Pathogenesis-Targeted Preventive Strategies for Multidrug Resistant Ventilator-Associated Pneumonia: A Narrative Review.

Antonella Cotoia,Savino Spadaro,Gilda Cinnella,Guido Gambetti,Despoina Koulenti

doi:10.3390/microorganisms8060821

Abstract

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU), accounting for relevant morbidity and mortality among critically ill patients, especially when caused by multidrug resistant (MDR) organisms. The rising problem of MDR etiologies, which has led to a reduction in treatment options, have increased clinician’s attention to the employment of effective prevention strategies. In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing MDR-VAP. Oral hygiene with Chlorhexidine (CHX), CHX body washing, selective oral decontamination (SOD) and/or digestive decontamination (SDD), multiple decontamination regimens, probiotics, subglottic secretions drainage (SSD), special cuff material and shape, silver-coated endotracheal tubes (ETTs), universal use of gloves and contact isolation, alcohol-based hand gel, vaporized hydrogen peroxide, and bundles of care have been addressed. The most convincing evidence came from interventions directly addressed against the key factors of MDR-VAP pathogenesis, especially when they are jointly implemented into bundles. Further research, however, is warranted to identify the most effective combination.

Highlights

Ventilator-associated pneumonia (VAP) is a nosocomial infection of the pulmonary parenchyma which develops in intensive care unit (ICU) patients who have been mechanically ventilated (MV) for at least 48 h [1]
In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing multidrug resistant (MDR)-VAP
MDR organisms (MDROs) incidence, can be even higher as reported by a recent cross-sectional study showing a prevalence of 35% over a two-year period, with 60.87% of the cases caused by MDR pathogens, especially among the late-onset VAP

Summary

Introduction

Ventilator-associated pneumonia (VAP) is a nosocomial infection of the pulmonary parenchyma which develops in intensive care unit (ICU) patients who have been mechanically ventilated (MV) for at least 48 h [1]. The pathogenesis of VAP is related to several bacterial strains colonizing the oropharyngeal and gastrointestinal tract that reach the lower respiratory tract primarily through the microaspiration of bacterial-laden secretions. Depending on their virulence and the host’s response, they can cause lung infection. In other studies, etiology between early- and late-onset VAP have been found to be similar [6], emphasizing the role of local ICU ecology as the most important risk factor for acquiring MDR pathogens, irrespective of the length of intubation. The rising problem of MDR etiologies has, at the same time, led to a reduction in treatment options, shifting the focus on the search for new and effective VAP preventive strategies, which could directly hit its pathogenesis

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