Att G20_Ventilator-Associated Pneumonia

Device-associated Module
PNEU/VAP

Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated
Pneumonia [PNEU]) Event
Introduction: In 2011, an estimated 157,000 healthcare-associated pneumonias occurred in
acute care hospitals in U.S.1 Patients with mechanically-assisted ventilation have a high risk
of developing healthcare-associated pneumonia. In 2012, the overall ventilator use in various
hospital unit types ranged from 0.01 to 0.47 per 100 patient days and the pooled incidence of
VAP in in these units ranged from 0.0 to 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 may occur in any inpatient pediatric location where denominator data
can be collected, such as critical/intensive care units (pedICUs), specialty care areas (SCA),
step-down units, wards, and long term care units. In 2015, in-plan surveillance for ventilatorassociated pneumonia (pedVAP) using the criteria found in this chapter will be restricted to
patients of any age in pediatric locations (excludes neonatal 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, pediatric
or neonatal patients. A complete listing of inpatient locations and instructions for mapping can
be found in the CDC Locations and Descriptions chapter.
Note: If you are following pedVAP in your monthly reporting plan it is not required to
monitor for VAPs after the patient is discharged from the facility. However, if discovered,
any VAPs with event date on the day of discharge or day after discharge should be reported
to NHSN (see Transfer Rule below). No additional ventilator days are reported.

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. Note: POA reporting exception
for PNEU/VAP: One chest radiograph 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.
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Note: For patients with underlying pulmonary or cardiac disease who are required to have
serial imaging test results, to satisfy the PNEU/VAP definitions, the second imaging test
must occur within seven days of the first but is not required to occur within the Infection
Window Period. The date of the first CXR will be utilized when determining if the
PNEU/VAP criteria are met within the infection window period. All other elements of
PNEU/VAP definition must be present within the infection window period.
Pneumonia (PNEU) is identified by using a combination of imaging, 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 1-4 and Figures 1 and 2),
general comments applicable to all site - specific criteria, and reporting instructions. Table 5
shows threshold values for cultured specimens used in the surveillance diagnosis of
pneumonia.
Date of event: For a PNEU/VAP the date of event is the date when the first element used to
meet the PNEU infection criterion occurred for the first time within the 7-day Infection
Window Period.
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.
Location of attribution: The inpatient location where the patient was assigned on the date of
the PNEU/VAP event (see Date of Event). See Exception of Location Attribution below.

Exception to Location of Attribution:
Transfer Rule: If the date of event for a PNEU/VAP is on the date of transfer or the next
day, the infection is attributed to the transferring/discharging location. If the patient was in
multiple locations within the transfer rule time frame, attribute the infection to the original
location initiating the transfer. This is called the Transfer Rule and examples are shown
below:
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





Child has been on a ventilator for 7 days in the PICU and is transferred on the
ventilator to the pediatric surgical ward. The criteria for PNEU are met and the date
of event is the day following the transfer. 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. The criteria for a PNEU are met and the date of event is the
day of transfer. 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). The patient meets the criteria for a
PNEU and the date of event is 4 days post transfer. This is reported to NHSN as a
VAP for the PICU.

General Comments Applicable to All Pneumonia Specific Site Criteria:








Physician’s diagnosis of pneumonia alone is not an acceptable criterion for POA
(present on admission) or HAI (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.
Pneumonia due to gross aspiration (for example, in the setting of intubation in the
field, emergency department, or operating room) that meets the PNEU/VAP
definition with a date of event during the HAI timeframe is considered healthcareassociated (HAI).
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, follow the Repeat
Infection Timeframe (RIT) guidance found in Chapter 2.
Excluded organisms and culture results that cannot be used to meet the PNEU/VAP
definition are as follows:
1. “Normal respiratory flora,” “normal oral flora,” “mixed respiratory flora,”
“mixed oral flora,” “altered oral flora” or other similar results indicating
isolation of commensal flora of the oral cavity or upper respiratory tract
2. The following organisms unless isolated from cultures of lung tissue or
pleural fluid
i. Candida species* or yeast not otherwise specified
ii. coagulase-negative Staphylococcus species
iii. Enterococcus species
*Candida species isolated from sputum or endotracheal aspirate specimen combined
with a matching blood culture can be used to satisfy the PNU3 definition.

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3. Additionally, because organisms belonging to the following genera are
typically causes of community-associated respiratory infections and are rarely
or are not known to be causes of healthcare-associated infections, they are
also excluded, and cannot be used to meet the PNEU/VAP definition when
isolated from any eligible specimen type (to include lung and pleural fluid):
Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus
and Pneumocystis.


Abbreviations used in the PNEU laboratory criteria:
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

Reporting Instructions:






There is a hierarchy of specific categories within the major site pneumonia. If the
patient meets criteria for more than one specific site during the infection window period
or the RIT, 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.
Secondary bloodstream infections can only be reported for PNU2 and PNU3 specific
events.
Report concurrent LUNG (e.g., abscess or empyema) and PNEU with at least one
matching organism(s) as PNEU.
Lung abscess or empyema without pneumonia is classified as LUNG

.

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Table 1: 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 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

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 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)
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 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)

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Table 2: Specific Site Algorithms for Pneumonia with Common Bacterial or Filamentous
Fungal Pathogens and Specific 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 following:

 Fever (>38.0°C or >100.4°F)



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)

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



≥5% BAL-obtained cells contain
intracellular bacteria on direct
microscopic exam (e.g., Gram’s stain)
Positive quantitative culture9 of lung
tissue

 New onset or worsening cough, or
dyspnea or tachypnea5



 Leukopenia (<4000 WBC/mm )
or leukocytosis (>12,000
WBC/mm3)
3

 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

 For adults >70 years old, altered
mental status with no other
recognized cause
And at least one of the following:

 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 3: 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 following:

 Fever (>38.0°C or >100.4°F)

 Positive culture of virus, Legionella or
Chlamydia from respiratory secretions

 New or progressive
and persistent infiltrate
 Consolidation
 Cavitation

 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:

 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

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

 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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 Positive non culture diagnostic
laboratory test of respiratory secretions
or tissue for virus, Bordetella,
Chlamydia, Mycoplasma, Legionella
(e.g., EIA, FAMA, shell vial assay,
PCR, micro-IF)
 Fourfold rise in paired sera (IgG) for
pathogen (e.g., influenza viruses,
Chlamydia)
 Fourfold rise in Legionella
pneumophila serogroup 1 antibody titer
to ≥1:128 in paired acute and
convalescent sera by indirect IFA.
 Detection of L. pneumophila serogroup
1 antigens in urine by RIA or EIA

Device-associated Module
PNEU/VAP

Table 4: 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 10 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
 New onset of purulent sputum3,
or change in character
ofsputum4, or increased
respiratory secretions, or
increased suctioning
requirements
 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)
 Hemoptysis
 Pleuritic chest pain

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6-8

 Matching positive blood and sputum or
endotracheal aspirate cultures with
Candida spp.11,12
 Evidence of fungi from minimallycontaminated 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
Any of the following from:
LABORATORY CRITERIA DEFINED
UNDER PNU2

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Figure 1: Pneumonia Flow Diagram for Patients of Any Age
Facility ID#_______________Event #______________________ Event Date __/__/____

IMAGING

Patient with underlying diseases1,2 has
2 or more imaging test results with one
of the following:
q New or progressive and
persistent infiltrate
q Consolidation
q Cavitation
q Pneumatoceles, in ≤ 1 y.o

Patient without underlying diseases 1,2 has
1 or more imaging test results with one of
the following:
q New or progressive and persistent
infiltrate
q Consolidation
q Cavitation
q Pneumatoceles, in ≤ 1 y.o.

LABORATORY

SIGNS & SYMPTOMS

At least one of the following:
q Fever (>38.0°C/100.4°F)
q Leukopenia (<4,000 WBC/mm3) or leukocytosis (≥12,000
WBC/mm3)
q Altered mental status with no other cause, in ≥70 y.o.

At least two of the following:
q New onset of purulent
sputum3, or change in
character of sputum, or ↑
respiratory secretions, or
↑ suctioning
requirements4
q New onset or worsening
cough, or dyspnea, or
tachypnea5
q Rales 6 or bronchial breath
sounds
q Worsening gas exchange
(e.g., O2 desats [e.g.,
PaO2/FiO2 < 240]7, ↑ O2
req, or ↑ ventilation
demand)

At least one of the following:
q New onset of purulent
sputum3, or change in
character of sputum, or
↑ respiratory
secretions, or
↑suctioning
requirements4
q New onset or worsening
cough, or dyspnea, or
tachypnea5
q Rales 6 or bronchial
breath sounds
q Worsening gas
exchange (e.g., O2
desats [e.g., PaO2/FiO2
< 240]7, ↑ O2 req, or
↑ ventilation demand)

At least one of the following:
q Positive blood culture not
related to another infection8
q Positive pleural fluid culture
q Positive quantitative culture9
from minimally-contaminated
LRT specimen (e.g., BAL or
protected specimen
brushing)
q ≥5% BAL-obtained cells
contain intracellular bacteria
on direct microscopic exam
q Positive quantitative culture9
of lung parenchyma
q Histopathologic exam shows
at least one of the following:
• Abscess formation or
foci of consolidation with
intense PMN
accumulation in
bronchioles and alveoli
• Evidence of lung
parenchyma invasion by
fungal hyphae or
pseudohyphae

At least one of the following in an
immunocompromised patient 10 :
q Fever (>38.0°C/100.4°F)
q Altered mental status with no
other cause, in ≥70 y.o.
q New onset of purulent sputum3, or
change in character of sputum, or
↑ respiratory secretions, or
↑ suctioning requirements4
q New onset or worsening cough, or
dyspnea, or tachypnea5
q Rales 6 or bronchial breath
sounds
q Worsening gas exchange (e.g.,
O2 desats [e.g., PaO2/FiO2 < 240]7,
↑ O2 req, or ↑ ventilation demand)
q Hemoptysis
q Pleuritic chest pain

Immunocompromised

At least one of the following:
q Positive culture of virus,
Legionella or Chlamydia
from respiratory secretions
q Positive non-culture
diagnostic laboratory test of
respiratory secretions or
tissue for virus, Chlamydia,

Mycoplasma, Legionella

q

q

q

(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

At least one of the following:
q Matching positive blood, and
sputum or endotracheal
aspirate cultures with
Candida species 11,12
q 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

Immunocompromised

PNU1

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PNU3

PNU2

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Figure 2: Pneumonia Flow Diagram, Alternative Criteria for Infants and Children
Facility ID#_______________Event #______________________ Event Date __/__/____

Instructions: Complete form only if imaging criteria are met

Signs and Symptoms

Imaging
Re

Patient with underlying diseases1, 2 has 2 or more
imaging test results with one of the following:
q New or progressive and persistent infiltrate

q
q
q

Patient without underlying diseases1, 2 has 1 or more
imaging test results with one of the following:

q
q
q
q

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.

q

At least three of the following:

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

q

Fever (>38.0°C/100.4°F) or hypothermia
(<36.0°C/96.8°F)

and three of the following:

q

q
q

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

Temperature instability

q

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

q

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

q

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

q
q

Rales6 or bronchial breath sounds



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

q

Apnea, tachypnea , nasal flaring with
retraction of chest wall or grunting.

q
q
q

Wheezing, rales6, or rhonchi

5

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

PNU1
January 2015 (Modified April 2015)

6-10 pneumonia
Clinically-defined

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

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Footnotes to Algorithms and Flow Diagrams:
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 (e.g., interstitial lung disease or congestive heart failure), the diagnosis of
pneumonia may be particularly difficult. Other non-infectious conditions (e.g., 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 multiple imaging test results
spanning over several calendar days. Pneumonia may have rapid onset and progression, but does not resolve
quickly. Imaging test evidence of pneumonia will persist. 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.

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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”?
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])?
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
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 semiquantitative 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.
In this situation, a report indicating the presence of
white blood cells, without quantitation, is sufficient
to meet the purulent secretions criterion.

4. 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 that are cultured from blood 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 isolated from sputum
or endotracheal aspirate specimen combined with a matching blood culture can be used to satisfy the PNU3
definition for immunocompromised patients.
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9. Refer to threshold values for cultured specimens with growth of eligible pathogens. (Table 5).
Note: a sputum and endotracheal aspirate are not minimally- contaminated specimens and therefore,
organisms 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
thoracentesis or initial 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 combined with a matching blood
culture can be used to meet the PNU3 definition.
10. 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).
11. Cultures of blood and sputum or endotracheal aspirate must have a collection date that occurs within the
Infection Window Period.
12. Semi-quantitative or non-quantitative cultures of sputum obtained by deep cough, induction,
aspiration, or lavage are acceptable. If quantitative culture results from minimally-contaminated
LRT specimen are available, refer to criteria that include such specific laboratory findings.

Table 5: Threshold values for cultured specimens used in the diagnosis of pneumonia

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Values†

Specimen
collection/technique
Lung tissue*

>104 CFU/g tissue

Bronchoscopically (B)
obtained specimens
Bronchoalveolar
lavage (B-BAL)
Protected BAL
(B-PBAL)
Protected
specimen
brushing (BPSB)

>104 CFU/ml
>104 CFU/ml
>103 CFU/ml

Nonbronchoscopically
(NB) obtained (blind)
specimens
NB-BAL
NB-PSB
CFU = colony forming units
g = gram
ml = milliliter

>104 CFU/ml
>103 CFU/ml

* Open-lung biopsy specimens and immediate post-mortem specimens obtained by
transthoracic or transbronchial biopsy
† Consult with your laboratory to determine if reported semi-quantitative results match
the quantitative thresholds. In the absence of additional information available from your
laboratory, a semi-quantitative result of “moderate” or “heavy” growth, or 2+, 3+ or 4+
growth is considered to correspond.
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:

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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 three
months.
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.
January 2015 (Modified April 2015)

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References:
1

Magill SS., Edwards, JR., Bamberg, W., et al. “Multistate Point-Prevalence Survey of Health CareAssociated Infections, 2011”. New England Journal of Medicine. 370: (2014): 1198-208.

2

Dudeck, MA., Weiner, LM., Allen-Bridson, K., et. al. National Healthcare Safety Network (NHSN)
Report, Data Summary for 2012, “Device-associated Module”. American Journal of Infection
Control 41: (2013):1148-66.

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. American Journal of Infection Control
37: (2009):783-805. Available at:
http://www.cdc.gov/nhsn/PDFs/dataStat/2009NHSNReport.PDF.

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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 2015

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.
Conditionally required. Enter the patient’s Medicare number for all
events reported as part of a CMS Quality Reporting Program.
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 PNEU infection criterion occurred for the first time,
during the Infection Window Period. 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.
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VAP

NHSN procedure code

ICD-9-CM procedure
code

MDRO Infection
Surveillance

Location

Date admitted to facility

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 protocol are allowed.
Note: ICD-10-CM/PCS codes will replace ICD-9-CM codes on
October 1, 2015 however NHSN will not have the ability to receive
these codes until the January 2016 release.
The NHSN guidance for entry of surgical denominator data for the
last quarter of 2015 data is to enter the NHSN Procedure Code (e.g.
COLO or HYST) but do not enter any ICD-10-CM/PCS codes
associated with the procedure.
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, Klebsiella
pneumoniae, Klebsiella oxytoca, or Enterobacter), MDRAcinetobacter, 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 on the date of the PNEU event. If the PNEU occurs on the
day of transfer/discharge or the next day, indicate the transferring/
discharging location, not the current location of the patient, in
accordance with the Transfer Rule (see Key Terms section).
Required. Enter date patient admitted to an inpatient location using
this format: MM/DD/YYYY.


January 2015

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

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VAP



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.
When reporting a PNEU which occurs on the day of or day after
discharge use the previous date of admission as admission date.

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 that had been in place for more than two calendar days on
the date of the event inclusive of the weaning period, 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 used to identify the
Specify criteria used
specific type of PNEU being reported..
Event Details:
Required. Check Y if there is a culture-confirmed bloodstream
Secondary bloodstream
infection (BSI) and a related PNEU, otherwise check N. For detailed
infection
instructions on identifying whether a blood culture represents a
secondary BSI, refer to the Secondary BSI Guide (Appendix 1) of
the BSI Event protocol.
Note: Secondary BSI is N if the specific event is PNU1
Event Details:
Died
Event Details:
PNEU contributed to
death
Event Details:
Discharge date
Event Details:
Pathogens identified
January 2015

Required. Check Y if patient died during the hospitalization,
otherwise check N.
Conditionally required. If the patient died, check Y if such evidence
is available (e.g., death/discharge note, autopsy report, etc.)
otherwise check N.
Optional. Date patient discharged from facility.
Required. Enter Y if Pathogen Identified, N otherwise; if Yes,
specify organism.
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VAP

Pathogen # for specified
Gram-positive
Organisms, Gramnegative Organisms,
Fungal Organisms, or
Other Organisms

Antimicrobial agent and
susceptibility results

Note: Pathogens identified defaults to N if the specific event is
PNU1
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 secondary
BSI pathogens are entered, they should be entered only after sitespecific pathogens are entered.. 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.


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.
For each box listing several drugs of the same class, at least one
drug susceptibility must be recorded.
Custom Fields

Comments

January 2015

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