosis Is Associated to Increased Severity of Lung Disease

Background: Gastroesophageal reflux (GER) and microaspiration of gastric contents has been proposed as an important mechanism in the pathogenesis of ventilator associated pneumonia (VAP) but properties of GER in patients receiving acid suppresive therapy in intensive care unit (ICU) and its effect on VAP and respiratory function in these patients is not elucidated. Aim: This study aims to assess the association between GER and VAP by defining the differences between VAP and non-VAP patients in ICU in terms of proximal extension and chemical properties of GER assessed by 24 hour combined esophageal intraluminal electrical impedance/pH measurements. We also aimed to study the association of impedance/pH values with respiratory function (PaO2/FiO2 ratio) and gastropulmonary microaspiration assessed by pepsin measurements in deep tracheal aspirates(DTA). Methods: 20 intubated patients on acid suppressive medication for stress ulcer prophylaxis in a neurological and medical ICU were included in this study. Patients who had pneumonia at the time of intubation or who were diagnosed with pneumonia during the first 48 hours after intubation were excluded. Pepsinmeasurements weremade onDTA samples on the third day. Afterwards esophageal impedance/pHmetry catheters were placed and 24 hour recordings were analyzed. Patients were followed throughout their stay in ICU for VAP and daily PaO2/FiO2 ratios were recorded for one week. Impedance/pH values and pepsin levels were compared between VAP and nonVAP patients. Results: 8 patients were diagnosed with VAP. VAP patients had more proximal reflux compared to non-VAP patients (7(2-14) vs. 3,5(0-8))(p=0,003). Proximal weakly acidic reflux was again more common in VAP patients (4,5(2-9) vs 2(04)(p=0,006). Pepsin levels in DTA samples were correlated with the number of weakly acidic reflux episodes(r=0,615;p=0,004). Pepsin levels were also correlated with the number of proximal reflux episodes, especially with proximal weakly acidic reflux(r=0,489;p=0,029 ; r=0,651,p=0,002 ). PaO2/FiO2 ratios were negatively correlated with both pepsin levels and proximal weakly acidic reflux (r=-0,585,p=0,007 ; r=-0,620;p=0,004). Conclusion: Proximal extension of GER, especially proximal weakly acidic reflux is associated with microaspiration, VAP and worsening of respiratory function in intubated ICU patients on acid suppressive therapy.

232 Another Extraesophageal Reflux Syndrome: Ventilator Associated Pneumonia and Deteriorating Respiratory Function in ICU Patients

Background: Gastroesophageal reflux (GER) and microaspiration of gastric contents has been proposed as an important mechanism in the pathogenesis of ventilator associated pneumonia (VAP) but properties of GER in patients receiving acid suppresive therapy in intensive care unit (ICU) and its effect on VAP and respiratory function in these patients is not elucidated. Aim: This study aims to assess the association between GER and VAP by defining the differences between VAP and non-VAP patients in ICU in terms of proximal extension and chemical properties of GER assessed by 24 hour combined esophageal intraluminal electrical impedance/pH measurements. We also aimed to study the association of impedance/pH values with respiratory function (PaO2/FiO2 ratio) and gastropulmonary microaspiration assessed by pepsin measurements in deep tracheal aspirates(DTA). Methods: 20 intubated patients on acid suppressive medication for stress ulcer prophylaxis in a neurological and medical ICU were included in this study. Patients who had pneumonia at the time of intubation or who were diagnosed with pneumonia during the first 48 hours after intubation were excluded. Pepsinmeasurements weremade onDTA samples on the third day. Afterwards esophageal impedance/pHmetry catheters were placed and 24 hour recordings were analyzed. Patients were followed throughout their stay in ICU for VAP and daily PaO2/FiO2 ratios were recorded for one week. Impedance/pH values and pepsin levels were compared between VAP and nonVAP patients. Results: 8 patients were diagnosed with VAP. VAP patients had more proximal reflux compared to non-VAP patients (7(2-14) vs. 3,5(0-8))(p=0,003). Proximal weakly acidic reflux was again more common in VAP patients (4,5(2-9) vs 2(04)(p=0,006). Pepsin levels in DTA samples were correlated with the number of weakly acidic reflux episodes(r=0,615;p=0,004). Pepsin levels were also correlated with the number of proximal reflux episodes, especially with proximal weakly acidic reflux(r=0,489;p=0,029 ; r=0,651,p=0,002 ). PaO2/FiO2 ratios were negatively correlated with both pepsin levels and proximal weakly acidic reflux (r=-0,585,p=0,007 ; r=-0,620;p=0,004). Conclusion: Proximal extension of GER, especially proximal weakly acidic reflux is associated with microaspiration, VAP and worsening of respiratory function in intubated ICU patients on acid suppressive therapy.

GlutamineSupplementedParenteralNutritiontoPreventVentilatorAssociated Pneumonia in the Intensive Care Unit

Ventilator-associated pneumonia (VAP) is a form of nosocomial pneumonia that increases patient morbidity and mortality, length of hospital stay, and healthcare costs. Glutamine preserves the intestinal mucosal structure, increases immune function, and reduces harmful changes in gut permeability in patients receiving total parenteral nutrition (TPN). We hypothesized that TPN supplemented by glutamine might prevent the development of VAP in patients on mechanical ventilator support in the intensive care unit (ICU). With the approval of the ethics committee and informed consent from relatives, 60 patients who were followed in the ICU with mechanical ventilator support were included in our study. Patients were divided into three groups. The first group received enteral nutrition (n=20), and the second was prescribed TPN (n=20) while the third group was given glutamine-supplemented TPN (n=20). C-reactive protein (CRP), sedimentation rate, body temperature, development of purulent secretions, increase in the amount of secretions, changes in the characteristics of secretions and an increase in requirement of deep tracheal aspiration were monitored for seven days by daily examination and radiographs. No statistically significant difference was found among groups in terms of development of VAP (p=0.622). Although VAP developed at a lower rate in the glutamine-supplemented TPN group, no statistically significant difference was found among any of the groups. Glutamine-supplemented TPN may have no superiority over unsupplemented enteral and TPN in preventing VAP.

Cerebral Arterial Air Embolism Associated with Mechanical Ventilation and Deep Tracheal Aspiration

Arterial air embolism associated with pulmonary barotrauma has been considered a rare but a well-known complication of mechanical ventilation. A 65-year-old man, who had subarachnoid hemorrhage with Glasgow coma scale of 8, was admitted to intensive care unit and ventilated with the help of mechanical ventilator. Due to the excessive secretions, deep tracheal aspirations were made frequently. GCS decreased from 8–10 to 4-5, and the patient was reevaluated with cranial CT scan. In CT scan, air embolism was detected in the cerebral arteries. The patient deteriorated and spontaneous respiratory activity lost just after the CT investigation. Thirty minutes later cardiac arrest appeared. Despite the resuscitation, the patient died. We suggest that pneumonia and frequent tracheal aspirations are predisposing factors for cerebral vascular air embolism.

Evaluation of the genotype MTBDRplus assay for the diagnosis of tuberculosis and rapid detection of rifampin and isoniazid resistance in clinical specimens*

To determine the performance of the Genotype MTBDRplus assay for diagnosis of tuberculosis and rapid detection of rifampin (RIF) and isoniazid (INH) resistance in clinical specimens. Materials and methods: A total of 90 clinical specimens of 57 patients (69 sputum samples, 11 bronchoscopic aspirates, 5 bronchoalveolar lavage, 4 deep tracheal aspirate, 1 lymph aspirate) sent to the Ege University Medical Faculty, Department of Medical Microbiology, Mycobacteriology Laboratory between December 2007 and 2009 during the clinical routine were included in the study. Results: Overall 80 valid results were obtained for 90 clinical specimens (88.9%) with MTBDRplus. While 74 of 82 (90.2%) smear positive specimens gave interpretable results by MTDRplus, 2 of 8 smear negative specimens gave invalid results. The overall rates of concordance between the results of the MTBDRplus assay and those of the drug susceptibility testing for the assessment of RIF and INH resistance were 97.5% (78/80) and 98.8% (79/80), respectively. Conclusion: Although the MTBDRplus assay could be a useful tool for rapid identification of RIF- and INH-resistant Mycobacterium tuberculosis in both clinical samples and strains, the test results must always be confirmed by culture and drug susceptibility testing.

Influenza‐associated pneumonia in a Turkish area with endemic avian influenza

The aim of the study was to describe the effects of influenza associated with community-acquired pneumonia (CAP) on the outcome of patients in an area characterized by endemic avian influenza. Sixty patients diagnosed with CAP and requiring hospitalization were studied for the presence of influenza. Based on the presence or absence of influenza, patients were divided into two groups: group 1 were CAP patients positive for influenza and group 2 included CAP patients negative for influenza. Laboratory investigations, CXR findings and prognosis were compared. Nasopharyngeal swabs or deep tracheal aspirates were tested for viral aetiology, and seven patients were positive for influenza AH3; one was positive for influenza AH1; seven were positive for influenza B; and one was positive for parainfluenza. Group 1 patients (n = 16) had a mean age of 56 years and group 2 patients (n = 45) had a mean age of 55 years. Significant increases in creatinine kinase and lymphopaenia were seen in group 1 patients. On CXR, interstitial infiltration was more marked in group 1. There was significantly higher mortality in group 1 than in group 2. CAP associated with influenza had a different clinical picture and outcome compared with patients without evidence of influenza.

CHOLERA-LIKE DIARRHEA AND SHOCK ASSOCIATED WITH COMMUNITY-ACQUIRED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (USA400 CLONE) PNEUMONIA

A 14-year-old girl presented with florid watery diarrhea, vomiting and hypotension without respiratory prodrome. Shock, multiorgan system failure and death rapidly ensued. Influenza A was detected from her nasopharynx and CA-MRSA (USA400), positive for pvl, mecA, sea, sec and seh genes was cultured from a deep tracheal aspirate.

Prospective Comparison of Bronchoalveolar Lavage and Quantitative Deep Tracheal Aspirate in the Diagnosis of Ventilator Associated Pneumonia

Prospective Comparison of Bronchoalveolar Lavage and Quantitative Deep Tracheal Aspirate in the Diagnosis of Ventilator Associated Pneumonia

Antimicrobial Resistance of Respiratory Pathogens Isolated from Pediatric Patients

Antimicrobial resistance of three major respiratory pathogens, Streptococcus pneumoniae , Haemophilus influenzae and Moraxella catarrhalis has been of increasing concern to clinical microbiologists over the past decade 1,2. In this study, commonly used antimicrobials and cefditoren, recently introduced for use in Turkey, were tested by Etest (AB Biodisk, Solna, Sweden) against 96 S. pneumoniae, 50 H. influenzae and 50 M. catarrhalis isolates from pediatric patients (515 years old) with community-acquired respiratory tract infections in 2004 in Ankara, Turkey. Of the isolates, 72.5% were from samples (sputum, broncoalveolar lavage, deep tracheal aspirate) from the lower and the rest from samples (tympanosynthesis, antral puncture) from the upper respiratory tract. All isolates were identified according to standard microbiologic criteria. The minimum inhibitory concentrations (MICs) were evaluated according to the NCCLS/CLSI 2004 guidelines 3. For M. catarrhalis strains, breakpoints for H. influenzae were applied. S. pneumoniae strains were tested against penicillin G, clarithromycin, trimethoprim-sulfamethoxazole (TMP-SMX), levofloxacin, vancomycin, cefuroxime, cefixime and cefditoren. H. influenzae was tested against ampicillin, amoxicillin+clavulanic acid, clarithromycin, TMPSMX, levofloxacin, cefuroxime, cefixime and cefditoren. M. catarrhalis strains were tested against amoxicillin+clavulanic acid, clarithromycin, TMPSMX, levofloxacin, and cefditoren. Also H. influenzae and M. catarrhalis isolates were tested for betalactamase production by using cefinase disks (Becton Dickonson, Cockeysville, Md). The control strains, S. pneumoniae ATCC 49619 and H. influenzae Journal of Chemotherapy Vol. 18 n. 5 (565-566) 2006

Prospective Comparison of Bronchoalveolar Lavage and Quantitative Deep Tracheal Aspirate in the Diagnosis of Ventilator Associated Pneumonia

Prospective Comparison of Bronchoalveolar Lavage and Quantitative Deep Tracheal Aspirate in the Diagnosis of Ventilator Associated Pneumonia

Prospective Comparison of Bronchoalveolar Lavage and Quantitative Deep Tracheal Aspirate in the Diagnosis of Ventilator Associated Pneumonia

Ventilator associated pneumonia (VAP) is common in trauma patients, and accurate diagnosis of VAP may improve survival. With the risk of development of bacterial resistance, we also strive to minimize the use of unnecessary antibiotics. Recent studies suggest that quantitative deep endotracheal aspirate (QDEA) is adequate in VAP diagnosis. We currently use bronchoalveolar lavage (BAL) diagnosis. The purpose of this study was to examine the accuracy of QDEA as compared with BAL in diagnosing VAP in trauma patients. We prospectively compared the results of BAL and QDEA in intubated patients suspected of having VAP during an 8-month period. Indication for BAL was pulmonary infiltrate, systemic inflammatory response syndrome, and C-reactive protein >17 mg/dL at > or =48 hours after admission. Study patients underwent QDEA immediately before BAL, and quantitative cultures were compared for both specimens. The techniques differ in that QDEA involves the direct culture of sputum suctioned from the distal trachea, whereas BAL involves lavage of the bronchoalveolar tree with sterile saline, which is then cultured. VAP was diagnosed on BAL if > or =10(5) cfu/mL was present on culture. The ability of QDEA to diagnose pneumonia was examined at cutoffs of > or =10(5) cfu/mL and > or =10(4) cfu/mL, as compared with BAL at > or =10(5). Sixty-one patients underwent BAL during this period, and 39 of these underwent both BAL and QDEA for the study. Of the 39 studied patients between March 16, 2002, and November 4, 2002, 20 (51%) were found to have VAP by BAL (> or =10(5) cfu/mL). Using this cutoff for QDEA, 18 of 20 (90%) would have been correctly diagnosed. Using > or =10 cfu/mL for QDEA, the rate of correct diagnosis would increase to 19 of 20 (95%). However, of the 19 who did not have pneumonia according to BAL, 6 (31%) would have been incorrectly diagnosed with VAP using the QDEA cutoff of > or =10(5) cfu/mL. A QDEA cutoff of > or =10 (4) cfu/mL would result in the even higher false-positive rate of 8 of 19 patients (42%). Whereas most patients with pneumonia by BAL would have been diagnosed by QDEA, use of QDEA in treatment decisions would have led to needless antibiotic administration in 31% of VAP-negative patients at a cutoff of > or =10(5) cfu/mL and 42% at > or =10(4) cfu/mL. The use of QDEA in VAP diagnosis is limited because of the rate of over-diagnosis. With the increasing problems associated with excess antibiotic use, we believe these results support the use of BAL over QDEA in the diagnosis of VAP in the ventilated trauma patient.

Impact of introducing quality control/quality assurance (QC/QA) guidelines in respiratory specimen processing

To assess the impact of the introduction of a new quality control/quality assurance (QA/QC) protocol on the processing and reporting of respiratory specimens. After implementation of guidelines for processing respiratory specimens, an investigation was carried out over a six-month period on 200 specimens, 105 sputa, and 95 deep tracheal aspirates (DTAs), assessed blindly by two independent investigators. Data regarding disagreement were arranged into two subgroups. A minor disagreement was defined as a difference in the two assessments of < 10 or 10-25 for white blood cell (WBC) or squamous epithelial cell (SEC) counts. A major disagreement was defined as one assessor reporting < 10 and the other > 25 for either WBC count or SEC count, or one assessor reporting the specimen as non-assessable, or both assessors having a minor disagreement in both the WBC count and the SEC count. Agreement was obtained on 111 samples. For 45 specimens, a major disagreement was documented, and in 44 cases, a minor disagreement was recorded, WBC being the most common cause of divergence. Data for sputa and DTAs were examined separately: of 45 major disagreements, 64.4% were observed for DTAs, while minor disagreements were recorded mostly for sputa. The role of the settings in which samples were taken in affecting quality was studied. Among the 105 sputa, 27 were from Community Health Centers (CHCs) and 78 from hospitalized patients. Agreement between the two observers was obtained in 48.1% of CHC cases versus 60.2% of hospital samples. To investigate how many of the rejected samples presented WBC > 25 suggestive of infection, we looked at the 107 samples rejected during the six-month period, grouped according to the suspected diagnosis. The highest number of rejected samples falls in the category of unrelated (non-respiratory) diagnosis, and clinical suspicion is not helpful in Gram stain interpretation. The annual saving (not culturing, not testing, and not treating) derived from this simple QC procedure totals about 5000 Euro. Standardization in microscopic screening of respiratory samples is difficult to achieve. Criteria for rejection must be adapted to local conditions after discussion with clinicians to increase their compliance with the newly introduced guidelines and to avoid sending unnecessary specimens. The effects on patient management and cost control are significant.