***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: STUDY OBJECTIVES To determine the influence of initially delayed appropriate antibiotic treatment ( IDAAT ) on the outcomes of patients with ventilator-associated pneumonia ( VAP ) .  SETTING Medical ICU of Barnes-Jewish Hospital , St. Louis , a university-affiliated urban teaching hospital . PATIENTS One hundred seven consecutive patients receiving mechanical ventilation and antibiotic treatment for VAP . INTERVENTIONS Prospect i ve patient surveillance and data collection . MEASUREMENTS AND RESULTS All 107 patients eventually received treatment with an antibiotic regimen that was shown in vitro to be active against the bacterial pathogens isolated from their respiratory secretions . Thirty-three patients ( 30.8 % ) received antibiotic treatment that was delayed for > or= 24 h after initially meeting diagnostic criteria for VAP . These patients were classified as receiving IDAAT . The most common reason for the administration of IDAAT was a delay in writing the antibiotic orders ( n = 25 ; 75.8 % ) . The mean time ( + /- SD ) interval from initially meeting the diagnostic criteria for VAP until the administration of antibiotic treatment was 28.6 + /- 5.8 h among patients classified as receiving IDAAT , compared to 12.5 + /- 4.2 h for all other patients ( p < 0.001 ) . Forty-four patients ( 41.1 % ) with VAP died during their hospitalization . Increasing APACHE ( acute physiology and chronic health evaluation ) II scores ( adjusted odds ratio , 1.13 ; 95 % confidence interval , 1.09 to 1.18 ; p < 0.001 ) , presence of malignancy ( adjusted odds ratio , 3.20 ; 95 % confidence interval , 1.79 to 5.71 ; p = 0.044 ) , and the administration of IDAAT ( adjusted odds ratio , 7.68 ; 95 % confidence interval , 4.50 to 13.09 ; p < 0.001 ) were identified as risk factors independently associated with hospital mortality by logistic regression analysis . CONCLUSION These data suggest that patients classified as receiving IDAAT are at greater risk for hospital mortality . Clinicians should avoid delaying the administration of appropriate antibiotic treatment to patients with VAP in order to minimize their risk of mortality Abstract Objectives : To evaluate ( a ) the routine accuracy of bronchoalveolar lavage by direct examination ( BAL-D ) in diagnosing ventilator-associated pneumonia ( VAP ) , and ( b ) the impact of a diagnostic strategy including clinical judgment , bronchoscopy , and BAL-D on the initial diagnosis and appropriateness of treatment when VAP is suspected . Design and setting : Prospect i ve cohort study in two academic ICUs in Paris , France . Patients and participants : Mechanically ventilated patients with suspected VAP underwent bronchoscopy with BAL and protected specimen brush ( PSB ) . BAL-D  results were available within 2 h , BAL on culture and PSB results after 24 h , and antibiotic susceptibility after 48 h. At each step in the strategy the senior and the resident in charge of the patient were asked their diagnosis and their therapeutic plan on the basis of presently available data . Definite diagnosis of suspected VAP was based on histology , appearance of cavitation , positive pleural fluid culture , results of PSB and BAL culture , and follow-up . Measurement and results : A total of 110 episodes of suspected VAP were studied ; 94 definite diagnoses were made ( 47 VAP , 47 no VAP ) . Using a threshold 1 % of infected cells , BAL-D discriminated well between patients with and those without VAP ( sensitivity 93.6 % , specificity 91.5 % , area under the receiver-operating characteristic curve 0.953 ) . The senior clinical judgment was correct in 71 % cases . It was correct in 78 % and 94 % of cases after airway visualization and BAL-D findings , respectively . After BAL-D the positive and negative predictive values in diagnosing VAP were 90 % and 98 % , respectively . However , the therapeutic plan was correct in only 65 % using clinical judgment ( 15 untreated patients , 3 ineffective treatment , 15 useless treatment ) , 66 % using airway visualization ( 14 untreated VAP , 4 ineffective treatment , 14 useless treatment ) , and 88 % using BAL-D results ( 1 untreated patients , 6 ineffective , 4 useless ) , according to definite diagnosis and final antibiotic susceptibility testings . Conclusions : A strategy based on bronchoscopy and BAL-D generally leads to a rapid and appropriate treatment of nosocomial pneumonia in ventilated patients STUDY OBJECTIVE To assess the usefulness of quantification of bronchoalveolar lavage ( BAL ) cells containing  intracellular organisms ( ICO ) in the diagnosis of ventilator-associated pneumonia . DESIGN The reliability of cytologic analysis in comparison with the protected specimen brush ( PSB ) and BAL quantitative cultures has been assessed in a prospect i ve study . SETTING An intensive care unit of a tertiary-referral teaching hospital . PATIENTS A total of 33 ventilated patients with suspected pneumonia based on clinical grounds and radiographic findings . INTERVENTIONS All patients underwent  fiberoptic bronchoscopy  within the first 24 h after clinical suspicion of pneumonia . Specimens were obtained by PSB and BAL and were processed for quantitative cultures using st and ard methods . Two 0.5-ml sample s of resuspended original BAL fluid were centrifuged and stained with Gram and modified May-Grünwald-Giemsa for differential cell counts and percentage of cells with ICO . RESULTS Pneumonia was the final diagnosis in 16 ( 49 percent ) of the 33 patients . In 14 ( 42 percent ) patients , pneumonia was excluded and in the remaining 3 the diagnosis was uncertain . Twelve of the 16 patients with pneumonia had their conditions diagnosed by PSB , 14 by BAL , and 10 by quantification of ICO . Only one patient 's condition was diagnosed exclusively by cytologic examination . There were no false-positive results with any of the diagnostic techniques . CONCLUSIONS Microscopic identification of ICO in cells recovered by BAL allows early and accurate diagnosis of pneumonia in mechanically ventilated patients . However , the sensitivity of this technique is lower than with either PSB or BAL The clinical pulmonary infection score-original or modified-has been proposed for the diagnosis and management of  ventilator-associated pneumonia .  In 79 episodes of suspected pneumonia , we prospect ively assessed the diagnostic accuracy of the physicians ' clinical  assessment of probability  and of the  modified clinical pulmonary infection score  , both measured before ( pretest ) and after ( post-test ) incorporating gram stains results , using bronchoalveolar lavage fluid culture as the reference test . The pretest clinical estimate was inaccurate ( sensitivity 50 % , specificity 58 % ) ; the mean clinical pulmonary infection score at baseline was 6.5 + /- 1.3 ( range , 3 - 9 ) and 5.9 + /- 1.7 ( range , 3 - 9 ) , respectively , for the 40 confirmed and the 39 nonconfirmed episodes ( p = 0.07 ) , and only slightly more accurate ( sensitivity 60 % , specificity 59 % ) than the clinical prediction . Incorporating the gram stain results of either directed or blind protected sampling increased the diagnostic accuracy ( sensitivity and specificity of 85 % and 49 % and 78 % and 56 % , respectively ) of the clinical score and increased the likelihood ratio for pneumonia of a score of more than six from 1.46 to 1.67 and 1.77 . The clinical pulmonary infection score has low diagnostic accuracy ; however , incorporating gram stains results into the score may help clinical decision making in patients with clinical ly suspected pneumonia OBJECTIVE It has been inferred from previous work that 40 % potassium hydroxide preparations of lower respiratory tract secretions that demonstrate elastin fibers have a 100 % specificity and positive predictive value in diagnosing bacterial pneumonia in intubated , mechanically ventilated patients without the adult respiratory distress syndrome ( ARDS ) . Our aim was to assess the specificity of 40 % potassium hydroxide preparations in diagnosing bacterial pneumonia in patients with ARDS and suspected pneumonia . DESIGN Prospect i ve , case-referral clinical study . SETTING Referral hospital . PATIENTS Of 24 patients with ARDS who were intubated and mechanically ventilated with suspected bacterial pneumonia , 22 were assessable and evaluated for this report . INTERVENTIONS Tracheo-bronchial aspirates were obtained from all patients and analyzed for elastin fibers using 40 % potassium hydroxide . MEASUREMENTS AND MAIN RESULTS Of the 22 assessable patients , ten patients did not have a complicating bacterial pneumonia . Six of these ten patients had potassium hydroxide preparations that demonstrated elastin fibers ( false positives ) . The other four patients had preparations that did not demonstrate elastin fibers ( true negatives ) . Specificity was 40 % . CONCLUSION Elastin fiber preparations are not specific for diagnosing bacterial pneumonia in patients with ARDS Objective Although quantitative microbiological cultures of sample s obtained by bronchoscopy are considered the most specific tool for diagnosing ventilator-associated pneumonia , this labor-intensive invasive technique is not widely used . The  Clinical Pulmonary Infection Score ( CPIS ) , a diagnostic algorithm that relies on easily available clinical , radiographic , and microbiological criteria , could be an attractive alternative for diagnosing ventilator-associated pneumonia . Initially , the CPIS scoring system was vali date d upon 40 quantitative cultures of bronchoalveolar lavage fluid from 28 patients , and only few other studies have evaluated this scoring system since then . Therefore , little is known about the accuracy of this score . Design We compared the scores of a slightly adjusted CPIS with results from quantitative cultures of bronchoalveolar lavage fluid in 99 consecutive patients with suspicion of ventilator-associated pneumonia , using growth of ≥104 cfu/ml in bronchoalveolar lavage fluid as a cut-off for diagnosing ventilator-associated pneumonia . In addition , the CPIS were calculated for 52 patients by two different intensivists to determine the inter-observer variability . Results Ventilator-associated pneumonia was diagnosed in 69 ( 69.6 % ) patients . When using a CPIS > 5 as diagnostic cutoff , the sensitivity of the score was 83 % and its specificity was 17 % . The area under the Receiver Operating Characteristic curve was 0.55 . The level of agreement for prospect ively measured Clinical Pulmonary Infection Score ( ≤6 and > 6 ) was poor ( kappa = 0.16 ) . Conclusions When compared to quantitative cultures of bronchoalveolar lavage fluid , the CPIS has a low sensitivity and specificity for diagnosing ventilator-associated pneumonia with considerable inter-observer variability The aetiological diagnosis of nosocomial pneumonia in intensive care unit ( ICU ) patients requires a valid , cheap and safe method . This method should be suitable for all mechanically-ventilated patients and all ICUs . The aim of this study was to assess the diagnostic yields of three methods : " blind " bronchial brushing (Accu-Cath)(protective specimen brush-nonbronchofibroscopic ( PSB-non BF ) ) ; bronchofibroscopic protected specimen brushing ( PSB-BF ) and bronchoalveolar lavage ( BAL ) . We prospect ively studied the diagnostic values of the three methods as well as the agreement between microbiological results in 74 patients with 88 episodes of clinical ly suspected ventilator-associated pneumonia ( VAP ) and 22 control subjects . VAP episodes were also divided into those with ( n = 24 ) and without antibiotic pretreatment ( n = 64 ) , and into those with ( n = 78 ) and without ( n = 10 ) right lower lobe infiltrates on chest radiography . No differences were found as regards the bacteriological yield of the three techniques . Furthermore , the rate of concordant results was high ; 92 % for PSB-BF and BAL ; 84 % for PSB-nonBF and BAL ; 85 % for PSB-nonBF and PSB-BF ; and 85 % for PSB-nonBF combined with both bronchoscopic techniques . The diagnostic yields in suspected VAP were 66 , 59 and 56 % for PSB-nonBF , PSB-BF and BAL , respectively . We conclude that " blind " bronchial brushing has similar accuracy to bronchoscopic techniques commonly used in the diagnosis of ventilator-associated pneumonia , constituting an interesting alternative in hospitals where fibreoptic bronchoscopy is not available Introduction Deferred or inappropriate antibiotic treatment in ventilator-associated pneumonia ( VAP ) is associated with increased mortality , and clinical and radiological criteria are frequently employed to establish an early diagnosis . Culture results are used to confirm the clinical diagnosis and to adjust or sometimes withdraw antibiotic treatment . Tracheal aspirates have been shown to be useful for these purpose s. Nonetheless , little is known about the usefulness of quantitative findings in tracheal secretions for diagnosing VAP . Methods To determine the value of quantification of bacterial colonies in tracheal aspirates for diagnosing VAP , we conducted a prospect i ve follow-up study of 106 intensive care unit patients who were under ventil 
    Output:
    
Clinical criteria , used in combination , may be helpful in diagnosing VAP , however , the considerable inter-observer variability and the moderate performance should be taken in account .
Bacteriologic data do not increase the accuracy of diagnosis as compared to clinical diagnosis .
Quantitative cultures obtained by different methods seem to be rather equivalent in diagnosing VAP .
Blood cultures are relatively insensitive to diagnose pneumonia .
The rapid availability of cytological data , including inflammatory cells and Gram stains , may be useful in initial therapeutic decisions in patients with suspected VAP .
C-reactive protein , procalcitonin , and soluble triggering receptor expressed on myeloid cells are promising biomarkers in diagnosing VAP .