Ventilator associated Pneumonia (VAP)

 

VAP (Ventilator associated Pneumonia

Ventilator associated pneumonia is a pneumonia that occurs in a patient who was intubated and ventilated at the time of or within 48 hours before the onset of the pneumonia.

The CDC has defined pneumonia using three specific sets of criteria.

1. Pneumonia 1 is clinically defined pneumonia
2. Pneumonia 2 is pneumonia with common bacterial pathogens
3. Pneumonia 3 is used for Immuno-compromised patients

 

CRITERIA

A.  PNU1 –Clinically Defined

X-Ray Findings

Patient with underlying disease has 2 or more serial X-rays with one of the following

• New or progressive and persistent infiltrate
• Consolidation
• Cavitation
• Pneumatoceles in <1 y.o.

Or

Patient without underlying diseases has 1 or more serial X-rays with one of the following

• New or progressive and persistent infiltrate
• Consolidation
• Cavitation
• Pneumatoceles in <1 y.o.

AND

Signs and symptoms

At least one of the following

• Fever (> 30°C/100.4°C) with no other cause
• Leukopenia (<4000 WBC/mm³) or leukocytosis (> 12000 WBC/mm³)
• Altered mental status with no other cause in > 70 y.o.

AND

At least two of the following

• New onset of purulent sputum, or change in character of sputum, or increase respiratory secretions or increased suctioning requirements.
• New onset or worsening cough or dyspnea or tachypnea
• Rales or Bronchial breath sounds
• Worsening Gas Exchange

B. PNU 2

X-Ray Findings

Patient with underlying disease has 2 or more serial X-rays with one of the following

• New or progressive and persistent infiltrate
• Consolidation
• Cavitation
• Pneumatoceles in <1 y.o.

Or

Patient without underlying diseases has 1 or more serial X-rays with one of the following

• New or progressive and persistent infiltrate
• Consolidation
• Cavitation
• Pneumatoceles in <1 y.o.

AND

Specific Laboratory findings

At least one of the following

• Fever (> 30°C/100.4°C) with no other cause
• Leukopenia (<4000 WBC/mm³) or leukocytosis (≥ 12000 WBC/mm³)
• Altered mental status with no other cause in Leukopenia (<4000 WBC/mm³) or leukocytosis (> 12000 WBC/mm³)
• Altered mental status with no other cause in > 70 yr.

AND

Signs & Symptoms

At least two of the following

• New onset of purulent sputum or change in the character of sputum or increased respiratory secretions or increased suctioning requirements
• New onset or worsening cough or dyspnea or tachypnea
• Rales or Bronchial breath sounds
• Worsening Gas Exchange

OR

At least one of the following

• New onset of purulent sputum or change in the character of sputum or increased respiratory secretions or increased suctioning requirements
• New onset or worsening cough or dyspnea or tachypnea
• Rales or Bronchial breath sounds
• Worsening Gas Exchange

And

At least one of the following

• Positive blood culture not related to another infection
• Positive pleural fluid culture
• Positive quantitative culture from minimally contaminated LRT specimen (e.g. BAL or protected specimen brushing)
• 5% BAL obtained cells contain intra cellular bacteria on direct microscope exam.
• Histopathologic exam shows one of the following

• 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

Or

At least one of the following

• Positive culture of virus or Chlamydia from respiratory secretions
• Positive detection of viral antigen or antibody from respiratory secretions (e.g. EIA, FAMA shell vial assay PCR)
• 4 fold rise in paired sera (IgG) for pathogen (e.g. Influenzae viruses, Chlamydia)
• Positive PCR for Chlamydia or Mycoplasma
• Positive Micro-IF test of Legionella Spp from respiratory secretions or tissue
• Detection of Legionella pneumophila serogroup 1 antigens in urine by RIA or EIA
• 4-fold rise in Legionella pneumophila antibody titer to ≥1:128 in paired acute and convalescent sera by indirect IFA

C. PNU3 –Immunocompromised

X-ray Findings

Patient with underlying disease has 2 or more serial X-rays with one of the following

• New or progressive and persistent infiltrate
• Consolidation
• Cavitation
• Pneumatoceles, in <1 y.o.

OR

Patient with underlying disease has 1 or more serial X-rays with one of the following

• New or progressive and persistent infiltrate
• Consolidation
• Cavitation
• Pneumatoceles, in <1 y.o.

Signs and symptoms

At least one of the following in a immunocompromised patient

• Fever (>38°C/100.4°F) with no other cause
• Altered mental status with no other cause in >70 y.o.
• New onset of pleural sputum or change in character of sputum or respiratory secretions or increased suctioning requirement
• New onset or worsening cough dysnea or tahypnea
• Rales or bronchial breath sounds
• Worsening gas exchange (e.g. O₂ desets {e.g. PaO₂/FIO₂≤240 }increase O₂  req. or increase ventilation demand)
• Hemoptysis
• Pleuritic Chest Pain

Lab Findings

At least one of following

• Matching positive blood and sputum cultures with Candida spp
• Evidence of fungi or Pneumocystis Carinii from minimally contaminated LRT specimen (e.g. BAL or protected specimen brushing) one of the following:
• Positive culture of fungi
• Direct microscopic exam

OR

• Any of the laboratory criteria from PNU2