Surveillance cultures in healthcare-associated pneumonia: sense or nonsense?

REVIEW URRENT C OPINION

Surveillance cultures in healthcare-associated pneumonia: sense or nonsense? Johannes B.J. Scholte a, Walther N.K.A. van Mook a, and Catharina F.M. Linssen b

Purpose of review This review explores the usefulness of surveillance cultures in healthcare-associated pneumonia (HCAP). Recent findings The definition of HCAP is controversial. Causative micro-organisms of HCAP resemble those found in hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Some types of surveillance cultures have proven useful in hospitalized patients. Whereas numerous studies have investigated the role of surveillance cultures in VAP, one may wonder whether surveillance culture implementation should belong in HCAP management guidelines. Summary Studies exploring the usefulness of obtaining surveillance cultures in VAP are numerous, but are mostly retrospective, observational and/or quasi-experimental in nature. Surveillance cultures may be useful for antibiotic guidance, but positive predictive value and specificity of surveillance cultures are low, obviously negatively impacting on cost effectiveness, especially in the large population at risk for HCAP. On the other hand, multidrug-resistance is increasing and surveillance cultures for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci in ICU-admitted patients appeared useful and cost-effective. Furthermore, surveillance cultures for the presence of multidrug-resistant Gram-negative bacilli might be useful for antibiotic guidance. Currently, neither community-acquired pneumonia, HCAP, HAP nor VAP guidelines incorporate surveillance cultures. In the future, surveillance cultures in populations at risk for HCAP may be able to differentiate HCAP from other kinds of pneumonia and authorize its reason for existence. Keywords guidelines, healthcare-associated pneumonia, ICUs, multidrug-resistant, surveillance cultures, ventilator-associated pneumonia

INTRODUCTION Healthcare-associated pneumonia (HCAP) is a relatively new phenomenon that develops outside the hospital, although in patients somehow related to the healthcare system. The population at risk for HCAP is inconsistently defined in literature, and consequently HCAP seems to occur in a rather heterogeneous population accounting for approximately one third of all pneumonia cases developing outside the hospital [1]. Yet, patients with HCAP are significantly older and suffer from more comorbidities [2,3 ,4 ]. According to the most widely used international guideline for HCAP by the American Thoracic Society (ATS) and Infectious Diseases Society of America [5], HCAP resembles hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), and consequently HCAP should be &

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included in the spectrum of HAP and VAP and treated accordingly. Indeed, large studies demonstrated that HCAP is frequently caused by similar pathogens as seen in HAP and VAP, especially methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa [2,3 ,6,7,8 ], although other studies demonstrated more resemblance to community-acquired &

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a Department of Intensive Care Medicine, Maastricht University Medical Center and bDepartment of Medical Microbiology, Atrium Medical Center, Heerlen, The Netherlands

Correspondence to Catharina F.M. Linssen, Department of Medical Microbiology, Atrium Medical Center, Heerlen, Postbox 4446, 6401 CX Heerlen, The Netherlands. Tel: +31 0 455767803; fax: +31 0 455767098; e-mail: [email protected] Curr Opin Pulm Med 2014, 20:259–271 DOI:10.1097/MCP.0000000000000044

1070-5287 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

www.co-pulmonarymedicine.com

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Infectious diseases

KEY POINTS The benefit of surveillance cultures will be higher in populations with a high prevalence of highly pathogenic MDR micro-organisms, in combination with a high risk for pneumonia development, such as ICU patients.

of suspicion of infection. Frequently, surveillance cultures are part of a broader framework of surveillance. Indeed, surveillance programs are acknowledged to reduce mortality [13–15,16 ]. For VAP, there appeared to be a microbiological continuity between airway colonization, biofilm formation (on endotracheal tubes) and the subsequent development of VAP [17 ]. Colonization is thus known to precede infection [18], and this finding is in support of surveillance culture use in VAP from a pathophysiological point of view. No prospective randomized trials comparing the implementation of surveillance cultures versus no surveillance cultures in the management of any type of pneumonia were available when preparing this review. Furthermore, no studies were powered for hard end points such as mortality or were prospective randomized clinical trials. Additionally, it is unknown how often surveillance cultures should be obtained; the frequency will depend on the aim of the surveillance cultures. Daily cultures may be profitable for the individual patient, since inadequate antibiotic use may be diminished [19]; however, monthly cultures may be sufficient when monitoring MDR is the goal. As concentrations of pathogenic micro-organisms may be high and stable before the onset of VAP, performing surveillance culture three times weekly appears to be too frequent [20], and consequently twice a week seems best practice [21 ]. The next sections provide an overview of the studies conducted on the use of surveillance cultures respectively in relation to VAP, MRSA, vancomycinresistant enterococci (VRE) and MDR Gram-negative bacilli, as well as several miscellaneous studies. Results are presented in Tables 1–3 [19,20,21 , 22–41,42 ,43–57]. &

&

The usefulness of surveillance cultures is frequently assessed in patients with (suspected) VAP and may be useful for antibiotic guidance. With increasing prevalence of MDR and increasing size of the HCAP population, surveillance cultures may have a future role in HCAP management. Contemporary HCAP guidelines so far do not recommend routine use of surveillance cultures. Further research on the usefulness of surveillance cultures in specific subpopulations of patients will improve the understanding and management of HCAP patients.

pneumonia (CAP) regarding causative microorganisms [4 ,9]. A recent review of 24 studies confirms that HCAP patients, when compared with CAP patients, are more at risk for infections with MRSA, multidrug-resistant (MDR) Enterobacteriaceae or P. aeruginosa [10 ]. Furthermore, some studies demonstrate that HCAP increases the length of hospital stay and mortality rates, possibly related to comorbidities and age [6,11]. Undoubtedly, MDR is an increasing problem worldwide [12] and the population at risk of HCAP is extending. Notwithstanding the abovementioned commonalities and differences between CAP, HCAP, HAP and VAP, one might hypothesize that surveillance cultures can play a role in the diagnosis of HCAP. Indeed, surveillance cultures of endotracheal aspirate (ETA) are already frequently used to guide antibiotic therapy for VAP by selecting patients with MDR micro-organisms. After providing a concise background regarding the use of surveillance cultures, this review aims to explore the potential usefulness of surveillance cultures in specific types of pneumonia and the extent to which surveillance cultures are included in current pneumonia guidelines, thereby attempting to provide recommendations regarding the role of surveillance cultures in future HCAP management. &

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SURVEILLANCE CULTURES FOR MANAGEMENT OF VENTILATORASSOCIATED PNEUMONIA Methods and results of studies concerning the use of surveillance cultures in VAP management are summarized in Table 1. One systematic review and 24 studies were included. The systematic review concerning the value of surveillance cultures of ETA included 791 episodes of clinically suspected or confirmed VAP derived from 14 studies [21 ]. The review calculated a pooled sensitivity between 72 and 84%, and a pooled specificity between 90 and 98% for surveillance cultures of ETA in predicting the bacterial pathogen in VAP. However, in many studies incorporated in the review &&

BACKGROUND OF SURVEILLANCE CULTURES Unlike cultures obtained for diagnostic purposes, surveillance cultures are obtained in the absence 260


Volume 20 Number 3 May 2014


Year

1993

1995

1997

1999

2000

2002

2003

2005

2006

Study

A’Court et al. [22]

de Latorre et al. [23]

Delclaux et al. [24]

Cardenosa et al. [19]

Flanagan et al. [25]

Hayon et al. [26]


Bouza et al. [27]

Michel et al. [28]

Depuydt et al. [29]

Belgium

France

Spain

France

United Kingdom

Spain

France

Spain

United Kingdom

Country

MO indentified by SC of ETA


MO identified by all SC


MO identified by SC of NBL





Bacteria

ETA thrice weekly

Quantitative culture of ETA twice a week

PBS or ETA after surgery, before extubation, 3 days after surgery and weekly thereafter

ETA, nasal, rectal and urine on admission and weekly. Catheters when removed

After 72 h on MV: NBL twice weekly and when VAP suspected

ETA, pharynx and gastric samples every 24 h

NBL every 48–72 h

Quantitative culture of ETA, pharyngeal and stomach samples thrice weekly.

NBL alternate-day

Site of SC

Single center retrospective observational study of 128 patients with HAP and bacteremia while on MV

Single center, observational, 299 patients on MV

356 patients in single center prospective after major heart surgery

Single center, observational 91 patients with 125 VAP episodes

3 ICUs, 145 patients > 72 h on MV

Single ICU, prospective. 123 patients on MV

Single center, 8 ICUs. Prospectively evaluation of 30 ARDS patients. 24 VAP episodes

Single ICU, prospective, 80 patients > 48 h on MV

Single center 150 patients on MV

Patients

Table 1. Methodology and results of studies concerning surveillance cultures for management of ventilator-associated pneumonia


(Continued )

67of 128 (SN 52%) HAP with bacteremia previously detected by tracheal SC. When SC detected correctly: more appropriate antibiotic use and better survival

34 of 41 (SN 84%) VAP-causative pathogens previously detected by ETA. More appropriate (95%) antibiotic use compared to guidelines based (83%)

1626 SC obtained. 28 VAP: SN 3.7%. PPV: 1.7%. mortality of colonized patients 11.5% versus 1.6% in noncolonized patients

58 of the732 SC were positive. 17 of 220 VAP causing pathogens previously detected (SN 7%). 453 false positive results

PPV 17% and SN 74% for development of VAP diagnosed with PSB or BAL

2316 SC samples, 255 positive. 25 VAP pathogens found. ETA SN 88%, pharynx SN 68%, stomach SN 28%. Low PPV and specificity

PPV 89% and SN 67% for development of VAP when NBL revealed colonization

SC pos 72/80, only 12 VAP cases, diagnosed with ETA (¼incorporation bias). 10 of 21 VAP (SN 48%) causing MO previously detected by SC of phagyneal or stomach samples

Concordance with BAL results 16/20 (SN 80%). CFU in NBL were increasing prior to VAP development and decreasing when clinical improvement

Outcome

Surveillance cultures in pneumonia Scholte et al.

261


262

2006

2007

2007

2008

2008

2008

2009

2009

2009

Bagnulo et al. [31]

Malacarne et al. [32]

Depuydt et al. [33]

Boots et al. [20]

Nair et al. [34]

Jung et al. [35]

Pirracchio et al. [36]

Lampati et al. [37]

Year

Depuydt et al. [30]

Study

Table 1 (Continued)

www.co-pulmonarymedicine.com Italy

France

France

India

Australia

Belgium

Italy

Uruguay

Belgium

Country


All MO, arranged by individual species




MDR MO

A.baumannii in late onset VAP

All MO, especially MDR


Bacteria

ETA once weekly in one ICU and twice weekly in the other ICU

Nose and throat at admission

ETA at admission and weekly thereafter

ETA after 48h of MV

NBL < 12 h after admission, 48h after admission and afterwards thrice weekly

Urinary samples and ETA thrice weekly. Oral, nasal, and rectal samples ad admission and weekly

ETA twice weekly in patients >72 h on MV

Semi-quantitative ETA twice weekly

Urine, ETA and oral thrice weekly and anal swab weekly 48–96 hrs before bacteremia

Site of SC

Two centers. Partly prospective. 56 VAP episodes

136 VAP (diagnosed using PSB) cases proven by PSB 85%, SN 20–85%

SN 72%. In 77 SC and BAL concordant: 85% received adequate antibiotic therapy. In 23 pts not concordant: 65% adequate antibiotic treatment. 71% adequate when ATS guidelines were followed equal mortality

6 of 11 (SN 55%) VAP (proven by BAL) causing MO previously detected by SC

49 of 58 VAP-causative MO previously detected by NBL. SN 84%, SP 50%, PPV 31%, NPV 93%

SN 69% (ETA), 82% (all SC) for MDR VAP. PPV 90% (ETA), 87% (all SC). Appropriate antibiotic use in 77% and 89% of MDR VAP compared to 76– 88% based on hypothetic antibiotic use. Limited use of broad spectrum antibiotics

SN 90%; 18 of 20 VAP episodes due to A.baumanii were previously positive in ETA SC. PPV 45% when VAP present

60% concordance between BAL and SC by ETA. 80% concordance when MDR

86 of 112 (SN 76%) previously detected by SC of ETA MDR HAP: 31/44 (SN 71%) ETA was concordant. 39/44 (SN 89%) any SC was concordant. 47 false positive SC. In a subgroup of patients with 2 risk factors for MDR: more appropriate antibiotic use when SC results were used

Outcome

Infectious diseases



USA

Argentina

2012

2012

2012

2013

Brusselaers et al. [40]

Brusselaers && et al. [21 ]

Chan et al. [41]

Luna et al. & [42 ]

1070-5287 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins MO indentified by SC of ETA

MRSA


MO, especially MDR identified by SC of ETA



ETA

Nose, oral swabs or ETA and wounds on admission and weekly

ETA

ETA thrice weekly

ETA at ICU admission and every second day

ETA every three days

283 patients 48 h on MV, 65 BAL-proven VAP episodes in 55 pts. Prospective observational cohort. Single center

Prospective observational single center study. 924 suspected VAP, 388 proven VAP, 37 MRSA VAP

Systematic review and diagnostic test accuracy meta-analysis. 14 articles. 791 (suspected) VAP episodes

53 burn patients. 70 VAP episodes. Single center. Retrospective observational cohort

Single pulmonary ICU, prospective, observational. 92 patients 4 days on MV

Single center. Prospective observational cohort of 200 patients 48 h on MV. VAP based on CPIS and ETA 105 cfu/ml

146 ETA/BAL pairs. Complete concordance 36%. Partial concordance 19%. ETA Two-fold contact precautions. Suggested reduction in VRE transmission

A: 17.1 VRE/100 000 patient days. More monoclonal B: 8.2 VRE/100 000 patient days. More polyclonal

Results

CI, confidence interval; ETA, endotracheal aspirate; MO, micro-organisms; MRSA, methicillin-resistant Staphylococcus aureus; MV, mechanical ventilation; PCR, polymerase chain reaction; SC, surveillance cultures; VRE, vancomycin-resistant enterococci.

Year

Study

Table 2. Methodology and results of larger studies concerning surveillance cultures for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci

Infectious diseases



Surveillance cultures in pneumonia Scholte et al. Table 3. Methodology and results of studies concerning surveillance cultures for multidrug-resistant Gram-negative bacilli and overage studies Study

Year

Country

Bacteria

SC

Method and patients

Outcome

Bertrand et al. [50]

2001

France

Pseudomonas aeruginosa

Rectal swab, nose swab and ETA at admission and weekly thereafter

3009 patients admitted to 4 ICUs

Rectal swab: SN 34%, SP 93%, PPV 29% and NPV 95% K 0.25 for development of P. aeruginosapositive clinical cultures ETA and oral swab: SN 22%, SP 96%, PPV 27% and NPV 95%. K 0.20

Blot et al. [51]

2005

Belgium

MDR GNB

Oral, urine, ETA thrice weekly. Rectal weekly

Single center, retrospective analysis of 157 episodes of MDR GNB bacteremia while on MV

SN 117/157 (75%). More appropriate initial antibiotic therapy when SC concordant. Equal mortality

Reddy et al. [52]

2007

USA

ESBL-producing Enterobacteriaceae

Rectal weekly

Single center observational, 17 872 high care patients

SCþ in 413/17 872 (2.3%). 50% also positive for VRE Bacteremia due to ESBL-producing Enterobacteriaceae: 102. SN 76%, SP 98%, PPV 8%, NPV 99%

Papadomichelakis et al. [53]

2008

Greece

MDR GNB in VAP or bacteremia

ETA twice weekly and rectal weekly in all ICU patients

Single ICU, retrospective 31 episodes of VAP and 55 episodes of bacteremia

SN 74% (23/31) for VAP and 67% (37/55) for bacteremia More appropriate antibiotic treatment when SC concordant. Equal mortality

Baba et al. [54]

2011

Australia

Nosocomial GNB bacteremia

Twice weekly rectal and ETA

Single center, retrospective 228 episodes of GNB bacteremia

All: SN 28%. Predictive value for MDR: SN 51–57%, SP 88–94%, PPV: 51–73%, NPV: 79–94%

2006

France

MRSA and ESBLproducing Enterobacteriaceae

Nasal and rectal swab at admission and weekly thereafter

Single center, prospective observational cohort 412 ICU patients

More nosocomial infections when MRSA or ESBL pos (RR 2.08)

Miscellaneous Galoisy-Guibal et al. [55]

SN 17%, SP 92%, PPV 38%, and NPV 79% for development of nosocomial infection Vandewoude et al. [56]

2006

Belgium

Aspergillus spp.

ETA thrice weekly

Single center, retrospective. analysis of 25 216 ICU patients

172 of 25 216 ICU patients SC of ETA positive for Aspergillus spp., 66 had probable and 17 had definitive invasive aspergillosis: PPV 48.3%

Sreeramoju et al. [57]

2008

USA

GNB

ETA 1 h after cardiac surgery, after surgery and weekly thereafter

Single center, prospective observational cohort of 286 post cardiac surgery patients

Colonization associated with (early) development of infection when >1 week on MV (RR 2.3) SN 73%, SP 75%, PPV 48%, NPV 90%

ESBL, extended-spectrum b-lactamase; ETA, endotracheal aspiration; GNB, Gram-negative bacilli; MDR, multidrug-resistant; MV, mechanical ventilation; NPV, negative predictive value; PPV, positive predictive value; RR, relative risk; SC, surveillance cultures; SN, sensitivity; SP, specificity; VAP, ventilator-associated pneumonia; VRE, vancomycin-resistant enterococci.



265


Infectious diseases

as well as in many of the 24 studies presented in Table 2, some methodological concerns arise. First, most studies concerned retrospective analysis of VAP episodes, and randomized controlled trials were lacking. The former may reveal higher predictive values for surveillance cultures compared with the value of surveillance cultures by taking all obtained surveillance cultures into account (the latter being a more correct method). Second, no worldwide accepted gold standard was available for diagnosing VAP [58 ] and studies used different diagnostic approaches, while not always distinguishing colonization from infection [50]. When ETA is used for VAP diagnosis, it is not correct to compare micro-organisms identified by ETA with VAP-causing micro-organisms, the latter also being based on ETA results. This so-called incorporation bias, which overestimates diagnostic accuracy [59], was most likely present in a significant number of studies [23,33,39,40,60,61]. In some studies, incorporation bias may be present, because diagnostic methods were not clearly described [24,50]. Third, studies were difficult to compare because of the heterogeneity in study population (postcardiac surgery, medical ICU), MDR prevalence, surveillance culture sampling sites and frequency, as well as the previously discussed method for VAP diagnosis. Furthermore, cutoff for positive ETA surveillance cultures varied. Some included surveillance cultures of ETA samples with at least 104 cfu/ml [35], whereas others included surveillance cultures of ETA samples with less than 105 cfu/ml [38]. Other studies compared individual micro-organisms identified in surveillance cultures, thereby artificially increasing the specificity by increasing the numbers of ‘true negatives’ [36]. Finally, some studies presented data from cases in the same hospital and same period, suggesting publication bias [29,30,33]. After taking into account these concerns, some studies suggest that more appropriate antibiotic treatment is given when guided by available surveillance cultures compared with ATS guidelines [5] or a hypothetical antibiotic treatment model [28–30,33,35,38]. However, the methodology used herein was perhaps less suited to demonstrate such correlation, and MDR presence may have been caused by other risk factors such as previous antibiotic treatment and prolonged mechanical ventilation (potential confounders). Whereas improved survival is suggested by one study [29], others demonstrate equal mortality [35] and no study was found to be sufficiently powered to demonstrate any mortality differences. Surveillance cultures of gastric samples appeared not useful for antibiotic guidance in &&

266


VAP management [19]. In one study, 33% of all VAP causative pathogens were previously detected by nasal swab, rectal swab or urine culture [26]. Sensitivity increased by 13–18% in two studies when the results of all performed surveillance cultures were taken into account [30,33]. However, the expected negative effect on positive predictive value and specificity of this strategy (taking into account all surveillance cultures) was not provided. Overall, sensitivity of previously available surveillance cultures for VAP seems moderate to even high, and therefore could more appropriately guide antibiotic treatment, especially in the case of P. aeruginosa and MDR. However, a decrease in infection attributable mortality when surveillance cultures were performed was so far not demonstrated. The positive predictive value of surveillance cultures seems low and, in our opinion, surveillance culture results should therefore always be used together with clinical criteria before the initiation of antibiotics.

SURVEILLANCE CULTURES FOR MANAGEMENT OF METHICILLINRESISTANT STAPHYLOCOCCUS AUREUS AND VANCOMYCIN-RESISTANT ENTEROCOCCI MRSA and VRE are resistant Gram-positive microorganisms that are frequently found in hospitaladmitted patients, and probably in the healthcare-associated population. MRSA infection is associated with increased mortality, morbidity and costs compared with methicillin-susceptible S. aureus [62,63]. MRSA is a more potent causative micro-organism for pneumonia than VRE, which is sometimes considered relatively harmless. As surveillance culture may early identify patients colonized with MRSA and/or VRE, subsequently implemented contact precautions and/or eradication protocols could prevent transmission and infection [64–66]. Studies concerning the usefulness of surveillance cultures in the light of MRSA and VRE are summarized in Table 2. Most studies originated from United States, where VRE and MRSA are relatively endemic, obviously limiting generalization to the European context because of marked differences in VRE and MRSA prevalence. Many studies demonstrated potential usefulness of surveillance cultures on high-risk units at admission and weekly thereafter in controlling the spread of both MRSA and VRE [43–47,67], and the prevention of hospital-acquired VRE or MRSA infections [43–45,47,68]. Currently, there is no evidence that the implementation of surveillance cultures for Volume 20 Number 3 May 2014



the management of MRSA/VRE reduces infections or mortality.

SURVEILLANCE CULTURES FOR MANAGEMENT OF MULTIDRUGRESISTANT GRAM-NEGATIVE BACILLI MDR Gram-negative bacilli are notorious causes of nosocomial infections and are increasingly jeopardizing patients. Surveillance cultures may lead to the identification of MDR and subsequent appropriate treatment in case of an infection. An overview of studies focusing on the usefulness of surveillance cultures in MDR Gram-negative bacilli infections is provided in Table 3. Overall, only quasi-experimental observational studies were available, studies were difficult to compare and results were frequently inconsistent. Nevertheless, specificity and negative predictive values appeared high, sensitivity moderate and positive predictive value low. Two studies demonstrated that appropriate antibiotic therapy was given more frequently to patients when surveillance cultures correctly predicted the micro-organism causing bacteremia [51,53]. Acknowledging that they were neither designed nor powered for mortality, two studies failed to demonstrate impact on mortality [51,53]. Additional studies are needed to establish the role of surveillance cultures for these micro-organisms, as it may have some beneficial aspects, especially in antibiotic guidance.

MISCELLANEOUS STUDIES, INCLUDING SURVEILLANCE CULTURES IN SELECTIVE DIGESTIVE TRACT DECONTAMINATION Summarized results of miscellaneous studies are incorporated in Table 3. Surveillance cultures of ETA positive for Gram-negative bacilli are predictive of subsequent nosocomial infections [57]. Moreover, surveillance culture of ETA positive for Aspergillus spp. in critically ill patients should prompt further analysis, given its positive predictive value of almost 50% for the subsequent presence of probable or definitive invasive aspergillosis [56]. Guidelines for selective digestive tract decontamination (SDD) suggest to obtain surveillance cultures of throat and rectal swabs twice a week [69,70]. SDD-resistant micro-organisms were detected earlier and more frequently on admission surveillance cultures [71]. Yet, no study currently available has demonstrated any evidence of usefulness of surveillance cultures in SDD. Nevertheless, surveillance cultures of throat and faeces samples may assess the SDD compliance and effectiveness, distinguish exogenous from endogenous infections and detect antimicrobial resistance [70].

COST-EFFECTIVENESS OF SURVEILLANCE CULTURES The presumed benefit of surveillance cultures lies in the early detection of MDR colonization and the subsequent contact precautions for individual patients, aiming to achieve lower MDR colonization and infection rates in the population, which in turn leads to less contact precautions, including declined long-term expensive antibiotic use. Furthermore, more appropriate antibiotic administration leads to lower rates of infection and, presumably, mortality. On the other hand, the costs of surveillance cultures consist of the labor associated with sample collection by the nurse, laboratory-processing costs and the possible attributable short-term costs for more contact precautions. Furthermore, a theoretical consequence of obtaining surveillance cultures may be the risk of infection due to frequent manipulations of endotracheal tubes and catheters. Although surveillance cultures may diminish antibiotic use in general [28,33], costs of the antibiotics eventually used may nevertheless be higher [28]. In nonepidemic situations, obtaining surveillance cultures for the presence of specific MDR micro-organisms appeared not cost-effective [72]. Surveillance culture implementation for VRE presence was cost-effective in one study [73]. Screening all ICU patients for MRSA colonization combined with the subsequent isolation and/or decolonization proved to be cost-effective for all ICU patients [46,74] during an MRSA outbreak [75], as well as in a theoretical model [76,77]. Overall, the potential financial benefit will be higher in the context of a high prevalence, more pathogenic MDR (MRSA > VRE) and a high risk for pneumonia, such as patients admitted to the ICU. With worldwide increasing numbers of MDR and of patients (becoming) at risk for HCAP, combined with possible lower laboratory costs, surveillance cultures may become more cost-effective in future.

GUIDELINES Guidelines concerning the management of CAP, HCAP, HAP and/or VAP are numerous [78]. A list of frequently used guidelines is provided in Table 4, including their statements on the use of surveillance cultures [5,79–91]. None of these guidelines provides clear recommendations concerning surveillance culture use.

SURVEILLANCE CULTURES FOR HEALTHCARE-ASSOCIATED PNEUMONIA Unfortunately, guidelines dealing with HCAP are numerous and contradictory. Furthermore, to our knowledge, no studies have dealt with the value of



267


268

www.co-pulmonarymedicine.com 2007 2008

2008

2009

2009 2009

2010

2011

Feldman et al. [81]

Muscedere et al. [82,83]

Masterton et al. [84]

Mosier et al. [85]

Correa et al. [86]

Lim et al. [87]

Menendez et al. [88]

Woodhead et al. [89]

Swedish Society of Infectious Disease

Dutch Working Party on Antibiotic Policy and Dutch Association of Chest Physicians

European Society of Clinical Microbiology and Infectious Disease and European Respiratory Society

Spanish Society of Pulmonology and Thoracic Surgery

British Thoracic Society

Brazilian Thoracic Society

American Burn Association

British Society of Antimicrobial Chemotherapy

VAP guidelines committee and Canadian Critical Care Trials Group

South African Thoracic Society

Gulf Cooperation Council

ATS and Infectious Diseases Society of America

ATS and Infectious Diseases Society of America

Organization

Swedish guidelines on the management of CAP in immunocompetent adults

Guidelines on the management of CAP in adults

Guidelines for the management of adult lower respiratory tract infections – full version

CAP. New guidelines of the Spanish Society of Chest Diseases and Thoracic Surgery

BTS guidelines for the management of CAP in adults: update 2009

Brazilian guidelines for CAP in immunocompetent adults

Guidelines for prevention, diagnosis, and treatment of VAP in burn patients

Guidelines for the management of HAP in the UK: Report of the Working Party on HAP

Comprehensive evidenced-based clinical practice guidelines for VAP

Management of CAP in adults

Practice guidelines for the management of CAP

Consensus guidelines on the management of CAP in adults

Treatment of HAP, VAP and HCAP

Name

Not mentioned

Not mentioned

Consider periodic surveillance of colonization in patients with exacerbations or bronchiectasis (level B3 evidence)

Not mentioned

Not mentioned

Not mentioned

Positive MRSA SC predicts MRSA VAP. No recommendation.

No studies for SC for HAP and consequently no recommendations

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Statement concerning SC

ATS, American Thoracic Society; BTS, British Thoracic Society; CAP, community-acquired pneumonia; HAP, hospital-acquired pneumonia; HCAP, healthcare-associated pneumonia; SC, surveillance cultures; VAP, ventilator-associated pneumonia.

2012

2007

Memish et al. [80]

Spindler et al. [91]

2007

Mandell et al. [79]

2012

2005

ATS [5]

Wiersinga et al. [90]

Year

Reference

Table 4. Current guidelines including their statement concerning surveillance cultures

Infectious diseases




surveillance cultures in HCAP. However, as mentioned earlier, micro-organisms involved in HCAP are comparable with those found in HAP and VAP [5]. As MDR is increasing [12] in both Gram-negative (e.g. Klebsiella pneumoniae, P. aeruginosa) and Grampositive (MRSA, VRE) micro-organisms involved in causing HAP, we thus hypothesize that surveillance cultures can also be of value in HCAP. In patients that have been previously identified as carriers of MDR micro-organisms, for example, one could argue that follow-up surveillance cultures to monitor the persistence of these MDR micro-organisms is indicated. This strategy could prevent patients from receiving inappropriate therapy when confronted with HCAP. Previously known surveillance cultures may also decrease the percentage of HCAP in which the causative micro-organism(s) remains unidentified, which is currently more than 30% [9]. As the Western population is increasingly becoming geriatric, with associated increases in healthcare services and costs, the population at risk for HCAP is also increasing annually. This will lead to additional costs, use of more antibiotics and/or potential increase of MDR micro-organisms. With this perspective, it seems paramount to optimize attempts to sequentially map the causative microorganisms involved.

CONCLUSION Although frequently quasi-experimental in nature and performed in heterogeneous populations, several studies have indicated that surveillance cultures could appropriately guide antibiotic treatment in VAP and MDR Gram-negative bacilli management. In a high-risk population, surveillance cultures for the presence of MRSA and VRE appeared useful, at least in countries with an already high prevalence of these micro-organisms. Surveillance cultures of ETA positive for Gram-negative bacilli and Aspergillus spp. are predictive for the development of nosocomial infections and invasive aspergillosis. Surveillance cultures could be cost-effective, especially in the context of a high prevalence of MDR in a population at high risk for pneumonia together with lower laboratory costs. So far, contemporary pneumonia management guidelines lack recommendations regarding the routine use of surveillance cultures. Despite these facts, surveillance cultures may have an important future role in HCAP management, especially owing to increasing MDR and population at risk. Further research on the usefulness of surveillance cultures is urgently needed to improve the understanding and management of HCAP patients, thereby proving its possible place in guidelines.

Acknowledgements We gratefully thank Helke A. van Dessel, medical microbiologist and Paul M.H.J. Roekaerts, professor of intensive care medicine, both associated with the Maastricht University Medical Center, Maastricht, The Netherlands for commenting on this manuscript. Conflicts of interest There are no conflicts of interest.

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Muscle sense, or nonsense?

[Cancer screening-- sense or nonsense?].

Transfusion and ecology: sense, nonsense, or missense?

[Sense or nonsense of unloader braces].

Making sense of nonsense.

Making sense of patent nonsense.

Nonsense and sense in shizophrenic language.

[Sense and nonsense of reducing diets].

[Sense and nonsense of ophthalmological eponyms].

Radiation protection: sense or nonsense? The British Institute of Radiology. London, 13 December 1989. Abstracts.

Intertwining extracorporeal membrane oxygenation and continuous renal replacement therapy: sense or nonsense?

MS for bioanalysis.

Reply to Solow: Sense and nonsense in the choice of extinction priors.

Ventilator associated pneumonia or ventilator induced pneumonia.

Screening and isolation to control meticillin-resistant Staphylococcus aureus: sense, nonsense, and evidence.

Biomechanical studies: science (f)or common sense?

Antimicrobial guidance in ventilator-associated pneumonia with routine endotracheal cultures.

Surveillance cultures in pediatric allogeneic hematopoietic stem cell transplantation.

Response to Sexton: Inhibiting the renin-angiotensin-aldosterone system in patients with heart failure and renal dysfunction: common sense or nonsense?

X-ray pelvimetry: useful procedure or medical nonsense.

The BRCA2 polymorphic stop codon: stuff or nonsense?

The "last breath" of the ventilator-associated pneumonia surveillance definition*.

Gastric cancer surveillance or prevention plus targeted surveillance.

Do cultures clarify models or do models clarify cultures?