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El diagnóstico etiológico de la neumonía asociada a ventilación mecánica (NAVM) es una urgencia microbiológica por su repercusión en la morbilidad y mortalidad asociadas a él. La obtención de muestras del tracto respiratorio inferior (TRI) debe hacerse antes del comienzo del tratamiento y de cualquier cambio de éste. No se recomiendan los cultivos sistemáticos en pacientes sin sospecha de NAVM. No existe una superioridad manifiesta de las técnicas broncoscópicas frente a las no broncoscópicas, pero es esencial que los procedimientos microbiológicos aporten resultados con cuantificación bacteriana que permitan diferenciar colonización de infección. En las condiciones anteriores, los cultivos negativos prácticamente excluyen la infección bacteriana, o al menos seleccionan a un grupo de pacientes que no mejora con antibióticos o los requiere durante un período muy corto.
Dado que la identificación y la determinación de la sensibilidad frente a los antimicrobianos suele demorarse hasta 3 o 4 días, se hace preciso recurrir a procedimientos rápidos que permitan avanzar información útil al clínico. La información rápida, si bien parcial o imperfecta, es claramente más beneficiosa para el paciente que la perfecta y tardía. La técnica de Gram proporciona una información orientadora e inmediata y tiene un razonable correlato con los resultados posteriores de los cultivos. En el momento presente se buscan procedimientos de antibiograma que, realizados en una muestra clínica directa, permitan disponer en menos de 24 h de una identificación presuntiva y de información sobre la sensibilidad frente a antibióticos de uso frecuente, y se está evaluando la repercusión clínica de aplicar este procedimiento.
Palabras clave:
Neumonía nosocomial
Neumonía asociada a ventilación mecánica
Infección respiratoria
Diagnóstico microbiológico
The etiologic diagnosis of ventilator-associated pneumonia (VAP) should be considered as a microbiological emergency due to its impact on morbidity and mortality. Sampling of the lower respiratory tract (LRT) must be performed before starting or modifying antimicrobial therapy. Surveillance cultures in patients without criteria of VAP are not recommended. There is no evidence of any superiority of bronchoscopic over non-bronchoscopic sampling procedures, but quantitative bacterial cultures are essential to allow colonization to be differentiated from true infection of the LRT. Under these conditions, negative cultures practically rule out bacterial infection or, at least, identify patients who will not benefit from antibiotic therapy or who will require a very short course of treatment.
Given that identification and antimicrobial susceptibility testing of microorganisms usually takes up to 3 or 4 days, rapid procedures that provide the clinician with useful information are essential. Rapid information, even if partial or less than perfect, is clearly better for the patient than a perfect but delayed report. Gram stain of LRT secretions is an immediate procedure that can guide management and it has a reasonable correlation with culture results. At present, new antibiogram procedures, performed on direct clinical samples, allow presumptive identification and information on susceptibility to commonly used antibiotics in less than 24 hours after sampling. The impact of using this procedure in clinical practice is currently under research.
Key words:
Nosocomial pneumonia
Ventilator-Associated pneumonia
Respiratory infection
Microbiological diagnoses
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