Actualización del Consenso “Neumonía asociada a ventilación mecánica” Primera parte. Aspectos diagnósticos
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The best strategy to resolve the diagnosis of ventilator-associated pneumonia (VAP) is unsettled, and periodic reviews of new evidence are necessary. An update was performed to renew the 2001 recommendations on the diagnosis of this condition by The Chilean Society of Infectious Diseases. The main proposals are: to incorporate a microbiology-based strategy when there is a suspicion of VAP to gather local epidemiologic data and design appropriate empirical therapy for next cases, and to apply a non-invasive approach such as an endotracheal aspirate or mini-bronchoalveolar lavage, to facilitate accessibility and lower costs. There is no advantage on survival using either quantitative or qualitative cultures for VAP and a definite recommendation cannot be issued. Nonetheless, quantitative cultures are more specific and could facilitate to reject the diagnosis, look for other alternatives, and avoid unnecessary antibiotics. Biomarkers to assist VAP diagnosis are not recommended due to their poor performance. However, serial procalcitonin determinations have been useful to decrease antibiotic use in critical care patients and this biomarker has a better diagnostic yield than C reactive protein in this setting. This consensus also recommends discriminating VAP from ventilator-associated tracheobronchitis (VAT). The latter represents a separate entity characterized by an inflammatory response with purulent tracheal secretions but without new pulmonary infiltrates. Although preliminary data supports a beneficial effect of antibiotics to treat this condition, evidence is limited yet, and both conditions deserve to be discriminated (VAP versus VAT).
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