Ventilator Associated Pneumonia (VAP)
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
ObjectivesIn 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)
General, objective evidence of infection/inflammation
Infection-Related Ventilator-Associated Complication (IVAC)
Designed to be suitable for use in potential future public reporting, inter-
facility comparisons, pay-for-performance programs
Infection-Related Ventilator-Associated Complication (IVAC)
Positive results of laboratory/microbiological testing
Possible VAP Designed to be suitable for
use in internal quality improvement
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)
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)
Ventilator-Associated Condition (VAC)
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 2Purulent 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 3One 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%)
VAE
VAC ↑PEEP ↑Fio2
IVAC ↑↓T./WBC AB≥4d.
PVAP 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
• 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 PNEU1,2 Hemoptysis Pleuritic chest pain
Laboratory PNEU2 At least one of the following:• Matching positive blood and sputum orendotracheal aspirate cultures withCandida spp
• Evidence of fungi from minimally contaminatedLRT specimen (e.g., BAL orprotected specimen brushing) from one ofthe 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
70
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
012
Blood leukocyte level, leukocytes/mm3 4000–11,000 <4000 or >11000 Plus band forms ≥500
012
Tracheal secretions <14+ (few) ≥14+ (moderate) Plus purulence
012
Oxygenation, PaO2:FiO2, mm Hg >240 or ARDS ≤240 and no ARDS
02
Pulmonary radiograph finding No infiltrate Diffuse or patchy infiltrate Localized infiltrate
012
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+
012