Comparison between a clinical diagnosis method and the surveillance technique of the Center for Disease Control and Prevention for identification of mechanical ventilator-associated pneumonia.

OBJECTIVE: >To evaluate the agreement between a new epidemiological surveillance method of the Center for Disease Control and Prevention and the clinical pulmonary infection score for mechanical ventilator-associated pneumonia detection. METHODS: This was a prospective cohort study that evaluated patients in the intensive care units of two hospitals who were intubated for more than 48 hours between August 2013 and June 2014. Patients were evaluated daily by physical therapist using the clinical pulmonary infection score. A nurse independently applied the new surveillance method proposed by the Center for Disease Control and Prevention. The diagnostic agreement between the methods was evaluated. A clinical pulmonary infection score of ≥ 7 indicated a clinical diagnosis of mechanical ventilator-associated pneumonia, and the association of a clinical pulmonary infection score ≥ 7 with an isolated semiquantitative culture consisting of ≥ 104 colony-forming units indicated a definitive diagnosis. RESULTS: Of the 801 patients admitted to the intensive care units, 198 required mechanical ventilation. Of these, 168 were intubated for more than 48 hours. A total of 18 (10.7%) cases of mechanical ventilation-associated infectious conditions were identified, 14 (8.3%) of which exhibited possible or probable mechanical ventilator-associated pneumonia, which represented 35% (14/38) of mechanical ventilator-associated pneumonia cases. The Center for Disease Control and Prevention method identified cases of mechanical ventilator-associated pneumonia with a sensitivity of 0.37, specificity of 1.0, positive predictive value of 1.0, and negative predictive value of 0.84. The differences resulted in discrepancies in the mechanical ventilator-associated pneumonia incidence density (CDC, 5.2/1000 days of mechanical ventilation; clinical pulmonary infection score ≥ 7, 13.1/1000 days of mechanical ventilation). CONCLUSION: The Center for Disease Control and Prevention method failed to detect mechanical ventilator-associated pneumonia cases and may not be satisfactory as a surveillance method.

Comparação entre um método de diagnóstico clínico e a técnica de vigilância do Center for Disease Control and Prevention para identificação de pneumonia associada à ventilação mecânica / Comparison between a clinical diagnosis method and the surveillance technique of the Center for Disease Control and Prevention for identification of mechanical ventilator-associated pneumonia

RESUMOObjetivo:Avaliar a concordância entre um novo método de vigilância epidemiológica do Center for Disease Control and Prevention e o Clinical Pulmonary Infection Score para detecção de pneumonia associada à ventilação mecânica.Métodos:Coorte prospectiva que avaliou pacientes internados nas unidades de terapia intensiva de dois hospitais que permaneceram intubados por mais de 48 horas no período de agosto de 2013 a junho de 2014. Os pacientes foram avaliados diariamente pelos fisioterapeutas com o Clinical Pulmonary Infection Score. De forma independente, um enfermeiro aplicou o novo método de vigilância proposto pelo Center for Disease Control and Prevention. Avaliou-se a concordância diagnóstica entre os métodos. Clinical Pulmonary Infection Score ≥ 7 foi considerado diagnóstico clínico de pneumonia associada à ventilação mecânica, considerando-se diagnóstico definitivo a associação de Clinical Pulmonary Infection Score ≥ 7 com germe isolado em cultura semiquantitativa ≥ 104 unidades formadoras de colônias.Resultados:De 801 pacientes admitidos nas unidades de terapia intensiva, 198 estiveram sob ventilação mecânica. Destes, 168 permaneceram intubados por mais de 48 horas. Identificaram-se 18 (10,7%) condições infecciosas associadas à ventilação mecânica e 14 (8,3%) pneumonias associadas à ventilação mecânica possíveis ou prováveis, representando 35% (14/38) diagnósticos clínicos de pneumonia associada à ventilação mecânica. O método do Center for Disease Control and Prevention identificou casos de pneumonia associada à ventilação mecânica com sensibilidade de 0,37 e especificidade de 1,0, com valor preditivo positivo de 1,0 e negativo de 0,84. As diferenças implicaram em discrepâncias na densidade de incidência de pneumonia associada à ventilação mecânica (CDC: 5,2/1000 dias de ventilação mecânica; Clinical Pulmonary Infection Score ≥ 7: 13,1/1000 dias de ventilação mecânica).Conclusão:O método do Center for Disease Control and Prevention falhou na detecção de casos de pneumonia associada à ventilação mecânica e pode não ser satisfatório como método de vigilância.Objective: To evaluate the agreement between a new epidemiological surveillance method of the Center for Disease Control and Prevention and the clinical pulmonary infection score for mechanical ventilator-associated pneumonia detection.

ABSTRACTObjective:>To evaluate the agreement between a new epidemiological surveillance method of the Center for Disease Control and Prevention and the clinical pulmonary infection score for mechanical ventilator-associated pneumonia detection.Methods:This was a prospective cohort study that evaluated patients in the intensive care units of two hospitals who were intubated for more than 48 hours between August 2013 and June 2014. Patients were evaluated daily by physical therapist using the clinical pulmonary infection score. A nurse independently applied the new surveillance method proposed by the Center for Disease Control and Prevention. The diagnostic agreement between the methods was evaluated. A clinical pulmonary infection score of ≥ 7 indicated a clinical diagnosis of mechanical ventilator-associated pneumonia, and the association of a clinical pulmonary infection score ≥ 7 with an isolated semiquantitative culture consisting of ≥ 104 colony-forming units indicated a definitive diagnosis.Results:Of the 801 patients admitted to the intensive care units, 198 required mechanical ventilation. Of these, 168 were intubated for more than 48 hours. A total of 18 (10.7%) cases of mechanical ventilation-associated infectious conditions were identified, 14 (8.3%) of which exhibited possible or probable mechanical ventilatorassociated pneumonia, which represented 35% (14/38) of mechanical ventilator-associated pneumonia cases. The Center for Disease Control and Prevention method identified cases of mechanical ventilator-associated pneumonia with a sensitivity of 0.37, specificity of 1.0, positive predictive value of 1.0, and negative predictive value of 0.84. The differences resulted in discrepancies in the mechanical ventilator-associated pneumonia incidence density (CDC, 5.2/1000 days of mechanical ventilation; clinical pulmonary infection score ≥ 7, 13.1/1000 days of mechanical ventilation).Conclusion:The Center for Disease Control and Prevention method failed to detect mechanical ventilatorassociated pneumonia cases and may not be satisfactory as a surveillance method.

Reduced mortality after the implementation of a protocol for the early detection of severe sepsis.

OBJECTIVE: We evaluate the impact that implementing an in-hospital protocol for the early detection of sepsis risk has on mortality from severe sepsis/septic shock. METHODS: This was a prospective cohort study conducted in 2 phases at 2 general hospitals in Brazil. In phase I, patients with severe sepsis/septic shock were identified and treated in accordance with the Surviving Sepsis Campaign guidelines. Over the subsequent 12 months (phase II), patients with severe sepsis/septic shock were identified by means of active surveillance for signs of sepsis risk (SSR). We compared the 2 cohorts in terms of demographic variables, the time required for the identification of at least 2 SSRs, compliance with sepsis bundles (6- and 24-hour), and mortality rates. RESULTS: We identified 217 patients with severe sepsis/septic shock (102 during phase I and 115 during phase II). There were significant differences between phases I and II in terms of the time required for the identification of at least 2 SSRs (34 ± 48 vs 11 ± 17 hours; P < .001) and in terms of in-hospital mortality (61.7% vs 38.2%; P < .001). CONCLUSION: The early detection of sepsis promoted early treatment, reducing in-hospital mortality from severe sepsis/septic shock.