We read with great interest the study performed by Paula Ramirez and colleagues [1]. The study included 71 patients with ventilator-associated pneumonia (VAP) and the authors coined a new term called “gradual VAP”. The result of this study indicated that an early antibiotic treatment for patients with gradual VAP was associated with an increased rate of early clinical response. Based on the results of previous studies and our observational data, we would like to make some comments.
There is still a grey area between ventilator-associated tracheobronchitis (VAT) and VAP in clinical practice, resulting in a situation where ventilator-associated event (VAE) and infection-related ventilator-associated complication (IVAC) are proposed as alternative terms for epidemiologic purposes [2, 3]. The nature of subjectivity and variability of chest radiograph interpretation makes chest imaging ill-suited for the definition of IVAC. However, it is challenging for the clinician to make a diagnosis of pneumonia without chest imaging, leading to the fact that the IVAC definition is mainly used in surveillance. Thus, it is a challenge to determine the timing of the initiation of antibiotic treatment.
Gradual VAP is a novel concept that might be a better bridge to link VAT and VAP than IVAC. Based on the 2016 clinical practice guidelines issued by the Infectious Diseases Society of America [4], 82 patients were diagnosed as VAP and enrolled in our prospective observational study from July 2016 to March 2017 in three teaching hospitals (Ren Ji, Rui Jin, and Minhang hospitals; 157 intensive care unit (ICU) beds in total). Among the VAP patients, 42 had gradual VAP, 34 had IVAC, and the remaining 6 patients had neither. The baseline characteristics were not significantly different between patients with gradual VAP and IVAC. Characteristics at the time of VAP diagnosis and outcome of VAP patients are compared in Table 1 [5].
The definition of IVAC includes “a new antimicrobial agent is started, and is continued for ≥4 calendar days”, which is the main difference to gradual VAP [3]. Furthermore, the definition criteria do not include changes in chest imaging. Our brief report indicated that starting empiric antibiotic treatment at the period of gradual VAP was associated with short ICU and hospital length of stay. The rate of antibiotic treatment failure and cost were also lower than IVAC. In conclusion, gradual VAP still needs to be well-defined so that it can be an intermediate form of ventilator-associated infection linking VAT and VAP.
Abbreviations
- IVAC:
-
Infection-related ventilator-associated complication
- VAE:
-
Ventilator-associated event
- VAP:
-
Ventilator-associated pneumonia
- VAT:
-
Ventilator-associated tracheobronchitis
References
Ramirez P, Lopez-Ferraz C, Gordon M, Gimeno A, Villarreal E, Ruiz J, et al. From starting mechanical ventilation to ventilator-associated pneumonia, choosing the right moment to start antibiotic treatment. Crit Care. 2016;20(1):169.
Guillamet CV, Kollef MH. Ventilator associated pneumonia in the ICU: where has it gone? Curr Opin Pulm Med. 2015;21(3):226–31.
Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, et al. Developing a new, national approach to surveillance for ventilator-associated events. Crit Care Med. 2013;41(11):2467–75.
Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61–e111.
Zhang Z. Univariate description and bivariate statistical inference: the first step delving into data. Ann Translat Med. 2016;4(5):91.
Acknowledgements
We thank Zhongheng Zhang from the Department of Emergency Medicine in Sir Run-Run Shaw Hospital for revising the language of the manuscript.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Authors’ contributions
YY and CZ both helped to draft and edit the article. CL performed the statistical analysis and helped to revise the manuscript. YG revised and approved the final manuscript. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Declaration
The table in our paper is original for this article.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Author information
Authors and Affiliations
Corresponding author
Additional information
See related research by Ramirez et al. https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1342-1
Rights and permissions
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
About this article
Cite this article
Yu, Y., Zhu, C., Liu, C. et al. How to remove the grey area between ventilator-associated pneumonia and ventilator-associated tracheobronchitis?. Crit Care 21, 165 (2017). https://doi.org/10.1186/s13054-017-1754-6
Published:
DOI: https://doi.org/10.1186/s13054-017-1754-6