Introduction 1

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Introduction 1
????? ??? ????? ????? ????? ??? ? ?????
Dr. Kiarash Ghazvini Department for bacteriology
and virology, Mashhad University of medical
Sciences
3
????? ??? ????? ??????????

• ??????? ?????????? ?? ????? ??? ???? ?? ?????????
  ?? 30 ?? 50 ???? ??? ? ??? ????? ?????
• ?? ??????? ????? ????? ???????(VAP) ? ????? ???
  ?? ????????? ????? ??? ????? ??? ???? ? ???????
  ????? ?? ICU ?????? ???.

4
????? ??? ????? ??????????

• ???? ????? ?? ????? ?? ???????? ?? ????? ?????
  ??????? ????? 6 ?? 20 ????? ???.

5
????? ??? ????? ??????????

• ??????? ????? ???? ????? ?? ???? ??? ????? ?
  ????? ??????? ??? ?????????? ??????????? ?????
  ????????? ? ????? ???? ????????? ??? ???? ?
  ?????????? ???? ?? ?? ???.
• ??? ????? ???? ??? ?????? ??? ????? ???????
  ????????? ????? ??? ???? ?? ??? ???? ??????? ???
  ???? ?? ????????? ????? ?? ???? ???????? ?????
  ?????????????????????? ????? ?? ??? ????? (MRSA)
  ? ?? ???????? ??? ???? ????? ?? ??? ???? ?? ?????
  ?????? ?? ??? ????? ?? ???.

6
????? ??? ????? ??????????

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  ???? ??????? ????? ??????
• ??????? ?????????? ??????? ???? ? ??? ?? ???????
  ?? ????? ????? ????? ????? ??????????? ?????
  ????? ? ????????? ????? ?? ?????????? ??????? ??
  ?????? ????? ???.

7
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8
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  ??? ????? ?? ???? ???????? ?. . . ?????????????
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9
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  ??? ????? ?? ????? ????? ????.

11
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  ?? ?????? ????? ?????? ???? ???.

12
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  ???? ????? ?????? ????? ?????? ?? ????? ????
  ????? ????? ????

13
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  ?????? ? ??????? ????? ?? ???? ???.

14
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  ?????? ????????? ? ?????? ????? ??????

15
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16
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  ?? ??? ???? ???? ????? ?? ???? ????? ???????????
  ????? ?????.

17
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  ?? ?? ???? ?????? ???.
• ??? ????? ?? ???? ?? ??? ?????? ??? ???? ? ??????
  ?? ????????? ????? ?????.

18
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  ??? ?? ????? ?? ????? ???? ???? ???? ????.
• ??? ??? ????? ???? ??????? ?????? ???
  ??????????????? ? ?????? ?????? ???? ?????
  ??????????? ?????? ????? ???.

19
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  ???? 15 ???? ???? ?????? ?10 ???? ??????? ????
  ???? 10 ????? ?? ?? ???? ???? ???? ?? ??? ?????.

20
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  ????? ???? ????? ????? ?? ?????? ?? ???? ???? ???
  ????? ????? ?????? ? ??????? ???? ??? ?????
  ?????.
• ????? ???? ????? ???? ???? ??? ?? ????? ?????
  ???? ?? ?? ??????? ?? ?????? ?????? ?? ?????
  ??????????? ?? ?????????? ?? ????? ????? ?? ????
  ???.

21
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• ?? 8 ?? 20 ???? ??????? ??? ????? ?? ??????????
  ??? ??? ???? ???.
• ????? ??????? ???? ???? ??? ?? ?? ??????? ??????
  ???????? ????? ????? ?? ????? ??? ???? ????.

22
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• ??????? ?? ?? ??? ??? ????? ????? ?? ????? ????
  ????????? ????? ?????? ????? ??????? ???? ?????
  ????? ????? ?? ??? ???? ??? ??????? ???? ???? ???
  ?? ?? 50 ???? ?? ?????? ?? ??? ??? ???? ???? ????
  ????? ?? ???? ????? ?? ??? ???? ????.
• ?? ??? ?????? ????????????? ?????? ?? ??? ?
  ?????? ?????? ????? ????? ????

23
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• ?????????? ???????????
• ???????????
• ?????? ??? ???

24
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  ????? ? ???? ???????? ?? ???? ?? ??? ???? ???
  ?????? ?? ???? ?????? ???? ???.

25
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  ???????? ?? ??? ????? ?? ???? ????? ??? ???.
• ?????? ????? ???? ????? ???.
• ??? ?????? ?? ????????? ???? ????? ??? ?????
  ????? ???.

26
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• ???????? ?? ???? ????? ??? ??? ?? ???? ??
  ???????? ??? ???? ? ???? ??????????? ??????????
  ??????? ??????.

27
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• ??? ??????????? ???? ??? ?????? ?????? ????
  ?????? ????? ??? ??? ?????????? ???? ??? ?? ????
  ??? ?????? ? ???? ??????? ????.
• ?? ??? ????? ???? ??? ????? ????? ?? ???????????
  ???? ????.

28
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  ??? ????? ?????? ???? ??? ?? ?????? ?????? ??
  ??????? ???.
• ?? ??????????? ?????? ?????? ???? ???? ??
  ???????? ?????? ??? ? ???? ?????? ??? ???? ????.

29
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  ?? ?????? ???? ?? ?? ?? ??? ?????.
• ??? ????? ?? ???? ????? ????? ?????? ?? ??? ???.

30
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• ????? ???? ???? ??????????? ??????? ???? ??????
  ??????? ??????????? ? ?????? ???? ???.
• ?? ??? ??? ??? ?????? ?? ??? ????????? (100 ??
  300 ???? ????) ?? ???? ??? ??????? ? ?????
  ??????.

31
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  ????? ???? ????? ?????? ??????.
• ?????? ???? ??? ????? ?? ??? ??? ???? ?????
  ??????????? ???? ?????? ?????? ???? ???????
  ????????? ????? ??? ???

32
???????????

• ???? ????? ??? ?????????????? ? ????? 5 ml ??
  BAL ????? ?????.

33

• ??? ????? ?? ????? ??? ????? ?? ??????
  ??????????? ?? ??? ?? ???? ??????? ???.
• ????? ??? ?? ??? ???? ?? ????? ??? ??? ??????
  ??????? ???? ??????? ??????????? ?? ???? ?? ?????
  ??????? ???? ?? ?????????? ??????? ???.

34

• ???? ????? ????? ?? ????? ??? ?? ??? ???? ??
  ???????? ??????? ???? ?? ?? ??? ????? ? ?? ?????
  ????? ???.
• ????? ???? ????? ?? ????? ?? ?? ?????? CFU
  ???????? ?? ?? ???? ???? ????? ???? ?????????
  ????? ???.

35
?????? ??? ???

• ??? ??? ?? ????? ?????? ?????? ???? ?? ?? ????
  ?????? ???? ?????? ????? ??????? ???.
• ???????? ?????? ?? ?? ???? ???? ??? ??? ???
  ??????? ????.

36
?????? ??? ???

• ?????? ?????? ?????? ???? ???? ??? ?? ??? ??? ??
  ???? ??? ?????? ??? ????? ???.
• ????? ??????????? ???? ??? ????? ?? 103 ?? 104
  ?????? ?? ???? ?? ??? ???? ??? ???.

37

• The advantages of using semiquantitative or
  quantitative endotracheal aspirates versus
  distal lung parenchyma sampling by
  BAL/protective specimen brush for the diagnosis
  of VAP remain controversial.

38

• Most hospitals in the United States use
  semiquantitative endotracheal aspirates for the
  diagnosis of VAP.

39

• In one large, prospective, randomized trial of
  VAP diagnosis, patients having bronchoscopic
  BAL or protective specimen brush diagnosis
  had a significantly lower 14-day mortality
  rate (16.2 vs. 25.8), less mean
  sepsis-related organ failure at day 3 (6.1
  vs. 7.0 P .03) and day 7 (4.9 vs. 5.8 P
  .04), and a decreased mean number of
  antibiotic-free days (5.0 vs. 2.2 P lt
  .001) than patients having a clinical
  diagnosis and sputum endotracheal aspirates.

40

• In a recent randomized study by a Canadian
  Critical Care Trials group, patients were
  randomly assigned to undergo bronchoscopic
  BAL versus semiquantitative endotracheal
  aspirates. The BAL group and the endotracheal
  aspiration group also had similar rates of
  targeted therapy (74.2 and 74.6,
  respectively P .90), similar number of days
  alive without antibiotics (10.4 vs. 10.6, P
  not significant), and maximum organ
  dysfunction scores (mean stan-dard
  deviation, 8.3 vs. 8.6 P not
  significant). The two groups did not differ
  significantly in the length of hospital or ICU
  stay.

41

• ????? ?????? ????? ????? ??? ?????? ?????

42

• ?????? ????? ??? ????? ???? ????? ??????????? ???
  ???? ?????? ???? ????? ???? ?? ? ?????? ??????
  ????? PCR ???.

43

• ???? ?? ????? ?? ????????? ????? ????????????? ??
  ?? ????
• ??? ?????
• ??? ???? ?????? ??? ??????? ????? ??? (?? ?????
  ???? ??????? ????? ????????????? ?? ???????????
  ?????? ?? ???????)

44

• ??? ????? ????? ? ??? ? ????? ??????????? ????
  ???? ???? ????? ?????? ? ??????????? ???? ?????
  ???.

45

• ???) ????? ??????????

46

• ???? ??? ????? ??? ?????? ????? ?????? ??????
  ????? ??? ????? ??? ???? ???.
• ???? ????? ???? ?????? ??? ???? ????? ???????
  ???????? ??????? ??? ? ???? ?????? ?????? ?????
  ?????? ???? WBC ???.

47

• ???? ??? ?? 1 ???? ??????? ???????? ?????????
  ?????? ?? ???? ????? ???? ???.

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Gram stain of a sputum specimen
demonstrating greater than 10 squamous
epithelial cells per low-power field, which
is unacceptable for culture.
50
????? ??? ????? ??? ?? ???

• ????? ??????? ???????? ??????? ? ????? WBC ??
  ????? 10 ????? ??????? ?? ????.
• ?? ????? ?? ???? ???????? ???? ? ?????? ?? ??
  ???? ????? ????? ???? ? ???? ?????? ????? ????.

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• ??? ?? ???????? ?? ????? ?? ????? ???? WBC ????
  ????? ?? ?? ????? ????.
• ???? ????? ??? ????? ??? ???? ???? ??? ?? ????
  ??? ????? ????
• Gram - negative bacilli predominant organism
  seen on Gram stain

53

• ?? ????? ??? ????? ??? ?? ???? ???? ??? ???????
  ??????? ??? ??????? ????.
• ???? ????? ??? ???????? ??? ???? ?? ??? ????? ???
  ???? ????? ??????? ??? ?? ????? ???? ????????????
  ???????? ????? ????.
• ??? ???????? ??? ???? ????? ????? ??? ????
  ????????? ?? ?????? ????? ???????? ?????????
  ????? ??????.

54

• ???? ????? ??? ?? ??? ???? ?? ??????? ????? ???
  ??????? ?? ??????? ?? ????? ????? ??? ??????? WBC
  ??????.

55

• ?) ??? ????? ???

56
???? ?????????? ?????? ?????? ????? ??????? ????
? ????? ??? ?????? ????

• ????? ??? ???? ?? ??????? ???????? ?? ????? ????
  ????? ??????? ??? ???? ??? ????? ?????? ?? ???
  ???? ????.
• ??? ???? BAL ???? ???? ?? 1 ???? ??????? ???????
  ?????? ????? ???? ???? ???. ? ??? ????? ?? 1 ????
  ??????? ???? ??????? ?????? ????? ??????? ????
  ???.

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• ??? ??? ?? 104 ?????? ?? ?? ???? ???? ?? ?????
  ????? ???? ????? ????? ????? ?????.

58

• ?? ????BAL ?????? ?????? ???? ?????.
• ?? ??? ????? ?? 0.1 ???? ???? ?? ???? ????? ??
  9.9 ???? ???? ????? ????? ????? ?? ??? ? ???
  ????? ???? ?????
• ? ???? ??? ?????? ????? ??? ???? ?? ????

59

• ??? ?? ?? ???? ?? ????? ????? ???? ???? ??? ????
  ???? ? ????? ???? ??? ???? ?????.

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61
???? ?????????? ?????? ?????? ????? ??????? ????
? ????? ??? ?????? ????

• ????? ?? ?? ??? ???? ?????? ???? ????? ????? ????
  ? ?? ????? ????(???? ??????? ???????? ??? ????)
  ??? ???? ?? ???? ????? 35???? ????????? ? CO2
  ?????? ????.
• ????? ?? ?? ?? 24 ? 48 ???? ?????????? ?????
  ????.

62
???? ?????????? ?????? ?????? ????? ??????? ????
? ????? ??? ?????? ????

• ???? ??? ????? ???? ?? ??? ?? ???? ???????
  ???????? ?????? ???? ??? ???????? ???? ????
  ?????? ?? ????????? ???? ???? ?????.
• ??? ???? ?????? ??? ??? ? ???? ?????? ??? ?????
  ?? ?????? ????????? ?????? ???? ???.

63
?????????? ???? ???? ?????????? ??? ? ????? ???
?????? ???

• ??? ??? ????? ??? ?????? ????? ???? ????? ???
  ?????? ??? ???? ?????? ???? ????? ????? ???? ? ??
  ????? ???? ? ??????????? ????? ??? ? ?? ????
  ????? 35 ???? ????????? ? CO2 (??? ????
  ???????????) ?????? ????.

64
?????????? ???? ???? ?????????? ??? ? ????? ???
?????? ???

• ??? ?????? ?? ?? ?? 24 ? 48 ???? ????? ????.
• ???? ??????????? ?? ?????? ?? 5 ??? ????? ????
  ??? ???? ???? ????? ???? ????? ?? ??? ????
  ????????? ? ?? ?? ?? ?? 5 ??? ??? ????????.

65
?????????? ???? ???? ?????????? ??? ? ????? ???
?????? ???

• ?????? ?? ?? ??????????? ??? ??? ? ??????? ???
  ???? ?????????? ?? ???????? ????.

66
?????????? ???? ???? ?????????? ??? ? ????? ???
?????? ???

• ??? ???? ???? ???? ??? ????? ?? ????? ??? ??
  ???? ???? ? ?????? ????
• ??? ?????????? ?? ????? ??? ?????? ????? ?? ?? ??
  ??? ???? ?? ?????? ????.
• ??? ??????????? ???? ??? ?? ??? ????? ??? ??????
  ?? ???? ??? ???????? ?? ??? ???? ?? ????? ????
  ???? ??????????? ?? ??? ???? ???? ????? ??? ????
  ????).

67
?????????? ???? ???? ?????????? ??? ? ????? ???
?????? ???

• ??????? ?? ?????? ?? ????? ?? ?????????? ???????
  ???? ??? ?????????? ?? ???? ???? ??????? ???? ??
  ????? ????.

68
??? ??? ??????? ???? ? ???? BAL

• ??????? ???? ?? ?? ?? ???? ???? ??? ?????????
  ???????? ? ??? ???? ?? ????? ???? ?? ???? ?? ???
  ??????? ??? ?????????? ???? ?? ?????? ??? ??
  ????? 10 ? 100 ?????????? ??????? ??? ???? ??????
  ???? ????? ????? ???? ? ?? ????? ???? ?
  ??????????? ??? ????.

69
??? ??? ??????? ???? ? ???? BAL

• ???? ??? ?? ?? ?? ???? ????? 35 ???? ????????? ?
  CO2 ?????? ????.
• ?????? ?? ?? ?? 24 ? 48 ???? ????? ????.
• ??? ??? ?????? ??? ????? ?? ?????? ????? ????
  ?????? ? ????? ????.

70

• ?) ????? ???

71
??? ???? ???

• ??? ??? ???? ??? ???? ?? ?? ???? ???? ???? ?????
  No growth ????? ????.
• ??? ?? ?? ?? ???? ??? ?? ???? ??? ???? Rare
  ????? ???? .
• ??? 3 ?? 10 ???? ?? ?? ???? ??????? Few ?????
  ????.
• ??? ????? ?? 10 ???? ?? ?? ???? ? ??? ?? ?????
  ????? ????? ?????? ????Moderate ????? ????.
• ??? ?????? ?? ????? ????? ????? ? ?????? ????????
  Heavy ????? ????.

72
??? ???

• ?? ??? ??? ???? ????? ????? ???????? ?? ????? ???
  ?????? ????? ?????? ?? ???? ????? ? ?? ??????? ??
  ??? ??????? ??????? ???.
• ????? ???? ??? ????? ?? ???? ?? ?? ???? ??? ???
  ??????.

73
??? ???

• ??? ????? ???? ?? ????? ????? ??? ?? ???????????
  ?? ???? ??? ?? 1000 CFU/ml ? ??? ????? ???? ??
  ????? BAL ??? ?? 10000 CFU/ml ????? ????????
  ????? ????? ? ????? ?????? ????.

74

• ????? ?????

75

• ????? ????? ? ????? ??????? ?????? ?? ???? ???
  ?????? ??? ?????? ??? ????? ? ???? ? ????? ????
  ???????? ?? ?? ?????? ????.
•  

76

• Some microbiology laboratories report
  quantitative endotracheal aspirates in which a
  pathogen growth of more than 105-6 CFU/mL is
  consistent with a diagnosis of VAP.

77

• Quantitative distal airway samples obtained by
  bronchoscopic bronchoalveolar lavage (BAL) (gt
  104 CFU/mL) or protective specimen brush (gt
  103 CFU/mL), or nonbronchoscopic BAL or
  protective specimen brush have good
  diagnostic sensitivity and probably a higher
  specificity than endotracheal aspirate samples,
  but these techniques are not widely available,
  are more expensive, and require expertise.

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