A new score based on procalcitonin and chest echography for diagnosis of ventilator-associated pneumonia: when? How? For whom?

We read with great interest the study published by Zagli et al 1 in a recent issue of CHEST (December 2014). In spite of originality and new insights concerning diag nosis of ventilator-associated pneumonia (VAP), some issues must be considered. First, seven Candida albicans microbiologically confi rmed VAP cases is quite an unusual incidence for this pathogen. Diagnosis of Candida pneumonia should be abandoned in ICU setting when immunocompetent subjects are considered. 2 Moreover, fungal airway colonization is a frequent fi nding in patients submitted to mechanical ventilation, and a Candida VAP diagnosis can only be fi rmly established based on histologic proof. Currently, some discrepancies are found in VAP diagnosis made by lung ultrasonography. Although wide exclusion criteria permitted a refi nement of study population (lowering external applicability), the inclusion of trauma patients can be concealing consolidations not related to pneumonia, especially in patients with pulmonary contusion. 3 Although based on consensus recommendations, the sonographic pneumonia diagnostic criteria are still controversial. As a matter of fact, it is level C quality of evidence (ie, “any estimate of eff ect or accuracy is very uncertain”). 4 An interstitial pattern (B lines) does not exclude an infectious cause for lung damage—a corollary of radiographic infi ltrates presented in the formal VAP diagnosis—and it was not clarifi ed in the present study. Thus, a model of lung ultrasound diagnosis based in a comprehensive score, as previously described, 5 should be a more promising tool.