الفهرس 
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Abstract
Ventilator-associated pneumonia (VAP) is common, costly, and associated with increased morbidity and mortality. Diagnosis of VAP is based on clinical suspicion and microbiologic confirmation of a sample obtained from the lower respiratory tract. Several methods are available to sample lower respiratory tract secretions, including ”non-invasive” sampling via endotracheal aspirate (ETA) and ”invasive” sampling via bronchoscopy using either a protected specimen brush or Broncho alveolar lavage and mini-BAL.
In clinical practice, VAP is usually diagnosed on a combination of clinical and radiographic criteria in combination with semi-quantitative cultures from tracheal aspirates. The combination of these criteria has a high sensitivity for VAP, but specificity is low.
As a result, many patients will be incorrectly diagnosed as having VAP, and a description of resolution of clinical parameters in such a population may be influenced by patients having colonization instead of infection of the respiratory tract.
Debate exists regarding the best diagnostic approach. However, in the absence of a gold standard to diagnose VAP, a rigorous comparison of different diagnostic techniques is challenging.
The aim of this comparative prospective study was to compare between invasive (based on mini-BAL culture) and non- invasive (according to clinical and radiological findings) methods in the diagnosis of ventilator-associated pneumonia in Intensive Care Unit patients.
The study was carried out on 50 patients admitted to ICU diagnosed as VAP. They were divided into two groups (25 patients each):
group A:
o The 25 patients were diagnosed using mini-BAL culture as invasive sampling method.
group B:
o The 25 patients were diagnosed using non-invasive method according to CPIS (> 6) based on five variables of six: temperature, blood leukocyte count, volume and purulence of tracheal secretions, oxygenation, and pulmonary radiography
o 18/25 patients had CPIS of 9 and 7/25 patients had CPIS of 7.
The results showed that;
1. The difference in gender, age, weight & height was not statistically significant (P=0.225, 0.68, 0.19 &0.19 respectively).
2. There was no statistical significant difference in Co-morbidities between two groups regarding the underling diseases; (COPD (48, 52%), Hypertension (40, 52%), Chest infection (36, 52%), Respiratory failure (32, 52%), diabetes mellitus (32, 20%) and Asthma (16, 24%) in group A and B respectively) except heart failure (24% in group A and 0% in group B) (FEp =0.022).
3. The microorganism(s) isolated from group A were mainly gram negative isolates (88%) (Enterobacter spp (32%), klebsiella pneumonia & Acinetobacter spp (24%) each, E-coli (16%), Pseudomonas aeruginosa (8%) and Proteus spp (4%) of cases).
All isolates were monomicrobial except in 5 cases polymicrobial was revealed. Regarding Gram-positive microrganisms, (Staphylococcus aureus) was isolated only from 2 cases (10%) and (candida spp) from 1 case (4%).
4. As regards Antibiotic resistance pattern, Amoxacillin - Clavulanic acid (AMC), Ceftriaxone (CRO), Cefotaxime (CTX), Cefuroxime, Erythromycin (E), Clarithromycin (CLR), Clindamycin (DA), Ofloxacin (OFX) showed the higher incidence of resistance (100%). While the most sensitive antibiotics were Colistin (CT) (83%) then Chloramephenicol (C) (55%) then, Meropenem (MTM) (47%) Pipracillin - Tazobactam (PTZ) & Imipenem (IMP) (36%) each then Doxycycline (DO) (33%) followed by Azteonam (ATM) (28%) and lastly, Ampicillin – Sulbactam (22%).
5. The two diagnostic methods was evaluated by comparing the prescription of the line of treatment (culture based or empiric) and its duration, the resolution of CPIS parameters and mortality rate between two groups.
There was no statistical significance difference regarding Usage of antibiotics in between both groups except in usage of Lincosamides (Clindamycin) and its duration (significantly prolonged in group A than group B as p= (P=0.039)), colistin and fluconazole antibiotics as (in group A was used in 4 cases (16%) vs. 0 % in group B, 2 cases (8%) vs. 0% and 1 case (4%) vs. 0% respectively).
Although the overall antibiotics duration treatment in group B 10 (7-12) days was shorter than group A 14 (7-21) days, this difference was not statistically significance (P=0.39).
• In group A the three parameters of VAP diagnosis (temperature, PaO2/FIO2 ratio, and leukocyte counts) improved significantly with time (between 1st and 4th, 4th and 7th days & 1st and 7th) after initiation of antibiotic treatment based on culture. While in group B, there was improvement in the three parameters between 4th and 7th days, and this improvement was statistically significant regarding leukocyte counts (F= 17.7, P=0.0001).
• Also, by comparing 2 groups (A&B) in different time intervals, these three parameters showed no statistically significant difference (1st, 4th and 7th day) except in 1th day in PaO2/FiO2 ratio, there was statistical significant difference (U=171.0, p=0.006).
• There was no significant difference in mortality rate between both groups as (P=0.39) as the mortality rate in group A was 40% while in group B was 56%.