The appropriate diagnostic threshold for ventilator-associated pneumonia using quatititative cultures

Background: The use of quantitative cultures of the bronchoalveolar lavage (BAL) effluent to distinguish between posttraumatic inflammatory response and ventilator-associated pneumonia (VAP) is becoming more common. However, the diagnostic threshold of either 10⁴ or 10⁵ colonies/mL remains debatable. Because mortality from VAP is related to treatment delay, some have chosen a lower diagnostic threshold (≥10⁴ colonies/mL). This may result in unnecessary antibiotic use with its sequelae: increased resistant organisms, antibiotic-related complications, and increased costs. The purpose of this study is to determine the optimal diagnostic threshold for VAP diagnosis using quantitative cultures of the BAL effluent. Methods: Data on patients with fiberoptic bronchoseopy with BAL are maintained in a prospectively collected database at our Level I trauma center. This database was reviewed for timing and frequency of BAL and the colony counts of each organism identified. Indication for bronchoseopy was clinical evidence of VAP. VAP was defined as ≥10⁵ colonies/mL in the BAL effluent. A false-negative BAL was defined as any patient who had <10⁵ colonies/mL and developed VAP with the same organism up to 7 days after the previous culture. Results: Over a 46-month period, 526 patients underwent 1,372 fiberoptic bronchoscopy procedures with BAL. Of these, 72% were male patients, 91% followed blunt injury, and mean age and Injury Severity Score were 43 years and 30, respectively. Overall mortality was 14%. There were 1,898 organisms identified (42% were gram-positive and 58% were gram-negative). VAP was diagnosed in 38% of BAL. Overall, there were 43 episodes in 38 patients defined as false-negative (3%). The false-negative rate was 9% in patients with 10⁴ organisms. The most common false-negative organisms were Pseudomonas and Acinetobacter species. Conclusion: The VAP diagnostic threshold for quantitative BAL in trauma patients should be ≥10⁵ colonies/mL. One may consider a threshold of ≥10⁴ colonies/mL in severely injured patients with Pseudomonas or Acinetobacter species.