Physician's Weekly Article - Preventing Ventilator-Associated Pneumonia

       New recommendations from infectious disease experts aim to help clinicians prevent ventilator-associated pneumonia, a common healthcare-associated infection.

      Ventilator-associated pneumonia (VAP) is one of the most common infections acquired by adults and children in ICUs. According to early research, between 10% and 20% of patients undergoing ventilation develop VAP, but more recent reports indicate that rates of VAP range from one to four cases per 1,000 ventilator-days. These rates can exceed 10 cases per 1,000 ventilator-days in some neonatal and surgical patient populations. “VAP is a cause of significant patient morbidity and mortality,” says Susan E. Coffin, MD, MPH. “It has also been associated with increased utilization of healthcare resources and excess cost.” The mortality attributable to VAP has been shown to exceed 10% in some studies.

      Patients with VAP often require prolonged periods of mechanical ventilation and are hospitalized for extended periods of time. VAP has also been associated with excess use of antimicrobial medications and increased direct medical costs. “Despite the significant burden of VAP, results of recent quality improvement initiatives suggest that many cases of VAP might be prevented by careful attention to processes of care,” Dr. Coffin says.

      In 2008, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America appointed a task force to create a concise compendium of recommendations for the prevention of common healthcare-associated infections (HAIs). The resulting recommendations, published in the October 2008 supplement to Infection Control and Hospital Epidemiology and available online at www.preventingHAIs.com, are designed to help acute care hospitals focus and prioritize efforts to implement evidence-based practices for the prevention of HAIs. “The document highlights practical recommendations in a concise format,” says Dr. Coffin, who was on the panel for the VAP segment of the compendium. “Our aim is to assist acute care hospitals in implementing and prioritizing their VAP prevention efforts.”

      Aim to Prevent VAP

      According to the recommendations, there are several general strategies that hospitals and physicians should implement to influence VAP risk. “One of the most important actions institutions can take is to perform active surveillance for VAP,” explains Dr. Coffin. “This requires trained infection control practitioners and partnerships between clinicians and infection control personnel so that patients with VAP can be identified. In addition, healthcare providers must be educated on risk factors for VAP so that they understand the rationale behind the preventive practices. Daily assessments should be performed to determine how ready patients are to be weaned off ventilators safely.” Other strategies include adhering to hand-hygiene guidelines published by the CDC or the World Health Organization, using noninvasive ventilation whenever possible, and minimizing the duration of ventilation. The compendium also provides recommendations for preventing aspiration, reducing colonization of the aerodigestive tract, and minimizing contamination of the equipment used to care for patients receiving mechanical ventilation (Table 1).

      The implementation of prevention strategies and monitoring protocols that are geared specifically toward VAP are important to reducing the burden of disease, Dr. Coffin says. “Efforts are needed for continued education of healthcare providers caring for patients with VAP. In addition, protocols must be in place so that active surveillance of VAP can be done vigilantly [Table 2]. It’s important that clinicians don’t overreact and attempt to prevent VAP by beginning antibiotic therapy for patients with changes in tracheal secretions without other signs or symptoms of lower respiratory tract infection.”

      Be Vigilant Every Day

      Dr. Coffin says that hospitals and clinicians should implement institutional practices that involve the entire staff so the burden of VAP can be reduced. “Incorporating several key activities into daily work rounds can be very helpful,” she says. “Physicians, nurses, and respiratory therapists should participate in these rounds. During rounds, VAP prevention activities should be evaluated. For example, the staff should determine whether or not the head of the patient’s bed is elevated to the appropriate angle each day. Efforts should also be made to ensure that patients are getting appropriate mouth care and that it’s being performed with the frequency recommended by the product manufacturer. Additionally, staff must be vigilant about changes in a patient’s status so that all patients can be weaned off invasive ventilation as rapidly as possible. To accomplish this task, patients must have their sedation lightened each day. Then, a trial should be performed to see whether or not respiratory status improves with less support.”

      Assess Performance

      It can be challenging for clinicians to diagnose VAP consistently because of the complexity of the disease. In lieu of this problem, Dr. Coffin suggests that hospitals assess their performance by monitoring VAP rates among their patients as well as the process measures associated with reductions in the disease. “Assessing the implementation of proper care protocols is important,” she says. “Since our methods to identify VAP aren’t very sensitive or specific, hospitals should compliment available data with processes of care data to ensure that efforts are being maximized to prevent VAP.”

      Susan E. Coffin, MD, MPH, has indicated to Physician’s Weekly that she has received research support from Sage Pharmaceuticals.