F1

Device-associated Events
VAP

Ventilator-Associated Pneumonia (VAP) Event
Introduction: In 2002, an estimated 250,000 healthcare-associated pneumonias developed in U.S.
hospitals and 36,000 of these were associated with deaths.1Patients with mechanically-assisted
ventilation have a high risk of developing healthcare-associated pneumonia. From 2006-2007,
within NHSN facilities almost 5,400 VAPs were reported and incidence for various types of hospital
units ranged from 2.1-11.0 per 1,000 ventilator days.1
Prevention and control of healthcare-associated pneumonia is discussed in the CDC/HICPAC
document, Guidelines for Prevention of Healthcare-Associated Pneumonia, 20032. The Guideline
strongly recommends that surveillance be conducted for bacterial pneumonia in ICU patients who
are mechanically ventilated to facilitate identification of trends and for interhospital comparisons.
Settings: Surveillance will occur in any inpatient location where denominator data can be
collected, which may include critical/intensive care units (ICU), specialty care areas (SCA), neonatal
units, including neonatal intensive care units (NICUs), stepdown units, wards, and long term care
units. A complete listing of inpatient locations can be found in Chapter 15.
NOTE: It is not required to monitor for VAPs after the patient is discharged from the facility,
however, if discovered, a VAP should be reported to NHSN. No additional ventilator days are
reported.
Requirements: Surveillance for VAP in at least one inpatient location in the healthcare institution
for at least one calendar month as indicated in the Patient Safety Monthly Reporting Plan (CDC
57.106).
Definitions: As for all infections reported to NHSN, infections associated with complications or
extensions of infections already present on admission, unless a change in pathogen or symptoms
strongly suggests the acquisition of a new infection area not considered healthcare associated.
Therefore, infections that become apparent within the first few days of admission must be carefully
reviewed to determine whether they should be considered healthcare associated.
Pneumonia (PNEU) is identified by using a combination of radiologic, clinical and laboratory
criteria. The following pages outline the various assessment criteria that may be used for meeting
the surveillance definition of healthcare-associated pneumonia (Tables 2-5 and Figures 1 and 2).
Report PNEUs that are ventilator-associated (i.e., patient was intubated and ventilated at the time of,
or within 48 hours before, the onset of the event).
NOTE: There is no minimum period of time that the ventilator must be in place in order for the
PNEU to be considered ventilator associated.
Location of attribution: The inpatient location where the patient was assigned on the date of the
PNEU event, which is further defined as the date when the first clinical evidence appeared or the
date the specimen used to meet the PNEU criterion was collected, whichever came first.
EXAMPLE: Patient is intubated and ventilated in the Operating Room and then is admitted to the
MICU. Within 24 hours of admission to the MICU, patient meets criteria for PNEU. This is
June, 2011
6-1

Device-associated Events
VAP

reported to NHSN as a VAP for the MICU, because the Operating Room is not an inpatient location
and no denominator data are collected there.
TRANSFER RULE EXCEPTION: If a VAP develops within 48 hours of transfer from one
inpatient location to another in the same facility or a new facility,, the infection is attributed to the
transferring location. This is called the Transfer Rule and examples are shown below:
• Patient on a ventilator in the SICU is transferred to the surgical ward. Thirty six (36) hours later,
the patient meets the criteria for PNEU. This is reported to NHSN as a VAP for the SICU.
• Patient is transferred to the medical ward from the MSICU after having ventilator removed.
Within 24 hours, the patient meets criteria for a PNEU. This is reported to NHSN as a VAP for
the MSICU.
• Patient on a ventilator is transferred from the medical ward to the coronary care ICU (CCU).
After 4 days in the CCU, the patient meets the criteria for a PNEU. This is reported to NHSN as
a VAP for the CCU.
• Patient on the Respiratory ICU (RICU) of Hospital A had the endotracheal tube and ventilator
removed and is discharged home a few hours later. The ICP from Hospital B calls the next day
to report that this patient has been admitted to Hospital B with a PNEU. This VAP should be
reported to NHSN for, and by, Hospital A and attributed to the RICU. No additional ventilator
days are reported.
Ventilator: A device to assist or control respiration continuously, inclusive of the weaning period,
through a tracheostomy or by endotracheal intubation.
NOTE: Lung expansion devices such as intermittent positive-pressure breathing (IPPB); nasal
positive end-expiratory pressure (PEEP); and continuous nasal positive airway pressure (CPAP,
hypoCPAP) are not considered ventilators unless delivered via tracheostomy or endotracheal
intubation (e.g., ET-CPAP).
General Comments Applicable to All Pneumonia Specific Site Criteria:
1.

Physician’s diagnosis of pneumonia alone is not an acceptable criterion for healthcareassociated pneumonia.
2.
Although specific criteria are included for infants and children, pediatric patients may meet
any of the other pneumonia specific site criteria.
3.
Ventilator-associated pneumonia (i.e., pneumonia in persons who had a device to assist or
control respiration continuously through a tracheostomy or by endotracheal intubation within
the 48-hour period before the onset of infection, inclusive of the weaning period) should be
so designated when reporting data.
4.
When assessing a patient for presence of pneumonia, it is important to distinguish between
changes in clinical status due to other conditions such as myocardial infarction, pulmonary
embolism, respiratory distress syndrome, atelectasis, malignancy, chronic obstructive
pulmonary disease, hyaline membrane disease, bronchopulmonary dysplasia, etc. Also, care
must be taken when assessing intubated patients to distinguish between tracheal colonization,
upper respiratory tract infections (e.g., tracheobronchitis), and early onset pneumonia.
Finally, it should be recognized that it may be difficult to determine healthcare-associated
pneumonia in the elderly, infants, and immunocompromised patients since such conditions
June, 2011
6-2

Device-associated Events
VAP

5.

6.

7.

8.

may mask typical signs or symptoms associated with pneumonia. Alternate specific criteria
for the elderly, infants and immunocompromised patients have been included in this
definition of healthcare-associated pneumonia.
Healthcare-associated pneumonia can be characterized by its onset: early or late. Early onset
pneumonia occurs during the first four days of hospitalization and is often caused by
Moraxella catarrhalis, H. influenzae, and S. pneumoniae. Causative agents of late onset
pneumonia are frequently gram negative bacilli or S. aureus, including methicillin-resistant
S. aureus. Viruses (e.g., Influenza A and B or Respiratory Syncytial Virus) can cause early
and late onset healthcare-associated pneumonia, whereas yeasts, fungi, legionellae, and
Pneumocystis carinii are usually pathogens of late onset pneumonia.
Pneumonia due to gross aspiration (for example, in the setting of intubation in the emergency
room or operating room) is considered healthcare-associated if it meets any specific criteria
and was not clearly present or incubating at the time of admission to the hospital.
Multiple episodes of healthcare-associated pneumonia may occur in critically ill patients with
lengthy hospital stays. When determining whether to report multiple episodes of healthcareassociated pneumonia in a single patient, look for evidence of resolution of the initial
infection. The addition of or change in pathogen alone is not indicative of a new episode of
pneumonia. The combination of new signs and symptoms and radiographic evidence or
other diagnostic testing is required.
Positive Gram stain for bacteria and positive KOH (potassium hydroxide) mount for elastin
fibers and/or fungal hyphae from appropriately collected sputum specimens are important
clues that point toward the etiology of the infection. However, sputum samples are
frequently contaminated with airway colonizers and therefore must be interpreted cautiously.
In particular, Candida is commonly seen on stain, but infrequently causes healthcareassociated pneumonia.

Table 1: Abbreviations used in PNEU laboratory criteria
BAL – bronchoalveolar lavage
LRT – lower respiratory tract
EIA – enzyme immunoassay
PCR – polymerase chain reaction
FAMA – fluorescent-antibody staining of
PMN – polymorphonuclear leukocyte
membrane antigen
IFA – immunofluorescent antibody
RIA − radioimmunoassay
REPORTING INSTRUCTIONS:
• There is a hierarchy of specific categories within the major site pneumonia. Even if a patient
meets criteria for more than one specific site, report only one:
o If a patient meets criteria for both PNU1 and PNU2, report PNU2
o If a patient meets criteria for both PNU2 and PNU3, report PNU3
o If a patient meets criteria for both PNU1 and PNU3, report PNU3
• Report concurrent lower respiratory tract infection (e.g., abscess or empyema) and pneumonia
with the same organism(s) as pneumonia
• Lung abscess or empyema without pneumonia are classified as LUNG
• Bronchitis, tracheitis, tracheobronchitis, or bronchiolitis without pneumonia are classified as
BRON.
Table 2: Specific Site Algorithms for Clinically Defined Pneumonia (PNU1)
June, 2011
6-3

Device-associated Events
VAP

Radiology

Signs/Symptoms/Laboratory

Two or more serial chest
radiographs with at least
1,2
one of the following :

FOR ANY PATIENT, at least one of the following:

New or progressive
and persistent infiltrate
Consolidation
Cavitation
Pneumatoceles, in
infants ≤ 1 year old

NOTE: In patients
without underlying
pulmonary or cardiac
disease (e.g. respiratory
distress syndrome,
bronchopulmonary
dysplasia, pulmonary
edema, or chronic
obstructive pulmonary
disease), one definitive
chest radiograph is
1
acceptable.

-Fever (>38°C or >100.4°F) with no other recognized cause
3
3
-Leukopenia (<4000 WBC/mm ) or leukocytosis (>12,000 WBC/mm )
-For adults >70 years old, altered mental status with no other recognized cause
and
at least two of the following:
3

4

-New onset of purulent sputum , or change in character of sputum , or increased
respiratory secretions, or increased suctioning requirements
5
-New onset or worsening cough, or dyspnea, or tachypnea
6
-Rales or bronchial breath sounds
7
-Worsening gas exchange (e.g. O2 desaturations (e.g., PaO2/FiO2 < 240) , increased
oxygen requirements, or increased ventilator demand)
ALTERNATE CRITERIA, for infants <1 year old:
Worsening gas exchange (e.g., O2 desaturations [e.g. pulse oximetry < 94%], increased
oxygen requirements, or increased ventilator demand)
and
at least three of the following:
-Temperature instability with no other recognized cause
3
3
-Leukopenia (<4000 WBC/mm ) or leukocytosis (>15,000 WBC/mm ) and left shift (>10%
band forms)
3
4
-New onset of purulent sputum or change in character of sputum , or increased
respiratory secretions or increased suctioning requirements
5
-Apnea, tachypnea , nasal flaring with retraction of chest wall or grunting
6
-Wheezing, rales , or rhonchi
-Cough
-Bradycardia (<100 beats/min) or tachycardia (>170 beats/min)
ALTERNATE CRITERIA, for child >1 year old or ≤ 12 years old, at least three of the
following:
-Fever (>38.4°C or >101.1°F) or hypothermia (<36.5°C or <97.7°F) with no other
recognized cause
3
3
-Leukopenia (<4000 WBC/mm ) or leukocytosis (≥15,000 WBC/mm )
3
4
-New onset of purulent sputum , or change in character of sputum , or increased
respiratory secretions, or increased suctioning requirements
5.
-New onset or worsening cough, or dyspnea, apnea, or tachypnea .
6
-Rales or bronchial breath sounds.
-Worsening gas exchange (e.g. O2 desaturations [e.g. pulse oximetry < 94%], increased
oxygen requirements, or increased ventilator demand)

June, 2011

6-4

Device-associated Events
VAP

Table 3: Specific Site Algorithms for Pneumonia with Common Bacterial or Filamentous Fungal

Pathogens and Specific Laboratory Findings (PNU2)
Radiology

Signs/Symptoms

Laboratory

Two or more serial
chest radiographs with
at least one of the
1,2
following :

At least one of the following:

New or progressive
and persistent infiltrate

Leukopenia (<4000 WBC/mm ) or
3
leukocytosis (>12,000 WBC/mm )

Consolidation

For adults >70 years old, altered
mental status with no other
recognized cause

At least one of the following:

Cavitation
Pneumatoceles, in
infants ≤ 1 year old

Fever (>38°C or >100.4°F) with no
other recognized cause
3

and

8

Positive growth in blood culture not related to another
source of infection
Positive growth in culture of pleural fluid
9

Positive quantitative culture from minimally
contaminated LRT specimen (e.g., BAL or protected
specimen brushing)
≥5% BAL-obtained cells contain intracellular bacteria
on direct microscopic exam (e.g., Gram stain)
Histopathologic exam shows at least one of the
following evidences of pneumonia:

at least one of the following:
3

NOTE: In patients
without underlying
pulmonary or cardiac
disease (e.g.
respiratory distress
syndrome,
bronchopulmonary
dysplasia, pulmonary
edema, or chronic
obstructive pulmonary
disease), one
definitive chest
radiograph is
1
acceptable.

June, 2011

New onset of purulent sputum , or
4
change in character of sputum , or
increased respiratory secretions, or
increased suctioning requirements
New onset or worsening cough, or
5
dyspnea or tachypnea
6

Rales or bronchial breath sounds
Worsening gas exchange (e.g. O2
desaturations [e.g., PaO2/FiO2 <
7
240] , increased oxygen
requirements, or increased
ventilator demand)

6-5

Abscess formation or foci of consolidation with intense
PMN accumulation in bronchioles and alveoli
9

Positive quantitative culture of lung parenchyma
Evidence of lung parenchyma invasion by fungal
hyphae or pseudohyphae

Device-associated Events
VAP

Table 4: Specific Site Algorithms for Viral, Legionella, and other Bacterial Pneumonias with

Definitive Laboratory Findings (PNU2)
Radiology

Signs/Symptoms

Laboratory

Two or more serial chest
radiographs with at least
1,2
one of the following :

At least one of the following:

At least one of the following

Fever (>38°C or >100.4°F) with
no other recognized cause

Positive culture of virus or Chlamydia from
respiratory secretions

New or progressive
and persistent infiltrate
Consolidation
Cavitation
Pneumatoceles, in infants
≤ 1 year old

3

Positive detection of viral antigen or antibody from
respiratory secretions (e.g., EIA, FAMA, shell vial
assay, PCR)

For adults >70 years old, altered
mental status with no other
recognized cause

Fourfold rise in paired sera (IgG) for pathogen
(e.g., influenza viruses, Chlamydia)
Positive PCR for Chlamydia or Mycoplasma

and

Positive micro-IF test for Chlamydia
3

New onset of purulent sputum ,
or change in character of
4
sputum , or increased
respiratory secretions, or
increased suctioning
requirements
New onset or worsening cough
5
or dyspnea, or tachypnea
6

Rales or bronchial breath
sounds
Worsening gas exchange (e.g.
O2 desaturations [e.g.,
7
PaO2/FiO2 < 240] , increased
oxygen requirements, or
increased ventilator demand)

June, 2011

:

Leukopenia (<4000 WBC/mm )
or leukocytosis (>12,000
3
WBC/mm )

at least one of the following:
NOTE: In patients
without underlying
pulmonary or cardiac
disease (e.g. respiratory
distress syndrome,
bronchopulmonary
dysplasia, pulmonary
edema, or chronic
obstructive pulmonary
disease), one definitive
chest radiograph is
1
acceptable.

10-12

6-6

Positive culture or visualization by micro-IF of
Legionella spp, from respiratory secretions or
tissue.
Detection of Legionella pneumophila serogroup 1
antigens in urine by RIA or EIA
Fourfold rise in L. pneumophila serogroup 1
antibody titer to ≥1:128 in paired acute and
convalescent sera by indirect IFA.

Device-associated Events
VAP

Table 5: Specific Site Algorithm for Pneumonia in Immunocompromised Patients (PNU3)
Radiology

Signs/Symptoms

Laboratory
At least one of the following:

Two or more serial chest
radiographs with at least
1,2
one of the following :

Patient who is
13
immunocompromised has at least
one of the following:

New or progressive and
persistent infiltrate

Fever (>38°C or >100.4°F) with no
other recognized cause

Consolidation

For adults >70 years old, altered
mental status with no other
recognized cause

Cavitation
Pneumatoceles, in
infants ≤ 1 year old

NOTE: In patients
without underlying
pulmonary or cardiac
disease (e.g. respiratory
distress syndrome,
bronchopulmonary
dysplasia, pulmonary
edema, or chronic
obstructive pulmonary
disease), one definitive
chest radiograph is
1
acceptable.

Matching positive blood and sputum cultures
14, 15
with Candida spp.
Evidence of fungi or Pneumocystis carinii from
minimally contaminated LRT specimen (e.g.,
BAL or protected specimen brushing) from
one of the following:
- Direct microscopic exam
- Positive culture of fungi

3

New onset of purulent sputum , or
4
change in character of sputum , or
increased respiratory secretions, or
increased suctioning requirements

Any of the following from
LABORATORY CRITERIA DEFINED UNDER
PNU2

New onset or worsening cough, or
5
dyspnea, or tachypnea
6

Rales or bronchial breath sounds
Worsening gas exchange (e.g. O2
desaturations [e.g., PaO2/FiO2 <
240]7, increased oxygen
requirements, or increased
ventilator demand)
Hemoptysis
Pleuritic chest pain

Footnotes to Algorithms:
1. Occasionally, in nonventilated patients, the diagnosis of healthcare-associated pneumonia may be quite
clear on the basis of symptoms, signs, and a single definitive chest radiograph. However, in patients with
pulmonary or cardiac disease (for example, interstitial lung disease or congestive heart failure), the diagnosis
of pneumonia may be particularly difficult. Other non-infectious conditions (for example, pulmonary edema
from decompensated congestive heart failure) may simulate the presentation of pneumonia. In these more
difficult cases, serial chest radiographs must be examined to help separate infectious from non-infectious
pulmonary processes. To help confirm difficult cases, it may be useful to review radiographs on the day of
diagnosis, 3 days prior to the diagnosis and on days 2 and 7 after the diagnosis. Pneumonia may have rapid
onset and progression, but does not resolve quickly. Radiographic changes of pneumonia persist for several
weeks. As a result, rapid radiographic resolution suggests that the patient does not have pneumonia, but rather
a non-infectious process such as atelectasis or congestive heart failure.
2. Note that there are many ways of describing the radiographic appearance of pneumonia. Examples include,
but are not limited to, “air-space disease”, “focal opacification”, “patchy areas of increased density”.
Although perhaps not specifically delineated as pneumonia by the radiologist, in the appropriate clinical
setting these alternative descriptive wordings should be seriously considered as potentially positive findings.

June, 2011

6-7

Device-associated Events
VAP

3. Purulent sputum is defined as secretions from the lungs, bronchi, or trachea that contain >25 neutrophils
and <10 squamous epithelial cells per low power field (x100). If your laboratory reports these data
qualitatively (e.g., “many WBCs” or “few squames”), be sure their descriptors match this definition of
purulent sputum. This laboratory confirmation is required since written clinical descriptions of purulence are
highly variable.
4. A single notation of either purulent sputum or change in character of the sputum, is not meaningful;
repeated notations over a 24 hour period would be more indicative of the onset of an infectious process.
Change in character of sputum refers to the color, consistency, odor and quantity.
5. In adults, tachypnea is defined as respiration rate >25 breaths per minute. Tachypnea is defined as >75
breaths per minute in premature infants born at <37 weeks gestation and until the 40th week; >60 breaths per
minute in patients <2 months old; >50 breaths per minute in patients 2-12 months old; and >30 breaths per
minute in children >1 year old.
6. Rales may be described as “crackles”.
7. This measure of arterial oxygenation is defined as the ratio of the arterial tension (PaO2) to the inspiratory
fraction of oxygen (FiO2).
8. Care must be taken to determine the etiology of pneumonia in a patient with positive blood cultures and
radiographic evidence of pneumonia, especially if the patient has invasive devices in place such as
intravascular lines or an indwelling urinary catheter. In general, in an immunocompetent patient, blood
cultures positive for coagulase negative staphylococci, common skin contaminants, and yeasts will not be the
etiologic agent of the pneumonia.
9. Refer to Threshold values for cultured specimens (Table 6). An endotracheal aspirate is not a minimally
contaminated specimen. Therefore, an endotracheal aspirate does not meet the laboratory criteria.
10. Once laboratory-confirmed cases of pneumonia due to respiratory syncytial virus (RSV), adenovirus, or
influenza virus have been identified in a hospital, clinician’s presumptive diagnosis of these pathogens in
subsequent cases with similar clinical signs and symptoms is an acceptable criterion for presence of
healthcare-associated infection.
11. Scant or watery sputum is commonly seen in adults with pneumonia due to viruses and Mycoplasma
although sometimes the sputum may be mucopurulent. In infants, pneumonia due to RSV or influenza yields
copious sputum. Patients, except premature infants, with viral or mycoplasmal pneumonia may exhibit few
signs or symptoms, even when significant infiltrates are present on radiographic exam.
12. Few bacteria may be seen on stains of respiratory secretions from patients with pneumonia due to
Legionella spp, mycoplasma, or viruses.
13. Immunocompromised patients include those with neutropenia (absolute neutrophil count <500/mm3),
leukemia, lymphoma, HIV with CD4 count <200, or splenectomy; those who are early post-transplant, are on
cytotoxic chemotherapy, or are on high dose steroids (e.g., >40mg of prednisone or its equivalent (>160mg
hydrocortisone, >32mg methylprednisolone, >6mg dexamethasone, >200mg cortisone) daily for >2weeks).
14. Blood and sputum specimens must be collected within 48 hours of each other.
15. Semiquantitative or nonquantitative cultures of sputum obtained by deep cough, induction, aspiration, or
lavage are acceptable. If quantitative culture results are available, refer to algorithms that include such
specific laboratory findings

June, 2011

6-8

Device-associated Events
VAP

Figure 1: Pneumonia Flow Diagram

PNEUM ONIA FLOW DIAGRAM
Facility ID # __ _____ ______

E ve nt # __ _____ ______

E vent D ate _ ___/__ _ _/__ _____ __

Instruct ions : Comp lete fo rm onl y if x-ra y c rite ria are met

X-Ray

Patient wi th u nderl yin g di seases1,2 has 2 or more
serial X-ra ys with one of the following:

Patient wi th ou t un derl yi ng disea ses1,2 has 1 or m ore
serial X-ra ys with one of the following:



New or p rog ressive an d persistent infiltrate



New or p rog ressive an d persistent infiltrate



Consolidation



Consolidation



Ca vitation



Ca vitation



Pneumat oceles, in ≤1 y. o.



Pneumat oceles, in ≤1 y. o.

Signs and Symptoms

At least one of the f ollowing:

At least one of the f ollowing in an
imm un oc om pro mise d patie nt13 :



Fever (> 38° C/10 0.4° F ) with no othe r cause



Leuko penia ( < 4,00 0 WBC/mm ³) or leu koc ytosis
(> 12,0 00 WBC/ mm³ )



Altered ment al status with no o ther ca use, in > 70 y.o .

At least two of t he following:

At least one of the f ollowing:





New onset of pu rulent sputu m,3
or change in cha racte r of
sputum, or ↑ respirato ry
secretions, or ↑ suctioning
requirem ents 4



New onset or worsening cou gh,
or d yspnea, o r tach ypne a5



Rales 6 or bronchial b reath
sounds



New onset of pu rulent sputu m,3
or change in cha racte r of sputu m,
or ↑ respirato r y secretions, o r
↑ suctioning requi rements 4



New onset or worsening cou gh,
or d yspnea, o r tach ypne a5



Rales 6 or bronchial b reath
sounds



Worsening gas e xchang e (e. g.,
O2 desats [e.g., Pa O2 /FiO2
< 240],7 ↑ O2 r eq, o r ↑ ventilation
demand )

Worsening gas e xchang e (e. g.,
O2 desats [e.g., Pa O2 /FiO2
< 240],7 ↑ O2 r eq, o r
↑ ventilation deman d)



Fever (> 38° C/10 0.4° F ) with no
other cause



Altered ment al status with no
other cause, in > 70 y.o.



New onset of pu rulent sputu m,3 or
change in characte r of sput um, o r
↑ respira tor y secretions, o r
↑ suctioning requi rements 4



New onset or worsening cou gh, o r
dyspnea, or t achyp nea5



Rales 6 or bronchial b reath sou nds



Worsening gas e xchang e (e. g., O2
desats [e.g., Pa O2 /Fi O2 < 240],7
↑ O2 req, o r ↑ ve ntilation demand )



Hemopt ysis



Pleuritic chest pain

ised

m
pro
com
uno

I mm

Laboratory

I

com
uno
mm

At least one of the f ollowing:

At least one of the f ollowing10-12 :



Positive blood culture n ot
related to anothe r infection8





Positive pleural fluid culture

Positive culture of virus o r
Chla mydia from respirato r y
secretions



Positive quantitative culture9
from minimally conta minated
LRT specimen (e.g., BA L or
protected specimen
brushing)



Positive detection of viral antige n
or antibod y f rom respirato ry
secretions (e.g., EIA , FA MA,
shell vial assay, PCR )



4-fold rise in paire d sera (Ig G) for
pathogen (e.g ., Influen za viruses,
Chla mydia)

> 5% BA L-obt ained cells
contain intracellular bacteria
on direct microscopic exam





Histopathologic exa m shows
one of the f ollowing:

Positive PCR fo r Chla mydia o r
Mycoplasma



Positive micro-IF test for
Chla mydia



Positive culture or micro-I F of
Legionella spp from respirat or y
secretions or tissue



Detection of Le gionella
pneu mophila ser ogro up 1
antigens in urine b y R IA or EIA



4-fold rise in L. p neu mop hila
antibody titer to > 1:12 8 in paired
acute and con valescent sera b y
indirect IFA

•

Positive quantitati ve
culture9 of lung
parench yma

• Evidence of lung
parench yma in vasion b y
fungal hyphae or
pseudoh yphae

d
ise

At least one of following:



• Abscess formation or f oci
of consolidation with
intense PMN
accumulation in
bronchioles and al veoli

m
pro



Matching positive blood
and sputum cultu res with
Candida spp14,15



Evidence of f ungi or
Pneu mocytis carinii from
minimally contaminated
LRT specimen (e.g., BAL
or pr otected specimen
brushing) f rom on e of the
following:
•

Direct microscopic
exam

•

Positive culture of
fungi

Immunoco
mpromise
d
Immunocomprom
ised



PNU2: Pne u mo nia wit h
com m on bac terial or
filam en to us f un gal pa th oge ns


PNU1: Cli nicall y

defi ne d p neu m onia

June, 2011

and spec ific l ab fin di ngs

 PNU2: Pne u mo nia wit h
v iral, Legi onell a, C hla mydi a,
Myco plas ma, a nd ot her
unc om m on pat ho ge ns a nd
speci fic la b fi n din gs

6-11

 PNU3: Pn eu mo nia i n
imm un oc om pro mise d
patie nt s

Device-associated Events
VAP

Figure 2: Pneumonia Flow Diagram, Alternative Criteria for Infants and Children

PNEUMONIA FLOW DIAGRAM
ALTERNATE CRITERIA FOR INFANTS AND CHILDREN
Facility ID # _____________

Event # _____________

Event Date _ ___/___ _/_________

Signs and Symptoms

X-Ray

Instructions: Complete form only if x-ray criteria are met
Patient with underlying diseases1,2 has 2 or more
serial X-rays with one of the following:

Patient without underlying diseases1,2 has 1 or more
serial X-rays with one of the following:

 New or progressive and persistent infiltrate

 New or progressive and persistent infiltrate

 Consolidation

 Consolidation

 Cavitation

 Cavitation

 Pneumatoceles, in ≤1 y.o.

 Pneumatoceles, in ≤1 y.o.

Infants < 1 y.o.

Children >1 or < 12 y.o.



At least three of the following:

Worsening gas exchange (e.g., O2 desats [e.g.,
pulse oximetry <94%], ↑ O2 req, or ↑ ventilation
demand)



Fever (>38.4° C/101.1° F) or hypothermia
(< 36.5° C/97.7°F) with no other recognized
cause

and three of the following:


Temperature instability with no other recognized
cause



Leukopenia (< 4,000 WBC/mm³)
or leukocytosis (> 15,000 WBC/mm³)



Leukopenia (< 4,000 WBC/mm³)
or leukocytosis (> 15,000 WBC/mm³) and left
shift (> 10% band forms)



New onset of purulent sputum,3 or change in
character of sputum4, or ↑ respiratory secretions,
or ↑ suctioning requirements



New onset of purulent sputum,3 or change in
character of sputum4, or ↑ respiratory secretions,
or ↑ suctioning requirements



New onset or worsening cough, or dyspnea,
apnea, or tachypnea5



Apnea, tachypnea5, nasal flaring with retraction
of chest wall or grunting



Wheezing, rales6, or rhonchi



Cough



Bradycardia (<100 beats/min.) or tachycardia
(> 170 beats/min.)



Rales6 or bronchial breath sounds



Worsening gas exchange ( e.g., O2 desats [e.g.,
pulse oximetry < 94%], ↑ O2 req, or ↑ ventilation
demand)

 PNU1:
Clinically defined pneumonia

June, 2011

6-12

Device-associated Events
VAP

Table 6: Threshold values for cultured specimens used in the diagnosis of pneumonia
Specimen collection/technique
Values
>104 cfu/g tissue

Lung parenchyma*
Bronchoscopically (B) obtained specimens
Bronchoalveolar lavage (B-BAL)

>104 cfu/ml

Protected BAL (B-PBAL)
Protected specimen brushing (B-PSB)

>104 cfu/ml
>103 cfu/ml

Nonbronchoscopically (NB) obtained
(blind)
specimens
NB-BAL

>104 cfu/ml

NB-PSB

>103 cfu/ml

cfu = colony forming units
g = gram
ml = milliliter
COMMENT:
* Open-lung biopsy specimens and immediate post-mortem specimens obtained by
transthoracic or transbronchial biopsy
Numerator Data: The Pneumonia (PNEU) from (CDC 57.111) is used to collect and
report each VAP that is identified during the month selected for surveillance. The
Instructions for Completion of Pneumonia Form (Tables of Instructions, Tables 4 and 2a)
includes brief instructions for collection and entry of each data element on the form. The
pneumonia form includes patient demographic information and information on whether
or not mechanically assisted ventilation was present. Additional data include the specific
criteria met for identifying pneumonia, whether the patient developed a secondary
bloodstream infection, whether the patient died, and the organisms isolated from cultures
and their antimicrobial susceptibilities.
Denominator data: Device days and patient days are used for denominators (see Chapter
16 Key Terms). Ventilator days, which are the number of patients managed with a
ventilatory device, are collected daily, at the same time each day, according to the chosen
location using the appropriate form (CDC 57.116, 57.117, and 57.118). These daily
counts are summed and only the total for the month is entered into NHSN. Ventilator
and patient days are collected for each of the locations monitored. When denominator
data are available from electronic sources (e.g., ventilator days from respiratory therapy),

June, 2011

6-13

Device-associated Events
VAP

these sources may be used as long as the counts are not substantially different (+/- 5%)
from manually collected counts.
Data Analyses: The SIR is calculated by dividing the number of observed infections by
the number of expected infections. The number of expected infections, in the context of
statistical prediction, is calculated using PNEU rates from a standard population during a
baseline time period as reported in the NHSN Report.
NOTE: The SIR will be calculated only if the number of expected HAIs (numExp) is
≥ 1.

While the PNEU SIR can be calculated for single locations, the measure also allows you
to summarize your data by multiple locations, adjusting for differences in the incidence
of infection among the location types. For example, you will be able to obtain one PNEU
SIR adjusting for all locations reported. Similarly, you can obtain one PNEU SIR for all
specialty care areas in your facility.
The VAP rate per 1000 ventilator days is calculated by dividing the number of VAPs by
the number of ventilator days and multiplying the result by 1000. The Ventilator
Utilization Ratio is calculated by dividing the number of ventilator days by the number of
patient days. These calculations will be performed separately for the different types of
ICUs, SCAs, and other locations in the institution, as well as by each birthweight
category in NICUs.
___________________________________________________
1

Klevens RM, Edward JR, et al. Estimating health care-associated infections and deaths in U.S. hospitals,
2002. Public Health Reports 2007;122:160-166.
2

Centers for Disease Control and Prevention. Guidelines for preventing health-care-associated pneumonia,
2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee.
MMWR 2004;53(No. RR-3).

June, 2011

6-14