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

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{{ICD10 category|Infectious disease}} {{ICD10 category|Respiratory}} {{ICD10 category|Pneumonia}} {{ICD10 category|Iatrogenic}}

==Criteria==

'''''Must meet all of #1, AND #2, AND #3, AND #4A or #4B'''''

1. VAP is an infectious pneumonia in a patient who, as of the day it was identified (“day of event”) had been on mechanical ventilation for >2 calendar days

*The mechanical ventilation must be delivered via an endotracheal tube or tracheostomy.

*e.g: if MV is started on Tuesday, first day that that VAP can occur is Thursday.

*It can occur on the day MV ends or the day following MV ends IF the MV had been in place already for >2 calendar days before ending.

2. 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

3. 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:

*Infiltrate

*Consolidation

*Cavitation

4A. Has at least TWO of the following 4 things (this is the criteria that does not ''require'' a positive culture):

*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

*Rales or bronchial breath sounds.

*Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240), increased oxygen requirements, or increased ventilator demand

4B. Meets BOTH of 4B part 1 and 4B part 2 (this is the criteria that DOES require a positive culture)

*4B part 1: Has at least ONE 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

**Rales or bronchial breath sounds.

**Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240), increased oxygen requirements, or increased ventilator demand

*4B part 2: Has at least ONE of the following 11 things:

**Organism identified from blood

**Organism identified from pleural fluid

**Positive quantitative culture, performed according to accepted protocols, from bronchoalveolar lavage or protected brush specimens

**>5% of cells obtained from bronchoalveolar lavage contain intracellular bacteria on direct microscopic exam

**Positive culture of lung tissue

**Histopathologic exam of lung tissue identifies abscess formation, or foci of consoliation with intense PMN accumulation in bronchioles and alveoli

**Histopathologic exam of lung tissue identifies lung invasion of fungal hyphae or pseudohyphae

**Virus, Bordetella, Legionella, Chlamydia or Mycoplasma identified from respiratory secretions or tissue by a culture or non-culture based microbiologic testing method

**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

**In an immunocomprimised patient: identification of matching Candida from blood and sputum, endotracheal aspirate, BAL or protected specimen brushing.

**In an immunocomprimised patient: Evidence of fungi from BAL or protected specimen brushing) from one of the following:

*Pathogens which ‘’cannot’’ be used to meet the criteria:

**Normal respiratory flora

**Normal oral flora

**Mixed respiratory flora

**coagulase-negative staph species (includes S. epidermidis)

**Enterococcus species

**Blastomyces species (blasto)

**Histoplasma species

**Coccidioides species

**Paracoccidioides species

**Cryptococcus species

**Pneumocystis species

== Attribution of the VAP to a 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 on the day of transfer OR the next day, the infection is attributed to the location from which they were transferred.

*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.

.

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== new info? ==

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-{{ICD10 category|Infectious disease}} {{ICD10 category|Respiratory}} {{ICD10 category|Pneumonia}}
+{{ICD10 category|Infectious disease}} {{ICD10 category|Respiratory}} {{ICD10 category|Pneumonia}} {{ICD10 category|Iatrogenic}}
+==Criteria==
+'''''Must meet all of #1, AND #2, AND #3, AND #4A or #4B'''''
+.  VAP is an infectious pneumonia in a patient  who, as of the day it was identified (“day of event”) had been on mechanical ventilation for >2 calendar days
+*The mechanical ventilation must be delivered via an endotracheal tube or tracheostomy.
+*e.g: if MV is started on Tuesday, first day that that VAP can occur is Thursday.
+*It can occur on the day MV ends or the day following MV ends IF the MV had been in place already for >2 calendar days before ending.
+.  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
+.  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:
+*Infiltrate
+*Consolidation
+*Cavitation
+A.  Has at least TWO of the following 4 things (this is the criteria that does not ''require'' a positive culture):
+*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
+*Rales or bronchial breath sounds.
+*Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240), increased oxygen requirements, or increased ventilator demand
+B. Meets BOTH of 4B part 1 and 4B part 2 (this is the criteria that DOES require a positive culture)
+*4B part 1: Has at least ONE 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
+**Rales or bronchial breath sounds.
+**Worsening gas exchange -- e.g., O2 desaturations (e.g., PaO2/FiO2 <240), increased oxygen requirements, or increased ventilator demand
+*4B part 2: Has at least ONE of the following 11 things:
+**Organism identified from blood
+**Organism identified from pleural fluid
+**Positive quantitative culture, performed according to accepted protocols, from bronchoalveolar lavage or protected brush specimens
+**>5% of cells obtained from bronchoalveolar lavage contain intracellular bacteria on direct microscopic exam
+**Positive culture of lung tissue
+**Histopathologic exam of lung tissue identifies abscess formation, or foci of consoliation with intense PMN accumulation in bronchioles and alveoli
+**Histopathologic exam of lung tissue identifies lung invasion of fungal hyphae or pseudohyphae
+**Virus, Bordetella, Legionella, Chlamydia or Mycoplasma identified from respiratory secretions or tissue by a culture or non-culture based microbiologic testing method
+**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
+**In an immunocomprimised patient: identification of matching Candida from blood and sputum, endotracheal aspirate, BAL or protected specimen brushing.
+**In an immunocomprimised patient: Evidence of fungi from BAL or protected specimen brushing) from one of the following:
+*Pathogens which ‘’cannot’’ be used to meet the criteria:
+**Normal respiratory flora
+**Normal oral flora
+**Mixed respiratory flora
+**coagulase-negative staph species (includes S. epidermidis)
+**Enterococcus species
+**Blastomyces species (blasto)
+**Histoplasma species
+**Coccidioides species
+**Paracoccidioides species
+**Cryptococcus species
+**Pneumocystis species
+== Attribution of the VAP to a 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 on the day of transfer OR the next day, the infection is attributed to the location from which they were transferred.
+*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.
+.
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 == new info? ==