Prevention of ventilator-associated pneumonia: selecting interventions that make a difference.

monia. This would seem to be a prudent approach, at least for patients able to produce adequate sputum for these preparations. Awareness and training of laboratory personnel would be another part of the equation, which would hopefully amount to a better chance of noninvasive diagnosis of pulmonary blastomycosis. If bronchoscopy or thoracoscopy/thoracotomy must enter the diagnostic sequence, a couple of caveats should be kept in mind. First, lidocaine treatment has been shown to inhibit the growth of B dermatitidis in culture. Thus, limiting the concentration of lidocaine to 1 g/dL has been recommended in suspected cases to reduce the antifungal effect.4 Second, B dermatitidis is frequently missed in standard hematoxylin and eosinstained histologic specimens, so special stains, usually silver or periodic acid-Schiff stains, are often needed to identify the organism. A serologic test, usually being inexpensive and noninvasive, might be an ideal way to screen for blastomycosis and direct the workup for possible active cases in endemic areas. Regrettably, Martynowicz and Prakash, like others, have found the currently available commonly used serologic techniques to have inadequate sensitivity for such an application. Yet work is ongoing in this area, and in the future, novel serologic or molecular biological techniques may make the job of uncovering veiled B dermatitidis infections easier. Blastomycosis is not a common infection. The Centers for Disease Control and Prevention estimates the incidence in endemic areas to be one to two cases per 100,000 population. Yet, the consequences of missing the diagnosis can be significant, including not only an unfavorable clinical outcome, but also substantial distress to the patient as he or she faces potentially unnecessary tests and procedures while having to cope with the uncertainty of diagnosis. Understanding the various forms of this treatable infection, especially by clinicians who practice in endemic areas, is the first step to smooth diagnosis and treatment. Then, suspicion in patients whose exposure history and disease presentation put blastomycosis into the differential diagnosis should direct collection of adequate, and perhaps, multiple sputum specimens to be cultured and stained for fungal detection, including by Papanicolaou stain. Specimens from bronchoscopy and other more invasive procedures should also be appropriately collected and processed. With the proper knowledge and watchfulness, hopefully the true identity of this great masquerader will, in more cases than not, be promptly exposed.