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Original Research: Critical Care |

Diagnosis of Ventilator-Associated PneumoniaScore for Ventilator-Associated Pneumonia Diagnosis: A Pilot, Exploratory Analysis of a New Score Based on Procalcitonin and Chest Echography FREE TO VIEW

Giovanni Zagli, MD, PhD; Morena Cozzolino, MD; Alessandro Terreni, BSc; Tiziana Biagioli, PhD; Anna Lucia Caldini, BSc; Adriano Peris, MD
Author and Funding Information

From the Anesthesia and Intensive Care Unit of the Emergency Department (Drs Zagli, Cozzolino, and Peris) and Laboratory Department (Mr Terreni, Dr Biagioli, and Ms Caldini), Careggi University Hospital, Florence, Italy.

CORRESPONDENCE TO: Giovanni Zagli, MD, PhD, Careggi University Hospital, Largo Brambilla 3, 50139, Florence, Italy; e-mail: giovanni.zagli@unifi.it


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):1578-1585. doi:10.1378/chest.13-2922
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BACKGROUND:  To facilitate the clinical diagnosis of ventilator-associated pneumonia (VAP) in the ICU, the Clinical Pulmonary Infection Score (CPIS) has been proposed but has shown a low diagnostic performance in subsequent studies. We propose a new score based on procalcitonin level and chest echography with the aim of improving VAP diagnosis: the Chest Echography and Procalcitonin Pulmonary Infection Score (CEPPIS).

METHODS:  This retrospective pilot study recruited patients admitted to the Intensive Care Unit of the Emergency Department, Careggi University Hospital (Florence, Italy), from January 2009 to December 2011. Patients were retrospectively divided into a microbiologically confirmed VAP group or a control group based on diagnosis of VAP and positive tracheal aspirate culture.

RESULTS:  A total of 221 patients were included, with 113 in the microbiologically confirmed VAP group and 108 in the control group. A CEPPIS > 5 retrospectively fixed was significantly better in predicting VAP (OR, 23.78; sensitivity, 80.5%; specificity, 85.2%) than a CPIS > 6 (OR, 3.309; sensitivity, 39.8%; specificity, 83.3%). The receiver operating characteristic area under the curve analysis also showed a significantly higher diagnostic value for CEPPIS > 5 than CPIS > 6 (0.829 vs 0.616, respectively; P < .0001).

CONCLUSIONS:  In this pilot, exploratory analysis, CEPPIS is effective in predicting VAP. Prospective validation is needed to confirm the potential value of this score to facilitate VAP diagnosis.

Figures in this Article

Ventilator-associated pneumonia (VAP) is a nosocomial complication affecting up to 27% of patients in the ICU receiving mechanical ventilation.1 VAP is associated with a longer duration of mechanical ventilation; an increase in total hospital length of stay (LOS) and, consequently, health-care costs; and a high mortality rate (up to 70%).24

Various criteria have been proposed for diagnosing VAP, including clinical signs, imaging techniques, microbiologic sampling, and biomarkers of host response. The clinical diagnosis of VAP was traditionally made based on the criteria proposed in 1972 by Johanson and colleagues5 associating a new or progressive consolidation on chest radiograph with at least two of the following variables: fever, leukocytosis or leukopenia, and purulent tracheal secretions. To facilitate the clinical diagnosis of VAP, Pugin and colleagues6 proposed the Clinical Pulmonary Infection Score (CPIS) based on six variables: fever, leukocytosis, tracheal aspirates, oxygenation, radiographic infiltrates, and semiquantitative cultures of tracheal aspirates. Despite its wide use, the CPIS has shown relatively low accuracy in various studies.7 Furthermore, despite its original high sensitivity and specificity, a multicenter randomized trial testing the discriminative effectiveness of CPIS to detect VAP in 739 patients did not find a significant score threshold to predict VAP, indicating the limited clinical utility of this score.8 The aim of the present study was to test the diagnostic utility of a new clinical score, including clinical infection signs, chest echography information, and procalcitonin levels, in the diagnosis of VAP in critically ill patients.

Patient Selection and Study Design

This retrospective, controlled study considered for enrollment all consecutive patients admitted from First Aid to the Intensive Care Unit of the Emergency Department, Careggi University Hospital (Florence, Italy), from January 2009 to December 2011. The ethical committee of Careggi University Hospital approved the study. Informed consent for anonymous data publication was obtained from all patients or their relatives.

Patients were considered for the study if the duration of mechanical ventilation was > 48 h. Only patients with chest echography performed within 12 h before chest radiography at the time of VAP suspicion were considered. Patients admitted for pulmonary infection, COPD exacerbation, or other potential sources of sepsis at the time of VAP suspicion were excluded, as were all patients receiving antibiotics at the time of VAP suspicion. Patients with clinical signs, new infiltrates on chest radiograph, and positive tracheal aspirate cultures were retrospectively included in the infected group (henceforth called the microbiologically confirmed VAP group), whereas patients with the absence of clinical signs, no infiltrates on chest radiograph, and negative tracheal aspirate cultures were assigned to the control group.

Tracheal cultures were obtained with a sterile catheter connected to a sterile microbiologic container. According to internal monitoring protocol, tracheal cultures were obtained at ICU admission and every 5 days in the absence of pulmonary infection suspicion. An oral cleaning with chlorhexidine 2% mouthwash was performed bid.

All patients underwent chest echographic examination between the third and fifth day of their ICU stay (more frequently if clinically necessary) following internal surveillance protocol.9 Procalcitonin dosing was performed daily in all patients. VAP diagnosis was made in the case of new infiltrates on chest radiograph, leukocytosis, purulent secretions, or fever.1,10,11 The microbiologically confirmed VAP group comprised patients in whom the tracheal aspirate culture results were positive (count > 104 colony-forming units/mL).12

Data Management

For each patient, the following data were collected: age, sex, BMI, medical history, Injury Severity Score in trauma patients, Simplified Acute Physiology Score II in all patients, duration of mechanical ventilation, laboratory and microbiologic data, LOS, and mortality. Admission diagnoses were divided into major trauma, medical (intracranial hemorrhages, intoxication, postanoxic coma, cardiac failure), and postsurgical (abdominal surgery, neurosurgery, vascular surgery).

Chest echography was performed as previously described9,13 using a multifrequency (3.5-5 MHz) convex probe (Mylab 30CV; Esaote SpA). Patients were examined in the supine position with the convex probe applied perpendicularly to the chest wall to ensure that all the intercostal spaces bilaterally from the base of the lung to the apex of the chest cavity were screened. Pneumonia was diagnosed as a subpleural echo-poor region or one with tissue-like echo texture according to international evidence-based recommendations.14,15

Score Definition

The proposed new score, the Chest Echography and Procalcitonin Pulmonary Infection Score (CEPPIS) (Table 1), included the following changes:

  • • Chest radiograph was replaced by chest echography.

  • • Leukocyte count was replaced by plasma procalcitonin concentration (ng/mL) based on Use of Procalcitonin to Reduce Patients’ Exposure to Antibiotics in Intensive Care Units (PRORATA) trial indications.16

  • • Culture of tracheal aspirate significance was considered positive if the count was > 104 colony-forming units/mL.12

  • • Tracheal secretion significance was considered positive only if purulent, independently from the number of aspirations performed by nurses. Definition of tracheal purulence was made by visual assessment performed by nurses and physicians.

Table Graphic Jump Location
TABLE 1 ]  The Proposed CEPPIS Compared With the Original CPIS

ARDS is defined as a Pao2/Fio2 ≤ 200, pulmonary artery wedge pressure < 18 mm Hg, and acute bilateral infiltrates. CEPPIS = Chest Echography and Procalcitonin Pulmonary Infection Score; CPIS = Clinical Pulmonary Infection Score.

The original CPIS score6 was used as the control score (Table 1).

Statistical Analysis

SPSS, version 18, software (IBM Corporation) was used for statistical analyses. Continuous variables were analyzed with two-tail Student t test or Mann-Whitney test (D’Agostino-Pearson normality test) as appropriate. Categorical variables were examined using Fisher exact test. P < .05 was considered significant. Univariate comparison is reported as OR with 95% CI.

A logistic regression model was used to investigate the predictors of VAP. Each predictor likely to be related to the outcome was evaluated according to statistical and clinical bases. Covariates associated with the response variables (P < .1) in univariate analysis were retained in the final model; therefore, multivariable logistic regression comprised age, sex, BMI, duration of mechanical ventilation, and ICU LOS.

A total of 221 patients were included in the study (113 in the microbiologically confirmed VAP group and 108 in the control group) (Fig 1). Male sex was predominant in both groups as a consequence of a higher percentage of men with traumatic injuries, representing the main cause of admission to our ICU (Table 2). No significant differences in severity of clinical condition at ICU admission (Simplified Acute Physiology Score II), severity of injuries (Injury Severity Score), or demographic characteristics were noted (Table 2).

Figure Jump LinkFigure 1 –  Flow diagram of the retrospective enrollment in the study. Percentages refer to the total ICU admissions during the study period. VAP = ventilator-associated pneumonia.Grahic Jump Location
Table Graphic Jump Location
TABLE 2 ]  Clinical Characteristics of the Microbiologically Confirmed VAP and Control Groups

Data are presented as mean ± SD or % (No.) unless otherwise indicated. Percentages refer to the total population of each group. For definition, ISS was calculated only in trauma patients. Statistical analysis included two-tailed Mann-Whitney test and two-tail Fisher exact test. P < .05 (infection vs control) was considered significant. ISS = Injury Severity Score; LOS = length of stay; SAPS = Simplified Acute Physiology Score; VAP = ventilator-associated pneumonia.

Table 2 shows the differences between groups regarding admission diagnosis. Trauma patients predominantly comprised the microbiologically confirmed VAP group (P = .0192), whereas medical patients more frequently comprised the control group (P = .0004). Both duration of mechanical ventilation and ICU LOS were significantly higher in microbiologically confirmed VAP group than in the control group (both P < .0001). Intra-ICU mortality did not differ significantly. In the microbiologically confirmed VAP group, the mean ± SD and median of CEPPIS were 6.4 ± 1.9 and 6 (interquartile range, 5-8), respectively. Distribution of CEPPIS values in both groups are illustrated in Figure 2. On the basis of this analysis, a CEPPIS > 5 was retrospectively chosen as the limit for subsequent calculations. Microbiology results in the microbiologically confirmed VAP group are summarized in Table 3.

Figure Jump LinkFigure 2 –  Distribution of CEPPIS values in microbiologically confirmed VAP and control groups. CEPPIS = Chest Echography and Procalcitonin Pulmonary Infection Score. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location
Table Graphic Jump Location
TABLE 3 ]  Microbiology Results in Microbiologically Confirmed VAP Group

See Table 2 legend for expansion of abbreviation.

Univariate analysis of the association between demographic and clinical variables and VAP is summarized in Table 4. As shown, variables significantly related to VAP were admission for trauma (OR, 3.23; P < .0001), duration of mechanical ventilation (OR, 1.1053; P < .0001), and ICU LOS (OR, 1.09; P < .0001). On the contrary, medical admission was associated with a reduced risk for VAP (OR, 0.25; P < .0001). The subsequent multivariate regression model clarifies that the only variable that can be considered an independent risk factor for VAP development remains admission for trauma (OR, 3.5938; P = .0009).

Table Graphic Jump Location
TABLE 4 ]  Univariate and Multivariate (in P < .10, out P < .05) Analysis for VAP Risk in Overall Population

See Table 2 legend for expansion of abbreviations.

Because all patients with VAP had positive tracheal aspiration cultures, we retrospectively assessed both the original CPIS and the proposed CEPPIS calculation. Positivity at CPIS calculation for VAP diagnosis (total score > 6) was found in 45 patients (39.8%), whereas CEPPIS > 5 identified 91 patients (80.5%) with microbiologically confirmed VAP. Thus, in the microbiologically confirmed VAP group, patients with CEPPIS > 5 had an up to 20-fold increased risk for VAP (OR, 23.78; P < .0001), with a sensitivity of 80.5%, a specificity of 85.2%, a positive predictive value of 85.1%, and a negative predictive value of 80.7% (Table 5). CPIS was also a statistically significant predictor, but patients with microbiologically confirmed VAP showed only a threefold increased risk for VAP at CPIS > 6 (OR, 3.309; P = .0002), with a sensitivity of 39.8%, a specificity of 83.3%, a positive predictive value of 71.4%, and a negative predictive value of 57% (Table 5). Considering that chest echography and procalcitonin levels are the main changes introduced in the score tested and are both well-established modalities in infection diagnosis, we analyzed the predictive power of chest echography and procalcitonin level alone and in combination. As summarized in Table 5, the presence of infiltrates on chest echograph was a statistically significant VAP predictor, with an eightfold increased risk in patients with microbiologically confirmed VAP (OR, 8.011; P < .0001) but with a lower sensitivity than CEPPIS (59.3% vs 80.5%, respectively). On the contrary, procalcitonin level alone was not significantly associated with VAP diagnosis (OR, 0.8571; P = .7369). The combination of chest echography and procalcitonin level was a good predictor for VAP (OR, 6.738; P = .0005), with an improvement in specificity when compared with chest echography alone (94.2% vs 84.6%, respectively), which is lower than CEPPIS but superior compared with CPIS. Finally, the superiority of CEPPIS in the prediction of VAP relative to CPIS, chest echography, and procalcitonin level was confirmed by receiver operating characteristic area under the curve analysis (Table 6).

Table Graphic Jump Location
TABLE 5 ]  Comparison of CEPPIS, CPIS, Chest Echography, Procalcitonin Level, and Chest Echography + Procalcitonin Level as Predictors of VAP Diagnosis

NPV = negative predictive value; PPV = positive predictive value. See Table 1 and 2 legends for expansion of other abbreviations.

Table Graphic Jump Location
TABLE 6 ]  Receiver Operating Characteristic AUCs of CEPPIS, CPIS, Chest Echography, Procalcitonin Level, and Chest Echography + Procalcitonin Level

AUC = area under the curve. See Table 1 legend for expansion of other abbreviations.

General Considerations

This study demonstrates that the CEPPIS is a valuable new tool for predicting VAP development. The original work of Pugin and colleagues6 in 28 patients showed a sensitivity of 93% and specificity of 100% using a CPIS > 6 as a clinical definition of pulmonary infection. Further studies comparing CPIS with a pathologic diagnosis7 and BAL fluid-established diagnosis17 of VAP showed a lower diagnostic performance compared with the original research, with limited sensitivity and specificity. Singh and colleagues18 used the CPIS not as a diagnostic tool but as a screen for decision-making regarding antibiotic therapy, incorporating the Gram stain result into the score. This modified CPIS, although having a better diagnostic accuracy and increased sensitivity compared with the original CPIS, still showed a suboptimal specificity.17 In the present study, we showed that simple changes in some parameters significantly increased both the sensitivity and the specificity of the score. Finally, the Horowitz ratio chosen for the original CPIS design was based on its simplicity; however, it has a very limited utility in patients receiving mechanical ventilation in whom mean airway pressure plays a pivotal role in alveolar recruitment and, consequently, the final Pao2/Fio2 ratio. The oxygenation index, which also includes mean airway pressure in its equation, should now be considered a more reliable parameter in respiratory pathology.19

Procalcitonin

The use of procalcitonin levels instead of leukocyte levels follows the current literature for antimicrobial therapy.16 Several biomarkers have been investigated for diagnosing VAP. Procalcitonin is secreted as part of the systemic inflammatory response to infection. A significant increase in the concentration of procalcitonin in serum has been observed in patients with confirmed VAP, suggesting that procalcitonin measurements may be useful for the early diagnosis of VAP.20,21 Despite its unquestionable role in sepsis diagnosis, procalcitonin level alone was not reliable in VAP diagnosis unless combined with the other CEPPIS variables, as shown in Tables 5 and 6.

Tracheal Secretion Monitoring

The CPIS, which incorporates subjective parameters such as quality of tracheal secretions and radiographic interpretation, has shown a high interobserver variability.22 In the CEPPIS calculation, we chose to simplify this parameter by deleting the subjectivity of nurses in the scoring, simplifying the subscore into purulent and nonpurulent.

Chest Echography

Chest radiography is currently considered a reference for assessing lung status in critically ill patients.1315 Pneumonia diagnosis is based on a new or progressive consolidation on chest radiography. However, various studies have reported a limited diagnostic performance of bedside portable chest radiography in critically ill patients.14,23 Chest echography has become a popular new tool for assessing lung status in critically ill patients receiving ventilatory support. As we previously reported, a protocol based on chest echography evaluation may decrease the number of chest radiographs without adversely affecting patient outcome.9 As shown in Table 5, the presence of infiltrates on chest echograph was a powerful predictor for VAP diagnosis in the present sample, and receiver operating characteristic curve analysis showed that the predictive level of chest echography can be comparable to CPIS (Table 6). However, the value of the combination of variables included in CEPPIS was significantly more reliable in VAP diagnosis (Tables 5, 6).

Limitations

Due to limitations, the present study should be considered a pilot, exploratory analysis of a new type of score. The main limitation is that CEPPIS was constructed without a derivation cohort, having only been tested in a retrospective cohort. Thus, we can only state that CEPPIS appears to offer advantages with respect to the original CPIS in the early diagnosis of VAP. The retrospective nature of the study has intrinsic limits, particularly the retrospective CEPPIS cutoff for VAP diagnosis (fixed at a value of > 5), even if derived from statistical calculation. The fixed cutoff of CEPPIS might also have overestimated the sensitivity and specificity of the score in VAP prediction. In this context, only a prospective evaluation in a homogeneous population would help in bias restriction and score validation. The multivariable analysis performed, although accurate, cannot completely eliminate this limitation, which is part of the study design. Additionally, the considerable number of patients excluded (about 80% of total consecutive ICU admissions [Fig 1]) represents a potential bias in the statistical sample. However, in consideration of the retrospective nature of the study, the very restricted criteria for enrollment might have limited the selection bias, thus increasing the accuracy of the CEPPIS. Finally, because previous studies that showed the CPIS score not to be accurate recruited > 700 patients, we cannot exclude that the present study may be underpowered.

We propose that CEPPIS, a score principally based on chest echography and procalcitonin levels, might be better associated with the diagnosis of VAP. Despite its limitations, we are optimistic about the validity of CEPPIS. Prospective studies of unselected patients evaluating CEPPIS are needed before we can state solid conclusions regarding the potential value of this score to facilitate VAP diagnosis.

Author contributions: G. Z. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. G. Z. and A. P. contributed to the study design; G. Z., M. C., and A. P. contributed to the literature review and writing of the manuscript; G. Z., M. C., A. T., T. B., and A. L. C. contributed to the data collection; G. Z. contributed to the statistical analysis; and G. Z., M. C., A. T., T. B., A. L. C., and A. P. contributed to the revision of the manuscript and approval of the final version.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

CEPPIS

Chest Echography and Procalcitonin Pulmonary Infection Score

CPIS

Clinical Pulmonary Infection Score

LOS

length of stay

VAP

ventilator-associated pneumonia

American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [CrossRef] [PubMed]
 
Tejerina E, Frutos-Vivar F, Restrepo MI, et al; Internacional Mechanical Ventilation Study Group. Incidence, risk factors, and outcome of ventilator-associated pneumonia. J Crit Care. 2006;21(1):56-65. [CrossRef] [PubMed]
 
Rello J, Ollendorf DA, Oster G, et al; VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122(6):2115-2121. [CrossRef] [PubMed]
 
Melsen WG, Rovers MM, Koeman M, Bonten MJ. Estimating the attributable mortality of ventilator-associated pneumonia from randomized prevention studies. Crit Care Med. 2011;39(12):2736-2742. [PubMed]
 
Johanson WG Jr, Pierce AK, Sanford JP, Thomas GD. Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med. 1972;77(5):701-706. [CrossRef] [PubMed]
 
Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis. 1991;143(5 pt 1):1121-1129. [CrossRef] [PubMed]
 
Fàbregas N, Ewig S, Torres A, et al. Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies. Thorax. 1999;54(10):867-873. [CrossRef] [PubMed]
 
Lauzier F, Ruest A, Cook D, et al; Canadian Critical Care Trials Group. The value of pretest probability and modified clinical pulmonary infection score to diagnose ventilator-associated pneumonia. J Crit Care. 2008;23(1):50-57. [CrossRef] [PubMed]
 
Peris A, Tutino L, Zagli G, et al. The use of point-of-care bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients. Anesth Analg. 2010;111(3):687-692. [CrossRef] [PubMed]
 
Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002;165(7):867-903. [CrossRef] [PubMed]
 
Rello J, Diaz E, Rodríguez A. Advances in the management of pneumonia in the intensive care unit: review of current thinking. Clin Microbiol Infect. 2005;11(suppl 5):30-38. [CrossRef] [PubMed]
 
Chastre J, Fagon JY, Bornet-Lecso M, et al. Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med. 1995;152(1):231-240. [CrossRef] [PubMed]
 
Peris A, Zagli G, Barbani F, et al. The value of lung ultrasound monitoring in H1N1 acute respiratory distress syndrome. Anaesthesia. 2010;65(3):294-297. [CrossRef] [PubMed]
 
Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: bedside lung ultrasound in critical care practice. Crit Care. 2007;11(1):205. [CrossRef] [PubMed]
 
Volpicelli G, Elbarbary M, Blaivas M, et al; International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. [CrossRef] [PubMed]
 
Bouadma L, Luyt CE, Tubach F, et al; PRORATA Trial Group. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet. 2010;375(9713):463-474. [CrossRef] [PubMed]
 
Fartoukh M, Maitre B, Honoré S, Cerf C, Zahar JR, Brun-Buisson C. Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med. 2003;168(2):173-179. [CrossRef] [PubMed]
 
Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med. 2000;162(2):505-511. [CrossRef] [PubMed]
 
Patroniti N, Zangrillo A, Pappalardo F, et al. The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks. Intensive Care Med. 2011;37(9):1447-1457. [CrossRef] [PubMed]
 
Duflo F, Debon R, Monneret G, Bienvenu J, Chassard D, Allaouchiche B. Alveolar and serum procalcitonin: diagnostic and prognostic value in ventilator-associated pneumonia. Anesthesiology. 2002;96(1):74-79. [CrossRef] [PubMed]
 
Ramirez P, Garcia MA, Ferrer M, et al. Sequential measurements of procalcitonin levels in diagnosing ventilator-associated pneumonia. Eur Respir J. 2008;31(2):356-362. [CrossRef] [PubMed]
 
Schurink CA, Van Nieuwenhoven CA, Jacobs JA, et al. Clinical pulmonary infection score for ventilator-associated pneumonia: accuracy and inter-observer variability. Intensive Care Med. 2004;30(2):217-224. [CrossRef] [PubMed]
 
Henschke CI, Yankelevitz DF, Wand A, Davis SD, Shiau M. Accuracy and efficacy of chest radiography in the intensive care unit. Radiol Clin North Am. 1996;34(1):21-31. [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Flow diagram of the retrospective enrollment in the study. Percentages refer to the total ICU admissions during the study period. VAP = ventilator-associated pneumonia.Grahic Jump Location
Figure Jump LinkFigure 2 –  Distribution of CEPPIS values in microbiologically confirmed VAP and control groups. CEPPIS = Chest Echography and Procalcitonin Pulmonary Infection Score. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  The Proposed CEPPIS Compared With the Original CPIS

ARDS is defined as a Pao2/Fio2 ≤ 200, pulmonary artery wedge pressure < 18 mm Hg, and acute bilateral infiltrates. CEPPIS = Chest Echography and Procalcitonin Pulmonary Infection Score; CPIS = Clinical Pulmonary Infection Score.

Table Graphic Jump Location
TABLE 2 ]  Clinical Characteristics of the Microbiologically Confirmed VAP and Control Groups

Data are presented as mean ± SD or % (No.) unless otherwise indicated. Percentages refer to the total population of each group. For definition, ISS was calculated only in trauma patients. Statistical analysis included two-tailed Mann-Whitney test and two-tail Fisher exact test. P < .05 (infection vs control) was considered significant. ISS = Injury Severity Score; LOS = length of stay; SAPS = Simplified Acute Physiology Score; VAP = ventilator-associated pneumonia.

Table Graphic Jump Location
TABLE 3 ]  Microbiology Results in Microbiologically Confirmed VAP Group

See Table 2 legend for expansion of abbreviation.

Table Graphic Jump Location
TABLE 4 ]  Univariate and Multivariate (in P < .10, out P < .05) Analysis for VAP Risk in Overall Population

See Table 2 legend for expansion of abbreviations.

Table Graphic Jump Location
TABLE 5 ]  Comparison of CEPPIS, CPIS, Chest Echography, Procalcitonin Level, and Chest Echography + Procalcitonin Level as Predictors of VAP Diagnosis

NPV = negative predictive value; PPV = positive predictive value. See Table 1 and 2 legends for expansion of other abbreviations.

Table Graphic Jump Location
TABLE 6 ]  Receiver Operating Characteristic AUCs of CEPPIS, CPIS, Chest Echography, Procalcitonin Level, and Chest Echography + Procalcitonin Level

AUC = area under the curve. See Table 1 legend for expansion of other abbreviations.

References

American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [CrossRef] [PubMed]
 
Tejerina E, Frutos-Vivar F, Restrepo MI, et al; Internacional Mechanical Ventilation Study Group. Incidence, risk factors, and outcome of ventilator-associated pneumonia. J Crit Care. 2006;21(1):56-65. [CrossRef] [PubMed]
 
Rello J, Ollendorf DA, Oster G, et al; VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122(6):2115-2121. [CrossRef] [PubMed]
 
Melsen WG, Rovers MM, Koeman M, Bonten MJ. Estimating the attributable mortality of ventilator-associated pneumonia from randomized prevention studies. Crit Care Med. 2011;39(12):2736-2742. [PubMed]
 
Johanson WG Jr, Pierce AK, Sanford JP, Thomas GD. Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med. 1972;77(5):701-706. [CrossRef] [PubMed]
 
Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis. 1991;143(5 pt 1):1121-1129. [CrossRef] [PubMed]
 
Fàbregas N, Ewig S, Torres A, et al. Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies. Thorax. 1999;54(10):867-873. [CrossRef] [PubMed]
 
Lauzier F, Ruest A, Cook D, et al; Canadian Critical Care Trials Group. The value of pretest probability and modified clinical pulmonary infection score to diagnose ventilator-associated pneumonia. J Crit Care. 2008;23(1):50-57. [CrossRef] [PubMed]
 
Peris A, Tutino L, Zagli G, et al. The use of point-of-care bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients. Anesth Analg. 2010;111(3):687-692. [CrossRef] [PubMed]
 
Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002;165(7):867-903. [CrossRef] [PubMed]
 
Rello J, Diaz E, Rodríguez A. Advances in the management of pneumonia in the intensive care unit: review of current thinking. Clin Microbiol Infect. 2005;11(suppl 5):30-38. [CrossRef] [PubMed]
 
Chastre J, Fagon JY, Bornet-Lecso M, et al. Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med. 1995;152(1):231-240. [CrossRef] [PubMed]
 
Peris A, Zagli G, Barbani F, et al. The value of lung ultrasound monitoring in H1N1 acute respiratory distress syndrome. Anaesthesia. 2010;65(3):294-297. [CrossRef] [PubMed]
 
Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: bedside lung ultrasound in critical care practice. Crit Care. 2007;11(1):205. [CrossRef] [PubMed]
 
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