Article infectious diseases

Ventilator-Associated Pneumonia in
Neonates: An Update
Jeffery S. Garland, MD,
SM*
Author Disclosure
Dr Garland has
disclosed no financial
relationships relevant
to this article. This
commentary does not
contain a discussion of
an unapproved/
investigative use of
a commercial product/
device.
Practice Gaps
1. Accurately determining the specific organism responsible for ventilator-associated
pneumonia is challenging in neonates.
2. Few randomized trials have been conducted to evaluate measures to prevent
ventilator-associated pneumonia in neonates.
3. It is not known whether a level or head-elevated position influences the risk of
ventilator-associated pneumonia (VAP).
Abstract
Health-care–associated infections affect neonatal morbidity and mortality, as well as
length of stay and hospital costs. Ventilator-associated pneumonia (VAP) accounts
for 6.8% to 32.2% of these infections. Low birthweight, duration of mechanical ven-
tilation, opiate treatment for sedation, frequent suctioning, and reintubation have all
been shown to increase the risk of VAP. Both Gram-positive and Gram-negative or-
ganisms that originate from endogenous or exogenous sources are responsible for
VAP. Accurately diagnosing VAP in neonates is challenging because procedures such
as tracheal aspirate culture and Gram-stain have low sensitivity, specificity, and positive
predictive value. Although several authors have shown that bronchial aspirates through
nonbronchoscopic bronchoalveolar lavage improve diagnostic accuracy, further stud-
ies are needed to investigate the diagnostic value and safety profile of these procedures.
Very few randomized trials have been conducted in neonates to evaluate methods to
prevent VAP, and thus most neonatal VAP prevention recommendations are based on
adult trials. This review summarizes the epidemiology, pathogenesis, diagnosis, and
treatment of VAP and touches on a number of practical steps to prevent VAP in
neonates.

Objectives After completing this article, the reader should be able to:
1. Describe the risk factors for neonatal ventilator-associated pneumonia (VAP).
2. Describe the current methods used to diagnose neonatal VAP.
3. List the most common organisms responsible for neonatal VAP.
4. Explain initial treatment of neonatal VAP.
5. Outline steps to prevent neonatal VAP.

Introduction
The Centers for Disease Control and Prevention (CDC) defines ventilator-associated
Abbreviations
CDC: Centers for Disease Control and Prevention
NHSN: National Healthcare Safety Network
SDD: selective digestive tract decontamination
VAP: ventilator-associated pneumonia
pneumonia (VAP) as an episode of pneumonia in a patient
who requires a device to assist or control respiration through
a tracheostomy or endotracheal tube within 48 hours before
the onset of the infection. (1) Although the exact incidence
of VAP is difficult to determine, VAP may be responsible for
as many as one-third of the health-care–related infections in
neonates. (2)(3)(4)(5)(6) The present review summarizes
the epidemiology, suspected pathogenesis, diagnosis, treat-
ment, and strategies for the prevention of VAP in neonates.

*Director of Neonatal-Perinatal Research, Wheaton Franciscan Healthcare–St Joseph Hospital, Milwaukee, WI.

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infectious diseases ventilator-associated pnuemonia

Epidemiology exogenous sources (Figs 1 and 2). A number of inves-

Increased permeability of the skin and mucous mem- tigators have described the role of pharyngeal and
branes, decreased complement activity, lower concen- subglottic secretions in the development of VAP in
trations of immunoglobulins, and an immature and adults. (16)(17)(18)(19)(20) Contaminated oral or
dysregulated immune system together increase the risk gastric secretions of intubated, ventilated adult patients
of health-care–acquired infections in critically ill neo- can pool above the cuff of the endotracheal tube, leak
nates. Multiple physiologic mechanisms optimally protect around the cuff, and enter the lower respiratory tract. Be-
the lung parenchyma from infection, including: anatom- cause neonates are ventilated with uncuffed endotracheal
ical barriers; the cough reflex; the tracheobronchial mu- tubes, they are likely at greater risk for aspiration of con-
cociliary lining and secretions; and cell-mediated and taminated oral or gastric secretions. Within the first 48
humoral immunity, including the phagocytic functions hours of mechanical ventilation, (21)(22) Gram-positive
of alveolar macrophages and neutrophils. If these de- oral organisms begin to colonize the trachea and endotra-
fenses are impaired, absent, or overcome by a high cheal tube, and Gram-negative bacilli generally colonize
inoculum of organisms or those of unusual virulence, endotracheal tubes in place for longer than 48 hours.
pneumonitis ensues. One study provided some evidence that neonatal position-
Data from the CDC’s National Healthcare Safety Net- ing may influence the incidence of lower respiratory tract
work (NHSN) (2006–2008) at 304 participating hospi- bacterial colonization. (23) In this study, tracheal coloni-
tals revealed VAP rates of 2.36 and 2.08 per 1,000 zation was less common among neonates placed in a lateral
device-days among neonates weighing less than 750 g position compared with neonates nursed in a supine
and between 750 and 1,000 g, respectively. (7) The true position.
rate of neonatal VAP is difficult to establish. Radiographic Organisms responsible for VAP may also originate
identification of neonatal pneumonia is difficult, compro- from the stomach, although the exact role gastric flora
mised by evolving parenchymal changes due to broncho- plays in the pathogenesis of VAP has been questioned.
pulmonary dysplasia and frequent episodes of atelectasis. (24)(25) Torres et al (26) noted that VAP in adults
Diagnostic procedures commonly used in adults to diag- was more common among supine patients compared
nose VAP (eg, bronchoscopic bronchoalveolar lavage, with semi-recumbent patients. Farhath et al (27) noted
protected specimen brushing) are
rarely used in the neonatal intensive
care unit (NICU), in part due to the
small size of neonatal endotracheal
tubes. Retrospective cohort studies
conducted at single institutions re-
port higher VAP rates (10.9–52 in-
fections per 1,000 ventilator-days)
than NHSN data. (2)(8)(9)(10)
(11)(12)(13) Risk factors reported
to be significantly associated with
VAP among ventilated neonates
also vary from study to study. Low
birthweight, prolonged mechanical
ventilation, opiate treatment for se-
dation, frequent suctioning and re-
intubation, bloodstream infection,
and steroid use have all been noted
to be associated with increased risk
of VAP. (14)(15)

Pathogenesis Figure 1. Endogenous sources of organisms responsible for ventilator-associated

Organisms responsible for VAP pneumonia (VAP). (Courtesy of Walt Earhart, Wheaton Franciscan Healthcare. From:
can originate from endogenous or NeoreviewsPlus
August 2010, Question 8, by AAP.)

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Figure 2. Exogenous sources of organisms responsible for ventilator-associated organisms were recovered from air-
pneumonia (VAP). (Courtesy of Walt Earhart, Wheaton Franciscan Healthcare. From: way secretions in 58% of cases. In a re-
NeoreviewsPlus
August 2010, Question 8, by AAP.)
that pepsin, a marker for gastric contents, was detected in
the trachea of 92% of a cohort of ventilated neonates, sug-
gesting that contaminated gastric contents could make
their way into the trachea of ventilated neonates. Based
on trials that used rigorous culturing techniques and stan-
dard definitions of VAP, oropharyngeal colonization likely
plays a greater role than aspiration of contaminated gastric
secretions. (22) Although previous bloodstream infection
has been identified as a risk factor for VAP, these infections
do not seem to be the source of VAP. (13) Bloodstream
infections and translocation of bacteria from the gastroin-
testinal tract are also believed to be an uncommon source
of endogenous organisms responsible for VAP.
Exogenous sources may also be responsible for the
pathogens causing VAP (Fig 2). Shortly after intubation,
bacteria can coat the surface of endotracheal tubes and
become enveloped within a biofilm produced by the mi-
crobes. This biofilm can serve as an exogenous source of
organisms responsible for VAP. In a study of adult pa-
tients, Adair et al (28) noted that 70% of patients who
have VAP had the same pathogens isolated from endotra-
cheal biofilms and tracheal secretions. Pathogens that
contaminate ventilator circuits, airway suctioning equip-
ment, humidifiers, nebulizers, and, most importantly, care-
givers’ hands (29) are sources of exogenous contamination
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infectious diseases ventilator-associated pnuemonia
that can lead to VAP. Gram-negative
organisms, which often colonize en-
dotracheal tubes, are frequently
noted in the flora that colonize the
hands of caregivers. (30)(31)
Microbiology
In adult and pediatric patients in
whom reliable cultures can be ob-
tained, Staphylococcus aureus and
Gram-negative organisms (Pseudomonas
aeruginosa, Escherichia coli, Klebsiella
pneumoniae, Enterobacter species, and
Acinetobacter species) are the most
common pathogens responsible for
VAP. Gram-negative organisms were
noted in 94% of tracheal aspirates
from neonates who had VAP in a co-
hort reported by Apisarnthanarak
et al. (13) S aureus was recovered
from w25% of cases, and multiple
cent work by Cernada et al, (32)
gram-negative organisms (particu-
larly P aeruginosa) were responsible for 62% of VAP
cases. This study diagnosed VAP by using bronchoalveolar
lavage with a blind protected catheter; with this tech-
nique, only 3 (16.7%) of 18 neonates had polymicrobial
infections.
Diagnosis
The primary controversy regarding VAP in neonates is
the criteria used to establish the diagnosis. (33) The
CDC’s NHSN VAP criteria included radiographic, clin-
ical, and microbiologic elements. (1) The difficulty in ob-
taining noncontaminated microbiologic specimens that
meet quantitative definitions for infection led the CDC
to include a purely clinical definition of VAP for infants
aged £1 year, as shown in Table 1. The criteria have
not been validated in neonates, and they are often open
to subjective interpretation because they overlap with
a number of disease processes. As of January 1, 2014,
the CDC and NHSN no longer analyze data for neonatal
pneumonia because the diagnosis is so subjective accord-
ing to a CDC working group. (34) Neonatal units may
still perform internal VAP surveillance, but the data will
not be analyzed by the NHSN.
Microbiologic criteria for VAP are shown in Table 2.
(1) Note that these criteria presume that pulmonary
specimens are obtained by using invasive testing, such
NeoReviews Vol.15 No.6 June 2014 e227
infectious diseases ventilator-associated pnuemonia

CDC Alternate Criteria for Diagnosis of VAP Among Infants Age

Table 1.

£1 Year
Radiographic criteriaa
New or progressive infiltrate and persistent infiltrate
Consolidation
Cavitation
Pneumatoceles
Clinical criteria
Worsening gas exchange (eg, oxygen desaturations, increased oxygen requirements, increased ventilator demand)
And three of the following
Temperature instability
Leukopenia (<4,000 WBC/mm3) or leukocytosis (>15,000 WBC/mm3) and left shift (>10% band forms)
New onset of purulent sputum or change in character of sputum, or increased respiratory secretions or increased suctioning
requirements
Apnea, tachypnea, nasal flaring with retraction of chest wall or nasal flaring with grunting
Wheezing, rales, or rhonchi
Cough
Bradycardia (<100 beats per minute) or tachycardia (>170 beats per minute)
CDC¼Centers for Disease Control and Prevention; VAP¼ventilator-assisted pneumonia; WBC¼white blood cell count.
a
In the absence of underlying conditions, one definitive chest radiograph is acceptable. Among infants who have underlying conditions, two or more serial
definitive radiographs are required. For neonates, underlying pulmonary or cardiac disease may include respiratory distress syndrome, bronchopulmonary
dysplasia, pulmonary edema, chronic obstructive pulmonary disease, and/or congenital heart disease.

as those obtained with bronchoalveolar lavage or through
a protected specimen brush, frequently used to diagnose
VAP in adults. As mentioned earlier, both techniques
need to be performed through a bronchoscope, thus pre-
cluding their widespread use in intubated neonates.
Köksal et al (35) used invasive testing with nonbroncho-
scopic bronchoalveolar lavage to obtain specimens from
ventilated neonates with suspected pneumonia. Ninety
percent of the 40 neonates who had clinically diagnosed
VAP had positive lavage culture results. Sensitivity, spec-
ificity, and positive and negative predictive values were
90%, 90%, 70%, and 97%, respectively. The presence of
intracellular bacteria in polymorphonuclear cells on
Giemsa-stained smears was significantly higher in neo-
nates who have VAP compared with colonized neonates.
There were no significant complications, but because the
procedure is blind to what actually is being cultured, it is
possible that the samples were taken more proximally

CDC Microbiologic Criteria for Diagnosis of Common Bacterial or

Table 2.

Fungal VAP
In addition to radiographic and clinical criteria, at least one of the following is present:
Positive growth in blood culture not related to another source of infection
Positive growth in culture of pleural fluid
Positive quantitative culture from minimally contaminated lower respiratory tract specimen (eg, BAL, protected specimen
brushing)
‡5% BAL-obtained cells contain intracellular bacteria on direct microscopic examination (eg, Gram-stain)
Histopathologic examination shows at least one of the following indications of pneumonia:
- Abscess formation or foci of consolidation with intense PMN accumulation in bronchioles and alveoli
- Positive quantitative culture of lung parenchyma
- Evidence of lung parenchyma invasion by fungal hyphae or pseudohyphae
BAL¼bronchoalveolar lavage; CDC¼Centers for Disease Control and Prevention; PMN¼polymorphonuclear leukocyte; VAP¼ventilator-assisted
pneumonia.

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from the trachea. Cernada et al (32) used a blind pro-
tected catheter to assist in diagnosing pneumonia in an-
other cohort of neonates who had suspected VAP. They
did not report sensitivity or specificity of the procedure. A
limitation of both of these studies is that they were com-
pared with clinically diagnosed VAP and not with a gold
standard such as a lung biopsy or tissue sample. Larger
trials need to be conducted to assess the diagnostic value
and safety profile of the procedures.
In many NICUs, tracheal aspirate cultures and Gram-
stains are commonly used to try to establish the diagnosis
of VAP in neonates. Tracheal aspirates have low sensitiv-
ity, specificity, and positive predictive value for diagnos-
ing VAP because it is difficult to distinguish between
tracheal colonization and true pneumonia. (36) However,
tracheal colonization of the airway with Gram-negative
bacteria has been associated with adverse outcomes.
(37) Tracheal aspirates from neonates who have sus-
pected VAP may play a role in helping to identify or-
ganisms colonizing the airway and aid in the choice
of appropriate antibiotic therapy. This finding may
be of value, given evidence that there is a greater risk of
death in adults from VAP if their pneumonia was initially
treated with the wrong antibiotic. (38)(39) Furthermore,
a sterile tracheal aspirate culture may also be of value in
that sterile cultures have a high negative predictive value
for VAP. (40)
Routine use of clinical biomarkers such as C-reactive
protein, soluble triggering receptor expressed on mye-
loid type 1 cells, or procalcitonin to help identify VAP
has not been supported in ventilated adults. (41) Stud-
ies have not been conducted to determine the utility
of biomarkers for the diagnosis of VAP in neonatal
patients.
Treatment
There are no clear consensus guidelines for the optimal
treatment of neonatal VAP. Most treatment recommen-
dations are taken from adult guidelines and are supported
by epidemiologic principles. Initial treatment should in-
clude broad empiric therapy, preferably informed by local
bacterial colonizing and antimicrobial sensitivity data.
Local NICU antibiotic combinations for the empiric
treatment of late-onset bloodstream infections should
be used for suspected VAP, unless individual infant
colonizing information is available. Empiric treatment
will often include an antipseudomonal agent such as
piperacillin/tazobactam or ticarcillin/clavulanate to pro-
vide coverage of both Gram-negative and Gram-positive
organisms. Carbapenems may be more appropriate for
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infectious diseases ventilator-associated pnuemonia
initial empiric therapy if local flora include extensive beta-
lactamase–producing organisms. Additional Gram-negative
coverage with an aminoglycoside is controversial but may
be indicated when bacteremia is suspected or significant
systemic symptoms are present. If systemic symptoms
are absent and the blood culture result is negative, de-
escalating therapy by discontinuing the aminoglycosides
may be appropriate. Gram-positive coverage for methicillin-
resistant S aureus may be required if local epidemiologic
data dictate its use.
Overall, multiple risk factors (eg, prolonged me-
chanical ventilation, previous antibiotic exposure, mul-
tisystem illness) place neonates at increased risk for
multidrug-resistant VAP, and there is no validated
means of assessing VAP severity or VAP improvement
after treatment, as there is in adults. Because of these
factors, most neonates who have VAP will receive a full
course of empiric broad-spectrum antibiotic therapy
unless specific culture results allow for the use of more
narrow-spectrum therapy. (14)(15)
Prevention of VAP
The CDC (42) and the American Thoracic Society (43)
have published guidelines for the prevention of health-
care–associated pneumonia. “Bundles” bring together
a number of evidence-based practices that, when applied
as a single intervention (ie, the bundle), may result in im-
provement that is greater than single evidence-based
practices. (44)(45)(46) These recommendations address
the following specific items.
Management of secretions and techniques for
suctioning
Adult VAP prevention bundles often include 30° to 45°
of head elevation to prevent aspiration of contaminated
oropharyngeal and gastric fluids. The results of Aly
et al (23) and Farhath et al (27) suggest that gravity
may be used to prevent pathogens from gaining entry in-
to the lower respiratory track of ventilated neonates.
Farhath et al showed that a majority of ventilated neo-
nates aspirated gastric pepsin, perhaps providing support
for elevating the head of the neonatal bed, but this study
did not evaluate the association between the presence
of pepsin in the trachea and VAP. Aly et al evaluated
tracheal colonization in supine and lateral-nursed venti-
lated infants and found that the lateral-nursed infants
had less tracheal bacterial colonization; however, the
study did not specifically assess VAP. The optimum po-
sition to nurse neonates for the prevention of VAP needs
further investigation.
NeoReviews Vol.15 No.6 June 2014 e229
infectious diseases ventilator-associated pnuemonia
The CDC recommends that secretions be cleared
from above the cuff of the endotracheal tube anytime
the tube is repositioned or removed. (42) Neonates are
usually cared for with uncuffed endotracheal tubes. Suc-
tioning the oropharynx around the endotracheal tube be-
fore adjusting it or removing it may reduce risk of
microaspiration of contaminated oropharyngeal secre-
tions. Although close systems are frequently used for
the care of ventilated neonates, they may present the po-
tential for bacterial contamination if pooled secretions in
the lumen are reintroduced into the respiratory tract with
repeated suctioning. Conversely, closed suctioning could
potentially reduce environmental contamination of the
respiratory tract. In a study of 133 ventilated neonates
randomized to a closed or open suction system, no differ-
ence was noted in tracheal colonization patterns between
groups, nor were there differences in VAP rates among
treatment groups. Physiologic disruptions were less with
the closed suction systems, and NICU nurses indicated
that these systems were easier to use than open suction
systems. (47) At minimum, separate suctioning equip-
ment should be used for tracheal and oral secretions.
One recent study evaluated a low-sodium, physiolog-
ically based solution for suctioning of ventilated neo-
nates. (48) A significant reduction in the VAP rate was
demonstrated after normal saline for airway suctioning
was replaced by the novel solution for airway suctioning.
Further trials with the solutions are necessary to confirm
these results. Finally, respiratory tubing should be
drained away from ventilated infants to prevent aspiration
of potentially contaminated condensate. (49) Breathing
circuits do not need routine changing unless they become
visibly soiled or they malfunction. (42)
Extubation procedures
VAP reduction bundles often recommend “sedation va-
cations” to assess extubation readiness. Because many
centers use minimal or no sedation for ventilated neo-
nates, sedation vacations are uncommon in most units.
Assessing for extubation readiness should be done on
a daily basis. Noninvasive measures such as nasal contin-
uous positive airway pressure and nasal prong ventilation
may help to reduce VAP rates. (9) Reintubation after ex-
tubation should be avoided if possible because of the in-
creased risk of VAP associated with reintubation. (50)
Gastrointestinal and oropharyngeal
interventions.
Manipulation of gastrointestinal contents is part of adult
VAP prevention. Although H2-blocker treatment is fre-
quently a standard intervention in bundles to prevent
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VAP in adults, current data do not support such treat-
ment in ventilated neonates. In addition, the use of
H2-blockers is associated with increased risk of late-onset
fungal infection and necrotizing enterocolitis among very
low birthweight NICU infants. (51)(52)
Selective digestive tract decontamination (SDD) with
enteral nonabsorbable antimicrobials and antimicrobials
applied directly to the oropharynx can decrease gastroin-
testinal colonization and potentially reduce respiratory
tract infections from microaspiration of gastrointestinal
organisms. CDC guidelines (42) offer no recommenda-
tion for the selective decontamination of the digestive
tract. In a nonrandomized prospective trial of ventilated
neonates, those who underwent SDD with polymyxin E,
tobramycin, and nystatin had fewer nosocomial infections
of intestinal origin. (53) VAP episodes were not reported
separately. SDD should be evaluated further before it is
considered for neonates outside of clinical trials. The
use of probiotic treatment to influence neonatal gastroin-
testinal colonization has focused on reducing late-onset
bloodstream infections and necrotizing enterocolitis,
but one recent trial of Lactobacillus reuteri administration
also demonstrated the effect of probiotic administration
on the incidence of VAP. (54)
The CDC recommends a comprehensive oral hygiene
program in patients at high risk for health-care–associated
pneumonia. (42) Although several groups have noted
a reduction in VAP among adult patients treated with
oral chlorhexidine gluconate decontamination, the
CDC makes no recommendation for the use of an oral
chlorhexidine gluconate rinse for the prevention of
VAP in ill patients. Chlorhexidine gluconate is not ap-
proved for neonates less than age 2 months. Because neo-
nates do not have gingivitis or the dental diseases adults
often have, oral care may not provide the benefit it does
in adult patients. Until further data are available, adhering
to the recommendation of the American Dental Associ-
ation to wipe off the gums and keep the mouth clean after
feedings and when needed seems prudent.
Infection control measures
Hand hygiene is likely the most important infection con-
trol intervention in health-care settings to reduce person–
person transmission of bacteria. Pathogens responsible
for neonatal VAP are carried on health-care workers’
hands and in the infants’ gastrointestinal tracts. Respira-
tory equipment can become colonized with these organ-
isms. (55) Thorough hand-washing before and after
contact with respiratory equipment should reduce
cross-contamination between patients.
 infectious diseases ventilator-associated pnuemonia

Figure 3. Relationship between preventative measures and pathogenesis of ventilator-associated pneumonia (VAP). (Adapted from
Garland JS. Strategies to prevent ventilator-associated pneumonia in neonates. Clin Perinatol. 2010;37(3):638. Copyright 2010,
with permission from Elsevier.)

Changes in endotracheal tube design have decreased
incidence of VAP in adults. A hole in the dorsal aspect
of endotracheal tubes above the inflated cuff allows for
clearing of subglottic secretions. The CDC recommends
the use of such tubes in ventilated adults. (42) Unfortu-
nately, such tubes are not available for neonates. Silver-
coated endotracheal tubes, which are not available for
neonates, have also been shown to reduce VAP in adults
by reducing biofilm formation and bacterial colonization.
Figure 3 summarizes how practical preventative inter-
ventions relate to the steps in the pathogenesis of VAP.
Improved diagnostic criteria and surveillance tech-
niques for VAP in the neonatal population need to be es-
tablished before the effectiveness of these strategies can
be accurately assessed.
American Board of Pediatrics Neonatal–Perinatal
Content Specifications
• Know the pathogenesis and causative
agents in an infant in whom neonatal
pneumonia is suspected.
• Plan the clinical, imaging, and laboratory
features and the management of an
infant in whom neonatal pneumonia is
suspected.

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infectious diseases ventilator-associated pnuemonia
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infectious diseases ventilator-associated pnuemonia

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1. A 10-day-old, 28-week-gestational-age male infant who has been on the ventilator has worsening clinical
status and is suspected of having pneumonia. Which of the following statements regarding the development of
ventilator-associated pneumonia (VAP) is correct?
A. Radiographic characteristics of VAP are very distinct and consistent, with a diffuse pattern of consolidation
at onset.
B. A patient needs to be intubated for at least 5 days before onset of infection to have an official diagnosis of
VAP.
C. Opiate treatment for sedation has been associated with increased risk of VAP.
D. A key feature in effective prevention of VAP is frequent suctioning and periodic replacement of the
endotracheal tube.
E. A concurrent bloodstream infection rules out the diagnosis of VAP.

2. In the 10-day-old, 28-week-gestational-age patient, which of the following statements regarding diagnosis
of VAP is correct?
A. It would be considered the standard of care to perform bronchoscopic bronchoalveolar lavage for the
purpose of diagnosis in this patient.
B. The definition of VAP for neonates has been well established since the 1998 criteria published in a joint
effort between the Centers for Disease Control and Prevention and the American Academy of Pediatrics.
C. A sterile tracheal aspirate culture has a high negative predictive value for VAP.
D. Tracheal aspirates have excellent sensitivity (>98%) but poor specificity for diagnosis of VAP.
E. C-reactive protein has been very useful in the diagnosis of VAP, for distinguishing VAP from other disease
processes, and for use in trials for establishing diagnostic criteria.

3. A tracheal aspirate is obtained from the patient who is suspected of having VAP. Which of the following has
been found regarding tracheal aspirates in neonates who have VAP?
A. Gram-positive organisms are the most common bacteria noted in tracheal aspirates.
B. In general, the most common finding from tracheal aspirates of neonates suspected of having VAP are
sterile or have a single-organism growth.
C. Streptococcus gallolyticus is found in 50% of neonates who have VAP.
D. Bronchoalveolar lavage with a blind protected catheter generally results in higher recovery of
polymicrobial infections.
E. Pseudomonas aeruginosa is a pathogen recovered from airway secretions in VAP by using both tracheal
aspirate and bronchoalveolar lavage methods.

4. The clinical care team has determined that the patient has VAP. What are appropriate principles regarding
treatment for VAP in neonates at this gestational age?
A. Clear consensus guidelines for the treatment of very low birthweight infants were published by the Centers
for Disease Control and Prevention (CDC), first in 1999 and updated in 2010.
B. In the majority of cases, if the patient’s condition is stable, the treatment of VAP is extubation to
continuous positive airway pressure or nasal cannula, and does not require antibiotics.
C. Antibiotics should only be started after a pathogenic organism associated with VAP has been identified.
D. Empiric treatment may include an antipseudomonal agent such as piperacillin/tazobactam.
E. Because organisms causing VAP are generally derived from mouth flora, penicillin is a reasonable first-line
treatment or can be used if treatment is desired when no organism is recovered.

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 infectious diseases ventilator-associated pnuemonia

5. Your neonatal intensive care unit (NICU) is developing a bundle for prevention of VAP. Which of the following
components may be a reasonable part of the protocol based on the studies discussed in this article?
A. Neonate should be positioned in the prone position at least one-half of the time if he or she has been
intubated for more than 2 days.
B. Separate suctioning equipment should be used for tracheal and oral secretions.
C. Respiratory circuits should be changed on a routine basis, daily or twice a day.
D. Normal saline has been shown to be the optimal solution for airway suctioning compared with all other
solutions.
E. To minimize gastric aspiration, moderate sedation for vigorously moving infants should be applied,
preferably with opioids.

NeoReviews Vol.15 No.6 June 2014 e235

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 Ventilator-Associated Pneumonia in Neonates: An Update
Jeffery S. Garland
NeoReviews 2014;15;e225
DOI: 10.1542/neo.15-6-e225

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 Ventilator-Associated Pneumonia in Neonates: An Update
Jeffery S. Garland
NeoReviews 2014;15;e225
DOI: 10.1542/neo.15-6-e225

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/15/6/e225

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