376. Careful Attention to Serial Interpretation of Chest X-rays (CXR) May Alter Surveillance Reporting of Ventilator-associated Pneumonia (VAP) Compared to Use of Radiographic Reports
Session: Poster Session: Hospital-acquired and Transplant Infections
Friday, October 30, 2009: 12:00 AM
Room: Poster Hall A
Background: Diagnosis of VAP remains difficult. Since VAP surveillance definitions utilize CXR reports, we sought to determine if serial review of CXRs by a single radiologist would change the surveillance diagnosis of VAP compared to using CXR reports alone.
Methods: Characteristics of patients undergoing mini-bronchoalveolar lavage for suspicion of VAP between 11/08 and 4/09 were reviewed. VAP was classified using either clinical or surveillance methods. Clinical VAP was determined prospectively by the clinical pulmonary/critical care service. Surveillance VAPs were determined as part of routine infection control activities using National Healthcare Safety Network (NHSN) definitions. All CXRs were reviewed by a single radiologist blinded to the presence of VAP and the diagnostic method.
Results: There were 41 clinical VAPs and 9 surveillance VAPs; all 9 surveillance VAPs were also clinically diagnosed. All 41 patients were treated with antibiotics for VAP. On review by a single radiologist, 39/41 (95%) clinical VAPs had abnormal baseline CXRs. Among all 41 clinical VAPs, 34 (84%) had persistent or progressive CXR changes potentially meeting NHSN CXR criteria. However, in 16 (39%) of these 34 CXRs there was marked improvement within 7 days, leaving 18 CXRs with persistent radiographic changes beyond 7 days. Review of the final CXR reports did not clearly delineate the sequential presence of NHSN radiographic criteria in any of these 18 CXR, all of whom also met NHSN clinical and microbiologic criteria. On the radiologist’s independent reading, 8/9 (89%) surveillance VAPs met NHSN CXR criteria.
Conclusion: The ubiquity of baseline abnormalities makes CXR assessment challenging in critically ill patients. Compared to the final radiology reports, examination of serial CXRs by a single radiologist doubled the number of patients meeting NHSN VAP criteria.
Eugene Berkowitz, MD1, Elaine Chang, NP1, Seth Clemens, MD1, Jesse Jacob, MD1, Kenneth Leeper, Jr, MD1, Monica Maher, RN1, James Steinberg, MD and  J. T. Jacob,
Baxter Healthcare Corp Received: Grant Recipient.
S. W. Clemens, None..
E. Chang, None..
M. Maher, None..
E. A. Berkowitz, None..
K. V. Leeper, Jr, None. 
J. P. Steinberg,
Baxter Healthcare Corp Received: Grant Recipient., (1)Emory University, Atlanta, GA