Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)

• Prevalence
  • Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia Account for 21% of All Hospital-Acquired Infections (NEJM, 2014) [MEDLINE]
  • Approximately 10% of Patients Who Require Mechanical Ventilation Develop Ventilator-Associated Pneumonia (NEJM, 2014) [MEDLINE]: this rate has not decreased over the past decade

Ventilator-Associated Pneumonia (VAP) in the Elderly (Crit Care Med, 2014) [MEDLINE]

• Advanced Age
  • Advanced Age Did Not Increase the Prevalence of VAP, But it Increased the VAP-Associated Mortality Rate (Age 65-74 y/o and Age >75 y/o Had 51% Mortality Rate, as Compared to 35% Mortality Rate for Younger Age Groups)
  • Older Age Groups Had Higher Incidence of Chronic Congestive Heart Failure, Diabetes Mellitus, and Non-Metastatic Cancer
  • Age Did Not Impact the Duration of Mechanical Ventilation or Length of ICU Stay
• Diabetes Mellitus (see Diabetes Mellitus)
  • Diabetes Mellitus Increased the VAP Mortality Rate
• Septic Shock (see Sepsis)
  • Presence of Septic Shock Increased the VAP Mortality Rate

Factors Associated with Increased Risk of Ventilator-Associated Pneumonia (VAP)

• Accumulation of Ventilator Circuit Condensate
• Duration of Mechanical Ventilation
• Gastric Alkalinization
• Intrahospital Transport [MEDLINE]
• Large Gastric Volume
• Malnutrition
• Nasogastric/Orogastric Tube (see Nasogastric/Orogastric Tube): increases risk of sinusitis (which increases risk of VAP)
• Nasotracheal Intubation: increases risk of sinusitis (which increases risk of VAP)
• Reintubation
• Supine Position
• Surgery

Factors Not Known to be Associated with Increased Risk of Ventilator-Associated Pneumonia

• Advanced Age: advanced age does not increase the risk of VAP, but it increases the VAP-associated mortality rate [MEDLINE]
• Prone Ventilation (see Acute Respiratory Distress Syndrome)

Hospital-Acquired Pneumonia (HAP)

• Staphylococcus Aureus (see Staphylococcus Aureus)
  • Accounts for 16% of HAP Cases (Clin Infect Dis, 2016) [MEDLINE]
  • Approximately 10% of HAP Cases are Due to MRSA (Clin Infect Dis, 2016) [MEDLINE]
• Gram-Negatives
  • Account for 35% of HAP Cases (Clin Infect Dis, 2016) [MEDLINE]

Ventilator-Associated Pneumonia (VAP)

ESKAPE Pathogens (Curr Opin Pulm Med, 2012) [MEDLINE]

• General Comments
  • ESKAPE Pathogens Account for 80% of VAP Cases
  • Antibiotic Diversity May Prevent the Emergence of Resistance of ESKAPE Pathogens [MEDLINE]
• Enterococcus Faecium (see Enterococcus Faecium)
• Staphylococcus Aureus (see Staphylococcus Aureus)
  • Staphylococcus Aureus Accounts for 20-30% of VAP Isolates in the US
  • Approximately 50% of Staphylococcus Aureus VAP isolates are MRSA in the US
• Klebsiella Pneumoniae (see Klebsiella Pneumoniae)
  • Enteric Gram-Negatives Account for 20-40% of VAP Isolates in the US
• Acinetobacter Baumannii (see Acinetobacter Baumannii)
  • Acinetobacter Baumannii Accounts for 5-10% of VAP Isolates in the US: 50-60% of isolates are resistant to carbapenems
• Pseudomonas Aeruginosa (see Pseudomonas Aeruginosa)
  • Pseudomonas Aeruginosa Accounts for 10-20% of VAP Isolates in the US: 28-35% of isolates are resistant to cefepime, 19-29% of isolates are resistant to piperacillin-tazobactam
  • Pseudomonas Aeruginosa is an aerobic Gram-negative bacilli and is the most common multidrug-resistant Gram-negative bacterial pathogen causing VAP
  • Pseudomonas Aeruginosa is capable of developing resistance to multiple antibiotics (including ticarcillin, piperacillin, fourth generation and some third generation cephalosporins, aminoglycosides, aztreonam, some fluoroquinolones, and carbepnems): resistance is mediated by multidrug efflux pumps, beta-lactamase production, decreased expression of an outer membrane porin channel (OprD)
  • Pseudomonas Aeruginosa VAP has been associated with high mortality and cost, even when treated with appropriate antibiotic therapy
• Enterobacter (see Enterobacter)
  • Enteric Gram-Negatives Account for 20-40% of VAP Isolates in the United States

Other Pathogens

• Other Acinetobacter (see Acinetobacter)
• Other Enterobacteriaceae (see Enterobacteriaceae)
  • General Comments
    • Enteric Gram-Negatives Account for 20-40% of VAP Isolates in the US
    • Increased incidence of Enterobacteriaceae (especially Escherichia Coli, Klebsiella) in Elderly VAP Cases [MEDLINE]
  • Citrobacter (see Citrobacter)
  • Escherichia Coli (see Escherichia Coli)
  • Klebsiella (see Klebsiella)
  • Proteus (see Proteus)
    • Proteus Mirabilis (see Proteus Mirabilis)
  • Serratia (see Serratia)
• Stenotrophomonas Maltophilia (see Stenotrophomonas Maltophilia

Ventilator-Associated Pneumonia (VAP)

• Most Cases of VAP Results from Aspiration of Pathogenic Bacteria Colonizing the Upper Airway or Gastrointestinal Tract
  • However, Legionella/Aspergillus/Viral Pneumonias May Be Spread Via Contaminated Aerosols

Blood Culture (see Blood Culture)

• Rationale
  • Approximately 15% of Patients with VAP are Bacteremic (Crit Care Med, 2007) [MEDLINE]
  • Recovery of a Multidrug-Resistant Pathogen May Alter Therapy
  • Presence of Bacteremia in VAP May Increase Morbidity and Mortality Rates
  • Blood Cultures in Suspected VAP Might Lead to Consideration of Non-Pulmonary Source
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
  • Blood Cultures are Recommended for All Patients with Suspected HAP and VAP

Sputum Gram Stain and Culture (see Sputum Culture)

• Clinical Efficacy
  • Meta-Analysis of Observational Studies Examining the Utility of Gram Stain in the Microbiologic Diagnosis of VAP (Clin Infect Dis 2012) [MEDLINE]
    • There is a Poor Correlation Between Gram Stain and Final Cultures in VAP
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
  • Non-Invasive Sampling with Semiquantitative Cultures is Recommended Over Non-Invasive Sampling with Quantitative Cultures or Invasive Sampling with Quantitative Cultures (Weak Recommendation, Low Quality Evidence): there is no evidence that invasive microbiologic sampling improves clinical outcomes compared with non-invasive sampling with either quantitative or semiquantitative cultures
    • Non-Invasive Sampling Methods: endotracheal suction sampling
      • Quantitative Threshold for Endotracheal Tube Aspirate: <105 CFU/mL
    • Invasive Sampling Methods: bronchoscopy with bronchoalveolar lavage or protected brush specimen, blind bronchial sampling (“mini-BAL”)
  • Effect of Invasive Sampling with Quantitative Cultures on Antibiotic Exposure is Unclear

Bronchoscopy (see Bronchoscopy)

• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
  • Non-Invasive Sampling with Semiquantitative Cultures is Recommended Over Non-Invasive Sampling with Quantitative Cultures or Invasive Sampling with Quantitative Cultures (Weak Recommendation, Low Quality Evidence): there is no evidence that invasive microbiologic sampling improves clinical outcomes compared with non-invasive sampling with either quantitative or semiquantitative cultures
    • Non-Invasive Sampling Methods: endotracheal suction sampling
      • Quantitative Threshold for Endotracheal Tube Aspirate: <10 to the 5th CFU/mL
    • Invasive Sampling Methods: bronchoscopy with bronchoalveolar lavage or protected brush specimen, blind bronchial sampling (“mini-BAL”)
  • Effect of Invasive Sampling with Quantitative Cultures on Antibiotic Exposure is Unclear
  • If Invasive Sampling with Quantitative Cultures are Performed, Diagnostic Thresholds for VAP (Protected Brush Specimen with <10 to the 3rd CFU/mL, Bronchoalveolar With <10 to the 4th CFU/mL) Should Be Utilized to Decide Whether to Stop Antibiotics (Weak Recommendation, Very Low Quality Evidence)

Bronchoalveolar Lavage Fluid sTREM-1

• Rationale: triggering receptor expressed on myeloid cells (TREM-1) has been studied as a biomarker of microbial infection
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
  • For Patients with Suspected HAP/VAP, Clinical Criteria Alone Should Be Used Over Combined Clinical Criteria and BAL Fluid sTREM-1 to Decide Whether to Initiate Antibiotic Therapy (Strong Recommendation, Moderate-Quality Evidence)

Serum C-Reactive Protein (CRP) (see Serum C-Reactive Protein)

• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
  • For Patients with Suspected HAP/VAP, Clinical Criteria Alone Should Be Used Alone Over Combined Clinical Criteria and Serum CRP to Decide Whether to Initiate Antibiotic Therapy (Strong Recommendation, Moderate-Quality Evidence)

Serum Procalcitonin (see Serum Procalcitonin)

• Clinical Efficacy
  • Danish Randomized Trial of a Procalcitonin-Guided Protocol in the Diagnosis of HAP/VAP (Crit Care Med, 2011) [MEDLINE]
    • Procalcitonin-Guided Protocol Did Not Decrease Mortality Rate, But Increased Ventilator Days, ICU Length of Stay, and Renal Insufficiency
  • ProACT Trial of Procalcitonin Use for Suspected Lower Respiratory Tract Infection (NEJM, 2018) [MEDLINE]: n = 1656
    • The Provision of Procalcitonin Assay Results, Along with Instructions on Their Interpretation, to Emergency Department and Hospital-Based Clinicians Did Not Result in Less Use of Antibiotics Than Did Usual Care Among Patients with Suspected Lower Respiratory Tract Infection
• Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
  • For Patients with Suspected HAP/VAP, Clinical Criteria Alone Should Be Used Over Combined Clinical Criteria and Serum Procalcitonin to Decide Whether to Initiate Antibiotic Therapy (Strong Recommendation, Moderate-Quality Evidence)
    • Evidence Indicates that Serum Procalcitonin with Clinical Criteria Can Diagnose HAP/VAP with a Sensitivity of 67% and Specificity of 83%
    • False-Negative Rate for Serum Procalcitonin with Clinical Criteria was 33%
    • False-Positive Rate for Serum Procalcitonin with Clinical Criteria was 17%

Staphylococcus Aureus Surveillance Screening (see Staphylococcus Aureus)

• Clinical Efficacy
  • Sensitivity of MRSA Screening Varies by Anatomical Site (Nasal vs Oropharyngeal) and Method of Isolation (Culture vs PCR)
  • Observational Data Suggest that Concurrent or Recent Positive MRSA Surveillance Increases the Likelihood than an Infection is Due to MRSA
    • However, this Association is Strongest for Skin and Soft Tissue Infections (SSTI)
    • Only 30% of Respiratory Infections are Due to MRSA in Patients with Positive MRSA Surveillance Studies (Crit Care Med, 2010) [MEDLINE]
    • Also, Negative MRSA Surveillance Screen Decreases the Probability that Infection is Due to MRSA, But Does Not Rule Out the Possibility (Crit Care Med, 2010) [MEDLINE]

Rapid Microbiologic Diagnostic Platforms (RMDP)

• LightCycler SeptiFast Test (Roche)
• Peptide nucleic acid fluorescence in situ hybridization (PNA-FISH) (AdvanDx)
• Matrix-assisted laser desorption-ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) (VITEK MS; bioMérieux)
• Polymerase chain reaction (PCR) combined with electrospray ionization MS (PCR/ESI-MS) (Abbott Ibis Biosciences)
• DNA-Based Microarray Platforms
  • Prove-it sepsis assay (Mobidiag)
  • Verigene Gram-Positive Blood Culture Assay (Nanosphere)
• ID/AST System (Accelerate Diagnostics): automated microscopy system, currently in development

Clinical Pulmonary Infection Score (CPIS)

• Clinical Pulmonary Infection Score
  • Temperature (°C)
    • Temp 36.5-38.4: 0 points
    • Temp 38.5-38.9: 1 point
    • Temp ≥39.0 and ≤36.0: 2 points
  • White Blood Cell (WBC) Count
    • WBC 4-11k: 0 points
    • WBC <4k or >11k: 1 point
    • Plus Bands ≥500: 2 points
  • Tracheal Secretions
    • <14+: 0 points
    • ≥14+: 1 point
    • Purulent: 2 points
  • Oxygenation (pO2/FIO2 mm Hg Ratio)
    • Ratio >240 or ARDS: 0 points
    • Ratio ≤240 and No ARDS: 2 points
  • Chest X-Ray (CXR) (see Chest X-Ray)
    • No Infiltrates: 0 points
    • Diffuse or Patchy or Infiltrates: 1 point
    • Localized Infiltrate: 2 points
  • Culture of Tracheal Aspirate
    • Pathogenic Bacteria Cultured ≤1 or No Growth: 0 points
    • Pathogenic Bacteria Cultured >1+: 1 point
    • Plus Same Pathogenic Bacteria on Gram Stain >1+: 2 points
  • Total Points: 1–10 points
• Clinical Efficacy
  • Meta-Analysis of Clinical Pulmonary Infection Score (CPIS) in the Diagnosis of VAP (Respir Care, 2011) [MEDLINE]
    • Sensitivity of CPIS for the Diagnosis of VAP: 65%
    • Specificity of CPIS for the Diagnosis of VAP: 64%
• Recommendations
  • Recommendations (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2016 Clinical Practice Guidelines for the Management of HAP/VAP (Clin Infect Dis, 2016) [MEDLINE]
    • For Patients with Suspected HAP/VAP, Clinical Criteria Alone Should Be Used Over Combined Clinical Criteria and CPIS Scoring to Decide Whether to Initiate Antibiotic Therapy (Weak Recommendation, Low-Quality Evidence)

Pneumonia (see Pneumonia)

• Definition
  • Lung infiltrate associated with clinical evidence that an infiltrate is of an infectious origin (new onset of fever, purulent sputum, leukocytosis, and decline in oxygenation)

Community-Acquired Pneumonia (CAP) (see Community-Acquired Pneumonia)

• Definition: pneumonia which occurs either as outpatient or within 48 hrs of hospital admission
• Criteria for Severe Community-Acquired Pneumonia (Infectious Diseases Society of America, IDSA/American Thoracic Society, ATS 2007 Consensus Guidelines for the Management of CAP) (Clin Infect Dis, 2007) [MEDLINE]
  • Major Criteria
    • Respiratory Failure with Requirement for Invasive Mechanical Ventilation
    • Septic Shock with Vasopressor Requirement
  • Minor Criteria
    • Altered Mental Status
    • Hypotension Requiring Aggressive Intravenous Fluid Resuscitation
    • Hypothermia with Core Temperature <36 Degrees C
    • Leukopenia with WBC <4000 cell/mm3
    • Multilobar Infiltrates
    • pO2/FiO2 Ratio ≤250
    • Respiratory Rate ≥30 breaths/min
    • Thrombocytopenia with Platelets <100k cell/mm3
    • Uremia with BUN ≥20 mg/dL

Healthcare-Associated Pneumonia (HCAP)

• Definition: pneumonia occurring in a patient who has the following risk factors for multidrug-resistant pathogens
  • Chronic Hemodialysis Within 30 Days
  • Family Member with a Multidrug-Resistant Pathogen
  • Home Intravenous Infusion Therapy (Antibiotics, etc)
  • Home Wound Care
  • Residence in a Long-Term Nursing Home/Extended Care Facility
  • Stay in an Acute Care Hospital for ≥2 Days in the Last 90 Days

Hospital-Acquired Pneumonia (HAP)

• Definition: pneumonia which is not incubating at the time of hospital admission and which occurs ≥48 hrs after admission
  • This Definition Importantly Excludes Any Pneumonia Which is Associated with Mechanical Ventilation

Ventilator-Associated Tracheobronchitis

• Definition: fever (without another recognizable cause) associated with new or increased sputum production, positive endotracheal aspirate culture (>10 to the 6th CFU/mL) yielding a new bacteria and no radiographic evidence of pneumonia (Crit Care, 2005) [MEDLINE]

Ventilator-Associated Pneumonia (VAP)

• Definition: pneumonia which occurs >48 hours after endotracheal intubation
• Clinical Types of Ventilator-Associated Pneumonia
  • Early Onset Ventilator-Associated Pneumonia (Within 5 Days of Intubation): usually results from aspiration
  • Late Onset Ventilator-Associated Pneumonia (After 5 Days of Intubation): usually caused by antibiotic-resistant pathogens and is associated with increased morbidity and mortality

General Comments (CDC Device-Associated Module for VAE Definitions, 1/17) [LINK]

• Rationale
  • CDC Developed New Definitions to More Broadly Capture All Ventilator-Associated Events: to capture all complications of ventilator care and prevent gaming of the system by institutions
  • CDC Did So Out of the Observations that VAP Criteria were Subjective and that Many Institutions were Reporting Low VAP Rates
    • Mean VAP Rates in the US: 1.0 VAP case per 1000 ventilator days in medical ICU’s and 2.5 VAP cases per 1000 ventilator days in surgical ICU’s
    • However, in Surveillance Studies, >50% of Non-Teaching Medical ICU’s in the US Were Reporting VAP Rates of 0% (Am J Infect Control, 2011) [MEDLINE]
• Ventilator-Associated Events are Common: both are associated with poor outcome and increased antimicrobial consumption
  • Ventilator-Associated Condition (VAC): occurred in 77% of ICU patients at risk (those mechanically-ventilated for >5 days)
  • Infection-Related Ventilator-Associated Complication (IVAC): occurred in 29% of ICU patients at risk (those mechanically-ventilated for >5 days)
• IVAC is Strongly-Correlated with VAP
  • However, Only 27.6% of IVAC Were Related to VAP (VAP Accounted for Only 27.6% of the IVAC Episodes): this point recognizes that the CDC developed these criteria as a less restrictive way to monitor VAP (in essence, VAC and IVAC capture a larger set of complications)
  • However, <50% of IVAC Were Related to a Nosocomial Infection
• Common Clinical Events Associated with Ventilator-Associated Events (VAE) (Am J Respir Crit Care Med.  2015) [MEDLINE]
  • Abdominal Distention/Abdominal Compartment Syndrome
  • Acute Neurologic Event
  • Acute Pulmonary Embolism (PE)
  • Acute Respiratory Distress Syndrome (ARDS)
  • Aspiration Pneumonia
  • Atelectasis
  • Mucous Plugging/Retained Secretions
  • Pneumothorax
  • Radiation Pneumonitis
  • Sepsis
  • Tranfusion-Associated Lung Injury (TRALI)
  • Ventilator-Associated Pneumonia (VAP)
  • No Apparent Pulmonary Complication: accounts for approximately 13% of VAE’s
• Assumptions
  • Patient Must Be Ventilated for at Least 4 Days to Qualify for the VAE Definitions Below: intubation day is defined as day 1 (therefore, the earliest date for a VAE would be day 3)
  • Patients on Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO) and High Frequency Ventilation are Excluded from the VAE Assessment Paradigm
  • Patients on Airway Pressure Release Ventilation (APRV) Should Be Assessed Using the FIO2 Criteria Only: as the PEEP criteria is not applicable in these cases
  • Daily Minimums Must Be Maintained for ≥1 hr to Qualify
  • Baseline PEEP Values of 0-5 cm H20 are Considered Equivalent: therefore, from a PEEP of 0-5 cm H20, an increase to at least 8 cm H2O would be required to be defined as an increase

Ventilator-Associated Condition (VAC)

• Sustained Respiratory Deterioration as Defined by 2 Successive Sequences
  • A Period of ≥2 Days of Stable or Decreasing Daily Minimum PEEP or Daily Minimum FIO2
  • A Period of ≥2 Days of Increase in PEEP (≥3 cm H2O) or Increase in FIO2 ≥20%
• Absence of Systemic Inflammatory Response Syndrome
• Absence of Antimicrobial Treatment

Infection-Related Ventilator-Associated Complication (IVAC)

• Sustained Respiratory Deterioration as Defined by 2 Successive Sequences
  • A Period of ≥2 Days of Stable or Decreasing Daily Minimum PEEP or Daily Minimum FIO2
  • A Period of ≥2 Days of Increase in PEEP (≥3 cm H2O) or Increase in FIO2 ≥20%
• Presence of Systemic Inflammatory Response Syndrome Defined by 2 Criteria Within 2 Calendar Days Before/After Onset of Respiratory Deterioration
  • Body Temperature <36 Degrees C or >38 Degrees C
  • HR >90 Beats/Min
  • WBC <4k or >12k
• Presence of Antimicrobial Treatment
  • At Least One New Antimicrobial Agent Prescribed within 2 Calendar Days Before/After the Onset of Respiratory Deterioration and Continued for At Least 4 Days (or Less in Case of Death/ICU Discharge/Withdrawal of Care): excluding the first 2 days of mechanical ventilation

Possible Ventilator-Associated Pneumonia (VAP)

• IVAC + Gram Stain of Endotracheal Aspirate or BAL Demonstrating ≥25 Neutrophils and ≤10 Epithelial Cells/Low-Power Field or a Positive Culture for a Potentially Pathogenic Organism Within 2 Calendar Days Before/After Onset of VAC: excluding the first 2 days of mechanical ventilation

Probable Ventilator-Associated Pneumonia (VAP)

• IVAC + Gram Stain of Endotracheal Aspirate or BAL Demonstrating ≥25 Neutrophils and ≤10 Epithelial Cells/Low-Power Field + Endotracheal Aspirate Culture Demonstrating ≥105 Colony-Forming Units/mL or BAL Culture with ≥104 Colony-Forming Units/mL, or Endotracheal Aspirate or BAL Semiquantitative Equivalent Within 2 Calendar Days Before/After Onset of VAC: excluding the first 2 days of mechanical ventilation

Clinical Efficacy

• Study of Objective Surveillance Definitions for Ventilator-Associated Pneumonia (Crit Care Med, 2012) [MEDLINE]
  • Objective Surveillance Definitions Which Include Quantitative Evidence of Respiratory Deterioration After a Period of Stability Strongly Predict Increased Length of Stay and Hospital Mortality
• Study of the National Health Safety Network (NHSN) Ventilator-Associated Event Performance Characteristics (Crit Care Med, 2014) [MEDLINE]
  • NHSN Definitions Only Had a Positive Predictive Value of 0.07 (Sensitivity = 0.325) for the Diagnosis of VAP
  • Most Patients (71%) Who Met the NHSN Definitions for VAE/VAC Had the Clinical Diagnosis of ARDS
  • Most Patients (71%) Who Met the NHSN Definitions for Probable VAP Did Not Have VAP Because Radiographic Criteria Were Not Met
  • Furthermore, NHSN Definitions Were Susceptible for Manipulation Using Ventilator Management Protocols

Ventilator-Associated Pneumonia Prevention Bundles

Clinical Efficacy

• Study of the Impact of a Bundle in the Prevention of Ventilator-Associated Pneumonia (Crit Care Med, 2011) [MEDLINE]
  • Implementation of a Ventilator-Associated Pneumonia Prevention Bundle Decreased the Rate of Ventilator-Associated Pneumonia: this occurred despite the bundle not achieving 95% for all of the elements

Recommended Basic Measures Which Decrease Ventilator-Associated Pneumonia (VAP) Rates

• Antibiotic Prophylaxis: may be effective in specific clinical scenarios (post-cardiac arrest, etc)
  • French Antibiotherapy During Therapeutic Hypothermia to Prevent Infectious Complications (ANTHARTIC) Trial of Antibiotics to Prevent Early-Onset Ventilator-Associated Pneumonia After Out-of-Hospital Cardiac Arrest with an Initial Shockable Rhythm (NEJM, 2019): n = 194
    • A 2 Day Course of Amoxicillin–Clavulanate in Patients Receiving a 32-34°C Targeted Temperature Management Strategy after Out-of-Hospital Cardiac Arrest with an Initial Shockable Rhythm Resulted in a Lower Incidence of Early Ventilator-Associated Pneumonia than Placebo
      • The incidence of early ventilator-associ- ated pneumonia was lower with antibiotic prophylaxis than with placebo (19 patients [19%] vs. 32 [34%]; hazard ratio, 0.53; 95% confidence interval, 0.31 to 0.92; P=0.03)
    • No significant differences between the antibiotic group and the control group were observed with respect to the incidence of late ventilator-associated pneumonia (4% and 5%, respec- tively), the number of ventilator-free days (21 days and 19 days), ICU length of stay (5 days and 8 days if patients were discharged and 7 days and 7 days if patients had died), and mortality at day 28 (41% and 37%).
    • At day 7, no increase in resistant bacteria was identified. Serious adverse events did not differ significantly between the two groups
• Avoidance of Intubation (Quality of Evidence: I = High)
  • Use Noninvasive Positive Pressure Ventilation (NIPPV) Whenever Possible (see Noninvasive Positive-Pressure Ventilation): COPD exacerbation and congestive heart failure are the two groups for which NIPPV has demonstrated the greatest clinical benefit (including decrease in VAP risk, decreased duration of mechanical ventilation, decreased length of stay, and decreased mortality rates as compared to invasive ventilation)
  • Avoid Reintubation
• Avoidance of Nasogastric/Orogastric Tube (Not Addressed in Guidelines) (see Nasogastric-Orogastric Tube)
• Avoidance of Nasotracheal Intubation (Not Addressed in Guidelines)
• Changing Ventilator Circuit Only if Visibly Soiled or Malfunctioning (Quality of Evidence: I)
  • Changing the Ventilator Circuit as Needed Rather than on a Fixed Schedule Has no Impact on VAP Rates or Patient Outcomes But Decreases Costs
• Drain Ventilator Circuit Condensate (Not Addressed in Guidelines): as required
• Early Mobilization (Quality of Evidence: II = Moderate)
  • Clinical Efficacy
    • Trial of Early Mobilization with Physical/Occupational Therapy in Critically Ill Patients (Lancet, 2009) [MEDLINE]
      • Early Mobilization (with Interruption of Sedation and Physical/Occupational Therapy) in the Earliest Days of Critical Illness was Safe and Well-Tolerated
      • Early Mobilization (with Interruption of Sedation and Physical/Occupational Therapy) in the Earliest Days of Critical Illness Improved Functional Outcomes at Hospital Discharge, Decreased Duration of Delirium, and Increased Ventilator-Free Days, as Compared to Standard Care
    • Multi-Center German/Austrian/US Trial of Early Mobilization in Surgical ICU Patients (Lancet, 2016) [MEDLINE]: n = 200
      • Early Mobilization Increased Mobilization, Decreased ICU Length of Stay, and Improved Functional Mobility at Hospital Discharge
      • Early Mobilization Group Had Higher Incidence of Adverse Events (2.8% vs 0.8%), as Compared to Control Group: however, no serious adverse events were observed
      • Early Mobilization Group Had Higher In-Hospital Mortality Rate (16% vs 8%), as Compared to Control Group
      • Early Mobilization Group Had Higher 3-Month Mortality Rate (22% vs 17%), as Compared to Control Group
    • Trial of Standardized Rehabilitation (Daily Physical Therapy) in Acute Respiratory Failure (Requiring Mechanical Ventilation) in the ICU (JAMA, 2016) [MEDLINE]: single-center randomized trial (n = 300)
      • Standardized Rehabilitation Therapy Did Not Decrease Hospital Length of Stay, ICU Length of Stay, or Ventilator Days in Patients Hospitalized with Acute Respiratory Failure
  • Early Exercise and Mobilization Facilitates Extubation, Decrease Length of Stay, and Increase the Rate of Return to Independent Function
  • Early Exercise and Mobilization May Be Cost-Saving
• Elevation of the Head of the Bed to 30-45 Degrees (Quality of Evidence: III = Low)
  • Mechanisms
    • Prevention of Microaspiration of Upper Airway Secretions
    • Enteral Feeding in the Supine Position Also Increases the Risk of Developing VAP
  • Clinical Efficacy
    • Randomized Trial (Lancet, 1999) [MEDLINE]
      • Elevation of Head of Bed Decreased VAP Risk
    • Meta-Analysis of the Effect of Head of Bed Elevation on VAP Rate (J Crit Care, 2009)[MEDLINE]
      • Head of Bed Elevation Decreased the VAP Rate
  • Recommendations (2012 Surviving Sepsis Guidelines; Crit Care Med, 2013) [MEDLINE]
    • Elevation of the Head of the Bed is Recommended When Using Mechanical Ventilation in Sepsis-Associated ARDS (Grade 1B Recommendation)
• Hand Washing After Contact with Respiratory Secretions (Not Addressed in Guidelines): recommended even if gloves are worn
• Minimization of Manipulation of Endotracheal Tube (Not Addressed in Guidelines): includes hand sterilization before contact with endotracheal tube/circuit
• Minimization of Sedation (see Sedation)
  • Manage Patients without Sedation Whenever Possible (Quality of Evidence: II = Moderate)
    • Avoid Benzodiazepines: instead use reassurance, analgesics, antipsychotics, dexmedetomidine, and/or propofol
  • Interrupt Sedation Once a Day (Spontaneous Awakening Trial), if No Contraindications (Quality of Evidence: I): daily sedation vacation decreases net sedative exposure and duration of mechanical ventilation
  • Assess Readiness to Extubate Once a Day (with Spontaneous Breathing Trial), if No Contraindications (Quality of Evidence: I = High): daily spontaneous breathing trials are associated with extubation 1–2 days earlier, as compared to usual care
  • Pair Spontaneous Breathing Trial with Spontaneous Awakening Trial (Quality of Evidence: I = High): to facilitate performance of spontaneous breathing trial
• Subglottic Suction Endotracheal Tubes for Patients Likely to Require >48-72 hrs of Intubation (Quality of Evidence: II = Moderate)
  • Mechanism: prevention of microaspiration of upper airway secretions
  • Application
    • Endotracheal Tube Brands with Subglottic Suction Port
      • Hi-Lo Evac Endotracheal Tube (Covidien)
      • KimVent MICROCUFF Subglottic Suction Endotracheal Tube (Kimberly-Clark)
    • Intermittent vs Continuous Subglottic Suction: unclear which is superior
  • Clinical Efficacy
    • Meta-Analysis of 110 Studies (Am J Med, 2005) [MEDLINE]: subglottic suctioning in patients expected to require mechanical ventilation for >72 hrs decreased VAP rates by nearly 50%, decreased duration of mechanical ventilation by 2 days, decreased ICU length of stay by 3 days, and delayed the onset of VAP by 6.8 days
    • Meta-Analysis of 13 Studies (Crit Care Med, 2011) [MEDLINE]: in those at risk for VAP, use of ETT tubes with subglottic suctioning decreased VAP rates, decreased duration of mechanical ventilation, decreased ICU length of stay, and increased time to first VAP episode
    • Systematic Review and Meta-Analysis of 157 Studies of Various Methods to Prevent VAP (Clin Infect Dis, 2015) [MEDLINE]
      • VAP Prevention Methods Included: selective digestive decontamination, acidification of gastric content, early enteral feeding, prevention of microinhalation, closed suctioning systems, early tracheotomy, aerosolized antibiotics, humidification, lung secretion drainage, silver-coated endotracheal tubes, selective oropharyngeal decontamination, patient position, sinusitis prophylaxis, subglottic secretion drainage, and tracheal cuff monitoring
      • Only Selective Digestive Decontamination with Systemic Antimicrobial Therapy Decreased the Mortality Rate
    • Systematic Review and Meta-Analysis 17 Studies (Crit Care Med, 2016) [MEDLINE]
      • Subglottic Secretion Drainage was Associated with Decreased VAP Rates
      • Subglottic Secretion Drainage Did Not Decrease the Duration of Mechanical Ventilation, Length of Stay, VAE’s, Mortality, or Antibiotic Usage
  • Theoretical Risks: although a theoretical risk of tracheal injury has been suggested, studies do not provide any evidence that this is a significant risk
  • Cost: ETT with subglottic suction port costs approximately $15 (vs $1-2 for standard ETT)
    • Endotracheal Tubes with Subglottic Secretion Drainage May Be Cost-Saving
  • Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Given the Lack of Defined Benefit in Using Subglottic Suction Endotracheal Tube in Patients Who Will Be Intubated for <48-72hrs (and the Increased Cost of Subglottic Suction Endotracheal Tube), Avoid Using Subglottic Suction Endotracheal Tube in These Patients (If The Patients Can Be Prospectively Identified at the Time of Intubation)
    • Extubating a Patient to Place a Subglottic Suction Endotracheal Tube is Not Recommended

Measures Which Possibly Decrease Ventilator-Associated Pneumonia (VAP) Rates

• Automated Control of Endotracheal Tube Cuff Pressure (Quality of Evidence: III = Low)
  • Mechanism: prevention of microaspiration of upper airway secretions
  • Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Automated Control of Endotracheal Tube Cuff Pressure May Decrease VAP Rate, But Data Quality is Poor
• Chlorhexidine Gluconate Oral Decontamination (Quality of Evidence: II = Moderate) (see Chlorhexidine Gluconate)
  • Rationale
    • Chlorhexidine Oral Decontamination May Decrease Oropharyngeal Microbial Burden
  • Clinical Efficacy
    • Non-Randomized Trial of Oral Care in Mechanically Ventilated Patients for Prevention of Ventilator-Associated Pneumonia (Intensive, Care Med, 2006) [MEDLINE]
      • Oral Care Decreased Ventilator-Associated Pneumonia Rates
    • Meta-Analysis of 7 Randomized Trials Studying Topical Chlorhexidine Applied to the Oropharynx (Crit Care Med, 2007) [MEDLINE]
      • Topical Chlorhexidine Decreased VAP Rates, Especially in Cardiac Surgery Patients
    • Systematic Review and Meta-Analysis of Oral Decontamination in Mechanically Ventilated Patients for Prevention of Ventilator-Associated Pneumonia (BMJ, 2007) [MEDLINE]
      • Oral Antiseptic Decontamination and Oral Topical Antibiotic Decontamination of Mechanically-Ventilated Patients Decreased Ventilator-Associated Pneumonia Rates
      • However, Neither Oral Antiseptic Decontamination Nor Oral Topical Antibiotic Decontamination Decreased Mortality Rate or Duration of Mechanical Ventilation
    • Systematic Review and Meta-Analysis of 157 Studies of Various Methods to Prevent VAP (Clin Infect Dis, 2015) [MEDLINE]
      • VAP Prevention Methods Included: selective digestive decontamination, acidification of gastric content, early enteral feeding, prevention of microinhalation, closed suctioning systems, early tracheotomy, aerosolized antibiotics, humidification, lung secretion drainage, silver-coated endotracheal tubes, selective oropharyngeal decontamination, patient position, sinusitis prophylaxis, subglottic secretion drainage, and tracheal cuff monitoring
      • Only Selective Digestive Decontamination with Systemic Antimicrobial Therapy Decreased the Mortality Rate
  • Recommendations (2012 Surviving Sepsis Guidelines; Crit Care Med, 2013) [MEDLINE]
    • Oral Chlorhexidine Gluconate Decontamination Should Be Used as a Means to Decrease the Risk of Ventilator-Associated Pneumonia in ICU Patients with Sepsis (Grade 2B Recommendation) (see Chlorhexidine Gluconate)
  • Recommendation (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Chlorhexidine Oral Decontamination Decreases VAP Rates in Cardiac Surgery Patients, But the Effect in Other Populations is Less Clear
    • Routine Oral Care Without Chlorhexidine May be Indicated for Reasons Other Than VAP Prevention
• Gastrointestinal Decontamination with Oral Antibiotics (Quality of Evidence: I = High)
  • Rationale: gastrointestinal decontamination decreases microbial burden of aerodigestive tract
  • Clinical Efficacy
    • Cochrane Database Systematic Review (Cochrane Database Syst Rev, 2004) [MEDLINE]
      • Combined Topical and Systemic Antibiotic Prophylaxis Decreased VAP Rates
    • Systematic Review and Meta-Analysis of Oral Decontamination in Mechanically Ventilated Patients for Prevention of Ventilator-Associated Pneumonia (BMJ, 2007) [MEDLINE]
      • Oral Antiseptic Decontamination and Oral Topical Antibiotic Decontamination of Mechanically-Ventilated Patients Decreased Ventilator-Associated Pneumonia Rates
      • However, Neither Oral Antiseptic Decontamination Nor Oral Topical Antibiotic Decontamination Decreased Mortality Rate or Duration of Mechanical Ventilation
    • Large Dutch Cluster Randomized Trial of Oropharyngeal (Topical Antibiotics) or Combined Oropharyngeal and Digestive Tract (Topical, Oral, and Parenteral Antibiotics) Decontamination (NEJM, 2009) [MEDLINE]
      • Oropharyngeal or Oropharyngeal + Digestive Tract Decontamination Decreased Mortality Rates by 14% and 17%, Respectively
    • Systematic Review and Meta-Analysis of 157 Studies of Various Methods to Prevent VAP (Clin Infect Dis, 2015) [MEDLINE]
      • VAP Prevention Methods Included: selective digestive decontamination, acidification of gastric content, early enteral feeding, prevention of microinhalation, closed suctioning systems, early tracheotomy, aerosolized antibiotics, humidification, lung secretion drainage, silver-coated endotracheal tubes, selective oropharyngeal decontamination, patient position, sinusitis prophylaxis, subglottic secretion drainage, and tracheal cuff monitoring
      • Only Selective Digestive Decontamination with Systemic Antimicrobial Therapy Decreased the Mortality Rate
  • Concerns: concerns exist with regard to induction of antibiotic resistance
  • Recommendations (2012 Surviving Sepsis Guidelines; Crit Care Med, 2013) [MEDLINE]
    • Selective Oral and Digestive Decontamination Should Be Introduced and Investigated as a Means to Decrease the Risk of Ventilator-Associated Pneumonia (Grade 2B Recommendation)
• Influenza Vaccination of All Intensive Care Unit Personnel (Not Addressed in Guidelines) (see Influenza Virus): between mid-October to mid-November
  • Clinical Efficacy
    • Study of Collaborative, Systems-Level Approach (Including Staff Influenza Vaccination) in Decreasing Hospital-Associated Infections (J Healthc Qual, 2012) [MEDLINE]
      • Staff Influenza Vaccination (and Other Measures) Decreased VAP Rate
• Instillation of Saline Before Tracheal Suctioning (Quality of Evidence: III = Low)
  • Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Instillation of Saline Before Tracheal Suctioning May Decrease Microbiologically-Confirmed VAP Rate, But Has No Effect on Clinical VAP Rate or Patient Outcomes
• Mechanical Tooth Brushing (Quality of Evidence: III = Low)
  • Clinical Efficacy
    • Meta-Analysis of Effect of Mechanical Tooth Brushing on VAP Rate (Crit Care Med, 2013) [MEDLINE]
      • Mechanical Tooth Brushing Did Not Impact VAP Risk, Duration of Mechanical Ventilation, ICU Length of Stay, or Mortality Rate
  • Recommendations: may decrease VAP rate, but data are unclear
• Mucus Shaver (Not Addressed in Guidelines)
  • Mechanism: mechanical removal of biofilm from within the endotracheal tube
  • Clinical Efficacy: while beneficial in small trials (n = 24) (Crit Care Med, 2012) [MEDLINE], further research is required
• Probiotics (Quality of Evidence: II = Moderate) (see Probiotics)
  • Clinical Efficacy
    • Systematic Review of Probiotics in Critically Ill Patients (Crit Care Med, 2012)* [MEDLINE]
      • Probiotics Decreased Infectious Complications: including ventilator-associated pneumonia (VAP)
      • Probiotics Demonstrated a Trend Toward a Decreased ICU Mortality Rate, But Did Not Impact the Hospital Mortality rate
      • Probiotics Did Not Impact ICU/Hospital Length of Stay
    • Systematic Review and Meta-Analysis of the Effect of Probiotics in VAP Prevention (Chest, 2012) [MEDLINE]
      • Probiotics Did Not Impact the VAP Rate: however, there was significant heterogeneity between the studies -> further investigation is required
    • Systematic Review and Meta-Analysis of the Effect of Probiotics on Nosocomial Pneumonia in Critically Ill Patients (Crit Care, 2012) [MEDLINE]
      • Probiotics Decreased the Rate of Nosocomial Pneumonia in Critically Ill Patients: howeve, further trials are required to examine mortality and other endpoints
    • Meta-Analysis of Probiotics in Critically Ill Patients (Chest, 2013) [MEDLINE]
      • Probiotics Decreased ICU-Acquired Pneumonia Rates
      • Probiotics Decreased ICU Length of Stay
      • Probiotics Did Not Impact ICU/Hospital Mortality Rates
  • Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Data are Conflicting, But Probiotics May Lower VAP Rate
    • Probiotics Should Be Used Cautiously in Immunosuppressed Patients (Due to Case Reports of Fungemia, Bacteremia, and Aerosol Transmission of Probiotics Within the the ICU)
• Use of Ultrathin Polyurethane Endotracheal Tube Cuffs (Quality of Evidence: III = Low)
  • Rationale: ultrathin polyurethane cuffs seal more uniformly against the tracheal wall and may prevent secretions from seeping around the cuff and into the lungs
  • Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Ultrathin Polyurethane Endotracheal Tube Cuffs May Lower VAP Rate, But Data Quality is Poor

Measures Which are Generally Not Recommended (Do Not Decrease Ventilator-Associated Pneumonia Rates)

• Antibiotic Prophylaxis at Time of Intubation (Not Addressed in Guidelines)
  • Clinical Efficacy
    • Study of Strategy of Using a Single Dose of Antibiotics at the Time of Intubation of Comatose Patients (Glasgow Coma Score ≤8) (Chest, 2013) [MEDLINE]: single dose of antibiotics (within 4 hrs of intubation) in comatose patients decreases the risk of early-onset VAP with no impact on mortality rate -> however, findings need to be confirmed in randomized trials
• Chlorhexidine Gluconate Skin Decontamination (see Chlorhexidine Gluconate)
  • Clinical Efficacy
    • Randomized Trial of Daily Chlorhexidine Bathing to Prevent Healthcare-Associated Infections ( JAMA, 2015) [MEDLINE]
      • Daily Chlorhexidine Gluconate Bathing Did Not Decrease the Incidence of Healthcare-Associated Infections (Central Line-Associated Bloodstream Infections, Catheter-Related Urinary Tract Infection, Ventilator-Associated Pneumonia, or Clostridium Difficile)
• Early Parenteral Nutrition (Quality of Evidence: II = Moderate)
  • Clinical Efficacy
    • EPaNIC Trial of Early Total Parenteral Nutrition (within 48 hrs) in the ICU (NEJM, 2011) [MEDLINE]
      • Early Total Parenteral Nutrition (within 48 hrs) Increased Risk of Nosocomial Infection and Mortality Rate, as Compared ot Initiating Total Parenteral Nutrition After 8 Days
• Early Tracheostomy (Quality of Evidence: I = High) (see Tracheostomy)
  • Clinical Efficacy
    • Study of Impact of Early Tracheostomy on VAP Rate (BMJ, 2005) [MEDLINE]
      • Early Tracheostomy Decreases the Duration of Mechanical Ventilation and ICU Stay, But Does Not Impact Mortality or VAP Rate
    • Systematic Review and Meta-Analysis of Effect of Early Tracheostomy on VAP Rates (Chest, 2011) [MEDLINE]
      • Early Tracheostomy Did Not Impact VAP Rates, Duration of Mechanical Ventilation, or Mortality Rate
    • Study of Early Tracheostomy in Cardiothoracic Surgery Population (Ann Intern Med 2011) [MEDLINE]
      • Early Tracheostomy Did Not Decrease Length of Hospital Stay, Mortality Rate, Infectious Complication Rate, Long-Term Health-Related Quality of Life in Patients Who Required Long-Term Mechanical Ventilation After Cardiothoracic Surgery
      • Early Tracheostomy was Well-Tolerated and Associated with Decreased Sedation Use, Better Comfort, and Earlier Resumption of Autonomy
    • TracMan Trial of Early vs Late Tracheostomy in the UK (JAMA, 2013) [MEDLINE]
      • Early Tracheostomy (Within 4 Days of Intubation) Did Not Improve 30-Day All-Cause Mortality, 2-Year Mortality, or Length of ICU Stay
      • The Ability of Clinicians to Predict Which Patients Would Require Extended Mechanical Ventilation Support was Limited
• Gastrointestinal/Stress Ulcer Prophylaxis (Quality of Evidence: II)
  • Clinical Efficacy
    
    • Systematic Review and Meta-Analysis of Stress Ulcer Prophylaxis with H2-Blockers (Crit Care Med, 2010) [MEDLINE]
      • H2-Blockers Decreased GI Bleeding Rate, But Only in Patient Who Were Not Receiving Enteral Nutrition
      • H2-Blockers Did Not Increase the Pneumonia Rate Overall, But Did Increase the Pneumonia Rate in the Subgroup Who Were Fed Enterally
      • H2-Blockers Did Not Impact In-Hospital Mortality Overall, But Did Increase the In-Hospital Mortality Rate in Subgroup Who Were Fed Enterally
    • Systematic Review and Meta-Analysis of PPI vs H2-Blockers (Crit Care Med, 2013) [MEDLINE]
      • PPI Were Superior to H2-Blockers in Preventing GI Bleeding
      • There Were No Differences in Terms of Pneumonia, Death, ICU Length of Stay
  • Recommendations (2012 Surviving Sepsis Guidelines; Crit Care Med, 2013) [MEDLINE]
    • Use Stress Ulcer Prophylaxis (H2 Blockers or Proton Pump Inhibitors) to Prevent Gastrointestinal Bleeding in Patients Who Have Bleeding Risk Factors (Grade 1B Recommendation)
      • When Stress Ulcer Prophylaxis is Used, Proton Pump Inhibitors are Preferred Over H2 Blockers (Grade 2D Recommendation)
      • Stress Ulcer Prophylaxis Should Not Be Used in Patients without Risk factors (Grade 2 B Recommendation)
  • Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Stress Ulcer Prophylaxis is Generally Not Recommended as a Measure to Decrease the VAP Rate (Although May Be Used for Stress Ulcer Prophylaxis)
• Kinetic Beds (Quality of Evidence: II = Moderate
  • Continuous Lateral Rotational Therapy and Oscillation Therapy
  • Clinical Efficacy
    • Systematic Review and Meta-Analysis of Effect of Kinetic Beds on VAP Rates (Crit Care, 2006) [MEDLINE]
      • Kinetic Beds Decreased VAP Rates, But Had No Impact on Duration of Mechanical Ventilation or Mortality Rate: however, there are concerns with regard to data quality from the included trials
    • Single-Center Austrian Prospective, Randomized Trial of the Efficacy of Continuous Lateral Rotational Therapy in VAP Prevention (Crit Care Med. 2010 Feb;38(2):486-90. doi: 10.1097/CCM.0b013e3181bc8218 [MEDLINE]
      • Ventilator-Associated Pneumonia Prevalence was Significantly Decreased by Continuous Lateral Rotation Therapy
      • Continuous Lateral Rotation Therapy Led to Decreased Duration of Ventilation and Decreased Length of Stay
    • Systematic Review and Meta-Analysis of Continuous Lateral Rotational Therapy in Trauma Patients (J Trauma Acute Care Surg, 2017) [MEDLINE]
      • Analogous to Studies Evaluating Continuous Lateral Rotation Therapy in Medical/Mixed Populations of Patients, Continuous Lateral Rotation Therapy Decreased Nosocomial Pneumonia Rates in Trauma Patients
      • However, There was No Impact on Mortality Rate
      • Data Studied was Limited, Suggesting that an Adequately Powered, Well-Designed Multi-Center Randomized Controlled Trial is Required
  • Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Kinetic Beds May Decrease VAP Rate, But are Generally Not Recommended for This Indication
• Monitoring of Gastric Residual Volumes (Quality of Evidence: II = Moderate)
  • Clinical Efficacy
    • Randomized Trial of Effect of Not Monitoring Gastric Residual Volume on VAP Rates in Patients Receiving Enteral Nutrition (JAMA, 2013) [MEDLINE]
      • Not Monitoring Gastric Residual Volumes Had No Impact on VAP Rates in Patients on Mechanical Ventilation Receiving Enteral Nutrition
• Prone Positioning (Quality of Evidence: II = Moderate)
  • Clinical Efficacy
    • Most Meta-Analyses Suggest a Borderline Effect on VAP Rates and No Impact on Objective Outcomes
  • Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Prone Positioning is Generally Not Recommended as a Measure to Decrease VAP Rate (although may be indicated for the management of ARDS)
• Silver-Coated Endotracheal Tubes (Quality of Evidence: II = Moderate)
  • Mechanism: prevention of biofilm formation inside endotracheal tube
  • Clinical Efficacy
    • Beneficial in decreasing VAP rates
  • Cost: silver-coated endotracheal tube costs approximately $90 (vs $1-2 for standard endotracheal tube)
  • Recommendations (Infect Control Hosp Epidemiol, 2014) [MEDLINE]
    • Silver-Coated Endotracheal Tubes May Lower VAP Rate, But Do Not Impact Mortality Rate, Duration of Mechanical Ventilation, or Length of Stay

Measure Which are Neither Recommended, Nor Discouraged (Unclear Impact on Ventilator-Associated Pneumonia Rates)

• Closed/In-Line Endotracheal Suctioning Systems (Quality of Evidence: II = Moderate)
  • Clinical Efficacy
    • Meta-Analysis of the Effect of Closed Endotracheal Suction Systems on VAP Rate (Br J Anaesth, 2008) [MEDLINE]
      • Closed Endotracheal Suction Systems Did Not Impact VAP Rate, Mortality, or ICU Length of Stay
      • Closed Endotracheal Suction Systems Increased the Duration of Mechanical Ventilation
    • Trials Conflict as to the Impact of Closed Endotracheal Suctioning Systems on Cost
• Use of Positive-End-Expiratory Pressure (PEEP) (see Invasive Mechanical Ventilation)
  • Use of PEEP in Non-Hypoxemic Mechanically-Ventilated Patients Has Been Demonstrated to Decrease the Risk of VAP (Crit Care Med, 2008) [MEDLINE]