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Correspondence

Indian Pediatr 2018;55: 76

Endotracheal Aspirate Microscopy and Culture in Early Prediction of Ventilator-associated Pneumonia in Neonates

 

Naveen Kumar Bhardwaj1 and Neeraj Gupta2

Department of 1Pediatrics and 2Neonatology, AIIMS Jodhpur, Rajasthan, India.
Email: [email protected]
 

   

 

We read the article by Gupta, et al. [1] with great interest, and would like to point out few issues:

First, the authors have collected endotracheal aspirate (ETA) for microscopy and culture in all the neonates on mechanical ventilation, irrespective of any clinical deterioration at the time of collecting ETA sample. Though the CDC definition of ventilator-associated pneumonia (VAP) [2] lacks specificity in the absence of isolation of the pathogen, the microbiological isolation or identification of pus cells in ETA is attempted only when there is clinical deterioration in terms of worsening gas exchange in patients on mechanical ventilation. The same has been highlighted by CDC while redefining possible VAP in adults [3]. Thus, the mere presence of organism or pus cells in ETA in absence of clinical worsening reflects colonization rather than infection [4]. Moreover, while doing any diagnostic study, the diagnostic test should be performed on those group of subjects in whom it will be applied in the real world clinical setting. Therefore, ventilated neonates having any deterioration in terms of increasing ventilator requirement should have been the ideal subjects for checking the utility of ETA in early diagnosis of VAP rather than enrolling both asymptomatic and symptomatic neonates.

Second, there should be an independent and blind comparison of the diagnostic test with the gold standard while doing any diagnostic study. This is to avoid the bias that might cause the over-or under-interpretation of the gold standard test. The authors have not commented anything about this comparison.

Third, the authors have instilled 0.5 mL of normal saline in endotracheal tube for the sample yield, which is not routinely recommended [5]. This becomes more important in light of no information about the ethics committee approval in the given article.

References

1. Gupta MK, Mondkar J, Swami A, Hegde D, Goel S. Endotracheal aspirate microscopy, cultures and endotracheal tube tip cultures for early prediction of ventilator associated pneumonia in neonates. Indian Pediatr. 2017;54:211-4.

2. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control. 1988;16:128-40.

3. Centers for Disease Control and Prevention. Ventilator-Associated Event (VAE). Available from: https://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL. pdf. Accessed April 28, 2017.

4. Gil-Perotin S, Ramirez P, Marti V, Sahuquillo JM, Gonzalez E, Calleja I, et al. Implications of endotracheal tube biofilm in ventilator-associated pneumonia response: a state of concept. Crit Care. 2012;16:R93.

5. Gardner DL, Shirland L. Evidence-based guideline for suctioning the intubated neonate and infant. Neonatal Netw. 2009;28:281-302.


 

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