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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Nosocomial infections &#40;NIs&#41; are infections that develop in relation to healthcare&#44; and are not a direct consequence of the background disease for which the patient is receiving treatment&#46; Urinary tract infections associated to bladder catheterization&#44; skin and soft tissue infections following surgical procedures&#44; or mediastinitis after heart surgery&#44; are examples of NIs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Intensive Care Units &#40;ICUs&#41; represent a favorable scenario for the development of infections of this kind&#44; since seriously ill patients are more susceptible to NIs&#46; Invasive procedures are typically carried out in the ICU that adversely affect the local defense barriers of the body&#44; and the patients admitted to these Units have often been previously exposed to antibiotics and are therefore susceptible to the development of bacterial resistances&#46; In the Intensive Care setting&#44; ventilator associated pneumonia &#40;VAP&#41; is the most prevalent infectious problem&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> ahead of catheter-related or urinary tract infections&#46; Moreover&#44; VAP is distinguished from the latter by its high associated mortality&#44; particularly when caused by multiresistant organisms&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Lastly&#44; it must be underscored that VAP is associated with a longer stay in the ICU and in hospital&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> increased antibiotic use&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and greater hospital costs&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The recently launched Pneumonia Zero &#40;PZ&#41; project undoubtedly represents a challenge for ICU professionals&#46; Following the satisfactory experience gained with the Bacteremia Zero &#40;BZ&#41; project&#44; we now face a new battle against the main type of infection found in ICUs&#8212;though a series of aspects need to be clarified&#58; What is the true starting incidence of the infection&#63; Does the diagnostic technique used exert an influence upon the incidence&#63; And in this context&#44; what diagnostic method should be used to assess the efficacy of the adopted preventive measures&#63;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The ENVIN-HELICS registry&#58; What is the true starting incidence of the infection&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall">The existence of a nosocomial infection vigilance system is undoubtedly the result of years of work on the part of the Infectious Diseases Work Group of the SEMICYUC &#40;GTEI-SEMICYUC&#41;&#46; The ENVIN-HELICS registry has become consolidated in recent years as one of the main ICU nosocomial infections registries&#46; It has grown from an initial total of 1884 patients in its first year in 1994 to 16&#44;950 cases in the last report corresponding to the year 2010&#46; This undoubtedly reflects the concern among intensivists regarding the vigilance and control of NIs&#44; and has contributed to assess and improve the quality of healthcare by establishing a map or profile of the true situation in our ICUs year by year&#44; with the ultimate aim of incorporating preventive measures for improving the safety of critically ill patients&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The &#8220;cultural&#8221; change of understanding that NIs are not simply the price to pay for admission to Intensive Care&#44; as an unavoidable risk or problem inherent to medical care&#44; has become manifest in the BZ project&#46; It has been shown that the adoption of a series of measures not only contributes to reduce the incidence of these infections&#44; but moreover has given rise to increased awareness of the importance of clinical safety&#8212;establishing concrete objectives&#44; identifying errors or inadequate practices&#44; and defining plans for improvement&#46; The launching in 2011 of the PZ project represents a further challenge that is fully justified and constitutes an ethical obligation destined to improve healthcare in search of excellence&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On examining the last few years &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; we see that after the decrease in the incidence of VAP recorded in the year 2009&#44; the figures have remained stable&#46; However&#44; the procedures used for the microbiological diagnosis of VAP have varied&#46; In this sense&#44; in the year in which the highest incidence of NIs was recorded&#44; qualitative cultures of upper airway samples were the most frequently used diagnostic technique &#40;51&#46;1&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The ongoing debate&#58; the clinical versus invasive strategy</span><p id="par0035" class="elsevierStylePara elsevierViewall">Over a decade ago&#44; Niederman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and Chastre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> started a debate on the microbiological diagnosis of VAP that persists to this day&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> This lack of a reference standard for the microbiological diagnosis of VAP has given rise to controversy regarding which diagnostic algorithms to use&#46; In this context&#44; there are two coexisting strategies&#58; &#8220;noninvasive&#8221; or &#8220;clinical&#8221;&#44; based on the culture of upper airway samples&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and &#8220;invasive&#8221;&#44; based on the use of quantitative cultures of lower respiratory tract samples usually obtained by bronchoscopy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a> The two randomized clinical trials that have compared these strategies&#44; with the inclusion of many patients and an important impact upon the scientific community&#44; have yielded conflicting results&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;18</span></a> Although the objectives of both studies appeared to be similar&#44; there were major differences in their design that can explain the observed lack of agreement&#46; In the study published by Fagon et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> treatment was guided by the results of gram staining&#46; Accordingly&#44; if germ isolation proved negative and there were no signs of sepsis&#44; treatment was suspended&#46; In the other study&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> treatment was started with broad-spectrum antibiotics in all patients&#44; regardless of whether they were at risk of infection caused by multiresistant organisms or not&#46; Another important difference between the two studies was the patient population involved&#44; since the Canadian trial<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> excluded individuals with immune deficiencies&#44; chronic diseases&#44; treatment with carbapenem or quinolones&#44; and colonization by microorganisms resistant to antibiotic treatment&#46; The profile of these excluded individuals&#44; representing over one-third of all the patients in the study&#44; coincides with the profile of most subjects admitted to the ICU with clinically suspected VAP&#44; and this is possibly the patient subpopulation that would benefit most from the invasive strategy&#8212;though no study has confirmed this to date&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although some authorities have suggested an end to the debate&#44; it seems logical to consider that a sample obtained from the lower respiratory tract with guidance toward the affected zone offers greater quality than a tracheal sample&#46; In any case&#44; and although it may seem overly ambitious&#44; we can debate whether one strategy or the other truly has impact upon mortality or not&#46; In this context&#44; although the clinical strategy has not been shown to be inferior to the invasive strategy in relation to the patient prognosis&#44; it has not been able to improve upon the established advantages of the bronchoscopic techniques&#58; greater confidence on the part of the clinician&#44; rational antibiotic use &#40;which can contribute to avoid the development of bacterial resistances&#41;&#44; and the importance of a negative reading obtained from a quality respiratory sample in redirecting the search for other infectious foci&#8212;particularly in patients without previous antibiotic treatment&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&#8220;ZERO&#8221; qualitative tracheal aspirate</span><p id="par0045" class="elsevierStylePara elsevierViewall">According to the ENVIN-HELICS registry&#44; up until the year 2009 qualitative tracheal aspiration was the microbiological technique most widely used to diagnose VAP in Spanish ICUs &#40;47&#46;3&#37; of the cases registered that year&#41;&#46; This is probably attributable to the fact that tracheal aspiration is rapid&#44; simple and causes few complications&#46; In coincidence with these observations&#44; a study on the diagnosis of VAP in Andalusia found qualitative tracheal aspiration to be the most frequently used technique &#40;42&#46;8&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The analysis carried out by the pneumonia work group of the European Society of Intensive Care Medicine &#40;EU-VAP&#47;CAP Study Group&#41; in 2009&#44; involving over 20 ICUs in 9 countries and the evaluation of 2436 patients with 827 cases of pneumonia&#44; likewise found qualitative tracheal aspiration to be the microbiological diagnostic method used in 46&#46;2&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A number of factors can explain this situation&#44; which has persisted for years&#46; Firstly&#44; the lack of a reference standard has given rise to great clinical variability in dealing with the diagnosis of VAP&#46; Such variability can be minimized through training programs&#44; emphasizing the fact that qualitative tracheal aspiration is not recommended&#44; regardless of the debate referred to the use of invasive or noninvasive techniques&#46; In this sense&#44; for example&#44; if we compare the mortality figures with those of other infectious diseases found in the ICU&#44; such as severe acute meningitis&#44; it is surprising that despite the similarities between these processes&#44; the attitude toward the microbiological samples differs&#58; cerebrospinal fluid is rapidly processed and immediate information is requested from the microbiologist&#44; while the approach tends to be more contemplative in the case of a tracheal aspirate or bronchoalveolar lavage&#46; We feel that a more active attitude is needed here&#59; coordination between the clinician &#40;the intensivist in this case&#41; and the microbiologist is essential&#44; with a view to insisting on the need for quantitative processing of the sample&#46; The decrease recorded in Spain regarding qualitative aspirate utilization in the registry corresponding to 2010 is promising&#44; and reflects greater adherence to the recommendations of the main scientific societies&#46; Independently of the recommendation of the American Thoracic Society &#40;ATS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which points to a reduction in mortality after 14 days with the &#8220;invasive&#8221; diagnostic strategy versus the &#8220;clinical&#8221; strategy&#44; supported by grade I evidence&#44; and based on the multicenter clinical trial published by Fagon et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> it is important to underscore the recommendations of both the ATS and the SEMICYUC<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;21</span></a> referred to the use of qualitative tracheal aspiration&#46; With grade II evidence&#44; it is recommended that lower respiratory tract samples should be obtained in all patients with clinically suspected VAP&#44; and that these samples may be tracheal aspirate&#44; bronchoalveolar lavage &#40;BAL&#41; or protected bronchial brush&#46; Based on the maximum evidence &#40;grade I&#41;&#44; both the ATS and the Spanish Society of Intensive Care Medicine advise against the routine use of qualitative tracheal aspiration for the microbiological diagnosis of VAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;21</span></a> The main argument in this sense is that such samples are unlikely to allow differentiation between colonization and infection&#44; since the airways of most patients on mechanical ventilation are colonized by potentially pathogenic microorganisms&#44; and we may be risking the over-diagnosis of cases of pneumonia which in fact correspond to tracheal colonization or tracheobronchitis&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Bronchoscopic methods represented 23&#46;3&#37; in the European study&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and did not exceed 10&#37; in the ENVIN-HELICS registry of 2010&#46; Probably the non-availability of fibrobronchoscopy in some ICUs&#44; the lack of experienced personnel and the need for prior training are some of the reasons for such limited utilization&#8212;though the technique is actually simple&#44; with few complications&#44; and can be performed at the patient bedside&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Influence of the microbiological diagnostic method upon incidence</span><p id="par0060" class="elsevierStylePara elsevierViewall">On analyzing the incidence of VAP&#44; the published results are seen to be very heterogeneous&#46; This is probably due to the existing clinical variability&#44; conditioned by the different patient populations and isolated pathogens in each study&#44; the different types of ICUs involved&#44; and the mentioned lack of consensus regarding the microbiological diagnosis&#46; The interval found in the literature varies greatly from 5&#37; or 9&#37; using invasive diagnostic methods<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> to 41&#37; or 67&#37; when based on clinical criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> In 53 patients with clinically suspected pneumonia&#44; Morris et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> analyzed the influence of qualitative and quantitative aspiration&#44; and bronchoalveolar lavage&#44; upon the incidence of the disorder&#8212;important differences being detected depending on whether sample processing in the laboratory was qualitative or quantitative&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Final considerations</span><p id="par0065" class="elsevierStylePara elsevierViewall">The possibility of error in diagnosing VAP is not without a price for both the patient and the healthcare system&#46; The risk of overdiagnosing pneumonias which in fact constitute colonization implies unnecessary antibiotic use&#8212;with the consequent drug cost increments&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> an increased risk of antibiotic toxicity&#44; and the appearance of bacterial resistances&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">There is no doubt that quantitative sample processing offers clinicians a greater degree of confidence in relation to patient management&#46; However&#44; we must abandon the concept of &#8220;positive culture&#8221; and &#8220;negative culture&#8221; and request sample quantification&#46; The described cutoff points accepted by the scientific community lack a validating reference standard&#59; as a result&#44; they must not be viewed isolatedly but in a clinical context&#8212;taking into account previous antibiotic treatment&#44; days on mechanical ventilation&#44; the microorganism&#44; the sample obtained&#44; the medical history&#44; and the immune condition of the patient&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The described variability in the diagnostic management of VAP implies differences in the assignment of resources&#44; and therefore the possibility that the offered diagnosis and treatment may be suboptimal&#44; depending on the setting involved&#46; Consensus on the diagnostic algorithm is therefore needed&#44; assuming the disagreement between those who defend the clinical strategy and those who prefer the invasive approach&#8212;but accepting the fact that both strategies can coexist&#44; provided they coincide on the need for recommending quantitative respiratory sample cultures&#46; Quantitative tracheal aspiration is a reasonable alternative that has been shown to offer sensitivity and specificity performances similar to those of the bronchoscopic techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The clinical trials that have compared the two strategies have concluded that there are no differences between them in terms of prognosis and mortality&#44; though antibiotic use is effectively greater with the invasive strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> In relation to the last issue raised in &#8220;Introduction&#8221; section&#44; it is necessary to clarify that the efficacy of the preventive measures cannot be comparable among hospitals as long as the diagnostic approach remains variable&#46; In the current scenario&#44; the incidence of VAP cannot be used as a comparative measure among different ICUs&#44; or as a prognostic quality predictor in critical patients subjected to ventilation&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a> in the way of days on mechanical ventilation&#44; stay in the ICU&#44; or mortality&#46; It is to be expected that the incidence of microbiologically confirmed VAP in hospitals that exclusively use endoscopic techniques is lower than in those centers that do not use these procedures&#46; It therefore seems prudent to propose a differentiated measure of the rates according to whether use is made of one technique or other&#44; in order to avoid transference bias and afford a true measure of the effect of the preventive actions taken&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The title to this article emphasizes the need to eliminate qualitative tracheal aspiration as a routine diagnostic method in VAP&#8212;limiting its use to those ICUs in which quantitative diagnostic procedures are not possible&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ventilator associated pneumonia &#40;VAP&#41; is the leading nosocomial infection in Intensive Care&#46; It is associated with increased ICU and hospital stay&#44; an increased use of antibiotics&#44; and greater hospital costs&#46; The recently launched Pneumonia Zero project &#40;NZ&#41; undoubtedly constitutes a challenge for professionals in the ICU&#44; and has been designed to reduce the high incidence rates described&#46; It is necessary to establish the true incidence&#44; and whether the latter is influenced by the diagnostic method employed&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The lack of a reference standard for the microbiological diagnosis of VAP has generated controversy over the diagnostic algorithms to be used&#44; with the distinction of two strategies&#58; a noninvasive or clinical strategy based on upper respiratory tract cultures&#44; and an invasive method based on the use of quantitative cultures of samples from the lower respiratory tract obtained by bronchoscopic techniques&#46; Despite the recommendations of scientific societies&#44; which do not justify the use of qualitative tracheal aspirates in the microbiological diagnosis of VAP&#44; this method is still routinely used&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This study underscores the need to stop using qualitative tracheal aspirates as a routine diagnostic method for VAP&#44; recommending the use of bronchoscopic techniques or quantitative tracheal aspirates&#46;</p>"
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        "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La neumon&#237;a asociada a ventilaci&#243;n mec&#225;nica &#40;NAVM&#41; es la principal infecci&#243;n nosocomial acontecida en cuidados intensivos&#44; se asocia a un aumento de la estancia en la unidad de cuidados intensivos &#40;UCI&#41; y hospitalaria&#44; a un mayor consumo de antibi&#243;ticos&#44; y del coste hospitalario&#46; El proyecto Neumon&#237;a Zero &#40;NZ&#41;&#44; recientemente iniciado&#44; es sin duda un reto para los profesionales de las UCI dirigido a disminuir las altas tasas de incidencia descritas&#46; Es necesario aclarar de qu&#233; incidencia real partimos y si el m&#233;todo diagn&#243;stico utilizado influye en esta&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La falta de un patr&#243;n de referencia para el diagn&#243;stico microbiol&#243;gico de NAVM ha suscitado una controversia respecto a los algoritmos diagn&#243;sticos a seguir&#44; distingui&#233;ndose dos estrategias que coexisten&#58; la &#171;no invasiva&#187; o &#171;cl&#237;nica&#187;&#44; basada en cultivos de v&#237;as respiratorias altas y la &#171;invasiva&#187;&#44; fundamentada en el uso de cultivos cuantitativos de muestras obtenidas del tracto respiratorio inferior mediante t&#233;cnicas broncosc&#243;picas&#46; A pesar de las recomendaciones de las sociedades cient&#237;ficas&#44; que no justifican la utilizaci&#243;n del aspirado traqueal cualitativo para el diagn&#243;stico microbiol&#243;gico de la NAVM&#44; este sigue siendo un m&#233;todo habitualmente utilizado&#46; El presente art&#237;culo incide en la necesidad de que el aspirado traqueal cualitativo deje de ser un m&#233;todo de diagn&#243;stico rutinario para la NAVM recomendando el uso de t&#233;cnicas broncosc&#243;picas o el aspirado traqueal cuantitativo&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Estella A&#44; &#193;lvarez-Lerma F&#46; &#191;Debemos mejorar el diagn&#243;stico de la neumon&#237;a asociada a ventilaci&#243;n mec&#225;nica&#63; Med Intensiva&#46; 2011&#59;35&#58;578&#8211;82&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Incidence of ventilator associated pneumonia and frequency of qualitative tracheal aspirate use in diagnosing the condition&#46; ENVIN-HELICS registry&#46;</p>"
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Should the diagnosis of ventilator associated pneumonia be improved?
¿Debemos mejorar el diagnóstico de la neumonía asociada a ventilación mecánica?
A. Estellaa,
Corresponding author
litoestella@hotmail.com

Corresponding author.
, F. Álvarez-Lermab
a Servicio de Medicina Intensiva, Hospital SAS de Jerez, Cádiz, Spain
b Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Nosocomial infections &#40;NIs&#41; are infections that develop in relation to healthcare&#44; and are not a direct consequence of the background disease for which the patient is receiving treatment&#46; Urinary tract infections associated to bladder catheterization&#44; skin and soft tissue infections following surgical procedures&#44; or mediastinitis after heart surgery&#44; are examples of NIs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Intensive Care Units &#40;ICUs&#41; represent a favorable scenario for the development of infections of this kind&#44; since seriously ill patients are more susceptible to NIs&#46; Invasive procedures are typically carried out in the ICU that adversely affect the local defense barriers of the body&#44; and the patients admitted to these Units have often been previously exposed to antibiotics and are therefore susceptible to the development of bacterial resistances&#46; In the Intensive Care setting&#44; ventilator associated pneumonia &#40;VAP&#41; is the most prevalent infectious problem&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> ahead of catheter-related or urinary tract infections&#46; Moreover&#44; VAP is distinguished from the latter by its high associated mortality&#44; particularly when caused by multiresistant organisms&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Lastly&#44; it must be underscored that VAP is associated with a longer stay in the ICU and in hospital&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> increased antibiotic use&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and greater hospital costs&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The recently launched Pneumonia Zero &#40;PZ&#41; project undoubtedly represents a challenge for ICU professionals&#46; Following the satisfactory experience gained with the Bacteremia Zero &#40;BZ&#41; project&#44; we now face a new battle against the main type of infection found in ICUs&#8212;though a series of aspects need to be clarified&#58; What is the true starting incidence of the infection&#63; Does the diagnostic technique used exert an influence upon the incidence&#63; And in this context&#44; what diagnostic method should be used to assess the efficacy of the adopted preventive measures&#63;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The ENVIN-HELICS registry&#58; What is the true starting incidence of the infection&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall">The existence of a nosocomial infection vigilance system is undoubtedly the result of years of work on the part of the Infectious Diseases Work Group of the SEMICYUC &#40;GTEI-SEMICYUC&#41;&#46; The ENVIN-HELICS registry has become consolidated in recent years as one of the main ICU nosocomial infections registries&#46; It has grown from an initial total of 1884 patients in its first year in 1994 to 16&#44;950 cases in the last report corresponding to the year 2010&#46; This undoubtedly reflects the concern among intensivists regarding the vigilance and control of NIs&#44; and has contributed to assess and improve the quality of healthcare by establishing a map or profile of the true situation in our ICUs year by year&#44; with the ultimate aim of incorporating preventive measures for improving the safety of critically ill patients&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The &#8220;cultural&#8221; change of understanding that NIs are not simply the price to pay for admission to Intensive Care&#44; as an unavoidable risk or problem inherent to medical care&#44; has become manifest in the BZ project&#46; It has been shown that the adoption of a series of measures not only contributes to reduce the incidence of these infections&#44; but moreover has given rise to increased awareness of the importance of clinical safety&#8212;establishing concrete objectives&#44; identifying errors or inadequate practices&#44; and defining plans for improvement&#46; The launching in 2011 of the PZ project represents a further challenge that is fully justified and constitutes an ethical obligation destined to improve healthcare in search of excellence&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On examining the last few years &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; we see that after the decrease in the incidence of VAP recorded in the year 2009&#44; the figures have remained stable&#46; However&#44; the procedures used for the microbiological diagnosis of VAP have varied&#46; In this sense&#44; in the year in which the highest incidence of NIs was recorded&#44; qualitative cultures of upper airway samples were the most frequently used diagnostic technique &#40;51&#46;1&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The ongoing debate&#58; the clinical versus invasive strategy</span><p id="par0035" class="elsevierStylePara elsevierViewall">Over a decade ago&#44; Niederman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and Chastre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> started a debate on the microbiological diagnosis of VAP that persists to this day&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> This lack of a reference standard for the microbiological diagnosis of VAP has given rise to controversy regarding which diagnostic algorithms to use&#46; In this context&#44; there are two coexisting strategies&#58; &#8220;noninvasive&#8221; or &#8220;clinical&#8221;&#44; based on the culture of upper airway samples&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and &#8220;invasive&#8221;&#44; based on the use of quantitative cultures of lower respiratory tract samples usually obtained by bronchoscopy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a> The two randomized clinical trials that have compared these strategies&#44; with the inclusion of many patients and an important impact upon the scientific community&#44; have yielded conflicting results&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;18</span></a> Although the objectives of both studies appeared to be similar&#44; there were major differences in their design that can explain the observed lack of agreement&#46; In the study published by Fagon et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> treatment was guided by the results of gram staining&#46; Accordingly&#44; if germ isolation proved negative and there were no signs of sepsis&#44; treatment was suspended&#46; In the other study&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> treatment was started with broad-spectrum antibiotics in all patients&#44; regardless of whether they were at risk of infection caused by multiresistant organisms or not&#46; Another important difference between the two studies was the patient population involved&#44; since the Canadian trial<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> excluded individuals with immune deficiencies&#44; chronic diseases&#44; treatment with carbapenem or quinolones&#44; and colonization by microorganisms resistant to antibiotic treatment&#46; The profile of these excluded individuals&#44; representing over one-third of all the patients in the study&#44; coincides with the profile of most subjects admitted to the ICU with clinically suspected VAP&#44; and this is possibly the patient subpopulation that would benefit most from the invasive strategy&#8212;though no study has confirmed this to date&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although some authorities have suggested an end to the debate&#44; it seems logical to consider that a sample obtained from the lower respiratory tract with guidance toward the affected zone offers greater quality than a tracheal sample&#46; In any case&#44; and although it may seem overly ambitious&#44; we can debate whether one strategy or the other truly has impact upon mortality or not&#46; In this context&#44; although the clinical strategy has not been shown to be inferior to the invasive strategy in relation to the patient prognosis&#44; it has not been able to improve upon the established advantages of the bronchoscopic techniques&#58; greater confidence on the part of the clinician&#44; rational antibiotic use &#40;which can contribute to avoid the development of bacterial resistances&#41;&#44; and the importance of a negative reading obtained from a quality respiratory sample in redirecting the search for other infectious foci&#8212;particularly in patients without previous antibiotic treatment&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&#8220;ZERO&#8221; qualitative tracheal aspirate</span><p id="par0045" class="elsevierStylePara elsevierViewall">According to the ENVIN-HELICS registry&#44; up until the year 2009 qualitative tracheal aspiration was the microbiological technique most widely used to diagnose VAP in Spanish ICUs &#40;47&#46;3&#37; of the cases registered that year&#41;&#46; This is probably attributable to the fact that tracheal aspiration is rapid&#44; simple and causes few complications&#46; In coincidence with these observations&#44; a study on the diagnosis of VAP in Andalusia found qualitative tracheal aspiration to be the most frequently used technique &#40;42&#46;8&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The analysis carried out by the pneumonia work group of the European Society of Intensive Care Medicine &#40;EU-VAP&#47;CAP Study Group&#41; in 2009&#44; involving over 20 ICUs in 9 countries and the evaluation of 2436 patients with 827 cases of pneumonia&#44; likewise found qualitative tracheal aspiration to be the microbiological diagnostic method used in 46&#46;2&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A number of factors can explain this situation&#44; which has persisted for years&#46; Firstly&#44; the lack of a reference standard has given rise to great clinical variability in dealing with the diagnosis of VAP&#46; Such variability can be minimized through training programs&#44; emphasizing the fact that qualitative tracheal aspiration is not recommended&#44; regardless of the debate referred to the use of invasive or noninvasive techniques&#46; In this sense&#44; for example&#44; if we compare the mortality figures with those of other infectious diseases found in the ICU&#44; such as severe acute meningitis&#44; it is surprising that despite the similarities between these processes&#44; the attitude toward the microbiological samples differs&#58; cerebrospinal fluid is rapidly processed and immediate information is requested from the microbiologist&#44; while the approach tends to be more contemplative in the case of a tracheal aspirate or bronchoalveolar lavage&#46; We feel that a more active attitude is needed here&#59; coordination between the clinician &#40;the intensivist in this case&#41; and the microbiologist is essential&#44; with a view to insisting on the need for quantitative processing of the sample&#46; The decrease recorded in Spain regarding qualitative aspirate utilization in the registry corresponding to 2010 is promising&#44; and reflects greater adherence to the recommendations of the main scientific societies&#46; Independently of the recommendation of the American Thoracic Society &#40;ATS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which points to a reduction in mortality after 14 days with the &#8220;invasive&#8221; diagnostic strategy versus the &#8220;clinical&#8221; strategy&#44; supported by grade I evidence&#44; and based on the multicenter clinical trial published by Fagon et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> it is important to underscore the recommendations of both the ATS and the SEMICYUC<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;21</span></a> referred to the use of qualitative tracheal aspiration&#46; With grade II evidence&#44; it is recommended that lower respiratory tract samples should be obtained in all patients with clinically suspected VAP&#44; and that these samples may be tracheal aspirate&#44; bronchoalveolar lavage &#40;BAL&#41; or protected bronchial brush&#46; Based on the maximum evidence &#40;grade I&#41;&#44; both the ATS and the Spanish Society of Intensive Care Medicine advise against the routine use of qualitative tracheal aspiration for the microbiological diagnosis of VAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;21</span></a> The main argument in this sense is that such samples are unlikely to allow differentiation between colonization and infection&#44; since the airways of most patients on mechanical ventilation are colonized by potentially pathogenic microorganisms&#44; and we may be risking the over-diagnosis of cases of pneumonia which in fact correspond to tracheal colonization or tracheobronchitis&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Bronchoscopic methods represented 23&#46;3&#37; in the European study&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and did not exceed 10&#37; in the ENVIN-HELICS registry of 2010&#46; Probably the non-availability of fibrobronchoscopy in some ICUs&#44; the lack of experienced personnel and the need for prior training are some of the reasons for such limited utilization&#8212;though the technique is actually simple&#44; with few complications&#44; and can be performed at the patient bedside&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Influence of the microbiological diagnostic method upon incidence</span><p id="par0060" class="elsevierStylePara elsevierViewall">On analyzing the incidence of VAP&#44; the published results are seen to be very heterogeneous&#46; This is probably due to the existing clinical variability&#44; conditioned by the different patient populations and isolated pathogens in each study&#44; the different types of ICUs involved&#44; and the mentioned lack of consensus regarding the microbiological diagnosis&#46; The interval found in the literature varies greatly from 5&#37; or 9&#37; using invasive diagnostic methods<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> to 41&#37; or 67&#37; when based on clinical criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> In 53 patients with clinically suspected pneumonia&#44; Morris et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> analyzed the influence of qualitative and quantitative aspiration&#44; and bronchoalveolar lavage&#44; upon the incidence of the disorder&#8212;important differences being detected depending on whether sample processing in the laboratory was qualitative or quantitative&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Final considerations</span><p id="par0065" class="elsevierStylePara elsevierViewall">The possibility of error in diagnosing VAP is not without a price for both the patient and the healthcare system&#46; The risk of overdiagnosing pneumonias which in fact constitute colonization implies unnecessary antibiotic use&#8212;with the consequent drug cost increments&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> an increased risk of antibiotic toxicity&#44; and the appearance of bacterial resistances&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">There is no doubt that quantitative sample processing offers clinicians a greater degree of confidence in relation to patient management&#46; However&#44; we must abandon the concept of &#8220;positive culture&#8221; and &#8220;negative culture&#8221; and request sample quantification&#46; The described cutoff points accepted by the scientific community lack a validating reference standard&#59; as a result&#44; they must not be viewed isolatedly but in a clinical context&#8212;taking into account previous antibiotic treatment&#44; days on mechanical ventilation&#44; the microorganism&#44; the sample obtained&#44; the medical history&#44; and the immune condition of the patient&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The described variability in the diagnostic management of VAP implies differences in the assignment of resources&#44; and therefore the possibility that the offered diagnosis and treatment may be suboptimal&#44; depending on the setting involved&#46; Consensus on the diagnostic algorithm is therefore needed&#44; assuming the disagreement between those who defend the clinical strategy and those who prefer the invasive approach&#8212;but accepting the fact that both strategies can coexist&#44; provided they coincide on the need for recommending quantitative respiratory sample cultures&#46; Quantitative tracheal aspiration is a reasonable alternative that has been shown to offer sensitivity and specificity performances similar to those of the bronchoscopic techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The clinical trials that have compared the two strategies have concluded that there are no differences between them in terms of prognosis and mortality&#44; though antibiotic use is effectively greater with the invasive strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> In relation to the last issue raised in &#8220;Introduction&#8221; section&#44; it is necessary to clarify that the efficacy of the preventive measures cannot be comparable among hospitals as long as the diagnostic approach remains variable&#46; In the current scenario&#44; the incidence of VAP cannot be used as a comparative measure among different ICUs&#44; or as a prognostic quality predictor in critical patients subjected to ventilation&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a> in the way of days on mechanical ventilation&#44; stay in the ICU&#44; or mortality&#46; It is to be expected that the incidence of microbiologically confirmed VAP in hospitals that exclusively use endoscopic techniques is lower than in those centers that do not use these procedures&#46; It therefore seems prudent to propose a differentiated measure of the rates according to whether use is made of one technique or other&#44; in order to avoid transference bias and afford a true measure of the effect of the preventive actions taken&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The title to this article emphasizes the need to eliminate qualitative tracheal aspiration as a routine diagnostic method in VAP&#8212;limiting its use to those ICUs in which quantitative diagnostic procedures are not possible&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ventilator associated pneumonia &#40;VAP&#41; is the leading nosocomial infection in Intensive Care&#46; It is associated with increased ICU and hospital stay&#44; an increased use of antibiotics&#44; and greater hospital costs&#46; The recently launched Pneumonia Zero project &#40;NZ&#41; undoubtedly constitutes a challenge for professionals in the ICU&#44; and has been designed to reduce the high incidence rates described&#46; It is necessary to establish the true incidence&#44; and whether the latter is influenced by the diagnostic method employed&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The lack of a reference standard for the microbiological diagnosis of VAP has generated controversy over the diagnostic algorithms to be used&#44; with the distinction of two strategies&#58; a noninvasive or clinical strategy based on upper respiratory tract cultures&#44; and an invasive method based on the use of quantitative cultures of samples from the lower respiratory tract obtained by bronchoscopic techniques&#46; Despite the recommendations of scientific societies&#44; which do not justify the use of qualitative tracheal aspirates in the microbiological diagnosis of VAP&#44; this method is still routinely used&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This study underscores the need to stop using qualitative tracheal aspirates as a routine diagnostic method for VAP&#44; recommending the use of bronchoscopic techniques or quantitative tracheal aspirates&#46;</p>"
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        "titulo" => "Resumen"
        "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La neumon&#237;a asociada a ventilaci&#243;n mec&#225;nica &#40;NAVM&#41; es la principal infecci&#243;n nosocomial acontecida en cuidados intensivos&#44; se asocia a un aumento de la estancia en la unidad de cuidados intensivos &#40;UCI&#41; y hospitalaria&#44; a un mayor consumo de antibi&#243;ticos&#44; y del coste hospitalario&#46; El proyecto Neumon&#237;a Zero &#40;NZ&#41;&#44; recientemente iniciado&#44; es sin duda un reto para los profesionales de las UCI dirigido a disminuir las altas tasas de incidencia descritas&#46; Es necesario aclarar de qu&#233; incidencia real partimos y si el m&#233;todo diagn&#243;stico utilizado influye en esta&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La falta de un patr&#243;n de referencia para el diagn&#243;stico microbiol&#243;gico de NAVM ha suscitado una controversia respecto a los algoritmos diagn&#243;sticos a seguir&#44; distingui&#233;ndose dos estrategias que coexisten&#58; la &#171;no invasiva&#187; o &#171;cl&#237;nica&#187;&#44; basada en cultivos de v&#237;as respiratorias altas y la &#171;invasiva&#187;&#44; fundamentada en el uso de cultivos cuantitativos de muestras obtenidas del tracto respiratorio inferior mediante t&#233;cnicas broncosc&#243;picas&#46; A pesar de las recomendaciones de las sociedades cient&#237;ficas&#44; que no justifican la utilizaci&#243;n del aspirado traqueal cualitativo para el diagn&#243;stico microbiol&#243;gico de la NAVM&#44; este sigue siendo un m&#233;todo habitualmente utilizado&#46; El presente art&#237;culo incide en la necesidad de que el aspirado traqueal cualitativo deje de ser un m&#233;todo de diagn&#243;stico rutinario para la NAVM recomendando el uso de t&#233;cnicas broncosc&#243;picas o el aspirado traqueal cuantitativo&#46;</p>"
      ]
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Estella A&#44; &#193;lvarez-Lerma F&#46; &#191;Debemos mejorar el diagn&#243;stico de la neumon&#237;a asociada a ventilaci&#243;n mec&#225;nica&#63; Med Intensiva&#46; 2011&#59;35&#58;578&#8211;82&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Incidence of ventilator associated pneumonia and frequency of qualitative tracheal aspirate use in diagnosing the condition&#46; ENVIN-HELICS registry&#46;</p>"
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