Development Of Ventilator-associated Pneumonia Research Articles

Gastroesophageal reflux in mechanically ventilated children: Not a risk factor for Ventilator Associated Pneumonia (VAP)?

Background : Gastroesophageal reflux (GER) is fairly common in children and mechanically ventilated children are at increased risk for the development of GER. Information on GER and development of ventilator associated pneumonia (VAP) is limited. Methods : A prospective observational cohort study was performed in mechanically ventilated children aged 1 year to 15 years within first 24 hrs of (initiation of mechanical ventilation) in Pediatric Intensive Care Unit (PICU), AIIMS using 24 hr esophageal pH metry and were followed up for 7 days for development of VAP using CDC criteria. Presence of GER was defined as fall in esophageal pH < 4 for more than 4% of total time . Results : A total of 61 patients (mean age (median): 73 (30-132), boys: 44 (72.1%), girls: 17 (27.9%)) were enrolled in the study. Total number of reflux episodes were 1855 and at least 1 episode of reflux was seen in 32 (52.46%) patients. As per definition of GER, 12 (19.7%) children had GER. Of the enrolled children, 17 (27.87%) patients developed VAP; 7 patients had VAP and at least 1 episode of acidic reflux however, no patient had both GER (as per definition) and VAP. Of 44 patients who did not develop VAP, at least 1 episode of reflux was seen in 25 patients while 12 patients (27.27%) had GER positive and 32 patients (72.72%) did not have GER. There was no correlation of age, sex, weight, mode of ventilation and PRISM score with GER. Conclusion : Acid reflux was common in ventilated patients but GER was less common and presence of acid reflux or GER did not increase the risk of development of ventilator associated pneumonia.

Antioxidant reserve of the lungs and ventilator-associated pneumonia: A clinical trial of high dose selenium in critically ill patients

PurposeTo evaluate the effect of supplemental selenium administration on the incidence of ventilator-associated pneumonia (VAP) in critically ill patients. MethodsNinety-nine mechanically ventilated patients were randomized to receive either selenium or isotonic saline infusion for 10days. The primary endpoint was serum glutathione peroxidase-3 (GPX-3) activity and secondary endpoints were development of VAP or death, ICU stay and vasopressor requirement. Serum concentrations of selenium and GPX-3 were measured on Day-1, Day-4 and Day-10. Chi Square and log-rank analyses were used for statistical analyses and odds ratios were calculated. ResultsSerum selenium and GPX-3 activity levels increased steadily in the treatment group within 10days (P<0.025), while they remained unchanged in the placebo group. The incidence of VAP was 19.4/1000days of mechanical ventilation in the placebo group while it was 15.8/1000 ventilated days in the treatment group (P=0.250). The risk of VAP or death was similar between the treatments and placebo groups. ConclusionDespite increasing the antioxidant activity, selenium supplementation did not affect the incidence of VAP in critically ill patients. The risk of developing VAP or death within 30days of ICU admission remained the same in the treatment and the controls.

Response

To evaluate the effect of supplemental selenium administration on the incidence of ventilator-associated pneumonia (VAP) in critically ill patients.Ninety-nine mechanically ventilated patients were randomized to receive either selenium or isotonic saline infusion for 10 days. The primary endpoint was serum glutathione peroxidase-3 (GPX-3) activity and secondary endpoints were development of VAP or death, ICU stay and vasopressor requirement. Serum concentrations of selenium and GPX-3 were measured on Day-1, Day-4 and Day-10. Chi Square and log-rank analyses were used for statistical analyses and odds ratios were calculated.Serum selenium and GPX-3 activity levels increased steadily in the treatment group within 10 days (P < 0.025), while they remained unchanged in the placebo group. The incidence of VAP was 19.4/1000 days of mechanical ventilation in the placebo group while it was 15.8/1000 ventilated days in the treatment group (P = 0.250). The risk of VAP or death was similar between the treatments and placebo groups.Despite increasing the antioxidant activity, selenium supplementation did not affect the incidence of VAP in critically ill patients. The risk of developing VAP or death within 30 days of ICU admission remained the same in the treatment and the controls.

Mechanical Ventilation Induces Interleukin 4 Secretion in Lungs and Reduces the Phagocytic Capacity of Lung Macrophages.

Patients receiving mechanical ventilation are at risk of developing ventilator-associated pneumonia. Here, we show that clinically utilized ventilation protocols in rats with 5 mL/kg or 8 mL/kg tidal volumes cause increased interleukin 4 (IL-4) expression, lowered ratio of TH1:TH2 transcriptional factors (Tbet:Gata3), and increased arginase 1-positive (Arg1+) macrophages and eosinophils in lungs. Macrophages from ventilated lungs had reduced ex vivo capacity toward phagocytosing bacteria. Ventilated animals, when further challenged with bacterial pneumonia, continued to show persistence of Arg1+ M2 macrophages as well as an increased bacterial burden compared with spontaneously breathing animals receiving the same bacterial dose. Increased IL-4 expression also occurred in a mouse ventilation model, and abrogation of IL-4 signaling restored lung bacterial burden in an IL-4Rα-/- ventilator-associated pneumonia model. Our data suggest that mechanical ventilation induces an immunosuppressive state in lungs, providing new insight in the development of ventilator-associated pneumonia.

Airway microbiome research: a modern perspective on surveillance cultures?

The incidence of ventilator-associated pneumonia (VAP) is estimated to be around 10% in a high-risk population. Over the last decade, major improvements have been made in the prevention of VAP, with great cost-effectiveness. However, we still do not understand the exact pathogenesis of VAP. A better understanding might explain why some patients develop ventilator-associated tracheobronchitis, while others develop VAP even though they are infected with the same types of pathogens. Microbiome research has been a hot topic in translational medicine over the past decade. Slowly, microbiome research has also been introduced to the intensive care setting. One of the areas where it may influence our pathophysiological considerations is in VAP. The adapted island has been proposed for the colonization and infection of the respiratory tract. In this model, not only the immigration of bacteria into the lung is important, but elimination and regional growth factors are of equal significance. The importance of these factors can be supported by epidemiological studies. Several small observational studies on the development of the pulmonary microbiome during mechanical ventilation also support this theory. We speculate on the consequences of the newest insights in microbiome research on the prevention and targeted treatment of VAP. We conclude that there is still a strong need for more in-depth analyses of the changes in the microbial composition of the pulmonary microbiome during mechanical ventilation and with the development of VAP.

Risk Factors for Pneumonia in Ventilated Trauma Patients with Multiple Rib Fractures.

BackgroundVentilator-associated pneumonia (VAP) is a common disease that may contribute to morbidity and mortality among trauma patients in the intensive care unit (ICU). This study evaluated the associations between trauma factors and the development of VAP in ventilated patients with multiple rib fractures.MethodsWe retrospectively and consecutively evaluated 101 patients with multiple rib fractures who were ventilated and managed at our hospital between January 2010 and December 2015, analyzing the associations between VAP and trauma factors in these patients. Trauma factors included sternal fracture, flail chest, diaphragm injury, traumatic aortic dissection, combined cardiac injury, pulmonary contusion, pneumothorax, hemothorax, hemopneumothorax, abbreviated injury scale score, thoracic trauma severity score, and injury severity score.ResultsForty-six patients (45.5%) had at least 1 episode of VAP, 10 (21.7%) of whom died in the ICU. Of the 55 (54.5%) patients who did not have pneumonia, 9 (16.4%) died in the ICU. Using logistic regression analysis, we found that VAP was associated with severe lung contusion (odds ratio, 3.07; 95% confidence interval, 1.12 to 8.39; p=0.029).ConclusionSevere pulmonary contusion (pulmonary lung contusion score 6–12) is an independent risk factor for VAP in ventilated trauma patients with multiple rib fractures.

Incidence of Ventilator-Associated Pneumonia in Critically Ill Children Undergoing Mechanical Ventilation in Pediatric Intensive Care Unit.

Background: Among hospital-acquired infections (HAIs) in children, ventilator-associated pneumonia (VAP) is the most common after blood stream infection (BSI). VAP can prolong length of ventilation and hospitalization, increase mortality rate, and directly change a patient’s outcome in Pediatric Intensive Care Units (PICU). Objectives: The research on VAP in children is limited, especially in Iran; therefore, the identification of VAP incidence and mortality rate will be important for both clinical and epidemiological implications. Materials and Methods: Mechanically ventilated pediatric patients were assessed for development of VAP during hospital course on the basis of clinical, laboratory and imaging criteria. We matched VAP group with control group for assessment of VAP related mortality in the critically ill ventilated children. Results: VAP developed in 22.9% of critically ill children undergoing mechanical ventilation. Early VAP and late VAP were found in 19.3% and 8.4% of VAP cases, respectively. Among the known VAP risk factors that were investigated, immunodeficiency was significantly greater in the VAP group (p = 0.014). No significant differences were found between the two groups regarding use of corticosteroids, antibiotics, PH (potential of hydrogen) modifying agents (such as ranitidine or pantoprazole), presence of nasogastric tube and total or partial parenteral nutrition administration. A substantial number of patients in the VAP group had more than four risk factors for development of VAP, compared to those without VAP (p = 0.087). Mortality rate was not statistically different between the VAP and control groups (p = 0.477). Conclusion: VAP is still one of the major causes of mortality in PICUs. It is found that altered immune status is a significant risk factor for acquiring VAP. Also, occurrence of VAP was high in the first week after admission in PICU.

PROSPECTIVE MONITORING OF AIRWAY COLONIZATION AS WAY TO VENTILATOR-ASSOCIATED PNEUMONIA PROPHYLAXIS

Introduction. Ventilator-associated pneumonia is the most common type of nosocomial infection. It’s characterized high mortality (24-76%), leads to increase of mechanical ventilation length, length of stay in intensive care units, significant increase of hospital length of stay and cost of care. The aim of this study was to perform the systematic analysis of the current literature devoted to the problem of airway bacterial colonization and ventilator-associated pneumonia (VAP) prophylaxis. Objectives of the study: the definition of the value of airway bacterial colonization in clinical practice, feasibility of airway bacterial colonization monitoring, prophylaxis, VAP diagnosis and prophylaxis which based on the bacterial colonization monitoring data. For the solution of the designated objectives in the scientific medical databases Medscape and Pubmed there was performed the search for the publications on subject headings, covering these problems. Conclusion. Airway bacterial colonization by potential infectious agent is a one of the key stage in VAP development. Prospective bacterial colonization monitoring (in addition to laboratory and instrumental analysis, clinical presentation) enable to get current microbiological data in prospective mode and to provide the targeted real-time antibacterial therapy in case of pneumonia onset. But at present this way is not convential and requires additional improvement. The guidelines to selection of time, type, technology and personalization VAP prophylaxis methods can be developed on basis of this technique.

Should We Immediately Start Antibiotics in Every Patient with a Clinical Suspicion of HAP/VAP?

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remain two of the most commonly diagnosed nosocomial infections. Both are responsible for significant morbidity and mortality in hospitalized patients. The development of HAP and VAP is related to bacterial colonization of the oropharynx (and endotracheal tube in VAP) with subsequent microaspiration and development of clinical infection. Diagnosis is made based on the clinical presentation and can be confirmed by obtaining either noninvasive or invasive microbiology culture specimens. Decisions addressing initiation of antimicrobial therapy can be divided into clinical and bacteriological strategies. These strategies differ in the criteria used to determine the timing of empiric therapy, with the clinical strategy basing the decision on radiographic evidence of infection plus clinical signs and symptoms and the bacteriological strategy requiring growth of pathogens above a certain threshold from invasively obtained culture specimens. Despite the delineated pathways, these decisions remain multifactorial and should also include consideration of patient-related factors, such as immunocompetence, the risk of multidrug-resistant infection, and overall clinical condition. Patients with risk factors or signs of clinical decompensation should have empiric therapy initiated at a lower threshold. However, when possible, therapy should be directed at a confirmed infection following a positive culture result. Decisions regarding specific empiric regimens should be based on the local prevalence of infectious microorganisms along with their associated antimicrobial susceptibilities. Patients deemed at risk of infection with multidrug-resistant pathogens merit broader spectrum therapy, and immunosuppressed patients should have consideration of antifungal coverage.

Bacterial Contamination of Ventilators in the Intensive Care Unit

Objectives: To investigate the level of bacterial contamination in ventilation devices after being connected to head trauma patients with confirmed ventilator-associated pneumonia. Methods: This prospective, cross sectional study was carried out at Shahid Mohammadi hospital, Bandar-e Abbas, Iran. Samples for assessing the contamination of ventilators were obtainedfromexpiratoryandinspiratory tube insertion sites before connecting the device to the patients. The patients were then observed for the development of ventilator-associated pneumonia and were enrolled in the study if considered eligible. Sampling was repeated after disconnecting the patient. The following variables were assessed in each patient: gender, age, Glasgow Coma Scale upon hospitalization, length of stay in the intensive care unit (ICU), and mortality. Results: A total of 33 patients, including 26 men and 7 women, were enrolled in the study. There was no significant association between ventilation contamination and time of sampling (before or after ventilation) in the evaluated sites (P > 0.05). However, based on McNemer’s test for equality of frequencies, the prevalence of positive culture after disconnecting the device from the patients (60.6%) was not the same as the prevalence before being connected to the patients (21.2%) at inspiratory tube insertion sites (P = 0.002). Also, at both sites, the variety and pathogenicity of microorganisms after disconnecting the device were higher than those of microorganisms, colonized from samples which were obtained before connecting the device. Conclusions: The findings of the present study showed that mechanical ventilation of patients with pulmonary infection leads to the contamination of ventilators. These findings suggest the need for designing and implementing new measures, which are easily available in developing and resource-deficient countries in order to reduce the contamination of ventilation devices and prevent cross-contamination.

Molecular analysis of endotracheal tube biofilms and tracheal aspirates in the pediatric intensive care unit.

BackgroundVentilator-associated pneumonia (VAP) is a known complication of mechanically ventilated children in the pediatric intensive care unit (PICU). Endotracheal tube (ETT) biofilms are often implicated in the development of VAP by providing a conduit for pathogens to the lower respiratory tract.MethodsA prospective cohort study from April 2010–March 2011 of children 4 weeks to 18 years of age ventilated for greater than 72 hours to determine the microbiota of ETT biofilms and tracheal aspirates.ResultsThirty-three patients were included with a mean age of 6.1 years (SD ± 5.1 years) and average length of intubation of 8.8 days (SD ± 5.0 days). Bacterial communities from tracheal aspirates and the proximal and distal ends of ETTs were determined using 16S rRNA gene libraries. Statistical analysis utilized two-part statistics and the Wilcoxon signed rank sum test for comparison of bacterial communities. Sequencing revealed a predominance of oropharyngeal microbiota including Prevotella and Streptococcus spp. Pathogenic bacterial genera including Staphylococcus, Burkholderia, Moraxella, and Haemophilus were also represented. Bacterial load was greatest at the proximal aspect of the ETT. Duration of intubation did not significantly impact bacterial load. Morisita Horn analysis across sites showed similar communities in 24/33 (72%) of patients.ConclusionsETT biofilms and tracheal aspirates of intubated patients in the PICU primarily consisted of oropharyngeal microbiota, but had a significant representation of potentially pathogenic genera. While the majority of patients had similar microbiota when comparing their ETT biofilms and tracheal aspirates, a subset of patients showed a divergence between communities that requires further investigation.

Incidence, Etiology and Outcome of Ventilator-Associated Pneumonia in Patients with Percutaneous Tracheotomy

Although the incidence of ventilator-associated pneumonia (VAP) is very high, there are still many uncertainties about clinical course of VAP among tracheotomized patients. The goal of the present study was to determine the impact of tracheotomy on VAP incidence and etiology, as well as outcome of VAP patients with tracheotomy. The study was conducted in a 15-bed Surgical and Neurosurgical Intensive Care Unit (ICU), Sestre milosrdnice University Hospital Center in Zagreb, Croatia. The study included all patients undergoing only percutaneous tracheotomy during the study period. According to our data, the incidence of VAP among percutaneous tracheotomized patients was 42%, not considering the time between tracheotomy and VAP onset. However, when only patients developing VAP after tracheotomy were taken into account, the incidence of VAP among tracheotomized patients dropped to 8% only. The most commonly isolated bacterium was Staphylococcus aureus, accounting for 17 (37%) isolates, followed by Haemophilus influenzae, accounting for another 10 (22%) isolates. The development of VAP among percutaneously tracheotomized patients was associated with longer total ICU stay (regardless of whether VAP developed before or after tracheotomy), while total duration of mechanical ventilation and mortality rate remained unaffected.

Assessment of surgical risk factors in the development of ventilator-associated pneumonia in neurosurgical intensive care unit patients: Alarming observations.

Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in patients receiving mechanical ventilation (MV) and contributes to a longer intensive care unit (ICU) stay, duration of MV, and a high morbidity and mortality. The purpose of study was to determine the incidence of VAP in neurosurgery ICU patients and to assess the probable contributing neurosurgical risk factors like the site and nature of the lesion in the brain, the duration of surgery, blood loss during surgery, and infection elsewhere in the body, in the development of VAP. The prospective clinical study included patients with a Glasgow Coma Scale (GCS) score>8 undergoing a neurosurgical procedure and postoperatively receiving MV for> 48 hours, who were followed for the development of VAP. The diagnosis of VAP was in accordance with the Centers for Disease control (CDC) guidelines and was confirmed with a positive quantitative culture in the endotracheal tube aspirate samples. The incidence of VAP in our study was 70%. Aneurysmal subarachnoid hemorrhage (SAH) [Grade 3, 4 and 5] was the most common underlying condition followed by posterior fossa surgery, and surgery of the craniovertebral junction and cervical spine. Patients with a supratentorial compartment etiology had a slightly higher incidence (53%) of VAP as compared to the infratentorial compartment one. Patients with significant intraoperative blood loss and receiving blood transfusion had a higher incidence of pulmonary complications. Acinetobacter baumannii was the most common pathogen isolated followed by Pseudomonas aeruginosa, with high resistance trends being prevalent among the commonly used antibiotics in the ICU. The incidence of VAP is high. Patients of aneurysmal SAH are at higher risk and VAP is as common in patients with supratentorial lesions as in those with infratentorial pathologies. The increase in resistance to the commonly used antibiotics is a cause for concern. Efforts should be taken to evolve more effective preventive measures.

Implementation of ventilator associated pneumonia prevention bundle in the neonatal intinsive care unit at Alexandria University Children’s Hospital, Egypt

Introduction Ventilator-associated pneumonia (VAP) is a nosocomial lung infection that develops at or later than 48 h after mechanical ventilation (MV). It is the second most frequent hospital-acquired infection in neonatal intensive care units (NICUs). It results in high morbidity, mortality, prolonged NICU length of stay, and increased cost of hospitalization. Egypt and other developing countries report higher VAP rates compared with developed countries. Furthermore, studies monitoring VAP rates and success of intervention strategies in Egyptian NICUs are few. Aim The aim of the present study was to estimate the incidence of VAP during the implementation of the prevention bundle and also to identify the causative agents and significant risk factors in the NICU at Alexandria University Children’s Hospital. Patients and methods A nonrandomized clinical trial with historical control was conducted. All neonates admitted to the NICU in the period from July 2015 till March 2016, who spent more than 48 h on MV, were subjected to a VAP prevention bundle. Eligible neonates who spent more than 48 h on MV were monitored closely for VAP development. A thorough assessment of history, clinical examination, routine investigations, and chest radiography were carried out on all enrolled infants. Neonates who developed clinically suspected VAP were further subjected to nonbronchoscopic bronchoalveolar lavage for bacteriological confirmation of the clinical diagnosis. A review of records was performed to determine the incidence of VAP in the 9 months before intervention. Oral swabs were taken to study the pattern of oral colonization in ventilated neonates to trace its role in VAP development. Also, cultures of residual gastric volume and water traps inserted into the ventilator circuits were studied. Results A total of 108 episodes of VAP were diagnosed, with a cumulative incidence of clinically diagnosed VAP equal to 37.6% (34.2 VAP cases/1000 ventilation days). The incidence of bacteriological-confirmed VAP in this study was 19.97/1000 ventilation days. The most important risk factors for the occurrence of VAP were prematurity, low birth weight, prolonged duration of ventilation, re-intubations, and enteral feeding. Gram-negative bacteria were the predominating cause of VAP in the NICU and Klebsiella was the most common pathogen isolated from nonbronchoscopic bronchoalveolar lavage cultures. Conclusion VAP is a severe complication of MV as it significantly increases neonatal mortality. The VAP preventive bundle implemented in the present work was associated with a reduction in the VAP rate in the NICU.

Incidence of ventilator associated pneumonia and its risk factors

Hospitals are intended to heal the sick; but they are also sources of infection. Ironically, the advances in medicine are partly responsible for the fact that today; hospital infections are the leading cause of death worldwide. Newer technology and latest surgical and medical diagnostic methods and treatment procedures have increased the number of invasive techniques leading to higher chances of nosocomial infection. Pneumonia is the leading cause of death due to nosocomial infections. Intubation &amp; mechanical ventilation greatly increases the risk for ventilator-associated pneumonia (VAP). In developing country like India, such hospital-acquired infections have a significant impact on patient’s morbidity, mortality, hospital stay and on financial concerns of the patient, hospital and community. The present investigation was aimed to determine the incidence of ventilator associated pneumonia in the neurosurgery intensive care unit of a tertiary care centre and to determine the risk factors of ventilator associated pneumonia. A total of 30 samples belonging to the age group of 15 to 75 years who where on mechanical ventilator for more than 48 hours in the neurosurgery intensive care unit of a tertiary care centre were selected using convenience sampling. The incidence of VAP was estimated to be 30%. The risk factors identified for the development of VAP was found to be combined head and cervical spine injury (P=0.001), associated injuries (P=0.035), additional surgeries (P=0.025), nasogastric feeding (P=0.001), intake of immuno suppressive drugs (P=0.004), pre operative antibiotics (p=0.000) and duration of mechanical ventilation &gt;5 days (P=0.000). The mortality among patients with VAP was found to be higher than patients without VAP (88.9% than non VAP patients).

Staff education aimed at reducing ventilator-associated pneumonia.

Mechanical ventilation is a life-saving invasive procedure performed in intensive care units (ICUs) where critical patients are given advanced support. The purpose of this study was to assess the effect of personnel training on the incidence of ventilator-associated pneumonia (VAP). The study, performed prospectively in the ICU, was planned in two periods. In both periods, patient characteristics were recorded on patient data forms. In the second period, ICU physicians and assistant health personnel were given regular theoretical and practical training. Twenty-two cases of VAP developed in the pre-training period, an incidence of 31.2. Nineteen cases of VAP developed in the post-training period, an incidence of 21.0 (P<0.001). Training reduced development of VAP by 31.7 %. Crude VAP mortality was 69 % in the first period and 26 % in the second (P<0.001). Statistically significant risk factors for VAP in both periods were prolonged hospitalization, increased number of days on mechanical ventilation, and enteral nutrition; risk factors determined in the first period were re-intubation, central venous catheter use and heart failure and, in the second period, erythrocyte transfusion >5 units (P<0.05). Prior to training, compliance with hand washing (before and after procedure), appropriate aseptic endotracheal aspiration and adequate oral hygiene in particular were very low. An improvement was observed after training (P<0.001). The training of personnel who will apply infection control procedures for the prevention of healthcare-associated infections is highly important. Hand hygiene and other infection control measures must be emphasized in training programmes, and standard procedures in patient interventions must be revised.

Splenectomy Does Not Affect the Development of Ventilator Associated Pneumonia Following Severe Traumatic Brain Injury

Splenectomy Does Not Affect the Development of Ventilator Associated Pneumonia Following Severe Traumatic Brain Injury

Effectiveness of Intraoral Chlorhexidine Protocols in the Prevention of Ventilator-Associated Pneumonia: Meta-Analysis and Systematic Review.

Ventilator-associated pneumonia (VAP) is common in critical patients and related with increased morbidity and mortality. We conducted a systematic review and meta-analysis, with intention-to-treat analysis, of randomized controlled clinical trials that assessed the effectiveness of different intraoral chlorhexidine protocols for the prevention of VAP. Search strategies were developed for the MEDLINE, EMBASE, and LILACS databases. MeSH terms were combined with Boolean operators and used to search the databases. Eligible studies were randomized controlled trials of mechanically ventilated subjects receiving oral care with chlorhexidine or standard oral care protocols consisting of or associated with the use of a placebo or no chemicals. Pooled estimates of the relative risk and corresponding 95% CIs were calculated with random effects models, and heterogeneity was assessed with the Cochran Q statistic and I(2). The 13 included studies provided data on 1,640 subjects that were randomly allocated to chlorhexidine (n = 834) or control (n = 806) treatments. A preliminary analysis revealed that oral application of chlorhexidine fails to promote a significant reduction in VAP incidence (relative risk 0.80, 95% CI 0.59-1.07, I(2) = 45%). However, subgroup analyses showed that chlorhexidine prevents VAP development when used at 2% concentration (relative risk 0.53, 95% CI 0.31-0.91, I(2) = 0%) or 4 times/d (relative risk 0.56, 95% CI 0.38-0.81, I(2) = 0%). We found that oral care with chlorhexidine is effective in reducing VAP incidence in the adult population if administered at 2% concentration or 4 times/d.

Oral health and ventilator-associated pneumonia among critically ill patients: a prospective study.

To evaluate the association between oral health and ventilator-associated pneumonia (VAP) among critically ill patients. A prospective cohort study was conducted among 162 critically ill patients newly intubated and treated with mechanical ventilator in one tertiary hospital in Thailand. Oral health status was assessed using Oral Health Assessment Tool (OHAT), Plaque Index (PI), and number of teeth. VAP, defined as Clinical Pulmonary Infection Score >6, was assessed on Day 4 after intubation. Hazard ratios and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression adjusted for confounders. Critically ill patients had deteriorating oral health status after intubation. Early-onset VAP developed in 69 patients (42.6%), with VAP incidence of 117 episodes per 1000 ventilator-days. Moderately unhealthy and unhealthy oral conditions based on OHAT scores were associated with a 2.92-fold (95% CI: 1.26-6.74) and 3.22-fold (95% CI: 1.34-7.76) increased risk of VAP. Patients with moderate-to-very poor oral hygiene assessed by PI had increased VAP risk of 1.66-folds (95% CI: 1.001-2.75). The number of teeth was not associated with VAP development. There is a strong association between poor oral health and increased risk for early-onset VAP. Routine oral care possibly prevents VAP development among critically ill patients treated with mechanical ventilator.

Scanning Electron Microscopic Biofilm Grading and Ventilator Associated Pneumonia in Relation to Duration of Intubation

Background: Ventilator associated pneumonia (VAP) accounts for 7-70% of infections in intensive care units (ICUs) leading to increase in hospitalization, mortality and cost. Endotracheal tube (ETT) is a risk factor for developing VAP caused by biofilm producing organisms resistant to antimicrobial agents. This study aimed to determine guidelines for ETT extubation through detection of biofilm formation and development of VAP. Objectives: Our aim was to assess biofilm formation on the luminal surface of ETTs in intubated patients in ICU in relation to duration of intubation bacteriologically and morphologically using Scanning Electron Microscope (SEM). Antimicrobial resistance and VAP development were also studied. Methodology: Our work was conducted on 20 ETTs divided into two groups: Group (1); 8 patients with ETTs<5 days, and group (2); 12 patients with ETTs of 5-12 days. Culture of the interior of the ETTs, identification of bacterial species, antibiotic susceptibility and presence with staging of biofilm into 3 grades by SEM were performed. Results: A highly significant relationship was observed between the duration of intubation and biofilm grading (p value <0.001). Also, the duration of intubation and VAP development were significantly correlated (p<0.001). A highly significant relationship was observed between VAP development and biofilm grading by SEM (p<0.001). A moderate significant relationship was found between VAP development and prognosis of patients (p<0.02). It was also observed that prolonged intubation was associated with prevalence of polymicrobial colonization with the predominance of Gram negative bacilli. Furthermore, a moderate significant relationship was observed between antimicrobial resistance and both biofilm grading and duration of intubation (p<0.02). Conclusion: Biofilm formation and grading as well as bacterial colonization with multidrug-resistant (MDR) bacteria were time dependent in patients on mechanical ventilation in ICU which may enhance their morbidity and mortality rates. Also a role of ETT biofilm is emphasized in the pathogenesis and prognostic outcome of VAP in patients intubated for a prolonged period. Accordingly, we recommend that ETT should be exchanged every 4 days to avoid such morbidity and mortality consequences.