Advertisement

Nosocomial Pneumonia in the ICU — New Perspectives on Current Controversies

  • C. D. A’Court
  • C. S. Garrard
Part of the Yearbook of Intensive Care and Emergency Medicine book series (YEARBOOK, volume 1995)

Abstract

The subject of nosocomial pneumonia in the critically ill has been regularly reviewed in recent years [1–6]. Central to every review is the difficulty with which the pneumonia is accurately diagnosed in the critically ill, mechanically ventilated patient. This stems from the lack of specificity of clinical diagnostic criteria, the vagaries of microbiological diagnostic samples, and limited availability in most studies of an irrefutable “gold standard”. The chapter which follows is not a comprehensive review, but addresses some of the developing and controversial issues.

Keywords

Bronchoalveolar Lavage Nosocomial Pneumonia Simplified Acute Physiologic Score Bacterial Pneumonia Current Controversy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Meduri G (1991) The role of bronchoalveolar lavage in diagnosing nonopportunistic bacterial pneumonia. Chest 100: 179–190PubMedCrossRefGoogle Scholar
  2. 2.
    Torres A, Gonzalez J, Ferrer M (1991) Evaluation of the available invasive and noninvasive techniques for diagnosing nosocomial pneumonia in mechanically ventilated patients. Intensive Care Med 17: 439–448PubMedCrossRefGoogle Scholar
  3. 3.
    A’Court C, Garrard C (1992) Nosocomial pneumonia in the intensive care unit: Mechanisms and significance. Thorax 47: 465–473PubMedCrossRefGoogle Scholar
  4. 4.
    Niederman M (1992) Pneumonia in the intensive care unit: Can critical care technology help? In: Vincent J (ed) Yearbook of intensive care and emergency medicine. Springer-Verlag, pp 475–483Google Scholar
  5. 5.
    Chastre J, Fagon J (1994) Invasive diagnostic testing should routinely be used to manage ventilated patients with suspected pneumonia. Am J Respir and Crit Care Med 150: 570–574Google Scholar
  6. 6.
    Niederman M, Torres A, Summer W (1994) Invasive diagnostic testing is not needed routinely to manage suspected ventilator-associated pneumonia. Am J Respir and Crit Care Med 150: 565–569Google Scholar
  7. 7.
    Craven DE, Kunches LM, Kilinsky V, Lichtenberg DA, Make BJ, McCabe WR (1986) Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 133: 792–796PubMedGoogle Scholar
  8. 8.
    Salata RA, Lederman MM, Shlaes DM, et al (1987) Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients. Am Rev Respir Dis 135: 426–432PubMedGoogle Scholar
  9. 9.
    Kerver A (1987) Colonisation and infection in surgical ICU patients, a prospective study. Intensive Care Med 13: 347–351PubMedCrossRefGoogle Scholar
  10. 10.
    Torres A, Aznar R, Gatell JM, et al (1990) Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 142: 523–528PubMedCrossRefGoogle Scholar
  11. 11.
    Rodriguez JL, Gibbons KJ, Bitzer LG, Dechert RE (1991) Pneumonia: Incidence, risk factors and outcome in injured patients. J Trauma 31: 907–914PubMedCrossRefGoogle Scholar
  12. 12.
    Johanson WG, Peirce AK, Sanford JP, et al (1972) Nosocomial respiratory infections with gram-negative bacilli: The significance of colonization of the respiratory tract. Ann Intern Med 77: 701–706PubMedGoogle Scholar
  13. 13.
    Stevens RM, Teres D, Skillman J, Feingold D (1974) Pneumonia in an ICU: A thirty month experience. Arch Int Med 134: 106–111CrossRefGoogle Scholar
  14. 14.
    Schwartz S, Dowling J, Benkovic C (1978) Sources of gram-negative bacilli colonizing the trachea of intubated patients. J Infect Dis 138: 227–231PubMedCrossRefGoogle Scholar
  15. 15.
    Torres A, Puig della 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: 306–310PubMedCrossRefGoogle Scholar
  16. 16.
    Bell R, Coalson J, Johanson W (1983) Multiple organ system failure and infection in adult respiratory distress syndrome. Ann Intern Med 99: 283–298Google Scholar
  17. 17.
    Wunderink R, Waldenberg L, Zeiss J, Day C, Clemens J, Lacher D (1992) The radiologic diagnosis of autopsy proven ventilator-associated pneumonia. Chest 101: 458–463PubMedCrossRefGoogle Scholar
  18. 18.
    Fagon JY, Chastre J, Hance AJ, 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: 110–116PubMedCrossRefGoogle Scholar
  19. 19.
    Chastre J, Fagon JY, 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: 499–506PubMedCrossRefGoogle Scholar
  20. 20.
    Guerra L, Baughman RP (1990) Use of bronchoalveolar lavage to diagnose bacterial pneumonia in mechanically ventilated patients. Crit Care Med 18: 169–173PubMedCrossRefGoogle Scholar
  21. 21.
    Meduri G, Wunderink R, Leeper K (1992) Management of bacterial pneumonia in ventilated patients. Protected bronchoalveolar lavage as a diagnostic tool. Chest 101: 500–508PubMedCrossRefGoogle Scholar
  22. 22.
    Fagon J, Chastre J, Hance A, Domart Y, Trouillet J, Gibert C (1993) Evaluation of clinical judgement in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest 103: 547–553PubMedCrossRefGoogle Scholar
  23. 23.
    Fagon JY, 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: 877–884PubMedGoogle Scholar
  24. 24.
    A’Court C, Garrard C, Crook D, et al (1993) Microbiological surveillance of the lungs using non-directed bronchial lavage. Quart J Med 86: 635–648PubMedGoogle Scholar
  25. 25.
    Kollef M (1993) Ventilator-associated pneumonia. A multivariate analysis. JAMA 270: 1965–1970PubMedCrossRefGoogle Scholar
  26. 26.
    Daschner F, Frey P, Wolff G, Baumann P, Suter P (1982) Nosocomial infections in intensive care wards, a multicentre prospective study. Intensive Care Med 8: 5–9PubMedCrossRefGoogle Scholar
  27. 27.
    Brown R, Hosmer D, Chen H (1985) A comparison of infection on different ICUs within the same hospital. Crit Care Med 13: 472–476PubMedCrossRefGoogle Scholar
  28. 28.
    Stoutenbeek CP, van Saene HFK, Miranda DR, Zandstra DF (1987) The effect of oropharyngeal decontamination using topical non-absorbable antibiotics on the incidence of nosocomial respiratory tract infections in multiple trauma patients. J Trauma 17: 357–364CrossRefGoogle Scholar
  29. 29.
    Mosconi P, Langer M, Cigada M, Mandelli M (1991) Epidemiology and risk factors of pneumonia in critically ill patients. Eur J Epidemiol 7: 320–327PubMedCrossRefGoogle Scholar
  30. 30.
    Langer M, Mosconi P, Cigada M, Mandelli M (1989) Long-term respiratory support and risk of pneumonia in critically ill patients. Am Rev Respir Dis 140: 302–305PubMedCrossRefGoogle Scholar
  31. 31.
    A’Court C, Garrard C, Crook D, Bowler I, Conlon C, Peto T (1994) A study of distal airway bacteriology in mechanically ventilated patients without pneumonia, using nondirected bronchial lavage. Am Rev Respir Crit Care Med 149: A935 (Abst)Google Scholar
  32. 32.
    Jimenez P, Torres A, Rodriguez-Roisin R, et al (1989) Incidence and etiology of pneumonia acquired during mechanical ventilation. Crit Care Med 17: 882–885PubMedCrossRefGoogle Scholar
  33. 33.
    Rouby JJ, Rossignon MD, Nicolas MH, et al (1989) A prospective study of protected bron-choalveolar lavage in the diagnosis of nosocomial pneumonia. Anesthesiology 71: 679–685PubMedCrossRefGoogle Scholar
  34. 34.
    Gaussorgues P, Piperno D, Bachmann P, Boyer F, Jean G, Gerard M (1989) Comparison of non-bronchoscopic bronchoalveolar lavage to open lung biopsy for bacteriologic diagnosis of pulmonary infections in mechanically ventilated patients. Intensive Care Med 15: 94–98PubMedCrossRefGoogle Scholar
  35. 35.
    Fagon JY, Chastre J, Trouillet JL, et al (1990) Characterization of distal bronchial microflora during acute exacerbations of chronic bronchitis. Am Rev Respir Dis 142: 1004–1008PubMedGoogle Scholar
  36. 36.
    Pham LH, Brun BC, Legrand P, et al (1991) Diagnosis of nosocomial pneumonia in mechanically ventilated patients. Comparison of a plugged telescoping catheter with the protected specimen brush. Am Rev Respir Dis 143: 1055–1061PubMedGoogle Scholar
  37. 37.
    Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM (1991) Diagnosis of ventilator associated pneumonia by bacteriologic analysis of bronchoscopic and non-bronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis 143: 1121–1129PubMedGoogle Scholar
  38. 38.
    Torres A, Puig de la Bellacasa J, Rodriguez-Roisin R, Jimenez M, Agusti Vidal A (1988) Diagnostic value of telescoping plugged catheters in mechanically ventilated patients with bacterial pneumonia using the Metras catheter. Am Rev Respir Dis 138: 117–120PubMedCrossRefGoogle Scholar
  39. 39.
    Marquette C, Herengt C, Mathieu D, Saulnier F, Courcol R, Ramon P (1993) Diagnosis of pneumonia in mechanically ventilated patients. Repeatability of the protected specimen brush. Am Rev Respir Dis 147: 211–214PubMedCrossRefGoogle Scholar
  40. 40.
    Chastre J, Viau F, Brun P, et al (1984) Prospective evaluation of the protected specimen brush for the diagnosis of pulmonary infections in ventilated patients. Am Rev Respir Dis 130: 924–929PubMedGoogle Scholar
  41. 41.
    Dotson R, Pingleton S (1993) The effect of antibiotic therapy on recovery of intracellular bacteria from broncho-alveolar lavage in suspected ventilator-associated nosocomial pneumonia. Chest 103: 541–546PubMedCrossRefGoogle Scholar
  42. 42.
    Rouby J, Lassale E, Poete P, et al (1992) Nosocomial bronchopneumonia in the critically ill. Histologic and bacteriologic aspects. Am Rev Respir Dis 146: 1059–1066PubMedGoogle Scholar
  43. 43.
    Kollef M, Wragge T (1994) Safety of mini-BAL performed by respiratory therapists for suspected ventilator-associated pneumonia (VAP). Am Rev Respir Crit Care Med 149: A968 (Abst)Google Scholar
  44. 44.
    Montravers P, Fagon J, Chastre J, et al (1993) Follow-up protected specimen brushes to assesses treatment in nosocomial pneumonia. Am Rev Respir Dis 147: 38–44PubMedCrossRefGoogle Scholar
  45. 45.
    A’Court C, Garrard C, Bowler I, Crook D, Conlon C, Peto T (1994) Lung flora in pneumonia free patients based on serial bronchial lavage (in press)Google Scholar
  46. 46.
    Johanson W, Seidenfeld J, Gomez P, de los Santos R, Coalson J (1988) Bacteriologic diagnosis of nosocomial pneumonia following prolonged mechanical ventilation. Am Rev Respir Dis 137: 259–264PubMedGoogle Scholar
  47. 47.
    Papazian L, Martin C, Albanese J, Saux P, Charrel J, Gouin F (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: 461–464PubMedCrossRefGoogle Scholar
  48. 48.
    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: 952–957PubMedGoogle Scholar
  49. 49.
    Timsit J, Misset B, Francoual S, Goldstein F, Vaury P, Carlet J (1993) Is protected specimen brush a reproducible method to diagnose ICU acquired pneumonia? Chest 104: 104–108PubMedCrossRefGoogle Scholar
  50. 50.
    Meduri G, Beals D, Maijub G, Baselski V (1991) Protected bronchoalveolar lavage: A new bronchoscopic technique to retrieve uncontaminated distal airway secretions. Am Rev Respir Dis 143: 855–864PubMedGoogle Scholar
  51. 51.
    Aubas S, Bartholomee S, Roustan J, Darbas H, du Cailar J (1992) Bronchoscopic or non-bronchoscopic broncho-alveolar lavage for diagnosing pneumonia on ICU. Intensive Care Med 18 (Suppl 2): S79 (Abst)Google Scholar
  52. 52.
    Violan J, de Castro F, Luna J, Benitez A, Alonso J (1993) Comparative efficacy of bronchoalveolar lavage and telescoping plugged catheter in the diagnosis of pneumonia in mechanically ventilated patients. Chest 103: 386–390CrossRefGoogle Scholar
  53. 53.
    Koumbourlis A, Kurland G (1993) Nonbronchoscopic bronchoalveolar lavage in mechanically ventilated infants: Technique, efficacy and applications. Pediatric Pulmonol 15: 257–262CrossRefGoogle Scholar
  54. 54.
    Kirkpatrick MB, Bass JB (1989) Quantitative bacterial cultures of bronchiolar lavage fluids and protected brush catheter specimens from normal subjects. Am Rev Respir Dis 139: 546–548PubMedCrossRefGoogle Scholar
  55. 55.
    Du Moulin GC, Paterson DG, Hedley-White J, Lisbon A (1982) Aspiration of gastric bacteria in antacid-treated patients: A frequent cause of post-operative colonization of the airway. Lancet 1: 242–245PubMedGoogle Scholar
  56. 56.
    Spray SB, Zuidema GD, Cameron JL (1976) Aspiration pneumonia. Incidence of aspiration with endotracheal tube. Am J Surg 131: 701–708PubMedCrossRefGoogle Scholar
  57. 57.
    Seegobin RD, Hasselt GL (1986) Aspiration beyond endotracheal cuffs. Can Anaes Soc J 33: 273CrossRefGoogle Scholar
  58. 58.
    Ibanez J, Penafiel A, Raurich J, et al (1988) Gastrooesophageal reflux and aspiration of gastric contents during nasogastric feeding: The effect of posture. Intensive Care Med 14 (Suppl 2): 296 (Abst)Google Scholar
  59. 59.
    Inglis J, Sherratt M, Sproat L, Gibson J, Hawkey P (1993) Gastroduodenal dysfunction and bacterial colonisation of the ventilated lung. Lancet 341: 911–913PubMedCrossRefGoogle Scholar
  60. 60.
    Timsit JF, Misset B, Renaud B, Goldstein F, Vaury P, Carlet J (1994) Diagnostic yield of morphological abnormalities of the bronchial tree for diagnosing nosocomial pneumonia on mechanically ventilated patients. Am J Respir Crit Care Med 149: A935 (Abst)Google Scholar
  61. 61.
    Niederman MS, Craven MD, Fein AM, Schultz DE (1990) Pneumonia in the critically ill hospitalized patient. Chest 1: 170–181CrossRefGoogle Scholar
  62. 62.
    Thorpe J, Baughman R, Frame P, Wesseler T, Staneck J (1987) Bronchoalveolar lavage for diagnosing acute bacterial infection. J Infect Dis 155: 855–861PubMedCrossRefGoogle Scholar
  63. 63.
    Wimberley N, Faling N, Bartlett J (1979) A fibreoptic bronchoscopic technique to obtain uncontaminated lower respiratory secretions for bacterial culture. Am Rev Respir Dis 119: 337–343PubMedGoogle Scholar
  64. 64.
    Gross PA, Van AC (1983) Nosocomial infections and hospital deaths. A case-control study. Am J Med 75: 658–662PubMedCrossRefGoogle Scholar
  65. 65.
    Hemmer M (1992) Incidence and risk factors of ICU acquired pneumonia. In: Vincent JL (ed) Yearbook of Intensive Care and Emergency Medicine. Springer-Verlag, pp 464–474Google Scholar
  66. 66.
    Rello J, Quintana E, Ausina V, et al (1991) Incidence, etiology, and outcome of nosocomial pneumonia in mechanically ventilated patients. Chest 100: 439–444PubMedCrossRefGoogle Scholar
  67. 67.
    Rello J, Ausina V, Ricart M, Castella J, Guillem P (1993) Impact of previous anti-microbial therapy on the aetiology and outcome of ventilator-associated pneumonia. Chest 104: 1230–1235PubMedCrossRefGoogle Scholar
  68. 68.
    Leu HS, Kaiser DL, Mori M, Woolson RF, Wenzel RP (1989) Hospital-acquired pneumonia. Attributable mortality and morbidity. Am J Epidemiol 129: 1258–1267PubMedGoogle Scholar
  69. 69.
    Fagon J, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C (1993) Nosocomial pneumonia in ventilated subjects. A cohort study evaluating attributable mortality and hospital stay. Am J Med 75: 658–661Google Scholar
  70. 70.
    Heyland D, Cook D, Jaesche R, Griffith L, Lee H, Guyatt G (1994) Selective decontamination of the digestive tract. An overview. Chest 105: 1221–1229PubMedCrossRefGoogle Scholar
  71. 71.
    Ledingham IMA, Alcock SR, Eastaway AT, McKay IC, McDonald JC, Ramsay G (1988) Triple regime of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in intensive care. Lancet 1: 785–790PubMedCrossRefGoogle Scholar
  72. 72.
    Kerver AJH, Rommes JH, Mevissen-Verhage A (1988) Prevention of colonization and infection in critically ill patients: A prospective randomized study. Crit Care Med 16: 1087–1093PubMedCrossRefGoogle Scholar
  73. 73.
    Vandenbroucke-Grauls CM, Vandenbroucke JP (1991) Effect of selective decontamination of the digestive tract on respiratory infections and mortality in the intensive care unit. Lancet 338: 859–862PubMedCrossRefGoogle Scholar
  74. 74.
    Kollef M (1994) The role of selective decontamination on mortality and respiratory tract infections. A Meta-analysis. Chest 105: 1101–1108PubMedCrossRefGoogle Scholar
  75. 75.
    Wunderink R (1993) Mortality and ventilator-associated pneumonia. The best antibiotics may be the least antibiotics. Chest 104: 993–995PubMedCrossRefGoogle Scholar
  76. 76.
    Seidenfeld J, Pohl D, Bell R, Harris G, Johanson W (1986) Incidence, site and outcome of infections in patients with adult respiratory distress syndrome. Am Rev Respir Dis 134: 12–16PubMedGoogle Scholar
  77. 77.
    Atherton S, White D (1978) Stomach as a source of bacteria colonising the respiratory tract during artificial ventilation. Lancet 2: 968–969PubMedCrossRefGoogle Scholar
  78. 78.
    Inglis T, Sproat L, Hawkry P, Gibson J (1993) Staphylococcal pneumonia in ventilated patients: A twelve month review of cases in an intensive care unit. J Hosp Infection 25: 207–220CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1995

Authors and Affiliations

  • C. D. A’Court
  • C. S. Garrard

There are no affiliations available

Personalised recommendations