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49 Redefining Ventilator-Associated Pneumonia (VAP) Surveillance in Pediatric Facilities

Saturday, April 2, 2011: 12:15 PM
Coronado A (Hilton Anatole)
Grace Lee, MD, MPH , Harvard Pilgrim Health Care Institute and Harvard Medical School; Children's Hospital Boston, Boston, MA
Thomas J. Sandora, MD, MPH , Children's Hospital Boston, Boston, MA
Dionne Graham, PhD , Children's Hospital Boston, Boston, MA
David Thompson , Children's Hospital Boston, Boston, MA
Sookee Choi , Children's Hospital Boston, Boston, MA
Alice Pappas, RN, PhD , Children's Hospital Boston, Boston, MA
Michael Klompas, MD, MPH , Harvard Medical School and Havard Pilgrim Health Care Institute, Boston, MA
Shelley Magill, MD, PhD , Centers for Disease Control and Prevention, Atlanta, GA
Gregory P. Priebe , Children's Hospital Boston, Boston, MA
Gail Potter-Bynoe , Children's Hospital Boston, Boston, MA
Marvin B. Harper , Children's Hospital Boston, Boston, MA
Background: Current VAP surveillance definitions incorporate subjective criteria and have limited inter-rater reliability.  Public reporting of healthcare-associated infections and inter-facility rate comparisons necessitate developing objective, new definitions, but the optimal components of a new definition are unknown, particularly in pediatric populations.

Objective: To evaluate the performance characteristics of an alternative VAP definition based on objective criteria in a pediatric population.

Methods: A retrospective chart review study of children admitted to neonatal, cardiac, and medical/surgical intensive care units of Children’s Hospital Boston between April 2009 and March 2010 was conducted.  Children requiring mechanical ventilation for ≥4 days were randomly selected for inclusion.  Key components of an alternative VAP surveillance definition were evaluated, including new and sustained (≥2 days) increases in peak end-expiratory pressure (PEEP) or FiO2 from baseline, temperature <36oC or >38oC, WBC <4 or >12, and purulent sputum (≥moderate polys in respiratory specimens).  Patient outcomes were also evaluated, including hospital length of stay (LOS), ICU LOS, duration of ventilation, and all-cause death.

Results: Among 220 patients, there were 251 consecutive episodes of mechanical ventilation for  ≥4 days (NICU N=82; CICU N=92; MSICU N=77) , and mean ages were 0.1, 0.9, and 6.2 years in each ICU, respectively.  Sustained changes of PEEP≥2 or FIO2≥15% were noted for 6.1% (NICU), 14.1% (CICU), and 26.0% (MSICU) of episodes.  Among those patients, a temperature <36oC or >38oC was noted for 40%, 92% and 80%; WBC <4 or >12 for 80%, 54%, and 55%; and purulent sputum for 40%, 15% and 30% in the NICU, CICU and MSICU, respectively.  If VAP were defined as worsened oxygenation + abnormal temperature or WBC, 4.9% (NICU), 14.1% (CICU) and 24.7% (MSICU) of episodes of mechanical ventilation would be considered VAP.  The additional requirement of purulent sputum for a surveillance definition would lower rates of VAP diagnosis to 2.4% (NICU), 2.2% (CICU) and 7.8% (MSICU).   Hospital LOS, ICU LOS, duration of ventilation and all-cause death were higher in patients with either definition of VAP using objective criteria. 

Conclusions: Up to 26% of patients receiving mechanical ventilation for ≥4 days would meet criteria for VAP if defined as sustained worsening in oxygenation alone.  An additional requirement for abnormal temperature or WBC as defined above makes little difference, but requiring purulent sputum would decrease the frequency of eligible patients and might improve specificity.  Additional work is needed to develop a suitable new VAP surveillance definition for pediatric populations.