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Inadequacy of Algorithmic Ventilator-Associated Pneumonia Diagnosis in Acute Care Surgery.

Abstract Clinical utility of algorithms to diagnose ventilator-associated pneumonia (VAP) in surgical patients has not been established. We aimed to test the diagnostic accuracy of two established methods to reliably diagnose VAP in acutely ill and injured surgical patients. After institutional review board approval, we prospectively collected data on 508 mechanically ventilated acute care surgery patients. Microbiologic samples were taken daily from all patients. Demographics, clinical, laboratory, and radiographic data were collected. The Johanson Criteria (JC) and Clinical Pulmonary Infection Score (CPIS) were calculated and analyzed. Sensitivity, specificity, and positive predictive values (PPV) and negative predictive value (NPV) were calculated in comparison to positive respiratory cultures. Of the 508 patients, 312 (61.4%) were acutely injured; emergent general surgery was performed in 141 (27.8%) patients, and 54 (10.6%) underwent elective operation. Positive respiratory cultures were identified in 198 (39%) of the 508 patients. JC diagnosed VAP in 291 (57.3%) patients (sensitivity 82.8%, specificity 59%, PPV 56.4%, NPV 84.3%, accuracy 68.3%). The CPIS resulted in 189 (37.2%) VAP diagnoses (sensitivity 61.1%, specificity 78.1%, PPV 64%, NPV 75.9%, and accuracy 71.5%). To address the inaccuracy of the algorithms, concordance testing was performed on the data to evaluate correlation between the algorithmic VAP diagnosis criteria and respiratory culture data. Nonconcordance with culture data diagnosis was identified with both JC (rho 0.41) and CPIS (rho 0.41). Sensitivity, specificity, PPV and NPV, and accuracy of both established clinical formulas was unacceptably low in acute care surgery patients.
PMID
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Authors

Mayor MeshTerms

Algorithms

Critical Care

Decision Support Techniques

Keywords
Journal Title the american surgeon
Publication Year Start




PMID- 29580362
OWN - NLM
STAT- MEDLINE
DCOM- 20180404
LR  - 20180404
IS  - 1555-9823 (Electronic)
IS  - 0003-1348 (Linking)
VI  - 84
IP  - 2
DP  - 2018 Feb 1
TI  - Inadequacy of Algorithmic Ventilator-Associated Pneumonia Diagnosis in Acute Care
      Surgery.
PG  - 300-304
AB  - Clinical utility of algorithms to diagnose ventilator-associated pneumonia (VAP) 
      in surgical patients has not been established. We aimed to test the diagnostic
      accuracy of two established methods to reliably diagnose VAP in acutely ill and
      injured surgical patients. After institutional review board approval, we
      prospectively collected data on 508 mechanically ventilated acute care surgery
      patients. Microbiologic samples were taken daily from all patients. Demographics,
      clinical, laboratory, and radiographic data were collected. The Johanson Criteria
      (JC) and Clinical Pulmonary Infection Score (CPIS) were calculated and analyzed. 
      Sensitivity, specificity, and positive predictive values (PPV) and negative
      predictive value (NPV) were calculated in comparison to positive respiratory
      cultures. Of the 508 patients, 312 (61.4%) were acutely injured; emergent general
      surgery was performed in 141 (27.8%) patients, and 54 (10.6%) underwent elective 
      operation. Positive respiratory cultures were identified in 198 (39%) of the 508 
      patients. JC diagnosed VAP in 291 (57.3%) patients (sensitivity 82.8%,
      specificity 59%, PPV 56.4%, NPV 84.3%, accuracy 68.3%). The CPIS resulted in 189 
      (37.2%) VAP diagnoses (sensitivity 61.1%, specificity 78.1%, PPV 64%, NPV 75.9%, 
      and accuracy 71.5%). To address the inaccuracy of the algorithms, concordance
      testing was performed on the data to evaluate correlation between the algorithmic
      VAP diagnosis criteria and respiratory culture data. Nonconcordance with culture 
      data diagnosis was identified with both JC (rho 0.41) and CPIS (rho 0.41).
      Sensitivity, specificity, PPV and NPV, and accuracy of both established clinical 
      formulas was unacceptably low in acute care surgery patients.
FAU - Quick, Jacob A
AU  - Quick JA
FAU - Breite, Matthew D
AU  - Breite MD
FAU - Barnes, Stephen L
AU  - Barnes SL
LA  - eng
PT  - Clinical Trial
PT  - Journal Article
PL  - United States
TA  - Am Surg
JT  - The American surgeon
JID - 0370522
SB  - IM
MH  - Adolescent
MH  - Adult
MH  - Aged
MH  - Aged, 80 and over
MH  - *Algorithms
MH  - *Critical Care
MH  - *Decision Support Techniques
MH  - Female
MH  - Humans
MH  - Male
MH  - Middle Aged
MH  - Pneumonia, Ventilator-Associated/*diagnosis
MH  - Predictive Value of Tests
MH  - Prospective Studies
MH  - Sensitivity and Specificity
MH  - Surgical Procedures, Operative
MH  - Young Adult
EDAT- 2018/03/28 06:00
MHDA- 2018/04/05 06:00
CRDT- 2018/03/28 06:00
PHST- 2018/03/28 06:00 [entrez]
PHST- 2018/03/28 06:00 [pubmed]
PHST- 2018/04/05 06:00 [medline]
PST - ppublish
SO  - Am Surg. 2018 Feb 1;84(2):300-304.