title: Is HELICS the Right Way? Lack of Chest Radiography Limits Ventilator-Associated Pneumonia Surveillance in Wales.
abstract: BACKGROUND
  The reported incidence of ventilator-associated pneumonia (VAP) in Wales is low compared with surveillance data from other European regions. It is unclear whether this reflects success of the Welsh healthcare-associated infection prevention measures or limitations in the application of European VAP surveillance methods. Our primary aim was to investigate episodes of ventilator-associated respiratory tract infection (VARTI), to identify episodes that met established criteria for VAP, and to explore reasons why others did not, according to the Hospitals in Europe Link for Infection Control through Surveillance (HELICS) definitions.
  
  
  METHODS
  During two 14-day study periods 2012-2014, investigators reviewed all invasively ventilated patients in all 14 Welsh Intensive Care Units (ICUs). Episodes were identified in which the clinical team had commenced antibiotic therapy because of suspected VARTI. Probability of pneumonia was estimated using a modified Clinical Pulmonary Infection Score (mCPIS). Episodes meeting HELICS definitions of VAP were identified, and reasons for other episodes not meeting definitions examined. In the second period, each patient was also assessed with regards to the development of a ventilator-associated event (VAE), according to recent US definitions.
  
  
  RESULTS
  The study included 306 invasively ventilated patients; 282 were admitted to ICU for 48 h or more. 32 (11.3%) patients were commenced on antibiotics for suspected VARTI. Ten of these episodes met HELICS definitions of VAP, an incidence of 4.2 per 1000 intubation days. In 48% VARTI episodes, concurrent chest radiography was not performed, precluding the diagnosis of VAP. Mechanical ventilation (16.0 vs. 8.0 days; p = 0.01) and ICU stay (25.0 vs. 11.0 days; p = 0.01) were significantly longer in patients treated for VARTI compared to those not treated. There was no overlap between episodes of VARTI and of VAE.
  
  
  CONCLUSIONS
  HELICS VAP surveillance definitions identified less than one-third of cases in which antibiotics were commenced for suspected ventilator-associated RTI. Lack of chest radiography precluded nearly 50% cases from meeting the surveillance definition of VAP, and as a consequence we are almost certainly underestimating the incidence of VAP in Wales.
authors: Department of Anaesthetics, Glan Clwyd Hospital Bodelwyddan, Wales.
authors: Richard
authors: R
authors: Pugh
authors: Public Health Wales, Temple of Peace and Health Cardiff, Wales.
authors: Wendy
authors: W
authors: Harrison
authors: Public Health Wales, Temple of Peace and Health Cardiff, Wales.
authors: Susan
authors: S
authors: Harris
authors: Adult Critical Care Services, University Hospital WalesCardiff, Wales; Cardiff Institute of Infection and Immunity, Cardiff UniversityCardiff, Wales.
authors: Hywel
authors: H
authors: Roberts
authors: Adult Critical Care Services, University Hospital Wales Cardiff, Wales.
authors: Gareth
authors: G
authors: Scholey
authors: Cardiff Institute of Infection and Immunity, Cardiff UniversityCardiff, Wales; Directorate of Critical Care, Royal Gwent HospitalNewport, Wales.
authors: Tamas
authors: T
authors: Szakmany
keywords: respiratory tract infection; surveillance; ventilator-associated complication; ventilator-associated event; ventilator-associated pneumonia; ventilator-associated tracheobronchitis