Diagnosis of Ventilator-Associated Pneumonia in Mechanically Ventilated Adult Patients: A Systematic Review and Meta-Analysis
CCCF ePoster library. Fernando S. 11/13/19; 283397; EP120
Dr. Shannon Fernando
Dr. Shannon Fernando
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Abstract
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ePoster
Topic: Systematic Review, Meta-Analysis, or Meta-Synthesis

Fernando, Shannon M., MD, MSc1,2; Tran, Alexandre, MD, MSc3,4; Cheng, Wei, PhD5; Klompas, Michael, MD, MPH6,7; Kyeremanteng, Kwadwo, MD, MHA1,5; Mehta, Sangeeta, MD8,9; English, Shane W., MD, MSc1,3,5; Muscedere, John, MD10; Cook, Deborah J., MD, MSc11,12; Torres, Antoni, MD, PhD13,14, Ranzani, Otavio T., MD, PhD15; Fox-Robichaud, Alison E., MD, MSc11; Alhazzani, Waleed, MD, MSc11,12; Munshi, Laveena, MD, MSc8,9; Guyatt, Gordon H., MD, MSc12,16; Rochwerg, Bram, MD, MSc11,12
 

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

Introduction: Ventilator-associated pneumonia (VAP) is a significant adverse event that can occur following mechanical ventilation, and is associated with morbidity and mortality in critically ill patients. Diagnosis of VAP is difficult, and often requires bronchoscopy with bronchoalveolar lavage (BAL), while culture results may be delayed. Therefore, clinicians often rely upon non-invasive clinical signs for presumptive diagnosis of VAP, and in deciding upon empiric antimicrobial therapy. 
 
Objectives: We conducted a systematic review and meta-analysis, with the aim of summarizing and comparing the accuracy of physical examination signs, chest radiography, bronchoscopy (either bronchoalveolar lavage [BAL] or protected specimen brush [PSB]), and the Clinical Pulmonary Infection Score (CPIS) for diagnosis of VAP in critically ill adults receiving mechanical ventilation.
 
Methods: We searched six databases, including MEDLINE, Embase, and PubMed, from inception through May 2019. We included English-language studies investigating accuracy of physical examination, chest radiography, bronchoscopy, or CPIS among critically ill adults receiving mechanical ventilation for ≥ 48 hours. Gold standard was histopathologic diagnosis of VAP following lung biopsy. We followed PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. Two reviewers independently extracted data and assessed study quality using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Summary estimates were generated using a Hierarchical Summary Receiver Operating Characteristic model.
 
Results: We included 26 studies. Of physical examination signs, pooled sensitivity and specificity for VAP were: leukocytosis (64.2% [95% CI: 46.9-78.4], 59.2% [95% CI: 45.0-72.0]), fever (66.4% [95% CI: 40.7-85.0], 53.9% [95% CI: 34.5-72.2) and purulent secretions (78.6% [95% CI: 65.1-87.9], 49.2% [95% CI: 34.9-63.6]). New or worsening infiltrates 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) for diagnosis of VAP. Among bronchoscopic tests, pooled sensitivity and specificity for VAP were: BAL ≥ 104 CFU/mL (71.1% [95% CI: 49.9-85.9], 79.6% [95% CI: 66.2-88.6]) and PSB ≥ 103 CFU/mL (61.4% [95% CI: 43.7-76.5], 76.5% [95% CI: 64.2-85.6]). Finally CPIS > 6 had a sensitivity of 75.7% (95% CI: 50.6-88.5) and specificity of 66.4% (43.9-83.3) for diagnosis of VAP.
 
Conclusions: No one particular physical examination feature had strong diagnostic accuracy for VAP. Changes in chest radiography had suitable sensitivity, but poor specificity. Among bronchoscopic tests, BAL culture had higher sensitivity and specificity than PSB culture. Increased CPIS score was neither sensitive nor specific for diagnosis of VAP. High suspicion of VAP may necessitate early empiric management, regardless of individual tests.


No references

ePoster
Topic: Systematic Review, Meta-Analysis, or Meta-Synthesis

Fernando, Shannon M., MD, MSc1,2; Tran, Alexandre, MD, MSc3,4; Cheng, Wei, PhD5; Klompas, Michael, MD, MPH6,7; Kyeremanteng, Kwadwo, MD, MHA1,5; Mehta, Sangeeta, MD8,9; English, Shane W., MD, MSc1,3,5; Muscedere, John, MD10; Cook, Deborah J., MD, MSc11,12; Torres, Antoni, MD, PhD13,14, Ranzani, Otavio T., MD, PhD15; Fox-Robichaud, Alison E., MD, MSc11; Alhazzani, Waleed, MD, MSc11,12; Munshi, Laveena, MD, MSc8,9; Guyatt, Gordon H., MD, MSc12,16; Rochwerg, Bram, MD, MSc11,12
 

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

Introduction: Ventilator-associated pneumonia (VAP) is a significant adverse event that can occur following mechanical ventilation, and is associated with morbidity and mortality in critically ill patients. Diagnosis of VAP is difficult, and often requires bronchoscopy with bronchoalveolar lavage (BAL), while culture results may be delayed. Therefore, clinicians often rely upon non-invasive clinical signs for presumptive diagnosis of VAP, and in deciding upon empiric antimicrobial therapy. 
 
Objectives: We conducted a systematic review and meta-analysis, with the aim of summarizing and comparing the accuracy of physical examination signs, chest radiography, bronchoscopy (either bronchoalveolar lavage [BAL] or protected specimen brush [PSB]), and the Clinical Pulmonary Infection Score (CPIS) for diagnosis of VAP in critically ill adults receiving mechanical ventilation.
 
Methods: We searched six databases, including MEDLINE, Embase, and PubMed, from inception through May 2019. We included English-language studies investigating accuracy of physical examination, chest radiography, bronchoscopy, or CPIS among critically ill adults receiving mechanical ventilation for ≥ 48 hours. Gold standard was histopathologic diagnosis of VAP following lung biopsy. We followed PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. Two reviewers independently extracted data and assessed study quality using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Summary estimates were generated using a Hierarchical Summary Receiver Operating Characteristic model.
 
Results: We included 26 studies. Of physical examination signs, pooled sensitivity and specificity for VAP were: leukocytosis (64.2% [95% CI: 46.9-78.4], 59.2% [95% CI: 45.0-72.0]), fever (66.4% [95% CI: 40.7-85.0], 53.9% [95% CI: 34.5-72.2) and purulent secretions (78.6% [95% CI: 65.1-87.9], 49.2% [95% CI: 34.9-63.6]). New or worsening infiltrates 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) for diagnosis of VAP. Among bronchoscopic tests, pooled sensitivity and specificity for VAP were: BAL ≥ 104 CFU/mL (71.1% [95% CI: 49.9-85.9], 79.6% [95% CI: 66.2-88.6]) and PSB ≥ 103 CFU/mL (61.4% [95% CI: 43.7-76.5], 76.5% [95% CI: 64.2-85.6]). Finally CPIS > 6 had a sensitivity of 75.7% (95% CI: 50.6-88.5) and specificity of 66.4% (43.9-83.3) for diagnosis of VAP.
 
Conclusions: No one particular physical examination feature had strong diagnostic accuracy for VAP. Changes in chest radiography had suitable sensitivity, but poor specificity. Among bronchoscopic tests, BAL culture had higher sensitivity and specificity than PSB culture. Increased CPIS score was neither sensitive nor specific for diagnosis of VAP. High suspicion of VAP may necessitate early empiric management, regardless of individual tests.


No references

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