View source for Pneumonia, ventilator-associated (VAP)

{{ICD10 dx
|ICD10 Code=J95.88
|MinimumCombinedCodes=2
|BugRequired=required
}}
{{ICD10 category|Infectious disease}}
{{ICD10 category|Infection requiring pathogen}}
{{ICD10 category|Respiratory}}
{{ICD10 category|Pneumonia}}
{{ICD10 category|Iatrogenic}}
{{ICD10 category|Iatrogenic infection}}
{{ICD10 transition status
| OldDxArticle =VAP - Ventilator Associated Pneumonia
| CurrentStatus = needs review 
| InitialEditorAssigned = Tina Tenbergen
}}

== Additional Info ==
*Only code VAP if the [[#VAP Criteria]] are met completely. 
*If a patient had any pneumonia previously during the same admission and then develops pneumonia again, meeting the VAP criteria, it is only a VAP if it is a new organism and/or has persistent or worsening infiltrates. If none of that is true, then the previous pneumonia has not completely been resolved, and you should not code a VAP.

==Regarding the Date of Onset == 
*The incident date for a VAP should be at the onset of the infection or when you determine the VAP was first brewing.  
This is determined when reviewing the chart retrospectively.   See Dr. Garland's comments below:  
*In general we want the date on which the VAP was first evident -- in retrospect.  This MAY NOT BE THE DAY it was first recognized as being present in real time by the medical team.
**e.g. An intubated patient had a CXR on Thursday showing a little wispy infiltrate on the CXR.  In the absence of other signs or symptoms, on that day the team did NOT think it was infectious.  But Friday the patient developed fever and leukocytosis and purulent sputum, AND the wispy infiltrate was now a big, dense consolidation.  A sputum culture was sent on Friday for the first time.  At this point the team began antibiotics for pneumonia.  The thing here is that only in RETROSPECT did it become clear that the wispy infiltrate seen on Thursday WAS the start of the VAP.  Thus, in this case the VAP appears to have clinically begun on Thursday, not Friday.  
***NOTE that IF the intubation was Tuesday or Wednesday or Thursday, then this is NOT a VAP, because the clinical onset of the pneumonia was <48 hours prior to intubation.  If the intubation was Monday or prior, then it is a VAP.
*This issue of timing can be VERY tricky -- and will always require judgement and retrospective assessment of the sequence of events.
**e.g. Patient has had fever and leukocytosis for 5 days due to a septic gallbladder, and has been intubated that whole time.  Now a new infiltrate with shows up, with purulent sputum and the team believes a new pneumonia has developed.  So here you can't use the pre-existing fever and elevated WBC to identify the clinical onset, and it's the change in the CXR that makes it.
**e.g. Patient has ARDS from multiple trauma and so the CXR has had diffuse fluffy infiltrates for a week.  He's also had a low-grade fever the whole time.  Now the fever becomes high-grade, the sputum becomes purulent, and though it's hard to tell for sure, the CXR seems to be a bit worse in the RUL.  The team concludes a pneumonia has developed.  So here, it's a judgement that the subtle change in the CXR and the change in the fever curve and the change in sputum is due to a VAP.

==Data Collection Instructions==
== VAP Criteria ==
*'''MUST MEET CDC CRITERIA AS FOLLOWS:''' 
**[[#1 - Ventilated 48 hrs]] '''+'''
**[[#2 - Infection]] '''+'''
**[[#3 - CXR indicators]] '''+'''
**ONE of:  [[#4 - Respiratory indicators]] '''OR''' [[#5 - Alternative indicators]]

=== 1 - Ventilated 48 hrs ===
VAP is an infectious pneumonia in a patient  who, as of the day it showed itself (“day of event”) had been on mechanical ventilation (MV), either continuously or intermittently for at least 48 hours before onset of infection.
*The mechanical ventilation must be delivered via an endotracheal tube or tracheostomy.
*Although it is arbitrary, for this purpose we will consider "intermittent ventilation" to mean this:  Over the 48 hours prior to the identification of the VAP, that the patient had been on the ventilator, via an ETT or trach, at least twice for periods of at least 1 hour each.

*Regarding whether ALL evidence/symptoms/signs of the pneumonia must be absent for the 48 hours after intubation for it to be called a VAP:
**The short answer is No for Criterion#2 but Yes for the Criteria#3,4 and 5, i.e. the respiratory symptoms/signs  
**Example 1:  The patient has had a pyelonephritis with leukocytosis and fever for the past 6 days.  He got intubated 4 days ago and developed new respiratory signs and symptoms today, i.e. 72 hours after intubation.  So even though Criterion#2 was present before the intubation and >48 hrs ago, the onset of the respiratory signs/symptoms were not present >48 hrs before intubation --- this IS a VAP. 
**Example 2:  The patient got intubated 4 days ago and developed new fever and leukocytosis yesterday (3 days after intubation).  And while he has the required respiratory symptoms/signs, they developed just 24 hours after intubation.  This is NOT a VAP, as the respiratory findings began <48 hrs after intubation.

=== 2 - Infection ===
==== If not immunocomprised ====
* has '''at least ONE''' of the following 3 things:
**Fever > 38.0
**WBC<4000 or >12,000
**If >70 years old, altered mental status without another recognized cause
*Note that these symptoms/signs can be present without infection, but it's often difficult to tell which they're from.  So if there is a VERY high level of belief that the fever or WBC changes are NOT due to infection, then don't count such criteria as being present.  But in the absence of such high certainty then DO count them toward the VAP diagnosis.  It's a judgement call.

==== If Immunocompromised ====
*There are ''different criteria'' for ''immunocompromised patients''
**immunocompromised for this purpose defined as any of:
***neutropenia defined as absolute neutrophil count or total white blood cell count (WBC) <500/mm3
***leukemia, lymphoma or who are HIV positive with CD4 count <200
***have had a splenectomy
***history of solid organ or hematopoietic stem cell transplant
***on cytotoxic chemotherapy
***on steroids (excluding inhaled steroids) daily for >2 weeks on the date of event
**''Immunocompromised'', must have '''at least ONE''' of the following 8 things: 
***Fever (>38.0°C)
***If >70 years old, altered mental status without another recognized cause
***New onset of purulent sputum, or change in character ofsputum, or increased respiratory secretions, or increased suctioning requirements
***New onset or worsening cough, or dyspnea, or tachypnea
***Rales or bronchial breath sounds
***Worsening gas exchange (for example: O2 desaturations, increased oxygen requirements, or increased ventilator demand)
***Hemoptysis
***Pleuritic chest pain

=== 3 - CXR indicators ===
*Chest imaging (X-ray) study or studies showing '''at least ONE''' of the following 3 things, that must be new & ''persistent'' OR ''progressive and persistent'': (CDC WORDING CHANGE).
**Infiltrate -- note that there are alternative words used for infiltrates, including "airspace opacities"
**Consolidation
**Cavitation 
*Regarding the identification of "persistent" here:
**Because it is well recognized that there are many non-infectious reasons for fleeting infiltrates in intubated ICU patients (e.g. atelectasis), [[#3 - CXR indicators]] requires that the listed changes be either "New and Persistent" or "Progressive and Persistent".  This necessarily means that there must be >1 CXR -- preferably over more than 1 day -- showing the "persistence". 
**Although it is somewhat arbitrary, we will consider chest imaging findings to be "persistent" if they remain similar (i.e. do not disappear, or mostly disappear) in imaging studies done at least 6 hours apart.
**But, of course, ICU patients who are believed to have significant lung pathology, including pneumonia, typically DO have followup CXRs that will allow for identification of persistence of the changes seen.
**In the (relatively rare situation) in which a ventilated patient qualifies for a VAP ''except'' that NO CXR was done during the next couple of days to demonstrate persistence, you could point out to the physician(s) that the CDC criterion require infiltrates be persistent by chest imaging and therefore we would require a followup CXR to confirm the diagnosis. If there is severe resistance to this from the ICU team, you could refer them to Drs. Garland or Paunovic.


'''AND'''

'''EITHER of #4 (respiratory indicators) OR #5 (alternative indicators)'''

=== 4 - Respiratory indicators === 
Has '''at least TWO''' of the following 4 things:
*New onset of purulent sputum or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements.
*New onset or worsening cough, or dyspnea, or tachypnea 
*Newly identified adventitia, crackles or bronchial breath sounds.
*Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240, arterial blood gas or pulse oximetry), increased oxygen requirements, or increased ventilator demand

'''OR'''

=== 5 - Alternative indicators ===
'''Has at least ONE item in [[#List 5a]] AND at least ONE item in [[#List 5b]]''' 

==== List 5a ====
(This is the same list as [[#4 - Respiratory indicators]], however, here it's '''just 1 item''' instead of 2 items)
*New onset of purulent sputum or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements.
*New onset or worsening cough, or dyspnea, or tachypnea 
*Newly identified Rales or bronchial breath sounds.
*Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240, arterial blood gas or pulse oximetry), increased oxygen requirements, or increased ventilator demand.

'''OR'''

==== List 5b ====
*Organism identified from blood (see [[#VAP Pathogen exclusion list]])
*Organism identified from pleural fluid (see [[#VAP Pathogen exclusion list]])
*Virus, Bordetella, Legionella, Chlamydia or Mycoplasma identified from respiratory secretions or tissue by a culture or non-culture based microbiologic testing method 
*In an immunocompromised patient: identification of matching Candida from blood and sputum, endotracheal aspirate, bronchoalveolar lavage (BAL) or protected specimen brushing. '''(This is a new CDC item)'''
*In an immunocompromised patient: Evidence of fungi (i.e. mycelia, not yeast) from BAL or protected specimen brushing)'''(This is a new CDC item)'''. Be aware that fungi is not the same as yeast (do not use candida spp). https://www.cdc.gov/fungal/diseases/index.html
*Positive '''quantitative culture''', performed according to accepted protocols, from BAL or protected brush specimens (see[[#VAP Pathogen exclusion list]]) 
** According to Dr. Garland this very rare and he has never seen one done at HSC. Most bronchoscopies are not "quantitative" therefore not valid for use in the VAP criteria unless candida is cultured in immunocompromised patients only and only if the patient also has a matching blood culture. 
*>5% of cells obtained from BAL contain intracellular bacteria on direct microscopic exam
*Positive culture of lung tissue (see [[#VAP Pathogen exclusion list]])
*Histopathologic exam of lung tissue identifies abscess formation, or foci of consolidation with intense PMN accumulation in bronchioles and alveoli
*Histopathologic exam of lung tissue identifies lung invasion of fungal hyphae or pseudohyphae
*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 

===VAP Pathogen exclusion list===
*'''NEW CDC LIST'''  (does not include candida b/c can be a valid pathogen in immunocompromised pts who have candida in both blood and ETT cultures (see list 5B, above)
**Normal respiratory flora
**Normal oral flora
**Mixed respiratory flora
**Cagulase-negative staph species (includes S. epidermidis, does '''not''' include S. aureus)
**Enterococcus species
**Blastomyces species (blasto)
**Histoplasma species
**Coccidioides species
**Paracoccidioides species
**Cryptococcus species
**Pneumocystis species
*Patients might be treated for infection with these pathogens, but do not code them as VAP. In that case you might be able to code it as a '''[[Hospital-acquired pneumonia (HAP) in ICD10]]''' or '''[[Community-acquired pneumonia (CAP) in ICD10]]'''.
*'''Being [[Colonized with organism (not infected)]] with [[Staphylococcus_aureus|MRSA]] does not exclude''' it from causing VAP, if they meet the listed criteria.

=== Sputum culture results do not qualify for VAP===
Endotracheal tube secretion / Sputum culture is '''not''' part of the CDC criteria defining a VAP because sputum is ''virtually never'' culture negative in intubated patients, even without infection.
You '''can use''' culture results of respiratory secretions to identify the '''[[Pathogen]] for your [[ICD10]] Diagnosis''' (though positive blood or pleural fluid culture is considered more definitive).

=== No such thing as "presumed VAP" ===
Following CDC criteria, we will not code "presumed VAP".

=== '''No special rules''' for "CAP developing VAP" ===
There are no guidelines for CAP developing VAP, other than meeting the VAP criteria. For example, the idea of a CXR showing a "New and persistent" or "Progressive and Persistent" infiltrate allows for coding a second pneumonia on top of a first one.

=== VAP supersedes other pneumonia codes ===
*This code supersedes the codes for [[Pneumonia, bacterial]], [[Pneumonia, fungal/yeast]], [[Pneumonia, viral]] and [[Pneumonia, NOS]]. 
{{Collapsable 
| always=Example
| full=If the patient qualifies for having a bacterial VAP, you code the VAP linked to the [[Pathogens|pathogen]], and you do NOT have to code [[Pneumonia, bacterial]].}}
*Data collectors should '''follow criteria''' listed below regardless of what a physician writes in chart. If patient meets criteria VAP below, code as VAP.  If patient does not meet all listed criteria, then '''do not code as VAP'''. It may qualify as a [[HAP]] or [[CAP]].

=== Recent previous pneumonia ===
*If a patient had any pneumonia previously during the same admission and then develops pneumonia again, meeting the VAP criteria, it is only a VAP if it is a new organism and has persistent or worsening infiltrates. If it is the same original organism, then the pneumonia has not completely been resolved, and you should NOT code it as a VAP.

== Instructions regarding the attribution of a VAP ==
We report [[Ventilator Associated Pneumonia Rate]] based only on [[Acquired Diagnosis / Complication]] occurring in a critical care unit. Whenever one of those exists, we also collect and report [[QA Infection VAP]]. To make sure we have optimal data for this, the [[Data Processor]] and the [[Statistician]] have processes to make sure nothing is missed. 

=== Attribution of the VAP to a Hospital Location ===
*The infection is attributed to the location where the patient was on the date the infection became clinically evident -- EXCEPT if all elements of the infection are present within the first 48 hours of arrival, the infection is attributed to the location from which they were transferred. 
**An important consequence of this is that if on admission to the current unit it was NOT recognized that the patient has a VAP, but by these rules it is then figured out to be so --> THEN the correct coding of this VAP is as an '''[[Admit Diagnosis]]''', not an [[Acquired Diagnosis]]. 
*The CDC case definition explicitly states that these rules should be followed -- that the physician’s statement of where the infection was acquired should not be substituted for these rules.
*A new VAP that is identified first on a medicine ward must be attributed to the ICU that sent the patient.

See also: [[Iatrogenic, infection, central venous catheter-related bloodstream infection (CVC-BSI, CLI)#Attribution of a CLI  to a Hospital Location]]

=== VAPs on medicine wards ===
*The only way VAP can be coded on a medicine ward is if -- as per [[#1 - Ventilated 48 hrs]] -- the patient's Mechanical Ventilation (MV) ended that day or the prior day in an ICU '''and''' patient met all the criteria. 
*If the medicine collector identifies that a new pneumonia is present soon after arrival to the ward, they should let the ICU collector know to assess whether it was a VAP or not. VAP can be coded by the medicine collector as an [[Admit Diagnosis]] or [[Acquired Diagnosis]] following the usual rules, and should notify the sending ICU collector so they can ensure that the VAP is a [[Acquired Diagnosis]] for them and they have done the tmp information and notification process.

=== Long term ventilator patients with pneumonia ===
*If a LTV patient is admitted from the community with a pneumonia, a '''C'''ommunity '''A'''cquired '''P'''neumonia ('''[[Community-acquired pneumonia (CAP) in ICD10]]''') should be coded, not VAP, even though it is technically a VAP. 
**The rationale for this is that we only are wanting to tracking '''Hospital Acquired VAP's''', not patients who have acquired an pneumonia while on long term home ventilators (LTV) in the community.   
*Of course, if the patient entered the hospital without a pneumonia, and develops one (and meets the VAP criteria), then that person would have a VAP we do want to code.

=== Reporting of complication when patients move units ===
The [[Ventilator Associated Pneumonia Rate]] we report is based only on [[Acquired Diagnosis / Complication]] occurring in a unit. If VAP is coded as an [[Admit Diagnosis]], we check if the patient came from one of the ICUs where we collect data, and if so, make sure that the VAP is coded as a [[Acquired Diagnosis / Complication]] and [[QA Infection VAP]] there. 

If a VAP [[Admit Diagnosis]] doesn't have a corresponding [[Acquired Diagnosis / Complication]] in the previous unit, the [[data processor]] will ask the collector to audit.


{{Template:ICD10 Guideline Iatrogenic}}

== Alternate ICD10s to consider coding instead or in addition ==
{{ListICD10Category | categoryName = Pneumonia}}
*[[Community-acquired pneumonia (CAP) in ICD10]]
*[[Hospital-acquired pneumonia (HAP) in ICD10]]

== Candidate [[Combined ICD10 codes]] ==
{{ICD10 Guideline Infection}}

== Related CCI Codes ==

{{Data Integrity Check List}}

== Data use ==
Used in:
* [[Quarterly report]]
* [[Ventilator Associated Pneumonia Rate]]

=== Criteria change ===
The update in criteria in 2017-11 will likely lead to a higher rate of identifying VAPs. This needs to be noted in reports.

== Related articles ==
{{Related Articles}}

{{ICD10 footer}}
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== Legacy ==
Use to be coded in TMP as [[QA Infection VAP]].  This was stopped 2019-Dec-31.  

[[Category:VAP - Ventilator Associated Pneumonia]]