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Critical Care  2009 

Death by acid rain: VAP or EXIT?

DOI: 10.1186/cc8169

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Ventilator-associated pneumonia (VAP) is defined as a new (nosocomial) lower respiratory tract infection diagnosed in mechanically ventilated patients ≥48 hours ('early-onset' VAP) or ≥4 days ('late-onset' VAP) after intubation [1-5]. Management of early-onset and late-onset VAP may differ as the causative factors and likely pathogens will influence treatment strategies, such as antimicrobial therapy [2,3,5]. VAP is associated with increased mortality and morbidity, prolonged duration of ventilation and hospital stay, and escalated costs of hospitalisation [2,3,5-9]. In resource-rich countries VAP is reported to be the second most common nosocomial/hospital-acquired infection in pediatric and neonatal intensive care units, with incidences ranging from 3 to 30% and VAP-attributable mortality rates up to 20% [5,7,9]. The potential devastating impact of VAP is emphasized by the study of Abdel Gawad and colleagues [1] where a 50% incidence of VAP and 70% mortality with VAP means that more than 80% of all the deaths in their unit were due to hospital-acquired infection/VAP.Defining VAP is the easy aspect, making the correct diagnosis (let alone confirmation) becomes more challenging, and establishing universally accepted criteria is a distant goal. There is no gold standard. The Clinical Pulmonary Infection Score (CPIS), utilized in the study by Abdel Gawad and colleagues, is based on five clinical parameters - fever, leucocytosis, purulence of secretions, oxygenation, extent of radiographic infiltrates - and strengthened by cultures from the lower respiratory tract (most often broncho-alveolar lavage (BAL)) [10]. It suffers from poor inter-rater agreement and retrograde influence from positive BAL results [11]. The current reference standard (read 'gold standard') comprises the clinical criteria for the diagnosis of VAP established by the National Nosocomial Infection Surveillance (NNIS) system of the Centers for Disease Control and Prevention (CDC), which incorporate a


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