SEPT 13 Built from the handwritten pages you uploaded on 13 September 2026.

Ventilator-associated pneumonia & the CPIS

Organisms, risk factors, diagnosis, the Clinical Pulmonary Infection Score, and prevention.

Definition & organisms

Pneumonia developing more than 48 hours after intubation.

Onset	Typical organisms
Early — days 2–4	Community flora: S. pneumoniae, H. influenzae, MSSA, sensitive Gram-negatives
Late — day 5 onward	MRSA, Pseudomonas aeruginosa (most common), E. coli, Klebsiella pneumoniae, Acinetobacter — multidrug-resistant, hospital-acquired

Group	Factors
1 · Patient	Age > 55, immunocompromise, malnutrition and low albumin, acute illness, COPD, polytrauma and burns, reduced GCS
2 · Colonisation of oropharynx and stomach	Poor oral hygiene, recent antibiotics
3 · Aspiration	Reintubation, nasogastric tube, supine or flat positioning, nasal endotracheal tube, heavy sedation, neuromuscular blockade
4 · Prolonged ventilation	ARDS, high PEEP requirement

Bronchoalveolar lavage or protected specimen brushing — the reference samples in practice.
Quantitative thresholds: BAL ≥ 10⁴ CFU/ml · protected brush ≥ 10³ · endotracheal aspirate ≥ 10⁵.
Antibiotics given first sterilise the sample and cause false negatives.

Six components, each scored 0–2, maximum 12.

Component	0	1	2
1 · Tracheal secretions	Rare	Abundant	Abundant and purulent
2 · Chest X-ray infiltrate	None	Diffuse	Localised
3 · Temperature (°C)	36.5–38.4	38.5–38.9	≥ 39 or ≤ 36
4 · White cells (×10⁹/L)	4–11	< 4 or > 11	< 4 or > 11 plus band forms
5 · PaO₂/FiO₂ (mmHg)	> 240, or ARDS present	—	≤ 240 with no ARDS
6 · Microbiology	Negative	—	Positive

A score of 6 or more is taken as VAP (Pugin's original cut-off is > 6 — know both).
The trick rows: localised X-ray scores more than diffuse; and ARDS scores 0 for oxygenation, because ARDS alone explains the hypoxia.
A score that stays low at 72 h supports stopping antibiotics.

Head of bed 30–45°.
Daily sedation hold and spontaneous breathing trial — extubate early.
Subglottic secretion drainage tubes; cuff pressure 20–30 cmH₂O.
Oral care; oral rather than nasal intubation; avoid unplanned extubation and reintubation.

> 48 h after intubation

Pseudomonas commonest late

BAL before antibiotics

CPIS ≥ 6 VAP

6 items max 12

240 P/F cut-off

30–45° head up