Ventilator Associated Pneumonia (VAP)

Objectives VAE PNEU1 PNEU2 PNEU3

VAE VAE= Ventilator Associated Event

VAE Surveillance 2014: VAE surveillance: ► Patient location-based ► Restricted to adult inpatient locations ► No longer be patient age-based

VAE Surveillance 2014, VAE surveillance: ► NOT be performed in: Pediatric Mixed age Neonatal patient locations

Objectives In 2014: Only adult inpatient locations will be able to perform VAE surveillance Patients who are <18 years of age but who are cared for in those adult locations will be included in VAE surveillance

VAE surveillance Will NOT be able to be performed in: Pediatric locations (even when there are patients ≥18 y. in those locations) Neonatal intensive care units (NICU)

VAE Definition The VAE definition algorithm is for use in surveillance

VAE Definition It is not a clinical definition algorithm It is not intended for use in the clinical management of patient

VAP Patient intubated and ventilated: At the time of Within 48 hours before The onset of the event

VAP Surveillance VAC IVAC PVAP

VAE Definition Patients must be MV for >2 calendar days. The day of intubation and initiation of MV is day 1.

Patient on mechanical ventilation > 2 days Baseline period of stability or improvement, followed by sustained period of worsening oxygenation Ventilator-Associated Condition (VAC) Designed to be suitable for use in potential future public reporting, inter-facility comparisons, pay-for-performance programs General, objective evidence of infection/inflammation Infection-Related Ventilator-Associated Complication (IVAC)

Infection-Related Ventilator-Associated Complication (IVAC) Positive results of laboratory/microbiological testing Designed to be suitable for use in internal quality improvement Possible VAP

PVAP= Resp. Culture /Purulence/ Serology/Pathology VAE PVAP= Resp. Culture /Purulence/ Serology/Pathology IVAC= ↑↓T./WBC + AB≥4d. VAC= ↑PEEP/Fio2

VAE Surveillance Algorithm Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values. The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2. After a period of stability or improvement on the ventilator, the patient has at least one of the following indicators of worsening oxygenation: 1) Increase in daily minimum FiO2 of ≥ 0.20 (20 points) over the daily minimum FiO2 in the baseline period, sustained for ≥ 2 calendar days. 2) Increase in daily minimum PEEP values of ≥ 3 cmH2O over the daily minimum PEEP in the baseline period*, sustained for ≥ 2 calendar days. *Daily minimum PEEP values of 0-5 cmH2O are considered equivalent for the purposes of VAE surveillance. Ventilator-Associated Condition (VAC)

Possible VAP Ventilator-Associated Condition (VAC) On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: 1) Temperature > 38 °C or < 36°C, OR white blood cell count ≥ 12,000 cells/mm3 or ≤ 4,000 cells/mm3. AND 2) A new antimicrobial agent(s)* is started, and is continued for ≥ 4 calendar days. Infection-related Ventilator-Associated Complication (IVAC) Possible VAP

Possible Ventilator-Associated Pneumonia (PVAP) 1)Criterion 1: Positive culture 2) Criterion 2: Purulent respiratory secretions 3) Criterion 3: Positive tests

PVAP, Criterion 1 Positive culture of one of the following specimens, without requirement for purulent respiratory secretions: • ETA, ≥ 105 CFU/ml or corresponding semi-quantitative result • BAL, ≥ 104 CFU/ml or corresponding semi-quantitative result • Lung tissue, ≥ 104 CFU/g or corresponding semi-quantitative result • PSB, ≥ 103 CFU/ml or corresponding semi-quantitative result

PVAP, Criterion 2 Purulent respiratory secretions ( secretions from the lungs, bronchi, or trachea that contain >25 PMN and <10 squamous epithelial cells per LPF [lpf, x100])† plus a positive culture of one of the following specimens (qualitative culture, or quantitative/semi-quantitative culture without sufficient growth to meet criterion #1): • Sputum • ETA • BAL • Lung tissue • PSB † If the laboratory reports semi-quantitative results, those results must correspond to the above quantitative thresholds.

PVAP, Criterion 3 One of the following positive tests: • P.E culture (thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube) • Lung histopathology, defined as: 1) Abscess / consolidation with intense PMN in bronchioles and alveoli 2) Lung parenchyma invasion by fungi (hyphae, pseudohyphae or yeast forms) 3) Infection with the viral pathogens (IHC assays, cytology, or microscopy on lung tissue) • Diagnostic test for Legionella species • Diagnostic test on respiratory secretions for influenza virus, RSV , adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus

Excluded Organisms Candida species or yeast Coagulase-negative Staphylococcus species Enterococcus species When isolated from cultures of : - Sputum - ETA - BAL - PSB

Pathogens ANY organism isolated from cultures of Lung tissue or Pleural fluid including : - Candida species - Coagulase-negative Staph species - Enterococcus species may be reported as pathogens for Possible or Probable VAP

Positive End-Expiratory Pressure (PEEP) The range: 0 - 15 cmH2O Criteria: sustained increase in the daily minimum PEEP of ≥ 3 cmH2O PEEP values from 0 to 5 cmH2O are considered equivalent

Fraction of inspired oxygen (FiO2) FiO2 of ambient air = 0.21 The oxygen concentration of ambient air =21% The range: 0.30 - 1.0 (oxygen concentration of 30-100%) Criteria: sustained increase in the daily minimum FiO2 of ≥ 0.20 (20%)

VAC IVAC PVAP VAE ↑PEEP ↑Fio2 ↑↓T./WBC AB≥4d. Culture/ Purulence Serology/ Pathology

Hierarchy of Definitions Within VAE If a patient meets criteria for VAC and IVAC, report as IVAC If a patient meets criteria for VAC, IVAC and Possible VAP, report Possible VAP

VAE CXR ? Physical Exam?

The VAE Rate Per 1000 Ventilator Days The VAE Rate: No. of VAEs No. of ventilator days Х 1000

The Ventilator Utilization Ratio Number of ventilator days Number of patient days

Previous Definition VAP PNUMONIA

Diagnostic Strategies and Approaches HAP: VAP/Non-VAP Clinical Strategy Bacteriologic Strategy

Clinically Defined Pneumonia (PNU1) CXR Criteria Symptoms & Signs Criteria CDC/NHSN Surveillance Definition of Healthcare-Associated Infection , June 2011

PNU2, Specific Laboratory Findings CXR Symptoms/Signs Lab

PNU3, Pneumonia in Immunocompromised Patients Imaging Test Evidence PNEU1,2 Signs/Symptoms Hemoptysis Pleuritic chest pain Laboratory PNEU2 At least one of the following: • Matching positive blood and sputum or endotracheal aspirate cultures with Candida spp • Evidence of fungi from minimally contaminated LRT specimen (e.g., BAL or protected specimen brushing) from one of the following: − Direct microscopic exam − Positive culture of fungi − Non-culture diagnostic laboratory test

Clinically Defined Pneumonia (PNU1) CXR Criteria Underlying pulmonary or cardiac disease: Respiratory distress syndrome Bronchopulmonary dysplasia Pulmonary edema COPD

CXR Criteria With underling disease, ≥2 serial CXR with at least 1 of the following: New or progressive and persistent infiltrate Consolidation Cavitation Pneumatoceles, in infants ≤1 year old Without underling dis., ≥1 serial CXR with at least 1 of the following: New or progressive and persistent infiltrate Consolidation Cavitation Pneumatoceles, in infants ≤1 year old

CXR Criteria The second imaging test must occur within seven days of the first 7 CXR

Signs/Symptoms Criteria FOR ANY PATIENT, at least 1 of the following: Fever >38C with no other recognized cause Leukopenia <4000 or leukocytosis ≥12,000/mm3 For adults ≥ 70 y., altered mental status with no other recognized cause And, at least 2 of the following: New onset of purulent sputum, or change in character of sputum, or ↑ respiratory secretions or ↑ suctioning requirements New onset or worsening cough, or dyspnea, or tachypnea Rales, or bronchial breath sounds Worsening gas exchange (O2 desaturations [ PaO2/FiO2≤ 240], ↑oxygen requirements, or ↑ ventilator demand)

PNU2, Specific Laboratory Findings At least 1 of the following: Positive growth in B/C not related to another source of infection Positive growth in culture of pleural fluid Positive quantitative culture from minimally contaminated LRT specimen (eg, BAL or PSB) ≥5% BAL-obtained cells contain intracellular bacteria on direct microscopic exam (eg, Gram stain) Histopathologic exam shows at least 1 of the following evidences of pneumonia: Abscess formation or foci of consolidation with intense PMN accumulation in bronchioles and alveoli Positive quantitative culture of lung parenchyma Evidence of lung parenchyma invasion by fungal hyphae or pseudohyphae

Parameter Clinical Pulmonary Infection Score Points Temperature, C 36.5–38.4 38.5–38.9 ≥39.0 and ≤36.0 1 2 Blood leukocyte level, leukocytes/mm3 4000–11,000 <4000 or >11000 Plus band forms ≥500 Tracheal secretions <14+ (few) ≥14+ (moderate) Plus purulence Oxygenation, PaO2:FiO2, mm Hg >240 or ARDS ≤240 and no ARDS Pulmonary radiograph finding No infiltrate Diffuse or patchy infiltrate Localized infiltrate Culture of tracheal aspirate specimen (semiquantitative: 0–1, 2, or 3+) Pathogenic bacteria cultured ≤1 or no growth Pathogenic bacteria cultured >1+ Plus same pathogenic bacteria on Gram stain >1+