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