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(Chest. 2000;117:212S-218S.)
© 2000 American College of Chest Physicians

Bronchoscopy in Nonresolving Nosocomial Pneumonia*

Michael S. Niederman, MD, FCCP

* From the Division of Pulmonary and Critical Care Medicine, Winthrop University Hospital, Mineola, NY.


   Introduction
TOP
 Introduction
Can Clinical Features Be...
 Defining Pneumonia Resolution
 Are Serial Bronchoscopy Data...
 Conclusions
 References
 
Few investigators have studied the role of bronchoscopy in evaluating and managing patients with nosocomial pneumonia who are not responding to initial antibiotic therapy. This discussion examines whether the information provided by bronchoscopy has value in this setting, as well as whether the concept of using bronchoscopy for the nonresponding patient is a logical one.

Importantly, serial bronchoscopy is generally performed while the patient is receiving antibiotic therapy. Such therapy can reduce the yield and accuracy of quantitative cultures of respiratory secretions. The presumption for using serial cultures in the nonresponding patient is that bacteria are present that have not been eliminated by currently administered antibiotics. Moreover, these organisms can be identified early enough so that changes in therapy will improve the outcome in these patients.


   Can Clinical Features Be Used to Predict the Likelihood of a Nonresponse to Therapy?
TOP
 Introduction
 Can Clinical Features Be...
Defining Pneumonia Resolution
 Are Serial Bronchoscopy Data...
 Conclusions
 References
 
A number of clinical findings have been identified as risk factors for mortality from nosocomial pneumonia. If a patient has a multitude of these features and is not responding to initial antibiotic therapy, the nonresponse may be the inevitable outcome of serious systemic illness and comorbidity. Serial bronchoscopic data are unlikely to reduce the expected high mortality rate in such a population. Such risk factors, identified in multivariate analysis, included the following: prolonged duration of ventilation, coma on admission, creatinine levels > 1.5 mg/dL, and transfer to the ICU from another ward67 ; the presence of certain high-risk pathogens, abnormal bilateral radiographic findings, inappropriate initial therapy, age > 60 years, and an ultimately terminal underlying condition62 ; shock, inappropriate initial therapy, and rapidly fatal underlying illness44 ; prior antibiotic therapy128 ; infection with a resistant organism, particularly Pseudomonas aeruginosa or Staphylococcus aureus129 ; multiple systems organ failure, nonsurgical primary diagnosis, late-onset infection with a high-risk pathogen, and prophylaxis for intestinal bleeding with a pH-elevating agent.127 More recently, Rello et al130 observed that if acute physiology and chronic health evaluation (APACHE) II scores are followed serially after the onset of P aeruginosa ventilator-associated pneumonia (VAP), the mortality rate in patients who had a rising score at 72 h, particularly if this score was >= 20, was nearly 100% (Table 22) .


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  		Table 22.. Studies Defining Risk Factors for Mortality in VAP*

 

   Defining Pneumonia Resolution
TOP
 Introduction
 Can Clinical Features Be...
 Defining Pneumonia Resolution
Are Serial Bronchoscopy Data...
 Conclusions
 References
 
The resolution of nosocomial pneumonia can be de fined clinically or microbiologically, but presumably a clinical nonresponse will the prompt consideration of bronchoscopic evaluation. Definable clinical end points include the following: resolution of all signs and symptoms of infection; improvement in all signs and symptoms of infection; slow or delayed resolution of signs and symptoms; relapse after initial infection (presumably representing recurrent infection); progression of signs and symptoms (rapid or gradual); superinfection that clinically resembles delayed resolution, progression, or relapse, but is characterized by these clinical findings in conjunction with the microbiological finding of an organism not present at the onset of pneumonia; and, finally, death due to unresolved infection, the ultimate outcome of a lack of response to therapy. Measurements to define these clinical end points include assessment of the following: fever, sputum purulence, leukocytosis, oxygenation, radiographic improvement, duration of organ failure, duration of mechanical ventilation, and need for changes in antibiotic therapy.

One way to assess the clinical resolution of pneumonia is to combine a number of clinical findings into a scoring system, such as the clinical pulmonary infection score (CPIS) of Pugin et al30 Using a modification of this system, Garrard and A’Court131 measured the CPIS on a daily basis in 83 patients with nosocomial pneumonia. The CPIS was used to diagnose pneumonia if the score was >= 6 (highest possible score, 10), based on the assessment of five variables, each with a score range of 0 to 2. These variables were the following: temperature, WBC count, purulence of secretions, oxygenation, and extent of radiographic infiltrates. The CPIS was observed to increase progressively from a baseline value of < 6 to a value of > 6 over the 2 days preceding the day of diagnosis and initiation of antibiotic therapy.30 Once therapy was begun, the CPIS fell gradually over the next 9 days, generally dropping below 6 by the fifth day. When the CPIS did not fall, clinical deterioration was usually due to infection with P aeruginosa.

Resolution also can be defined by bacteriologic end points that are based on the assessment of serial qualitative cultures of respiratory secretions. Microbiological eradication is defined by the elimination of the original pathogen from the culture of the secretion, usually sputum. Persistence is defined by a failure to eliminate the organism. Reinfection refers to elimination of the organism, followed by its return, and superinfection refers to the appearance of a new organism in the culture. Quantitative microbiology cultures of respiratory secretions obtained bronchoscopically or nonbronchoscopically also can be used to define the resolution of nosocomial pneumonia.

Garrard and A’Court131 used serial quantitative cultures of nondirected, nonbronchoscopic lung specimens obtained by lavage from patients receiving ventilation who have nosocomial pneumonia and correlated the findings with serial measurement using the CPIS. Using a 14-gauge tracheal suction catheter with 20 mL normal saline solution, the authors evaluated 89 episodes of nosocomial in 83 patients by using alternate-day sampling and quantitative cultures of respiratory secretions. Culture counts rose during the 2 days preceding the clinical onset of pneumonia and fell rapidly with the initiation of therapy. Patients showing a clinical response to therapy had a rapid fall in colony counts by 24 h, in most instances, and usually no later than 48 to 72 h, unless there was a lack of response to treatment. The patients who had no response to treatment usually had P aeruginosa pneumonia; these patients had a persistence of colony counts of > 10,000 cfu/mL and a high mortality rate. Serial quantitative cultures correlated well with clinical response and mortality, with the counts of those patients responding falling rapidly. This microbiological pattern was analogous to the clinical findings, as reflected by the CPIS. Nonresponse to therapy was not predicted more accurately by microbiological findings than by clinical findings. While a microbiological nonresponse could be defined at 24 to 72 h, recognizing a clinical nonresponse generally took longer.

Serial bronchoscopy also has been used to determine whether a patient is not responding to initial therapy, and if so, why. Dreyfuss et al60 collected data using a serial protected-specimen brush (PSB) technique for 34 episodes in 30 patients in whom there was clinical suspicion of pneumonia and found borderline results (102 to 103 cfu/mL) with the initial cultures. Patients had repeat bronchoscopy within 72 h if the suspicion of pneumonia persisted and if patients were not given antibiotics. In 12 episodes, the same organism was isolated on the repeat bronchoscopy, but the concentration was then > 103 cfu/mL and antibiotics were given. In 22 episodes, pneumonia was excluded as a diagnosis. The mortality rate in the eight patients having a positive culture finding on repeat bronchoscopy was 75% (6 patients), which was significantly higher than the mortality rate in the 18 patients with a negative culture finding on repeat bronchoscopy (22%; 4 patients; p < 0.04). Serial bronchoscopy can identify pneumonia patients who cannot contain a bacterial challenge or who had a prior false-negative culture finding. The high mortality rate may be related to the delayed initiation of antibiotic therapy after an initial false-negative culture result.

Montravers et al32 studied the results of cultures with specimens gathered using the serial PSB method in 76 patients with VAP. A clinical suspicion of pneumonia in the enrolled patients was confirmed by a bacteria count of >= 103 cfu/mL in a sample. The clinicians’ initial antibiotic choice was modified on the basis of bronchoscopy results. All patients had a second bronchoscopy 3 days after entry into the study. The clinical outcome and serial microbiological data were compared, with clinical outcomes classified as improved, relapse, or failure. Bacteriologic outcomes were grouped by the eradication of the pathogen, the continued isolation of the pathogen, or the emergence of a new pathogen. Any pathogens present on the repeat bronchoscopy were noted as being at low (ie, < 103 cfu/mL) or high (ie, >= 103 cfu/mL) concentrations.

In the study by Montravers et al32 , 51 patients had sterile pulmonary secretions by day 3, 16 patients had persistent low-level infection, and 9 patients had persistent high-level infection (Table 23) . Clinical improvement was seen in 96% of those with microbiological eradication, in 81% of those with persistent low-level infection, and in 44% of those with persistent high-level infection (p < 0.01).


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  		Table 23.. Studies of Repeat Bronchoscopy During the Course of Suspected VAP*

 
Follow-up bronchoscopy can be used to identify patients with a clinical nonresponse to therapy. The highest rates of clinical nonresponse occurred in the patient whose follow-up bronchoscopy showed a high concentration of bacteria. The finding of persistent bacterial infection can be used to predict a poor outcome, but there are no data to suggest that interventions based on these results will improve patient outcome.


   Are Serial Bronchoscopy Data Likely to Help the Nonresponding Patient?
TOP
 Introduction
 Can Clinical Features Be...
 Defining Pneumonia Resolution
 Are Serial Bronchoscopy Data...
Conclusions
 References
 
The results of the study by Montravers et al32 suggest that data taken from serial PSB sampling provide a microbiological explanation for clinical nonresponse. However, it is uncertain whether this information leads to improved outcome. The outcome in patients with nosocomial pneumonia may be dictated by the efficacy of initial therapy. Bronchoscopic data may be available too late to influence the course of illness.

Luna et al33 used bronchoscopy with quantitative BAL and found an etiologic pathogen in 65 of 132 patients (49%) who had a clinical diagnosis of nosocomial pneumonia. More than half of the patients were already receiving antibiotics for either community-acquired pneumonia or a previous episode of nosocomial pneumonia. In this group, 50 of the 65 patients (77%) received immediate antibiotic therapy, prior to the bronchoscopy, which was performed within 24 h after the clinical diagnosis of pneumonia. For 16 of 65 patients (25%) whose initial therapy was adequate (as defined by BAL bacteriology study), the mortality rate was 38%; for those with inadequate therapy, the mortality rate was 91%.

After bronchoscopy was completed, 42 of the 65 patients (65%) received adequate therapy and the other 23 received inadequate therapy, but the mortality rate in the two groups was comparable. Similarly, outcomes did not improve after bronchoscopic data were known, although almost all patients received adequate therapy at that time. The generalizability of these findings is limited by the very high mortality rates reported by Luna et al33 in all patient groups. Bronchoscopy may identify organisms that are not responding to the initial antibiotic regimen. Whether this information will improve the outcome is uncertain but needs to be formally investigated.

Recently Rello et al132 studied 113 patients with VAP, 100 of whom (88%) had an organism identified by bronchoscopy. Based on these data, 27 patients had initial inadequate antibiotic therapy. This group had a significantly higher mortality rate than those receiving adequate therapy (37% vs 15.4%, respectively). However, when antibiotic therapy was changed, based on bronchoscopic data, 17 of the 27 patients (63%) had clinical resolution, and 10 of those 17 patients (59%) survived and were discharged. Thus, bronchoscopically directed changes in therapy may have been beneficial, although aspiration cultures may have provided similar data.

The potential limitations of serial bronchoscopy include the following: (1) information may become available too late; (2) the bacteriologic information could be provided by simpler, more readily available methods, such as tracheal aspiration culture; and (3) repeat testing usually isolates highly resistant organisms that would not be eliminated by changes in antibiotic therapy. The last limitation was suggested by Garrard and A’Court,131 who found that nonresponding patients had persistent high-level infections with organisms that are difficult to eradicate, such as P aeruginosa. Similarly, Silver et al133 described the phenomenon of recurrent infection with P aeruginosa in critically ill patients. Silver et al133 documented that recurrent infection with this organism is common (ie, found in 10 of 20 patients [50%] who survived a first episode of P aeruginosa pneumonia) and often fatal (mortality rate, 60% for those patients with recurrent P aeruginosa pneumonia vs 10% for those without).

Souweine and colleagues36 confirmed that bronchoscopy can identify the bacteria responsible for nonresponse to therapy in patients with VAP. When bronchoscopy was performed in 31 patients who had received antibiotic therapy for > 72 h, diagnostic sensitivity was 83% for BAL and 77% for PSB. Of the 15 organisms isolated, 11 were resistant to the current antibiotic, suggesting that bronchoscopy can document the presence of persistent and resistant pathogens in patients not responding to therapy.


   Conclusions
TOP
 Introduction
 Can Clinical Features Be...
 Defining Pneumonia Resolution
 Are Serial Bronchoscopy Data...
 Conclusions
References
 

The impact of repeated quantitative cultures (bronchoscopic or nonbronchoscopic) on the outcomes of patients with VAP has been incompletely studied.
Serial microbiological diagnostic studies in VAP patients may identify those at increased risk for mortality.
With invasive techniques, the persistent recovery of high concentrations of potential pathogens identifies patients at high risk for mortality.
There are insufficient data to show that repeated bronchoscopy affects the survival rate of patients who did not respond to initial therapy.


   Footnotes
 
Abbreviations: APACHE = acute physiology and chronic health evaluation; CPIS = clinical pulmonary infection score; PSB = protected-specimen brush; VAP = ventilator-associated pneumonia


   References
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 Introduction
 Can Clinical Features Be...
 Defining Pneumonia Resolution
 Are Serial Bronchoscopy Data...
 Conclusions
 References
 

  1. Wimberly, N, Faling, L, Bartlett, J (1979) A fiberoptic bronchoscopy technique to obtain uncontaminated lower airway secretions for bacterial culture. Am Rev Respir Dis 119,337-343[ISI][Medline]
  2. Niedermann M, Torres A, Summer W. Invasive diagnostic testing is not needed routinely to manage suspect ventilator-associated pneumonia. Am J Respir Crit Care Med 1994:565–569
  3. Chastre J, Fagon J. Invasive diagnostic testing should be routinely used to manage ventilated patients with suspected pneumonia. Am J Respir Crit Care Med 1994:570–574
  4. Kollef, M (1993) Ventilator-associated pneumonia. JAMA 270,1965-1970[Abstract]
  5. . American Thoracic Society. (1995) Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies. Am J Respir Crit Care Med 153,1711-1725[ISI][Medline]
  6. Fagon, J, Chastre, J, Hance, A, et al (1993) Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94,281-288[CrossRef][ISI][Medline]
  7. Boyce, J, Potter-Bynoe, G, Dziobek, L, et al (1991) Nosocomial pneumonia in Medicare patients: hospital costs and reimbursement patterns under the prospective payment system. Arch Intern Med 151,1109-1114[CrossRef][ISI][Medline]
  8. Wunderink, R, Woldenberg, L, Zeiss, J, et al (1992) Radiologic diagnosis of autopsy-proven ventilator-associated pneumonia. Chest 101,458-463[Abstract/Free Full Text]
  9. Winer-Muram, H, Rubin, S, Ellis, J, et al (1993) Pneumonia, and ARDS. in patients receiving mechanical ventilation: Diagnostic accuracy of chest radiography. Radiology 188,479-485[Abstract/Free Full Text]
  10. Lefcoe, M, Fox, G, Leasa, D (1994) Accuracy of portable chest radiography in the critical care setting: diagnosis of pneumonia based on quantitative cultures obtained from protected brush catheter. Chest 105,885-887[Abstract/Free Full Text]
  11. Fagon, J, Chastre, J, Hance, A (1993) Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest 103,547-553[Abstract/Free Full Text]
  12. Sutherland, K, Steinberg, K, Maunder, R, et al (1995) Pulmonary infection during the acute respiratory distress syndrome. Am J Respir Crit Care Med 152,550-556[Abstract]
  13. El-Ebiary, M, Torres, A, Gonzalez, J, et al (1993) Quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia. Am Rev Respir Dis 148,1552-1557[ISI][Medline]
  14. Sauaia, A, Moore, F, Moore, E, et al (1993) Diagnosing pneumonia in mechanically ventilated trauma patients: endotracheal aspirate versus bronchoalveolar lavage. J Trauma 35,512-517[ISI][Medline]
  15. Torres, A, Puig de la Bellacasa, J, Xaubet, A, et al (1989) Diagnostic value of quantitative cultures of bronchoalveolar lavage and telescoping plugged catheters in mechanically ventilated patients with bacterial pneumonia. Am Rev Respir Dis 140,306-310[ISI][Medline]
  16. Lambert, R, Vereen, L, George, R (1989) Comparison of tracheal aspirates and protected brush catheter specimens for identifying pathogenic bacteria in mechanically ventilated patients. Am J Med Sci 297,377-382[ISI][Medline]
  17. Shepherd, K, Lynch, J, Brown, E, et al (1995) Elastin fibers and the diagnosis of bacterial pneumonia in adult respiratory distress syndrome. Crit Care Med 23,1829-1834[CrossRef][ISI][Medline]
  18. Marquette, C, Copin, M, Wallet, F, et al (1995) Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard. Am J Respir Crit Care Med 151,1878-1888[Abstract]
  19. Solé-Violán, J, Rodriguez de Castro, F, Rey, A, et al (1996) Comparison of bronchoscopic diagnostic techniques with histological findings in brain dead organ donors without suspected pneumonia. Thorax 51,929-931[Abstract/Free Full Text]
  20. Papazian L, Thomas P, Garbe L, et al. Bronchoscopic or blind sampling techniques for the diagnosis of ventilator-associated pneumonia. Am J Respir Crit Care Med 1995:1982–1991
  21. Timsit, J-F, Misset, B, Goldstein, F, et al (1995) Reappraisal of distal diagnostic testing in the diagnosis of ICU-acquired pneumonia. Chest 108,1632-1639[Abstract/Free Full Text]
  22. Vallés, J, Rello, J, Fernandez, R, et al (1994) Role of bronchoalveolar lavage in mechanically ventilated patients with suspected pneumonia. Eur J Clin Microbiol Infect Dis 13,549-558[CrossRef][ISI][Medline]
  23. Torres, A, Martos, A, Puig de la Bellacasa, J, et al (1993) Specificity of endotracheal aspiration, protected specimen brush, and bronchoalveolar lavage in mechanically ventilated patients. Am Rev Respir Dis 147,952-957[ISI][Medline]
  24. Chastre, J, Fagon, J, Soler, P, et al (1988) Diagnosis of nosocomial bacterial pneumonia in intubated patients undergoing ventilation: comparison of the usefulness of bronchoalveolar lavage and the protected specimen brush. Am J Med 85,499-506[ISI][Medline]
  25. Montravers, P, Gauzit, R, Dombret, M, et al (1993) Cardiopulmonary effects of bronchoalveolar lavage in critically ill patients. Chest 104,1541-1547[Abstract/Free Full Text]
  26. Baughman, R, Thorpe, J, Staneck, J, et al (1987) Use of the protected specimen brush in patients with endotracheal or tracheostomy tubes. Chest 91,233-236[Abstract/Free Full Text]
  27. Marquette, C, Herengt, F, Mathieu, D, et al (1993) Diagnosis of pneumonia in mechanically ventilated patients: repeatability of the protected specimen brush. Am Rev Respir Dis 147,211-214[ISI][Medline]
  28. Timsit, J-F, Misset, B, Renaud,, et al (1995) Effect of previous antimicrobial therapy on the accuracy of the main procedures used to diagnose nosocomial pneumonia in patients who are using ventilation. Chest 108,1036-1040[Abstract/Free Full Text]
  29. Chastre, J, Viau, F, Brun, P, et al (1984) Prospective evaluation of the protected specimen brush for the diagnosis of pulmonary infections in the ventilated patients. Am Rev Respir Dis 130,924-929[ISI][Medline]
  30. Pugin, J, Auckenthaler, R, Mili, N, et al (1991) Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic "blind" bronchoalveolar lavage fluid. Am Rev Respir Dis 143,1121-1129[ISI][Medline]
  31. Marik, P, Brown, W (1995) A comparison of bronchoscopic vs blind protected speciman brush sampling in patients with suspected ventilator-associated pneumonia. Chest 108,203-207[Abstract/Free Full Text]
  32. Montravers, P, Fagon, J, Chastre, J, et al (1993) Follow-up protected specimen brushes to assess treatment in nosocomial pneumonia. Am Rev Respir Dis 147,38-44[ISI][Medline]
  33. Luna, C, Vujacich, P, Niederman, M, et al (1997) Impact of BAL data on the therapy and outcome of ventilator associated pneumonia. Chest 111,676-685[Abstract/Free Full Text]
  34. Sanchez-Nieto, J, Torres, A, Garcia-Cordoba, F, et al (1998) Impact of invasive and non-invasive quantitative culture sampling on outcome of ventilator-associated pneumonia. Am J Respir Crit Care Med 157,371-376[Abstract/Free Full Text]
  35. Bonten, M, Bergmans, D, Stobberingh, E, et al (1997) Implementation of bronchoscopic techniques in the diagnosis of ventilator-associated pneumonia to reduce antibiotic use. Am J Respir Crit Care Med 156,1820-1824[Abstract/Free Full Text]
  36. Souweine, B, Verber, B, Bedos, J, et al (1998) Diagnostic accuracy of protected specimen brush and bronchoalveolar lavage in nosocomial pneumonia: impact of previous antimicrobial treatments. Crit Care Med 26,236-244[CrossRef][ISI][Medline]
  37. Rouby, J, Rossignon, M, Nicholas, M, et al (1989) A prospective study of protected bronchoalveolar lavage in the diagnosis of nosocomial pneumonia. Anesthesiology 71,679-685[ISI][Medline]
  38. Bell, R, Coalson, J, Smith, J, et al (1983) Multiple organ system failure and infection in adult respiratory distress syndrome. Ann Intern Med 99,293-298
  39. Andrews, C, Coalson, J, Smith, J (1981) Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury. Chest 80,254-258[Abstract/Free Full Text]
  40. Fagon, J, Chastre, J, Hance, A, et al (1988) Detection of nosocomial lung infection in ventilated patients: use of a protected specimen brush and quantitative culture techniques in 147 patients. Am Rev Respir Dis 138,110-116[ISI][Medline]
  41. Torres, A, El-Ebiary, M, Padró, L, et al (1994) Validation of different techniques for the diagnosis of ventilator-associated pneumonia: comparison with immediate postmortem pulmonary biopsy. Am J Respir Crit Care Med 149,324-331[Abstract]
  42. Sackett, DL, Richardson, WS, Rosenberg, W, et al (1997) Evidence-based medicine. how to practice and teach EBM. ,124-125 Churchill Livingstone New York, NY.
  43. Rodriguez de Castro, F, Solé, J, Elcuaz, R (1994) Quantitative cultures of protected brush specimens and bronchoalveolar lavage in ventilated patients without suspected pneumonia. Am J Respir Crit Care Med 149,320-332[Abstract]
  44. Fagon, J, Chastre, J, Domart, Y, et al (1989) Nosocomial pneumonia in patients receiving continuous mechanical ventilation: prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis 139,877-884[ISI][Medline]
  45. Torres, A, Aznar, R, Gatell, J, et al (1990) Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 142,523-528[ISI][Medline]
  46. Torres, A, Puig de la Bellacasa, J, Rodriguez Roisin, R, et al (1988) Diagnostic value of telescoping plugged catheters in mechanically ventilated patients with bacterial pneumonia using the Metras catheter. Am Rev Respir Dis 138,117-120[ISI][Medline]
  47. Bartlett, J, O’Keefe, P, Tally, F, et al (1986) Bacteriology of hospital-acquired pneumonia. Arch Intern Med 146,868-871[CrossRef][ISI][Medline]
  48. Rello, J, Quintana, E, Ausina, V, et al (1991) Incidence, etiology, and outcome of nosocomial pneumonia in mechanically ventilated patients. Chest 100,439-444[Abstract/Free Full Text]
  49. Horan T, Culver D, Jarvis, et al. Pathogens causing nosocomial infections. CDC Antimicrobe Newsletter 1988:65–67
  50. Tablan, O, Anderson, L, Arden, N, et al (1994) Guideline for prevention of nosocomial pneumonia: Part 1. Issues on prevention of nosocomial pneumonia. Infect Control Hosp Epidemiol 15,588-625
  51. Weinstein, R (1991) Epidemiology and control of nosocomial infections in adult intensive care units. Am J Med 91,3B-179S–3B-184S
  52. Prod’hom, G, Leuenberger, P, Koerfer, J, et al (1994) Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. Ann Intern Med 120,653-662[Abstract/Free Full Text]
  53. Reusser, P, Zimmerli, W, Scheidegger, D, et al (1989) Role of gastric colonization in nosocomial infections and endotoxemia: a prospective study in neurosurgical patients on mechanical ventilation. J Infect Dis 60,414-421
  54. Vallés, J, Artigas, A, Rello,, et al (1995) Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med 122,179-186[Abstract/Free Full Text]
  55. Schleupner, C, Cobb, D (1992) A study of the etiologies and treatment of nosocomial pneumonia in a community-based teaching hospital. Infect Control Hosp Epidemiol 13,515-525[ISI][Medline]
  56. Dal Nogare, A (1994) Nosocomial pneumonia outside the intensive care unit. Niederman, MS Sarosi, GA Glassroth, J eds. Respiratory infections ,139-146 WB Saunders Philadelphia, PA.
  57. Maki, D (1978) Control of colonization and transmission of pathogenic bacteria in the hospital. Ann Intern Med 89,777-780
  58. Inglis, T, Sproat, L, Hawkey, P, et al (1993) Staphylococcal pneumonia in ventilated patients: a twelve month review of cases in an intensive care unit. J Hosp Infect 25,207-210[CrossRef][ISI][Medline]
  59. Rello, J, Torres, A, Ricart, M, et al (1994) Ventilator-associated pneumonia by Staphylococcus aureus: comparison of methicillin-resistant and methicillin-sensitive episodes. Am J Respir Crit Care Med 150,1545-1549[Abstract]
  60. Craven, D, Reed, C, Kollisch, N, et al (1981) A large outbreak of infections caused by a strain of Staphylococcus aureus resistant to oxacillin and aminoglycosides. Am J Med 71,53-58[CrossRef][ISI][Medline]
  61. Dreyfuss, D, Mier, L, Le Bordelles, G, et al (1993) Clinical significance of borderline quantitative protected specimen culture results. Am Rev Respir Dis 147,946-951[ISI][Medline]
  62. Hanson, L, Weber, D, Rutala,, et al (1992) Risk factors for nosocomial pneumonia in the elderly. Am J Med 92,161-166[CrossRef][ISI][Medline]
  63. Celis, R, Torres, A, Gatell, J, et al (1988) Nosocomial pneumonia: a multivariate analysis of risk and prognosis. Chest 93,318-324[Abstract/Free Full Text]
  64. Cross, A, Roup, B (1981) Role of respiratory assistance devices in endemic nosocomial pneumonia. Am J Med 70,681-685[CrossRef][ISI][Medline]
  65. Haley, R, Hooton, T, Culver, D, et al (1981) Nosocomial infections in U.S. hospitals, 1975–1976: estimate frequency by selected characteristics of patients Am J Med 70,947-959[CrossRef][ISI][Medline]
  66. Langer, M, Mosconi, P, Cigada, M, et al (1989) Long-term respiratory support and risk of pneumonia in critically ill patients. Am Rev Respir Dis 140,302-305[ISI][Medline]
  67. George, D (1993) Epidemiology of nosocomial ventilator-associated pneumonia. Infect Control Hosp Epidemiol 14,163-169[ISI][Medline]
  68. Craven, D, Kunches, L, Kilinsky, V, et al (1986) Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 133,792-796[ISI][Medline]
  69. Rhame, F, Streifel, A, Kersey, J, et al (1984) Extrinsic risk factors for pneumonia in the patient at high risk for infection. Am J Med 76,42-52[CrossRef][ISI][Medline]
  70. Driks, M, Craven, D, Celli, B, et al (1987) Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers: the role of gastric colonization. N Engl J Med 317,1376-1382[Abstract]
  71. Chevret, S, Hemmer, M, Carlet, J, et al (1993) Incidence and risk factors of pneumonia acquired in intensive care units. Intensive Care Med 19,256-264[CrossRef][ISI][Medline]
  72. Kirby, B, Snyder, K, Meyer, R, et al (1980) Legionnaires’ disease: report of sixty-five nosocomially acquired cases and review of the literature. Medicine 59,188-205[Medline]
  73. Jarvis, W, Edwards, J, Culver, D, et al (1991) Nosocomial infection rates in adult and pediatric intensive care units in the United States. Am J Med 91(suppl 3B),185S-191S[CrossRef][Medline]
  74. Lareau, S, Ryan, K, Diener, C (1978) The relationship between frequency of ventilator circuit changes and infectious hazard. Am Rev Respir Dis 118,493-496[ISI][Medline]
  75. Graybill, J, Marshall, L, Charache, P, et al (1973) Nosocomial pneumonia: a continuing major problem. Am Rev Respir Dis 108,1130-1140[ISI][Medline]
  76. Gross, P, Neu, H, Aswapokee, P, et al (1980) Deaths from nosocomial infections: experience in a university hospital and a community hospital. Am J Med 68,219-223[CrossRef][ISI][Medline]
  77. Freeman, J, Rosner, B, McGowan, J (1979) Adverse effects of nosocomial infection. J Infect Dis 140,732-740[ISI][Medline]
  78. Craven, D, Steger, K, Fleming, C (1997) Preventing hospital-acquired pneumonia: current concepts and strategies. Semin Respir Crit Care Med 18,85-200
  79. Daschner, F, Nadjem, H, Langmaack, H, et al (1978) Surveillance, prevention and control of hospital-acquired infections: III. Nosocomial infections as cause of death: retrospective analysis of 1,000 autopsy reports. Infection 6,261-265[CrossRef][ISI][Medline]
  80. Craig, C, Connelly, S (1984) Effect of intensive care unit nosocomial pneumonia on duration of stay and mortality. Am J Infect Control 12,233-238[CrossRef][ISI][Medline]
  81. Baker, A, Meredeth, J, Haponik, E (1996) Pneumonia in intubated trauma patients: microbiology and outcomes. Am J Respir Crit Care Med 153,343-349[Abstract]
  82. Papazian, L, Bregeon, F, Thirion, X, et al (1996) Effect of ventilator-associated pneumonia on mortality and morbidity. Am J Respir Crit Care Med 154,91-97[Abstract]
  83. Leu, H, Kaiser, D, Mori, M, et al (1989) hospital-acquired pneumonia: attributable mortality and morbidity. Am J Epidemiol 129,1258-1267[Abstract/Free Full Text]
  84. Meduri, G, Mauldin, G, Wunderink, R, et al (1994) Causes of fever and pulmonary densities in patients with clinical manifestations of ventilator-associated pneumonia. Chest 106,221-235[Abstract/Free Full Text]
  85. Rouby, J, De Lassale, E, Poete, P, et al (1992) Nosocomial bronchopneumonia in the critically Ill. Am Rev Respir Dis 146,1059-1056[ISI][Medline]
  86. Meduri, G, Chastre, J (1992) The standardization of bronchoscopic techniques for ventilator-associated pneumonia. Chest 102(suppl),557S-564S
  87. Beydon, L, Saada, M, Liu, N, et al (1992) Can portable chest x-ray examination accurately diagnose lung consolidation after major abdominal surgery?: a comparison with computed tomography scan Chest 102,1698-1703
  88. Ely, E, Johnson, M, Chiles, C, et al (1996) Chest x-ray changes in air space disease are associated with parameters of mechanical ventilation in ICU patients. Am J Respir Crit Care Med 154,1543-1550[Abstract]
  89. Torres, A, Serra-Batles, J, Ros, E, et al (1992) Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 116,540-543
  90. Timsit, J-F, Chevret, S, Valcke, J, et al (1996) Mortality of nosocomial pneumonia in ventilated patients: influence of diagnostic tools. Am J Respir Crit Care Med 154,116-123[Abstract]
  91. Sterling, T, Ho, E, Brehm, W (1996) Diagnosis and treatment of ventilator-associated pneumonia-impact on survival. Chest 110,1025-1034[Abstract/Free Full Text]
  92. Hill, J, Ratliff, J, Parrott, J, et al (1976) Pulmonary pathology in acute respiratory insufficiency: lung biopsy as a diagnostic tool. J Thorac Cardiovasc Surg 71,64-71[Abstract]
  93. Baigelman, W, Bellin, S, Cupples, A, et al (1986) Bacterologic assessment of the lower respiratory tract in intubated patients. Crit Care Med 14,864-868[ISI][Medline]
  94. Middleton, R, Broughton, W, Kirkpatrick, M (1992) Comparison of four methods for assessing airway bacteriology in intubated mechanically ventilated patients. Am J Med Sci 304,239-245[ISI][Medline]
  95. Jourdain, B, Novara, A, Joly-Guillou, M, et al (1995) Role of quantitative cultures of endotracheal aspirates in the role of nosocomial pneumonia. Am J Respir Crit Care Med 152,241-246[Abstract]
  96. Marquette, C, Georges, H, Wallett, F, et al (1993) Diagnostic efficiency of endotracheal aspirates with quantitative bacterial cultures in intubated patients with suspected pneumonia. Am Rev Respir Dis 148,138-144[ISI][Medline]
  97. Villers, D, Derriennic, M, Raffi, F, et al (1985) Reliability of the bronchoscopic protected catheter brush in intubated and ventilated patients. Chest 88,527-530[Abstract/Free Full Text]
  98. Torres, A, El-Ebiary, M, Fàbregas, N, et al (1996) Value of intracullular bacteria detection in the diagnosis of ventilator-associated pneumonia. Thorax 51,378-384[Abstract/Free Full Text]
  99. Barreiro, B, Dorca, J, Manresa, F, et al (1996) Protected bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia. Eur Respir J 9,1500-1507[Abstract]
  100. Chastre, J, Fagon, J, Bornet-Lecso, M, et al (1995) Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 152,231-240[Abstract]
  101. Meduri, G, Wunderink, R, Leeper, K (1992) Management of bacterial pneumonia in ventilated patients: protected bronchoalveolar lavage as a diagnostic tool. Chest 101,500-508[Abstract/Free Full Text]
  102. Meduri, G, Beals, D, Maijub, A, et al (1991) Protected bronchoalveolar lavage: a new bronchoscopic technique to retrieve uncontaminated distal airway secretions. Am Rev Respir Dis 143,855-864[ISI][Medline]
  103. Guerra, L, Baughman, R (1990) Use of bronchoalveolar lavage to diagnose bacterial pneumonia in mechanically ventilated patients. Crit Care Med 18,169-173[ISI][Medline]
  104. Solé-Violán, J, Rodriguez de Castro, F, Rey, A, et al (1994) Usefulness of microscopic examination of intracellular organisms in lavage fluid in ventilator-associated pneumonia. Chest 106,889-894[Abstract/Free Full Text]
  105. Aubas, S, Aubas, P, Capdevila, X, et al (1994) Bronchoalveolar lavage for diagnosing bacterial pneumonia in mechanically ventilated patients. Am J Respir Crit Care Med 149,860-866[Abstract]
  106. Steinberg, K, Mitchell, D, Maunder, R, et al (1993) Safety of bronchoalveolar lavage in patients with adults respiratory distress syndrome. Am Rev Respir Dis 148,556-561[ISI][Medline]
  107. Hernández, C, El-Ebiary, M, Torres, A, et al (1997) Side-effects of two different types of protected bronchoalveolar lavage in mechanically ventilated patients [abstract]. Am J Respir Crit Care Med 155(Suppl),A397
  108. Pugin, J, Suter, P (1992) Diagnostic bronchoalveolar lavage in patients with pneumonia produces sepsis-like systemic effects. Intensive Care Med 18,6-10[CrossRef][ISI][Medline]
  109. Wunderink, R, Mayhall, C, Gibert, C (1992) Methodology for clinical investigation of ventilator-associated pneumonia: epidemiology and therapeutic intervention. Chest (suppl); 102,580S-588S
  110. Marquette, C, Wallet, F, Neviere, R, et al (1994) Diagnostic value of direct examination of the protected specimen brush in ventilator-associated pneumonia. Eur Respir J 7,105-113[Abstract]
  111. Teague, R, Wallace, R, Awe, R (1981) The use of quantitative sterile brush culture and Gram stain analysis in the diagnosis of lower respiratory tract infections. Chest 79,157-161[Abstract/Free Full Text]
  112. Wimberly, N, Faling, L, Bartlett, J (1979) A fiberoptic bronchoscopy technique to obtain uncontaminated lower airway secretions for bacterial culture. Am Rev Respir Dis 119,337-343
  113. Keely, S, Pai, H, Baughman, R, et al (1994) Pneumocystis species inferred from analysis of multiple genes. J Eukaryot Microbiol 41(suppl),94S[Medline]
  114. Baselski, V, El-Torky, M, Coalson, J, et al (1992) The standardization of criteria for processing and interpreting laboratory specimens in patients with suspected ventilator-associated pneumonia. Chest 102(suppl),571S-579S
  115. Bassin, A, Niederman, M (1995) Prevention of ventilator-associated pneumonia: an attainable goal? Clin Chest Med 16,195-208[ISI][Medline]
  116. Timsit, J-F, Misset, B, Francoual,, et al (1993) Is protected specimen brush a reproducible method to diagnose ICU-acquired pneumonia? Chest 104,104-108[Abstract/Free Full Text]
  117. Solé-Violán, J, Rodriguez de Castro, F, Caminero Luna, J, et al (1993) Comparative efficacy of bronchoalveolar lavage and telescoping plugged catheter in the diagnosis of pneumonia in mechanically ventilated patients. Chest 103,386-390[Abstract/Free Full Text]
  118. Richard, C, Pezzano, M, Bouhaja, B, et al (1988) Comparison of non-protected lower respiratory tract secretions and protected specimen brush samples in the diagnosis of pneumonia. Intensive Care Med 14,30-33[CrossRef][ISI][Medline]
  119. Marquette, C, Herengt, F, Saulnier, F, et al (1993) Protected specimen brush in the assessment of ventilator-associated pneumonia: selection of a certain lung segment for bronchoscopic sampling is unnecessary. Chest 103,243-247[Abstract/Free Full Text]
  120. Kollef, M, Bock, K, Richards, R, et al (1995) The safety and diagnostic accuracy of minibronchoalveolar lavage in patients with suspected ventilator-associated pneumonia. Ann Intern Med 122,743-748[Abstract/Free Full Text]
  121. Pham, L, Brun-Buisson, C, Legrand, P, et al (1991) Diagnosis of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 143,1055-1061[ISI][Medline]
  122. Papazian, L, Martin, C, Albanese, J, et al (1989) Comparison of two methods of bacteriologic sampling of the lower respiratory tract: a study in ventilated patients with nosocomial bronchopneumonia. Crit Care Med 17,461-464[ISI][Medline]
  123. Papazian, L, Martin, C, Meric, B, et al (1993) A reappraisal of blind bronchial sampling in the microbiologic diagnosis of nosocomial bronchopneumonia: a comparative study in ventilated patients. Chest 103,236-242[Abstract/Free Full Text]
  124. Leal-Noval, S, Alfaro-Rodriguez, E, Murillo-Cabeza, F, et al (1992) Diagnostic value of the blind brush in mechanically ventilated patients with nosocomial pneumonia. Intensive Care Med 18,410-414[CrossRef][ISI][Medline]
  125. Gaussorgues, P, Piperno, D, Bachmann, P, et al (1989) Comparison of nonbronchoscopic bronchoaveolar lavage to open lung biopsy for bacteriologic diagnosis of pulmonary infections in mechanically ventilated patients. Intensive Care Med 15,94-98[CrossRef][ISI][Medline]
  126. Jorda, R, Parras, F, Ibanez, J (1993) Diagnosis of nosocomial pneumonia in mechanically ventilated patients by the blind protected telescoping catheter. Intensive Care Med 19,377-382[CrossRef][ISI][Medline]
  127. A’Court, C, Garrard, C, Crook, D (1993) Microbiological lung surveillance in mechanically ventilated patients, using non-directed bronchial lavage and quantitative culture. Q J Med 86,635-648[ISI][Medline]
  128. Kollef, M, Silver, P, Murphy, D, et al (1995) The effect of late-onset ventilator-associated pneumonia in determining patient mortality. Chest 108,1655-1662[Abstract/Free Full Text]
  129. Rello, J, Ausina, V, Ricart, M, et al (1993) Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest 104,1230-1235[Abstract/Free Full Text]
  130. Malangoni, M, Crafton, R, Mocek, F (1994) Pneumonia in the surgical intensive care unit: Factors determining successful outcome. Am J Surg 167,250-255[CrossRef][ISI][Medline]
  131. Rello, J, Jubert, P, Vallés, J, et al (1996) Evaluation of outcome for intubated patients with pneumonia due to Pseudomonas aeruginosa. Clin Infect Dis 23,973-978[ISI][Medline]
  132. Garrard, C, A’Court, C (1995) The diagnosis of pneumonia in the critically ill. Chest 108(suppl),17S-25S[Medline]
  133. Rello, J, Gallego, M, Mariscal, D, et al (1997) The value of routine microbial investigation in ventilator-associated pneumonia. Am J Respir Crit Care Med 156,196-200[Abstract/Free Full Text]
  134. Silver, D, Cohen, I, Weinberg, P (1992) Recurrent Pseudomonas. aeruginosa pneumonia in an intensive care unit. Chest 101,194-198[Abstract/Free Full Text]
  135. Wunderink, RG, Russell, GB, Mezger, E, et al (1991) The diagnostic utility of the antibody-coated bacteria test in intubated patients. Chest 99,84-88[Abstract/Free Full Text]
  136. Salata, RA, Lederman, MM, Shlaes, DM, et al (1987) Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients. Am Rev Respir Dis 135,426-432[ISI][Medline]



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