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Jennifer Watkins of NHSN emphasizes imaging as the pivotal and most-challenging component of 2025 pneumonia surveillance
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Summary
At a 2025 NHSN training, Jennifer Watkins outlined the three pneumonia surveillance criteria and said imaging—must be new/progressive and persistent—is the gating element for all pneumonia events; she reviewed how to handle equivocal findings, persistence timelines and radiology report review.
Jennifer Watkins, a member of the NHSN protocol and training team, led a 2025 training on the NHSN pneumonia surveillance definition and said the imaging element is the central, most challenging part of meeting pneumonia criteria. "Determining if the imaging test results meet the imaging requirement is the most challenging part of pneumonia surveillance," she told attendees.
Watkins summarized that the pneumonia surveillance definition can be met by any of three criteria: pneumonia 1 (clinically defined; no laboratory evidence required), pneumonia 2 (requires laboratory evidence in addition to imaging and signs/symptoms), and pneumonia 3 (applies to patients who meet the immunocompromised definition in footnote 10 and also requires laboratory evidence). She said the imaging element must be met before signs/symptoms or laboratory elements are considered.
On what counts as positive imaging, Watkins listed infiltrate, consolidation, cavitation and—for infants ≤1 year—pneumatoceles as definitive imaging findings. She said nonspecific findings such as opacities, densities or "airspace disease" can be considered potentially eligible imaging evidence only if they are not documented as representing another cause (for example, atelectasis or pulmonary edema) and are interpreted in context per footnote guidance.
Watkins explained the new/progressive and persistence requirements: a finding is new if it was not present on prior imaging and progressive if it is worse than prior imaging. Persistence must be demonstrated (she recommended reviewing available imaging for at least seven days when possible). Rapid radiologic resolution, she said, argues against pneumonia and suggests a noninfectious process.
When imaging is equivocal, Watkins instructed reviewers to first seek subsequent imaging for clarification; if subsequent imaging is definitive for pneumonia, earlier equivocal images become eligible. If no clarifying images exist, physician documentation of antimicrobial treatment for pneumonia can serve as clinical correlation under footnote 13 to clarify equivocal imaging findings. She cautioned, "Clinical correlation can only be used to clarify equivocal imaging findings; if the imaging findings are not eligible, the imaging requirement cannot be met even with clinical correlation."
Watkins urged reviewers to read the entirety of an imaging report (findings and impressions) because format and language vary across reports; where reports use nonspecific terms, the radiologist's impression and the overall imaging picture must guide eligibility determinations. She closed the section with case-study practice illustrating persistence, rapid resolution, and the serial imaging requirement for patients with underlying pulmonary or cardiac disease.
The training materials, she said, including the pneumonia protocol (chapter 6 of the NHSN Patient Safety Component Manual), the pneumonia training page and FAQs on the pneumonia events webpage, contain the algorithms, tables and footnotes that implement these rules. For additional assistance, Watkins directed attendees to the NHSN ServiceNow portal or nhsn@cdc.gov.
