Ventilator-Associated Pneumonia: Overdiagnosis and Treatment Are Common in Medical and Surgical Intensive Care Units

Nussenblatt, Véronique; Avdic, Edina; Berenholtz, Sean M.; Daugherty, Elizabeth L.; Hadhazy, Eric; Lipsett, Pamela A.; Maragakis, Lisa L.; Perl, Trish M.; Speck, Kathleen; Swoboda, Sandra M.; Ziai, Wendy; Cosgrove, Sara E.

doi:10.1086/675279

Cited by 61 publications

(50 citation statements)

References 29 publications

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“…Inclusion of this criterion in a formal definition of VRI would of course render the definition applicable only to surveillance reporting, not to clinical diagnosis and treatment, given that it relies in part on knowing whether the treatment team elected to administer antibiotics. We acknowledge that there may be variability between physicians as to what clinical circumstances warrant treatment with a full course of antibiotics, as has been noted with respect to discordance in physician preference regarding administration of antimicrobials in patients with pneumonia 27,30 . However, we believe that treatment teams regularly weigh the risks of antibiotics (development of Clostridium difficile 31 , adverse drug reactions including anaphylaxis or systemic toxicity 32,33 , and development of infections due to resistant pathogens 32,34–36 ) against the degree of clinical concern for infection when assessing a positive culture.…”

Section: Limitationsmentioning

confidence: 95%

Ventriculostomy-related infections: The performance of different definitions for diagnosing infection

Lewis

Wahlster

Karinja

et al. 2015

British Journal of Neurosurgery

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Introduction Comparison of rates of ventriculostomy-related infections (VRI) across institutions is difficult due to the lack of a standard definition. We sought to review published definitions of VRI and apply them to a test cohort to determine the degree of variability in VRI diagnosis. Materials and Methods We conducted a PubMed search for definitions of VRI using the search strings “ventriculostomy-related infection” and “ventriculostomy-associated infection.” We applied these definitions to a test cohort of 18 positive cerebrospinal fluid (CSF) cultures taken from ventriculostomies at two institutions to compare the frequency of infection using each definition. Results We found 16 unique definitions of VRI. When the definitions were applied to the test cohort, the frequency of infection ranged from 22–94% (median 61% with interquartile range (IQR) 56–74%). The concordance between VRI diagnosis and treatment with VRI-directed antibiotics for at least seven days ranged from 56–89% (median 72%, IQR 71–78%). Conclusions The myriad of definitions in the literature produce widely different frequencies of infection. In order to compare rates of VRI between institutions for the purposes of qualitative metrics and research, a consistent definition of VRI is needed.

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Section: Limitationsmentioning

confidence: 95%

Ventriculostomy-related infections: The performance of different definitions for diagnosing infection

Lewis

Wahlster

Karinja

et al. 2015

British Journal of Neurosurgery

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“…Clinical audits suggest that up to 75% of patients treated for VAP most likely do not have pneumonia. 47 Autopsy series also find that 40 -60% of subjects who meet clinical criteria for VAP do not have histological evidence of pneumonia. 21 VAP is therefore a questionable standard against which to measure the accuracy of VAE definitions.…”

Section: The Sensitivity Of Vae Definitions For Vap Is Lowmentioning

confidence: 99%

Should Ventilator-Associated Events become a Quality Indicator for ICUs?

Klompas,

Berra

2016

Respir Care

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in 2013. Controversy abounds as to whether VAE definitions are potentially suitable to serve as quality indicators for ICUs. On the pro side, VAE definitions overcome many of the weaknesses of traditional VAP surveillance. VAE definitions are objective, reproducible, electronically computable, and strongly predict poor outcomes for patients. There is an increasing amount of data on clinical correlates, risk factors, and approaches to prevent VAEs. Potential strategies to prevent VAEs are highly aligned with accepted best practices in critical care. VAE surveillance therefore has the potential to catalyze better care and to help hospitals track outcomes in ventilated patients more rigorously and more efficiently. On the con side, the complete VAE definition set with subtiers is complicated, neither sensitive nor specific for VAP, non-physiological compared with other ICU metrics, susceptible to gaming, and may bring about changes in clinician behavior that could paradoxically end up harming patients.

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“…1,20 Substantial over-diagnosis (58%) of VAP has also been reported when clinically diagnosed cases are subsequently adjudicated by expert, multidisciplinary committees. 21 This is because clinical criteria used to diagnose VAP are partly based upon non-specific signs common to other conditions (eg, ARDS, sepsis, trauma), whereas other signs are inherently subjective (eg, changes in sputum characteristics and chest radiographs, deteriorating oxygenation). Even when these clinical signs are conjoined with microbiological data, the estimated VAP rate varies widely.…”

Section: Inherent Limitations In Diagnosing Ventilator-associated Pnementioning

confidence: 99%

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

Kallet

2015

Respir Care

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SummaryVentilator-associated pneumonia (VAP) is an acquired infection related primarily to the consequences of prolonged endotracheal intubation. It is considered the most important infectious challenge in the critical care setting. Preventable complications of hospital care are considered an important source of wasted health-care costs believed to consume up to 47% of annual expenditures in the United States. Whether VAP is preventable has become a highly contentious debate since public reporting commenced a decade ago. This selective review focuses on specific aspects of this debate, including the inherent vagaries in the diagnosis of VAP and the marked disparities between VAP rates based on clinical diagnosis versus surveillance data. Also discussed is how this debate has impacted public policy, leading to the new paradigm of ventilator-associated events. The limited ability of artificial airways to prevent microaspiration and biofilm build-up, as well as non-modifiable conditions increasing the risk of VAP, is described in detail. In addition, the origins of the mistaken but widely embraced notion that zero VAP is a realistic achievement are examined.

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Ventilator-Associated Pneumonia: Overdiagnosis and Treatment Are Common in Medical and Surgical Intensive Care Units

Cited by 61 publications

References 29 publications

Ventriculostomy-related infections: The performance of different definitions for diagnosing infection

Ventriculostomy-related infections: The performance of different definitions for diagnosing infection

Should Ventilator-Associated Events become a Quality Indicator for ICUs?

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

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