Ipg.uni-linz.ac.at

infection control and hospital epidemiology s u p p l e m e n t a r t i c l e : s h e a / i d s a p r a c t i c e r e c o m m e n d a t i o n Strategies to Prevent Ventilator-Associated Pneumonia
in Acute Care Hospitals
Susan E. Coffin, MD, MPH; Michael Klompas, MD; David Classen, MD, MS; Kathleen M. Arias, MS, CIC;
Kelly Podgorny, RN, MS, CPHQ; Deverick J. Anderson, MD, MPH; Helen Burstin, MD; David P. Calfee, MD, MS;
Erik R. Dubberke, MD; Victoria Fraser, MD; Dale N. Gerding, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD;
Keith S. Kaye, MD; Evelyn Lo, MD; Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; Lindsay Nicolle, MD;
David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS;
Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPH
natal and surgical patient populations.5-9 The results ofrecent quality improvement initiatives, however, suggest Previously published guidelines are available that provide that many cases of VAP might be prevented by careful comprehensive recommendations for detecting and prevent- ing healthcare-associated infections. The intent of this doc-ument is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing a. VAP is a cause of significant patient morbidity and and prioritizing their ventilator-associated pneumonia (VAP) mortality, increased utilization of healthcare resources, and prevention efforts. Refer to the Society for Healthcare Epi- demiology of America/Infectious Diseases Society of America i. The mortality attributable to VAP may exceed “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and ac- ii. Patients with VAP require prolonged periods of companying editorial for additional discussion.
mechanical ventilation,23 extended hospitalizations,4,11,16 s e c t i o n 1 : r a t i o n a l e a n d s t a t e m e n t s excess use of antimicrobial medications, and increaseddirect medical costs.11,13,14 1. Occurrence of VAP in acute care facilities.
3. Pathogenesis of and risk factors for VAP a. VAP is one of the most common infections acquired a. VAP arises when there is bacterial invasion of the by adults and children in intensive care units (ICUs).1,2 pulmonary parenchyma in a patient receiving mechanical i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP.3,4 More- i. Inoculation of the formerly sterile lower respiratory recent publications report rates of VAP that range from tract typically arises from aspiration of secretions, col- 1 to 4 cases per 1,000 ventilator-days, but rates may onization of the aerodigestive tract, or use of contami- exceed 10 cases per 1,000 ventilator-days in some neo- From the Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (S.E.C.); the Brigham and Women’s Hospital and Harvard Medical School, Boston (M.K., D.S.Y.), and the Institute for Healthcare Improvement, Cambridge (F.A.G.), Massachusetts;the University of Utah, Salt Lake City (D.C.); the Association for Professionals in Infection Control and Epidemiology (K.M.A.) and the National QualityForum (H.B.), Washington, D.C.; the Loyola University Chicago Stritch School of Medicine (D.N.G.), the Stroger (Cook County) Hospital and the RushUniversity Medical Center (R.A.W.), Chicago, the Joint Commission, Oakbrook Terrace (K.P., R.W.), and the Hines Veterans Affairs Medical Center, Hines(D.N.G.), Illinois; the Duke University Medical Center, Durham, North Carolina (D.J.A., K.S.K.); the Mount Sinai School of Medicine, New York, NewYork (D.P.C.); the Washington University School of Medicine, St. Louis, Missouri (E.R.D., V.F., J.M.); the Hackensack University Medical Center, Hackensack(P.G.) and the University of Medicine and Dentistry–New Jersey Medical School, Newark (P.G.), New Jersey; the Warren Alpert Medical School of BrownUniversity and Rhode Island Hospital, Providence, Rhode Island (L.A.M.); the David Geffen School of Medicine at the University of California, Los Angeles(D.A.P.); the Johns Hopkins Medical Institutions and University, Baltimore, Maryland (T.M.P.); the Ann Arbor Veterans Affairs Medical Center and theUniversity of Michigan Medical School, Ann Arbor, Michigan (S.S.); the Medical University of South Carolina, Charleston (C.D.S.); and the University ofManitoba, Winnipeg, Canada (E.L., L.N.).
Accepted June 4, 2008; electronically published September 16, 2008.
Infect Control Hosp Epidemiol 2008; 29:S31–S40᭧ 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0005$15.00. DOI: 10.1086/591062 infection control and hospital epidemiology ii. Risk factors for VAP include prolonged intuba- ii. Colonization of the aerodigestive tract tion,25 enteral feeding,26 witnessed aspiration,27 paralytic iii. Use of contaminated equipment agents,27 underlying illness,7,11,27,28 and extremes of age.28 2. General strategies that have been found to influence the s e c t i o n 2 : s t r a t e g i e s t o d e t e c t v a p i. Conduct active surveillance for VAP.52,53 a. The definition of VAP is perhaps the most subjective ii. Adhere to hand-hygiene guidelines published by of the common device-related healthcare-associated infec- the Centers for Disease Control and Prevention or the tions.29-32 Most hospital epidemiologists and infection pre-vention and control professionals use the VAP definition put forth by the National Healthcare Safety Network, which iii. Use noninvasive ventilation whenever possible.54-61 uses 3 groups of criteria: clinical, radiographic, and iv. Minimize the duration of ventilation.53,62,63 v. Perform daily assessments of readiness to wean5,50 i. Despite the use of a common definition, significant interobserver variability has been noted.34-36 vi. Educate healthcare personnel who care for patients ii. Factors such as the surveillance strategy, diagnostic undergoing ventilation about VAP.52,53,70,71 techniques, and microbiology and laboratory procedures likely account for some of the differences in VAP rates i. Maintain patients in a semirecumbent position (30Њ-45Њ elevation of the head of the bed) unless thereare contraindications.28,50,52,53,57,65,72-76 (a) Experimental trials have demonstrated that a. Active surveillance is required to accurately identify backrest elevation is associated with a reduced risk of patients with VAP.22,37 Case finding by review of adminis- trative data alone, such as discharge diagnosis codes, is (b) Multivariable analysis of risk factors associated inaccurate and lacks both sensitivity and specificity.38,39 with VAP found up to a 67% reduction in VAP among i. Case finding of VAP is complex as a result of clinical patients maintained in semirecumbency during the criteria that vary with age and other host factors.
first 24 hours of mechanical ventilation.28 ii. The need for review of 2 or more chest radiographs (c) The impact of semirecumbency was confirmed for patients with underlying pulmonary or cardiac dis- in an observational study50 and a randomized trial.73 ease also contributes to the difficulties in identifying (d) However, recent studies indicate that semire- cumbent positioning is rarely maintained77 and may iii. Gram staining and semiquantitative culture of en- not be associated with a reduced rate of tracheal col- dotracheal secretions or quantitative culture of speci- mens obtained through bronchoalveolar lavage should ii. Avoid gastric overdistention.26,57,79,80 be performed for a patient suspected to have VAP. The iii. Avoid unplanned extubation and reintuba- question of which method is optimal for specimen col- lection of lower respiratory tract secretions for diagnosis iv. Use a cuffed endotracheal tube with in-line or iv. Information technology, such as electronic sur- (a) Meta-analysis demonstrated that subglottic se- veillance tools, can assist in the identification of patients cretion drainage was effective in preventing early-on- with possible VAP but cannot provide definitive iden- tification and are not yet widely available.43,44 v. Maintain an endotracheal cuff pressure of at least s e c t i o n 3 : s t r a t e g i e s t o p re v e n t v a p c. Strategies to reduce colonization of the aerodigestive 1. Existing guidelines and recommendations a. Guidelines to prevent VAP have been published by i. Orotracheal intubation is preferable to nasotracheal several expert groups and, when fully implemented, im- prove patient outcomes and are cost-effective.45-51 (a) Nasotracheal intubation increases the risk of b. Because few studies have evaluated the prevention of sinusitis,88,89 which may increase the risk for VAP.90,91 VAP in children, the majority of these recommendations ii. Avoid histamine receptor 2 (H2)–blocking agents stem from studies that were performed in adults. The core and proton pump inhibitors for patients who are not at recommendations are designed to interrupt the 3 most high risk for developing a stress ulcer or stress (a) Acid-suppressive therapy may increase the col- onization density of the aerodigestive tract with po- I. Basic practices for prevention and monitoring of VAP:
recommended for all acute care hospitals
(b) Seven meta-analyses have yielded inconsistent results regarding the magnitude of risk associated withthe colonization of the aerodigestive tract.93-98 Health- 1. Educate healthcare personnel who care for patients un- care Infection Control Practices Advisory Committee dergoing ventilation about VAP, including information about Guidelines identified the preferential use of sucralfate or H2-blocking agents as an unresolved issue.52 (c) A single retrospective study of children under- going ventilation found that the rate of VAP did not vary according to the strategy used to prevent gastro-intestinal bleeding.99 2. Educate clinicians who care for patients undergoing iii. Perform regular oral care57,100-103 with an antiseptic ventilation about noninvasive ventilatory strategies (B-III).
solution.101,104-108 The optimal frequency for oral care isunresolved.
d. Strategies to minimize contamination of equipment used to care for patients receiving mechanical ventilation 1. Perform direct observation of compliance with VAP- i. Use sterile water to rinse reusable respiratory a. VAP-specific process measures include hand hygiene, ii. Remove condensate from ventilatory circuits. Keep bed position, daily sedation interruption and assessment of readiness to wean, and regular oral care.
b. Use structured observation tools at regularly sched- iii. Change the ventilatory circuit only when visibly iv. Store and disinfect respiratory therapy equipment 2. Conduct active surveillance for VAP and associated pro- cess measures in units that care for patients undergoing ven-tilation who are known or suspected to be at high risk for s e c t i o n 4 : re c o m m e n d a t i o n s f o r VAP on the basis of risk assessment (A-II).
i m p l e m e n t i n g p re v e n t i o n a n d a. Collect data that will support the identification of patients with VAP and calculation of VAP rates (ie, thenumber of VAP cases and number of ventilator-days for Recommendations for preventing and monitoring VAP are all patients who are undergoing ventilation and in the pop- summarized in the following section. They are designed to assist acute care hospitals in prioritizing and implementingtheir VAP prevention efforts. Criteria for grading the strength of recommendation and quality of evidence are described inthe Table.
1. Implement policies and practices for disinfection, ster- Strength of Recommendation and Quality of Evidence Good evidence to support a recommendation for use Moderate evidence to support a recommendation for use Poor evidence to support a recommendation Evidence from x1 properly randomized, controlled trial Evidence from x1 well-designed clinical trial, without randomization; from cohort or case-control analyticstudies (preferably from 11 center); from multipletime series; or from dramatic results from uncontrolledexperiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports ofexpert committees Adapted from the Canadian Task Force on the Periodic Health Examination.115 infection control and hospital epidemiology ilization, and maintenance of respiratory equipment that are tient education are accountable for ensuring that appropriate aligned with evidence-based standards (eg, guidelines from training and educational programs to prevent VAP are de- the Centers for Disease Control and Prevention and profes- veloped and provided to personnel, patients, and families.
a. See the Appendix for a list of recommended practices.
8. Personnel from the infection prevention and control program, the laboratory, and information technology de- 2. Ensure that all patients (except those with medical con- partments are responsible for ensuring that systems are in traindications) are maintained in a semirecumbent position place to support the surveillance program.
II. Special approaches for the prevention of VAP
3. Perform regular antiseptic oral care in accordance with Perform a VAP risk assessment. These special approaches are recommended for use in locations and/or populations withinthe hospital that have unacceptably high VAP rates despite 4. Provide easy access to noninvasive ventilation equip- implementation of the basic VAP prevention procedures listed ment and institute protocols to promote the use of nonin- 1. Use an endotracheal tube with in-line and subglottic suctioning for all eligible patients (B-II).
1. The hospital’s chief executive officer and senior man- 2. Ensure that all ICU beds used for patients undergoing agement are responsible for ensuring that the healthcare sys- ventilation have a built-in tool to provide continuous mon- tem supports an infection prevention and control program itoring of the angle of incline (B-III).
III. Approaches that should not be considered a routine
2. Senior management is accountable for ensuring that an part of VAP prevention
adequate number of trained personnel are assigned to theinfection prevention and control program.
1. Do not routinely administer intravenous immunoglob- ulin,52 white-cell–stimulating factors (filgrastim or sargra- 3. Senior management is accountable for ensuring that mostim),52 enteral glutamine,52 or chest physiotherapy52,116 (A- healthcare personnel, including licensed and nonlicensed per- sonnel, are competent to perform their job responsibilities.
2. Do not routinely use rotational therapy with kinetic or 4. Direct healthcare providers (such as physicians, nurses, continuous lateral rotational therapy beds (B-II).52,117 aides, and therapists) and ancillary personnel (such as house-keeping and equipment-processing personnel) are responsible 3. Do not routinely administer prophylactic aerosolized or for ensuring that appropriate infection prevention and con- trol practices are used at all times (including hand hygiene,standard and isolation precautions, cleaning and disinfection IV. Unresolved issues
of equipment and the environment, aseptic techniques when 1. Avoidance of H2 antagonist or proton pump inhibitors suctioning secretions and handling respiratory therapy equip- for patients who are not at high risk for developing gastro- ment, patient positioning, sedation and weaning protocols, 2. Selective digestive tract decontamination for all patients 5. Hospital and unit leaders are responsible for holding their personnel accountable for their actions.
3. Use of antiseptic-impregnated endotracheal tubes129,130 6. The person who manages the infection prevention and control program is responsible for ensuring that an active program to identify VAP is implemented, that data on VAPare analyzed and regularly provided to those who can use the s e c t i o n 5 : p e r f o r m a n c e m e a s u re s information to improve the quality of care (eg, unit staff, I. Internal reporting
clinicians, and hospital administrators), and that evidence-based practices are incorporated into the program.
These performance measures are intended to support internalhospital quality improvement efforts and do not necessarily 7. Personnel responsible for healthcare personnel and pa- The process and outcome measures suggested here are de- be adjusted on the basis of compliance rates (eg, as com- rived from published guidelines, other relevant literature, and pliance improves, less frequent observations may be the opinions of the authors. Report both process and outcome measures to senior hospital leadership, nursing leadership, b. Preferred measure of assessment of compliance with and clinicians who care for patients at risk for VAP.
i. Numerator: number of patients undergoing ven- tilation with daily documentation of regular oral careaccording to product instructions.
1. Compliance with hand-hygiene guidelines for all cli- ii. Denominator: number of patients undergoing nicians who deliver care to patients undergoing ventilation a. Collect data on a sample of healthcare personnel from iii. Multiply by 100 so that the measure is expressed all disciplines who provide hands-on care to patients un- dergoing ventilation, including physicians, nurses, respi-ratory therapists, and radiology technicians. Perform ob- 4. Compliance with semirecumbent positioning for all el- servations at regular intervals (eg, 1 set of measurements per week). The frequency of observations can be adjusted a. Assessment should be performed for all patients cur- on the basis of compliance rates (eg, as compliance im- rently undergoing ventilation, by direct observation of the proves, less frequent observations may be needed).
position of the head of bed. Perform assessments at regular b. Preferred measure for hand-hygiene compliance intervals (eg, 1 set of measurements per week). The fre- i. Numerator: number of observed appropriate hand- quency of observations can be adjusted on the basis of hygiene episodes performed by healthcare personnel.
compliance rates (eg, as compliance improves, less frequent ii. Denominator: number of observed opportunities b. Preferred measure of assessment of semirecumbent iii. Multiply by 100 so that the measure is expressed i. Numerator: number of patients undergoing ven- tilation who are in a semirecumbent position (30Њ-45Њ 2. Compliance with daily sedation interruption and as- elevation of the head of the bed) at the time of a. Assessment should be performed by chart review of ii. Denominator: number of patients undergoing ven- a sample of all patients currently undergoing ventilation.
tilation who are eligible to be in a semirecumbent Evidence of daily documentation on the patient’s chart, bedside paperwork, or electronic medical record of a se- iii. Multiply by 100 so that the measure is expressed dation interruption and assessment of readiness to wean should be present unless clinically contraindicated. Per-form assessments at regular intervals (eg, 1 set of mea- surements per week). The frequency of observations can Perform ongoing surveillance of the incidence density of be adjusted on the basis of compliance rates (eg, as com- VAP on units that care for patients undergoing ventilation pliance improves, less frequent observations may be who are known or suspected to be at high risk for VAP, to permit longitudinal assessment of process of care.
b. Preferred measure of compliance with sedation in- terruption and assessment of readiness to wean 1. Incidence density of VAP, reported as the number of i. Numerator: number of patients undergoing ven- episodes of VAP per 1,000 ventilator-days.
tilation with daily documentation of consideration of a. Preferred measure of VAP incidence density sedation interruption and assessment of readiness to i. Numerator: number of patients undergoing me- chanical ventilation who have VAP, defined using Na- ii. Denominator: number of patients undergoing tional Healthcare Safety Network definitions.
ii. Denominator: number of ventilator-days.
iii. Multiply by 100 so that the measure is expressed iii. Multiply by 1,000 so that the measure is expressed II. External reporting
3. Compliance with regular antiseptic oral care a. Assessment should be performed by chart review of There are many challenges in providing useful information a sample of all patients currently undergoing ventilation.
to consumers and other stakeholders while preventing un- Perform assessments at regular intervals (eg, 1 set of mea- intended adverse consequences of public reporting of health- surements per week). The frequency of observations can care-associated infections.135 Recommendations for public re- infection control and hospital epidemiology porting of healthcare-associated infections have been b. Whenever possible, use steam sterilization or high- provided by the Hospital Infection Control Practices Advisory level disinfection by wet heat pasteurization at tempera- Committee,136 the Healthcare-Associated Infection Working tures higher than 70ЊC (158ЊF) for 30 minutes for repro- Group of the Joint Public Policy Committee,137 and the Na- cessing semicritical equipment or devices (ie, items that come into direct or indirect contact with mucous mem- Because of the difficulties in diagnosing VAP,30 the validity branes of the lower respiratory tract). Use low-temperature of comparing VAP rates between facilities is poor, and external sterilization methods (as approved by the Office of Device reporting of rates of VAP is not recommended.29 Evaluation, Center for Devices and Radiologic Health, USFood and Drug Administration) for equipment or devices that are heat or moisture sensitive. After disinfection, pro- 1. Hospitals in states that have mandatory reporting re- ceed with appropriate rinsing, drying, and packaging, tak- quirements for VAP must collect and report the data required ing care not to contaminate the disinfected items (category 2. For information on local requirements, check with your c. Preferentially use sterile water to rinse reusable sem- icritical respiratory equipment and devices when rinsing isneeded after chemical disinfection. If this is not feasible, rinse the device with filtered water (ie, water that has beenthrough a 0.2-mm filter) or tap water, and then rinse with 1. Hospitals that participate in external quality initiatives isopropyl alcohol and dry with forced air or in a drying or state programs must collect and report the data required d. Adhere to provisions in the US Food and Drug Ad- ministration’s enforcement document for single-use de-vices that are reprocessed by third parties (category IC).
For Potential Conflicts of Interest statements and information on financial support, please see the Acknowledgments in the Executive Summary, on page a. Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators (category II).
s t e r i l i z a t i o n , d i s i n f e c t i o n , a n d a. Do not, on the basis of duration of use, routinely m a i n t e n a n c e o f re s p i r a t o ry change the breathing circuit (ie, ventilator tubing and ex- e q u i p m e n t , b a s e d o n h e a l t h c a re halation valve and the attached humidifier) that is in use i n f e c t i o n c o n t r o l p r a c t i c e s by an individual patient. Change the circuit when it is visibly soiled or mechanically malfunctioning (category b. Periodically drain and discard any condensate that The Healthcare Infection Control Practices Advisory Com- collects in the tubing of a mechanical ventilator, taking mittee52 system for categorization of recommendations is as precautions not to allow condensate to drain toward the Category IA: Strongly recommended for implementation c. Wear gloves to perform the above procedure or han- and strongly supported by well-designed experimental, d. Decontaminate hands with soap and water (if hands Category IB: Strongly recommended for implementation are visibly soiled) or with an alcohol-based hand rub, after and supported by some experimental, clinical, or epi- performing the procedure or handling the fluid (category demiologic studies and a strong theoretical rationale.
Category IC: Required for implementation, as mandated e. Use sterile (not distilled nonsterile) water to fill bub- by federal or state regulation or standard.
Category II: Suggested for implementation and supported f. Change a heat-moisture exchanger that is in use by by suggestive clinical or epidemiological studies or a a patient when it malfunctions mechanically or becomes g. Do not routinely change more frequently than every a. Thoroughly clean all respiratory equipment to be 48 hours a heat-moisture exchanger that is in use by a sterilized or disinfected (category IA).
Address reprint requests to the Reprints Coordinator, University of Chi- pneumonia on mortality and morbidity. Am J Respir Crit Care Med cago Press, 1427 E. 60th St., Chicago, IL 60637 ([email protected]) or contact the journal office ([email protected]).
21. Kollef M. Prolonged use of ventilator circuits and ventilator-associated pneumonia: a model for identifying the optimal clinical practice. Chest1998; 113:267-269.
22. Luna C, Vujacich P, Niederman M, et al. Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest 1997;111:676-685.
1. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infec- 23. Fischer JE, Allen P, Fanconi S. Delay of extubation in neonates and tions in pediatric intensive care units in the United States. National children after cardiac surgery: impact of ventilator-associated pneu- Nosocomial Infections Surveillance System. Pediatrics 1999; 103:e39.
monia. Intensive Care Med 2000; 26:942-949.
2. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infec- 24. Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-asso- tions in combined medical-surgical intensive care units in the United ciated pneumonia: its relevance to developing effective strategies for States. Infect Control Hosp Epidemiol 2000; 21:510-515.
prevention. Respir Care 2005; 50:725-739; discussion 739-741.
3. Ibrahim EH, Tracy L, Hill C, Fraser VJ, Kollef MH. The occurrence of 25. Torres A, Gatell JM, Aznar E, et al. Re-intubation increases the risk of ventilator-associated pneumonia in a community hospital: risk factors nosocomial pneumonia in patients needing mechanical ventilation. Am and clinical outcomes. Chest 2001; 120:555-561.
J Respir Crit Care Med 1995; 152:137-141.
4. Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic 26. Ibrahim E, Mehringer L, Prentice D, et al. Early versus late enteral consequences of ventilator-associated pneumonia: a systematic review.
feeding of mechanically ventilated patients: results of a clinical trial.
Crit Care Med 2005; 33:2184-2193.
JPEN J Parenter Enteral Nutr 2002; 26:174-181.
5. American Thoracic Society, Infectious Diseases Society of America.
27. Cook DJ, Walter SD, Cook RJ, et al. Incidence of and risk factors for Guidelines for the management of adults with hospital-acquired, ven- ventilator-associated pneumonia in critically ill patients. Ann Intern Med tilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388-416.
28. Kollef MH. Ventilator-associated pneumonia: a multivariate analysis.
6. Stover BH, Shulman ST, Bratcher DF, Brady MT, Levine GL, Jarvis WR.
Nosocomial infection rates in US children’s hospitals’ neonatal and 29. Klompas M, Platt R. Ventilator-associated pneumonia—the wrong qual- pediatric intensive care units. Am J Infect Control 2001; 29:152-157.
ity measure for benchmarking. Ann Intern Med 2007; 147:803-805.
7. Elward AM, Warren DK, Fraser VJ. Ventilator-associated pneumonia 30. Klompas M. Does this patient have ventilator-associated pneumonia? in pediatric intensive care unit patients: risk factors and outcomes.
Pediatrics 2002; 109:758-764.
31. Torres A, Ewig S. Diagnosing ventilator-associated pneumonia. N Engl 8. Apisarnthanarak A, Holzmann-Pazgal G, Hamvas A, Olsen MA, Fraser VJ. Ventilator-associated pneumonia in extremely preterm neonates in 32. Baltimore RS. The difficulty of diagnosing ventilator-associated pneu- a neonatal intensive care unit: characteristics, risk factors, and outcomes.
monia. Pediatrics 2003; 112:1420-1421.
Pediatrics 2003; 112:1283-1289.
33. National Healthcare Safety Network members page. Available at: http: 9. Edwards JR, Peterson KD, Andrus ML, et al. National Healthcare Safety //www.cdc.gov/ncidod/dhqp/nhsn_members.html. Accessed August 7, Network (NHSN) report, data summary for 2006, issued June 2007.
Am J Infect Control 2007; 35:290-301.
34. Cook D, Walter S, Freitag A, et al. Adjudicating ventilator-associated 10. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit pneumonia in a randomized trial of critically ill patients. J Crit Care 11. Rello J, Ollendorf DA, Oster G, et al. Epidemiology and outcomes of 35. Fagon JY, Chastre J, Hance AJ, Domart Y, Trouillet JL, Gibert C. Eval- ventilator-associated pneumonia in a large US database. Chest 2002; uation of clinical judgment in the identification and treatment of nos- ocomial pneumonia in ventilated patients. Chest 1993; 103:547-553.
12. Shorr AF, Kollef MH. Ventilator-associated pneumonia: insights from 36. Schurink CA, Van Nieuwenhoven CA, Jacobs JA, et al. Clinical pul- recent clinical trials. Chest 2005; 128:583S-591S.
monary infection score for ventilator-associated pneumonia: accuracy 13. Shorr AF, Wunderink RG. Dollars and sense in the intensive care unit: and inter-observer variability. Intensive Care Med 2004; 30:217-224.
the costs of ventilator-associated pneumonia. Crit Care Med 2003; 31: 37. Shorr A, Sherner JH, Jackson WL, Kollef M. Invasive approaches to 14. Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost the diagnosis of ventilator-associated pneumonia: a meta-analysis. Crit of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 2003; 31:1312-1317.
38. Sherman ER, Heydon KH, St John KH, et al. Administrative data fail 15. Crouch Brewer S, Wunderink RG, Jones CB, Leeper KV Jr. Ventilator- to accurately identify cases of healthcare-associated infection. Infect associated pneumonia due to Pseudomonas aeruginosa. Chest 1996; 109: Control Hosp Epidemiol 2006; 27:332-337.
39. Julian KG, Brumbach AM, Chicora MK, et al. First year of mandatory 16. Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C.
reporting of healthcare-associated infections, Pennsylvania: an infection Nosocomial pneumonia in ventilated patients: a cohort study evaluating control–chart abstractor collaboration. Infect Control Hosp Epidemiol attributable mortality and hospital stay. Am J Med 1993; 94:281-288.
17. Kollef MH, Silver P, Murphy DM, Trovillion E. The effect of late-onset 40. Fagon JY, Chastre J, Wolff M, et al. Invasive and noninvasive strategies ventilator-associated pneumonia in determining patient mortality. Chest for management of suspected ventilator-associated pneumonia: a ran- domized trial. Ann Intern Med 2000; 132:621-630.
18. Cordero L, Ayers LW, Miller RR, Seguin JH, Coley BD. Surveillance of 41. Fabregas N, Ewig S, Torres A, et al. Clinical diagnosis of ventilator ventilator-associated pneumonia in very-low-birth-weight infants. Am associated pneumonia revisited: comparative validation using imme- J Infect Control 2002; 30:32-39.
diate post-mortem lung biopsies. Thorax 1999; 54:867-873.
19. Grossman RF, Fein A. Evidence-based assessment of diagnostic tests for 42. Heyland D, Dodek P, Muscedere J, Day A. A randomized trial of di- ventilator-associated pneumonia. Executive summary. Chest 2000; 117: agnostic techniques for ventilator-associated pneumonia. N Engl J Med 20. Papazian L, Bregeon F, Thirion X, et al. Effect of ventilator-associated 43. Haas JP, Mendonca EA, Ross B, Friedman C, Larson E. Use of com- infection control and hospital epidemiology puterized surveillance to detect nosocomial pneumonia in neonatal 64. Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented intensive care unit patients. Am J Infect Control 2005; 33:439-443.
sedation protocol on the duration of mechanical ventilation. Crit Care 44. Klompas M, Kleinman K, Platt R. Development of an algorithm for surveillance of ventilator-associated pneumonia with electronic data and 65. Dellinger R, Vincent J. The Surviving Sepsis Campaign sepsis change comparison of algorithm results with clinician diagnoses. Infect Control bundles and disease. Crit Care 2005; 9:653-654.
Hosp Epidemiol 2008; 29:31-37.
66. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of 45. Boyce JM, White RL, Spruill EY, Wall M. Cost-effective application of sedative infusions in critically ill patients undergoing mechanical ven- the Centers for Disease Control Guideline for Prevention of Nosocomial tilation. N Engl J Med 2000; 342:1471-1477.
Pneumonia. Am J Infect Control 1985; 13:228-232.
67. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse- 46. Gaynes RP, Solomon S. Improving hospital-acquired infection rates: the staffing levels and the quality of care in hospitals. N Engl J Med 2002; CDC experience. Jt Comm J Qual Improv 1996; 22:457-467.
47. Goldmann DA, Weinstein RA, Wenzel RP, et al. Strategies to prevent 68. Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Pro- and control the emergence and spread of antimicrobial-resistant mi- tocol weaning of mechanical ventilation in medical and surgical patients croorganisms in hospitals: a challenge to hospital leadership. JAMA by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest 2000; 118:459- 48. Joiner GA, Salisbury D, Bollin GE. Utilizing quality assurance as a tool for reducing the risk of nosocomial ventilator-associated pneumonia.
69. Thorens JB, Kaelin RM, Jolliet P, Chevrolet JC. Influence of the quality Am J Med Qual 1996; 11:100-103.
of nursing on the duration of weaning from mechanical ventilation in 49. Kelleghan SI. An effective continuous quality improvement approach patients with chronic obstructive pulmonary disease. Crit Care Med to the prevention of ventilator-associated pneumonia. Am J Infect Con- 70. Babcock HM, Zack JE, Garrison T, et al. An educational intervention 50. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T.
to reduce ventilator-associated pneumonia in an integrated health sys- Using a bundle approach to improve ventilator care processes and re- tem: a comparison of effects. Chest 2004; 125:2224-2231.
duce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 71. Ely EW, Meade MO, Haponik EF, et al. Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: evidence- 51. Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practice based clinical practice guidelines. Chest 2001; 120:454S–463S.
guideline for the prevention of ventilator-associated pneumonia. Ann 72. Torres A, Serra-Batlles J, Ros E, et al. Pulmonary aspiration of gastric Intern Med 2004; 141:305-313.
contents in patients receiving mechanical ventilation: the effect of body 52. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for position. Ann Intern Med 1992; 116:540-543.
preventing health-care–associated pneumonia, 2003: recommendations 73. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M.
of CDC and the Healthcare Infection Control Practices Advisory Com- Supine body position as a risk factor for nosocomial pneumonia in mittee. MMWR Recomm Rep 2004; 53:1-36.
mechanically ventilated patients: a randomised trial. Lancet 1999; 354: 53. Erhart LM, Rangel MC, Lu PJ, Singleton JA. Prevalence and charac- teristics of children at increased risk for complications from influenza, 74. Helman DL Jr, Sherner JH 3rd, Fitzpatrick TM, Callender ME, Shorr United States, 2000. J Pediatr 2004; 144:191-195.
AF. Effect of standardized orders and provider education on head-of- 54. Antonelli M, Conti G, Rocco M, et al. A comparison of noninvasive bed positioning in mechanically ventilated patients. Crit Care Med positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998; 339:429- 75. Orozco-Levi M, Torres A, Ferrer M, et al. Semirecumbent position protects from pulmonary aspiration but not completely from gastroe- 55. Brochard L. Mechanical ventilation: invasive versus noninvasive. Eur sophageal reflux in mechanically ventilated patients. Am J Respir Crit Respir J Suppl 2003; 47:31s–37s.
Care Med 1995; 152:1387-1390.
56. Girou E, Brun-Buisson C, Taille S, Lemaire F, Brochard L. Secular trends 76. Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated in nosocomial infections and mortality associated with noninvasive ven- pneumonia: an evidence-based systematic review. Ann Intern Med 2003; tilation in patients with exacerbation of COPD and pulmonary edema.
77. van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al.
57. Kollef MH. Prevention of hospital-associated pneumonia and ventila- Feasibility and effects of the semirecumbent position to prevent ven- tor-associated pneumonia. Crit Care Med 2004; 32:1396-1405.
tilator-associated pneumonia: a randomized study. Crit Care Med 2006; 58. Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl 78. Girou E, Buu-Hoi A, Stephan F, et al. Airway colonisation in long-term 59. Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation mechanically ventilated patients: effect of semi-recumbent position and in the weaning of patients with respiratory failure due to chronic ob- continuous subglottic suctioning. Intensive Care Med 2004; 30:225-233.
structive pulmonary disease: a randomized, controlled trial. Ann Intern 79. Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary 60. Girou E, Schortgen F, Delclaux C, et al. Association of noninvasive microaspiration: results of a randomized controlled trial. Crit Care Med ventilation with nosocomial infections and survival in critically ill pa- tients. JAMA 2000; 284:2361-2367.
80. Niederman MS, Craven DE. Devising strategies for preventing noso- 61. Nourdine K, Combes P, Carton MJ, Beuret P, Cannamela A, Ducreux comial pneumonia—should we ignore the stomach? Clin Infect Dis JC. Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey. Intensive Care Med 1999; 25:567-573.
81. Rello J, Torres A. Microbial causes of ventilator-associated pneumonia.
62. Burns KE, Adhikari NK, Meade MO. Noninvasive positive pressure Semin Respir Infect 1996; 11:24-31.
ventilation as a weaning strategy for intubated adults with respiratory 82. Valles J, Artigas A, Rello J, et al. Continuous aspiration of subglottic failure. Cochrane Database Syst Rev 2003; (4):CD004127.
secretions in preventing ventilator-associated pneumonia. Ann Intern 63. Kollef MH. Avoidance of tracheal intubation as a strategy to prevent ventilator-associated pneumonia. Intensive Care Medicine 1999; 25:553- 83. Mahul P, Auboyer C, Jospe R, et al. Prevention of nosocomial pneu- monia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Med care reduces incidence of ventilator-associated pneumonia in ICU pop- ulations. Intensive Care Med 2006; 32:230-236.
84. Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of con- 104. Bergmans DC, Bonten MJ, Gaillard CA, et al. Prevention of ventilator- tinuous aspiration of subglottic secretions in cardiac surgery patients.
associated pneumonia by oral decontamination: a prospective, random- ized, double-blind, placebo-controlled study. Am J Respir Crit Care Med 85. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S.
Subglottic secretion drainage for preventing ventilator-associated pneu- 105. Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry monia: a meta-analysis. Am J Med 2005; 118:11-18.
LO. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in re- 86. Cook DJ, Kollef MH. Risk factors for ICU-acquired pneumonia. JAMA ducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care 2002; 11:567-570.
87. Rello J, Sonora R, Jubert P, Artigas A, Rue M, Valles J. Pneumonia in 106. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA.
intubated patients: role of respiratory airway care. Am J Respir Crit Care Prevention of nosocomial infection in cardiac surgery by decontami- nation of the nasopharynx and oropharynx with chlorhexidine glu- 88. Salord F, Gaussorgues P, Marti-Flich J, et al. Nosocomial maxillary conate: a randomized controlled trial. JAMA 2006; 296:2460-2466.
sinusitis during mechanical ventilation: a prospective comparison of 107. Silvestri L, van Saene JJ, van Saene HK, Weir I. Topical chlorhexidine orotracheal versus the nasotracheal route for intubation. Intensive Care and ventilator-associated pneumonia. Crit Care Med 2007; 35:2468.
108. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for 89. Rouby JJ, Laurent P, Gosnach M, et al. Risk factors and clinical relevance prevention of pneumonia in mechanically ventilated adults: systematic of nosocomial maxillary sinusitis in the critically ill. Am J Respir Crit review and meta-analysis. BMJ 2007; 334:889.
109. Craven DE, Goularte TA, Make BJ. Contaminated condensate in me- 90. Holzapfel L, Chastang C, Demingeon G, Bohe J, Piralla B, Coupry A.
chanical ventilator circuits: a risk factor for nosocomial pneumonia? A randomized study assessing the systematic search for maxillary si- Am Rev Respir Dis 1984; 129:625-628.
nusitis in nasotracheally mechanically ventilated patients: influence of 110. Stamm AM. Ventilator-associated pneumonia and frequency of circuit nosocomial maxillary sinusitis on the occurrence of ventilator-associ- changes. Am J Infect Control 1998; 26:71-73.
ated pneumonia. Am J Respir Crit Care Med 1999; 159:695-701.
111. Kollef MH, Shapiro SD, Fraser VJ, et al. Mechanical ventilation with 91. Holzapfel L, Chevret S, Madinier G, et al. Influence of long-term oro- or without 7-day circuit changes: a randomized controlled trial. Ann or nasotracheal intubation on nosocomial maxillary sinusitis and pneu- Intern Med 1995; 123:168-174.
monia: results of a prospective, randomized, clinical trial. Crit Care Med 112. Hess DR, Kallstrom TJ, Mottram CD, Myers TR, Sorenson HM, Vines DL. Care of the ventilator circuit and its relation to ventilator-associated 92. Saint S, Matthay MA. Risk reduction in the intensive care unit. Am J pneumonia. Respir Care 2003; 48:869-879.
113. Dreyfuss D, Djedaini K, Weber P, et al. Prospective study of nosocomial 93. Cook DJ. Stress ulcer prophylaxis: gastrointestinal bleeding and nos- pneumonia and of patient and circuit colonization during mechanical ocomial pneumonia: best evidence synthesis. Scand J Gastroenterol Suppl ventilation with circuit changes every 48 hours versus no change. Am Rev Respir Dis 1991; 143:738-743.
94. Cook DJ, Reeve BK, Guyatt GH, et al. Stress ulcer prophylaxis in crit- 114. Markowicz P, Ricard JD, Dreyfuss D, et al. Safety, efficacy, and cost- ically ill patients: resolving discordant meta-analyses. JAMA 1996; 275: effectiveness of mechanical ventilation with humidifying filters changed every 48 hours: a prospective, randomized study. Crit Care Med 2000; 95. Tryba M, Cook DJ. Gastric alkalinization, pneumonia, and systemic infections: the controversy. Scand J Gastroenterol Suppl 1995; 210:53- 115. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121:1193-1254.
96. Tryba M. Sucralfate versus antacids or H2-antagonists for stress ulcer 116. Ntoumenopoulos G, Presneill JJ, McElholum M, Cade JF. Chest phys- prophylaxis: a meta-analysis on efficacy and pneumonia rate. Crit Care iotherapy for the prevention of ventilator-associated pneumonia. In- tensive Care Med 2002; 28:850-856.
97. Messori A, Trippoli S, Vaiani M, Gorini M, Corrado A. Bleeding and 117. Goldhill DR, Imhoff M, McLean B, Waldmann C. Rotational bed ther- pneumonia in intensive care patients given ranitidine and sucralfate for apy to prevent and treat respiratory complications: a review and meta- prevention of stress ulcer: meta-analysis of randomised controlled trials.
analysis. Am J Crit Care 2007; 16:50-61; quiz 62.
118. Hoth JJ, Franklin GA, Stassen NA, Girard SM, Rodriguez RJ, Rodriguez 98. Cook D, Guyatt G, Marshall J, et al. A comparison of sucralfate and JL. Prophylactic antibiotics adversely affect nosocomial pneumonia in ranitidine for the prevention of upper gastrointestinal bleeding in pa- trauma patients. J Trauma 2003; 55:249-254.
tients requiring mechanical ventilation. Canadian Critical Care Trials 119. Kahn JM, Doctor JN, Rubenfeld GD. Stress ulcer prophylaxis in me- Group. N Engl J Med 1998; 338:791-797.
chanically ventilated patients: integrating evidence and judgment using 99. Lopriore E, Markhorst DG, Gemke RJ. Ventilator-associated pneumonia a decision analysis. Intensive Care Med 2006; 32:1151-1158.
and upper airway colonisation with Gram negative bacilli: the role of 120. Kantorova I, Svoboda P, Scheer P, et al. Stress ulcer prophylaxis in stress ulcer prophylaxis in children. Intensive Care Med 2002; 28:763- critically ill patients: a randomized controlled trial. Hepatogastroenter- 100. Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia 121. Yildizdas D, Yapicioglu H, Yilmaz HL. Occurrence of ventilator-asso- in older patients in nursing homes. J Am Geriatr Soc 2002; 50:430-433.
ciated pneumonia in mechanically ventilated pediatric intensive care 101. DeRiso AJ 2nd, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlor- patients during stress ulcer prophylaxis with sucralfate, ranitidine, and hexidine gluconate 0.12% oral rinse reduces the incidence of total nos- omeprazole. J Crit Care 2002; 17:240-245.
ocomial respiratory infection and nonprophylactic systemic antibiotic 122. Levy MJ, Seelig CB, Robinson NJ, Ranney JE. Comparison of ome- use in patients undergoing heart surgery. Chest 1996; 109:1556-1561.
prazole and ranitidine for stress ulcer prophylaxis. Dig Dis Sci 1997; 102. Rumbak MJ, Cancio MR. Significant reduction in methicillin-resistant Staphylococcus aureus ventilator-associated pneumonia associated with 123. Liberati A, D’Amico R, Pifferi, Torri V, Brazzi L. Antibiotic prophylaxis the institution of a prevention protocol. Crit Care Med 1995; 23:1200- to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev 2004; (1):CD000022.
103. Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral 124. van Nieuwenhoven CA, Buskens E, van Tiel FH, Bonten MJ. Relation- infection control and hospital epidemiology ship between methodological trial quality and the effects of selective 131. Collier B, Diaz J Jr, Forbes R, et al. The impact of a normoglycemic digestive decontamination on pneumonia and mortality in critically ill management protocol on clinical outcomes in the trauma intensive care patients. JAMA 2001; 286:335-340.
unit. JPEN J Parenter Enteral Nutr 2005; 29:353-358; discussion 359.
125. Bonten MJ. Selective digestive tract decontamination—will it prevent 132. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy infection with multidrug-resistant gram-negative pathogens but still be in the critically ill patients. N Engl J Med 2001; 345:1359-1367.
applicable in institutions where methicillin-resistant Staphylococcus au- 133. Toschlog EA, Newton C, Allen N, et al. Morbidity reduction in critically reus and vancomycin-resistant enterococci are endemic? Clin Infect Dis ill trauma patients through use of a computerized insulin infusion protocol: a preliminary study. J Trauma 2007; 62:1370-1375; discussion 126. de Jonge E, Schultz MJ, Spanjaard L, et al. Effects of selective decon- tamination of digestive tract on mortality and acquisition of resistant 134. Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and bacteria in intensive care: a randomised controlled trial. Lancet 2003; pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358:125- 127. Krueger WA, Lenhart FP, Neeser G, et al. Influence of combined in- 135. Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcare- travenous and topical antibiotic prophylaxis on the incidence of infec- associated infections: the role of the Society for Healthcare Epidemi- tions, organ dysfunctions, and mortality in critically ill surgical patients: ology of America. Infect Control Hosp Epidemiol 2005; 26:210-212.
a prospective, stratified, randomized, double-blind, placebo-controlled 136. McKibben L, Horan TC, Tokars JI, et al. Guidance on public reporting clinical trial. Am J Respir Crit Care Med 2002; 166:1029-1037.
of healthcare-associated infections: recommendations of the Healthcare 128. Silvestri L, van Saene HK, Milanese M, Gregori D, Gullo A. Selective decontamination of the digestive tract reduces bacterial bloodstream Infection Control Practices Advisory Committee. Infect Control Hosp infection and mortality in critically ill patients: systematic review of randomized, controlled trials. J Hosp Infect 2007; 65:187-203.
137. The Healthcare-Associated Infection Working Group of the Joint Public 129. Pacheco-Fowler V, Gaonkar T, Wyer PC, Modak S. Antiseptic impreg- Policy Committee. Essentials of public reporting of healthcare-associ- nated endotracheal tubes for the prevention of bacterial colonization.
ated infections: a tool kit. Available at: http://www.cdc.gov/ncidod/ J Hosp Infect 2004; 57:170-174.
dhqp/pdf/ar/06_107498_Essentials_Tool_Kit.pdf. Accessed April 6, 130. Berra L, De Marchi L, Yu ZX, Laquerriere P, Baccarelli A, Kolobow T.
Endotracheal tubes coated with antiseptics decrease bacterial coloni- 138. The National Quality Forum. National voluntary consensus standards, zation of the ventilator circuits, lungs, and endotracheal tube. Anes- endorsed November 15, 2007. Available at: http://www.qualityforum thesiology 2004; 100:1446-1456.
.org/pdf/news/lsCSACMeasures.pdf. Accessed December 20, 2007.

Source: http://www.ipg.uni-linz.ac.at/qip_pneu.pdf