Editorials

722 www.ccmjournal.org March 2014 Volume 42 Number 3

B
edside clinicians know better than anyone that diagnos-
ing ventilator-associated pneumonia (VAP) can be dev-
ilishly difcult. Intensivists admitted to being less than
50% condent about more than 30% of patients they diagnose
with VAP (1). Their uncertainty is well placed. Autopsy series
afrm that clinical diagnostic criteria miss a third or more of
true cases and wrongly suggest VAP in almost one half of all
cases (2). Requiring microbiological conrmation does little
to improve condence. The sensitivity and positive predictive
value of quantitative bronchoalveolar lavage cultures are only
about 50% and 70%, respectively, relative to histology (37).
As with clinical diagnoses, so too with surveillance designa-
tions. Infection preventionists are just as likely to get it wrong.
In fact, infection preventionists may be more prone to error
because they often rely on indirect evidence, such as radio-
graphic reports rather than images, to make their determina-
tions. The problem is further compounded by subjectivity.
There are no ofcial standards for concepts such as worsen-
ing oxygenation, increased secretions, or progressive inltrates.
Surveyors are instead left to their own discretion. Not surpris-
ingly, reasonable practitioners often disagree (8, 9).
In this issue of Critical Care Medicine, the article by Ste-
vens et al (10) reminds us just how unreliable and variable VAP
classications can be. Stevens et al (10) developed six clinical
vignettes describing possible cases of VAP. They distributed
the vignettes to a nationally representative sample of infection
preventionists and hospital epidemiologists and asked them to
rate whether each patient has VAP or not. They found almost
no agreement between survey respondents. Answers followed
a near normal distribution suggesting near random variation
in VAP assignments. Although it is possible that agreement
may have been better if respondents had had access to the full
medical charts or bedside evaluations rather than just vignettes
alone, the ndings by Stevens et al (10)are consistent with
other published surveys using different methodologies (8, 9).
These sobering results remind us yet again that VAP is a
fundamentally unreliable outcome measure. This is true
regardless of whether the application is benchmarking hos-
pitals, determining remuneration, studying the impact of
different prevention strategies, or evaluating the efcacy of
new treatments. VAP is simply too subjective, inaccurate,
and prone to bias to yield dependable answers in any of these
spheres. Furthermore, the use of this VAP surveillance deni-
tion had led to the misinterpretation and misuse of pneumo-
nia bundles of care (11).
These results also remind us of why the Centers for Dis-
ease Control and Prevention (CDC) retired their longstanding
clinical surveillance denitions for VAP and created venti-
lator-associated event (VAE) denitions instead (12). VAE
denitions were designed to enhance objectivity and facilitate
automated surveillance by eliminating subjective criteria (such
as worsening oxygenation or increased secretions) and
substituting quantitative alternatives instead (e.g., an increase
in the daily minimum positive end-expiratory pressure [PEEP]
of 3 cm H
2
O sustained for 2 d) (13). More broadly, the VAE
framework was designed to overcome the limited accuracy of
VAP denitions by shifting from diagnosis-specic surveil-
lance to syndrome-based surveillance. Ventilator-associated
conditions (VAC), the core concept within the VAE framework,
can be thought of as a surveillance marker for the syndrome of
nosocomial respiratory deteriorations.
To get the most out of VAE surveillance, however, we have
to appreciate its unique strengths and respect its limitations.
First and foremost, VAC is not VAP. Pneumonia only accounts
for a small fraction of VACs just as pneumonia only accounts
for a small fraction of attributable mortality in ICUs (14).
Acute respiratory distress syndrome, severe sepsis, pulmonary
Copyright 2013 by the Society of Critical Care Medicine and Lippincott
Williams & Wilkins
DOI: 10.1097/CCM.0000436119.32758.69
*See also p. 497.
Key Words: surveillance; variability; ventilator-associated pneumonia
Dr. Klompas lectured for Premier Healthcare Alliance and received
support for travel and accommodation expenses from Society of Health-
care Epidemiologists of America, Infectious Disease Society of America,
and Infectious Disease Association of California. His institution received
grant support from CDC. Dr. Kalil disclosed that he does not have any
potential conficts of interest.
Michael Klompas, MD, MPH
Department of Population Medicine
Harvard Medical School and Harvard Pilgrim
Health Care Institute; and
Department of Medicine
Brigham and Womens Hospital
Boston, MA
Andre C. Kalil, MD, MPH
Infectious Diseases Division
Department of Internal Medicine
University of Nebraska Medical Center
Omaha, NE
The Last Breath of the Ventilator-Associated
Pneumonia Surveillance Denition*
Editorials
Critical Care Medicine www.ccmjournal.org 723
edema, atelectasis, and other complications account for many
more deaths. VAC detects many of these complications in
addition to pneumonia (15, 16). To prevent VACs and improve
outcomes for all ventilated patients, we need new ventilator
bundles that include strategies that better target all these con-
ditions (17). Second, VAC is a surveillance concept not a clini-
cal concept. VACs strengths lie in its objectivity, its suitability
for electronic analysis, and its strong association with adverse
outcomes (18). It is designed to give a population-level pic-
ture of complication rates rather than patient-level diagnostic
information to inform immediate management. The price we
pay for VACs simplicity and objectivity is that VAC will likely
miss some milder pneumonias and overcall some nonprevent-
able deteriorations. In return, though, VAC should provide a
more consistent yardstick to measure relative complication
rates between institutions and across time.
The article by Stevens et al (10) is also a welcome prompt
to think more deeply about VAEs objectivity. VAE denitions
have the ring of objectivity insofar as they are built solely upon
quantitative criteria and computers can successfully apply
them (18). VAEs objectivity cannot be taken for granted,
however. There are potential sources of variability second-
ary to patient care and surveillance practices that we need to
understand better and guard against if VAE rates are to be valid
benchmarks. On the patient care side, clinicians and centers
may differ in how they choose to manage ventilator settings for
similar scenarios. This is an important area for investigation
and quantication. On the surveillance side, there is a very real
possibility that surveyors charged with manually nding and
processing daily minimum PEEPs and FIO
2
will nd different
cases than electronic systems that analyze ventilators minute-
by-minute settings. It is also likely that human assessors manu-
ally screening ventilator settings and antibiotic exposures will
occasionally make mistakes. Hence, we welcome Stevens et al
(10) suggestion that research to demonstrate the interfacil-
ity and interobserver reliability of the new denition (VAE) is
needed before adopting it for hospital comparison purposes.
To enhance VAEs objectivity, we need to encourage as many
hospitals as possible to automate VAE surveillance and we need
to dene common standards for the interpretation of electronic
ventilator data. For example, should a single minute spent at
a very low PEEP qualify as an eligible daily minimum PEEP?
It will both help hospitals and increase the credibility of VAE
surveillance if CDC could disseminate VAE detection computer
algorithms or web services to assure hospitals that their cases
are valid and comparable to those of other centers. Centraliz-
ing the development and dissemination of analytic algorithms
will also allow CDC to detect attempts to game the new de-
nitions by manipulating ventilator settings in small clinically
meaningless ways that serve only to undermine VAE detection.
After so many years using CDCs former VAP surveillance
denitions, we can now safely conclude that any potential
agreement achieved between observers, or between hospitals,
was no better than chance alone. The study by Stevens et al (10)
clearly shows that the old VAP denition reached its very last
breath. Although we believe that VAE denitions are a major
step forward, these new denitions now require scientic repli-
cation and external validity to assess their suitability for bench-
marking, accreditation, and remuneration.
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