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Pneumonia, ventilator-associated (VAP): Difference between revisions

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


== Additional Info ==
== Additional Info ==
Only code VAP if the [[#VAP Criteria]] are met completely. If they are met, also enter tmp as per [[QA Infection VAP]].
*Only code VAP if the [[#VAP Criteria]] are met completely.  
 
==Regarding the Date of Onset ==
*This guideline changed on October 15, 2024
*As before, the date of onset can really only be adjudicated ''in retrospect'', as to be a VAP all criteria (see section below on "VAP Criteria") must be met within a 7 day "infection window period".
**This MAY NOT BE THE DAY it was first recognized as being present in real time by the medical team.
*Generally --- consider the date of onset of a VAP to be the date on which (assuming all criteria are met with a 7 day window period) the chest imaging study (e.g. CXR, Chest CT, etc) criterion was first met
**The one exception is when, for whatever reason, a chest imaging study was quite delayed -- and in that case consider the date of onset of the VAP to be the earliest date on which any of the other VAP criteria was met.
*Example:  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, 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.
 
 
===Infection Window Period===
*The infection window period (IWP) is defined as the 7-days during which all site-specific infection criteria must be met. It includes the collection date of the first positive chest imaging study (date of onset), that is used as an element to meet the site-specific infection criterion, the 3 calendar days before and the 3 calendar days after.
 
{{Template:ICD10 Recent Previous Pneumonia}}


==Data Collection Instructions==
==Data Collection Instructions==
== VAP Criteria ==
== VAP Criteria ==
Must meet the CDC criteria: (all of [[#1 - Ventilated 48 hrs]] + [[#2 - Infection]] + [[#3 - CXR indicators]]) + (EITHER OF [[#4 - Respiratory indicators]] OR [[#5 - Alternative indicators]])
*'''MUST MEET CDC CRITERIA AS FOLLOWS:'''
**[[#1 - Ventilated 48 hrs]] '''+'''
**[[#2 - Infection]] '''+'''
**[[#3 - Chest imaging indicators]] '''+'''
**ONE of:  [[#4 - Respiratory indicators]] '''OR''' [[#5 - Alternative indicators]]


=== 1 - Ventilated 48 hrs ===
=== 1 - Ventilated 48 hrs ===
VAP is an infectious pneumonia in a patient  who, as of the day it was identified (“day of event”) had been on mechanical ventilation (MV), either continuously or intermittently for at least 48 hours before onset of infection.
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.
*The mechanical ventilation must be delivered via an endotracheal tube or tracheostomy.
* While the CDC excludes patients that are on ECMO, we will '''include''' patients that are on ECMO
*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.
*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.
==== Criteria 1 clarifications ====
 
*If the '''symptoms''' of infection (pneumonia) are evident prior to being on mechanical ventilation for 48 hours, then it is not a VAP, even if the positive ''culture'' is done after the 48 hour mark. {{Discuss | who=Allan |question= Is this about all of the criteria headings, or only some?}}
*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 ===
=== 2 - Infection ===
Has '''at least ONE''' of the following 3 things:
==== If not immunocomprised ====
*Fever > 38.0
* has '''at least ONE''' of the following 3 things:
*WBC<4000 or >12,000
**Fever > 38.0
*If >70 years old, altered mental status without another recognized cause
**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.


=== 3 - CXR indicators ===
==== If Immunocompromised ====
*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).
*There are ''different criteria'' for ''immunocompromised patients''
**Infiltrate
**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 - Chest Imaging indicators ===
*Chest imaging (X-ray, CT, etc) study or studies showing '''at least ONE''' of the following 3 things, that must be '''new & persistent''' OR '''progressive and persistent''': (CDC WORDING CHANGE). Note: If the pt has had an ABD CT or AXR the radiologist will often comment on the lung fields.
**Infiltrate -- note that there are alternative words used for infiltrates, including "airspace opacities"
**Consolidation
**Consolidation
**Cavitation  
**Cavitation  
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**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.
**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.
**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.
*Regarding the use of chest imaging interpretation ie. radiologist vs clinical team
** It is important to consider the overall clinical picture, if all of the VAP criteria are present use the interpretation of chest imaging that aligns with the clinical picture. ie If the radiologist interprets a CXR as atelectasis but the bedside team documents it as an opacity consistent with pneumonia, and the patient meets the VAP criteria then code it as a VAP. 
'''AND'''
'''EITHER of #4 (respiratory indicators) OR #5 (alternative indicators)'''


=== 4 - Respiratory indicators ===  
=== 4 - Respiratory indicators ===  
Has '''at least TWO''' of the following 4 things:
Has '''at least TWO''' of the following 4 things (from separate bullets) :
*New onset of purulent sputum or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements.
*New onset of purulent respiratory secretions or change in amount or character of respiratory secretions.
**In general it is secretions from the lungs (tracheal secretions, BAL sampling) that is relevant here.  In intubated patients, sputum secretions mainly represent the status of the oral, orophayngeal and upper tracheal mucosa, not the lungs. 
***Increased ET tube suctioning requirements may be the sole indicator of such changes in respiratory secretions.
*New onset or worsening cough, or dyspnea, or tachypnea  
*New onset or worsening cough, or dyspnea, or tachypnea  
*Newly identified Rales or bronchial breath sounds.
*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
*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 ===
=== 5 - Alternative indicators ===
Has '''at least ONE''' item in '''BOTH''' of [[#List 5a]] and [[#List 5b]]  
'''Has at least ONE item in [[#List 5a]] AND at least ONE item in [[#List 5b]]'''


==== List 5a ====
==== List 5a ====
(This is the same list as [[#4 - Respiratory indicators]], however, here it's '''just 1 item''' instead of 2 items)
(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 of purulent respiratory secretions or change in amount or character of respiratory secretions.
*New onset or worsening cough, or dyspnea, or tachypnea  
*New onset or worsening cough, or dyspnea, or tachypnea  
*Newly identified Rales or bronchial breath sounds.
*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.
*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 ====
==== List 5b ====
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*Organism identified from pleural fluid (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  
*Virus, Bordetella, Legionella, Chlamydia or Mycoplasma identified from respiratory secretions or tissue by a culture or non-culture based microbiologic testing method  
*In a compromised 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: identification of matching Candida from blood and sputum, endotracheal aspirate, bronchoalveolar lavage (BAL) or protected specimen brushing. '''(This is a new CDC item)'''
*In a compromised 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
*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]])  
*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. {{Discussion}} if there has to also be a blood culture then this whole comment is kind of moot, no? Ttenbergen 19:35, 2018 October 1 (CDT)
** 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
*>5% of cells obtained from BAL contain intracellular bacteria on direct microscopic exam
*Positive culture of lung tissue (see [[#VAP Pathogen exclusion list]])
*Positive culture of lung tissue (see [[#VAP Pathogen exclusion list]])
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*Fourfold rise in paired sera (IgG) for pathogen (e.g., influenza viruses, Chlamydia)  
*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.  
*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  
**Detection of L. pneumophila serogroup 1 antigens in urine by RIA or EIA
 
====== what is this? ======
* '''See below for detailed list of '''all possible sources''' for cultures: {{Discuss | who=all |question = where is that list of sources, did it get lost in an edit? }}


===VAP Pathogen exclusion list===
===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)
*'''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 respiratory flora
*Normal oral flora
**Normal oral flora
*Mixed respiratory flora
**Mixed respiratory flora
*Cagulase-negative staph species (includes S. epidermidis, does '''not''' include S. aureus)
**Cagulase-negative staph species (includes S. epidermidis, does '''not''' include S. aureus)
*Enterococcus species
**Enterococcus species
*Blastomyces species (blasto)
**Blastomyces species (blasto)
*Histoplasma species
**Histoplasma species
*Coccidioides species
**Coccidioides species
*Paracoccidioides species
**Paracoccidioides species
*Cryptococcus species
**Cryptococcus species
*Pneumocystis 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]]'''.
*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]]'''.
*Some Notes:
*'''Being [[Colonized with organism (not infected)]] with [[Staphylococcus_aureus|MRSA]] does not exclude''' it from causing VAP, if they meet the listed criteria.
**Prior colonization with MRSA does not exclude it from causing VAP, if they meet the listed criteria.


=== Sputum culture results do not qualify for VAP===
=== 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.
*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).
*However, 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).
 
{{ICD10 Secondary infections of aspiration}}


=== No such thing as "presumed VAP" ===
=== No such thing as "presumed VAP" ===
Following CDC criteria, we will not code "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 ===
=== VAP supersedes other pneumonia codes ===
*This code supersedes the codes for [[Pneumonia, bacterial]], [[Pneumonia, fungal/yeast]], [[Pneumonia, viral]] and [[Pneumonia, NOS]].  
*If you identify a VAP, use this code instead of the codes for [[Pneumonia, bacterial]], [[Pneumonia, fungal/yeast]], [[Pneumonia, viral]] and [[Pneumonia, NOS]].  
{{Collapsable  
{{Collapsable  
| always=Example
| always=Example
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*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]].
*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 ==
== Instructions regarding the attribution of a VAP ==
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=== VAPs on medicine wards ===
=== VAPs on medicine wards ===
*The only way VAP can be coded (as an [[Admit Diagnosis]]) 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.  
*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. This can be put in the [[Admit Diagnosis]] of the medicine collector but the sending ICU collector would have to ensure that the VAP is a complication for them and they have done the tmp information and notification process.  
*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 ===
=== Long term ventilator patients with pneumonia ===
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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.
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.


== Iatrogenic Guideline ==
{{Template:ICD10 Guideline Iatrogenic}}


== Alternate ICD10s to consider coding instead or in addition ==
== Alternate ICD10s to consider coding instead or in addition ==
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== Related CCI Codes ==
== Related CCI Codes ==
* [[ETT Present (TISS Item)]]
* [[Invasive Mechanical Ventilation (TISS Item)]]


== Data Integrity Checks ==
{{Data Integrity Check List}}
{{Data Integrity Check List}}


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


[[Category:VAP - Ventilator Associated Pneumonia]]
[[Category:VAP - Ventilator Associated Pneumonia]]
Retrieved from "https://ccmdb.kuality.ca/index.php?title=Pneumonia,_ventilator-associated_(VAP)"