Pugin et al. [64] proposed to combine the seven variables (temperature, leukocytes, tracheal aspirate volume and purulence of tracheal secretions, chest X-ray, oxygenation-PaO 2 /FiO 2 -and semiquantitative culture of tracheal aspirate) for the diagnosis of VAP, defined as clinical pulmonary infection score (CPIS) ( Table 4 ). The score varied from 0 to 12 points and was reported that a CPIS of more than six was associated with a sensitivity of 93% and a specificity of 100% for the diagnosis of pneumonia. In a post mortem study, Papazian and colleagues [65] reported a high diagnostic accuracy of CPIS at a threshold of 6 (72% sensitivity and 85% specificity). However, the original scoring system has some limitations; that it requires 24-48 hours for the results of tracheal aspirate cultures, and also identifying pulmonary infiltrates progression depends on intensivist experience. Singh et al. [66] used a modified CPIS (calculated at baseline from the first five clinical variables, and CPIS at 72 hours was based on all variables of the score) that antibiotics were stopped in patients with a persistent low score (<6) after 3 days of therapy, avoiding unnecessary use of antibiotics, and all patients who discontinued the therapy improved. In a recent study, Fartoukh et al. [67] reported that the modified CPIS does not perform better when the clinical suspicion of pneumonia is high, so they proposed incorporating the results of specimens gram stain (by adding two more points when gram stains were positive) to modified CPIS to increase the sensitivity of the score and the physicians' diagnostic accuracy.