title: Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates.
abstract: BACKGROUND
  No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients.
  
  
  METHODS
  A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients.
  
  
  RESULTS
  Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41).
  
  
  CONCLUSIONS
  The lack of standard diagnostic criteria for VAP resulted in variable reporting to different agencies. Emphasis on establishing a consensus VAP definition should be undertaken.
authors.affiliation: 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina.
authors.forename: Kenji L
authors.initials: KL
authors.lastname: Leonard
authors.affiliation: 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina.
authors.forename: Gregory M
authors.initials: GM
authors.lastname: Borst
authors.affiliation: 2 Department of Surgery, University of Virginia , School of Medicine, Charlottesville, Virginia.
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Davies
authors.affiliation: 3 Department of Infection Control, Vidant Medical Center , Greenville, North Carolina.
authors.forename: Michael
authors.initials: M
authors.lastname: Coogan
authors.affiliation: 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina.
authors.forename: Brett H
authors.initials: BH
authors.lastname: Waibel
authors.affiliation: 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina.
authors.forename: Nathaniel R
authors.initials: NR
authors.lastname: Poulin
authors.affiliation: 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Bard
authors.affiliation: 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina.
authors.forename: Claudia E
authors.initials: CE
authors.lastname: Goettler
authors.affiliation: 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina.
authors.forename: Shane M
authors.initials: SM
authors.lastname: Rinehart
authors.affiliation: 1 Department of Surgery, Division of Trauma and Acute Care Surgery, The Brody School of Medicine, East Carolina University , Greenville, North Carolina.
authors.forename: Eric A
authors.initials: EA
authors.lastname: Toschlog
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D012042:Registries; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014193:Trauma Centers; D014481:United States; D014947:Wounds and Injuries / Q000150:complications*; D055815:Young Adult