Advertisement

Ventilator-Associated Pneumonia: Diagnostic Test Stewardship and Relevance of Culturing Practices

  • Blaine KenaaEmail author
  • Mary Elizabeth Richert
  • Kimberly C. Claeys
  • Andrea Shipper
  • Kaede V. Sullivan
  • Gregory M. Schrank
  • Lyndsay M. O’Hara
  • Daniel J. Morgan
  • Carl Shanholtz
  • Surbhi Leekha
Healthcare Associated Infections (G Bearman and D Morgan, Section Editors)
  • 56 Downloads
Part of the following topical collections:
  1. Topical Collection on Healthcare Associated Infections

Abstract

Purpose of Review

Ventilator-associated pneumonia (VAP) is one of the most common infections in the ICU. Prompt diagnosis is vital as mortality increases with delayed antibiotic therapy. However, accurate diagnosis is challenging due to non-specific clinical features in a complicated patient cohort. Microbiological culture data remains a crucial aspect in confirming diagnosis.

Recent Findings

Literature data comparing the benefit of invasive respiratory sampling to non-invasive is inconclusive. Differences in culturing practices translate in overidentification of organisms of unclear significance. Positive culture data in a low pre-test probability does not differentiate between true infection and colonization resulting in overtreatment. Furthermore, there are also opportunities for modifying the reporting of respiratory tract cultures that can better guide antimicrobial therapy.

Summary

Under the umbrella of antimicrobial stewardship, diagnostic stewardship can be incorporated to create a systematic approach that would target culturing practices to match the right pre-test probability. Ideal outcome will be targeting cultures to the right patient population and minimizing unnecessary treatment.

Keywords

Ventilator-associated pneumonia Diagnostic stewardship Antimicrobial stewardship Selective culture reporting Invasive respiratory culturing Endotracheal aspirate 

Notes

Compliance with Ethical Standards

Conflict of Interest

Dr. Kenaa declares that she has nothing to disclose.

Dr. Richert declares that she has nothing to disclose.

Dr. Claeys reports personal fees from Luminex Corporation, other from BioFire Diagnostics, from GenMark Diagnostics, outside the submitted work.

Ms. Shipper declares that she nothing to disclose.

Dr. O’Hara declares that she has nothing to disclose.

Dr. Sullivan declares that he has nothing to disclose.

Dr. Schrank declares that he has nothing to disclose.

Dr. Morgan reports grants from CDC, NIH, AHRQ, grants from VA HSRD, other from IDSA and SHEA for expenses to organize or present at national meetings, other from Springer Nature Inc., outside the submitted work.

Dr. Shanholtz declares that he has nothing to disclose.

Dr. Leekha reports grants from CDC and AHRQ, outside the submitted work.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Ferrer M, Torres A. Epidemiology of ICU-acquired pneumonia. Curr Opin Crit Care. 2018 Oct;24(5):325–31.PubMedCrossRefGoogle Scholar
  2. 2.
    Piriyapatsom A, Lin H, Pirrone M, De Pascale G, Corona De Lapuerta J, Bittner EA, et al. Evaluation of the infection-related ventilator-associated events algorithm for ventilator-associated pneumonia surveillance in a trauma population. Respir Care. 2016;61(3):269–76.PubMedCrossRefGoogle Scholar
  3. 3.
    Wang Y, Eldridge N, Metersky ML, Verzier NR, Meehan TP, Pandolfi MM, et al. National trends in patient safety for four common conditions, 2005–2011. N Engl J Med. 2014;370(4):341–51.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    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 Sep 1;63(5):e61–111.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Dudeck MA, Weiner LM, Allen-Bridson K, Malpiedi PJ, Peterson KD, Pollock DA, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module Am J Infect Control 2013;Google Scholar
  6. 6.
    Browne E, Hellyer TP, Baudouin S V, Morris AC, Linnett V, McAuley DF, et al. A national survey of the diagnosis and management of suspected ventilatorassociated pneumonia. BMJ Open Respir Res [Internet]. 2014 Dec;1(1).PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    • Morgan DJ, Malani P, Diekema DJ. Diagnostic stewardship - leveraging the laboratory to improve antimicrobial use. JAMA - Journal of the American Medical Association. 2017; This editorial discusses the importance of engaging the laboratory to ensure culture testing in the right pre-test probability. It also highlights the role of collection, processing, and reporting of the sample play a role in appropriate treatment of infections. Google Scholar
  8. 8.
    Nussenblatt V, Avdic E, Berenholtz S, Daugherty E, Hadhazy E, Lipsett PA, et al. Ventilator-associated pneumonia: overdiagnosis and treatment are common in medical and surgical intensive care units. Infect Control Hosp Epidemiol. 2014 Mar;35(3):278–84.PubMedCrossRefGoogle Scholar
  9. 9.
    Baur D, Gladstone BP, Burkert F, Carrara E, Foschi F, Döbele S, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet Infect Dis. 2017;17(9):990–1001.PubMedCrossRefGoogle Scholar
  10. 10.
    Sarg M, Waldrop GE, Beier MA, Heil EL, Thom KA, Preas MA, et al. Impact of changes in urine culture ordering practice on antimicrobial utilization in intensive care units at an Academic Medical Center. Infect Control Hosp Epidemiol. 2016;37(4):448–54.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Bashir A, Gray J, Bashir S, Ahmed R, Theodosiou E. Critical points in the pathway of antibiotic prescribing in a children’s hospital: the Antibiotic Mapping of Prescribing (ABMAP) study. J Hosp Infect [Internet]. 2018;44:1–6.Google Scholar
  12. 12.
    Barlam TF, Cosgrove SE, Abbo LM, Macdougall C, Schuetz AN, Septimus EJ, et al. Executive summary: implementing an antibiotic stewardship program: guidelines by the infectious diseases society of America and the society for healthcare epidemiology of America. Clin Infect Dis. 2016.Google Scholar
  13. 13.
    Quick JA, Breite MD, Barnes SL. Inadequacy of algorithmic ventilator-associated pneumonia diagnosis in acute care surgery. Am Surg. 2018;84(2):300–4.PubMedGoogle Scholar
  14. 14.
    Bello G, Pennisi MA, Di Muzio F, De Pascale G, Montini L, Maviglia R, et al. Clinical impact of pulmonary sampling site in the diagnosis of ventilator-associated pneumonia: a prospective study using bronchoscopic bronchoalveolar lavage. J Crit Care. 2016 Jun;33:151–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Chao WC, Chang WL, Wu CL, Chan MC. Using objective fluid balance data to identify pulmonary edema in subjects with ventilator-associated events. Respir Care. 2018 Aug 7;Google Scholar
  16. 16.
    Shan J, Chen HL, Zhu JH. Diagnostic accuracy of clinical pulmonary infection score for ventilator-associated pneumonia: a meta-analysis. Respir Care. 2011 Aug;56(8):1087–94.PubMedCrossRefGoogle Scholar
  17. 17.
    Group CCCT. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med. 2006;355(25):2619–30.CrossRefGoogle Scholar
  18. 18.
    Fagon JY, Chastre J, Wolff M, Gervais C, Parer-Aubas S, Stéphan F, et al. Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial. Ann Intern Med [Internet]. 2000;132(8):621–30.CrossRefGoogle Scholar
  19. 19.
    Solé Violán J, Fernández JA, Benítez AB, Cardeñosa Cendrero JA, Rodríguez de C. Impact of quantitative invasive diagnostic techniques in the management and outcome of mechanically ventilated patients with suspected pneumonia. Crit Care Med [Internet] 2000;28(8):2737–2741.PubMedCrossRefGoogle Scholar
  20. 20.
    Ruiz M, Torres A, Ewig S, Marcos MA, Alcón A, Lledó R, et al. Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome. Am J Respir Crit Care Med [Internet]. 2000;162(1):119–25.CrossRefGoogle Scholar
  21. 21.
    Sanchez-Nieto JM, Torres A, Garcia-Cordoba F, El-Ebiary M, Carrillo A, Ruiz J, et al. Impact of invasive and noninvasive quantitative culture sampling on outcome of ventilator-associated pneumonia: a pilot study. Am J Respir Crit Care Med [Internet]. 1998;157(2):371–6.CrossRefGoogle Scholar
  22. 22.
    Berton DC, Kalil AC, Teixeira PJZ. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database of Systematic Reviews. 2014.Google Scholar
  23. 23.
    •• Lascarrou JB, Lissonde F, Le Thuaut A, Bachoumas K, Colin G, Henry Lagarrigue M, et al. Antibiotic therapy in comatose mechanically ventilated patients following aspiration: differentiating pneumonia from pneumonitis. Crit Care Med [Internet]. 2017;45(8):1268–1275. In this prospective observational study, investigators highlight the challenge in clinically differentiating bacterial aspiration pneumonia from non-bacterial aspiration pneumonitis. With invasive respiratory sampling, it is possible to get culture data that can guide in early discontinuation of empiric antibiotics. PubMedCrossRefGoogle Scholar
  24. 24.
    Frota OP, Ferreira AM, Barcelos L, da Watanabe SE, Carvalho NCP, Rigotti MA. Collection of tracheal aspirate: safety and microbiological concordance between two techniques TT - Colheita de aspirado traqueal: segurança e concordância microbiológica entre duas técnicas TT - Recolección de aspirado traqueal: seguridad y concordanci. Rev da Esc Enferm da USP [Internet]. 2014;48(4):618–24.CrossRefGoogle Scholar
  25. 25.
    Torres A, Niederman MS, Chastre J, Ewig S, Fernandez-Vandellos P, Hanberger H, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia. Eur Respir J [Internet]. 2017 Sep;50(3).PubMedCrossRefGoogle Scholar
  26. 26.
    Schnabel RM, van der Velden K, Osinski A, Rohde G, Roekaerts PM, Bergmans DC. Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients. BMC Pulm Med. 2015;15:101–7.CrossRefGoogle Scholar
  27. 27.
    Morency-Potvin P, Schwartz DN, Weinstein RA. Antimicrobial stewardship: how the microbiology laboratory can right the ship. Clin Microbiol Rev. 2017;30(1):381–407.PubMedGoogle Scholar
  28. 28.
    Bouza E, Muñoz P, Burillo A. Role of the clinical microbiology laboratory in antimicrobial stewardship. Medical Clinics of North America. 2018.Google Scholar
  29. 29.
    Kneidinger N, Warszawska J, Schenk P, Fuhrmann V, Bojic A, Hirschl A, et al. Storage of bronchoalveolar lavage fluid and accuracy of microbiologic diagnostics in the ICU: a prospective observational study. Crit Care [Internet]. 2013;17(4).PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    •• Shokouhi S, Darazam IA, Sadeghi M, Gachkar L, Dolatshahi S. Diagnostic yield of a direct quantitative smear of lower respiratory tract secretions in patients with suspected pneumonia compared with a semi-quantitative culture. Tanaffos. 2017;16(1):9–12. In this prospective study, investigators evaluated how Direct Quantitative Smear with proper staining maybe an easy, cost-effective, and rapid method. They compared respiratory sample from BAL and endotracheal aspirate to identify a 35 microorganisms in10 HPF of microscopy was the ideal cutoff. Though still novel and difficult to apply for different microorganisms and in different laboratory settings, this approach could be investigated further as a way to quickly identify the absence of pathogenic organisms and discontinue antibiotics earlier. Google Scholar
  31. 31.
    • Yoshimura J, Kinoshita T, Yamakawa K, Matsushima A, Nakamoto N, Hamasaki T, et al. Impact of Gram stain results on initial treatment selection in patients with ventilator-associated pneumonia: a retrospective analysis of two treatment algorithms. Crit Care [Internet]. 2017;21(1) In this study, investigators wanted to evaluate if bedside Gram stain of endotracheal aspirates could be used to determine appropriate initial antimicrobial therapy for VAP as compared with ATS/IDSA guidelines algorithmic approach. Google Scholar
  32. 32.
    Sullivan KV, Dien BJ. New and novel rapid diagnostics that are impacting infection prevention and antimicrobial stewardship. Curr Opin Infect Dis [Internet]. 2019;32:–1.PubMedCrossRefGoogle Scholar
  33. 33.
    Rhee C. Using procalcitonin to guide antibiotic therapy. Open Forum Infect Dis. 2017;4(1):1–10.Google Scholar
  34. 34.
    Raman K, Nailor MD, Nicolau DP, Aslanzadeh J, Nadeau M, Kuti JL. Early antibiotic discontinuation in patients with clinically suspected ventilator-associated pneumonia and negative quantitative bronchoscopy cultures. Crit Care Med. 2013;41(7):1656–63.PubMedCrossRefGoogle Scholar
  35. 35.
    •• Musgrove MA, Tibbetts R, Peters M, Samuel L, Davis SL, Kendall RE, et al. Microbiology comment nudge improves pneumonia prescribing. Open Forum Infect Dis. 2018;5(7):1–5 In this single pre and post quasi experimental study, investigators enrolled two hundred and ten patients who were treated with anti-MRSA and anti-pseudomonal antibiotics for respiratory infections. Reporting of cultures for patients without dominant organisms were labeled as “commensal respiratory flora only: no S.aureus/MRSA or P.aeroginosa.” In the post intervention group, there was a 5.5 increased odds of antibiotic de-escalation. CrossRefGoogle Scholar
  36. 36.
    Cunney R. Interpretative reporting and selective antimicrobial susceptibility release in non-critical microbiology results. J Antimicrob Chemother. 2002;45(5):705–8.CrossRefGoogle Scholar
  37. 37.
    Klompas M, Kleinman K, Khan Y, Evans RS, Lloyd JF, Stevenson K, Samore M, Platt R, CDC Prevention Epicenters Program. Rapid and reproducible surveillance for ventilator-associated pneumonia. Clin Infect Dis 2012;54(3):370–377.PubMedCrossRefGoogle Scholar
  38. 38.
    • Naik AD, Skelton F, Amspoker AB, Glasgow RA, Trautner BW. A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria. PLoS One. 2017;12(3) Improving the diagnostic and treatment accuracy for CAUTI by implementing a fast and frugal algorithm results in the reduction of overtreatment of asymptomatic bacteruria.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Blaine Kenaa
    • 1
    Email author
  • Mary Elizabeth Richert
    • 2
  • Kimberly C. Claeys
    • 3
  • Andrea Shipper
    • 4
  • Kaede V. Sullivan
    • 5
  • Gregory M. Schrank
    • 6
  • Lyndsay M. O’Hara
    • 7
  • Daniel J. Morgan
    • 7
  • Carl Shanholtz
    • 1
  • Surbhi Leekha
    • 7
  1. 1.Department of Medicine, Department of Pulmonary and Critical CareUniversity of Maryland School of MedicineBaltimoreUSA
  2. 2.Division of Internal Medicine, PGY-3, Department of Medicine, University of Maryland School of MedicineUniversity of Maryland Medical CenterBaltimoreUSA
  3. 3.Infectious Diseases, Department of Pharmacy Practice and ScienceUniversity of Maryland School of PharmacyBaltimoreUSA
  4. 4.Health Sciences and Human Services LibraryUniversity of Maryland BaltimoreBaltimoreUSA
  5. 5.Pathology and Laboratory Medicine, Medicine Education and Research BuildingLewis Katz School of MedicinePhiladelphiaUSA
  6. 6.Division of Infectious Diseases, Department of Medicine, University of Maryland School of MedicineUniversity of Maryland Medical CenterBaltimoreUSA
  7. 7.Department of Epidemiology and Public HealthUniversity of Maryland School of MedicineBaltimoreUSA

Personalised recommendations