Nosocomial pneumonia in patients receiving ventilation is a common ICU occurrence. The exact frequency is not known because of the lack of specificity of the clinical diagnosis and existing standard diagnostic techniques. We have attempted to come to consensus in identifying a patient population with a clinical suspicion of nosocomial pneumonia and establishing a definition of pneumonia by which new diagnostic techniques can be compared.

During the last decade, several centers have directed their research efforts at defining more efficient modalities for the accurate diagnosis of ventilator-associated pneumonia (VAP). Accurate diagnosis is an essential prerequisite for clinical investigation. Initial studies, which correlated histologic findings and quantitative bacterial cultures of the lung with the findings of protected specimen brush cultures have stimulated clinical investigation of VAF! Two diagnostic techniques, protected specimen brushing (PSB) and bronchoalveolar lavage (BAL), have been extensively investigated and have shown promising results. Advancements in the field, however, have been limited by the lack of standardization, particularly for BAL. In this communication, we attempt to standardize methodology for presently available bronchoscopic techniques and interpretation of data obtained by bronchoscopy to facilitate comparisons among investigations and to promote multicenter collaboration.

The technical limitations of portable chest radiography, the lack of lateral radiographs, and the difficulties in positioning critically ill patients hinder the radiologic diagnosis of pneumonia, especially in patients receiving mechanicalventilation (MV). Optimally, anteroposterior (AP) portable radiographs are obtained utilizing high kilovoltage (120 to 130 kV), short exposure time, and fast filmscreen combinations to increase radiographic latitude and decrease motion unsharpness. Whenever possible, constant source-tofilm and source-to-patient distance should be maintained to allow for proper assessment of changes in mediastinal or cardiac diameters. Multiple factors should be recorded, including radiographic technique, focus-film distance, kilovoltage (kv), milliampere (mA), patient position, and ventilator settings for positive end-expiratory pressure (PEEP) and peak inspiratory pressure (PIP).

The microbiologic analysis of respiratory specimens is a key component of both the clinical investigation of ventilator-associated pneumonia (VAP) and patient care. Although there is a substantial body of literature on the use of a variety of lower respiratory tract specimens, there is little standardization of the approaches to processing and interpreting results from the various specimens. The purpose of this communication is to delineate specific recommendations for the microbiologic analysis of specimens originating from the lower respiratory tract, as developed by the Laboratory Analysis Group of the Consensus Conference.

We now have the ability to accurately diagnose ventilator-associated pneumonia (VAP), which should lead to re-examination of nondiagnostic aspects of VAP Previous data regarding the epidemiology, treatment, and prevention of VAP were derived almost exclusively from studies in which the diagnoses were based on clinical criteria and cultures of endotracheal aspirates. These criteria are inaccurate in as many as 60 percent of cases compared to autopsy or quantitative cultures of bronchoscopic specimens. Many recent studies of VAP have focused on the accuracy of bronchoscopic and other methods of obtaining uncontaminated specimens from the lower respiratory tract for diagnosis. In anticipation of the use of these more accurate techniques to validate conclusions derived from studies based on the clinical diagnosis of VAP, the appropriateness of the design and conclusions of these published studies have been reviewed. In this communication, we discuss the areas in which sufficient data exist to reach consensus regarding methods for future studies in the epidemiology, treatment, and prevention of VAP and also attempt to delineate areas for future research endeavors.

The purpose of this report is to describe the workings of continuous quality improvement (CQI) in a nonprofit community teaching hospital. An earlier report reviewed the adoption by a hospital system of CQI and discussed the implications and opportunities for the discipline of hospital epidemiology. This article will further develop the theme of CQI, discussed in recent months in Infection Control and Hospital Epidemiology and other journals, by offering a case history of one hospital's journey down the CQI management pathway-the origins, the aids, and the barriers to adoption, the development of the first CQI teams, and future prospects.