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Non-Ventilator ICU-Acquired Pneumonia After Cardiothoracic Surgery: Accuracy of Diagnostic Tools and Outcomes
François Stéphan1, Youssef Zarrouki2, Christine Mougeot3
1Cardiothoracic Intensive Care Unit f.stephan@ccml.fr.
Background:
Non-ventilator ICU-acquired pneumonia after cardiothoracic surgery is challenging to diagnose, and little is known about its impact on patient outcomes. Here, our primary objective was to compare the sensitivity and specificity of cultures of 2 types of fiberoptic bronchoscopy (FOB) specimens: endotracheal aspirates (FOB-EA) and bronchoalveolar lavage fluid (FOB-BAL). The secondary objectives were to evaluate the sensitivity and specificity of spontaneous sputum cultures and of the modified Clinical Pulmonary Infection Score (CPIS) and to describe patient outcomes.
Methods:
We conducted a prospective observational study of consecutive cardiothoracic surgery subjects with suspected non-ventilator ICU-acquired pneumonia. Using FOB-BAL cultures ≥10(4) cfu/mL as the reference standard, we evaluated the accuracy of FOB-EA ≥10(5) cfu/mL and spontaneous sputum ≥10(7) cfu/mL. On the day of FOB, we determined the modified CPIS. Mortality and antibiotic treatments were recorded.
Results:
Of 105 subjects, 57 (54.3%) received a diagnosis of non-ventilator ICU-acquired pneumonia. FOB-EA cultures had 82% (95% CI 69-91%) sensitivity and 100% (95% CI 89-100%) specificity and were significantly less sensitive than FOB-BAL cultures (P < .004). Spontaneous sputum was obtained from one-third of subjects. Spontaneous sputum cultures had 82% (95% CI 56-95%) sensitivity and 94% (95% CI 68-100%) specificity and were non-significantly less sensitive than FOB-BAL (P = .061). A modified CPIS >6 had 42% (95% CI 29-56%) sensitivity and 87% (95% CI 74-95%) specificity for non-ventilator ICU-acquired pneumonia. Antibiotic therapy was stopped in all subjects without non-ventilator ICU-acquired pneumonia, after 1.6 ± 1.2 d, without deleterious effects.
Conclusions:
The modified CPIS has low diagnostic accuracy for non-ventilator ICU-acquired pneumonia. FOB-EA cultures perform less well than do FOB-BAL cultures for diagnosing non-ventilator ICU-acquired pneumonia. Spontaneous sputum is valuable when FOB cannot be performed but could be obtained in only a minority of subjects. When cultures are negative, antibiotic discontinuation is safe.
Insights
Diagnosing non-ventilator ICU-acquired pneumonia after cardiothoracic surgery is challenging. Fiberoptic bronchoscopy with bronchoalveolar lavage (FOB-BAL) is more sensitive than endotracheal aspirates (FOB-EA) for detecting this infection.
Area of Science:
- Critical Care Medicine
- Infectious Diseases
- Thoracic Surgery
Background:
- Non-ventilator ICU-acquired pneumonia (NV-ICUAP) poses diagnostic challenges in cardiothoracic surgery patients.
- Limited data exist on the impact of NV-ICUAP on patient outcomes.
- Accurate diagnosis is crucial for appropriate treatment and improved patient prognosis.
Purpose of the Study:
- To compare the diagnostic accuracy of fiberoptic bronchoscopy with endotracheal aspirates (FOB-EA) versus bronchoalveolar lavage fluid (FOB-BAL) for NV-ICUAP.
- To evaluate the utility of spontaneous sputum cultures and the modified Clinical Pulmonary Infection Score (CPIS).
- To describe patient outcomes, including mortality and antibiotic use.
Main Methods:
- A prospective observational study involving cardiothoracic surgery patients with suspected NV-ICUAP.
- FOB-BAL cultures (≥10^4 cfu/mL) served as the reference standard.
- Accuracy of FOB-EA (≥10^5 cfu/mL) and spontaneous sputum (≥10^7 cfu/mL) cultures were assessed.
- Modified CPIS was determined on the day of FOB.
Main Results:
- FOB-EA cultures demonstrated 82% sensitivity and 100% specificity, significantly less sensitive than FOB-BAL (P < .004).
- Spontaneous sputum cultures (obtained in one-third of subjects) showed 82% sensitivity and 94% specificity.
- The modified CPIS (>6) had low sensitivity (42%) but high specificity (87%) for diagnosing NV-ICUAP.
Conclusions:
- Modified CPIS has limited diagnostic accuracy for NV-ICUAP.
- FOB-EA cultures are less effective than FOB-BAL cultures for diagnosing NV-ICUAP.
- Spontaneous sputum is a viable alternative when FOB is not feasible, though collection is limited.
- Discontinuation of antibiotics is safe when cultures are negative.
