1. Ventilator Associated Pneumonia (VAP)

2. Objectives
VAE
PNEU1
PNEU2
PNEU3

3. VAE
VAE=
Ventilator
Associated
Event

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

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

6. 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

7. 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)

8. VAE Definition
The VAE definition algorithm is for use in surveillance

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

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

11. VAP Surveillance
VAC
IVAC
PVAP

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

13. 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)

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

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

16. 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)

17. 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

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

19. 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

20. 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.

21. 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: ) Abscess / consolidation with intense PMN in bronchioles and alveoli ) Lung parenchyma invasion by fungi (hyphae, pseudohyphae or yeast forms) ) 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

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

23. 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

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

25. Fraction of inspired oxygen (FiO2)
FiO2 of ambient air = 0.21
The oxygen concentration of ambient air =21%
The range: (oxygen concentration of %)
Criteria: sustained increase in the daily minimum FiO2 of ≥ 0.20 (20%)

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

27. 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

28. VAE
CXR ?
Physical Exam?

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

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

33. Previous Definition VAP
PNUMONIA

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

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

36. PNU2, Specific Laboratory Findings
CXR
Symptoms/Signs
Lab

37. 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

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

39. 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

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

41. 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)

42. 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

43. 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+