4 ( 5 .. ..

(Thai Clinical Practice Guidelines for Management and Prevention of Adults with
Hospital-acquired and Ventilator-associated Pneumonia)

1.
(clinical practice guidelines)
(hospital-acquired pneumonia, HAP)
(ventilator-associated pneumonia, VAP)
(supportive therapy)
(intensive
monitoring)

(evidence-based)

(expert opinion) (quality of evidence)

(strength of recommendation) (Infectious Diseases Society of
America, IDSA) (United States Public Health Service)
11

I.
(hospital-acquired pneumonia, HAP)
48 1
(ventilator-associated pneumonia, VAP)
48 48
1
(healthcare-associated pneumonia, HCAP)
48 90
nursing home long-term care facility
30
(hemodialysis unit)1
(early-onset HAP or VAP)
HAP VAP 48 4 1
(late-onset HAP or VAP)
HAP VAP 4 1
> 38.3 1 > 38 1
> 37.52
(endotracheal tube) (orotracheal)
(nasotracheal) (tracheostomy tube)1
neutrophils>
25 /low-power field (LPF) squamous epithelial cells <10 /LPF3

(HCAP) (aspiration pneumonia)

nursing home longterm
care facility
(immunocompetent adults)
(human immunodeficiency virus, HIV) (hematologic malignancy)
(neutropenia) (transplantation)
(good clinical judgement)

II. HAP VAP1-8
2.1

3
2 HAP VAP (etiologic
pathogen) HAP
VAP HAP VAP (clinical suspicion)
(new onset)
(purulent sputum)


(complete blood count, CBC) (chest X-ray)
HAP VAP infiltrate (new)
(progressive) 2 3
.
. ()
. 12,000 / (12 x 109
/) 4,000 / (4 x 109 /)1,5,8
HAP VAP

1 3
(empirical antibiotic)
(over diagnosis) 3
(under diagnosis)
Fabregas
(gold standards) HAP VAP
69 75 5
HAP VAP
sepsis


1

(pulmonary embolism)

Pugin 4 HAP VAP
clinical pulmonary infection score (CPIS)4
6
HAP VAP (quantitative culture)
(bronchoalveolar lavage, BAL) (bronchoscopy)

4
(gold standard)
Fabregas 5 CPIS
77 42
CPIS HAP VAP CPIS
(Gram staining) endotracheal aspirate
(protected specimen brush, PSB)6
endotracheal aspirate
(inflammatory cells)
72 HAP VAP 94 ( IIA)9
Singh 7 modified CPIS ( 26)
HAP VAP 5 6

3
7
1 3
6 3
10-21
HAP VAP 3 6

( IA)

HAP VAP infiltrate 2 3

.
.
. 12,000 /
4,000 /
HAP VAP

endotracheal aspirate
72 HAP VAP
infiltration
modified CPIS Singh
empirical 3 6

5
(
1)

(> 24 )
modified CPIS
3
6 6
HAP VAP
2.2
endotracheal aspirate, BAL PSB 3

1. (qualitative culture)

( IA)10-13
2. (semiquantitative culture) endotracheal aspirate (1+, 2+
3+ ) HAP
VAP ( IA)10-13
3. (quantitative culture) (bacterial
threshold)



72

(quantitative
culture) 14
HAP VAP ( IA)9

(non-bronchoscopic BAL) HAP VAP

(bronchoscope) ( IIA)14

1.
2. endotracheal aspirate HAP VAP
106 colony-forming unit (cfu)/

6
38-82 ( + 76
+ 9) 72-85 ( + 75 + 28) 15
3.
> 104 > 105 cfu/ 42-93 ( +
73 + 18) 45-100 ( +
82 + 19) 16
4. PSB > 103 cfu/
33-100 ( + 66 + 19)
50-100 ( + 90 + 15) 16

(expectorated sputum) endotracheal aspirate (
) BAL PSB




fiberoptic BAL PSB

modified CPIS
3

3+
72
HAP VAP infiltrate
anaerobes

4+
HAP VAP

HAP VAP infiltrate

7
72 infiltrate

48 72

(empyema thoracis)
(phlebitis)
infiltrate
3+

4+
HAP VAP
HAP VAP
HAP VAP
6, 15
16
III.
3.1
HAP VAP

Iregui VAP 107 17 33 ( 30.8)
24 VAP 25 (
75.8)

24
24 ( 69.7 28.4 p<0.001) ( IIA)
.. 2548
24
(p=0.024) 24
24
18
3.2

HAP VAP ( IA)19-21
empirical
(multidrug-resistant strains) 31,22-25
HAP VAP

8

HAP VAP ( IIA)26-28
29
endotracheal aspirate (surveillance) 1
VAP VAP BAL

.. 254830
empirical treatment
active VAP

endotracheal aspirate
VAP VAP
(cost effectiveness) endotracheal
aspirate VAP

(combination therapy)
empirical ( IA)31
aminoglycoside 5-7
( IIIA)32
(monotherapy) HAP VAP
( IA)19-21
aerosolized HAP
VAP ( IA)33 (adjunctive therapy) HAP
VAP

empirical HAP VAP

HAP VAP

Staphylococcus aureus
(cluster) endotracheal aspirate BAL PSB

9
cloxacillin glycopeptide
S. aureus methicillin (methicillin-resistant S. aureus, MRSA)
empirical
S. aureus 41 51
3.3
empirical
(colonization
of antibiotic-resistant bacteria) (secondary infection by
antibiotic-resistant bacteria)




VAP 62
66.1 24.4
4 34
3.4
HAP VAP
14-21 Dennesen
VAP Haemophilus influenzae Streptococcus pneumoniae 2
Enterobacteriaceae, S. aurues Pseudomonas aeruginosa
35 6
Luna CPIS VAP
3-5 36 Chastre multicenter
randomized controlled trial 8
14 37 (relapse) P. aeruginosa
Acinetobacter spp. ( IA)

HAP, VAP P. aeruginosa Acinetobacter spp. 8
38

HAP VAP P. aeruginosa

Acinetobacter spp. 7-10 infiltrate
3.5
P. aeruginosa

10
P. aeruginosa
meta- analysis aminoglycoside
-lactam ( IA)31
aminoglycoside

-lactam -lactam quinolone

-lactam

Acinetobacter spp.
Acinetobacter spp. carbapenem
(pandrug-resistant strains)
sulbactam, polymyxins, colistin, tigecycline fosfomycin
randomized controlled trial
case series (case reports)39
Extended-spectrum -lactamase (ESBL)-producing Enterobacteriaceae
randomized controlled trial HAP
VAP Enterobacteriaceae ESBL carbapenem
ertapenem ( P. aeruginosa, Acinetobacter spp.)
imipenem, meropenem fosfomycin40,
colistin41 tigecycline41
S. aureus methicillin (methicillin-resistant S. aureus, MRSA)
Vancomycin teicoplanin HAP VAP MRSA
40 prospective randomized trial
quinupristin-dalfopristin vancomycin ( IA)42
quinupristin-dalfopristin 2 multicenter
linezolid HAP MRSA vancomycin
( IIA)43 randomized controlled trial

11

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management of adults with hospital-acquired, ventilator-associated, and healthcare-associated
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3. Ioanas M, Ferrer R, Angrill J, Ferrer M, Torres A. Microbial investigation in ventilator-associated
pneumonia. Eur Respir J 2001;17:791-801.
4. Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM. Diagnosis of ventilator-associated
pneumonia by bacteriologic analysis of bronchoscopic and non bronchoscopic blind
bronchoalveolar lavage fluid. Am Rev Respir Dis 1991;143:1121-9.
5. Fabregas N, Ewig S, Torres A, El-Ebiary M, Ramirez J, de la Bellacasa SP, Bauer T, Cabello H.
Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using
immediate postmortem lung biopsies. Thorax 1999;54:867-73.
6. Fartoukh M, Maitre B, Monore S, Cerf C, Zahar JR, Brun-Buisson C. Diagnosing pneumonia during
mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med
2003;168:173-9.
7. Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short-course empiric antibiotic therapy for
patients with pulmonary infiltrates in the intensive care unit: a proposed solution for indiscriminate
antibiotic prescription. Am J Respir Crit Care Med 2000;162:505-11.
8. Johanson WG, Pierce AK, Sanford JP, Thomas GD. Nosocomial infections with gram-negative bacilli.
The significance of colonization of the respiratory tract. Ann Intern Med 1972;77:701-6.
9. Blot F, Raynard B, Chachaty E, Tancrede C, Antoun S, Nitenberg G. Value of Gram stain examination
of lower respiratory tract secretions for early diagnosis of nosocomial pneumonia. Am J Respir Crit
Care Med 2000;162:1731-7.
10. Fagon JY, Chastre J, Wolff M, Gervais C, Parer-Aubas S, Stephan F, Similowski T, Mercat A, Diehl JL,
Sollet JP, et al. Invasive and noninvasive strategies for management of suspected ventilatorassociated pneumonia a randomized trial. Ann Intern Med 2000;132:621-30.
11. Sanchez-Nieto JM, Torres A, Garcia-Cordoba F, EI-Ebiary M, Carrillo A, Ruiz J, Nunez ML, Niederman
M. Impact of invasive and noninvasive quantitative sampling on outocome of ventilator-associated
pneumonia: a pilot study. Am J Respir Crit Care Med 1998;157:371-6.
12. Ruiz M, Torres A, Ewig S, Marcos MA, Alcon A, Lledo R, Asenjo MA, Maldonaldo A. Noninvasive
versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome. Am
J Respir Crit Care Med 2000;162:119-25.

12
13. Sole Violan J, Fernandez JA, Benitez AB, Cardenosa Cendrero JA, Rodriguez de Castro F. Impact of
quantitative invasive diagnostic techniques in the management and outcome of mechanically
ventilated patients with suspected pneumonia. Crit Care Med 2000;28:2737-41.
14. Campbell GD. Blinded invasive diagnostic procedures in ventilator-associated pneumonia. Chest
2000;117:207S-11S.
15. Cook D, Mandell L. Endotracheal aspiration in the diagnosis of ventilator-associated pneumonia.
Chest 2000;117:195S-7S.
16. Torres A, EI-Ebiary M. Bronchoscopic BAL in the diagnosis of ventilator-associated pneumonia. Chest
2000;117:198S-202S.
17. Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH. Clinical importance of delays in the initiation of
appropriate antibiotic treatment for ventilator-associated pneumonia. Chest 2002;122:262-8.
18. Chaicharn Pothirat, Attavuj Deesomchoke, Chalerm Liewsrisakul, Chaiwat Bumrungkit, Theerakorn
Theerakittikul, Juthamas Innchai. Impact of the appropriateness and time to start antibiotic
treatment on hospital-acquired pneumonia outcome: a survival analysis. In the proceedings of annual
meeting of Thoracic Society of Thailand 2005 at Imperial Hotel Phukaew, Petchaboon; 18-20 January
2006. (Abstract).
19. West M, Boulanger BR, Fogarty C, Wiesinger B, Orossw M, Wu SC, Fowler C, Morgan N, Kahn JB.
Levofloxacin compared with imipenem/cilastatin followed by ciprofloxacin in adult patients with
nosocomial pneumonia: a multicenter, prospective, randomized, open-label study. Clin Ther
2003;25:485-506.
20. Nicolau DP, McNabb J, Lacy MK, Quintiliani R, Nightingale CH. Continuous versus intermittent
administration of ceftazidime in intensive care unit patients with nosocomial pneumonia. Int J
Antimicrob Agents 2001;17:497-504.
21. Rubinstein E, Lode H, Grassi C, Antibiotic Study Group. Ceftazidime monotherapy vs
ceftriaoxone/tobramycin for serious hospital-acquired gram-negative infections. Clin Infect Dis
1995;20:1217-28.
22. , , , .
(risk factors for multidrug-resistant infections in Siriraj Hospital).
2543;10:16-26.
23. Apisarnthanarak A, Mundy LM. Treatment, prevalence and outcomes of infections due to extendedspectrum beta-lactamase producing microorganisms. Infect Control Hosp Epidemiol 2006;27:326-7.
24. Apisarnthanarak A, Kiratisin P, Saifon P, Kitphati R, Dejsirilert S, Mundy LM. Healthcare-associated
extended-spectrum beta-lactamases producing Escherichai coli and Klebsiella pneumoniae: risk
factors and outcomes for adults in a Thai tertiary care center. In: Program and abstract of the 16th
annual scientific meeting of Society for Healthcare Epidemiology of North America, Chicago, IL, USA.
(Abstract#242).

13
25. Chaiwarith R, Mahatthanaphak S, Boonchoo M, Supparatpinyo K, Sirisanthana T. Pandrug-resistant
Acinetobacter baumannii at Maharaj Nakorn Chiang Mai Hospital. J Infect Dis Antimicrob Agents
2005;22:1-8.
26. Rello J, Sa-Borges M, Correa H, Leal SR, Baraibar J. Variations in etiology of ventilator-associated
pneumonia across four treatment sites: implications for antimicrobial prescribing practices. Am J
Respir Crit Care Med 1999;160:608-13.
27. Ibrahim EH, Ward S, Sherman G, Schaiff R, Fraser VJ, Kellef MH. Experience with a clinical guideline
for the treatment of ventilator-associated pneumonia. Crit Care Med 2001;29:1109-15.
28. Namias N, Samiian L, Nino D, Shirazi E, ONeill K, Kett DH, Ginzburg E, McKenney MG, Sleeman D,
Cohn SM. Incidence and susceptibility of pathogenic bacteria vary between intensive care units
within a single hospital: implications for empiric antibiotic strategies. J Trauma 2000;49:638-45.
29. Parimon T, Wongtim S, Suankratay C, Udompanich V, Sittipunt C. Correlation between tracheal
secretion surveillance culture and bronchoalveolar lavage culture in mechanically ventilated patients
with ventilator associated pneumonia. Thai J Tuberc Chest Dis Crit Care 2003:24:137-42.
30. Chaicharn Pothirat, Attavuj Deesomchoke, Chalerm Liewsrisakul, Chaiwat Bumrungkit, Theerakorn
Theerakittikul, Juthamas Inchai. Efficacy of the holistic intensive intervention on ventilator-associated
pneumonia in medical intensive care units. In the proceedings of annual meeting of Thoracic Society
of Thailand 2005 at Imperial Hotel Phukaew, Petchaboon; 18-20 January 2006. (Abstract).
31. Paul M, Benuri-Silbiger I, Soares-WeiserK, Liebovici L. -Lactam monotherapy versus -lactamaminoglycoside combination therapy for sepsis in immunocompetent patients. Systematic review and
metaanalysis of randomized trials. BMJ 2004;
32. Gruson D, Hilbert G, Vargas F, Valentino R, Bebear C, Allery A, Bebear C, Gbikpi-Benissan G,
Cardinaud JP. Rotation and restricted use of antibiotics in a medical intensive care unit: impact on the
incidence of ventilator-associated pneumonia caused by antibiotic-resistant gram-negative bacteria.
Am J Respir Crit Care Med 2000;102:837-43.
33. Brown RB, Kruse JA, Counts GW, Ruscell JA, Christou NV, Sands ML. Endotracheal Tobramycin
Study Group. Double-blind study of endotracheal tobramycin in the treatment of gram-negative
bacterial pneumonia. Antimicrob Agents Chemother 1990;34:269-72.
34. Chaicharn Pothirat, Somphop Mahatthanaphak , Juthamas Inchai. Efficacy of de-escalation therapy for
hospital-acquired pneumonia: a comparative study between the protocol-based and physicians
judgment-based antibiotic groups. In the proceedings of annual meeting of Thoracic Society of
Thailand 2005 at Imperial Hotel Phukaew, Petchaboon; 18-20 January 2006. (Abstract).
35. Dennesen PJ, Van der Ven AJ, Kessels AG, Ramsay G, Bonten MJ. Resolution of infectious
parameters after antimicrobial therapy in patients with ventilator-associated pneumonia. Am J Respir
Crit Care Med 2001;163:1371-5.

14
36. Luna CM, Blanzaco D, Niederman MS, Matarucco W, Baredes NC, Desmery P, Palizas F, Menga G,
Rios F, Apezteguia C. Resolution of ventilator-associated pneumonia: prospective evaluation of the
clinical pulmonary infection score as an early clinical predictor of outcome. Crit Care Med
2003;31:676-82.
37. Chastre J, Wolff M, Fagon JY, Chevret S, Thomas F, Wermert D, Clementi E, Gonzalez J, Susserand
D, Asfan P, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated
pneumonia in adult: a randomized trial. JAMA 2003;290:2588-98.
38. Chaicharn Pothirat, Ratapum Champunot, Juthamas Inchai. The optimal antibiotic duration of
antibiotic treatment for hospital-acquired pneumonia: comparative study between the two-Antibiotic
discontinuation policies. Chest (In press).
39. Garnacho-Montere J, Orhz-Leyba C, Jimenez-Jimenez FJ, Barrero-Almodovr AE, Garcia-Garmendi
JL, Bernabeu-Wittell M, Gallego-Lara SL, Madrazo-Osuna J. Treatment of multidrug-resistant
Acinetobacter baumannii ventilator-associated pneumonia (VAP) with intravenous colistin: a
comparison with imipenem-susceptible VAP. Clin Infect Dis 2003:36:1111-8.
40. Tharavichitkul P, Khantawa B, Bousoung V, Boonchoo M. Activity of fosfomycin against extendedspectrum--lactamase-producing Klebsiella pneumoniae and Escherichia coli in Maharaj Nakorn
Chiang Mai Hospital. J Infect Dis Antimicrob Agents 2005;22:121-6.
41. Pattarachai Kiratisin, Surapee Tiengrim, Thitiya Yungyuen, Visanu Thamlikitkul. In Vitro Activity of
colistin and tigecycline against extended-spectrum-beta-lactamase (ESBL)-producing Escherichia
coli and Klebsiella pneumoniae isolated from Patients in Siriraj Hospital. J Infect Dis Antimicrob
Agents 2006;23:21-4.
42. Fagon J, Patrick H, Haas DW, Torres A, Gilbert C, Cheadle WG, Falcone RE, Anholm JD, Paganin F,
Fabian TC, et al. Nosocomial Pneumonia Group. Treatment of gram-positive nosocomial pneumonia:
prospective randomized comparison of quinupristin/dalfopristin versus vancomycin. Am J Respir Crit
Care Med 2000;161:753-62.
43. Wunderink RE, Rello j, Cammarata SK, Cross-Dubrera RV, Kollet MH. Linezolid vs vancomycin:
analysis of two double-blind studies of patients with methicillin-resistant Staphylococcus aureus
nosocomial pneumonia. Chest 2003;124:1789-97.

15

1.
(quality of evidence)
(strength of recommendation) (Infectious Diseases
Society of America, IDSA) (United States Public Health
Service)1

A
B
C
D
E

I
II

III

(optional)


> 1 randomized controlled meta-analysis
> 1 non-randomized controlled
cohort case-controlled analytic 1
multiple time-series
uncontrolled

descriptive

16
2. modified clinical pulmonary infection score (CPIS)6
1
1. ()
36.5-38.4
38.5-38.9
< 36.0 > 39
2. (/)
4,000-11,000
< 4,000 > 11,000
Band forms > 50%
3.

(nonpurulent)

4. Oxygenation: PaO2/FIO2 (.)

> 240 ARDS (PaO2/ FIO2 < 200 PAWP < 18 .
infiltrate )
< 240 ARDS
5.
infiltrate
Infiltrate diffuse patchy
Infiltrate localized
6. infiltrate

( ARDS )
7. tracheal aspirate
(pathogenic bacteria)
(rare or light growth)
(moderate or heavy
growth)

1
0
1
2
0
1
2
0
1
2
0
2
0
1
2
0
2
0
1
2

ARDS: acute respiratory distress syndrome, PAWP: pulmonary artery wedge pressure, PaO2/FIO2: arterial oxygen pressure
fraction of inspired oxygen
1
modified CPIS

17
3.
(multidrug-resistant strains)
1,22-25

1. 90
2. 5
3.
4.

4.
empirical hospital-acquired pneumonia
(HAP) ventilator-associated pneumonia (VAP) ( 1)

1. Gram-negative bacilli
Pseudomonas aeruginosa
Acinetobacter spp.2
Escherichia coli3
Klebsiella pneumoniae3
Other Enterobacteriaceae3

1
Antipseudomonal cephalosporin

Antipseudomonal carbapenem

-lactam/-lactamase inhibitor
+
Antipseudomonal quinolone

Aminoglycoside

2. Staphylococcus aureus

Cloxacillin glycopeptide4

4

3
2
Acinetobacter spp. carbapenem carbapenem
3
extended-spectrum -lactamases (ESBLs)
carbapenem
4
cloxacillin glycopeptide S. aureus methicillin

18
5. hospital-acquired pneumonia
(HAP) ventilator-associated pneumonia (VAP)

1. Non-antipseudomonal third-generation
cephalosporins
Ceftriaxone
2 24
Cefotaxime
1 6-8
2. Antipseudomonal cephalosporins
2 8
Ceftazidime
1
1-2 8-12
Cefepime
1
1-2 8-12
Cefpirome
3. Carbapenems
Ertapenem2
1 24
Imipenem
500 6 1 8
Meropenem
1 8
4. -lactam/-lactamase inhibitors
4.5 6
Piperacillin/tazobactam
1-2 12
Cefoperazone/sulbactam3
5. Aminoglycosides
7 / 24
Gentamicin
20 / 24
Amikacin
7 / 24
Netilmicin
7 / 24
Tobramycin
6. Antipseudomonal quinolones
400 8
Ciprofloxacin
750 24
Levofloxacin
2 4-6
7. Cloxacillin
8. Glycopeptides
15 / 12
Vancomycin
6 / 24 ( 3 6-12
Teicoplanin
/ 12 3 )
600 12
9. Linezolid
4
2-4 8-12
10. Fosfomycin
5
100 50 12
11. Tigecycline
1

Pseudomonas aeruginosa, Acinetobacter baumannii

P. aeruginosa, Acinetobacter baumannii
3
Acinetobacter baumannii sulbactam 4-6
4
vancomycin
5
multidrug-resistant Pseudomonas aeruginosa
2

19

1.

Clinical suspicion of HAP or VAP1
Culture of LRT samples, blood, pleural
fluid,
and microscopic examinaton2
Low suspicion
Observe and search
for other etiology

High suspicion
Empirical antimicrobial therapy3
Assessment of clinical response4
and cultures at 48-72 hours
Clinical response

No
Quantitative culture

Positive
culture
Adjust antibiotics
Search for

complications,
other etiology

Negative
culture
Search for
other etiology

Yes
Semiquantitative or
qualitative culture

Positive
Negative
culture
culture
Consider
Search for
adjustment
other
etiology
of antibiotic
Search for other
etiology

Quantitative culture

Semiquantitative or
qualitative culture

Positive
Negative
Positive
Negative
culture
culture
culture
culture
De-escalate Discontinue
Consider
Discontinue
of antibiotics
de-escalation
antibiotics
antibiotics
of antibiotics Search for
Search for
other etiology Search for
other etiology
other etiology

LRT: lower respiratory tract, HAP: hospital-acquired pneumonia, VAP: ventilator-associated pneumonia
1
HAP VAP new progressive infiltrate 2 3
. > 38.3 . (purulent) .
(complete
blood count, CBC) (leukocytosis) > 12 x 109/ (12 x 103/)
2

3
3, 4 5
4

20

I. (semiquantitative culture) endotracheal aspirate1

endotracheal aspirate
0:
1+ (rare growth, < 10 ): quadrant 1
2+ (a few growth, 10-102 ): quadrant 1 2
3+ (moderate growth, >102-103 ): quadrant 1, 2
quadrant 3
4+ (numerous growth, >103-104 ): quadrant 1, 2 3
5+ (numerous growth, >104 ): 4 quadrants
II. (quantitative culture) endotracheal aspirate (ETA)
bronchoalveolar lavage (BAL)2-4
2.1 Processing of endotracheal aspirate (ETA)
1. endotracheal (ET) aspiration catheter 22-inch, 12 F
2. catheter ET tube 30 .
3. vibrate 10
4.
5. ETA ETA catheter Lukian tube
6. ETA 1 .
2.2 Processing of bronchoalveolar lavage (BAL)
1. bronchoscope ( protected system ) ET tube
subsegmental bronchus ( bronchus 3 4) occlude
proximal (chest X-ray)
2. 7 aliquots (7 ) aliquot 20 . sterile saline solution
(gently) 7
3. 2
4. 5 ( 5 aliquots )
2.3 Microbiological processing ( 1)
1. ETA BAL ( 15
60 )
2. ETA BAL
1
3. ETA BAL glass beads 1 vortex
4. centrifuge 3,000 10
5. sterile saline solution 1:10, 1:1,000
1:100,000 ( 1)

21

1. Fartoukh M, Maitre B, Monore S, Cerf C, Zahar JR, Brun-Buisson C. Diagnosing pneumonia during
mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med
2003;168:173-9.
2. Baselski VS, EI-Torky M, Coalson JJ, Criffin JP. The standardization of criteria for processing and
interpreting laboratory specimens in patients with suspected ventilator-associated pneumonia. Chest;
1992 (Suppl):571S-9S.
3. Loanas M, Ferrer R, Angrill J, Ferrer M, Torres A. Microbial investigation in ventilator-associated
pneumonia. Eur Resp J 2001;17:791-801.
4. Wu CL, Yang DI, Wang NC, Kuo HT, Chen PZ. Quantitative culture of endotracheal aspirates in the
diagnosis of ventilator-associated pneumonia in patients with treatment failure. Chest 2002;122:662-8.

22
1. Criteria endotracheal aspirate (ETA) bronchoalveolar
lavage (BAL) (quantitative culture)
ETA
> 25/LPF
< 10/LPF
ND
> 105-106

1. Neutrophils
2. Squamous epithelial cells
3. Intracellular organisms
4. Quantitative culture threshold (cfu/ml)
LPF: low-power field, ND: no data, cfu: colony-forming units

BAL
77-82%
< 1%
> 5%
> 104

2. endotracheal aspirate (ETA) bronchoalveolar lavage

(BAL) hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP)
1.
2.

ETA ()
38-100
14-100

BAL()
42-93
45-100

1. serial dilution (quantitative culture).

CTF: centrifugation, ETA: endotracheal aspirate, BAL: bronchoalveolar lavage
ETA

BAL

Vortex 60
CTF 10 3,000

Plate 0.1 ml 3 agars

Chocolate
Blood
MacConkey
Dilute 0.1 ml
to 9.9 ml saline

Dilute 0.1 ml
to 9.9 ml saline

Final dilutions
1:10

Plate 0.1 ml 3 agars

1:1,000

Plate 0.1 ml 3 agars

1:100,000

23
2.
I.
42
.. 2544
( 34.1 )
9,938 1
12.4

22.2 (95%CI = 18.626.6)1 .. 2547 12.6
1,000 ventilator-days 11.5-14.3 1,000 ventilator-days2
II.



12 .. 2545-2546


sucralfate
40.5
24.0 12.5 8.73
VAP
504
III.

Nocardia spp.

24

0.

1.
2.

3.

4.

5-8

hygienic hand antisepsis ( IA)5-8

( IA)5-7
( II)7
( IB)7
( III)7
hand hygiene
( IA)7,8
hand hygiene
( IIIA)7,8
pressure cuff 12 pressure 20-30 . 9,10,11

( deflate cuff) ( II)7

( IIIA)

catheter
catheter ( II)7
( II)
alcohol 70% circuit ( III)
5.

6.

( IB)7
non-invasive positive-pressure ventilation (NIV)
( IB)7
> 30 5-7
( II)
0.12% chlorhexidine ( II)7


48 (coagulopathy)

6
(
IB)7

( IB)7

25
7. ( IA)7
semicritical (high-level disinfection)

(sterilization)
pasteurization > 70 o (or >158o) 30 glutaraldehyde
()
, ,
( IB)7 1
(humidifier) (nebulizer)
( IA)7

( IIIB)

( IA)7
breathing circuit
( IA)7

( IB)7
heat-moisture exchange (HME) dead space circuit HME
48 . ( II)7 4
( II)7 heated-wire circuit heated humidifier
breathing circuit water trap
( IA)7

(mist tent) low level
2% acetic acid pasteurization ( II)7

8.

resuscitator bag 1

high-level disinfection ( IB)7

oxygen humidifier
(oxygen tubing) (face mask) (prongs)
( II)7
circuit

( IB)7


1,000

26
1 (sterilization) high-level
disinfection

(face mask) (tracheal tube)

(inspiratory and expiratory tubing)
(Y piece)
(reservoir bag)
(humidifier)
(breathing circuits)
(bronchoscopes) (accessories) (
)
(endotracheal tubes) (endobronchial tubes)
(laryngoscope blades)
(mouthpieces)
(nebulizers) (reservoirs)
Airways (oral and nasal airways)
(probes)
(resuscitation bags)
(stylets)
(suction catheters)
(temperature sensors)

27

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