Diagnosis of ventilator-associated pneumonia in critically ill adult patients-a systematic review and meta-analysis

Shannon M Fernando^{1

2}, Alexandre Tran^{3

4

5}, Wei Cheng⁶, Michael Klompas^{7

8}, Kwadwo Kyeremanteng^{3

6}, Sangeeta Mehta^{9

10}, Shane W English^{3

4

6}, John Muscedere¹¹, Deborah J Cook^{12

13}, Antoni Torres^{14

15}, Otavio T Ranzani^{16

17}, Alison E Fox-Robichaud¹², Waleed Alhazzani^{12

13}, Laveena Munshi^{9

10}, Gordon H Guyatt^{13

18}, Bram Rochwerg^{12

13}

Affiliations

¹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. sfernando@qmed.ca.
² Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. sfernando@qmed.ca.
³ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁴ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
⁵ Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
⁶ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁷ Department of Population Medicine, Harvard Medical School, Boston, MA, USA.
⁸ Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.
⁹ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Medicine, Sinai Health System, Toronto, ON, Canada.
¹¹ Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.
¹² Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
¹³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
¹⁴ Department of Pulmonary and Critical Care Medicine, Hospital Clinic Barcelona, Barcelona, Spain.
¹⁵ Faculty of Medicine, University of Barcelona, Barcelona, Spain.
¹⁶ Pulmonary Division, Heart Institute, Universidade de Sao Paulo, São Paulo, Brazil.
¹⁷ Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain.
¹⁸ Department of Medicine, McMaster University, Hamilton, ON, Canada.

PMID: 32306086
PMCID: PMC7223448
DOI: 10.1007/s00134-020-06036-z

Meta-Analysis

Diagnosis of ventilator-associated pneumonia in critically ill adult patients-a systematic review and meta-analysis

Shannon M Fernando et al. Intensive Care Med. 2020 Jun.

. 2020 Jun;46(6):1170-1179.

doi: 10.1007/s00134-020-06036-z. Epub 2020 Apr 18.

Authors

Affiliations

¹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. sfernando@qmed.ca.
² Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. sfernando@qmed.ca.
³ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁴ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
⁵ Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
⁶ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁷ Department of Population Medicine, Harvard Medical School, Boston, MA, USA.
⁸ Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.
⁹ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Medicine, Sinai Health System, Toronto, ON, Canada.
¹¹ Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.
¹² Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
¹³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
¹⁴ Department of Pulmonary and Critical Care Medicine, Hospital Clinic Barcelona, Barcelona, Spain.
¹⁵ Faculty of Medicine, University of Barcelona, Barcelona, Spain.
¹⁶ Pulmonary Division, Heart Institute, Universidade de Sao Paulo, São Paulo, Brazil.
¹⁷ Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain.
¹⁸ Department of Medicine, McMaster University, Hamilton, ON, Canada.

PMID: 32306086
PMCID: PMC7223448
DOI: 10.1007/s00134-020-06036-z

Abstract

The accuracy of the signs and tests that clinicians use to diagnose ventilator-associated pneumonia (VAP) and initiate antibiotic treatment has not been well characterized. We sought to characterize and compare the accuracy of physical examination, chest radiography, endotracheal aspirate (ETA), bronchoscopic sampling cultures (protected specimen brush [PSB] and bronchoalveolar lavage [BAL]), and CPIS > 6 to diagnose VAP. We searched six databases from inception through September 2019 and selected English-language studies investigating accuracy of any of the above tests for VAP diagnosis. Reference standard was histopathological analysis. Two reviewers independently extracted data and assessed study quality. We included 25 studies (1639 patients). The pooled sensitivity and specificity of physical examination findings for VAP were poor: fever (66.4% [95% confidence interval [CI]: 40.7-85.0], 53.9% [95% CI 34.5-72.2]) and purulent secretions (77.0% [95% CI 64.7-85.9], 39.0% [95% CI 25.8-54.0]). Any infiltrate on chest radiography had a sensitivity of 88.9% (95% CI 73.9-95.8) and specificity of 26.1% (95% CI 15.1-41.4). ETA had a sensitivity of 75.7% (95% CI 51.5-90.1) and specificity of 67.9% (95% CI 40.5-86.8). Among bronchoscopic sampling methods, PSB had a sensitivity of 61.4% [95% CI 43.7-76.5] and specificity of 76.5% [95% CI 64.2-85.6]; while BAL had a sensitivity of 71.1% [95% CI 49.9-85.9] and specificity of 79.6% [95% CI 66.2-85.9]. CPIS > 6 had a sensitivity of 73.8% (95% CI 50.6-88.5) and specificity of 66.4% (95% CI 43.9-83.3). Classic clinical indicators had poor accuracy for diagnosis of VAP. Reliance upon these indicators in isolation may result in misdiagnosis and potentially unnecessary antimicrobial use.

Keywords: Critical care; Mechanical ventilation; Nosocomial infections; Ventilator-associated pneumonia.

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Conflict of interest statement

None of the authors report any relevant conflict of interest.

Figures

**Fig. 1**
Flow chart summarizing evidence search and study selection

See this image and copyright information in PMC

Comment in

A way towards ventilator-associated lower respiratory tract infection research.
Martin-Loeches I, Povoa P, Nseir S. Martin-Loeches I, et al. Intensive Care Med. 2020 Jul;46(7):1504-1505. doi: 10.1007/s00134-020-06101-7. Epub 2020 May 25. Intensive Care Med. 2020. PMID: 32451575 Free PMC article. No abstract available.
A way toward ventilator-associated lower respiratory tract infection research: reply.
Fernando SM, Klompas M, Rochwerg B. Fernando SM, et al. Intensive Care Med. 2020 Jul;46(7):1506-1507. doi: 10.1007/s00134-020-06135-x. Epub 2020 Jun 4. Intensive Care Med. 2020. PMID: 32500179 Free PMC article. No abstract available.

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Diagnosis of ventilator-associated pneumonia in critically ill adult patients-a systematic review and meta-analysis

Affiliations

Diagnosis of ventilator-associated pneumonia in critically ill adult patients-a systematic review and meta-analysis

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

Comment in

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources