Introduction
Review
Literature search and selection strategy
Definitions
Neonates
| Onset >72 h after birth and one of the following radiologic criteria: |
-new or progressive infiltrates | |
-consolidations | |
-adhesions or fluid in lobar fissures/pleura | |
And
| |
Worsening gas exchange (SaO2 ↓; O2 requirement ↑; Ventilation parameters ↑) | |
And
| |
Four of the following signs and symptoms: | |
-fever (>38.0°C), hypothermia (<36.5°C), or temperature instability | |
-new onset or increasing bradycardia (<80/min) or tachycardia (>200/min) | |
-new onset or increasing tachypnoea (>60/min) or apnoea (>20 seconds) | |
-new onset or increasing signs of dyspnoea (retractions, nasal flaring, grunting) | |
-increasing production of respiratory secretions and need for suctioning | |
-purulent tracheal secretion | |
-isolation of a pathogen in respiratory secretions | |
-elevated C-reactive protein (>20 mg/L) | |
I/T-ratio >0.2 | |
Infants: 2–11 months
| One of the following radiologic criteria: |
-new or progressive infiltrate | |
-consolidations | |
-cavitations | |
-pneumatoceles | |
And
| |
Worsening gas exchange (SaO2 ↓; O2 requirement ↑; Ventilation parameters ↑) | |
And
| |
Three of the following signs and symptoms: | |
-fever (>38.0°C), hypothermia (<36.5°C), or temperature instability | |
-leucopenia (<4000 WBC/mm3) or leucocytosis (≥15,000 WBC/mm3) with left shift (≥10% band forms) | |
-new onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements | |
-apnoea or dyspnoea (tachypnoea, nasal flaring, retraction of chest wall, grunting) | |
-wheezing, rales, or rhonchi | |
-cough | |
-bradycardia (<100/min) or tachycardia (>170/min) | |
Children: 1–16 years
| One of the following radiologic criteria: |
-new or progressive and persistent infiltrate | |
-consolidation | |
-cavitation | |
And
| |
Three of the following signs and symptoms: | |
-fever (>38.4°C) or hypothermia (<36.5°C) | |
-leukopenia (<4000 WBC/mm3) or leucocytosis (≥15,000 WBC/mm3) | |
-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 dyspnoea, apnoea, or tachyponea | |
-rales or bronchial breath sounds | |
-worsening gas exchange (SaO2 ↓; O2 requirement ↑; Ventilation parameters ↑) |
Definite VAP
| A child who fulfils the case definitions for hospital-acquired pneumonia (Table 1) and has one of the following: |
-same pathogen isolated from bronchial secretions/BAL and blood | |
-pathogen or virus isolated from lung biopsy, or positive growth in culture of pleural fluid, or histopathologic examination with evidence of pneumonia manifested as abscess formation, positive culture of lung parenchyma, or fungal hyphae | |
-Pathogen or virus isolated from BAL (bacteria ≥104 CFU/ml), or ≥5% of BAL-obtained cells contain intracellular bacteria on direct microscopic exam, or protected brush with a threshold of ≥104 CFU/ml, or distal protected aspirate with a threshold of ≥104 CFU/ml, or positive exams for particular microorganisms (Legionella, Aspergillus, mycobacteria, Mycoplasma, Pneumocystis jirovecii) | |
Probable VAP
| A child who fulfils the case definitions for hospital-acquired pneumonia (Table 1) and has one of the following: |
-pathogen isolated from BAL (bacteria <104 CFU/ml) | |
-pathogen or virus isolated from bronchial secretions, or quantitative culture of lower respiratory tract specimen (endotracheal aspirate) with a threshold of bacteria ≥106 CFU/ml | |
Possible VAP
| A child who fulfils the case definitions for hospital-acquired pneumonia (Table 1) with non-quantitative lower respiratory tract specimen culture or no positive microbiology, but has been treated for hospital-acquired pneumonia |
Clinical criteria
Radiologic criteria
Epidemiology
Region | Reference (Author, Country, Year of publication, Ref No) | Setting | Patients | VAP* | VD* | Incidence density (N/1000 ventilation-days) | %** |
---|---|---|---|---|---|---|---|
Middle | Afjeh, Iran, 2012 [27] | NICU* | 281 | 14 | 1207 | 11.6 | 17.3 |
East/Persia | Almuneef, Saudi Arabia, 2004 [28] | PICU* | 2361 | 37 | 4173 | 8.9 | 10.3 |
Shaath, Saudi Arabia, 2013 [29] | Cardiac surgery | 1137 | 9 | 306 | 29.4 | 6.6 | |
South Asia | Awasthi, India, 2013 [19] | PICU* | 2105 | 38 | - | - | 36.2 |
East Asia | Yuan, China, 2007 [30] | NICU* | 2259 | 52 | 1130 | 46.0 | 20.1 |
Navoa-Ng, Philippines, 2011 [31] | PICU* | 3252 | 6 | 391 | 0.44 | 2.4 | |
Navoa-Ng, Philippines, 2011 [31] | NICU* | 31813 | 1 | 2279 | 12.8 | 0.06 | |
Xu, China, 2007 [32] | NICU* | 33942 | 143 | 2259 | 63.3 | 3.6 | |
Cai, China, 2010 [33] | NICU* | 31159 | 38 | 779 | 48.8 | 3.3 | |
Europe | Geffers, Germany, 2008 [21] | NICU* (<1500 g) | 38677 | 176 | 64090 | 2.7 | 2.0 |
Leistner, Germany, 2013 [22] | NICU* (<1500 g) | - | 345 | 158024 | 2.2 | - | |
Tekin, Turkey, 2013 [34] | NICU* | 36932 | 76 | 11939 | 6.4 | 1.1 | |
Yalaz, Turkey, 2012 [35] | NICU* | 2162 | 40 | 2907 | 13.8 | 24.7 | |
Patria, Italy, 2013 [25] | PICU* | 3451 | 30 | - | - | 6.7 | |
Hentschel, Switzerland, 2005 [36] | NICU* | 121 | 1 | 80 | 12.5 | 4.8 | |
Roeleveld, Netherlands, 2011 [37] | Cardiac surgery | 1125 | 11 | 644 | 17.1 | 8.8 | |
Gastmeier, Germany, 2002 [38] | Burn unit | 341 | 8 | 145 | 55.2 | 19.5 | |
Oezdemir, Turkey, 2011 [39] | PICU* | 3203 | - | - | 15.7 | - | |
Jordan Garcia, Spain, 2014 [40] | PICU* | 3300 | 4 | 422 | 9.5 | 1.3 | |
Turkish Neonatal Society; 2010 [41] | NICU* | 39359 | - | - | - | 1.7 | |
North | Edwards, USA, 2008 [23] | PICU* | - | 176 | 85809 | 2.1 | - |
America | Edwards, USA, 2008 [23] | NICU* | - | 410 | 203466 | 2.0 | - |
Edwards, USA, 2007 [42] | PICU* | - | 81 | 32936 | 2.5 | - | |
Edwards, USA, 2007 [42] | NICU* | - | 121 | 63075 | 1.9 | - | |
Hocevar, USA, 2012 [43] | NICU* | - | 701 | 336527 | 2.1 | - | |
Stover, USA, 2001 [44] | PICU* | - | - | - | 3.7 | - | |
Stover, USA, 2001 [44] | NICU* | - | - | - | 2.5 | - | |
Apisarnthanarak, USA, 2003 [45] | NICU* (ELBW) | 2211 | 24 | 4173 | 5.8 | 11.4 | |
Elward, USA, 2002 [46] | PICU* | 1595 | 34 | 2931 | 11.6 | 5.1 | |
Weber, USA, 1997 [47] | Burn unit | 140 | 7 | 614 | 11.4 | 17.5 | |
Martinez-Aguilar, Mexico, 2001 [48] | PICU* | - | 44 | 1571 | 28 | - | |
South | Abramczyk, Brazil, 2003 [11] | PICU* | 3515 | 40 | 2120 | 18.7 | 7.8 |
America | Pessoa-Silva, Brazil, 2004 [49] | NICU* | 34878 | 83 | 10494 | 7.9 | 1.7 |
Araujo da Silva Brazil, 2012 [50] | Homecare | 19 | 23 | 3394 | 6.8 | - | |
Casado, Brazil, 2011 [51] | PICU* | 1366 | 39 | 1439 | 27.1 | 10.7 | |
Duenas, Argentina, 2011 [52] | PICU* | 31145 | 93 | 7709 | 12.1 | 8.1 | |
Duenas, Argentina, 2011 [52] | NICU* | 31270 | 139 | 8634 | 16.1 | 10.9 | |
Becerra, Peru, 2010 [53] | PICU* | 3414 | 27 | 3420 | 7.9 | 6.5 | |
Fernandez Jonusas, Argentina, 2011 [54] | NICU* | 31530 | 6 | 3157 | 1.9 | 0.4 | |
Africa | Rasslan , Egypt, 2012 [20] | PICU* | 3143 | 18 | 567 | 31.8 | 12.6 |
Rogers, South Africa, 2014 [55] | Burn unit | 292 | 41 | - | 30.0 | 40.2 | |
El-Kholy, Egypt, 2012 [56] | PICU* | 1211 | 54 | 1478 | 36.5 | 25.6 | |
El-Kholy, Egypt, 2012 [56] | NICU* | 1127 | 26 | 1003 | 25.9 | 20.5 | |
Ben Jaballah, Tunisia, 2006 [57] | PICU/NICU* | 3340 | 7 | 1591 | 4.4 | 2.1 | |
Badr, Egypt, 2011 [58] | NICU* | 256 | 32 | 315 | 101.6 | 57.1 | |
El-Nawawy, Egypt, 2006 [59] | PICU* | - | - | - | 10.9 | - | |
Australia | Gautam, Australia, 2012 [26] | PICU* | 2269 | 18 | 2564 | 7.0 | 6.7 |
Weight categories | Edwards USA 2007[42] | Edwards USA 2008[23] | Rosenthal INICC 2010[71] | Hocevar USA 2012[43] | Stover USA 2001[44] | Pessoa-Silva Brazil 2004[49] | Van der Zwet The Netherlands 2005[8] | Geffers Germany 2008[21] | Leistner Germany 2013[22] |
---|---|---|---|---|---|---|---|---|---|
≤ 750 g | 2.5 | 2.6 | 11.8 | 2.4 | 3.5* | 7.0* | 19.7* | 2.8* | 2.3* |
751-1000 g | 2.2 | 2.1 | 9.2 | 2.1 | |||||
1001-1500 g | 1.4 | 1.5 | 8.2 | 1.3 | 4.9 | 9.2 | 14.7 | 2.3 | 1.6 |
1501-2500 g | 1.1 | 1.0 | 7.2 | 0.9 | 1.1 | 7.8 | 5.8 | - | - |
>2500 g | 1.2 | 0.9 | 6.2 | 0.7 | 0.9 | 8.3 | 7.4 | - | - |
Risk factors
Risk factor | Reference (Author, Ref No) | Setting | Patients | VAP, n | VAP, % | Odds ratio [95% CI] | P-value |
---|---|---|---|---|---|---|---|
Gender (female) | Srinivasan [77] | NICU/ PICU | 60 | 19 | 32 | 10.3 [52.9-37.2] | <0.001 |
Genetic syndromes | Elward [46] | PICU | 595 | 34 | 5.1 | 2.4 [1.0-5.5] | 0.043 |
Trauma | Bigham [72] | PICU | 2846 | 42 | 1.47 | - | 0.020 |
Post-surgical admission diagnosis | Srinivasan [77] | NICU/ PICU | 60 | 19 | 32 | 10.0 [2.2-46.1] | 0.003 |
Subglottic or tracheal stenosis | Bigham [72] | PICU | 2846 | 42 | 1.47 | - | 0.020 |
PRISM III score >10 | Roeleveld [37] | Cardiac surgery | 125 | 11 | 8.8 | 4.4 [1.1-18.0] | 0.041 |
Prolonged ventilation | Awasthi [19] | Ventilatory units | 105 | 38 | 36.2 | 3.8 [1.4- 10.0] | 0.008 |
Casado [51] | PICU | 366 | 39 | 10.7 | 1.0 [1.0-1.1] | 0.017 | |
Reintubation | Patria [25] | PICU | 451 | 30 | 6.6 | 9.5 [3.3-26.8] | <0.001 |
Elward [46] | PICU | 595 | 34 | 5.1 | 2.7 [1.2-6.2] | 0.011 | |
Tracheostomy | Patria [25] | PICU | 451 | 30 | 6.6 | 4.4 [1.0-20.0] | 0.040 |
Bigham [72] | PICU | 2846 | 42 | 1.47 | - | 0.040 | |
Bronchoscopy | Almuneef [28] | PICU | 361 | 37 | 10.3 | 5.0 [1.7-15.3] | <0.001 |
Use of gastric tube | Casado [51] | PICU | 366 | 39 | 10.7 | 2.9 [1.4-5.9] | 0.003 |
Enteral feeding | Patria [25] | PICU | 451 | 30 | 6.6 | 13.2 [1.5-114.2] | 0.020 |
Srinivasan [77] | NICU/PICU | 60 | 19 | 32 | 8.8 [2.1- 36.2] | 0.003 | |
Almuneef [28] | PICU | 361 | 37 | 10.3 | 2.3 [1.1-4.8] | 0.004 | |
Prior antibiotic therapy | Almuneef [28] | PICU | 361 | 37 | 10.3 | 2.5 [1.1-5.4] | 0.026 |
Administration of blood products | Srinivasan [77] | NICU/PICU | 60 | 19 | 32 | 0.1 [0.02- 0.6] | 0.009 |
Use of sedatives/analgesics | Srinivasan [77] | NICU/PICU | 60 | 19 | 32 | 77.5 [7.1- 844.6] | <0.001 |
Casado [51] | PICU | 366 | 39 | 10.7 | 2.5 [1.3-4.7] | 0.007 | |
Neuromuscular blockade | Da Silva [80] | PICU | 317 | - | 5 | - | 0.010 |
Transport out of the PICU* | Elward [46] | PICU | 595 | 34 | 5.1 | 8.9 [3.8-20.7] | <0.001 |