Att G.20_Ventilator -Associated Pneumonia

Device-associated Events
VAP

Pneumonia (Ventilator-Associated[VAP] and non-ventilator associated Pneumonia [PNEU]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.1 Patients
with mechanically-assisted ventilation have a high risk of developing healthcareassociated pneumonia. For the year 2012, NHSN facilities reported more than 3,957
VAPs and the incidence for various types of hospital units ranged from 0.0-4.4 per 1,000
ventilator days.2
Prevention and control of healthcare-associated pneumonia is discussed in the
CDC/HICPAC document, Guidelines for Prevention of Healthcare-Associated
Pneumonia, 20033. 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 inter-hospital comparisons.
Settings: Surveillance will occur in any inpatient pediatric location where denominator
data can be collected, which may include critical/intensive care units (PICUs), specialty
care areas (SCA), step-down units, wards, and long term care units. In 2015, in-plan
surveillance for ventilator-associated pneumonia (PNEU) using the criteria found in this
chapter will be restricted to patients of any age in pediatric locations. In 2015 in-plan
surveillance conducted for mechanically-ventilated patients in adult locations (regardless of
age) will use the Ventilator-Associated Event (VAE) protocol (see VAE chapter). The PNEU
definitions are still available for those units seeking to conduct off-plan PNEU surveillance
for mechanically-ventilated adult, pediatric and neonatal patients and non-ventilated adults,
pediatricor neonatal patients. A complete listing of inpatient locations and instructions for
mapping can be found in the CDC Locations and Descriptions chapter.
NOTE: It is not required to monitor for PNEU /VAP after the patient is discharged from
the facility. However, if discovered, any PNEU /VAP with event date on the day of
discharge or the next day should be reported to NHSN if you are following (PedVAP) in
your monthly reporting plan. (see Transfer Rule below). No additional ventilator days
are reported.
Requirements: For in-plan reporting surveillance for PedVAP will occur in at least one
inpatient pediatric location in the healthcare institution for at least one calendar month as
indicated in the Patient Safety Monthly Reporting Plan (CDC 57.106).
Definitions:
Present on Admission (POA): Infections that are POA, as defined in Chapter 2, are not
considered HAIs and therefore are never reported to NHSN.

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POA reporting exception for PNEU/VAP: If all other elements are present per the POA
criteria, one chest radiograph alone is acceptable to meet POA criteria for PNEU/VAP,
protocol, regardless of whether the patient has underlying pulmonary or cardiac disease.
Healthcare-associated infections (HAI): All NHSN site specific infections must first meet
the HAI definition as defined in Chapter 2 before a site specific infection
(e.g.,PNEU/VAP) can be reported to NHSN.
How to Apply HAI Definition to the PNEU/VAP Protocol:
A serial chest radiograph (CXR) on or after day 3 of admission (HAI) and a second later
CXR may be used to meet the radiology finding requirement in a patient with underlying
disease. The second CXR must occur within 7 days of the first. These findings can be
used to fulfill the current HAI PNEU/VAP criteria for the required 2 CXR findings are
considered 1 element of the PNEU/VAP criteria. All other elements of PNEU/VAP
should be met per the HAI definition. The PNEU/VAP HAI criteria are met even if all
other elements required for PNEU/VAP are not present at the time the second CXR is
obtained.
Pneumonia (PNEU) is identified by using a combination of radiologic, clinical and
laboratory criteria. The following pages detail the various criteria that may be used for
meeting the surveillance definition of healthcare-associated pneumonia (Tables 2-5 and
Figures 1 and 2), general comments applicable to all specific site criteria, and reporting
instructions. Table 6 shows threshold values for cultured specimens used in the
surveillance diagnosis of pneumonia.
Date of event: For PNEU/VAP the date of event is the date when the first element used
to meet the Pneumonia (PNEU) criteria occurred. Synonyms: infection date.
Ventilator: A device to assist or control respiration 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).
Ventilator-associated pneumonia(VAP): A pneumonia where the patient is on mechanical
ventilation for >2 calendar days on the date of event, with day of ventilator placement
being Day 1,
and
the ventilator was in place on the date of event or the day before. If the patient is admitted
or transferred into a facility on a ventilator, the day of admission is considered Day1.

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Location of attribution: The inpatient location where the patient was assigned on the date
of the VAP event, which is further defined as the date when the last element used to meet
the PNEU criterion occurred (see exception below).
EXCEPTION TO LOCATION OF ATTRIBUTION:
Transfer Rule: If all elements of a PNEU/VAP are present within 2 days of transfer from
one inpatient location to another in the same facility or a new facility (i.e., on the day of
transfer or the next day), the infection is attributed to the transferring location or facility.
If the patient was in multiple locations within the transfer rule time frame, attribute the
infection to the original location initiating the transfer. Receiving facilities should share
information about such HAIs with the transferring facility to enable reporting. This is
called the Transfer Rule and examples are shown below:
 Child has been on a ventilator for 7 days in the PICU and is transferred on the
ventilator to the pediatric surgical ward. On the next day, the patient meets the criteria
for PNEU. This is reported to NHSN as a VAP for the PICU.
 Child has been on a ventilator for 5 days and is transferred in the morning to the
pediatric medical ward from the pediatric medical critical care unit after having
ventilator discontinued. Later that night, the child meets criteria for a PNEU. This is
reported to NHSN as a VAP for the pediatric medical critical care unit.
 Pediatric patient on a ventilator is transferred from the neonatal intensive care unit
(NICU) to the pediatric intensive care unit (PICU). After 4 days in the PICU, the
patient meets the criteria for a PNEU. This is reported to NHSN as a VAP for the
PICU.
 Pediatric patient on the Respiratory ICU (RICU) of Hospital A had the endotracheal
tube and ventilator removed after being on the ventilator for 5 days and is discharged
home a few hours later. The IP 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 for the RICU are reported.
General comments applicable to all pneumonia specific site criteria:
1.
2.

3.

Physician’s diagnosis of pneumonia alone is not an acceptable criterion for
healthcare-associated pneumonia.
Although specific criteria are included for infants and children and
immunocompromised patients, all patients may meet any of the other pneumonia
specific site criteria.
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

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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 may mask typical signs or symptoms associated with pneumonia.
Alternate specific elements for the elderly, infants and immunocompromised
patients have been included in this definition of healthcare-associated pneumonia.
4.
Pneumonia due to gross aspiration (for example, in the setting of intubation in the
field, emergencydepartment, or operating room) that does not meet NHSN POA
definition is considered healthcare-associated if it meets any PNEU definition.
5.
Multiple episodes of healthcare-associated pneumonia may occur in critically ill
patients with lengthy hospital stays. When determining whether to report multiple
episodes of healthcare-associated pneumonia in a single patient, see Note
following HAI definition in Chapter 2. The addition of or change in pathogen
alone is not indicative of a new episode of pneumonia.
6. . Excluded organisms that cannot be used to meet pneumonia definitions are as
follows: results indicating isolation of oral cavity or upper respiratory tract flora
(e.g., Normal Oral Flora, Mixed Oral Flora); Candida species or yeast* not
otherwise specified; coagulase-negative Staphylococcus species; and
Enterococcus species, when isolated from cultures of sputum, endotracheal
aspirates, bronchoalveolar lavage, or protected specimen brushings.
NOTE:
ANY organism isolated from cultures of lung tissue or pleural fluid (where specimen was
obtained during thoracentesis or initial placement of chest tube and NOT from an
indwelling chest tube), including Candida species or yeast not otherwise specified,
coagulase-negative Staphylococcus species or Enterococcus species may be reported as
pathogens for PNEU
EXCEPTION:*
Candida species or yeast not otherwise specified isolated from sputum or endotracheal
aspirate specimen and blood culture can be used to satisfy the PNU3 definition.

Abbreviations
BAL–bronchoalveolar lavage
EIA–enzyme immunoassay
FAMA–fluorescent-antibody staining of membrane antigen
IFA–immunofluorescent antibody
LRT–lower respiratory tract
PCR–polymerase chain reaction
PMN–polymorphonuclear leukocyte
RIA–radioimmunoassay

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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 PNEU.
 Lung abscess or empyema without pneumonia is classified as LUNG.
 Secondary bloodstream infections can be reported for PNU1, PNU2 and PNU3
definition. Do not report any pneumonias (PNU1, PNU2, PNU3) where
Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus or
Pneumocystis. is found to be the causative agent of pneumonia.

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Table 2: Specific Site Algorithms for Clinically Defined Pneumonia (PNU1)
Imaging Test
Evidence

Signs/Symptoms/Laboratory

Two or more serial chest
imaging test results with
at least one of the
following1,2:

For ANY PATIENT, at least one of the following:

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

 Fever (>38.0°C or >100.4°F)
 Leukopenia (<4000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3)
 For adults >70 years old, altered mental status with no other recognized cause
and
at least two of the following:
 New onset of purulent sputum3 (refer to Table ?#) or change in character of
sputum4, or increased respiratory secretions, or increased suctioning requirements
 New onset or worsening cough, or dyspnea, or tachypnea 5
 Rales6 or bronchial breath sounds
 Worsening gas exchange (e.g., O2 desaturations (e.g., PaO2/FiO2 <240)7, increased
oxygen requirements, or increased ventilator demand)
ALTERNATE CRITERIA, for 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
imaging test result is
acceptable.1

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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
 Leukopenia (<4000 WBC/mm3) or leukocytosis (>15,000 WBC/mm3) and left shift
(>10% band forms)
 New onset of purulent sputum3 (refer to Table ?) or change in character of sputum4,
or increased respiratory secretions or increased suctioning requirements
 Apnea, tachypnea5 , nasal flaring with retraction of chest wall or nasal flaring with
grunting
 Wheezing, rales6, or rhonchi
 Cough
 Bradycardia (<100 beats/min) or tachycardia (>170 beats/min)

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VAP

Imaging Test
Evidence

Signs/Symptoms/Laboratory
ALTERNATE CRITERIA, for child >1 year old or ≤12 years old, at least three of the
following:
 Fever (>38. 0°C or >100. 4°F) or hypothermia (<36. 0°C or <96. 8°F)
 Leukopenia (<4000 WBC/mm3) or leukocytosis (≥15,000 WBC/mm3)
 New onset of purulent sputum3 (refer to Table ?#) or change in character of
sputum4, or increased respiratory secretions, or increased suctioning requirements
 New onset or worsening cough, or dyspnea, apnea, or tachypnea 5.
 Rales6 or bronchial breath sounds
 Worsening gas exchange (e.g., O2 desaturations [e.g., pulse oximetry <94%],
increased oxygen requirements, or increased ventilator demand)

Table 3: Specific Site Algorithms for Pneumonia with Common Bacterial or
Filamentous Fungal Pathogens and Specific Laboratory Findings (PNU2)
Imaging Test
Evidence

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Signs/Symptoms

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Laboratory

Device-associated Events
VAP

Two or more serial chest
imaging test results with at
least one of the
following1,2:

At least one of the following:

At least one of the following:

 Fever (>38.0°C or >100.4°F)
 Leukopenia (<4000 WBC/mm )
or leukocytosis (>12,000
WBC/mm3)



Positive growth in blood culture8
not related to another source of
infection



Positive growth in culture of pleural
fluid9



Positive quantitative culture9 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’s
stain)
Positive quantitative culture9 of
lung parenchyma

3

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

 For adults >70 years old, altered
mental status with no other
recognized cause
and
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 imaging test result is
acceptable.1

January 2015

 New onset of purulent sputum3
(refer to Table ?) or change in
character of sputum4, or increased
respiratory secretions, or
increased suctioning requirements
 New onset or worsening cough, or
dyspnea or tachypnea5
 Rales6 or bronchial breath sounds




Histopathologic exam shows at
least one of the following evidences
of pneumonia:
o

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

o

Evidence of lung
parenchyma invasion by
fungal hyphae or
pseudohyphae

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

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Table 4: Specific Site Algorithms for Viral, Legionella, and other Bacterial
Pneumonias with Definitive Laboratory Findings (PNU2)
Imaging Test
Evidence

Signs/Symptoms

Laboratory

Two or more serial chest
imaging test results with
at least one of the
following1,2:

At least one of the following:

At least one of the following10, 11, 12:

 Fever (>38.0°C or >100.4°F)

 Positive culture of virus, Legionella or
Chlamydia from respiratory secretions
 Positive non culture diagnostic
laboratory test of respiratory secretions
or tissue for virus, Chlamydia,
Mycoplasma, Legionella (e.g., EIA,
FAMA, shell vial assay, PCR, microIF)

 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 imaging test result
is acceptable.1

January 2015

 Leukopenia (<4000 WBC/mm3) or
leukocytosis (>12,000 WBC/mm3)
 For adults >70 years old, altered
mental status with no other
recognized cause
and
at least one of the following:
 New onset of purulent
sputum3(refer to Table ?) or change
in character of sputum4, or
increased respiratory secretions, or
increased suctioning requirements

 Fourfold rise in paired sera (IgG) for
pathogen (e.g., influenza viruses,
Chlamydia)
 Fourfold rise in L. pneumophila
serogroup 1 antibody titer to ≥1:128 in
paired acute and convalescent sera by
indirect IFA.

 New onset or worsening cough or
dyspnea, or tachypnea5
 Rales6 or bronchial breath sounds
 Worsening gas exchange (e.g., O2
desaturations [e.g., PaO2/FiO2
<240]7, increased oxygen
requirements, or increased
ventilator demand)

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 Detection of Legionella pneumophila
serogroup 1 antigens in urine by RIA or
EIA


Device-associated Events
VAP

Table 5: Specific Site Algorithm for Pneumonia in Immunocompromised Patients (PNU3)
Imaging Test
Evidence

Signs/Symptoms

Laboratory

Two or more serial chest
imaging test results with
at least one of the
following1,2:

Patient who is
immunocompromised ( see
definition in footnote 13) has at least
one of the following:

At least one of the following:

 New or progressive
and persistent
infiltrate

 Fever (>38.0°C or >100.4°F)

 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 imaging test result
is acceptable.1

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

 Matching positive blood and sputum or
endotracheal aspirate cultures with
Candida spp.14,15
 Evidence of fungi or from minimallycontaminated LRT specimen (e.g., BAL or
protected specimen brushing) from one of
the following:

 New onset of purulent sputum3,
or change in character of
sputum4, or increased respiratory
secretions, or increased
suctioning requirements

 Direct microscopic exam
 Positive culture of fungi
 non-culture diagnostic laboratory test
Any of the following from

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

LABORATORY CRITERIA DEFINED
UNDER PNU2

 Rales6 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 non-ventilated patients, the diagnosis of healthcare-associated pneumonia may be quite
clear on the basis of symptoms, signs, and a single definitive chest imaging test result. 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 imaging test results must be examined to help separate infectious
from non-infectious pulmonary processes. To help confirm difficult cases, it may be useful to review imaging
test results 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. Imaging test evidence of

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pneumonia persists for several weeks. As a result, rapid imaging 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 imaging 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.
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). Refer to the table below if your laboratory
reports these data semi-quantitatively or uses a different format for reporting Gram stain or direct examination
results (e.g., “many WBCs” or “few squamous epithelial cells”). This laboratory confirmation is required
since written clinical descriptions of purulence are highly variable. See Table?

How do I use the purulent respiratory
secretions criterion if …
My laboratory reports counts of “white
blood cells” or “polymorphonuclear
leukocytes” or “leukocytes” rather than
counts of “neutrophils”?

Instruction

My laboratory reports semi-quantitative
results (not quantitative results) for
numbers of neutrophils and squamous
epithelial cells?
My laboratory cannot provide additional
information on how its semi-quantitative
reporting corresponds to quantitative
reporting ranges for neutrophils and
squamous epithelial cells?

My laboratory reports only the numbers of
neutrophils present, without reporting the
number of squamous epithelial cells?

My laboratory uses different reporting
thresholds for neutrophils and squamous
epithelial cells (e.g., maximum report of ≥
20 neutrophils per low power field [x100],
or minimum report of ≤ 15 squamous
epithelial cells per low power field
[x100])?

January 2015

Assume that counts of cells identified by
these other descriptors (e.g., “white blood
cells”) are equivalent to counts of
neutrophils, unless the laboratory tells you
this is not the case.
Check with the laboratory to get
information about what quantitative ranges
the semi-quantitative reports correspond
to.
Use the following direct examination
results to meet the purulent respiratory
secretions criterion: heavy, 4+, or ≥25
neutrophils per low power field (lpf)
[x100], AND rare, occasional, few, 1+ or
2+, or ≤10 squamous epithelial cells per
lpf [x100] [19].
In this situation, the purulent secretions
criterion may be met using the specified
quantitative and semi-quantitative
thresholds for neutrophils alone (i.e.,
heavy, 4+, or ≥25 neutrophils per lpf
[x100]).
In this situation, the purulent secretions
criterion may be met using the laboratory’s
specified maximum quantitative threshold
for neutrophils, and/or minimum
quantitative threshold for squamous
epithelial cells.

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How do I use the purulent respiratory
secretions criterion if …
My laboratory processes respiratory
specimens such as bronchoalveolar lavage
fluid using a centrifugation procedure
(e.g., “cytospin”), and there is no
quantitation or semi-quantitation of
neutrophils or white blood cells in the
direct examination report?

Instruction
In this situation, a report indicating the
presence of white blood cells, without
quantitation, is sufficient to meet the
purulent secretions criterion.

4. A single notation of 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. . Coagulase-negative Staphylococcus species, Enterococcus species and Candida species or yeast not
otherwise specified cultured from blood from an immunocompetent patient cannot be deemed secondary to a
PNEU, unless the organism was also cultured from pleural fluid (where specimen was obtained during
thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube) or lung tissue.
Candida species or yeast not otherwise specified and isolated from sputum or endotracheal aspirate specimen
and blood culture can be used to satisfy the PNU3 definition.9. Refer to threshold values for cultured
specimens (Table 6). A sputum and endotracheal aspirate are not minimally- contaminated specimens and
therefore,organisims isolated from these specimens do not meet the laboratory criteria for PNU2.
Because they are an indication of commensal flora of the oral cavity or upper respiratory tract, the following
organisms can only be used to meet PNEU definitions when isolated from pleural fluid obtained during
thoracentesisor intial placement of chest tube (not from an indwelling chest tube) or lung tissue:
 Coagulase-negative Staphylococcus species
 Enterococcus species
 Candida species or yeast not otherwise specified. Candida species or yeast not otherwise specified
can be used to meet the PNU3 specific laboratory criteria.
13. Immunocompromised patients include those with neutropenia (absolute neutrophil count or total white
blood cell count (WBC) <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 or endotracheal aspirate specimens must satisfy gap day definition (see key terms) 15.
Semiquantitative or non-quantitative 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
Facility ID#_______________Event #_______________
Event Date
specific laboratory findings.Figure 1: PNEUMONIA FLOW DIAGRAM

__/__/____

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IMAGING TEST RESULTS

Device-associated Events
VAP

1,2

1,2

Patient with underlying diseases has 2 or
more imaging test results with one of the
following:

New or progressive and persistent
infiltrate

Consolidation

Cavitation

Pneumatoceles, in≤ 1 y.o.

Patient without underlying diseases has 1 or
more imaging test results 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:
 Fever (>38.0C/100.4F)
 Leukopenia (<4,000 WBC/mm³) or leukocytosis (>12,000
WBC/mm³)
 Altered mental status with no other cause, in >70 y.o.

At least two of the following:
 New onset of purulent
3
sputum, or change in
character of sputum, or 
respiratory secretions, or 
4
suctioning requirements
 New onset or worsening
cough, or dyspnea, or
5
tachypnea
6
 Rales or bronchial breath
sounds
 Worsening gas exchange
(e.g., O2 desats [e.g.,
7

LABORATORY

PaO2/FiO2 <240],  O2 req, or
 ventilation demand)

At least one of the following:
 New onset of purulent
3
sputum, or change in
character of sputum, or 
respiratory secretions, or 
4
suctioning requirements
 New onset or worsening
cough, or dyspnea, or
5
tachypnea
6
 Rales or bronchial breath
sounds
 Worsening gas exchange
(e.g., O2 desats [e.g.,



Abscess formation or foci of
consolidattion with intense PMN
accumulation in bronchioles and
alveoli
Evidene of lung parenchyma
invasion by fungal hyphae or
pseudohyphae

PNU1
January 2015

7




[e.g., PaO2/FiO2 <240],  O2 req, or 
ventilation demand)
Hemoptysis
Pleuritic chest pain

7

PaO2/FiO2 <240],  O2 req,
or  ventilation demand)

At least one of the following:
 Positive blood culture not related to
8
another infection
 Positive pleural fluid culture
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
9
 Positive quantitative culture of lung
parenchyma
 Histopathologic exam shows one of
the following:


At least one of the following in an
13
immunocompromised patient :
 Fever (>38.0C/100.4F)
 Altered mental status with no other cause, in
>70 y.o.
3
 New onset of purulent sputum, or change in
character of sputum, or  respiratory
4
secretions, or  suctioning requirements
 New onset or worsening cough, or dyspnea,
5
or tachypnea
6
 Rales or bronchial breath sounds
 Worsening gas exchange (e.g., O2 desats

10-12

At least one of the following
:
 Positive culture of virus,
Legionella or Chlamydia from
respiratory secretions
 Positive non-culture diagnostic
laboratory test of respiratory
secretions or tissue for virus,
Chlamydia, Mycoplasma,
Legionella (e.g., EIA, FAMA,
shell vial assay, PCR, micro-IF)
 4-fold rise in paired sera (IgG) for
pathogen (e.g., Influenza viruses,
Chlamydia)
 4-fold rise in L. pneumophila
antibody titer to >1:128 in paired
acute and convalescent sera by
indirect IFA
 Detection of Legionella
pneumophila serogroup 1
antigens in urine by RIA or EIA

PNU2
6-13

At least one of following:
 Matching positive blood and
sputum or endotracheal
aspirate cultures with
14,15
Candida species
 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

PNU 3

Device-associated Events
VAP

Figure 1: Pneumonia Flow Diagram, Alternative Criteria for Infants and Children

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

Event #__________________

Date of Event____/_____/________

Instructions: Complete form only if x-ray criteria are met
1,2

X-Ray
Signs and Symptoms

1,2

Patient with underlying diseases has 2 or more
imaging test results with one of the following:
 New or progressive and persistent infiltrate





Patient without underlying diseases has 1 or more
imaging test results with one of the following:






Consolidation
Cavitation
Pneumatoceles, in ≤1 y.o.

New or progressive and persistent infiltrate
Consolidation
Cavitation
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 (>38.0°C/101.4°F) or hypothermia
(<36.0°C/96.8°F)

and three of the following:






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

Temperature instability



New onset of purulent sputum,3 or change
in character of sputum,4 or   respiratory
secretions, or  suctioning requirements



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



New onset of worsening cough, or
dyspnea, apnea, or tachypnea6




Rales6 or bronchial breath sounds



Leukopenia (<4,000 WBC/mm3) or
leukocytosis (≥15,000 WBC/mm3) and left
shift (≥10% band forms)
3



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)

 PNU1:
Clinically-defined pneumonia

January 2015

6-14

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

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

>104 CFU/ml
>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
* Open-lung biopsy specimens and immediate post-mortem specimens obtained by
transthoracic or transbronchial biopsy
Numerator Data: The Pneumonia (PNEU) form (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 (PNEU) form contains 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 mechanicallyassisted 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, the organisms isolated from cultures, and the organisms’
antimicrobial susceptibilities.
REPORTING INSTRUCTION:
 If no VAPs are identified during the month of surveillance, the Report No Events
box must be checked on the appropriate denominator summary screen, e.g.,
Denominators for Intensive Care Unit (ICU)/Other Locations (Not NICU or
SCA/ONC), etc.
Denominator Data: Device days and patient days are used for denominators (see Key
Terms chapter). 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
days and patient days are collected for each of the locations where VAP is monitored.
When denominator data are available from electronic sources (e.g., ventilator days from
respiratory therapy), these sources may be used as long as the counts are not substantially
different (+/- 5%) from manually-collected counts, validated for a minimum of 3 months.

January 2015

6-15

Device-associated Events
VAP

Data Analyses: 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.
The Standardized Infection Ratio (SIR4) is another measure of VAP incidence that can be
calculated by dividing the number of observed infections by the number of predicted
infections. The number of predicted infections can be calculated using VAP rates from a
standard population during a baseline time period, which represents a standard
population’s VAP experience.5
NOTE: The SIR should be calculated only if the number of expected HAIs (numExp) is
≥1 in order to enforce a minimum precision criterion
NOTE: The VAP SIR is not available from within the NHSN application, but can be
calculated using the methods described above.
While the VAP 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 can calculate one VAP SIR
adjusting for all locations reported. Similarly, you can calculate one VAP SIR for all
oncology locations in your facility.

Descriptive analysis options of numerator and denominator data are available in the
NHSN application, such as line listings, frequency tables, and bar and pie charts. VAP
rates and run charts are also available. Guides on using NHSN analysis features are
available from: http://www.cdc.gov/nhsn/PS-Analysis-resources/reference-guides.html.
___________________________________________________
1

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

Dudeck MA, Weiner LM, et al. National Healthcare Safety Network (NHSN) Report, Data Summary for
2012, Device-associated Module.
3

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).
4

Your guide to the Standardized Infection Ratio (SIR). October 2010.
http://www.cdc.gov/nhsn/PDFs/Newsletters/NHSN_NL_OCT_2010SE_final.pdf
5

Edwards JR, Peterson KD, Mu Y, et al. National Healthcare Safety Network (NHSN) report: Data
summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009;37:783-805. Available
at: http://www.cdc.gov/nhsn/PDFs/dataStat/2009NHSNReport.PDF.

January 2015

6-16

VAP

Instructions for Completion of Pneumonia (PNEU) Form (CDC
57.111)
Data Field
Facility ID
Event #
Patient ID

Social Security #
Secondary ID
Medicare #
Patient name
Gender
Date of birth
Ethnicity
Race

Event type
Date of event

Post-procedure PNEU
Date of procedure

January 2014

Instructions for Data Collection
The NHSN-assigned facility ID will be auto entered by the
computer.
Event ID number will be auto entered by the computer.
Required. Enter the alphanumeric patient ID number. This is the
patient identifier assigned by the hospital and may consist of any
combination of numbers and/or letters.
Optional. Enter the 9-digit numeric patient Social Security Number.
Optional. Enter the alphanumeric ID number assigned by the
facility.
Optional. Enter the patient’s Medicare number.
Optional. Enter the last, first, and middle name of the patient.
Required. Check Female, Male, or Other to indicate the gender of
the patient.
Required. Record the date of the patient birth using this format:
MM/DD/YYYY.
Optional. Specify if the patient is either Hispanic or Latino, or Not
Hispanic or Not Latino.
Optional. Specify one or more of the choices below to identify the
patient’s race:
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Required. PNEU.
Required. The date of event is the date when the first element used
to meet the CDC/NHSN site-specific infection criterion occurred.
Synonyms: infection date, date of infection. Enter date of this event
using this format: MM/DD/YYYY.
NOTE: If a device has been pulled on the first day of the month in a
location where there are no other device days in that month, and a
device-associated infection develops after the device is pulled,
attribute the infection to the previous month.
Optional. Check Y if this event occurred after an NHSN- defined
procedure but before discharge from the facility, otherwise check N.
Conditionally required. If Post-procedure PNEU = Y, then enter the
date the procedure was done.
17

VAP

NHSN procedure code

ICD-9-CM procedure
code

MDRO Infection
Surveillance

Location

Date admitted to facility

January 2014

Conditionally required. Answer this question only if this patient
developed the PNEU during the same admission as an operative
procedure. Enter the appropriate NHSN procedure code.
NOTE: A PNEU cannot be “linked” to an operative procedure
unless that procedure has already been added to NHSN. If the
procedure was previously added, and the “Link to Procedure” button
is clicked, the fields pertaining to the operation will be auto entered.
Optional. The ICD-9-CM code may be entered here instead of (or in
addition to) the NHSN Procedure Code. If the ICD-9-CM code is
entered, the NHSN code will be auto entered by the computer. If the
NHSN code is entered first, you will have the option to select the
appropriate ICD-9-CM code. In either case, it is optional to select
the ICD-9-CM code. Only those ICD-9-CM codes identified in
Table 1 of the Surgical Site Infection Event Chapter (Chapter 9 of
NHSN Manual: Patient Safety Component Protocol) are allowed.
Required. Enter “Yes”, if the pathogen is being followed for
Infection Surveillance in the MDRO/CDI Module in that location as
part of your Monthly Reporting Plan: MRSA, MSSA
(MRSA/MSSA), VRE, CephR-Klebsiella, CRE-E. coli, CREEnterobacter ,CRE-Klebsiella, MDR-Acinetobacter or C. difficile.
If the pathogen for this infection happens to be an MDRO but your
facility is not following the Infection Surveillance in the
MDRO/CDI Module in your Monthly Reporting Plan, answer “No”
to this question.
Required. Enter the inpatient location to which the patient was
assigned when the last element used to meet the PNEU infection
criterion occurred. If the PNEU develops in a patient within 2
calendar days of transfer (i.e. day of transfer or next day) from a
location, indicate the transferring location, not the current location
of the patient; day of transfer counts as Day 1
Required. Enter date patient admitted to facility using this format:
MM/DD/YYYY. An NHSN Inpatient is defined as a patient whose
date of admission to the healthcare facility and the date of discharge
are different calendar days. When determining a patient’s admission
dates to both the facility and specific inpatient location, the NHSN
user must take into account all such days, including any days spent
in an inpatient location as an “observation” patient before being
officially admitted as an inpatient to the facility, as these days
contribute to exposure risk. Therefore, all such days are included in
the counts of admissions and patient days for the facility and
specific location, and facility and admission dates must be moved
back to the first day spent in the inpatient location.
18

VAP

NOTE- Recently Discharged Patients: If a previously unreported
VAP is identified on the day of discharge or the day after discharge,
enter the previous date of admission.
Risk Factors
Ventilator Required. Check Y if the patient with PNEU had a device to assist
or control respiration through a tracheostomy or by endotracheal
intubation, inclusive of the weaning period, for >2 calendar days
when the first element of the PNEU criteria was present (date of
event) and the device must have been in place on the date of the
event or the day before., otherwise check N. Date of device insertion
= Day 1.
Birth weight
Optional. For off-plan reporting in a NICU patient, enter the
patient’s birth weight in grams, not the weight on the date of event.
Location of device
Optional. Enter the patient location where the intubation and
insertion
ventilation procedure was performed
Date of device insertion Optional. Enter the date the intubation and ventilation procedure
was performed.
Event Details: PNEU
Required. Check one: Clinically Defined Pneumonia (PNU1),
Specific event
Pneumonia with specific laboratory findings (PNU2), or Pneumonia
in immunocompromised patients (PNU3), whichever criteria are met
for this event.
Event Details:
Required. Check each of the elements that were met.
Specify criteria used
Event Details:
Required. Check Y if there is a culture-confirmed bloodstream
Secondary bloodstream
infection (BSI) and a related pneumonia, otherwise check N.
infection
NOTE: Only genus and species identification should be utilized to
determine the sameness of organisms (i.e., matching organisms). No
additional comparative methods should be used (e.g., morphology or
antibiograms) because laboratory testing capabilities and protocols
may vary between facilities. This will reduce reporting variability
solely due to laboratory practice between facilities reporting LCBIs
meeting Criterion 2. Report the organism to the genus/species level
only once, and if antibiogram data are available, report the results
from the most resistant panel.
Event Details:
Required. Check Y if patient died during the hospitalization,
Died
otherwise check N.
Event Details:
Conditionally required. If the patient died, check Y if the PNEU
PNEU contributed to
contributed to death, otherwise check N.
death
Event Details:
Optional. Date patient discharged from facility.
Discharge date
Event Details:
Required. Enter Y if Pathogen Identified, N otherwise; if Yes,
January 2014

19

VAP

Pathogen identified
Pathogen # for specified
Gram-positive
Organisms, Gramnegative Organisms,
Fungal Organisms, or
Other Organisms
Antimicrobial agent and
susceptibility results

specify on reverse.
Up to three pathogens may be reported. If multiple pathogens are
identified, enter the pathogen judged to be the most important cause
of infection as #1, the next most as #2, and the least as #3 (usually
this order will be indicated on the laboratory report). If the species is
not given on the lab report or is not found on the NHSN organism
list, then select the “spp” choice for the genus (e.g., Bacillus natto is
not on the list so would be reported as Bacillus spp.).
Conditionally required if Pathogen Identified = Y.
 For those organisms shown on the back of an event form,
susceptibility results are required only for the agents listed.


Custom Fields

Comments

January 2014

For organisms that are not listed on the back of an event form,
the entry of susceptibility results is optional.

Circle the pathogen’s susceptibility result using the codes on the
event forms.
Additional antimicrobial agents and susceptibility results may be
reported for up to a total of 20 agents.
Optional. Up to 50 fields may be customized for local or group use
in any combination of the following formats: date
(MM/DD/YYYY), numeric, or alphanumeric.
Note: Each Custom Field must be set up in the Facility/Custom
Options section of the application before the field can be selected for
use.
Optional. Enter any information on the event.

20