Ventilator-associated pneumonia (VAP) is a type of hospital-acquired pneumonia that occurs in patients on mechanical ventilation for more than 48 hours. It is diagnosed using clinical criteria like fever, leukocytosis, and radiographic evidence of pneumonia combined with microbiological testing of respiratory samples. Treatment involves administering antibiotics based on the local hospital antibiogram, with empiric therapy targeting likely gram-positive and gram-negative pathogens. Prevention strategies focus on reducing ventilator days through daily weaning assessments and using bundles of care involving oral hygiene, elevation of the head, and peptic ulcer/DVT prophylaxis.

1. VENTILATOR ASSOCIATED PNEUMONIA
DR. NYABOM TAJI
GUIDE- DR. ASHWINI DEDWAL

2. 1. INTRODUCTION
2. SOURCE OF INFECTION
3. PATHOGENESIS AND RISK FACTOR
4. DIAGNOSIS
5. TREATMENT AND PREVENTION
6. SUMMARY
OVERVIEW

3. • Definition:
•According to CDC: 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.
• According to American Thoracic Society and Infectious Disease Society of
America defined as “Pneumonia in patients with mechanical ventilation for more
than 48 hours and characterized by presence of new or progressive infiltrates,
signs of systemic infection (temperature, blood cell count) changes in sputum
characteristics, and detection of causative agents.”
INTRODUCTION

4. • TYPES:
a) Early-onset VAP: Occurs during the first 4 days of mechanical ventilation.
Caused by pneumococcus, H. influenzae, MSSA and Moraxella catarrhalis.
b) Late-onset VAP: Develops 5 days after the mechanical ventilation and is
associated with greater mortality. Caused by MDR GNB.
• VENTILATOR ASSOCIATED PNEUMONIA (VAP) is the second most common
nosocomial infection after UTI.
• Incidence ranges from 5%-67% with mortality rate of 30%-70%.
INTRODUCTION

5. SOURCE OF INFECTION
• Endogenous source of infection i.e. microbial
flora of oropharynx, nasopharynx, sinuses and
GI tract.
1. Endemic VAP
• Contaminated Respiratory Equipment
2. Epidemic VAP

6. • Pathogenesis of VAP is multifactorial which includes endotracheal tube, presence
of risk factors, virulence of invading bacteria and host immunity.
• Infectious organism reaches lower respiratory tract by:
(1) Microaspiration it may occur during intubation.
(2) Development of a biofilm laden with bacteria (typically Gram- negative
bacteria and fungal species) within the endotracheal tube.
(3) Pooling and trickling of secretions around the cuff.
(4) Impairment of mucociliary.
PATHOGENESIS AND RISK FACTOR

7. Pathogenesis.
• Endotracheal tube is the most important risk factor among all, it disrupts
natural defense mechanism cough reflex of glottis and larynx.
• Ventilators exerts positive pressure thereby thrusting the bacterium laden
material towards the respiratory pathway.
PATHOGENESIS AND RISK FACTOR

8. DIAGNOSIS
No universal and gold
standard diagnostic
criterion.
Diagnosis based on
combination-
1. clinical suspicion.
2. new or progressive and
persistent radiological finding.
3. positive microbiological culture
from lower respiratory tract.
Clinical criteria is
the first step for
diagnosis of VAP.
Widely used criteria for
diagnosis of VAP-
1. Johanson’s clinical
criteria.
2. Clinical Pulmonary
Infection Score.
3. CDC guidelines.

9. JOHANSON’S CLINICAL CRITERIA
• Presence of a new or progressive radiographic infiltrate.
• Plus at least two of three clinical features:
- Fever > 38°C.
- Leukocytosis or leukopenia.
- Purulent secretions.
DIAGNOSIS

10. CDC GUIDELINES
• For adults, the CDC’s VAP diagnostic guidelines require at least one of the
following:
 Fever greater than 100.4° Fahrenheit .
 Leukopenia white blood cell count less than 4,000, or Leucocytosis
defined as a white blood cell count higher than 12,000 .
 In adults 70 or older, an altered state with no other clear cause .
DIAGNOSIS

11. Two of the following must also be present:
• Change in character of sputum, or newly purulent sputum.
• Increased airway secretions.
• Increased need for suctioning.
• New or worsening cough, tachypnea, or dyspnea.
• Rattling breathing or abnormal bronchial sounds .
• Worse gas exchange that may require more oxygen or ventilator use .
DIAGNOSIS

12. DIAGNOSIS

13. CLINICAL PULMONARY INFECTION SCORE
• Most popular and widely used.
• Maximum score 12 , score of greater than 6 is diagnostic of VAP.
• Sensitivity of 65% and specificity of 64% compared to histology autopsy.
DIAGNOSIS

14. DIAGNOSIS

15. MICROBIOLOGICAL CRITERIA
1. Invasive: Obtained by bronchoscopic technique :
• Bronchoalveolar lavage (BAL) .
• Protected specimen brush (PSB) .
• Plugged telescoping catheter (PTC) .
2. Non-invasive: Endotracheal Aspirate (ETA) most commonly sent specimen .
The collected sample should be processed immediately. Delay of no more than
2 hours .
DIAGNOSIS

16. TYPE OF SUCTIONING
1.OPEN SUCTION
• Open suction catheter package & connect it to suction tubing
• Disconnect the ventilator
• Kink the suction tube & insert the catheter into the ETT until resistance is
felt
• Resistance is felt - the suction catheter should be withdrawn 1cm
out before applying suction
• Turn on suction apparatus
• Monitor
• the patients vitals,
• Oxygen saturation
• duration of disconnection from the ventilator

17. • Apply continuous suction while rotating the suction catheter during removal
• The duration of each suctioning-less than 15 sec
• Instill 3 to 5 ml of sterile normal saline into the artificial airway if
required & ventilate the patient for 2 mins
• Resumes the ventilator/ ambu bag
• Return patient to ventilator
• Clean the catheter with a sterile gauze piece
• Flush the catheter with hot water in the suction tray
• Suction nares & oropharynx above the artificial airway with a different
suction catheter
• Clean & flush the suction tube with hot water

18. • Auscultate the chest
• Check saturation (SpO2) and the vitals of the patient
• Raise head end of the patient’s bed & Wash hands
• Document including colour, consistency and amount of
secretions, indications for suctioning & any changes in vitals &
patient’s tolerance

19. 2.Closed system suctioning
• Connect tubing to closed suction port
• Pre-oxygenate the patient with 100% O2
• Gently insert catheter tip into artificial airway without applying suction, stop if you meet resistance
or when patient starts coughing and pull back 1cm out
• Turn on suction machine
• Place the dominant thumb over the control vent of the suction port, applying continuous
or intermittent suction for no more than 10 to 15 sec as you withdraw the catheter into the
sterile sleeve of the closed suction device
• Repeat steps above if needed
• Clean suction catheter with sterile saline until clear
• Suction oropharynx above the artificial airway with a different catheter

20. • GRAM STAIN -Negative gram strain suggest low likelihood of VAP.
1. Gram stain of ETA is negative: Antibiotic should not be prescribed.
2. Gram stain of PSB is positive: Antibiotic therapy can be started based on the
result of Gram stain, as it is very likely that the patient has VAP. Antibiotics can
be adjusted later based on culture result.
3. Gram stain of PSB is negative and the Gram stain of ETA is
positive: Antibiotic therapy may only be started depending on the severity of the
patient's clinical condition or when the VAP is confirmed by the culture.
DIAGNOSIS

21. CULTURE
• Ideally specimen should be collected before starting antibiotics or when there is no
change in antibiotic therapy in the past 3 days.
• It have high negative predictive value.
• False negative in prior antibiotic therapy.
DIAGNOSIS
1. Qualitative culture: High sensitivity but poor specific.
2. Semi quantitative culture: Moderate to heavy growth- colony count more than
or equal 105 CFU/ml
3. Quantitative culture: Performed by serial dilution of specimen.

22. Tracheal aspirate
(TA):
Threshold of more than 1,000,000 CFU/ml (106) is taken as
positive.
BAL Threshold of more than100,000 CFU/ml (105) is taken as
positive.
Mini-BAL Threshold of more than 10,000 CFU/ml (104) is taken as
positive.
PBS Threshold of more than 1000 CFU/ml (103) is taken as
positive.
• Threshold value: diagnosis of pneumonia is based on the number of CFU/ml.
DIAGNOSIS

23. VAP surveillance
• Challenges - Lack of objective and reliable definitions.
• NHSN in 2013 replaced Ventilator Associated Pnuemonia (VAP) in adult locations with
Ventilator Associated Events (VAE).
VAE criteria PNEU/VAP criteria
• Adult locations only • Pediatric locations (excluding neonatal locations)
• Immunocompromised
• >18year old in paediatric location
• More objective • Less objective
• Based on no. of symptoms
• Chest X ray
DIAGNOSIS

24. IVAC+ any one
Culture (quantitative or semi-quantitative) or
Gram stain (PC/EC) and Culture (qualitative) or
Non-culture techniques +ve (histopath/ resp viruses/Legionella)
Possible ventilator associated pneumonia (PVAP)
VAC + [Temp ↑↓ or WBC count ↑↓] + New antimicrobial for 4 days
Infection related ventilator associated complication (IVAC)
2 days: Worsening oxygenation (↑ dm FIO2 or ↑ dmPEEP)
Ventilator associated condition (VAC)
Mechanical ventilation criteria
2 days of Baseline period- Stable or decreasing oxygenation (dm FiO2 or dm PEEP)
DIAGNOSIS

25. Ventilator Associated Events - Terminologies
• Date of event: Date of onset of worsening oxygenation. The day 1 of the required
≥ 2 calendar period of worsening oxygenation following a ≥ 2 day period of
stability on ventilator.
• VAE Window Period: It is 5-day period* which includes
– 2 days before
– The VAE event date and
– 2 days after
*Excluding the first two days of MVs
DIAGNOSIS

26. MV day 1 2 3 4 5 6 7
VAE
criterion
Day 1 of
stability or
improvement
Day 2 of
stability or
improvement
Day 1 of
worsening of
oxygenation
Day 2 of
worsening of
oxygenation
DOE & WP 5days
MV day 1 2 3 4 5 6 7
VAE
criterion
Day 1 of
stability or
improvement
Day 2 of
stability or
improvement
Day 1 of
worsening of
oxygenation
Day 2 of
worsening of
oxygenation
DOE & WP 3days
MV day 1 2 3 4 5 6 7
VAE
criterion
Day 1 of
stability or
improvement
Day 2 of
stability or
improvement
Day 1 of
worsening of
oxygenation
Day 2 of
worsening of
oxygenation
DOE & WP 4days
DIAGNOSIS

27. VAC Terminologies(cont.)
• Fraction of inspired oxygen: FiO2
 Fraction of oxygen in inspired gas.
 It can be adjusted depending on the patient’s oxygenation needs from 0.3 to 1.0
(30%-100%).
 Its normally maintained at <0.3(30%).
• Positive End-Expiratory Pressure: PEEP
 Used to maintain airway pressure greater than atmospheric pressure at the end of
exhalation by the introduction of a mechanical impedance to exhalation.
 PEEP values ranges from 0 to 15 cm H2O.
 Value of 0-5 cm H2O is considered baseline and equivalent.
DIAGNOSIS

28. daily minimum PEEP is 5
daily minimum PEEP is 8
DIAGNOSIS

29. Time 6 pm 7 pm 8 pm 9 pm 10 pm 11 pm
PEEP
(cmH20)
10 8 5 5 8 8
DIAGNOSIS
EXAMPLE : the patient is intubated at 6 pm. PEEP is set at following values
through the remainder of the calender day.
Daily Minimum PEEP Is 5
Daily Minimum PEEP Is 8
Time 6 pm 7 pm 8 pm 9 pm 10 pm 11 pm
PEEP
(cmH20)
8 8 5 8 5 8

30. Exclusions from VAE surveillance
• Patients on high frequency ventilation or extracorporeal life support or brain
dead.
• Lung expansion devices such as intermittent positive-pressure breathing (IPPB).
• Nasal positive end-expiratory pressure (nasal PEEP).
• Continuous nasal positive airway pressure (CPAP, hypo CPAP).
DIAGNOSIS

31. Pathogens excluded
• Normal respiratory flora.
• Candida or yeast not otherwise specified.
• CoNS and Enterococcus- commensal for all respiratory specimens- except for
lungs tissue and pleural fluid- considered pathogens.
• Dimorphic fungi.
DIAGNOSIS

32. • Identified by using a combination of imaging, clinical and
laboratory criteria.
• More subjective
• Used only for pediatric, immunocompromised patients
• >18year old in paediatric location
DIAGNOSIS
PNEU and VAP

33. Pediatric VAP criteria- < 1 year
DIAGNOSIS

34. Pediatric VAP criteria- 1- 12 year
DIAGNOSIS

35. Pediatric VAP contd..
DIAGNOSIS

36. Pediatric VAP- immunocompromised
DIAGNOSIS

37. • TREATMENT: Choice of empirical treatment should depend on the local
antibiogram of the hospital.
• According to infectious diseases society of America {IDSA} course of antimicrobial
treatment should be 7 days for VAP and 14 days in immunocompromised patients.
• Risk factors for getting Multi Drug Resistant (MDR) VAP are:
-Prior intravenous antibiotic use within 90 days.
-Septic shock at the time of diagnosis of VAP.
TREATMENT AND PREVENTION

38. -ARDS preceding VAP.
-Five or more days of hospitalization prior to the occurrence of VAP.
-Acute renal replacement therapy prior to VAP onset.
Empiric treatment options for clinically suspected VAP in places where MRSA and
double antipseudomonal/Gram-Negative coverage are appropriate.
A. Gram-Positive antibiotics with MRSA Activity
- Glycopeptides: Vancomycin
- Oxazolidinones: Linezolid
TREATMENT AND PREVENTION

39. B. Gram-Negative antibiotics with antipseudomonal activity:
β-Lactam–Based Agents
- Piperacillin-Tazobactum(PTZ)
- Cephalosporins:Cefipime, Ceftazidime
- Carbapenams: Imipenam,Meropenam
- Monobactam: Aztreonam
C. Gram-Negative antibiotics with antipseudomonal activity:
Non-β-Lactam–Based Agents
- Fluroquinolnes:Ciprofloxacin,Levofloxacin
- Aminoglycoside: Amikacin,Gentamicin
- Polymixins: Colistin,Polymixin B
TREATMENT AND PREVENTION

40. PREVENTION
1. Bundle Care
Ventilator Bundle components are as follows:
(a) Elevation of the head of the bed to 30°–45°.
(b) Daily ‘sedation vacation’ and daily assessment of readiness to extubate.
(c) Peptic ulcer disease prophylaxis.
(d) Deep venous thrombosis (DVT) prophylaxis.
2. Education and training. Suctioning of secretion after every 4 hour, oral
care every 12 hours
TREATMENT AND PREVENTION

41. 3.Hand hygiene
4. Personal protective equipment
5. Disinfection
6. Overcrowding
7. Weaning trials to indicate if the ventilator is still
needed daily
TREATMENT AND PREVENTION

42. • Criteria for Weaning:
• Minute ventilation close to 10L/min.
• pO2 > 60 mm Hg.
• PCO2 < 45.
• pH 7.35 to 7.45.
• Adequate haematocrit.
• Have any renal failure, arrhythmias, and fever under control.
• Ability to cough or mobilize secretions.
• Withdrawal of sedatives.
• Clear or clearing CXR.
TREATMENT AND PREVENTION

43. TREATMENT AND PREVENTION

44. Role of microbiologist -
1. Diagnosis of VAP.
2. Prevention.
3. Reduce mortality and morbidity.
SUMMARY

45. THANK YOU