What is new in the prevention of nosocomial pneumonia in the ICU?

Abstract

To summarize and contextualize recent evidence on preventing ventilator-associated pneumonia (VAP). Many centers continue to report dramatic decreases in VAP rates after implementing ventilator bundles. Interpreting these reports is complicated, however, by the subjectivity and lack of specificity of VAP definitions. More objective data suggest VAP rates may not have meaningfully changed over the past decade. If so, this compels us to re-examine and revise the prevention bundles we have been using to prevent VAP. New analyses suggest that most hospitals' ventilator bundles include a mix of helpful and potentially harmful elements. Spontaneous awakening trials, spontaneous breathing trials, head-of-bed elevation, and thromboprophylaxis appear beneficial. Oral chlorhexidine and stress ulcer prophylaxis may be harmful. Subglottic secretion drainage, probiotics, and novel endotracheal cuff designs do not clearly improve objective outcomes. Selective digestive decontamination by contrast appears to lower VAP and mortality rates. Effective implementation is as important as choosing the right bundle components. Best practices include engaging and educating staff, creating structures that facilitate bundle adherence, and providing regular feedback on process measure performance and outcome rates. VAP rates may still be elevated despite multiple reports to the contrary. Recent evidence suggests new ways to optimize the selection of ventilator bundle components and their implementation.