January 2025

Pneumonia (Ventilator-associated [VAP] and non-ventilator-

associated Pneumonia [PNEU]) Event

Table of Contents

Introduction .................................................................................................................................................. 1
Settings ......................................................................................................................................................... 2
Key Terms and Abbreviations ....................................................................................................................... 2
Definitions Specific to PNEU/VAP Surveillance ............................................................................................. 3
Guidance for Determination of Eligible Imaging Test Evidence ................................................................... 3
General Comments Applicable to All Pneumonia Specific Site Criteria........................................................ 4
Reporting Instructions .................................................................................................................................. 5
Table 1: Specific Site Algorithms for Clinically Defined Pneumonia (PNU1) ................................................. 6
Table 2: Specific Site Algorithm for Pneumonia with Common Bacterial or Filamentous Fungal Pathogens
and Specific Laboratory Findings (PNU2) ...................................................................................................... 7
Table 3: Specific Site Algorithm for Viral, Legionella, and other Bacterial Pneumonias with Definitive
Laboratory Findings (PNU2) .......................................................................................................................... 8
Table 4: Specific Site Algorithm for Pneumonia in Immunocompromised Patients (PNU3) ........................ 9
Figure 1: Pneumonia Flow Diagram for Patients of Any Age ...................................................................... 10
Figure 2: Pneumonia Flow Diagram, Alternative Criteria for Infants and Children .................................... 11
Footnotes to Algorithms and Flow Diagrams ............................................................................................. 12
Table 5: Threshold values for cultured specimens used in the diagnosis of pneumonia ........................... 15
Numerator Data .......................................................................................................................................... 16
Denominator Data ...................................................................................................................................... 16
Data Analyses .............................................................................................................................................. 17
Table 6: VAP Measures Available in NHSN ................................................................................................. 18
References .................................................................................................................................................. 19

Introduction
In 2015 CDC conducted a point-prevalence survey in a sample of acute care hospitals in U.S. and
determined that of the 427 healthcare-associated infections identified, pneumonia was the most
common infection with 32% of those being ventilator associated.1 Patients receiving invasive mechanical
ventilation are at risk for numerous complications, including pneumonia. Ventilator-associated
pneumonia (VAP) and other healthcare-associated pneumonias are important, common healthcare-
associated infections, but national surveillance for VAP has long been a challenge because of the lack of
objective, reliable definitions. Due to these challenges, in January 2013 the National Healthcare Safety
Network (NHSN) replaced surveillance for ventilator-associated pneumonia (VAP) in adult inpatient
locations with surveillance for ventilator-associated events (VAE).2 Based on discussions with an expert

6-1
 January 2025 Device-associated Module
PNEU

working group in 2012-2013, NHSN also discontinued in-plan VAP surveillance in neonatal locations. As
of January 2014, in-plan VAP surveillance is only available in pediatric inpatient locations.

Settings
Surveillance may occur in any inpatient pediatric location where denominator data can be
collected, such as critical/intensive care units (pediatric ICUs), specialty care areas (SCA), step-down
units, wards, and long-term care units. In-plan surveillance for pediatric ventilator-associated
pneumonia (pedVAP) using the criteria found in this chapter is restricted to patients of any age in
pediatric locations only (excludes neonatal locations). In-plan surveillance conducted for mechanically
ventilated patients in adult locations (regardless of age) will use the Ventilator-Associated Event (VAE)
protocol (see VAE chapter).
The PNEU definitions are still available for those units seeking to conduct off-plan PNEU surveillance for
mechanically ventilated adult, pediatric, and neonatal patients and non-ventilated adult, pediatric, and
neonatal patients. The PNEU definitions are also available for secondary bloodstream infection
assignment when performing Central Line-Associated Bloodstream Infection (CLABSI) surveillance in
ventilated or non-ventilated patients of any age in any location. A complete listing of inpatient locations
and instructions for mapping can be found in Chapter 15 CDC Locations and Descriptions.
Note: Post-discharge surveillance for pedVAPs is not required. However, if discovered, any pedVAPs
with a date of event (DOE) on the day of discharge or day after discharge is attributed to the discharging
location and should be included in any pedVAPs reported to NHSN by the discharging location. No
additional ventilator days are reported.

Key Terms and Abbreviations

Refer to the NHSN Patient Safety Manual, Chapter 2 Identifying Healthcare-associated Infections (HAI)
for NHSN Surveillance and Chapter 16 General Key Terms for definitions of the following universal
concepts for conducting HAI surveillance.

I Date of event (DOE)

II Healthcare associated infection (HAI)
III Infection window period (IWP)
IV Present on admission (POA)
V Repeat infection timeframe (RIT)
VI Secondary BSI attribution period (SBAP)
VII Location of attribution (LOA)
VIII Transfer rule

6-2
 January 2025 Device-associated Module
PNEU

Definitions Specific to PNEU/VAP Surveillance

Pneumonia (PNEU) is identified by using a combination of imaging, clinical, and laboratory criteria. The
following pages detail the various criteria that may be used for meeting the surveillance definition of
healthcare-associated pneumonia (Tables 1, 2, 3, and 4 and Figures 1 and 2), general comments
applicable to all site-specific criteria, footnotes applicable to specific elements, and reporting
instructions.

Ventilator: Any device used to support, assist, or control respiration (inclusive of the weaning period)
through the application of positive pressure to the airway when delivered via an artificial airway,
specifically an oral/nasal endotracheal or tracheostomy tube.
Ventilation and lung expansion devices that deliver positive pressure to the airway (for example, CPAP,
BiPAP, Bi-level, IPPB, and PEEP) via non-invasive means (for example, nasal prongs, nasal mask, full face
mask, total mask, etc.) are not considered ventilators unless positive pressure is delivered via an
artificial airway (oral/nasal endotracheal or tracheostomy tube).

Ventilator-associated pneumonia (VAP): A pneumonia where the patient is on mechanical ventilation for
> 2 consecutive calendar days on the date of event, with day of ventilator placement being Day 1*
AND
the ventilator was in place on the date of event or the day before.
*If the ventilator was in place prior to inpatient admission, the ventilator day count begins with the
admission date to the first inpatient location.
If a break in mechanical ventilation occurs for at least one full calendar day, ventilator day count for
ventilator association starts anew upon reintubation and/or re-initiation of mechanical ventilation.

Guidance for Determination of Eligible Imaging Test Evidence

• If only one imaging test is available, it is acceptable for this to satisfy the imaging requirement
for PNEU/VAP POA determinations regardless of whether the patient has underlying pulmonary
or cardiac disease.
• When multiple imaging test results are available, persistence of imaging test evidence of
pneumonia is a requirement for all patients, not just those with underlying cardiac or pulmonary
disease.
• The date of the first eligible imaging test will be utilized when determining if the PNEU/VAP
criteria are met within the IWP. All elements of PNEU/VAP definition must be present within the
Infection Window Period (IWP). The exception may occur when identifying persistence of
imaging test evidence of pneumonia, as the second imaging test must occur within seven days
of the first but is not required to occur within the IWP.

6-3
 January 2025 Device-associated Module
PNEU

General Comments Applicable to All Pneumonia Specific Site Criteria

1. Physician’s diagnosis of pneumonia alone is not an acceptable criterion for present on admission
(POA) or healthcare-associated (HAI) pneumonia.
2. Although specific criteria are included for infants and children and immunocompromised
patients, all patients may meet any of the other pneumonia site-specific criteria.
3. Pneumonia due to gross aspiration (for example, in the setting of intubation in the field,
emergency department, or operating room) that meets the PNEU/VAP definition with a date of
event during the HAI timeframe is considered healthcare associated.
4. Multiple episodes of healthcare-associated pneumonia may occur in critically ill patients with
lengthy hospital stays. When determining whether to report multiple episodes of healthcare-
associated pneumonia in a single patient, follow the Repeat Infection Timeframe (RIT) guidance
found in Chapter 2.
5. Excluded organisms that cannot be used to meet the PNEU/VAP definition are as follows:
a. “Normal respiratory flora,” “normal oral flora,” “mixed respiratory flora,” “mixed oral
flora,” “altered oral flora,” or other similar results indicating isolation of commensal
flora of the oral cavity or upper respiratory tract. NOTE: A report of “flora” does not
exclude the use of an eligible organism isolated or identified from the specimen. Only
the “flora” is excluded from use.
b. The following organisms, unless identified from lung tissue or pleural fluid (where
specimen was obtained during thoracentesis or within 24 hours of chest tube
placement; pleural fluid specimens collected after a chest tube is repositioned or from a
chest tube in place > 24 hours are not eligible):
i. Any Candida species as well as a report of “yeast” that is not otherwise specified
ii. Any coagulase-negative Staphylococcus species
iii. Any Enterococcus species
6. If the excluded pathogens, any Candida species* or yeast not otherwise specified, any
coagulase-negative Staphylococcus species, and any Enterococcus species, are identified from
blood they can only be attributed as a secondary BSI to PNEU if PNU2 or PNU3 is met with a
matching organism identified from lung tissue or pleural fluid (where specimen was obtained
during thoracentesis or within 24 hours of chest tube placement; pleural fluid specimens
collected after a chest tube is repositioned or from a chest tube in place > 24 hours are not
eligible) and the blood specimen collection date is within the Secondary BSI Attribution Period
(SBAP).
*The exception to this is any Candida species or yeast not otherwise specified identified
from blood can be attributed as a secondary BSI to PNEU if PNU3 is met using the blood
specimen and a sputum, endotracheal aspirate, bronchoalveolar lavage (BAL), or
protected specimen brushing with matching Candida species, and both specimens have
a collection date in the IWP.
7. Additionally, because organisms belonging to the following genera are typically causes of
community-associated infections and are rarely or are not known to be causes of healthcare-

6-4
 January 2025 Device-associated Module
PNEU

associated infections, they are also excluded and cannot be used to meet any NHSN definition:
Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus, and Pneumocystis.
8. Abbreviations used in the PNEU laboratory criteria:
BAL – bronchoalveolar lavage
EIA – enzyme immunoassay
IFA – immunofluorescent antibody
LRT – lower respiratory tract
PMN – polymorphonuclear leukocyte
RIA – radioimmunoassay

Reporting Instructions
• There is a hierarchy of specific categories within the major type pneumonia (PNEU). If the patient
meets criteria for more than one specific type during the IWP or the RIT, report only one:
o If a patient meets criteria for both PNU1 and PNU2, report PNU2.
o If a patient meets criteria for both PNU2 and PNU3, report PNU3.
o If a patient meets criteria for both PNU1 and PNU3, report PNU3.
• Pathogens and secondary bloodstream infections can only be reported for PNU2 and PNU3 specific
events.
• Report concurrent LUNG and PNEU with at least one matching organism(s) as PNEU.

6-5
 January 2025 Device-associated Module
PNEU

Table 1: Specific Site Algorithms for Clinically Defined Pneumonia (PNU1)

NOTE: The PNEU Algorithms (PNU1,2,3) and Flowcharts include FOOTNOTE references. The interpretation and
guidance provided in the FOOTNOTES are an important part of the algorithms and must be incorporated into the
decision-making process when determining if a PNEU definition is met.

Imaging Test Signs/Symptoms

Evidence
Two or more serial For ANY PATIENT, at least one of the following:
chest imaging test • Fever (> 38.0°C or > 100.4°F)
results with at least one • Leukopenia (≤ 4000 WBC/mm3) or leukocytosis (≥ 12,000 WBC/mm3)
of the following • For adults ≥ 70 years old, altered mental status with no other recognized cause
(1,2,13):
And at least two of the following (from separate bullets):
New and persistent • New onset of purulent sputum (3) or change in character of sputum (4), or increased
or respiratory secretions, or increased suctioning requirements
Progressive and • Dyspnea, or tachypnea (5), or new onset or worsening cough
persistent • Rales (6) or bronchial breath sounds
• Worsening gas exchange (for example, O2 desaturations [for example, PaO2/FiO2
• Infiltrate ≤ 240] (7), increased oxygen requirements, or increased ventilator demand)

• Consolidation ALTERNATE CRITERIA, for infants ≤ 1 year old:

Worsening gas exchange (for example, O2 desaturations [for example, pulse oximetry
• Cavitation < 94%], increased oxygen requirements, or increased ventilator demand)
And at least three of the following (from separate bullets):
• Pneumatoceles, in
infants ≤1 year old • Temperature instability
• Leukopenia (≤ 4000 WBC/mm3) or leukocytosis (≥ 15,000 WBC/mm3) and left shift
(≥ 10% band forms)
Note: In patients • New onset of purulent sputum (3) or change in character of sputum (4), or increased
respiratory secretions, or increased suctioning requirements
without underlying
• Apnea, tachypnea (5), nasal flaring with retraction of chest wall, or nasal flaring with
pulmonary or cardiac
grunting
disease (such as • Wheezing, rales (6), or rhonchi
respiratory distress • Cough
syndrome, • Bradycardia (< 100 beats/min) or tachycardia (> 170 beats/min)
bronchopulmonary
dysplasia, pulmonary ALTERNATE CRITERIA, for child > 1 year old or ≤ 12 years old, at least three of the
edema, or chronic following (from separate bullets):
obstructive pulmonary • Fever (> 38. 0°C or > 100. 4°F) or hypothermia (< 36. 0°C or < 96.8°F)
disease), at least one • Leukopenia (≤ 4000 WBC/mm3) or leukocytosis (≥ 15,000 WBC/mm3)
definitive imaging test • New onset of purulent sputum (3) or change in character of sputum (4), or increased
result is acceptable. (1) respiratory secretions, or increased suctioning requirements
• Dyspnea, or apnea, or tachypnea (5), or new onset or worsening cough
• Rales (6) or bronchial breath sounds
• Worsening gas exchange (for example, O2 desaturations [for example, pulse oximetry
< 94%], increased oxygen requirements, or increased ventilator demand)

6-6
 January 2025 Device-associated Module
PNEU

Table 2: Specific Site Algorithm for Pneumonia with Common Bacterial or

Filamentous Fungal Pathogens and Specific Laboratory Findings (PNU2)
NOTE: The PNEU Algorithms (PNU1,2,3) and Flowcharts include FOOTNOTE references. The interpretation and
guidance provided in the FOOTNOTES are an important part of the algorithms and must be incorporated into the
decision-making process when determining if a PNEU definition is met.

Imaging Test Evidence Signs/Symptoms Laboratory

Two or more serial chest At least one of the following: At least one of the following:
imaging test results with at
least one of the following
• Fever (> 38.0°C or > 100.4°F) • Organism identified from blood
(1,2,13):
(8,12)
• Leukopenia (≤ 4000 WBC/mm3) or
New and persistent leukocytosis (≥ 12,000 WBC/mm3)
• Organism identified from pleural
or • For adults ≥ 70 years old, altered fluid (9,12)
Progressive and persistent mental status with no other
recognized cause • Positive quantitative culture or
• Infiltrate corresponding semi-quantitative
And at least one of the following: culture result (9) from minimally
• Consolidation contaminated LRT specimen
(specifically, BAL, protected
• New onset of purulent sputum (3) or specimen brushing, or endotracheal
• Cavitation change in character of sputum (4), aspirate)
or increased respiratory secretions,
• Pneumatoceles, in or increased suctioning
infants ≤1 year old • ≥ 5% BAL-obtained cells contain
requirements
intracellular bacteria on direct
microscopic exam (for example,
• Dyspnea, or tachypnea (5), or new Gram’s stain)
Note: In patients without onset or worsening cough
underlying pulmonary or
• Positive quantitative culture or
cardiac disease (such as • Rales (6) or bronchial breath sounds corresponding semi-quantitative
respiratory distress culture result (9) of lung tissue
syndrome, • Worsening gas exchange (for
bronchopulmonary example, O2 desaturations [for • Histopathologic exam shows at least
dysplasia, pulmonary example, PaO2/FiO2 ≤ 240] (7), one of the following evidences of
edema, or chronic increased oxygen requirements, or pneumonia:
obstructive pulmonary increased ventilator demand)
disease), at least one o Abscess formation or foci of
definitive chest imaging test consolidation with intense PMN
result is acceptable. (1) accumulation in bronchioles and
alveoli

o Evidence of lung parenchyma

invasion by fungal hyphae or
pseudohyphae

6-7
 January 2025 Device-associated Module
PNEU

Table 3: Specific Site Algorithm for Viral, Legionella, and other Bacterial
Pneumonias with Definitive Laboratory Findings (PNU2)
NOTE: The PNEU Algorithms (PNU1,2,3) and Flowcharts include FOOTNOTE references. The interpretation and
guidance provided in the FOOTNOTES are an important part of the algorithms and must be incorporated into
the decision-making process when determining if a PNEU definition is met.

Imaging Test Evidence Signs/Symptoms Laboratory

Two or more serial chest At least one of the following: At least one of the following:
imaging test results with at
least one of the following • Fever (> 38.0°C or > 100.4°F) • Virus, Bordetella, Legionella,
(1,2,13): Chlamydia, or Mycoplasma
• Leukopenia (≤ 4000 WBC/mm ) or 3

leukocytosis (≥ 12,000 WBC/mm3) identified from respiratory

New and persistent secretions or tissue by a
or • For adults ≥ 70 years old, altered
culture or non-culture
Progressive and persistent mental status with no other
recognized cause based microbiologic testing
method which is performed
• Infiltrate for purposes of clinical
And at least one of the following:
diagnosis or treatment (for
• Consolidation
example, not Active
• New onset of purulent sputum (3) or
change in character of sputum (4), or Surveillance Culture/Testing
• Cavitation
increased respiratory secretions, or (ASC/AST)
• Pneumatoceles, in increased suctioning requirements
infants ≤1 year old • Fourfold rise in paired sera
• Dyspnea, or tachypnea (5), or new (IgG) for pathogen (for
onset or worsening cough example, influenza viruses,
Note: In patients without Chlamydia)
underlying pulmonary or • Rales (6) or bronchial breath sounds
cardiac disease (such as • Fourfold rise in Legionella
respiratory distress • Worsening gas exchange (for
pneumophila serogroup 1
syndrome, example, O2 desaturations [for
example, PaO2/FiO2 ≤ 240] (7), antibody titer to ≥ 1:128 in
bronchopulmonary paired acute and
increased oxygen requirements, or
dysplasia, pulmonary increased ventilator demand) convalescent sera by
edema, or chronic indirect IFA
obstructive pulmonary
disease), at least one
• Detection of Legionella
definitive chest imaging test
pneumophila serogroup 1
result is acceptable. (1)
antigens in urine by RIA or
EIA

6-8
 January 2025 Device-associated Module
PNEU

Table 4: Specific Site Algorithm for Pneumonia in Immunocompromised

Patients (PNU3)
NOTE: The PNEU Algorithms (PNU1,2,3) and Flowcharts include FOOTNOTE references. The interpretation and
guidance provided in the FOOTNOTES are an important part of the algorithms and must be incorporated into
the decision-making process when determining if a PNEU definition is met.

Imaging Test Evidence Signs/Symptoms Laboratory

Patient who is immunocompromised
Two or more serial chest At least one of the following:
(see definition in footnote 10) has at
imaging test results with at
least one of the following:
least one of the following • Identification of matching Candida
(1,2,13): spp. from blood and one of the
• Fever (> 38.0°C or > 100.4°F) following respiratory specimens:
New and persistent sputum, endotracheal aspirate, BAL,
• For adults ≥ 70 years old, altered or protected specimen brushing
or
mental status with no other (11,12); blood specimen and
Progressive and persistent recognized cause respiratory specimen must have
collection dates that occur within
• Infiltrate • New onset of purulent sputum (3), or the same IWP
change in character of sputum (4), or
• Consolidation increased respiratory secretions, or • Evidence of fungi (excluding any
increased suctioning requirements Candida and yeast not otherwise
• Cavitation specified) from minimally
• Dyspnea, or tachypnea (5), or new contaminated LRT specimen
• Pneumatoceles, in onset or worsening cough (specifically BAL, protected
infants ≤1 year old specimen brushing or endotracheal
• Rales (6) or bronchial breath sounds aspirate) from one of the following:

Note: In patients without • Worsening gas exchange (for − Direct microscopic exam
underlying pulmonary or example, O2 desaturations [for − Positive culture of fungi
cardiac disease (such as example, PaO2/FiO2 ≤ 240] (7), − Non-culture diagnostic
respiratory distress increased oxygen requirements, or laboratory test
syndrome, increased ventilator demand)
bronchopulmonary OR
dysplasia, pulmonary • Hemoptysis
edema, or chronic Any of the following from:
• Pleuritic chest pain
obstructive pulmonary
disease), at least one LABORATORY CRITERIA DEFINED
definitive chest imaging UNDER PNU2
test result is acceptable. (1)

6-9
 January 2025 Device-associated Module
PNEU

Figure 1: Pneumonia Flow Diagram for Patients of Any Age

NOTE: The PNEU Algorithms (PNU1,2,3) and Flowcharts include FOOTNOTE references. The interpretation and
guidance provided in the FOOTNOTES are an important part of the algorithms and must be incorporated into
the decision-making process when determining if a PNEU definition is met.

Patient with underlying disease 1,2,13 has 2 or more Patient without underlying disease1,2,13 has 1 or more
imaging test results with at least one of the following: OR imaging test results with at least one of the following: PNU 1
IMAGING

New & persistent OR New & persistent OR PNU 2

Progressive & persistent Progressive & persistent PNU 3
 Infiltrate  Infiltrate
 Consolidation  Consolidation
 Cavitation  Cavitation
 Pneumatoceles, in ≤ 1 y.o  Pneumatoceles, in ≤ 1 y.o.

PNU1 / PNU2
At least one of the following:
 Fever (> 38.0°C or > 100.4°F)
 Leukopenia (≤ 4,000 WBC/mm3) or leukocytosis (≥ 12,000 WBC/mm3)
 Altered mental status with no other cause, in ≥ 70 y.o.
SIGNS & SYMPTOMS

PNU1 PNU2 PNU3

And at least two of the following (from And at least one of the following: At least one of the following in an immunocompromised
separate bullets):  New onset of purulent sputum3, patient10 :
 New onset of purulent or change in character of
sputum3, or change in character sputum4, or increased  Fever (> 38.0°C or > 100.4°F)
of sputum4, or increased respiratory secretions, or  Altered mental status with no other cause, in ≥ 70 y.o.
respiratory secretions, or increased suctioning  New onset of purulent sputum3, or change in character of
increased suctioning requirements sputum4, or increased respiratory secretions, or increased
requirements  Dyspnea, or tachypnea5, or new suctioning requirements
 Dyspnea, or tachypnea5, or new onset or worsening cough  Dyspnea, or tachypnea5, or new onset or worsening cough
onset or worsening cough  Rales 6 or bronchial breath  Rales 6 or bronchial breath sounds
 Rales 6 or bronchial breath sounds  Worsening gas exchange (for example, O 2 desaturations
sounds  Worsening gas exchange (for [for example, PaO2/FiO 2 ≤ 240]7, increased oxygen
 Worsening gas exchange (for example, O 2 desaturations [for requirements, or increased ventilator demand)
example, O2 desaturations [for example, PaO2/FiO 2 < 240]7,  Hemoptysis
example, PaO2/FiO 2 ≤ 240]7, increased oxygenation  Pleuritic chest pain
increased oxygen requirements, or increased
requirements, or increased ventilator demand)
ventilator demand)

PNU2 / PNU3 PNU2 / PNU3 PNU3

At least one of the following: At least one of the following: At least one of the following:
 Organism identified from blood8,12  Virus, Bordetella, Legionella,  Identification of matching Candida
 Organism identified from pleural Chlamydia, or Mycoplasma identified spp. from blood and one of the
fluid9,12 from respiratory secretions or tissue following respiratory specimens:
 Positive quantitative culture or by a culture or non-culture based sputum, endotracheal aspirate, BAL
microbiologic testing method which or protected specimen brushing 11,12;
LABORATORY

corresponding semi-quantitative
result9 from minimally-contaminated is performed for purposes of clinical blood specimen and respiratory
LRT specimen (specifically, BAL, diagnosis or treatment (for example, specimen must have collection dates
protected specimen brushing, or not Active Surveillance Culture/ that occur within the same IWP
endotracheal aspirate) Testing (ASC/AST))  Evidence of fungi (excluding any
 ≥ 5% BAL-obtained cells contain  4-fold rise in paired sera (IgG) for Candida spp. and yeast not
intracellular bacteria on direct pathogen (for example, influenza otherwise specified) from minimally
microscopic exam viruses, Chlamydia) contaminated LRT specimen
 Positive quantitative culture or  4-fold rise in Legionella pneumophila (specifically BAL, protected specimen
corresponding semi-quantitative antibody titer to ≥ 1:128 in paired brushing or endotracheal aspirate)
result9 of lung tissue acute and convalescent sera by from one of the following:
 Histopathologic exam shows at least indirect IFA • Direct microscopic exam
one of the following:  Detection of Legionella pneumophila • Positive culture of fungi
• Abscess formation or foci of serogroup 1 antigens in urine by RIA • Non-culture diagnostic
consolidation with intense or EIA laboratory test
PMN accumulation in
bronchioles and alveoli
• Evidence of lung
parenchyma invasion by
fungal hyphae or
pseudohyphae

PNU1 PNU2 PNU3

6 - 10
 January 2025 Device-associated Module
PNEU

Figure 2: Pneumonia Flow Diagram, Alternative Criteria for Infants and

Children
NOTE: The PNEU Algorithms (PNU1,2,3) and Flowcharts include FOOTNOTE references. The interpretation and
guidance provided in the FOOTNOTES are an important part of the algorithms and must be incorporated into
the decision-making process when determining if a PNEU definition is met.

Patient with underlying disease1,2,13 has 2 or more Patient without underlying disease1,2,13 has 1 or more
imaging test results with at least one of the following: imaging test results with at least one of the following:
IMAGING

New & persistent New & persistent

OR OR
Progressive & persistent Progressive & persistent
 Infiltrate  Infiltrate
 Consolidation  Consolidation
 Cavitation  Cavitation
 Pneumatoceles, in ≤ 1 y.o  Pneumatoceles, in ≤ 1 y.o.

ALTERNATE CRITERIA for infants ALTERNATE CRITERIA for children

≤ 1 year old > 1 year old or ≤ 12 years old

Worsening gas exchange (for example, O2 At least THREE of the following (from separate
SIGNS & SYMPTOMS


desaturations [for example, pulse bullets):
oximetry < 94%], increased oxygen
requirements, or increased ventilator  Fever (> 38.0°C or > 100.4°F) or
demand) hypothermia (< 36.0°C or < 96.8°F)
 Leukopenia (≤ 4000 WBC/mm3) or
AND at least THREE of the following (from leukocytosis (≥ 15,000 WBC/mm3)
separate bullets):  New onset of purulent sputum3, or
change in character of sputum4, or
 Temperature instability increased respiratory secretions, or
 Leukopenia (≤ 4000 WBC/mm3) or increased suctioning requirements
leukocytosis (≥ 15,000 WBC/mm3) and  Dyspnea, or apnea, or tachypnea5, or new
left shift (≥ 10% band forms) onset or worsening cough
 New onset of purulent sputum3, or  Rales6 or bronchial breath sounds
change in character of sputum4, or  Worsening gas exchange (for example, O2
increased respiratory secretions, or desaturations [for example, pulse
increased suctioning requirements oximetry < 94%], increased oxygen
 Apnea, tachypnea5, nasal flaring with requirements, or increased ventilator
retraction of chest wall, or nasal flaring demand)
with grunting
 Wheezing, rales6, or rhonchi
 Cough
 Bradycardia (< 100 beats/min) or
tachycardia (> 170 beats/min)

PNU1

6 - 11
 January 2025 Device-associated Module
PNEU

Footnotes to Algorithms and Flow Diagrams

1. To help confirm difficult cases, multiple imaging test results spanning over several calendar days
must be considered when determining if there is imaging test evidence of pneumonia.
Pneumonia may have rapid onset and progression but does not resolve quickly. Imaging test
evidence of pneumonia will persist. Rapid imaging resolution suggests that the patient does not
have pneumonia, but rather a non-infectious process such as atelectasis or congestive heart
failure.
• The diagnosis of healthcare-associated pneumonia may be quite clear on the basis of
signs, symptoms, and a single definitive chest imaging test result. Therefore, in a patient
without underlying pulmonary or cardiac disease and when there is only one imaging
test available, if the imaging finding is an eligible and definitive finding, the imaging test
evidence requirement can be met.
• In patients without underlying disease, if more than one imaging test is available the
serial imaging test results (within a 7-day timeframe) must also be evaluated and must
demonstrate persistence of eligible and definitive findings.
• In patients with underlying pulmonary or cardiac disease (such as interstitial lung
disease, congestive heart failure, etc.), the diagnosis of pneumonia may be particularly
difficult. For example, imaging findings of pulmonary edema from decompensated
congestive heart failure may simulate the presentation of pneumonia. Therefore, in
patients with underlying disease, serial chest imaging test results (within a 7-day
timeframe) must be examined and must demonstrate persistence of eligible and
definitive findings to help separate infectious from non-infectious pulmonary processes.

2. Note that there are many ways of describing the imaging appearance of pneumonia. Examples
include, but are not limited to, “air-space disease,” “focal opacification,” “patchy areas of
increased density.” Although perhaps not specifically delineated as pneumonia by the
radiologist, in the appropriate clinical setting these alternative descriptive wordings should be
seriously considered as potentially positive findings. If provided and the findings are not
documented as attributed to another issue (for example, pulmonary edema, chronic lung
disease), they are eligible for meeting imaging test evidence of pneumonia.

3. Purulent sputum is defined as secretions from the lungs, bronchi, or trachea that contain ≥ 25
neutrophils and ≤ 10 squamous epithelial cells per low power field (x100). Refer to the table
below if your laboratory reports these data semi-quantitatively or uses a different format for
reporting Gram stain or direct examination results (for example, “many WBCs” or “few
squamous epithelial cells”). This laboratory confirmation is required since written clinical
descriptions of purulence are highly variable.

6 - 12
 January 2025 Device-associated Module
PNEU

How do I use the purulent respiratory Instruction

secretions criterion if …
My laboratory reports counts of “white blood Assume that counts of cells identified by these other
cells” or “polymorphonuclear leukocytes” or descriptors (for example, “white blood cells”) are
“leukocytes” rather than counts of equivalent to counts of neutrophils, unless the
“neutrophils”? laboratory tells you this is not the case.
My laboratory reports semi-quantitative Check with the laboratory to get information about
results (not quantitative results) for numbers what quantitative ranges the semi-quantitative reports
of neutrophils and squamous epithelial cells? correspond to.
My laboratory cannot provide additional Use the following direct examination results to meet
information on how its semi-quantitative the purulent respiratory secretions criterion: many,
reporting corresponds to quantitative heavy, numerous 4+, or ≥ 25 neutrophils per low
reporting ranges for neutrophils and power field (lpf) [x100], AND no, rare, occasional, few,
squamous epithelial cells? 1+ or 2+, or ≤ 10 squamous epithelial cells per lpf
[x100].
My laboratory reports only the numbers of In this situation, the purulent secretions criterion may
neutrophils present, without reporting the be met using the specified quantitative and semi-
number of squamous epithelial cells? quantitative thresholds for neutrophils alone
(specifically many, heavy, numerous, 4+, or ≥ 25
neutrophils per lpf [x100]).
My laboratory uses different reporting In this situation, the purulent secretions criterion may
thresholds for neutrophils and squamous be met using the laboratory’s specified maximum
epithelial cells (for example, maximum report quantitative threshold for neutrophils, and/or
of ≥ 20 neutrophils per low power field minimum quantitative threshold for squamous
[x100], or minimum report of ≤ 15 squamous epithelial cells.
epithelial cells per low power field [x100])?
My laboratory processes respiratory In this situation, a report indicating the presence of
specimens such as bronchoalveolar lavage white blood cells, without quantitation, is sufficient to
fluid using a centrifugation procedure (for meet the purulent secretions criterion.
example, “cytospin”), and there is no
quantitation or semi-quantitation of
neutrophils or white blood cells in the direct
examination report?

4. Change in character of sputum refers to the color, consistency, odor, and quantity.
5. In adults, tachypnea is defined as respiration rate > 25 breaths per minute. Tachypnea is defined
as > 75 breaths per minute in premature infants born at < 37 weeks gestation and until the 40th
week; > 60 breaths per minute in patients < 2 months old; > 50 breaths per minute in patients 2-
12 months old; and > 30 breaths per minute in children > 1 year old.
6. Rales may be described as “crackles”.

6 - 13
 January 2025 Device-associated Module
PNEU

7. This measure of arterial oxygenation is defined as the ratio of the arterial tension (PaO2) to the
inspiratory fraction of oxygen (FiO2).
8. Any coagulase-negative Staphylococcus species, any Enterococcus species, and any Candida
species or yeast not otherwise specified that are identified from blood cannot be deemed
secondary to a PNEU event unless the organism was also identified from lung tissue or pleural
fluid (where specimen was obtained during thoracentesis or within 24 hours of chest tube
placement; a pleural fluid specimen collected after a chest tube is repositioned or from a chest
tube in place > 24 hours is not eligible). This applies when meeting PNU2 or when meeting PNU3
(for patients meeting the immunocompromised definition) with the laboratory findings found in
PNU2. Identification of matching Candida spp. from blood and sputum, endotracheal aspirate,
BAL, or protected specimen brushing with specimen collection dates in the same IWP can be
used to satisfy PNU3 definition for patients meeting the immunocompromised definition (see
footnote 10).
9. Refer to threshold values in Table 5 for cultured specimens (lung tissue, BAL, protected
specimen brushing, or endotracheal aspirate) with growth of eligible pathogens.
Notes:
• A specimen that is not obtained through an artificial airway (specifically an endotracheal
tube or a tracheostomy) from a ventilated patient is not considered minimally
contaminated and is not eligible for use in meeting the laboratory criteria for PNEU
(PNU2 or PNU3 when using the laboratory findings found in PNU2). Sputum or tracheal
secretions collected from a non-ventilated patient are not minimally contaminated
specimens.
• The following organisms can only be used to meet PNEU definitions when identified
from lung tissue or pleural fluid obtained during thoracentesis or within 24 hours of
chest tube placement (not from a chest tube that has been repositioned or from a chest
tube that has been in place > 24 hours):
o Any coagulase-negative Staphylococcus species
o Any Enterococcus species
o Any Candida species or yeast not otherwise specified.
• Exception: identification of matching Candida spp. from blood and
sputum, endotracheal aspirate, BAL, or protected specimen brushing
with specimen collection dates in the same IWP can be used to satisfy
PNU3 definition for immunocompromised patients (see footnote 10).
10. Immunocompromised patients include only

• those with neutropenia defined as absolute neutrophil count or total white blood cell count
(WBC) < 500/mm3
• those with leukemia, lymphoma, or who are HIV positive with CD4 count < 200
• those who have undergone splenectomy
• those who have a history of solid organ or hematopoietic stem cell transplant
• those on cytotoxic chemotherapy
• those on enteral or parenteral administered steroids (excludes inhaled and topical steroids)
daily for > 14 consecutive days on the date of event

6 - 14
 January 2025 Device-associated Module
PNEU

11. Sputum obtained by any method (such as deep cough, induction, aspiration, or lavage) are
acceptable specimens. Any quantity of organism identified is acceptable, to include all non-
quantitative, semi-quantitative, and quantitative results.
12. Identification of organism by a culture or non-culture based microbiologic testing method which
is performed for purposes of clinical diagnosis or treatment (for example, not Active Surveillance
Culture/Testing (ASC/AST)).
13. If the imaging test result is equivocal for pneumonia, check to see if subsequent imaging tests
are definitive. For example, if a chest imaging test result states infiltrate vs. atelectasis and a
subsequent imaging test result is definitive for infiltrate, the initial imaging test would be eligible
for use. In the absence of finding a subsequent imaging result that clarifies the equivocal finding,
if there is clinical correlation then the equivocal imaging test is eligible for use. See Chapter 16
for definitions of equivocal imaging and clinical correlation.

Table 5: Threshold values for cultured specimens used in the diagnosis of

pneumonia
Specimen collection/technique Values*
Lung tissue† ≥ 104 CFU/g tissue
Bronchoscopically (B) obtained specimens
Bronchoalveolar lavage (B-BAL) ≥ 104 CFU/ml
Protected BAL (B-PBAL) ≥ 104 CFU/ml
Protected specimen brushing (B-PSB) ≥ 103 CFU/ml
Nonbronchoscopically (NB) obtained (blind) specimens
NB-BAL ≥ 104 CFU/ml
NB-PSB ≥ 103 CFU/ml
Endotracheal aspirate (ETA) ≥ 105 CFU/ml
CFU = colony forming units, g = gram, ml = milliliter
*Consult with your laboratory to determine if reported semi-quantitative results match the quantitative
thresholds. In the absence of additional information available from your laboratory, a semi-quantitative
result of “moderate” or “heavy” or “many” or “numerous” growth, or 2+, 3+, or 4+ growth is considered
to correspond.
†Lung tissue specimens obtained by either open or closed lung biopsy methods. For post-mortem
specimens, only lung tissue specimens obtained by transthoracic or transbronchial biopsy that are
collected immediately post-mortem are eligible for use.

6 - 15
 January 2025 Device-associated Module
PNEU

Numerator Data
The Pneumonia (PNEU) form (CDC 57.111) is used to collect and report each VAP that is identified during
the month selected for surveillance. The Instructions for Completion of Pneumonia (PNEU) form contains
brief instructions for collection and entry of each data element on the form. The pneumonia form
includes patient demographic information and information on whether or not mechanically assisted
ventilation was present. Additional data include the specific criteria met for identifying pneumonia,
whether the patient developed a secondary bloodstream infection, whether the patient died, the
organisms identified from culture or non-culture based microbiologic testing methods, and the
organisms’ antimicrobial susceptibilities.
Reporting Instruction: If no VAPs are identified during the month of surveillance, the “Report No Events”
box must be checked on the appropriate denominator summary screen, for example, Denominators for
Intensive Care Unit (ICU)/Other Locations (Not NICU or SCA/ONC), etc.

Denominator Data
Device days and patient days are used for denominators (see Chapter 16). Ventilator days, which are the
number of patients managed with a ventilatory device, are collected daily, at the same time each day,
according to the chosen location using the appropriate form (CDC 57.116 [NICU], 57.117 [Specialty Care
Areas], and 57.118 [ICU/Other Locations]). These daily counts are summed and only the total for the
month is entered into NHSN. Ventilator days and patient days are collected for each of the locations
where VAP is monitored. When denominator data are available from electronic sources, these sources
may be used as long as the counts are within +/- 5% of manually collected counts, validated for a
minimum of three consecutive months. Validation of electronic counts should be performed separately
for each location conducting VAP surveillance.
When converting from one electronic counting system to another electronic counting system, the new
electronic system should be validated against manual counts as above. If electronic counts for the new
electronic system are not within 5% of manual counts, resume manual counting and continue working
with IT staff to improve design of electronic denominator data extraction (while reporting manual
counts) until concurrent counts are within 5% for 3 consecutive months.
Note: This guideline is important because validating a new electronic counting system against an
existing electronic system can magnify errors and result in inaccurate denominator counts.

6 - 16
 January 2025 Device-associated Module
PNEU

Data Analyses
All data that is entered into NHSN can be analyzed at event or summary level. The data in NHSN can be
visualized and analyzed in various ways, specifically, descriptive analysis reports for both the
denominator and numerator data.

Types of VAP Analysis Reports

VAP Rate
The VAP rate per 1000 ventilator days is calculated by dividing the number of VAPs by the number of
ventilator days and multiplying the result by 1000 (ventilator days).

𝑁𝑁𝑁𝑁. 𝑁𝑁𝑜𝑜 𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉

VAP Rate per 1000 ventilator days = * 1000
𝑁𝑁𝑁𝑁. 𝑁𝑁𝑜𝑜 𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑁𝑁𝑉𝑉 𝐷𝐷𝑉𝑉𝐷𝐷𝑉𝑉

Device Utilization Ratio

The Ventilator Utilization Ratio is calculated by dividing the number of ventilator days by the number of
patient days. These calculations will be performed separately for the different types of ICUs, SCAs, and
other locations in the institution.

𝑁𝑁𝑁𝑁. 𝑁𝑁𝑜𝑜 𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑁𝑁𝑉𝑉 𝐷𝐷𝑉𝑉𝐷𝐷𝑉𝑉

DUR =
𝑁𝑁𝑁𝑁. 𝑁𝑁𝑜𝑜 𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉 𝐷𝐷𝑉𝑉𝐷𝐷𝑉𝑉

Descriptive Analysis Output Options

Descriptive analysis output options of numerator and denominator data, such as line listings, frequency
tables, and bar and pie charts are also available in the NHSN application.
Line List: Creating a Line List
Frequency Tables: Creating a Frequency Table
Bar Chart: Creating a Bar Chart
Pie Chart: Creating a Pie Chart
Rate Table: Creating a Rate Table

Analysis Resources Links

Analysis Resources Website
Analysis Quick Reference Guides

Data Quality Resources Links

Data Quality Website
Data Quality Manual
Data Quality Training

6 - 17
 January 2025 Device-associated Module
PNEU

Table 6: VAP Measures Available in NHSN

Measure Calculation Application

The number of VAPs for a location Location specific

VAP Rates X 1000
The number of Ventilator Days for that location measure only

Location specific
DUR The number of Ventilator Days for a location
measure only
The number of Patient Days for that location

NHSN Group Analysis

NHSN Group Users can perform the same analysis as facility level users in NHSN. A few helpful tools in
NHSN for groups are listed in the resources below. These tools are guides on how to start and join a
Group; how to create a template to request data from facilities; how to determine the level of access
granted by the facility following the previous steps, and how to analyze the facilities data.

Group Analysis Resources

NHSN Group Users Page:
https://www.cdc.gov/nhsn/group-users/index.html
Group User’s Guide to the Membership Rights Report:
https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/GroupAnalysisWebinar.pdf
Group User’s Guide to the Line Listing - Participation Alerts:
https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/group-alerts.pdf

6 - 18
 January 2025 Device-associated Module
PNEU

References
1
Magill SS, O’Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care–Associated Infections in U.S.
Hospitals. N Engl J Med. 2018;379(18):1732-1744.
2
Magill SS, Klompas M, Balk R, et al. Developing a new, national approach to surveillance for ventilator-
associated events. Crit Care Med. 2013;41(11):2467-2475.

6 - 19