However, before the large-scale adoption of the surveillance EA culture strategy, we should address the following important issues related to surveillance EA cultures. First, this is an exciting investigation, but it is still a small study that includes only 41 cases of VAP confirmed by BAL fluid cultures. Second, this study used 103 cfu/mL as an interpretative cutoff point for the surveillance culture EA specimens, which is substantially lower than the cutoff points used for diagnosing VAP (ie, 106 to 107 cfu/mL). Despite the low cutoff points used for the surveillance EA cultures, the study by Michel et al reported a surprisingly high concordance (83%) between pre-VAP BAL fluid and EA cultures at a cutoff point of 103 cfu/mL. Clearly, a larger scale study using the same strategy with similar success is needed. Third, there was still a 5% rate of false-negative results in pre-VAP EA cultures, which stresses that negative results of surveillance EA cultures cannot exclude a diagnosis of VAP. Fourth, this study did not focus on clinical outcomes. Thus, there were no available data to indicate whether a strategy of using surveillance EA quantitative cultures leads to better patient survival or to the reduction of critical care unit or hospital stays. Last, the cost of routine surveillance EA quantitative cultures in all patients receiving mechanical ventilation is clearly an important consideration.