Evaluación de la concordancia entre dos métodos de lavado broncoalveolar para el diagnóstico microbiológico de la neumonía en pacientes con asistencia respiratoria mecánica
Palabras clave:
neumonía/etiología, respiración artificial, técnicas y procedimientos diagnósticos, técnicas microbiológicas, lavado broncoalveolar
Resumen
Introducción. El diagnóstico microbiológico de la neumonía permite optimizar el uso de antibióticos en pacientes con asistencia respiratoria mecánica. Para ello se han cultivado cuantitativamente las muestras del lavado broncoalveolar broncoscópico, procedimiento que no siempre es posible.Objetivo. Evaluar la concordancia microbiológica entre muestras respiratorias tomadas por lavado broncoalveolar broncoscópico y no broncoscópico, y establecer si el uso previo de antibióticos y el momento de presentación de la neumonía pueden afectarla.
Materiales y métodos. Estudio prospectivo realizado en el Hospital Universitario San Vicente de Paúl, en 38 pacientes con sospecha de neumonía y con asistencia respiratoria mecánica. En todos se practicó el lavado broncoalveolar por fibrobroncoscopia y el lavado no broncoscópico usando un catéter telescopado de punta preformada (Balcath®). Todas las muestras fueron procesadas siguiendo protocolos microbiológicos convencionales.
Resultados. Considerando el lavado broncoalveolar por fibrobroncoscopia como patrón de referencia, los cultivos permitieron identificar el agente en 60,5% de los casos. El acuerdo diagnóstico se logró en 82% de los pacientes y 79% de los aislamientos. Utilizando el índice kappa de Cohen, la concordancia general entre los dos métodos fue 0,76 [0,60-0,93]; pero en quienes habían recibido antibióticos previos fue 0,26 [0,05-0,48], versus 1,0 en quienes no lo habían hecho (p<0,0001). La concordancia no difirió significativamente cuando se compararon los casos de neumonía temprana y tardía.
Conclusiones. La concordancia general entre los dos métodos de lavado broncoalveolar es buena en pacientes con neumonía y respiración asistida mecánicamente. Sin embargo, el uso previo de antibióticos y no el momento de aparición de la neumonía, disminuye ésta significativamente.
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Referencias bibliográficas
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5. Fagon JY, Chastre J, Wolff M, Gervais C, Parer- Aubas S, Stéphan F, et al. Invasive and non-invasive strategies for management of suspected ventilator associated pneumonia: a randomized trial. Ann Intern Med. 2000;132:621-30. 6. The Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med. 2006;21:2619-30.
7. Torres A, El-Ebiary M, Padró L, González J, de la Bellacasa JP, Ramírez J. Validation of different techniques for the diagnosis of ventilator-associated pneumonia. Comparison with immediate postmortem pulmonary biopsy. Am J Respir Crit Care Med.1994; 149:324-31.
8. Marik P, Brown W. A comparison of bronchoscopic Vs. blind protected specimen brush sampling in patients with suspected ventilator-associated pneumonia. Chest. 1995;108:203-7.
9. Torres A, El-Ebiary M. Invasive diagnostic techniques for pneumonia: protected specimen brush, bronchoalveolar lavage and lung biopsy methods. Infect Dis Clin North Am. 1998;12;701-22.
10. Pittet D, Harbarth S. What techniques for diagnosis of ventilator-associated pneumonia? Lancet. 1998; 352:83-4. 11. Casetta M, Blot F, Antoun S, Leclercq B, Tancrède C, Doyon F, et al. Diagnosis of nosocomial pneumonia in cancer patients undergoing mechanical ventilation: a prospective comparison of the plugged telescoping catheter with the protected specimen brush. Chest. 1999;115:1641-5.
12. Heyland DK, Cook DJ, Marshall J, Heule M, Guslits B, Lang J, et al. The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia. Canadian Care Trials Group. Chest. 1999;115:1076-84. 13. Grossman R, Fein A. Evidence-based assessment of diagnostic test for ventilator associated pneumonia: executive summary. Chest. 2000;117:177S-81.
14. American Thoracic Society. Clinical role of bronchoalveolar lavage in adults with pulmonary disease. Am J Respir Crit Care Med. 1990;142:481-86.
15. Kahn FW, Jones JM. Analysis of bronchoalveolar lavage specimens from immunocompromised patients with a protocol applicable in the microbiology laboratory. J Clin Microbiol. 1988;26:1150-5.
16. Mayhall CG. Ventilator-associated pneumonia or not? Contemporary diagnosis. Emerg Infect Dis. 2001;7:200-4.
17. Souweine B, Veber B, Bedos JP, Gachot B, Dombret MC, Regnier B, et al. Diagnostic accuracy of protected specimen brush and bronchoalveolar lavage in nosocomial pneumonia: Impact of previous antimicrobial treatments. Crit Care Med. 1998;26:236-44.
18. Campbell GD. Blinded invasive diagnostic procedures in ventilator-associated pneumonia. Chest. 2000;117:207S-11.
19. Woske HG, Röding T, Schulz I, Lode H. Ventilatorassociated pneumonia in a surgical intensive care unit: epidemiology, etiology and comparison of three bronchoscopic methods for microbiological specimen sampling. Crit Care. 2001;5:167-73.
20. Chastre J, Fagon JY, Bornet-Lecso M, Calvat S, Dombret MC, al Khani R, et al. Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med. 1995;152:231-40.
21. Pham LH, Brun-Buisson C, Legrand P, Rauss A, Verra F, Brochard L, et al. Diagnosis of nosocomial pneumonia in mechanically ventilated patients. Comparison of a plugged telescoping catheter with the protected specimen brush. Am Rev Respir Dis. 1991;143:1055-61.
22. Wearden PD, Chendrasekhar A, Timberlake GA. Comparison of nonbronchoscopic techniques with bronchoscopic brushing in the diagnosis of ventilatorassociated pneumonia. J Trauma. 1996;41:703-7.
23. Bello S, Tejada A, Chacón E, Villuendas MC, Senar A, Gascon M, et al. “Blind” protected specimen brush ing versus bronchoscopic techniques in the aetiolological diagnosis of ventilator-associated pneumonia. Eur Respir J. 1996;9:1494-9.
24. Jordá R, Parras F, Ibañez J, Reina J, Bregada J, Raurich JM. Diagnosis of nosocomial pneumonia in mechanically ventilated patients by the blind protected telescoping catheter. Intensive Care Med. 1993; 19: 377-82.
25. Papazian L, Martin C, Meric B, Dumon JF, Gouin F. A reappraisal of blind bronchial sampling in the microbiologic diagnosis of nosocomial bronchopneumonia. A comparative study in ventilated patients. Chest. 1993;103:236-42.
26. Middleton RM III, Huff W, Brickey DA, Kirkpatrick MB. Comparison of quantitative cultures to semiquantitative loop cultures of bronchoscopic protected specimen brush samples. Chest. 1996; 109:1204-9.
27. Leal-Noval SR, Alfaro-Rodríguez E, Murillo-Cabeza F, Garnacho-Montero J, Rey-Pérez J, Muñoz- Sánchez MA. Diagnostic value of the blind brush in mechanically ventilated patients with nosocomial pneumonia. Intensive Care Med. 1992;18:410-4.
28. Wood AY, Davit AJ II, Ciraulo DL, Arp NW, Richart CM, Maxwell RA, et al. A prospective assessment of diagnostic efficacy of blind protective bronchial brushings compared with bronchoscope-assisted lavage, bronchoscope-directed brushings, and blind endotracheal aspirates in ventilator-associated pneumonia. J Trauma. 2003; 55:825-34.
29. Torres A, Puig de la Bellacasa J, Rodríguez-Roisin R, Jiménez deAnta MT, Agusti-Vidal A. Diagnostic value of telescoping plugged catheters in mechanically ventilated patients with bacterial pneumonia using the Metras catheter. Am Rev Respir Dis.1988;138:117-20.
30. Kollef MH, Bock KR, Richards RD, Hearns ML. The safety and diagnostic accuracy of minibronchoalveolar lavage in patients suspected of ventilator-associated pneumonia. Ann Intern Med. 1995;122:743-8.
31. Levy H. Comparison of Ballard catheter bronchoalveolar lavage with bronchoscopic bronchoalveolar lavage. Chest. 1994;106:1753-8.
32. Timsit JF, Misset B, Renaud B, Goldstein FW, Carlet J. Effect of previous antimicrobial therapy on the accuracy of the main procedures used to diagnose nosocomial pneumonia in patients who are using ventilation. Chest. 1995;108:1036-40.
33. Solé Violán J, Rodríguez de Castro F, Caminero J, Bordes A, Manzano JL. Comparative efficacy of broncoalveolar lavage and telescoping plugged catheter in the diagnosis of pneumonia in mechanically ventilated patients. Chest. 1993;103:386-90.
34. Torres A, Martos A, Puig de la Bellacasa J, Ferrer M, el-Ebiary M, González J, et al. Specificity of endotracheal aspiration, protected specimen brush, and broncoalveolar lavage in mechanically ventilated patients. Am Rev Respir Dis. 1993;147:952-7.
35. Marik PE, Careau P. A comparison of minibronchoalveolar lavage and blind-protected specimen brush sampling in ventilated patients with suspected pneumonia. J Crit Care. 1998;13:67-72.
36. Sirvent JM, Vidaur L, González S, Castro P, de Batle J, Castro A, et al. Microscopic examination of intracellular organisms in protected bronchoalveolar mini-lavage fluid for the diagnosis of ventilator-associated pneumonia. Chest. 2003;123:518-23.
37. De Jaeger A, Litalien C, Lacroix J, Guertin MC, Infante-Rivard C. Protected specimen brush or bronchoalveolar lavage to diagnose bacterial nosocomial pneumonia in ventilated adults: a meta-analysis. Crit Care Med. 1999;27:2548-60.
38. Dotson RG, Pingleton SK. The effect of antibiotic therapy on recovery of intracellular bacteria from bronchoalveolar lavage in suspected ventilator-associated nosocomial pneumonia. Chest. 1993;103:541-6.
39. Trouillet JL, Chastre J, Vuagnat A, Joly-Guillou ML, Combaux D, Dombret MC, et al. Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998; 157:531-9.
40. Fridkin SK, Lawton R, Edwards JR, Tenover FC, McGowan JE, Gaynes RP, et al. Monitoring antimicrobial use and resistance: comparison with a national benchmark on reducing vancomycin use and vancomycin- resistant enterococci. Emerg Infect Dis. 2002;8:702-7.
41. Chastre J. Evolving problems with resistant pathogens. Clin Microbiol Infect. 2008;14:3-14.
42. Rello J, Ausina V, Ricart M, Castella J, Prats G. Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest. 1993;104:1230-5.
43. Lynch JP. Hospital-acquired pneumonia. Risk factors, microbiology, and treatment. Chest. 2001;119:373S-84.
44. Ewig S, Bauer T, Torres A. The pulmonary physician in critical care. Nosocomial pneumonia. Thorax. 2002;57:366-71.
2. Bercault N, BoulainT. Mortality rate attributable to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective casecontrol study. Crit Care Med. 2001;29:2303-9.
3. Fagon JY, Chastre AJ, Hance AJ, Montravers P, Novara A, Gilbert C. Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med. 1993;94:281-8.
4. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002;165:867-903.
5. Fagon JY, Chastre J, Wolff M, Gervais C, Parer- Aubas S, Stéphan F, et al. Invasive and non-invasive strategies for management of suspected ventilator associated pneumonia: a randomized trial. Ann Intern Med. 2000;132:621-30. 6. The Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med. 2006;21:2619-30.
7. Torres A, El-Ebiary M, Padró L, González J, de la Bellacasa JP, Ramírez J. Validation of different techniques for the diagnosis of ventilator-associated pneumonia. Comparison with immediate postmortem pulmonary biopsy. Am J Respir Crit Care Med.1994; 149:324-31.
8. Marik P, Brown W. A comparison of bronchoscopic Vs. blind protected specimen brush sampling in patients with suspected ventilator-associated pneumonia. Chest. 1995;108:203-7.
9. Torres A, El-Ebiary M. Invasive diagnostic techniques for pneumonia: protected specimen brush, bronchoalveolar lavage and lung biopsy methods. Infect Dis Clin North Am. 1998;12;701-22.
10. Pittet D, Harbarth S. What techniques for diagnosis of ventilator-associated pneumonia? Lancet. 1998; 352:83-4. 11. Casetta M, Blot F, Antoun S, Leclercq B, Tancrède C, Doyon F, et al. Diagnosis of nosocomial pneumonia in cancer patients undergoing mechanical ventilation: a prospective comparison of the plugged telescoping catheter with the protected specimen brush. Chest. 1999;115:1641-5.
12. Heyland DK, Cook DJ, Marshall J, Heule M, Guslits B, Lang J, et al. The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia. Canadian Care Trials Group. Chest. 1999;115:1076-84. 13. Grossman R, Fein A. Evidence-based assessment of diagnostic test for ventilator associated pneumonia: executive summary. Chest. 2000;117:177S-81.
14. American Thoracic Society. Clinical role of bronchoalveolar lavage in adults with pulmonary disease. Am J Respir Crit Care Med. 1990;142:481-86.
15. Kahn FW, Jones JM. Analysis of bronchoalveolar lavage specimens from immunocompromised patients with a protocol applicable in the microbiology laboratory. J Clin Microbiol. 1988;26:1150-5.
16. Mayhall CG. Ventilator-associated pneumonia or not? Contemporary diagnosis. Emerg Infect Dis. 2001;7:200-4.
17. Souweine B, Veber B, Bedos JP, Gachot B, Dombret MC, Regnier B, et al. Diagnostic accuracy of protected specimen brush and bronchoalveolar lavage in nosocomial pneumonia: Impact of previous antimicrobial treatments. Crit Care Med. 1998;26:236-44.
18. Campbell GD. Blinded invasive diagnostic procedures in ventilator-associated pneumonia. Chest. 2000;117:207S-11.
19. Woske HG, Röding T, Schulz I, Lode H. Ventilatorassociated pneumonia in a surgical intensive care unit: epidemiology, etiology and comparison of three bronchoscopic methods for microbiological specimen sampling. Crit Care. 2001;5:167-73.
20. Chastre J, Fagon JY, Bornet-Lecso M, Calvat S, Dombret MC, al Khani R, et al. Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med. 1995;152:231-40.
21. Pham LH, Brun-Buisson C, Legrand P, Rauss A, Verra F, Brochard L, et al. Diagnosis of nosocomial pneumonia in mechanically ventilated patients. Comparison of a plugged telescoping catheter with the protected specimen brush. Am Rev Respir Dis. 1991;143:1055-61.
22. Wearden PD, Chendrasekhar A, Timberlake GA. Comparison of nonbronchoscopic techniques with bronchoscopic brushing in the diagnosis of ventilatorassociated pneumonia. J Trauma. 1996;41:703-7.
23. Bello S, Tejada A, Chacón E, Villuendas MC, Senar A, Gascon M, et al. “Blind” protected specimen brush ing versus bronchoscopic techniques in the aetiolological diagnosis of ventilator-associated pneumonia. Eur Respir J. 1996;9:1494-9.
24. Jordá R, Parras F, Ibañez J, Reina J, Bregada J, Raurich JM. Diagnosis of nosocomial pneumonia in mechanically ventilated patients by the blind protected telescoping catheter. Intensive Care Med. 1993; 19: 377-82.
25. Papazian L, Martin C, Meric B, Dumon JF, Gouin F. A reappraisal of blind bronchial sampling in the microbiologic diagnosis of nosocomial bronchopneumonia. A comparative study in ventilated patients. Chest. 1993;103:236-42.
26. Middleton RM III, Huff W, Brickey DA, Kirkpatrick MB. Comparison of quantitative cultures to semiquantitative loop cultures of bronchoscopic protected specimen brush samples. Chest. 1996; 109:1204-9.
27. Leal-Noval SR, Alfaro-Rodríguez E, Murillo-Cabeza F, Garnacho-Montero J, Rey-Pérez J, Muñoz- Sánchez MA. Diagnostic value of the blind brush in mechanically ventilated patients with nosocomial pneumonia. Intensive Care Med. 1992;18:410-4.
28. Wood AY, Davit AJ II, Ciraulo DL, Arp NW, Richart CM, Maxwell RA, et al. A prospective assessment of diagnostic efficacy of blind protective bronchial brushings compared with bronchoscope-assisted lavage, bronchoscope-directed brushings, and blind endotracheal aspirates in ventilator-associated pneumonia. J Trauma. 2003; 55:825-34.
29. Torres A, Puig de la Bellacasa J, Rodríguez-Roisin R, Jiménez deAnta MT, Agusti-Vidal A. Diagnostic value of telescoping plugged catheters in mechanically ventilated patients with bacterial pneumonia using the Metras catheter. Am Rev Respir Dis.1988;138:117-20.
30. Kollef MH, Bock KR, Richards RD, Hearns ML. The safety and diagnostic accuracy of minibronchoalveolar lavage in patients suspected of ventilator-associated pneumonia. Ann Intern Med. 1995;122:743-8.
31. Levy H. Comparison of Ballard catheter bronchoalveolar lavage with bronchoscopic bronchoalveolar lavage. Chest. 1994;106:1753-8.
32. Timsit JF, Misset B, Renaud B, Goldstein FW, Carlet J. Effect of previous antimicrobial therapy on the accuracy of the main procedures used to diagnose nosocomial pneumonia in patients who are using ventilation. Chest. 1995;108:1036-40.
33. Solé Violán J, Rodríguez de Castro F, Caminero J, Bordes A, Manzano JL. Comparative efficacy of broncoalveolar lavage and telescoping plugged catheter in the diagnosis of pneumonia in mechanically ventilated patients. Chest. 1993;103:386-90.
34. Torres A, Martos A, Puig de la Bellacasa J, Ferrer M, el-Ebiary M, González J, et al. Specificity of endotracheal aspiration, protected specimen brush, and broncoalveolar lavage in mechanically ventilated patients. Am Rev Respir Dis. 1993;147:952-7.
35. Marik PE, Careau P. A comparison of minibronchoalveolar lavage and blind-protected specimen brush sampling in ventilated patients with suspected pneumonia. J Crit Care. 1998;13:67-72.
36. Sirvent JM, Vidaur L, González S, Castro P, de Batle J, Castro A, et al. Microscopic examination of intracellular organisms in protected bronchoalveolar mini-lavage fluid for the diagnosis of ventilator-associated pneumonia. Chest. 2003;123:518-23.
37. De Jaeger A, Litalien C, Lacroix J, Guertin MC, Infante-Rivard C. Protected specimen brush or bronchoalveolar lavage to diagnose bacterial nosocomial pneumonia in ventilated adults: a meta-analysis. Crit Care Med. 1999;27:2548-60.
38. Dotson RG, Pingleton SK. The effect of antibiotic therapy on recovery of intracellular bacteria from bronchoalveolar lavage in suspected ventilator-associated nosocomial pneumonia. Chest. 1993;103:541-6.
39. Trouillet JL, Chastre J, Vuagnat A, Joly-Guillou ML, Combaux D, Dombret MC, et al. Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998; 157:531-9.
40. Fridkin SK, Lawton R, Edwards JR, Tenover FC, McGowan JE, Gaynes RP, et al. Monitoring antimicrobial use and resistance: comparison with a national benchmark on reducing vancomycin use and vancomycin- resistant enterococci. Emerg Infect Dis. 2002;8:702-7.
41. Chastre J. Evolving problems with resistant pathogens. Clin Microbiol Infect. 2008;14:3-14.
42. Rello J, Ausina V, Ricart M, Castella J, Prats G. Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest. 1993;104:1230-5.
43. Lynch JP. Hospital-acquired pneumonia. Risk factors, microbiology, and treatment. Chest. 2001;119:373S-84.
44. Ewig S, Bauer T, Torres A. The pulmonary physician in critical care. Nosocomial pneumonia. Thorax. 2002;57:366-71.
Cómo citar
1.
Vélez L, Loaiza N, Gaviria LM, Maya MA, Rueda ZV, Correa LT, et al. Evaluación de la concordancia entre dos métodos de lavado broncoalveolar para el diagnóstico microbiológico de la neumonía en pacientes con asistencia respiratoria mecánica. Biomed. [Internet]. 1 de diciembre de 2008 [citado 4 de abril de 2025];28(4):551-6. Disponible en: https://revistabiomedicaorg.biteca.online/index.php/biomedica/article/view/60
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